Chapter 8: Enteral Nutrition in the Critically ill Child

INTRODUCTION

Enteral nutrition (EN) is the preferred method of nutrition support in critically ill children, as parenteral nutrition (PN) is associated with increased costs, infections, and other complications.¹ Enteral feeding is tolerated by most pediatric intensive care unit (PICU) patients and can effectively meet energy and protein goals. The time from admission to initiation, route, composition, and cumulative intake of EN have the potential to positively influence the course of critical illness. Multiple obstacles to enteral feeding are common to the PICU environment; these must be anticipated and minimized to achieve improved outcomes with EN therapy.

EARLY ENTERAL NUTRITION

Although there is enthusiasm for EN, the optimal timing for introducing enteral feeds in a critically ill child remains unclear. In an effort to maximize the benefits of EN and to achieve nutrient delivery goals, the concept of early EN is gaining traction. The benefits of this approach need to be balanced against the potential of EN intolerance in the early phase of illness or injury.

Benefits of Early Enteral Nutrition

Few randomized controlled studies have evaluated the effects of early versus delayed EN in pediatric critical illness, and those conducted in children with burn injuries have demonstrated multiple benefits. In a large study, 688 children with a mean of 20% total body surface area (TBSA) burns were randomized to early (fed within 6 hours) or delayed (no sooner than 48 hours from injury) EN.² Length of hospital stay (12.6 ± 1.3 days vs. 16.4 ± 3.7 days, P < .05) and mortality (8.5% vs. 12%, P < .05) were significantly lower in the group that received early EN.

In another study, 21 children with a median of 30% TBSA burns were randomized either to early enteral resuscitation and early EN or intravenous resuscitation with late EN.³ All children were fed via nasojejunal tubes (NJT) placed under fluoroscopy or at the bedside. Enteral nutrition was initiated by a median of 10.7 hours and reached the target in 16 hours in the early group. In children randomized to late EN, feeding commenced at a median of 54 hours, with the goal rate achieved in the next 10 hours. Significantly higher serum insulin and lower growth hormone levels were demonstrated in the early compared to delayed group, suggesting an improved anabolic response with early enteral resuscitation and feeding. Recipients of early EN were reported to have decreased incidence of weight loss (3% vs. 7.75%), antibiotic treatment (11 days vs. 14 days), and diarrhea. In a similar study, 77 critically ill children with severe burns of approximately 50% TBSA were randomized to EN via postpyloric feeding tube within 24 hours or delayed after 48 hours.⁴ Significantly reduced caloric deficits and protein breakdown were demonstrated in the early EN group. Serum insulin was also significantly higher in children receiving early EN. The definition of ...