Delaying Supplemental Parenteral Nutrition Benefits Critically Ill Children

EBM Focus - Volume 11, Issue 13

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Reference - N Engl J Med 2016 Mar 24;374(12):1111 (level 1 [likely reliable] evidence)

  • Parenteral nutrition is often used to supplement enteral nutrition in critically ill children, but some evidence suggests it may increase the risk of complications.
  • A recent randomized trial comparing early (within 24 hours) vs. late (day 8) initiation of supplemental parenteral nutrition in 1,440 critically ill children with medium-to-high risk of malnutrition found a significant decrease in new infections and length of pediatric intensive care unit (PICU) stay with late administration.
  • Subgroup analyses of critically ill neonates and children at high risk of malnutrition found an even greater benefit of late parenteral nutrition in these populations, further suggesting delaying parenteral nutrition is safe and beneficial.

Evidence evaluating nutritional support for critically ill children admitted to a PICU is sparse and studies performed in adult populations may not adequately translate to growing children with different nutritional needs. Nevertheless, current guidelines recommend early nutritional evaluation and the initiation of aggressive feeding protocols to prevent or combat malnutrition in critically ill children (JPEN J Parenter Enteral Nutr 2009 May-Jun;33(3):260). Enteral nutrition provided by a nasogastric tube is the preferred method for supplying nutritional support, but enteral nutrition is frequently interrupted or not tolerated (Crit Care Med 2012 Jul;40(7):2204, Pediatr Crit Care Med 2016 Jan;17(1):10). Supplemental parenteral nutrition is often administered to adequately meet nutritional goals, but may increase the risk of complications such as infection (JPEN J Parenter Enteral Nutr 2016 Jan 7 early online). To further evaluate this issue, 1,440 critically ill children (median age 18 months) admitted to the PICU with medium-to-high risk of malnutrition were randomized to supplemental parental nutrition initiated within 24 hours of PICU admission (early) vs. on PICU day 8 (late).

All children received early enteral nutrition and IV micronutrients. Children in the late parenteral nutrition group received 5% dextrose and saline IV to match the fluid administration in the early parenteral nutrition group. Comparing early vs. late parenteral nutrition, new infections occurred in 18.5% vs. 10.7% (p< 0.001, NNT 13). This increase in infections with early parenteral nutrition was mainly due to an increase in airway and bloodstream infections. The mean length of PICU stay was 9.2 days with early parenteral nutrition vs. 6.5 days with late parenteral nutrition (p = 0.002). Early parenteral nutrition was also associated with increased mean durations of mechanical ventilation and hospital stay. There was no significant difference in 90-day mortality. These benefits of late parenteral nutrition were independent of age, diagnosis, illness severity, or risk of malnutrition.

The results of this trial show that delaying parenteral nutrition by 1 week significantly improved outcomes in critically ill children. The consistency of these results in both multivariate and subgroup analyses further strengthens this claim. In fact, critically ill neonates and children at high risk of malnutrition, who would be expected to benefit most from parenteral nutrition, actually appear to benefit more from later administration of parenteral nutrition than lower risk populations. Late parenteral nutrition did increase the risk of hypoglycemic episodes in the first 7 days, but these episodes responded to treatment within 2 hours in almost all children. Overall, these results suggest that enteral nutrition alone is sufficient for critically ill children admitted to the PICU and supplementation with parenteral nutrition can safely be delayed for at least 1 week.

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