Proefschrift Kerklaan

Chapter 8

nutrients exceed the adverse effects of its provision. This moment is likely to depend on the age and clinical status of the child (Chapter 4) and also on the phase of critical illness (Chapter 1 and 4). With the PEPaNIC trial, the most optimal timing so far for initiation of PN in critically ill children is determined at 8 days after PICU admission. Since the majority of patients will have left the PICU by that time, they will not receive any PN during their stay on the PICU. Effect of early parenteral nutrient restriction in children at nutritional risk The clinical superiority of late PN was present irrespective of the admission diagnosis, the severity of illness and the STRONGkids category. Certain populations within the PICU, such as neonates and malnourished children, are presumed to have less metabolic reserve 75 . Other children are at greater nutritional risk 76 due to higher requirements, decreased intake or increased losses 77-79 . Especially for these groups of ‘at-risk’ patients, fear for profound cumulative macronutrient deficits exists. Indeed, malnourishment was frequently mentioned as condition for early initiation of PN in the survey (Chapter 2, data not shown). The PEPaNIC trial did not stratify for different nutritional risk categories a priori. Planned subgroup analyses of this trial will investigate differences in effect size of withholding PN between certain patient groups, and may generate new hypotheses. STRONGkids score The beneficial effect size observed in children in the highest STRONGkids risk category was larger than in children in the medium STRONGkids risk category (Chapter 7), even after correction for diagnosis, age and severity of illness. The STRONGkids screening tool was initially developed and validated to identify hospitalised children at nutritional risk 76 . We successfully used this tool to also identify critically ill children at nutritional risk. Clinically, the highest STRONGkids scores were mainly reserved for critically ill children with malignancies, severe cardiac disease (cardiomyopathy, hypoplastic heart syndrome) or after surgical correction of gastro-intestinal tract anomalies. In order to implement the strategy of withholding PN during the first week of PICU stay in children at nutritional risk and to identify children that will possibly benefit most from this strategy, determination of the STRONGkids or another nutritional risk score in every child upon admission to the PICU is recommended. The distinct effect in children at higher nutritional risk, questions the reservation of early PN for children at-risk, as often applied in North American PICUs. The effect of late PN on clinical outcomes in children that are malnourished (SD-score for BMI <-2) and on children with a contra-indication for EN will be investigated in planned sub-group analyses. Possible underlying explanations for the enhanced effect in these children at higher nutritional risk will also be studied by comparing the amount of PN provided andmacro- andmicronutrient status upon admission.

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