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Chapter 1
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Outline of this thesis
Part I: Introduction
This thesis aims to provide insight in current nutritional support during stay on the paediatric
intensive care unit (PICU), concerning the route, timing and amount of artificial nutrition,
with focus on the identification and risk of caloric overfeeding and the use of (supplemental)
parenteral nutrition.
Part II: Current nutritional practices
The second part of this thesis describes daily nutritional practice in the PICU. Chapter 2
highlights the variation in current clinical practice regarding several aspects of nutritional
support by an international online survey in 156 PICUs across the world. To compare intended
with applied nutritional practice, this survey identifies information on local strategies as well
as their execution in patients by use of point prevalence data.
Part III: Energy expenditure
The third part focuses on the determination of resting energy expenditure (REE) by indirect
calorimetry in critically ill children. Chapter 3 aimed to validate an alternative method for
measurement of energy expenditurewith indirect calorimetry by use of ventilator-derivedVCO
2
measurements in 41 mechanically ventilated children. In Chapter 4 different internationally
used definitions of caloric overfeeding are compared in order to find the most adequate
method to identify overfeeding. In order to do so, measurements of REE and respiratory
quotient from 79 mechanically ventilated children are studied in relation to caloric intake.
Part IV: Supplemental parenteral nutrition
In this part the effect of timing of parenteral nutrition in the PICU is investigated. Chapter 5
reviews the current scarce evidence for the use of parenteral nutrition in the PICU, thereby
underlining the need for large nutritional RCTs. In Chapter 6 and 7 a multicentre, international
RCT in 1440 critically ill children at nutritional risk is described. The strategy of withholding
supplemental parenteral nutrition for one week in the PICU is compared to providing early
parenteral nutrition. Primary clinical outcomes are the number of patients with new infections
and length of PICU stay.
Part V: General discussion, including future perspectives, and summary
The last part of this thesis is dedicated to the general discussion and suggestions for future
research in nutritional support, which can be read in Chapter 8. A summary of the major
findings of this thesis can be found in Chapter 9 (English and Dutch).