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General discussion
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INTRODUCTION
Understanding the stress response to critical illness is essential for nutritional recommendations
in critically ill children. Nutrient restriction early during critical illness might be beneficial
for short and long-term outcomes, while inclining caloric and protein requirements allow
for a more aggressive feeding approach during the stable and recovery phase. In order to
provide the optimal amount of nutrition and prevent the detrimental effects associated with
malnutrition, both under- and overfeeding should be identified, but current definitions fail
to do this accurately. Although the enteral route is preferred because of its association with
improved outcome, (supplemental) parenteral nutrition (PN) is often administered to improve
intake adequacy despite potential disadvantages.
This thesis provided insight in the practice and evidence of the timing and goals of PN and thus
the development and the subsequent outcome of underfeeding or overfeeding in critically ill
children.
CURRENT NUTRITIONAL PRACTICES
Paediatric guidelines
Globally, guidelines for nutritional support have been released by expert committees of
non-profit nutritional organisations such as the American Society for Parenteral and Enteral
Nutrition (A.S.P.E.N.), the European Society for Clinical Nutrition and Metabolism (ESPEN), and
the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)
(Chapter 2). Due to a lack of high-level evidence, the consensus-based guidelines offer basic
recommendations that are largely driven by expert opinion and extrapolations from studies in
adults or noncritically ill children
1,2
.
Current guidelines versus clinical practices worldwide
These inconclusive guidelines make clinical implementation in PICUs across the world difficult.
This leads to a wide variation of nutritional practices in PICUs, which were quantified by use of
an online worldwide survey (Chapter 2). The first survey described local nutritional strategies
in 156 PICUs worldwide. Subsequently, a point prevalence study was performed to collect
nutritional data from critically ill children on a single day in these same PICUs. By comparing
results from the initial survey with the point prevalence data, the deviation between intended
and applied nutritional practices was highlighted. Aspects that differed most between PICUs
can therefore be presumed to be in greatest need of high-quality evidence to guide future
clinical practice. These aspects were identified in both parts of the survey. In chapters 1 and 5
the lack of clinical outcome studies on the use of PN in the PICU has been underlined. Indeed,