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Introduction
15
1
Table 2.
Perceived barriers to (early) enteral nutrition in critically ill children
Barriers
Facts
Delayed
initiation
(Non)-invasive positive
pressure ventilation
Early enteral feedings are feasible, well tolerated, and cost-
effective in mechanically ventilated children
60,61
Gastro-intestinal
surgery
Early enteral nutrition after small and large operations in
children, including intestinal resection, is safe and feasible. It
promotes rapid elimination of intestinal paresis, early activation
of motor function, mucosal regeneration and early activation of
absorptive function, thereby reducing infection rate and length
of hospital stay
62,63
Use of vasoactive drugs Enteral nutrition in patients on vasoactive drugs improves
gut blood flow and is associated with no difference in gastro-
intestinal outcomes and a tendency towards lower mortality
61
Interruption
of delivery
High GRV
Available large RCTs in adults consistently showed no beneficial
effect of GRV monitoring
64
, with a higher chance of achieving
nutrient goals if GRV is not monitored
65
The accuracy of GRV measurement to predict enteral nutrition
intolerance has not been studied in critically ill children
66
Procedures requiring
fasting, including
surgery and planned
extubation
A reduced fasting protocol by use of clear fluids is safe and
feasible
67
Absence of bowel
sounds
Auscultation of bowel sounds has limited clinical utility and
should not be used to guide provision of enteral nutrition
68
Fluid
restriction
Diagnosis dependent,
often in cardiac or renal
patients
Use of energy and protein enriched formulas might increase
the chance of achieving caloric goals
69
. Interdisciplinary team
interventions improve nutrition delivery
70
GRV, gastric residual volume; RCT, randomised controlled trial
Early parenteral nutrition in critically ill children
Evidence on the impact of (supplemental) parenteral nutrition on clinical outcomes in critically
ill children is currently lacking
6
. Some nonrandomised studies, or studies with surrogate
outcome measures, have pointed toward potential disadvantages of parenteral nutrition in
this population. In a retrospective study of 204 nonsurgical critically ill children eligible for
enteral nutrition provision, supplementation of parenteral nutrition was associated with a
higher nosocomial infection rate than administration of enteral nutrition alone (34.0 vs.10.9%,
P
less than 0.001)
73
. The use of parenteral nutrition was one of the most significant predictors
for nosocomial infections in a prospective cohort of 1106 cardiac PICU patients (odds ratio
1.2, 95% confidence interval 1.1-1.4)
74
. Use of parenteral nutrition has shown to be the single
significant factor determining energy intake in mixed-effect modelling and is also identified
as risk factor for overfeeding
1,75
, possibly because higher provision of energy is possible,
while administration is less interrupted compared to enteral nutrition. In septic adolescents,
metabolic side effects, such as enhanced endogenous glucose production and lipolysis, were