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Chapter 2
44
because only 20 children received glucose infusion exclusively during the first 24 hours of
admission. Target blood glucose levels varied between tight control
20
and a target glucose
less than 10 mmol/L or 180 mg/dL. This discrepancy in definitions and implementation in
glucose management has been highlighted before
39,40
. The discrepancy in definitions and
implementation stems from the fact that uncertainties about risks and benefits remain
20,41
. A
recent U.K. trial showed no benefit
42
and another trial in North America is underway.
The strength of our study is the fact that we surveyed the local nutritional strategies as well as
their implementation in clinical practice. Furthermore, to our knowledge, it is the first study to
describe the practices in relation to income characteristics of countries in six continents.
However, our survey may not provide accurate representations of these geographic regions.
No response rate can be calculated, since the exact number of PICUs represented byWFPICCS is
unknown. The total number of PICUs in all countries joined in theWFPICCS, as identified in the
literature, is at least 969, so our 156 PICUs represent a small proportion of all PICUs worldwide.
Our
point prevalence
data represent a small fraction of children in the PICUs per center as well
as in the cohort invited to participate.
The smaller number of PICUs in the
point prevalence
study may have caused an aggravation
of the selection bias, since it is possible that we mainly received
point prevalence
data from
PICUs with a strict protocol adherence. Hence, observations may not depict actual practices
in these centers. However, characteristics of responding PICUs for the
point prevalence
were
similar compared with the overall
survey
respondents (Table 1).
Furthermore, many physicians have limited knowledge of nutritional practices in their centers.
Our study may also be limited by the possibility that nonrespondents of this survey were less
interested in nutritional practices leading to a selection bias and possible distorted reflection.
On the other hand, this selection bias may strengthen our conclusion, if even in the nutrition-
minded respondents, adherence to available guidelines is limited.
Finally, the heterogeneity of the PICU population may have caused some difficulties; many
of the questions required an unambiguous answer, so only most applicable answers were
provided. And, as feeding practices differ between populations, answers from combined PICUs
(with neonates or adults; respectively, 20 and 6% of the responding PICUs in this study) may
falsely increase the perception of variability.
Nevertheless, our survey clearly demonstrates the international variation in nutritional practice
in critically ill children and the differences due to the limited available guidelines, especially on
macronutrient administration and calculation of energy targets. Evidence-based guidelines are
needed, but are challenging to develop due to a heterogeneous PICU population. Guidelines
can be either very specific in respect to disease and settings, leading to wide variation of
practice, or be generally applicable with risk of being unfocused and therefore irrelevant in
specific situations.