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General discussion
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and the optimal macronutrient and micronutrient composition of both enteral and parenteral
formulas.
Suggestions for clinical implementation
Protocol adherence in a research setting mainly depends on the effectiveness of the research
team. Successful clinical implementation of study results on the other hand, depends on the
personal adherence of the involved clinicians and other health care workers. This process could
be improved by modification of a protocol to local context while considering current practice,
resources and costs. Nonetheless, extensive education of all involved clinicians remains
essential. Continuous evaluation on the execution of the new strategy is needed to detect the
challenges and pitfalls of this practice when carried out in a in a clinical setting.
In order to implement the PEPaNIC strategy in the PICU of the Sophia Children’s Hospital–
ErasmusMC in Rotterdam, several concessions to the study protocol have beenmade to comply
with the availability and compatibility of local PN components and the current infrastructure
of the local pharmacy.
Based on the results presented in this thesis and the available literature, the following
nutritional strategies in critically ill children are recommended:
1. Critically ill children at nutritional risk should be identified in order to decide which
type of nutritional support should be given
2. Use of a nutritional risk score such as the STRONGkids is recommended
3. In critically ill children at nutritional risk, parenteral amino acids and lipids should be
withheld and parenteral glucose intake should be reduced during the first week of
PICU stay (Fig 1. and Table 1)
4. Electrolytes, minerals, trace elements and vitamins should be provided as
recommended by the guidelines
2
in an age-dependent manner from day 2 onwards.
Parenteral supplementation should be stopped as soon as enteral nutrition provides
≥80% of caloric goal (Fig. 1)
5. Enteral macronutrient intake in the first week of PICU stay depends on the route of
nutrition, weight of the child and phase of critical illness (Table 1)
6. Enteral nutrition should ideally be initiated within 24-48 hours after admission
7. Increase of macronutrient intake after 1 week in the PICU depends on the phase of
critical illness and can be classified as follows:
a. acute phase: requirement of (escalating) vital organ support
b. stable phase: stabilisation or weaning of vital organ support
c. recovery phase: clinical mobilisation of the child, that is no longer in need of
vital organ support