Nutrition support in pediatric intensive care is an integral part of a complex approach to treating critically ill children. Smaller energy reserves with higher metabolic demands (a higher basal metabolism rate) compared to adults makes children more vulnerable to starvation. The nutrition supportive therapy should be initiated immediately after intensive care admission and initial vital sign stabilization. In absence of contraindications (unresolving/decompensated shock, gut ischemia, critical gut stenosis, etc.), the preferred type of enteral nutrition is oral or via a gastric tube. In the acute phase of critical illness, due to gluconeogenesis and muscle breakdown with proteolysis, the need for high protein delivery should be emphasized. After patient condition stabilization, the acute phase with predominant catabolism converts to the anabolic phase and intensive rehabilitation, where high energy demands are the keystone of a positive outcome.

Department of Anaesthesiology and Intensive Care Medicine The Donaustadt Clinic Republic Lango Bardenstraße 122 1220 Vienna Austria

Department of Anaesthesiology and Intensive Care Medicine University Hospital Martin and Jessenius Medical Faculty in Martin Comenius University Bratislava Malá Hora 4a 03601 Martin Slovakia

Department of Paediatric Anaesthesiology and Intensive Care Medicine University Hospital Brno and Faculty of Medicine Masaryk University Kamenice 5 625 00 Brno Czech Republic

Department of Simulation Medicine Faculty of Medicine Masaryk University Kamenice 5 625 00 Brno Czech Republic

Paediatric Intensive Care Unit NH Hospital Inc 268 01 Horovice Czech Republic

Zobrazit více v PubMed

Tume L.N., Valla F.V., Joosten K., Jotterand Chaparro C., Latten L., Marino L.V., Macleod I., Moullet C., Pathan N., Rooze S., et al. Nutritional Support for Children during Critical Illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) Metabolism, Endocrine and Nutrition Section Position Statement and Clinical Recommendations. Intensive Care Med. 2020;46:411–425. doi: 10.1007/s00134-019-05922-5. PubMed DOI PMC

Joosten K.F.M., Kerklaan D., Verbruggen S.C.A.T. Nutritional Support and the Role of the Stress Response in Critically Ill Children. Curr. Opin. Clin. Nutr. Metab. Care. 2016;19:226–233. doi: 10.1097/MCO.0000000000000268. PubMed DOI

Joosten K.F.M., Eveleens R.D., Verbruggen S.C.A.T. Nutritional Support in the Recovery Phase of Critically Ill Children. Curr. Opin. Clin. Nutr. Metab. Care. 2019;22:152–158. doi: 10.1097/MCO.0000000000000549. PubMed DOI

Singer P., Blaser A.R., Berger M.M., Alhazzani W., Calder P.C., Casaer M.P., Hiesmayr M., Mayer K., Montejo J.C., Pichard C., et al. ESPEN Guideline on Clinical Nutrition in the Intensive Care Unit. Clin. Nutr. 2019;38:48–79. doi: 10.1016/j.clnu.2018.08.037. PubMed DOI

Van Puffelen E., Hulst J.M., Vanhorebeek I., Dulfer K., Van den Berghe G., Verbruggen S.C.A.T., Joosten K.F.M. Outcomes of Delaying Parenteral Nutrition for 1 Week vs. Initiation Within 24 Hours Among Undernourished Children in Pediatric Intensive Care: A Subanalysis of the PEPaNIC Randomized Clinical Trial. JAMA Netw. Open. 2018;1:e182668. doi: 10.1001/jamanetworkopen.2018.2668. PubMed DOI PMC

Prince N.J., Brown K.L., Mebrahtu T.F., Parslow R.C., Peters M.J. Weight-for-Age Distribution and Case-Mix Adjusted Outcomes of 14,307 Paediatric Intensive Care Admissions. Intensive Care Med. 2014;40:1132–1139. doi: 10.1007/s00134-014-3381-x. PubMed DOI PMC

