Malnutrition and Nutrition Support in Latin American PICUs: The Nutrition in PICU (NutriPIC) Study.

OBJECTIVES: To characterize the nutritional status of children admitted to Latin American (LA) PICUs and to describe the adequacy of nutrition support in reference to contemporary international recommendations. DESIGN: The Nutrition in PICU (NutriPIC) study was a combined point-prevalence study of malnutrition carried out on 1 day in 2021 (Monday 8 November) and a retrospective cohort study of adequacy of nutritional support in the week preceding. SETTING: Four-one PICUs in 13 LA countries. PATIENTS: Patients already admitted to the PICU of 1 month to 18 years old on the study day were included in the point-prevalence study. For the retrospective arm, we included patients receiving nutritional support on the study day and with a PICU length of stay (LOS) greater than or equal to 72 hours. Exclusion criteria were being a neonate, conditions that precluded accurate anthropometric measurements, and PICU LOS greater than 14 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 316 patients screened, 5 did not meet age criteria. There were 191 of 311 patients who were included in the point-prevalence study and underwent anthropometric evaluation. Underweight and length for age less than -2 z scores were present in 42 of 88 children (47.7%) and 41 of 88 children (46.6%) less than 24 months old, and 14 of 103 (13.6%) and (23/103) 22.3% of 103 children greater than or equal to 24 months, respectively. Evidence of obesity (body mass index > 2 z score) was present in 7 of 88 children (5.7%) less than 24 months old and 13 of 103 children (12.6%) greater than or equal to 24 months. In the 115 of 311 patients meeting criteria for the retrospective arm, a total of 98 patients reported complete nutritional data. The 7-day median (interquartile range) adequacy for delivered versus recommended enteral energy and protein requirement was 114% (75, 154) and 99% (60, 133), respectively. CONCLUSIONS: The NutriPIC study found that in 2021 malnutrition was highly prevalent especially in PICU admissions of less than 24 months old. Retrospectively, the 7-day median nutritional support appears to meet both energy and protein requirements.

Bioelectrical Impedance Phase Angle and Morbidity and Mortality in Critically Ill Children.

BACKGROUND: Nutrition markers may be useful for diagnosis and monitoring and, also, as additional indicators of estimating death risk. We tested the association of body composition indicators (mid-upper arm circumference and phase angle) with pediatric intensive care unit (PICU) length of stay and mortality in critically ill pediatric patients. METHODS: Data from children aged 2 months-18 years were collected, and bioelectrical impedance was performed to obtain phase angle. Severity was evaluated by scoring the Pediatric Index of Mortality. Descriptive statistics were reported for nominal variables. Receiver operating characteristic curve was used to analyze the association of phase angle with 30-day mortality and to find the best cutoff. Survival probabilities and PICU length of stay were estimated using the Kaplan-Meier method. RESULTS: We evaluated 247 children with a median age of 4.8 years whose main cause of admission was sepsis. Survival curves showed higher survival in patients with phase angle >2.8° compared with patients with phase angle ≤2.8° (P < .0001). Kaplan-Meier time-to-event analysis showed that children with lower phase angle values were more likely to remain in the PICU (hazard ratio, 1.84; P = .003). Lower survival was also observed in patients who presented mid-upper arm circumference values ≤5th percentile (P < .03). CONCLUSIONS: Mid-upper arm circumference and phase angle were associated with mortality and morbidity in critically ill children, suggesting that these parameters may be useful not only for nutrition diagnosis and monitoring, but also as an additional indicator in estimating prognosis.

The Latin American and Spanish Survey on Nutrition in Pediatric Intensive Care (ELAN-CIP2).

OBJECTIVE: To characterize the practices of nutritional support in Latin American and Spanish PICUs. DESIGN: Survey with a questionnaire sent to Latin American Society of Pediatric Intensive Care members. SETTING: PICUs of participant hospitals. PATIENTS: Critically ill children between 1 month and 18 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Forty-seven surveys from 17 countries were analyzed. Sixty-seven percent of PICUs were from university-affiliated hospitals, with a median of 380 admissions/yr. Sixty-eight percent and 48.9% had a nutritional support team and nutritional support protocol, respectively. Seventy-five percent completed nutritional evaluations, with 34.2% at admission. PICUs with high-volume admissions were likely to have a nutritional support team (p < 0.005), and university-affiliated hospitals showed a trend of having a nutritional support team (p = 0.056). Measured, estimated, and ideal weights were used in 75%, 14.6%, and 10.4%, respectively. Energy requirements were calculated using Holliday & Segar and Schofield equations in 90% of the PICUs; 43% used correction factors. Only three PICUs had indirect calorimetry. At day 3 of initiation of nutritional support, 57.3% of PICUs provided at least 50% of the calculated energy requirement, and 91.5% at day 5. Protein needs were estimated according to American Society for Parenteral and Enteral Nutrition and European Society for Clinical Nutrition and Metabolism/European Society for Paediatric Gastroenterology Hepatology and Nutrition guidelines in 55.3% and 40.4%, respectively. Enteral nutrition was the preferred feeding method, initiated in 97.7% at 48 hours. The feeding route was gastric (82.9%), by bolus (42.5%) or continuous (57.4%). Monitoring methods included gastric residual measurement in 55.3%. Enteral nutrition was discontinued in 82.8% when gastric residual was 50% of the volume. Prokinetics were used in 68%. More than half of PICUs used parenteral nutrition, with 95.8% of them within 72 hours. Parenteral nutrition was administered by central vein in 93.6%. Undernourished children received parenteral nutrition sooner, whether or not enteral nutrition intolerance was present. When enteral nutrition was not tolerated beyond 72 hours, parenteral nutrition was started in 57.4%. Parenteral nutrition was initiated when enteral nutrition delivered less than 50% in 97%. CONCLUSIONS: Nutritional practices are heterogeneous in Latin American PICUs, but the majority use nutritional support strategies consistent with international guidelines.

Lipid profiles of children and adolescents with inflammatory response in a paediatric emergency department.

BACKGROUND: To compare the lipid profile between patients with and without inflammatory process in according nutritional status, gender and age. METHODS: One hundred and twenty-four children and adolescents in the emergency department were separated into two groups according to the levels of C-reactive protein (CRP). Total cholesterol, high-density lipoprotein (HDL) and low-density lipoprotein (LDL), triglycerides (TG) and albumin in patients with CRP < 5 mg/L were compared with patients with CRP ≥ 5 mg/L. Nutritional status was assessed by anthropometric measurements. RESULTS: Patients were mostly classified as well-nourished (76.5%) and had low levels of HDL (70%). There was no significant difference in lipid profile between the two groups of CRP. Linear regression analysis, however, it became clear that for each increase of 1 mg/L in the values of CRP expected an average reduction of 0.072 mg/dL of HDL, the 0.083 mg/dL of LDL, the 0.002 g/dL albumin and an average increase of 0.564 mg/dL of TG. CONCLUSIONS: Patients with an inflammatory process exhibit changes in the serum levels of the lipids HDL, LDL and TG that are related to the degree of inflammation. These changes occurred regardless of nutritional status. Key Messages Lipoproteins are structures composed of lipids and proteins that transport fats in the circulation: HDL, LDL, IDL, VLDL and chylomicrons. Lipoproteins, especially HDL, undergo changes during the systemic inflammatory response and play an important role as a modulator of the inflammatory response. We believe this is a first study to show that inflammatory process modifies the serum levels of the lipoproteins and triglycerides independent of nutritional status, in paediatric patients.