Phase angle as a prognostic indicator in critically ill children: A systematic review.

Phase angle (PhA) may reflect the integrity of cellular membranes, hydration status, and total body cell mass. Studies have shown that PhA can be used as a good predictor for evaluation of disease severity in critically ill adults. However, there is a lack of studies assessing the association between PhA and clinical outcomes in critically ill children. This systematic review described the association between PhA at pediatric intensive care unit (PICU) admission with clinical outcomes in critically ill children. The search was conducted using PubMed/Medline, Scopus, Web of Science, EMBASE and LILACS until July 22, 2022. Studies that evaluate the association between PhA at PICU admission in critically ill children and clinical outcomes were eligible. Data regarding population, study design, setting, bioelectrical impedance analysis (BIA) protocol used, PhA classification, and outcome analysis were extracted. Risk of bias was assessed by Newcastle-Ottawa Scale. Among the 4669 articles screened, five prospective studies were included. The studies have shown association between lower values of PhA at PICU admission with longer PICU and hospital length of stay, duration of mechanical ventilation, septic shock, and higher mortality risk. Small sample size, different clinical conditions, and methodological differences of the studies regarding BIA equipment and cutoffs of PhA were observed. Although the studies have limitations, the PhA has a potential role in predicting clinical outcomes in critically ill children. Larger studies with standardized PhA protocols and other relevant clinical outcomes are necessary.

Enteral Protein Supplementation in Critically Ill Children: A Randomized Controlled Pilot and Feasibility Study.

BACKGROUND: Loss of muscle mass in critically ill children can negatively impact outcomes. The aims of this study were to conduct a pilot randomized control trial (RCT) to examine the difference in protein delivery and nitrogen balance in critically ill children with enteral protein supplementation vs controls. We also aimed to assess the feasibility, safety, and tolerance of the pilot trial. METHODS: This is a 3-arm RCT in critically ill children eligible for enteral nutrition (EN) therapy. Patients were randomized to 1 of the 3 groups: (1) control (routine EN), (2) polymeric protein module added to EN to reach protein goal by day 4, or (3) oligomeric protein supplementation. Demographics, clinical characteristics, nutrition status, and daily nutrition intake variables were recorded. Protein delivery, nitrogen balance, feasibility variables, and rate of adverse events were the outcomes. RESULTS: After screening 286 consecutive patients admitted to the pediatric intensive care unit over 11 months, we enrolled and randomized 25 patients. Twenty-two patients (88% of the enrolled) completed the study procedures. Significantly higher protein prescription and actual protein intake within the first 5 days was achieved in the intervention groups, compared with the control group. Nitrogen balance was obtained in 15 patients. There was no significant difference between the groups for the rate of adverse effects and clinical outcomes. CONCLUSION: In our pilot trial, protein supplementation was safe and well tolerated. Our preliminary results suggest that a larger RCT is potentially feasible, with some modifications of the entry criteria. Trial enrollment was low, likely due to restrictive entry criteria.

Feasibility of Enteral Protein Supplementation in Critically Ill Children.

BACKGROUND: We describe the protein type and concentration in standard enteral nutrition (EN) formulas and the effect of protein supplementation on the osmolality of standard formulas. We also aimed to examine factors associated with optimal protein delivery in critically ill children. METHODS: Protein content and other characteristics of pediatric EN formulas used worldwide were recorded. Factors associated with achievement of recommended protein delivery and tolerance of protein-supplemented formulas were recorded prospectively in a cohort of critically ill children. A range of protein supplement doses was added to 2 standard formulas and water, and the osmolality was recorded by cryoscopy in a bench experiment. RESULTS: We reviewed 125 formulas used in a multicenter study including sites from >13 countries. A majority of the EN formulas (73.6%) were polymeric, with a nonprotein calorie/nitrogen ratio of 182 ± 66 and protein content of 3.53 ± 2.00 g/100 mL. In the cohort of critically ill children, 28.5% achieved protein intake goal within 4 days, with no intolerance. In addition to optimal protein prescription (P < 0.001), protein supplementation (P = 0.018) and early EN initiation (P = 0.006) were associated with significantly higher odds of achieving goal protein intake. Formulas supplemented with up to 8 g/100 mL polymeric protein had osmolality <450 mOsm/kg. CONCLUSIONS: The protein content of current pediatric formulas may be inadequate to meet the needs of critically ill children. Protein supplementation of formulas allows early achievement of goal and is likely to be safe.).

Impact of the structure and dose of protein intake on clinical and metabolic outcomes in critically ill children: A systematic review.

OBJECTIVE: The aim of this study was to describe the effects of structure/type and total amount of protein intake on protein balance and clinical outcomes in critically ill children. METHODS: We conducted a systematic review of relevant literature on Embase, PubMed/Medline, Web of Science, Scopus, and Latin American and Caribbean Health Sciences. A partial gray literature search was undertaken and the reference lists of the selected articles were searched manually. Observational and clinical trials that evaluated the total protein intake, structure of the protein source, or both, in critically ill children were included. Nitrogen balance and clinical outcomes (mortality, length of stay, and duration of mechanical ventilation) were the main outcomes of interest. RESULTS: We found 18 eligible studies, of which 17 assessed the quantity and one described protein structure in relation to the outcomes. In all, 2118 pediatric critically ill patients <18 y of age were included. The total daily protein intake ranged from 0.67 to 4.7 g/kg. Average daily total protein intake >1.1 g/kg, especially >1.5 g/kg, was associated with positive protein balance and lower mortality. CONCLUSION: In critically ill children, total daily protein intake >1.1 g/kg was associated with positive effects on clinical outcomes and protein balance. The existing data are not sufficient for determining the optimal structure of protein delivered by enteral route in critically ill children.

Problems With Optimal Energy and Protein Delivery in the Pediatric Intensive Care Unit.

BACKGROUND: Optimal nutrition therapy (NT) delivery is associated with improved outcomes in critically ill children. However, avoidable barriers impede delivery of optimal energy and protein in the pediatric intensive care unit (PICU). This study aims to describe the gap between energy and protein prescription and actual intake. METHODS: Single-center prospective cohort study, including consecutive children (age: 1 month to 15 years) admitted to the PICU in southern Brazil. Demographics, clinical characteristics, and NT details were recorded. RESULTS: We enrolled 130 patients: 37% female; median (interquartile range) age, 29.43 months (4.03, 100.63); PICU length of stay, 6 days (4, 13). Median predicted energy expenditure by Schofield equation and prescribed and actual energy intake were 47.13 kcal/kg/d (38.60, 55.38), 31.94 kcal/kg/d (13.99, 51.90), and 25.06 kcal/kg/d (10.21, 46.92), respectively. On average, actual energy intake was 47% of the predicted energy expenditure, and 68% of patients were underfed. Actual protein intake was 49% of the estimated requirement. NT was interrupted in 64% of patients. CONCLUSIONS: There were significant gaps among the predicted requirement, prescription, and actual delivery of energy and protein in the PICU. Suboptimal prescription and multiple feeding interruptions resulted in underfeeding.