Enteral nutrition (EN) protocols are thought to improve clinical outcomes in the pediatric intensive care unit (PICU); however, critical evaluation of their efficacy is limited. We conducted a systematic review with the aim of assessing the effect of EN protocols on important clinical outcomes in these children. We searched MEDLINE, Cochrane Database for Reviews, Embase, and CINAHL using predetermined keywords and MESH terms. We included randomized controlled trials (RCTs) and observational studies that involved EN protocols in children admitted to the PICU for >24 hours. We included studies that reported at least 1 of our outcomes of interest. Studies that exclusively studied premature neonates or adults were excluded. Primary outcomes were PICU or hospital mortality, PICU or hospital length of stay (LOS), duration of mechanical ventilation, gastrointestinal (GI) complications, and infective complications. Secondary outcomes were time to initiate feeds and time to achieve goal feeds. In total, we included 9 studies (total 1564 children) in our systematic review (1 RCT, 4 before-and-after studies, 1 single-arm cohort study, 1 prospective descriptive study, and 2 audits). There is low-level evidence that the use of EN protocols is associated with a reduction in GI and infective complications and improved timeliness of feed initiation and achievement of goal feeds. Current medical literature does not have compelling data on the effects of an EN protocol on clinical outcomes among critically ill children. Future clinical trials should look into using standardized interventions and outcome measures to strengthen the existing evidence.
PollackMMWileyJSKanterRHolbrookPR. Malnutrition in critically ill infants and children. JPEN J Parenter Enteral Nutr. 1982Jan-Feb;6(1):20-24.
2.
PollackMMRuttimannUEWileyJS. Nutritional depletions in critically ill children: associations with physiologic instability and increased quantity of care. JPEN J Parenter Enteral Nutr. 1985May-Jun;9(3):309-313.
3.
HulstJJoostenKZimmermannL. Malnutrition in critically ill children: from admission to 6 months after discharge. Clin Nutr. 2004Apr;23(2):223-232.
4.
DelgadoAFOkayTSLeoneCNicholsBDel NegroGMVazFA. Hospital malnutrition and inflammatory response in critically ill children and adolescents admitted to a tertiary intensive care unit. Clinics. 2008Jun;63(3):357-362.
5.
LeiteHPIsatugoMKSawakiLFisbergM. Anthropometric nutritional assessment of critically ill hospitalized children. Rev Paul Med. 1993Jan-Feb;111(1):309-313.
6.
MehtaNM. Approach to enteral feeding in the PICU. Nutr Clin Pract. 2009Jun-Jul;24(3):377-387.
7.
McClaveSAHeylandDK. The physiologic response and associated clinical benefits from provision of early enteral nutrition. Nutr Clin Pract. 2009Jun-Jul;24(3):305-315.
8.
PrietoMBCidJL-H. Malnutrition in the critically ill child: the importance of enteral nutrition. Int J Environ Res Pub Health. 2011;8(11):4353-4366.
9.
de SouzaMenezes FLeiteHPKochNogueira PC. Malnutrition as an independent predictor of clinical outcome in critically ill children. Nutrition. 2012Mar;28(3):267-270.
10.
MarikPEZalogaGP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001Dec;29(12):2264-2270.
11.
ChellisMJSandersSVWebsterHDeanJMJacksonD. Early enteral feeding in the pediatric intensive care unit. JPEN J Parenter Enteral Nutr.1996Jan-Feb;20(1):71-73.
12.
MehtaNMMcAleerDHamiltonS. Challenges to optimal enteral nutrition in a multidisciplinary pediatric intensive care unit. JPEN J Parenter Enteral Nutr. 2010Jan1;34(1):38-45.
13.
de NeefMGeukersVGDralALindeboomRSauerweinHPBosAP. Nutritional goals, prescription and delivery in a pediatric intensive care unit. Clin Nutr. 2008Feb;27(1):65-71.
14.
JoffeAAntonNLequierL. Nutritional support for critically ill children. Cochrane Database Syst Rev. 2009;(2):CD005144.
15.
MehtaNMBechardLJCahillN. Nutritional practices and their relationship to clinical outcomes in critically ill children—an international multicenter cohort study. Crit Care Med. 2012Jul;40(7):2204-2211.
16.
MorganJYoungLMcGuireW. Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants. Cochrane Database Syst Rev. 2011;(3):CD001241.
17.
GuyattGOxmanADAklEA. GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011Apr;64(4):383-394.
18.
SchunemannHJJaeschkeRCookDJ. An official ATS statement: grading the quality of evidence and strength of recommendations in ATS guidelines and recommendations. Am J Respir Crit Care Med. 2006Sep1;174(5):605-614.
19.
SwigloBAMuradMHSchunemannHJ. A case for clarity, consistency, and helpfulness: state-of-the-art clinical practice guidelines in endocrinology using the Grading of Recommendations, Assessment, Development, and Evaluation system. J Clin Endocrinol Metab. 2008Mar;93(3):666-673.
20.
GottschlichMMJenkinsMEMayesTKhouryJKaganRJWardenGD. The 2002 Clinical Research Award. An evaluation of the safety of early vs delayed enteral support and effects on clinical, nutritional, and endocrine outcomes after severe burns. J Burn Care Rehabil. 2002Nov-Dec;23(6):401-415.
21.
del CastilloSLMcCulleyMEKhemaniRG. Reducing the incidence of necrotizing enterocolitis in neonates with hypoplastic left heart syndrome with the introduction of an enteral feed protocol. Pediatr Crit Care Med. 2010May;11(3):373-377.
