The American journal of clinical nutrition | 2021
Time to achieve delivery of nutrition targets is associated with clinical outcomes in critically ill children.
Abstract
BACKGROUND\nOptimal nutrition in critically ill children involves a complex interplay between the doses, route, and timing of macronutrient delivery.\n\n\nOBJECTIVES\nWe aimed to examine the association between the time to achieve delivery of 60% of the prescribed energy and protein targets and clinical outcomes in mechanically ventilated children.\n\n\nMETHODS\nWe conducted a prospective, observational cohort study of mechanically ventilated children admitted to pediatric intensive care units (PICUs) worldwide. Daily energy and protein delivery were recorded for up to 10 d in the PICU. We calculated adequacy as the percentage of the prescribed energy or protein goal delivered by enteral nutrition (EN), parenteral nutrition (PN), and total nutrition (EN\xa0+\xa0PN). Based on the days required to reach 60% energy or protein adequacy after PICU admission, we categorized patients into 3 groups: early (≤3 d), pragmatic (4 to 7 d), and late (more than 7 d). The primary outcome was 60-d all-cause mortality; secondary outcomes were the incidence of acquired infections and 28-d ventilator-free days (VFDs).\n\n\nRESULTS\nFrom 77 participating PICUs, 1844 patients, with a median age of 1.64 y (IQR, 0.47-7.05), were included; the 60-d mortality rate was 5.3% (n\xa0=\xa097). The average adequacies of delivery via EN\xa0+\xa0PN was 49% (IQR, 26-70) for energy and 66% (IQR, 44-89) for protein. In multivariable models adjusted for confounders, mortality was significantly lower in patients who achieved targets within 7 d, for energy (adjusted HR, 0.48; 95% CI: 0.28-0.82; P\xa0=\xa00.007) or protein (adjusted HR, 0.55; 95% CI: 0.33-0.94; P\xa0=\xa00.027) delivery. There were no clinically significant differences in infections or VFDs between groups.\n\n\nCONCLUSIONS\nAchieving 60% of energy or protein delivery targets within the first 7 d after PICU admission is associated with lower 60-d mortality in mechanically ventilated children, and is not associated with a greater incidence of infections or a reduction in VFDs compared to later achievement of targets. This trial was registered at clinicaltrials.gov as NCT03223038.