Timing of the initiation of parenteral nutrition in critically ill children

Abstract

Purpose of Review To review the current literature evaluating clinical outcomes of early and delayed parenteral nutrition initiation among critically ill children. Recent Findings Nutritional management remains an important aspect of care among the critically ill, with enteral nutrition (EN) generally preferred. However, inability to advance enteral feeds to caloric goals and contraindications to EN often leads to reliance on parenteral nutrition (PN). The timing of PN initiation is varied among critically ill children, and derives from an assessment of nutritional status, energy requirements, and physiologic differences between adults and children, including higher nutrient needs and lower body reserves. A recent randomized control study among critically ill children suggests improved clinical outcomes with postponing initiation of PN to 1 week after admission to the pediatric intensive care unit (PICU). Summary Although there is no consensus on the optimal timing of PN initiation among critically ill children, recent literature does not support the immediate initiation of PN on PICU admission. A common theme in the reviewed literature highlights the importance of accurate assessment of nutritional status and energy expenditure in deciding when to initiate PN. As with all medical interventions, the initiation of PN should be considered in light of the known benefits of judiciously provided nutritional support with the known risks of artificial, parenteral feeding.

Plasma metabolomics of early parenteral nutrition followed with enteral nutrition in pancreatic surgery patients

“…In extreme cases like sepsis, blockage of lipid oxidation and catabolism of amino acid deteriorate the homeostasis and eventually lead to poor prognosis or death 15,26 . Therefore, decreased gluconeogenesis from amino acid and utilization of lipid in the present study suggested the TPN support may help the metabolic transition to homeostasis and thus enhance the patients’ recovery 25,28 .…”

“…Total parenteral nutrition (TPN) provides nutrients of amino acids, lipids, and vitamins, which may provide additional benefits for the transition of metabolism and help the body be tolerant of following EN 5,7 , while the risk of blood glucose disorder or infection are significant concerns for TPN application 7,28 . In the present study, though the sample size is relatively small, clinical outcomes between the two groups indicated no increased infection or other complications.…”

Influencing the timing of parenteral nutrition initiation in the pediatric intensive care unit

“…These recommendations acknowledge the study results to begin PN after seven days, but counter with expert opinion the option to begin PN 24 hours after PICU admission. Thus, current guideline recommendations lack focused specificity for standard provision of care regarding PN initiation 7. The broad national debate over appropriate PN initiation, reflects the range of opinions expressed at our facility during our initial consensus discussions.…”

Nutrition Support During Pediatric Extracorporeal Membrane Oxygenation

“…In addition, there were several aspects of the study design that limit external validity . In the absence of data, a reasonable approach in infants and children receiving ECMO may be to emphasize early and cautious advancement of EN and to initiate PN within 3–5 days in children with malnutrition and within 5–7 days in well‐nourished children if nutrient delivery goal has not been achieved by EN alone …”