Relationship Between Adequacy of Caloric Support and Outcomes in Pediatric TBI

Traumatic brain injury (TBI) remains a leading cause of death and disability in children younger than age 18 years. Management of TBI primarily relies on treatment of secondary injuries such as increased intracranial pressure (ICP). Children with TBI have been shown to be in a catabolic state of nutrition, suggesting increased caloric needs. Data demonstrating the benefit of early and increased caloric adequacy is lacking, but in 2016 a joint statement of the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition recommended early and adequate nutrition to maintain lean body mass during any pediatric critical illnesses.¹ This recommendation was supported by a 2018 trial that found decreased mortality and a trend toward improved outcomes in children with TBI and early (less than 72 hours post-injury) initiation of nutrition.² In 2019, the Brain Trauma Foundation guidelines recommended early initiation of enteral nutrition in children with TBI.³

In 2025, Elliott et al sought to determine a positive association between the adequacy of caloric support and functional outcomes.⁴ In this retrospective cohort, the authors used a local trauma registry to study pediatric patients aged 18 years and younger with severe TBI, defined as having a Glasgow Coma Scale score of 8 or lower and/or undergoing placement of an ICP monitor or decompressive craniectomy between 2010 and 2022. Analyses were limited to patients who were intubated for greater than 48 hours and had a PICU length of stay (LOS) of at least 7 days. This was a single-center study, and TBI management was based on local institutional protocols with goals of ICP less than 20 mm Hg.

Per hospital protocol, patients were screened by a dietitian within two days after admission with a goal of initiating nutrition (preferably enteral over parenteral) to achieve specific caloric and protein load goals. The Schofield equation was used to determine caloric goals in patients over 12 months; goals for children younger than age 12 months was 75% of daily recommended intake. Adequacy of caloric support was defined as the proportion of prescribed calories delivered to a patient over the first seven days of admission with a goal of 60%. Patients were divided into groups based on adequacy of caloric support: low (0-33.3%), moderate (33.4-66.7%), and high (66.8%-100%).

The Functional Status Scale (FSS) and Glasgow Outcome Scale Extended for Pediatrics (GOS-E Peds) scores were used to assess the patients at the time of hospital discharge and six weeks to six months after discharge (the latter being used for patients with multiple outpatient appointments). FSS scores were divided into good (FSS 6-7) and abnormal (FSS ≥ 8) while GOS-E Peds scores were dichotomized into favorable (1-4) and unfavorable (5-8).

Demographics and clinical characteristics—including Pediatric Risk of Mortality (PRISM) III scores, Injury Severity Scores, the need for surgical intervention, PICU LOS, ventilator days, and hospital LOS—were described using medians and interquartile ranges for continuous variables or percentages for categorical variables. The authors then sought to determine the relationship between adequacy of caloric support and clinical outcomes by using regression analyses with the outcomes serving as response variables and adequacy of caloric support as a continuous variable.

Overall, 93 patients were included in the final analyses. After seven days, the median caloric adequacy for all the patients was 42% (IQR 28%-62%). Most of the patients in the cohort did not meet the target of 60% caloric adequacy by day 7. However, at the time of discharge, the authors found no association between FSS or GOS-E Peds score and caloric adequacy. A total of 59 patients were included in the six-month follow-up analysis (median time 4.7 months after discharge). Unlike with the earlier data, the authors unexpectedly found a positive association between FSS and GOS-E Peds score in patients with better adequacy of caloric support. Specifically, the odds of having a higher follow-up FSS (i.e., a worse prognosis) increased by 10% with a 10% increase in caloric delivery. A caloric delivery increase by 10% was associated with a 16% increase in the odds of having a worse GOS-E Peds score.

Although most patients in this study had enteral feeds initiated by 72 hours, only 27% were able to meet the target of 60% of calorie goal by day 7. Curiously, there was no association between caloric adequacy and discharge outcomes and a negative association between caloric adequacy and functional outcomes six months after discharge. The authors explain that malnutrition and hypermetabolism after acute stresses such as TBI may be related to inherent metabolic derangements that cannot be rectified by providing more calories and macronutrients. They further state that, given the study limitations, including the absence of indirect calorimetry to measure caloric adequacy and the loss of patients between discharge and six months, this article should serve primarily to generate further hypotheses and studies.


References
1.     McClave SA, Taylor BE, Martindale RG, et al; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211.
2.    Meinert E, Bell MJ, Buttram S, et al; Pediatric Traumatic Brain Injury Consortium: Hypothermia Investigators. Initiating nutritional support before 72 hours is associated with favorable outcome after severe traumatic brain injury in children: a secondary analysis of a randomized, controlled trial of therapeutic hypothermia. Pediatr Crit Care Med. 2018 Apr;19(4):345-352.
3.    Kochanek PM, Tasker RC, Carney N, et al. Guidelines for the management of pediatric severe traumatic brain injury, third edition: update of the Brain Trauma Foundation guidelines, executive summary. Neurosurgery. 2019 Jun 1;84(6):1169-1178.
4.    Elliott EC, Trujillo-Rivera EA, Dughly O, et al. Quantity of caloric support after pediatric severe traumatic brain injury: description of associated outcomes in a single retrospective center cohort, 2010-2022. Pediatr Crit Care Med. 2025 Jan 1;26(1):e12-e22.