Sascha Verbruggen, MD, PhD Pediatric intensivist Erasmus MC-Sophia Children's Hospital

When Should Children in Pediatric Intensive Care Receive Parenteral Nutrition? Interview with:

Sascha Verbruggen, MD, PhD Pediatric intensivist Erasmus MC-Sophia Children's Hospital

Dr. Verbruggen

Sascha Verbruggen, MD, PhD
Pediatric intensivist
Erasmus MC-Sophia Children’s Hospital What is the background for this study?

Response: In critically ill children treated in the pediatric intensive care unit (PICU) are often difficult to feed. The subsequent macronutrient deficit was found to be associated with impaired outcomes in the PICU. Furthermore, being undernourished in the PICU has also been associated with poor outcome of critical illness in children.

These associations formed the basis for guidelines recommending initiation of parenteral nutritional support early when enteral feeding is insufficient. However, the multicenter randomised controlled trial (RCT) ‘Pediatric Early versus Late Parenteral Nutrition in Critical Illness’ (PEPaNIC), including 1440 critically ill children, showed that withholding PN for one week (Late-PN) resulted in fewer new infections and reduced the duration of PICU stay as compared to initiating PN at day 1 (Early-PN). However, withholding PN for one week in critically ill children, who are already undernourished upon admission to the PICU, raised concerns among experts.

Therefore we set out to investigate the impact of withholding supplemental PN in a subgroup of critically ill children who were acutely undernourished upon admission to the PICU. What are the main findings?

Response: We found that, compared with well-nourished PICU-patients, undernourishment upon admission was associated with lower likelihood of an earlier live PICU discharge.

However, among undernourished PICU-patients, withholding PN for one week was clinically superior to Early-PN. Withholding PN reduced the risk of new infections with 11.0% (adjusted OR 0.39 (0.19-0.78); p=0.008), and shortened the duration of PICU stay with median 2 days (adjusted HR for earlier live PICU discharge 1.37 (1.06-1.75); p=0.01). The safety outcomes mortality, incidence of hypoglycemia during the first week, and incidence of weight deterioration during PICU stay were similar between the treatment groups. What should readers take away from your report?

Response: Compared with well-nourished PICU-patients, being acutely undernourished upon admission to the PICU was associated with prolonged intensive care dependency.  However, in contrast with concerns raised by experts, withholding supplemental PN for one week, as compared with early (<24 hours) supplemental PN, is also clinically superior in undernourished critically ill children with insufficient enteral nutritional intake, perceived to be vulnerable to macronutrient deficits. What recommendations do you have for future research as a result of this work? 

Response: The results of the PEPaNIC RCT, including this secondary analysis, ratify the opinion of many experts that nutritional support should be approached as a pharmacological therapy during critical illness. Therefore we need to understand the interaction between nutrients and a critically ill child during different phases of illness; acute, stable and recovering.

Our study has shown that providing as many nutrients as early as possible, might not be the optimal approach during acute critical illness. Why are critically ill patients so difficult to feed enterally, and how can we predict when a patient becomes tolerant to sufficient amounts of nutrients? What is the role of fasting, and its interaction with nutritional support, in the recovery of critical illness?

No disclosures


van Puffelen E, Hulst JM, Vanhorebeek I, et al. Outcomes of Delaying Parenteral Nutrition for 1 Week vs Initiation Within 24 Hours Among Undernourished Children in Pediatric Intensive CareA Subanalysis of the PEPaNIC Randomized Clinical TrialJAMA Network Open. 2018;1(5):e182668. doi:10.1001/jamanetworkopen.2018.2668

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Sep 17, 2018 @ 2:50 pm

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