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Running head: INTEGRATED REVIEW

Integrative Literature Review

Katherine Vest

Bon Secours Memorial College of Nursing

Dr. Arlene Holowaychuk

Nursing Research NUR 4322

April 10th, 2020

“I pledge”
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INTEGRATED REVIEW
Abstract

The purpose of this integrated literature review is to evaluate the correlation between

implementation of nutrition and patient outcomes in critically ill patients by asking the PICO

question: In critically ill pediatric patients in the intensive care unit (ICU), how does the

implementation of nutritional support versus the de-implementation of nutritional support affect

patient outcomes? Nutritional care is often overlooked by providers in the critical care setting

and it is important that healthcare providers are educated on the benefits and risks of initiating

nutrition in critically ill patients. The review includes five studies, primarily randomized cohort

studies that contain quantitative data. The findings indicate a need for further research to be

conducted in order to provide sufficient guidelines regarding nutritional support for critically ill

pediatric patients.
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Integrative Review

The purpose of this integrated review is to examine the similarities and differences

among research studies that analyze the multitude of nutritional treatments that are implemented

among critically ill patients in intensive care and the effects upon patient outcomes. While

nutrition in critical care is a widely discussed topic in healthcare across all populations, the

outcomes of nutritional support in pediatric patients remains unclear (Fivez et al., 2016). Optimal

nutrition is identified to be essential in promoting positive patient outcomes in the critical care

setting (van Puffelen et al., 2019). Involvement of a healthcare professional, such as a nutrition

nurse, with expertise in nutritional benefits and guidelines improves consistency of feeds and

patient outcomes (Aydemir, Saghk, Sekili & Tekin, 2018). Constructing the associations

between type, time of initiation and implementation of nutrition and patient outcomes will

suggest the need for well-defined guidelines for healthcare professionals to follow to ensure

adequate nutrition to promote positive patient outcomes in ICU settings. The aim of this review

is to investigate research data as it correlates to the researcher’s PICO question: In critically ill

pediatric patients in the intensive care unit (ICU), how does the implementation of nutritional

support versus the de-implementation of nutritional support affect patient outcomes?

Design and Search Methods

The research design is an integrated review. Three search engines, EBSCO Nursing

Reference Center Plus and Ovid Discovery Services, were utilized to locate articles pertaining to

the researcher’s topic. Keywords used in the search included ‘pediatric’ ‘intensive’ ‘critical’

‘care’ and ‘nutrition’. EBSCO Nursing Reference Center Plus generated 490 results and Ovid

Discovery Plus generated 9692 results. Searches were limited to English, peer-reviewed, full text

articles with a publication year between 2015-2020, which resulted in 181 articles from EBSCO
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Nursing Reference Center Plus and 31 articles from Ovid Discovery Services. With the

remaining articles, a screening was completed to determine relevancy to the PICO question

identified by the researcher: In critically ill pediatric patients in the intensive care unit (ICU),

how does the implementation of nutritional support versus the de-implementation of nutritional

support affect patient outcomes? Articles which were not found relevant to the topic of nutrition

in intensive care patients were excluded. Articles deemed relevant were then selected based upon

author accreditations, major themes and results. Five total quantitative studies within the

publication years of 2016-2020 were selected and referenced in this integrative review.

Findings and Results

Three of the five reviewed studies indicate that de-implementation of nutritional support

in critically ill pediatric patients within the first seven days promotes positive patient outcomes,

such as decreased ICU stay, duration of mechanical ventilation and infection risk, as well as

decreases health complications in critically ill patients (Fivez et al., 2016; van Puffelen et al.,

2019; van Puffelen et al., 2020). In comparison, two of the five articles supported earlier

implementation of nutrition within the first seven days (Aydemir et al., 2018; Bechard et al.,

2016). The articles referenced in Appendix 1 supply evidence of different supporting themes

which pertain to what adequate nutrition is comprised of to promote beneficial patient outcomes.

This integrative review is based upon the following themes found among critically ill patients

regarding nutritional status: engagement of nutrition initiation, nutritional education and

admitting nutritional status

Engagement of Nutrition Initiation

Three of the five research articles indicated a correlation between the engagement of the

initiation of parenteral nutrition (PN) in critically ill patients and positive patient outcomes.
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INTEGRATED REVIEW
Fivez, T. et al. (2016) conducted the Early versus Late Parenteral Nutritional in the Pediatric

Intensive Care Unit (PEPaNIC) trial involving 1440 intensive care pediatric patients. The design

was a multicenter, prospective, randomized trial. The sample was randomly divided into two

groups initiating PN at 24 hours after admission (n=723) and seven days after admission

(n=717). The two patient outcomes to be studied were new infections and duration of intensive

care. Data was analyzed with the use of the chi-square test and the Wilcoxon rank-sum test. The

results indicated that withholding parenteral nutrition for seven days resulted in better patient

outcomes, such as shorter pediatric intensive care unit (PICU) stay, a 7.8% decrease in newly

acquired infections, and a shorter duration of mechanical ventilation.

