Concise Critical Appraisal: Use of Early Versus Late Enteral Nutrition in Critically Ill Children

Early enteral nutrition has been shown to lead to improved clinical outcomes in critically ill adults. While improved clinical outcomes have been shown in some studies involving critically ill children, there is a paucity of definitive literature for this group (Doig et al. Intensive Care Med. 2009;35:2018-2027). The literature that is available in critically ill children is mixed as to the clinical importance of early enteral feeds (Mikhailov et al. JPEN J Parenter Enteral Nutr. 2018;42:920-925; Haney et al. Clin Nutr ESPEN. 2018;26:42-46; Prakash et al. Intensive Care Med. 2016;42:481-482).
 
Srinivasan et al (Pediatr Crit Care Med. 2020;21:213-221) sought to determine the beneficial effects of early enteral nutrition (less than 48 hours) compared to no early enteral nutrition (enteral nutrition at greater than 48 hours or no enteral nutrition at all during the time of study enrollment) in a secondary analysis of data from the Heart and Lung Failure-Pediatric Insulin Titration (HALF-PINT) study. The HALF-PINT study was a randomized controlled trial of tight glycemic control in critically ill children. The primary outcome measure was 90-day hospital mortality. Secondary measures included 28-day mortality, ICU-free days, ventilator-free days, hospital-free days, and organ dysfunction, as measured by the peak daily Pediatric Logistic Organ Dysfunction (PELOD) score.
 
Of the 698 patients enrolled in the HALF-PINT study, 608 were eligible for this secondary analysis, with 331 receiving early enteral nutrition (EN) and 277 receiving no early EN. The 2 groups were somewhat dissimilar in that the EN group had fewer subjects with immunodeficiencies, used less intropic support, and had lower Pediatric Risk of Mortality (PRISM) and PELOD scores than the no-EN group.
 
The authors found that, after controlling for a number of items including severity of illness and mean vasopressor-inotrope score, the EN group’s 90-day mortality rate was significantly lower than that of the no-EN group (8% vs. 17%). The EN group had more ICU-free days, hospital-free days, and ventilator-free days and less organ dysfunction. The authors also compared the EN group to those patients who received late EN (ie, excluding patients in the no-EN group) and found that these secondary outcomes persisted.
 
Both groups had similar average daily total caloric intake, but the total daily protein intake was lower in the EN group. This finding reflects the importance of enteral protein intake compared to receiving protein parenterally, a finding consistent with an earlier study demonstrating the hazards of parenteral nutrition in critically ill pediatric patients (Fivez et al. N Engl J Med. 2016; 374:1111-1121). Finally, Srinivasan et al noted that the mean vasopressor-inotrope score was lower in the EN group than in the no-EN group, which suggests that clinicians are reluctant to enterally feed patients who are receiving inotropes for hemodynamic instability despite evidence for its safety (Panchal et al. JPEN J Parenter Enteral Nutr. 2016; 40:236-241).
 
While this study has some deficiencies, such as differences in types of illness between the groups and the absence of prerandomized subject nutritional information, this secondary analysis of the HALF-PINT study affirmed an important finding. Srinivasan et al demonstrated that early EN, across a variety of pediatric critical illnesses and a number of pediatric ICUs across the country, provided a significant benefit compared to late or no EN. This study’s findings should be strongly considered, and early EN should be implemented in critically ill children whenever possible.
 
Author of this installment of Concise Critical Appraisal:
 
Daniel E. Sloniewsky, MD, FCCM, is an associate professor in the Division of Pediatric Critical Care Medicine in the Department of Pediatrics at Stony Brook Long Island Children’s Hospital. Dr. Sloniewsky is an editor of Concise Critical Appraisal.