Value of artificial nutrition in ICU children challenged

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Critically ill children in intensive care are unable to eat independently. The current standard of care for such children is based mostly on the assumption that they need to eat to regain their strength. Therefore, the method that is applied worldwide is to artificially feed these children during the first days of their stay in intensive care. This artificial nutrition is meant to strengthen their muscles, prevent complications, and speed up their recovery. The artificial nutrition is infused directly into the bloodstream.

An international team of researchers from University Hospitals Leuven (Belgium), Sophia Children’s Hospital Rotterdam (The Netherlands), and Stollery Children’s Hospital Edmonton (Canada) has now challenged the validity of this common practice. They conducted a randomised controlled trial that involved 1,440 critically ill children. The researchers examined whether fasting or receiving very small amounts of feeding during the first week in the paediatric intensive care unit was better for the children than full feeding through an IV.

The results are remarkable. “We found that the current practice of feeding children in an early stage does not contribute to their recovery”, says lead author Professor Greet Van den Berghe from KU Leuven / University Hospitals Leuven. “On the contrary, the children who had built up a nutritional deficiency after receiving little to no feedings had fewer infections, less organ failure, and a quicker recovery than children who had been fed through the IV. The effect was present in everyone, regardless of the type of disease, the children’s age, or the hospital in which they were staying.”

These findings provide strong evidence against common practice and can thus be expected to change paediatric intensive care worldwide.

Previous research by Van den Berghe and her team had already shown that early artificial feeding should be avoided to treat adults in intensive care.

Recent trials have questioned the benefit of early parenteral nutrition in adults. The effect of early parenteral nutrition on clinical outcomes in critically ill children is unclear.
We conducted a multicenter, randomized, controlled trial involving 1440 critically ill children to investigate whether withholding parenteral nutrition for 1 week (i.e., providing late parenteral nutrition) in the pediatric intensive care unit (ICU) is clinically superior to providing early parenteral nutrition. Fluid loading was similar in the two groups. The two primary end points were new infection acquired during the ICU stay and the adjusted duration of ICU dependency, as assessed by the number of days in the ICU and as time to discharge alive from ICU. For the 723 patients receiving early parenteral nutrition, parenteral nutrition was initiated within 24 hours after ICU admission, whereas for the 717 patients receiving late parenteral nutrition, parenteral nutrition was not provided until the morning of the 8th day in the ICU. In both groups, enteral nutrition was attempted early and intravenous micronutrients were provided.
Although mortality was similar in the two groups, the percentage of patients with a new infection was 10.7% in the group receiving late parenteral nutrition, as compared with 18.5% in the group receiving early parenteral nutrition (adjusted odds ratio, 0.48; 95% confidence interval [CI], 0.35 to 0.66). The mean (±SE) duration of ICU stay was 6.5±0.4 days in the group receiving late parenteral nutrition, as compared with 9.2±0.8 days in the group receiving early parenteral nutrition; there was also a higher likelihood of an earlier live discharge from the ICU at any time in the late-parenteral-nutrition group (adjusted hazard ratio, 1.23; 95% CI, 1.11 to 1.37). Late parenteral nutrition was associated with a shorter duration of mechanical ventilatory support than was early parenteral nutrition (P=0.001), as well as a smaller proportion of patients receiving renal-replacement therapy (P=0.04) and a shorter duration of hospital stay (P=0.001). Late parenteral nutrition was also associated with lower plasma levels of γ-glutamyltransferase and alkaline phosphatase than was early parenteral nutrition (P=0.001 and P=0.04, respectively), as well as higher levels of bilirubin (P=0.004) and C-reactive protein (P=0.006).
In critically ill children, withholding parenteral nutrition for 1 week in the ICU was clinically superior to providing early parenteral nutrition.

University Hospitals Leuven material
New England Journal of Medicine abstract

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