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Chapter 8
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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.