Van Puffelen E., Hulst J.M., Vanhorebeek I., Dulfer K., Van den Berghe G., Joosten K.F.M., Verbruggen S.C.A.T. Effect of Late versus Early Initiation of Parenteral Nutrition on Weight Deterioration during PICU Stay: Secondary Analysis of the PEPaNIC Randomised Controlled Trial. Clin. Nutr. 2020;39:104–109. doi: 10.1016/j.clnu.2019.02.014. PubMed DOI

Mihatsch W., Fewtrell M., Goulet O., Molgaard C., Picaud J.-C., Senterre T., Braegger C., Bronsky J., Cai W., Campoy C., et al. ESPGHAN/ESPEN/ESPR/CSPEN Guidelines on Pediatric Parenteral Nutrition: Calcium, Phosphorus and Magnesium. Clin. Nutr. 2018;37:2360–2365. doi: 10.1016/j.clnu.2018.06.950. PubMed DOI

McClave S.A., Taylor B.E., Martindale R.G., Warren M.M., Johnson D.R., Braunschweig C., McCarthy M.S., Davanos E., Rice T.W., Cresci G.A., et al. 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.) J. Parenter. Enter. Nutr. 2016;40:159–211. doi: 10.1177/0148607115621863. PubMed DOI

Bechard L.J., Duggan C., Touger-Decker R., Parrott J.S., Rothpletz-Puglia P., Byham-Gray L., Heyland D., Mehta N.M. Nutritional Status Based on Body Mass Index Is Associated with Morbidity and Mortality in Mechanically Ventilated Critically Ill Children in the PICU. Crit. Care Med. 2016;44:1530–1537. doi: 10.1097/CCM.0000000000001713. PubMed DOI PMC

Mehta N.M., Bechard L.J., Cahill N., Wang M., Day A., Duggan C.P., Heyland D.K. Nutritional Practices and Their Relationship to Clinical Outcomes in Critically Ill Children—An International Multicenter Cohort Study. Crit. Care Med. 2012;40:2204–2211. doi: 10.1097/CCM.0b013e31824e18a8. PubMed DOI PMC

Mehta N.M., Bechard L.J., Zurakowski D., Duggan C.P., Heyland D.K. Adequate Enteral Protein Intake Is Inversely Associated with 60-d Mortality in Critically Ill Children: A Multicenter, Prospective, Cohort Study. Am. J. Clin. Nutr. 2015;102:199–206. doi: 10.3945/ajcn.114.104893. PubMed DOI PMC

Ross P.A., Newth C.J.L., Leung D., Wetzel R.C., Khemani R.G. Obesity and Mortality Risk in Critically Ill Children. Pediatrics. 2016;137:e20152035. doi: 10.1542/peds.2015-2035. PubMed DOI

de Souza Menezes F., Leite H.P., Koch Nogueira P.C. Malnutrition as an Independent Predictor of Clinical Outcome in Critically Ill Children. Nutr. Burbank. 2012;28:267–270. doi: 10.1016/j.nut.2011.05.015. PubMed DOI

Delgado A.F., Okay T.S., Leone C., Nichols B., Del Negro G.M., Vaz F.A.C. Hospital Malnutrition and Inflammatory Response in Critically Ill Children and Adolescents Admitted to a Tertiary Intensive Care Unit. Clinics. 2008;63:357–362. doi: 10.1590/S1807-59322008000300012. PubMed DOI PMC

Briassoulis G., Zavras N., Hatzis T. Malnutrition, Nutritional Indices, and Early Enteral Feeding in Critically Ill Children. Nutrition. 2001;17:548–557. doi: 10.1016/S0899-9007(01)00578-0. PubMed DOI

Hulst J., Joosten K., Zimmermann L., Hop W., van Buuren S., Büller H., Tibboel D., van Goudoever J. Malnutrition in Critically Ill Children: From Admission to 6 Months after Discharge. Clin. Nutr. 2004;23:223–232. doi: 10.1016/S0261-5614(03)00130-4. PubMed DOI

