Proefschrift Kerklaan

Introduction

measured REE 120 and during the acute phase of critical illness 117 . Therefore, application of this parameter may be limited to the stable and recovery phase of critical illness.

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In conclusion it can be stated that:

• Low-grade and inconclusive evidence-based guidelines, resulting from a scarcity of high-level evidence on all aspects of nutritional support in critically ill children, are likely to allow wide variations in nutritional practices between PICUs.

• Understanding the stress response to critical illness and the characteristics of its three phases is essential for nutritional recommendations in critically ill children.

• During the course of critical illness, the enteral route is preferred, but several misconceptions concerning the provision of enteral nutrition prevent adequate intake. • Use of parenteral nutrition in critically ill children is associated with potential disadvantages, but clinical outcome studies are lacking. Parenteral nutrient restriction early during critical illness might be beneficial for short and long-term outcomes by amplifying the acute catabolic stress response and stimulating autophagy and muscle integrity. • During the stable and recovery phase, inclining caloric and protein requirements allow for a more aggressive feeding approach, together with mobilisation, to enable recovery, rehabilitation and (catch-up) growth.

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