91 / 208
Evidence for the use of PN in the PICU
89
5
INTRODUCTION
For critically ill children who require an admission to the Pediatric Intensive Care Unit (PICU),
nutritional support is advised as soon as possible to prevent or reduce catabolism, with the
intention to enhance recovery while allowing normal growth
1
. The enteral route is preferred
as it has been suggested that feeding via the gut maintains gut integrity and may reduce the
risk of infection, in comparison with feeding via the parenteral route
1
. However, when only
enteral nutrition (EN) is provided during PICU stay, caloric targets are often not reached. This is
explained by intestinal dysfunction as part of the critical illness, the administered medication
that affects the gastrointestinal tract, frequent interruptions of enteral feeding and the need
for fluid restriction
2
. Hence, a caloric deficit quickly builds up in critically ill children, the
severity of which has been associated with poor outcomes and impaired growth
3,4
. Children
are particularly vulnerable for accumulating a pronounced caloric deficit as their relative
energy requirements are 2-3 times higher than those of adults. Reaching the preset caloric
targets is easier when parenteral nutrition (PN) is administered. However, feeding children
via the parenteral route has shown to increase the risk of metabolic disturbances such as
hyperglycemia and dyslipidemia and to be associated with more nosocomial infections
5
.
Therefore, the question remains if, and when, PN should be initiated for critically ill children
in the PICU.
The currently available guidelines are not very specific on how energy requirements should be
determined for critically ill children nor on how the caloric deficit should best be prevented.
The European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Society
for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines state that the
initiation of PN depends on the clinical condition and the age and size of the infant or child
6
.
These guidelines advocate to start PN in infants shortly after admission to PICU whenever
EN fails, but in older children and adolescents longer periods of inadequate nutrition may
be tolerated. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines
make no specific recommendations for the use and dosing of PN for children treated in the
PICU
1
. However, the A.S.P.E.N. guidelines state that for older children, a caloric deficit can be
tolerated for up to one week. These different and rather non-specific recommendations have
resulted in nutritional practices that vary widely among PICUs worldwide
7
.
Therefore, we performed an up to date review to assess all available evidence from randomized
controlled trials (RCTs), with hard clinical as well as surrogate endpoints, that supports the use
of parenteral nutrition in children during critical illness.