Mehta N.M., Skillman H.E., Irving S.Y., Coss-Bu J.A., Vermilyea S., Farrington E.A., McKeever L., Hall A.M., Goday P.S., Braunschweig C. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Pediatr. Crit. Care Med. 2017;18:675–715. doi: 10.1097/PCC.0000000000001134. PubMed DOI

Heyland D.K., Dhaliwal R., Jiang X., Day A.G. Identifying Critically Ill Patients Who Benefit the Most from Nutrition Therapy: The Development and Initial Validation of a Novel Risk Assessment Tool. Crit. Care. 2011;15:R268. doi: 10.1186/cc10546. PubMed DOI PMC

Kondrup J., Rasmussen H.H., Hamberg O., Stanga Z., Ad Hoc ESPEN Working Group Nutritional Risk Screening (NRS 2002): A New Method Based on an Analysis of Controlled Clinical Trials. Clin. Nutr. 2003;22:321–336. doi: 10.1016/S0261-5614(02)00214-5. PubMed DOI

Sermet-Gaudelus I., Poisson-Salomon A.S., Colomb V., Brusset M.C., Mosser F., Berrier F., Ricour C. Simple Pediatric Nutritional Risk Score to Identify Children at Risk of Malnutrition. Am. J. Clin. Nutr. 2000;72:64–70. doi: 10.1093/ajcn/72.1.64. PubMed DOI

Gerasimidis K., Macleod I., Maclean A., Buchanan E., McGrogan P., Swinbank I., McAuley M., Wright C.M., Flynn D.M. Performance of the Novel Paediatric Yorkhill Malnutrition Score (PYMS) in Hospital Practice. Clin. Nutr. 2011;30:430–435. doi: 10.1016/j.clnu.2011.01.015. PubMed DOI

McCarthy H., Dixon M., Crabtree I., Eaton-Evans M.J., McNulty H. The Development and Evaluation of the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP©) for Use by Healthcare Staff. J. Hum. Nutr. Diet. Off. J. Br. Diet. Assoc. 2012;25:311–318. doi: 10.1111/j.1365-277X.2012.01234.x. PubMed DOI

White M., Lawson K., Ramsey R., Dennis N., Hutchinson Z., Soh X.Y., Matsuyama M., Doolan A., Todd A., Elliott A., et al. Simple Nutrition Screening Tool for Pediatric Inpatients. JPEN J. Parenter. Enteral Nutr. 2016;40:392–398. doi: 10.1177/0148607114544321. PubMed DOI

Chourdakis M., Hecht C., Gerasimidis K., Joosten K.F., Karagiozoglou-Lampoudi T., Koetse H.A., Ksiazyk J., Lazea C., Shamir R., Szajewska H., et al. Malnutrition Risk in Hospitalized Children: Use of 3 Screening Tools in a Large European Population. Am. J. Clin. Nutr. 2016;103:1301–1310. doi: 10.3945/ajcn.115.110700. PubMed DOI

Wischmeyer P.E., San-Millan I. Winning the War against ICU-Acquired Weakness: New Innovations in Nutrition and Exercise Physiology. Crit. Care. 2015;19((Suppl. 3)):S6. doi: 10.1186/cc14724. PubMed DOI PMC

Looijaard W.G.P.M., Dekker I.M., Stapel S.N., Girbes A.R.J., Twisk J.W.R., Oudemans-van Straaten H.M., Weijs P.J.M. Skeletal Muscle Quality as Assessed by CT-Derived Skeletal Muscle Density Is Associated with 6-Month Mortality in Mechanically Ventilated Critically Ill Patients. Crit. Care. 2016;20:386. doi: 10.1186/s13054-016-1563-3. PubMed DOI PMC

Thibault R., Makhlouf A.-M., Mulliez A., Cristina Gonzalez M., Kekstas G., Kozjek N.R., Preiser J.-C., Rozalen I.C., Dadet S., Krznaric Z., et al. Fat-Free Mass at Admission Predicts 28-Day Mortality in Intensive Care Unit Patients: The International Prospective Observational Study Phase Angle Project. Intensive Care Med. 2016;42:1445–1453. doi: 10.1007/s00134-016-4468-3. PubMed DOI

