There can be no doubt that ENT is essential for the care of children with cancer in a Paediatric Intensive Care Unit and that an early use has been widely recommended. In this study, the start time of ENT was consistent with that found by other authors and was according to the recommendations by the quality indicators of the International Life Sciences Institute, which has suggested a target of 80% of children should received ENT in the first 48 hours of PICU admission.4
An observational study in two paediatric intensive care units in Europe, which the primary outcome used in this study was the percentage of target energy requirements achieved per day of the child’s PICU stay, shows that There were no significant differences in the median percentage of energy targets achieved in the first 4 days of PICU admission. However Time to first feed (hours) mean was 7.84 (± 7.38 ) in the PICU that mensure gastric residual volume. On the other hand, in the PICU that do not mensure gastric residual volume it was 21.5 (± 18.3). 22
In the literature, there is still a controversy over the appropriate time for the commencement of ENT. However, recent studies have compared the provisions of early versus late ENT on the outcomes most studied in critically ill patients, especially those of HT and MVT.7–23 The relationship between an early ENT and these outcomes could not be confirmed in this study, probably due to the limited number of patients. Due to the heterogeneity of the methods that were used in the studies and the characteristics of the PICU in question, most authors cited or discussed the relationships of early ENT with HT and MVT, although not all affirmed those associations. Similar results to this study were found by Mikhailov TA24, whose study also showed no significant associations of these kinds of relationships.
The proposed benefits of early ENT include: reducing the incidence of sepsis, intestinal trophism, immune system stimulation, preservation of the intestinal barrier and preventing bacterial translocation.3
Another relevant issue was the prescription of enteral formulas. An enteral diet should consider the nutritional status of the paediatric patients, their nutritional needs and their medical conditions. The prescriber must know the caloric densities, the osmolarities, and the contents of the macronutrients and the micronutrients, when prescribing the formulas. However, there is no consensus on the types of formula to be used.3–23
Regarding the placement of the catheter when used for the administration of ENT, in this study, the post pyloric position was used more often. The American Society for Parenteral and Enteral Nutrition suggests that there is no need to indicate the enteric positioning for those children in a Paediatric Intensive Care Unit, except for those suffering from gastrointestinal complications.3
López-Herce J9 has pointed out that often the child in an intensive care unit has a difficulty when tolerating gastric positioning, especially those MV patients, due to a reduced secondary gastric motility drug use, or the disease itself, coursing with abdominal distension and an increased gastric residue. These factors limit the scope of the full nutritional needs in paediatric critical patients. It is believed that an increase in these complications that are related to the gastrointestinal tract may negatively interfere with the clinical outcomes of these critically ill children, as the impact of diarrhoea and abdominal distension affects the HT and MVT outcomes, respectively, as has been shown in this study.
Vasoactive drugs may also reduce intestinal perfusion, affecting the tolerance of enteral feeding. Moreover, the need for sedatives, frequent in this study’s population, can lead to a reduced gastrointestinal motility.9–25
There is no data on the frequency of constipation in paediatric critical patients. However, this complication may result from immobilisation, dehydration, drugs that influence the intestinal motility and the absence of fibre in a diet.9Among the complications that are unrelated to the gastrointestinal tract and that are responsible for the interruption of enteral feeding, De Oliveira Iglesias5 highlighted haemodynamic instability (34.5%), handling procedures (38%) and an accidental loss of the enteral catheter (27%). The authors found that the high frequency of procedures may also be reflected in difficulties when trying to achieve a full diet.
An inadequate supply of nutrients may also reflect a deterioration of the nutritional status of these patients, contributing to an increased frequency of malnutrition conditions that have been associated in various studies with an increased mortality, the length of stay, an increased number of organ dysfunctions and complications.3–26
Analyses of the cumulative caloric-protein deficiencies in children in a PICU in the Netherlands significantly associated these deficits in reducing the Z scores for the anthropometrical indicators.27 Many indicators have revealed the barriers for a proper nutritional supply in a PICU, which contribute to a worsening nutritional status. Among these, the most frequently reported in the literature are: gastrointestinal disorders, breaks in procedures, and the restrictions of a water supply.23
A study by Manaf ZA28, conducted with paediatric critical patients, with a median age of 10.2 (5.1–50.5) months, found cumulative deficits of energy and proteins of 200 ± 397 kcal/kg and 11.4 ± 22. 8 g/kg in 14 days, respectively. The main factors that were associated with the deficits of nutrients were the frequency of interruptions in the nutritional therapy and the duration of the interruptions in feeding. Hulst J19, when analysing patients between 1 month and 18 years old, with the usage of energy and protein recommendations that were based upon the recommended Dietary Allowances (RDA) for age and gender, found that after 14 days in the PICU, the cumulative deficit of energy was 162 ± 27 kcal/kg and the cumulative deficit of proteins was 2.4 ± 0.8 g/ kg – and that these deficits were associated with the anthropometrical changes during their hospitalisation in the PICU. In this same study, the younger patients had a higher risk of cumulative caloric deficits, as well as HT and security, similar to the findings in this series .
In this context, a great discussion in clinical practices has been the determination of actual energy expenditure of this population, since the gold standard is indirect calorimetry and predictive formulas have questioned its accuracy when calculating the younger patients’ nutritional needs.29–30 However, the recommendations of health committees has been for the use of prediction formulas, in the absence of any indirect calorimetry.3
In a multicentre study that was conducted in a different PICU with 31 children undergoing an MV procedure, an energy supply of at least 66.7% of their enteral energy needs was associated with a reduced mortality over 60 days. Among the factors that are associated with higher energy percentages of receiving patients on enteral nutrition are: younger children, an increased length of stay in the PICU, a shorter duration of MVT, the reasons for a clinical hospitalisation, the non-use of parenteral nutrition and fewer interruptions of ENT.27
When considering the indicators for ENT, only the presence of diarrhoea, the presence of an abdominal distension, together with a cumulative deficit of energy, were able to predict HT and MVT.
The limitations of this study can be considered by the fact that this was a retrospective study, as well as the dependency on information from the medical records, together with the sample size that is small and this may well be why some variables were not significant, and the difficulties of comparisons with other studies of children with cancer in a paediatric intensive care unit. These limitations were justified by a lack of evidence in this particular population and the difficulties in studying the outcomes and the secondary peculiarities of children with cancer. You can also add the fact that in this study, we have used prediction formulas for the calculation of their energy needs, instead of indirect calorimetry, since this is still not a reality in most PICUs.
The key point is that this is the first study to examine specifically ENT in oncology children in PICU and they have cumulative energy and protetin deficits. Diarrhoea, younger age and the cumulative caloric deficiencies were HT predictors. On the other hand, abdominal distention and younger age were associated with a higher MVT.