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Late parenteral nutrition in children clinically superior to early nutrition

Delaying parenteral nutrition in critically ill children for 1 week in the ICU resulted in clinically superior health outcomes compared with early parenteral feeding, according to data published in the New England Journal of Medicine.

“Since nutrition should equal basic metabolic needs and in children should allow for growth, children require relatively more macronutrients than adults,” Tom Fivez, MD, of the KU Leuven University Hospital, in Belgium, and colleagues wrote. “Hence, the current standard of pediatric care is to meet these requirements early. When enteral nutrition fails, parenteral nutrition is advised, but current nutritional practices in pediatric ICUs vary owing to concerns about the overdosing of parenteral nutrition.”

To determine whether delaying parenteral nutrition for 1 week among children in ICU settings leads to better health outcomes than early parenteral nutrition, the researchers conducted a multicenter, randomized control trial with 1,440 participants aged 0 to 17 years. The 732 children placed in the early group received parenteral nutrition within 24 hours after ICU admission. The 717 children in the late group did not receive parenteral nutrition until the morning of their eighth day in the ICU.

Fluid loading was similar in both groups, and, for all patients, enteral nutrition was attempted and IV micronutrients were provided. Primary end points were new infection developed in the ICU, and the adjusted duration of ICU dependency, measured by length of stay and as time to discharge alive from ICU.

According to the researchers, the percentage of chronically ill children who acquired a new infection in the ICU was 10.7% in the late group, compared with 18.5% in the early group (aOR 0.48; 95% CI, 0.35-0.66). However, mortality was similar in both groups. The mean length of stay was 6.5 ± 0.4 days in the late group, compared with 9.2 ± 0.8 days in the early group. In addition, those in the late group had a higher likelihood of an earlier discharge from the ICU at any time (aOR 1.23; 95% CI, 1.11-1.37).

Delaying parenteral nutrition 1 week was also associated a shorter duration of mechanical ventilator support than early parenteral nutrition (P = .001), and those in the late group had a smaller proportion of participants undergoing renal-replacement therapy (P = .04). They also had a shorter duration of hospital stay (P = .001). Lastly, late parenteral nutrition, compared with those in the early group, was associated with lower plasma levels of γ-glutamyltransferase (P = .001) and alkaline phosphatase (P = .04), and higher levels of bilirubin (P = .004) and C-reactive protein (P = .006).

“The clinical superiority of late parenteral nutrition was shown irrespective of diagnosis, severity of illness, risk of malnutrition, or age of the child,” Fivez and colleagues wrote. “… In conclusion, in critically ill children, withholding parenteral nutrition for 1 week while administering micronutrients intravenously was clinically superior to providing parenteral nutrition to supplement insufficient enteral nutrition.” – by Jason Laday

Disclosure: Researcher Sascha Verbruggen, MD, PhD, reports receiving lecture fees from Nutricia. The other researchers report no relevant financial disclosures.