Reintam Blaser A., Starkopf J., Alhazzani W., Berger M.M., Casaer M.P., Deane A.M., Fruhwald S., Hiesmayr M., Ichai C., Jakob S.M., et al. Early Enteral Nutrition in Critically Ill Patients: ESICM Clinical Practice Guidelines. Intensive Care Med. 2017;43:380–398. doi: 10.1007/s00134-016-4665-0. PubMed DOI PMC

Kreymann K.G., Berger M.M., Deutz N.E.P., Hiesmayr M., Jolliet P., Kazandjiev G., Nitenberg G., van den Berghe G., Wernerman J., DGEM (German Society for Nutritional Medicine) et al. ESPEN Guidelines on Enteral Nutrition: Intensive Care. Clin. Nutr. 2006;25:210–223. doi: 10.1016/j.clnu.2006.01.021. PubMed DOI

Singer P., Berger M.M., Van den Berghe G., Biolo G., Calder P., Forbes A., Griffiths R., Kreyman G., Leverve X., Pichard C., et al. ESPEN Guidelines on Parenteral Nutrition: Intensive Care. Clin. Nutr. 2009;28:387–400. doi: 10.1016/j.clnu.2009.04.024. PubMed DOI

Kerklaan D., Augustus M.E., Hulst J.M., van Rosmalen J., Verbruggen S.C.A.T., Joosten K.F.M. Validation of Ventilator-Derived VCO2 Measurements to Determine Energy Expenditure in Ventilated Critically Ill Children. Clin. Nutr. 2017;36:452–457. doi: 10.1016/j.clnu.2016.01.001. PubMed DOI

van Goudoever J.B., Carnielli V., Darmaun D., Sainz de Pipaon M., Braegger C., Bronsky J., Cai W., Campoy C., Carnielli V., Darmaun D., et al. ESPGHAN/ESPEN/ESPR/CSPEN Guidelines on Pediatric Parenteral Nutrition: Amino Acids. Clin. Nutr. 2018;37:2315–2323. doi: 10.1016/j.clnu.2018.06.945. PubMed DOI

Fivez T., Kerklaan D., Mesotten D., Verbruggen S., Wouters P.J., Vanhorebeek I., Debaveye Y., Vlasselaers D., Desmet L., Casaer M.P., et al. Early versus Late Parenteral Nutrition in Critically Ill Children. N. Engl. J. Med. 2016;374:1111–1122. doi: 10.1056/NEJMoa1514762. PubMed DOI

van Puffelen E., Vanhorebeek I., Joosten K.F.M., Wouters P.J., Van den Berghe G., Verbruggen S.C.A.T. Early versus Late Parenteral Nutrition in Critically Ill, Term Neonates: A Preplanned Secondary Subgroup Analysis of the PEPaNIC Multicentre, Randomised Controlled Trial. Lancet Child Adolesc. Health. 2018;2:505–515. doi: 10.1016/S2352-4642(18)30131-7. PubMed DOI

Mesotten D., Joosten K., van Kempen A., Verbruggen S., Braegger C., Bronsky J., Cai W., Campoy C., Carnielli V., Darmaun D., et al. ESPGHAN/ESPEN/ESPR/CSPEN Guidelines on Pediatric Parenteral Nutrition: Carbohydrates. Clin. Nutr. 2018;37:2337–2343. doi: 10.1016/j.clnu.2018.06.947. PubMed DOI

NICE-SUGAR Study Investigators. Finfer S., Chittock D.R., Su S.Y.-S., Blair D., Foster D., Dhingra V., Bellomo R., Cook D., Dodek P., et al. Intensive versus Conventional Glucose Control in Critically Ill Patients. N. Engl. J. Med. 2009;360:1283–1297. doi: 10.1056/NEJMoa0810625. PubMed DOI