22.
BraudisNJCurleyMABeaupreK. Enteral feeding algorithm for infants with hypoplastic left heart syndrome poststage I palliation. Pediatr Crit Care Med. 2009Jul;10(4):460-466.
23.
GeukersVGDijsselhofMESauerweinHPBosAP. Effect of a nurse-driven feeding algorithm and the institution of a nutritional support team on energy and macronutrient intake in critically ill children. e-SPEN J. 2012;7(1):0-eng.
24.
Petrillo-AlbaranoTPettignanoRAsfawMEasleyK. Use of a feeding protocol to improve nutritional support through early, aggressive, enteral nutrition in the pediatric intensive care unit. Pediatr Crit Care Med. 2006Jul;7(4):340-344.
25.
MeyerRHarrisonSSargentSRamnarayanPHabibiPLabadariosD. The impact of enteral feeding protocols on nutritional support in critically ill children. J Hum Nutr Diet. 2009Oct;22(5):428-436.
26.
TumeLLattenLDarbyshireA. An evaluation of enteral feeding practices in critically ill children. Nurs Crit Care. 2010Nov-Dec;15(6):291-299.
27.
BriassoulisGCZavrasNJHatzisMT. Effectiveness and safety of a protocol for promotion of early intragastric feeding in critically ill children. Pediatr Crit Care Med. 2001Apr;2(2):113-121.
28.
GhanayemNSJaquissRDCavaJR. Right ventricle-to-pulmonary artery conduit versus Blalock-Taussig shunt: a hemodynamic comparison. Ann Thorac Surg. 2006Nov;82(5):1603-1609; discussion 9-10.
29.
RajaSGAtamanyukIKostolnyMTsangV. In hypoplastic left heart patients is Sano shunt compared with modified Blalock-Taussig shunt associated with deleterious effects on ventricular performance?Interact Cardiovasc Thorac Surg. 2010Apr;10(4):620-623.
30.
WoolfSHGrolRHutchinsonAEcclesMGrimshawJ. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999Feb20;318(7182):527-530.
31.
HelwigABowerDWolffMGuseC. Residents find clinical practice guidelines valuable as educational and clinical tools. Fam Med. 1998Jun;30(6):431-435.
32.
RestrepoRDFortenberryJDSpainhourCStockwellJGoodfellowLT. Protocol-driven ventilator management in children: comparison to nonprotocol care. J Intensive Care Med. 2004Sep-Oct;19(5):274-284.
33.
VerhoevenJJBrandJBvandePolderMMJoostenKF. Management of hyperglycemia in the pediatric intensive care unit; implementation of a glucose control protocol. Pediatr Crit Care Med. 2009Nov;10(6):648-652.
34.
DeeterKHKingMARidlingDIrbyGLLynnAMZimmermanJJ. Successful implementation of a pediatric sedation protocol for mechanically ventilated patients. Crit Care Med. 2011Apr;39(4):683-688.
35.
HeylandDKCahillNEDhaliwalRSunXDayAGMcClaveSA. Impact of enteral feeding protocols on enteral nutrition delivery: results of a multicenter observational study. JPEN J Parenter Enteral Nutr. 2010Nov-Dec;34(6):675-684.
36.
MartinCMDoigGSHeylandDKMorrisonTSibbaldWJ. Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ. 2004Jan20;170(2):197-204.
37.
BarrJHechtMFlavinKEKhoranaAGouldMK. Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol. Chest. 2004Apr;125(4):1446-1457.
38.
DoigGSSimpsonFFinferS. Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial. JAMA. 2008Dec17;300(23):2731-2741.
39.
WoienHBjorkIT. Nutrition of the critically ill patient and effects of implementing a nutritional support algorithm in ICU. J Clin Nurs. 2006Feb;15(2):168-177.
40.
GriffithsRD. Guidelines for nutrition in the critically ill: are we altogether or in-the-altogether?JPEN J Parenter Enteral Nutr. 2010Nov1;34(6):595-597.
41.
MackenzieSLZygunDAWhitmoreBLDoigCJHameedSM. Implementation of a nutrition support protocol increases the proportion of mechanically ventilated patients reaching enteral nutrition targets in the adult intensive care unit. JPEN J Parenter Enteral Nutr. 2005Mar-Apr;29(2):74-80.
42.
BlueJWColburnWA. Efficacy measures: surrogates or clinical outcomes?J Clin Pharmacol. 1996Sep;36(9):767-770.
43.
HozoSPDjulbegovicBHozoI. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005;5:13.
44.
HornDChaboyerW. Gastric feeding in critically ill children: a randomized controlled trial. Am J Crit Care. 2003Sep;12(5):461-468.
45.
HornDChaboyerWSchluterPJ. Gastric residual volumes in critically ill paediatric patients: a comparison of feeding regimens. Aust Crit Care. 2004Aug;17(3):98-100, 2-3.
46.
PollackMMWileyJSHolbrookPR. Early nutritional depletion in critically ill children. Crit Care Med. 1981Aug;9(8):580-583.
47.
GramlichLKichianKPinillaJRodychNJDhaliwalRHeylandDK. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition. 2004Oct;20(10):843-848.
48.
DobsonKScottA. Review of ICU nutrition support practices: implementing the nurse-led enteral feeding algorithm. Nurs Crit Care. 2007May-Jun;12(3):114-123.
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