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Chapter 2
42
Variation inpracticewas not onlyobservedbetweenPICUs inour current study; we also received
conflicting statements within single institutions. We corrected for this issue, by weighting by
the inverse of the number of completed questionnaires per center. The conflicting statements
underline the observed variation of nutritional practices, which occurs not only between but
also within individual institutions. A similar discordance in practice within institutions was
reported in a U.K. survey of glycemic control in PICUs
22
.
Globally, guidelines for nutritional support have been released by nutritional organizations.The
American (A.S.P.E.N). and European (ESPEN/ESPGHAN) societies provide specific guidelines for
nutrition in critically ill children
7,8
. However, they do not advise on every aspect of nutritional
support. Agreements and differences between these guidelines and current practice, as shown
by our survey, are summarized in Supplementary Table 2.
Overall, the most striking similarity between guidelines and local implementation is the
preference for EN as the preferred route of nutrient delivery and its early initiation in critically
ill children.
A specialized NST and feeding protocol are recommended by the A.S.P.E.N guidelines for
critically ill children
7
. Availability of an EN protocol is associated with a lower prevalence
of hospital-acquired infections
3
, implementation of an NST with an increase in EN use, and
decreased reliance on PN
23
. Our
survey
showed that a nutritional protocol and/or NST were
available in approximately half the PICUs. In our
point prevalence,
we found no significant
difference in caloric intake and use of EN between patients from centers with and without
a protocol. However, since this was a secondary analysis, it cannot prove or disprove the
utility of NST/protocols in general. In single centers, a stepwise EN algorithm has been shown
to significantly improve the timing of EN initiation and the ability to reach nutrient delivery
goals
24,25
. The role of protocols and NSTs in optimizing clinical outcomes in the PICU population
needs to be further examined in well-designed trials.
The ESPEN/ESPGHAN guidelines prefer the measurement of resting energy expenditure (REE)
to the use of equations. The A.S.P.E.N. guidelines recommend targeted use of IC in a select
group of patients with suspected metabolic alterations or malnutrition. Both state that in the
absence of IC, reasonable values can also be derived from formulas, for example, Schofield
17
,
but only when applied without the use of universal correction factors
7,8
. Several other sources
state that nutritional therapy should be targeted at REE throughout the course of illness
26,27
.
However, due to the limited availability and practice of IC
11
, and also to inaccurate predictive
equations
26-28
, it is difficult to assess REE in critically ill children. Use of the WHO and Schofield
equations, most commonly used to determine requirements, may lead to underfeeding and
overfeeding and potentially impacts morbidity and mortality
3,4
. We confirmed the finding of
previous studies
11
that IC to measure REE is used in a small minority of European (20%) and