A study conducted by van Puffelen et al. (2020) examined the effects on weight

deterioration by initiating early or late PN in PICUs. The aim of this study was to assess the

effect of withholding PN during the first seven days on z-score change in PICUs and to

determine patient outcomes. This study was an analysis of the PEPaNIC trial, which created a

subgroup of 470 patients who were admitted with a longitudinal weight Z-score. The patients of

this subgroup received PN either 24 hours after enteral nutrition was deemed insufficient (early-

PN) or seven days after (late-PN). The change in weight z score was then calculated for each

patient until discharge from PICU and adjusted per age group. The data was analyzed using x2

test, t-test and Mann-Whitney test per variables as well as using logistic regression and Cox

proportional hazard analyses to examine risk for infection. The results indicate that late-PN is

correlated with a decreased risk of new infection and a shorter ICU stay, while less weight z-

score deterioration was correlated with a lower risk of new infections as well.

In a study conducted by van Puffelen et al. (2019), it was identified that attempting to

achieve adequate nutrition by utilizing PN before seven days was harmful. De-implementation of
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INTEGRATED REVIEW
early PN initiation was found to be superior to implementing PN during the first seven days on a

PICU when enteral feeding was proven to be insufficient. This cross-sectional online survey

analyzed 81 results stemming from 43 PICUs worldwide in order to examine the degree of de-

implementation and the factors relating to healthcare professionals’ decisions to implement or

de-implement PN within the first seven days of PICU admission in relation to the PEPaNIC

guideline for PN de-implementation. The methods of research for this study included a

LimeSurvey GmbH version 2.06lts cross-sectional survey consisting of 41 questions evaluating

the use of PN on PICUs. The results from the survery were analyzed using IBM SPSS statistics

version 24. Results indicated that 76% still administered PN during the first week because it was

believed that early initiation of nutrition carried benefits for the patient. Identified factors for

implementing PN were concerns of withholding nutrition, safety of a malnourished patient, long-

term effects and waiting on updated guidelines. It was found necessary to increase awareness and

education surrounding PN in intensive care settings in order to accelerate the de-implementation

of harmful care such as the utilization of PN earlier than seven days.

Nutritional Education

Two of the five articles found a relationship between healthcare provider education and

the implementation of nutrition in critically ill patients. Puffelin et al. (2019) indicated this

correlation in the study of the degree of de-implementation of nutrition in PICUs worldwide. The

study analyzed healthcare knowledge of the PEPaNIC study, which found that 76% of healthcare

providers still provided PN due to lack of education or uncertainties surrounding the evidence.

In a study conducted by Aydemir et al. (2018), it was identified that there is a correlation

to employing a nurse with nutritional expertise and positive patient outcomes. The authors held a

retrospective cohort study including 98 preterm newborns to analyze growth and nutrition
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INTEGRATED REVIEW
outcomes of a pre-nutrition-nurse period and a post-nutrition-nurse period. The tool used to

analyze the data was the presence of postnatal growth retardation (PGR). Results were compared

utilizing student t-test or Mann-Whitney U test. The study found a correlation between the post-

nutrition-nurse period and the improved quality of nutritional support, increased breastfeeding

occurrences and decreased PGR in the sample population. The nutrition nurse also had an earlier

implementation time of PN. The involvement of a nutritional nurse was beneficial regarding the

patient outcomes of this population indicating that nutritional education has a correlation with

implementation of nutrition.

Admitting Nutritional Status

Two studies provided insight on the correlation between admitting nutritional status and

the implementation of nutrition in critically ill patients. van Puffelen et al. (2020) utilized the

measurement of z-scores upon admission to analyze the change in this numerical data in

correlation with early-PN and late-PN. It was found that the less weight z-score deterioration did

have a lower risk of contracting new infections. There was no significance found between early-

PN and late-PN and its effect on z-score.