Lapillonne A., Fidler Mis N., Goulet O., van den Akker C.H.P., Wu J., Koletzko B., Braegger C., Bronsky J., Cai W., Campoy C., et al. ESPGHAN/ESPEN/ESPR/CSPEN Guidelines on Pediatric Parenteral Nutrition: Lipids. Clin. Nutr. 2018;37:2324–2336. doi: 10.1016/j.clnu.2018.06.946. PubMed DOI

Jochum F., Moltu S.J., Senterre T., Nomayo A., Goulet O., Iacobelli S., Braegger C., Bronsky J., Cai W., Campoy C., et al. ESPGHAN/ESPEN/ESPR/CSPEN Guidelines on Pediatric Parenteral Nutrition: Fluid and Electrolytes. Clin. Nutr. 2018;37:2344–2353. doi: 10.1016/j.clnu.2018.06.948. PubMed DOI

Chesney C.R. The Maintenance Need for Water in Parenteral Fluid Therapy, by Malcolm A. Holliday, MD, and William E. Segar, MD, Pediatrics, 1957;19:823-832. Pediatrics. 1998;102:229–230. PubMed

Mahmoodpoor A., Shadvar K., Sanaie S., Hadipoor M.R., Pourmoghaddam M.A., Saghaleini S.H. Effect of Vitamin C on Mortality of Critically Ill Patients with Severe Pneumonia in Intensive Care Unit: A Preliminary Study. BMC Infect. Dis. 2021;21:616. doi: 10.1186/s12879-021-06288-0. PubMed DOI PMC

Fowler A.A., Truwit J.D., Hite R.D., Morris P.E., DeWilde C., Priday A., Fisher B., Thacker L.R., Natarajan R., Brophy D.F., et al. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients with Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial. JAMA. 2019;322:1261–1270. doi: 10.1001/jama.2019.11825. PubMed DOI PMC

Bronsky J., Campoy C., Braegger C., Braegger C., Bronsky J., Cai W., Campoy C., Carnielli V., Darmaun D., Decsi T., et al. ESPGHAN/ESPEN/ESPR/CSPEN Guidelines on Pediatric Parenteral Nutrition: Vitamins. Clin. Nutr. 2018;37:2366–2378. doi: 10.1016/j.clnu.2018.06.951. PubMed DOI

Domellöf M., Szitanyi P., Simchowitz V., Franz A., Mimouni F., Braegger C., Bronsky J., Cai W., Campoy C., Carnielli V., et al. ESPGHAN/ESPEN/ESPR/CSPEN Guidelines on Pediatric Parenteral Nutrition: Iron and Trace Minerals. Clin. Nutr. 2018;37:2354–2359. doi: 10.1016/j.clnu.2018.06.949. PubMed DOI

Ichimaru S. Methods of Enteral Nutrition Administration in Critically Ill Patients: Continuous, Cyclic, Intermittent, and Bolus Feeding. Nutr. Clin. Pract. 2018;33:790–795. doi: 10.1002/ncp.10105. PubMed DOI

Kolaček S., Puntis J.W.L., Hojsak I., Braegger C., Bronsky J., Cai W., Campoy C., Carnielli V., Darmaun D., Decsi T., et al. ESPGHAN/ESPEN/ESPR/CSPEN Guidelines on Pediatric Parenteral Nutrition: Venous Access. Clin. Nutr. 2018;37:2379–2391. doi: 10.1016/j.clnu.2018.06.952. PubMed DOI

Riskin A., Picaud J.-C., Shamir R., Braegger C., Bronsky J., Cai W., Campoy C., Carnielli V., Darmaun D., Decsi T., et al. ESPGHAN/ESPEN/ESPR/CSPEN Guidelines on Pediatric Parenteral Nutrition: Standard versus Individualized Parenteral Nutrition. Clin. Nutr. 2018;37:2409–2417. doi: 10.1016/j.clnu.2018.06.955. PubMed DOI

Nutrition in Critically Ill Children with AKI on Continuous RRT: Consensus Recommendations