Enteral Nutrition Intolerance and Delivery Adequacy in Pediatric Critical Care: Development of a Score Using a 2018 Multinational Cohort Study Dataset.

Abstract

Objectives: To examine the explanatory factors of enteral nutrition (EN) intolerance and EN delivery.

Design: Secondary analysis of a 2018 multinational cohort study dataset.

Setting: A total of 77 PICUs with eight or more beds from 17 countries.

Patients: Children from 1 month to 18 years old requiring mechanical ventilation within 48 hours of PICU admission, with a PICU length of stay of 3 or more days.

Interventions: None.

Measurements and main results: We reviewed demographic, clinical, and nutrition data (e.g., EN adequacy), and gastrointestinal (GI) symptoms (i.e., abdominal distension, vomiting/emesis, high gastric residual volume (GRV), diarrhea, and subjective abdominal discomfort) during the first 10 days of PICU admission. Our primary outcome was time to reach 60% EN adequacy. Explanatory variables included clinical factors and GI symptoms. We performed an extended Cox multivariable regression analysis with frailty adjusted for confounders and developed an EN tolerance score. Of the 1844 patients in the dataset, 1838 patients received EN. Mean (sd) age was 4.36 years (5.21 y), and 55.4% were male. Abdominal distension, vomiting/emesis and high GRV were associated with a lower hazard (adjusted hazard ratio [aHR] with 95% CI) of achieving 60% EN goal: abdominal distension-aHR, 0.11 (95% CI, 0.03-0.45); p = 0.002; vomiting/emesis-aHR, 0.49 (95% CI, 0.27-0.90); p = 0.021; high GRV-aHR, 0.30 (95% CI, 0.15-0.59); p < 0.0001). The EN tolerance score components included age, opioid, vasopressor, and paralytic exposure, abdominal distention, vomiting/emesis, high GRV, continuous days of EN, and GI bleeding; for every 10 points on the score, the hazard of not achieving 60% EN adequacy doubled.

Conclusions: In this 2018 dataset, GI symptoms, individually or as a composite, are associated with EN tolerance and adequacy. These symptoms, in conjunction with clinical factors, were used to develop a risk score that serves as a measure of EN tolerance.