Bechard et al. (2016) conducted a multicenter cohort study to examine the correlation

between admitting nutritional status, outlined by BMI Z-score, and mortality, infection, and

mechanical ventilation. Data from 1622 patients from 90 PICUs were included in the trial and

were classified into 4 groups: underweight, normal weight, overweight, and obese based on BMI

z-score. Data was analyzed using a Meier time to event analysis, logistic and multiple linear

regression generalized estimating equations (GEE), and a hierarchical Cox proportional hazards

regression model. The authors found that malnourished children were at higher risk for infection,

mortality, and fewer ventilator-free days, while obese children were at higher risk for infection
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INTEGRATED REVIEW
and a lower chance for hospital-discharge. This study put forward astounding evidence in the

relationship between presenting nutritional status and patient outcomes.

Discussion and Implications

The purpose of this literature review is to supply insight on the implementation or de-

implementation of nutrition in critically ill pediatric patients. The PICO question, in critically ill

pediatric patients in the intensive care unit (ICU), how does the implementation of nutritional

support versus the de-implementation of nutritional support affect patient outcomes, was not able

to be settled based on the literature provided. Research conducted by Fivez et al. (2016), van

Puffelen et al. (2019) and van Puffleen et al. (2020) supported the de-implementation of

parenteral nutrition in pediatric patients. However, Aydemir et al. (2018) found that with the

employment of a nurse with nutritional expertise, positive patient outcomes were increased while

poor outcomes were consecutively reduced. Bechard et al. highlights important findings that

regarding nutritional status and patient outcomes, admitting nutritional status must also be taken

into account as malnourished and obese pediatric patients carry predispositions putting them at

risk for poor outcomes. The implications of these findings suggest that future research must be

conducted on specific populations in order to analyze if de-implementation of nutrition in

critically ill children improves patient outcomes.

Limitations

A literature review assists in promoting evidence-based practice, yet, limitations still

remain by both the literature and the researcher. The researcher is inexperienced in conducting

an integrative literature review. The researcher did not research more than five articles in the

review thus making the review too minimal to be considered relevant enough to encorporate into

evidence-based practice.
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INTEGRATED REVIEW
Limitations exist throughout the five articles included in the review. The sample sizes of

the five articles combined is not sufficient to adequately represent the entire pediatric population.

The study conducted by Aydemir et al. (2016) may contain response bias. The topic of nutrition

in critically ill pediatric patients is also a limiting factor as patients with different diagnoses in

the PICU may have different nutritional requirements and outcomes due to the pathophysiology

of their diagnoses.

Conclusion

The findings throughout the literature raise awareness to the correlation between the

implementation of nutrition in critically ill pediatric patients and promoting positive patient

outcomes. The results of the integrated review indicate that the de-implementation of nutrition

promotes positive patient outcomes and reduces poor patient outcomes in critically ill pediatric

patients. Additionally, employing a nurse with nutritional expertise increases patient outcomes

and earlier implementation of nutrition. It was also found that patients with predispositions, such

as obesity and malnutrition, were at higher risk for poor patient outcomes regardless of

nutritional implementation during admission. The findings in this review raise awareness

towards the important topic of efficient nutritional care in pediatric intensive care units.
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INTEGRATED REVIEW
References

Aydemir, O., Saghk, A., Sekili, Z. & Tekin, A. (2018). Employing a nutrition nurse in neonatal

intensive care unit improved nutrition and growth outcomes in preterm neonates.

American Society for Parenteral and Enteral Nutrition, 34(4). doi: 10.1002/ncp.10216

Bechard, L., Duggan, C., Touger-Decker, R., Parrott, J. S., Rothpletz-Puglia, P., Bytham-Gray,

L., Heyland, D. & Mehta, N. (2016). Nutritional status based on body mass index is

associated with morbidity and mortality in mechanically ventilated critically ill children

in the PICU. Critical Care Medicine, 44(8), 1530-1537. doi:

10.1097/CCM.000000000000.1713

Fivez, T., Kerklaan, D., Mesotten, D., Verbruggen, S., Wouters, P., Vanhorebeek, I., Debaveye,

Y., Vlasselaers, D., Desmet, L., Casaer, M., Guerra, G., Hanot, J., Joffe, A., Tibboel, D.,

Joosten, K. & Van den Berghe, G. (2016). Early versus late parenteral nutrition in

critically ill children. The New England Journal of Medicine, 374(4). doi:

10.1056/NEJMoa1514762

van Puffelen, E., Jacobs, A., Verdoorn, C., Joosten, K., van den Berghe, G., Ista, E. &

