Nutrition association with skin integrity and pressure injury in critically ill pediatric patients.

BACKGROUND: Current research highlights the positive impact of nutrition therapy, particularly enteral nutrition, in critical illness. However, little attention is given to the impact of nutrition on skin integrity during critical illness. Skin integrity is at risk in critically ill children owing to necessary clinical therapies and challenges of providing nutrition therapy. METHODS: We conducted a narrative literature review with three main thematic concepts to drive our literature search: the association of nutrition therapy with (1) skin integrity; (2) injury, wounds, and wound healing; and (3) differences of skin color. Using pertinent search and subject terms, PubMed, CINAHL, EMBASE, and SCOPUS databases were searched, yielding 316 articles. After removal of duplicates, articles were reviewed based on inclusion and exclusion criteria defined by the authors; only eight articles met the defined criteria to inform this review. RESULTS: Large and important gaps exist in the current literature regarding an association between nutrition therapy, skin injury, and wound healing. Little to no attention was found for associations with skin color. The resulting narrative review addresses these topics and subtopics with additional references included that are independent of the original search strategy. CONCLUSIONS: A dearth of evidence exists describing associations between nutrition and disruption of skin integrity in pediatric critical illness. Children with dark skin are at increased risk, as manifestation and identification of disruption to skin integrity may not be recognized. Research is needed to describe these associations and the impact of nutrition on skin integrity, including differences of skin color.

A scoping review to inform a multi-disciplinary approach for nutrition therapy in critically ill children with pressure injuries.

Nutrition status plays a critical role in pressure injury (PI) healing and yet the available literature, especially in pediatric patients, is limited. Critically ill pediatric patients are at an increased risk of skin integrity compromise and PI development. Adequate nutritional intake can often be challenging to achieve in this population and immobility and illness present additional obstacles to maintaining skin integrity in this vulnerable population. Despite the unique nutritional challenges and needs of this group, there is no standardized approach to macro- and micronutrient management and monitoring. Here, several key vitamins and minerals believed to play a role in PI healing are discussed and an approach to nutritional management and monitoring for PI healing in pediatric patients is proposed. Registered dietitians (RD) are essential to assess individual patient macro and micronutrient requirements, to identify gaps and make recommendations to optimize nutritional therapy that may exist and impact wound healing. We used a scoping review to focus on the interplay of nutrition and PI healing and inform a multidisciplinary approach to PI identification and management. Through this review, we propose a strategy for the nutritional management of pediatric patients <30 kg at risk for and who present with PI.

Enteral feeding and caloric intake in neonates after cardiac surgery.

BACKGROUND: Adequate enteral nutrition may be difficult to achieve early in neonates after cardiac surgery, but it is essential for growth, wound healing, and immune function. OBJECTIVE: To assess caloric intake in neonates receiving enteral nutrition after surgery. METHODS: A retrospective chart review was conducted of daily enteral caloric intake in the cardiac intensive care unit of a tertiary children's hospital. Data on the institution of enteral feeding and the discontinuation of parenteral nutrition were assessed for full-term neonates who had undergone cardiac surgery. RESULTS: Caloric intake was assessed in 100 patients, 52 with biventricular cardiac defects and 48 with a functional single ventricle. The median duration of stay in the cardiac intensive care unit was 13 days (range, 4-69), and patients received enteral feeding exclusively for a median of 5 days (range, 1-43). In total, 705 patient days were evaluated. The median caloric intake per day was 93 kcal/kg (range, 43-142). A goal of 100 kcal/kg was achieved for 48.4% of patient days and 120 kcal/kg for only 19.7% of patient days. Median weight change for the period of enteral feeding was -20 g (range, -775 to 1485 g). CONCLUSIONS: Enteral feeding alone is often suboptimal after neonatal cardiac surgery. New strategies to improve caloric intake may enhance postoperative recovery.

Too fat or too thin? Body habitus assessment in children listed for heart transplant and impact on outcome.

BACKGROUND: Body habitus assessment (BHA), be it wasted or obese, is a useful marker of nutritional status and overall medical condition. Wasting and obesity pre-heart transplant adversely affects outcomes in adults. The utility of BHA as a prognostic factor in children post-transplant is unknown. METHODS: Weight and height at listing and standard growth charts were used to determine the ideal body weight (%IBW) and percentiles for body mass index for age (BMI%) and weight-for-length (W:L%). Wasting was defined as <90%IBW and/or 120%IBW and/or >or=95th percentile BMI% or W:L%. Outcomes of cohorts based on these criteria were compared. RESULTS: From June 1990 to December 2006, 180 children, aged 5.81 +/- 6 years, were listed for transplant. Wasting occurred in 66 (37%) and obesity in 22 (12%) children, without differences between diagnoses of cardiomyopathy or congenital heart disease. %IBW was a prognostic factor for survival post-transplant on multivariate analysis: obese patients had a hazard ratio (HR) of 3.82 (95% confidence interval [CI] 1.81 to 8.06) compared with normal BHA (p < 0.001). Wasting had a survival advantage compared with normal BHA (HR 0.51, 95% CI 0.27 to 0.94, p = 0.032). There were no significant differences between cohorts in incidence of infections, first-year rejections or graft vasculopathy. CONCLUSIONS: Abnormal BHA at listing was a prognostic factor for survival post-transplant. Obese children had increased mortality, but wasting did not adversely affect post-transplant survival in our population. Body habitus assessment may risk-stratify children at listing, potentially providing a complex target for intervention.