Continuous Versus Bolus Gastric Feeding in Children Receiving Mechanical Ventilation: A Systematic Review.

BACKGROUND: Nutrition guidelines recommend enteral nutrition in the form of gastric feedings for critically ill children and acknowledge a lack of evidence describing an optimal method for providing these feedings. OBJECTIVE: To determine the state of the science regarding the efficacy of bolus (intermittent) or continuous gastric feedings to improve nutrition delivery in critically ill children receiving mechanical ventilation. METHODS: Five hundred seventy-nine abstracts met the inclusion criteria and were screened by 2 reviewers according to prespecified criteria. Full-text reviews were performed on 28 articles; 11 studies were selected for detailed analysis. Because of the small number of eligible studies, broader searches were conducted. RESULTS: Only 5 studies with a collective enrollment of fewer than 200 children closely addressed the specific research question. These 5 studies did not report any similarity in feeding regimens, nor did they report nutritional outcomes. Two of the articles described findings from the same study population. Although 4 of the 5 studies randomized children to bolus versus continuous feedings, only 3 studies described attainment of nutrient delivery goals in both the intervention and the control groups; the remaining study did not report this outcome. The heterogeneity in methodology and outcomes among the 5 studies did not allow for a meta-analysis. CONCLUSIONS: The dearth of evidence regarding best practices and outcomes related to bolus versus continuous gastric feedings in critically ill children receiving mechanical ventilation requires additional rigorous investigation.

Co-ingestion of methanol and nitromethane: using falsely elevated creatinine as indicator for methanol antidote use.

OBJECTIVE: To report a case of co-ingestion of methanol and nitromethane in a child in order to heighten the awareness of false elevation of serum creatinine from nitromethane ingestion. DESIGN: Case report. SETTING: Pediatric intensive care unit. PATIENT: A 4-yr-old previously healthy girl ingested an unknown quantity of "Blue Thunder" model-engine fuel, which consisted of methanol and nitromethane. The patient was treated with fomepizole for methanol ingestion using elevated creatinine level as a reason for treatment. RESULTS: The patient was asymptomatic but her creatinine level increased ten-fold (from 0.4 mg/dL to 4 mg/dL) within 6 hrs. Blood urea nitrogen, anion gap, and osmolar gap remained within normal limits. When the serum creatinine level was measured with enzymatic method instead of Jaffe's method, a normal creatinine level was obtained. The falsely elevated creatinine level was due to nitromethane. CONCLUSION: The falsely elevated serum creatinine levels due to nitromethane ingestion can lead to unnecessary therapeutic interventions. We intend to heighten awareness of this potential misstep by reporting this case.