Verbruggen, S. (2019). International survey of de-implementation of initiating parenteral

nutrition in paediatric intensive care units. BMC Health Services Research, 19(379). doi:

10.1186/s12913-019-4223-x

van Puffelen, E., Hulst, J., Vanhorebeek, I., Dulfer, K., Van den Burghe, G., Joosten, K. &

Verbruggen, S. (2020). Effect of late versus early initiation of parenteral nutrition on

weight deterioration during PICU stay: Secondary analysis of the PEPaNIC randomised

controlled trial. Clinical Nutrition, 39, 104-109. doi: 10.1016.j.clnu.2019.02.014

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Running head: INTEGRATED REVIEW
Appendix 1 – Quantitative Article Summary Evaluation Tables

APA Citation Author Aydemir, O., Saghk, A., Sekili, Z. & Tekin, A. (2018). Employing a nutrition nurse
Qualifications in neonatal intensive care unit improved nutrition and growth outcomes in preterm
neonates. American Society for Parenteral and Enteral Nutrition, 34(4). doi:
10.1002/ncp.10216
 Aydemir, O. MD, Neonatal Intensive Care Unit, Eskisehir Osmangazi
University Hospital, Buyukdere Mah.
 Saghk, A. MD.
 Sekili, Z., MSN.
 Tekin, A., MD.
Background/Problem Background: Nutritional nurses are nurses who have expertise in nutritional support.
Statement Problem statement: The study examines the differences in nutrition and growth
outcomes after employing a nutrition nurse in a level III neonatal intensive care unit
(NICU).
Conceptual/theoretica None
l Framework

Design/ Design: Quantitative retrospective cohort study

Method/Philosophical Method: Medical records
Underpinnings Philosophical underpinnings: none

Sample/ Sample: 98 infants – 48 from pre-nutrition-nurse period & 50 from post-nutrition-

Setting/Ethical nurse period
Considerations Setting: Level III NICUs
Ethical considerations: Approved by the institutional ethics committee
Major Variables  Gestational age
Studied (and their  Birth weight
definition), if  Gender
appropriate  Perinatal characteristics
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Measurement Measurement tool: Postnatal growth retardation (PGR)

Tool/Data Collection Data collection method: Documents/Records
Method

Data Analysis  Student t-test or Mann-Whitney U test

Findings/Discussion  Pre-nutrition and post-nutrition periods were similar in gestational age, birth
weight, gender and perinatal characteristics.
 Initiation of parenteral nutrition (PN) and full enteral feeding was earlier in
the post-nutrition-nurse period.
 Primary outcome of PGR was lower in post-nutrition-nurse period.
 Employing a nutrition nurse increased breast feeding and improved the
quality of nutritional support.

Appraisal/Worth to These findings can help initiate new studies with nutrition-nurses in other NICUs.
practice

APA Citation Author Bechard, L., Duggan, C., Touger-Decker, R., Parrott, J. S., Rothpletz-Puglia, P.,
Qualifications Bytham-Gray, L., Heyland, D. & Mehta, N. (2016). Nutritional status based on body
mass index is associated with morbidity and mortality in mechanically ventilated
critically ill children in the PICU. Critical Care Medicine, 44(8), 1530-1537. doi:
10.1097/CCM.000000000000.1713
 Bechard, L. – PhD, RD, LDN
 Duggan, C. – MD, MPH
 Touger-Decker, R. – PhD, RD, FADA
 Parrott, J. S. – PhD
 Rothpletz-Puglia, P. – EdD, RD
 Bytham-Gray, L. – PhD, RD
 Heyland, D. – MD
 Mehta, N. – MD
Background/Problem Background: Pediatric patients requiring mechanical ventilation are at risk of
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Statement mortality due to their severity and comorbidities. Nutritional status on admission to
the PICU has been associated with poor outcomes.
Problem statement: To examine the influence of admission nutritional status,
assessed by z-score, on clinical outcomes in mechanically ventilated pediatric
patients.
Conceptual/theoretica None
l Framework

Design/ Design: Quantitative multicenter cohort study

Method/Philosophical Philosophical underpinnings: None
Underpinnings

Sample/ Sample: 1622 pediatric patients

Setting/Ethical Setting: 90 PICUs in 16 countries
Considerations Ethical considerations: approved by ethics committee, consent was obtained by
parents/legal guardians of patients
Major Variables  Nutritional status
Studied (and their  BMI
definition), if  Z-score
appropriate  60-day mortality
 Hospital acquired infections (HAIs)
 Length of ICU stay
 Days without being on ventilator
Measurement Measurement tool: medical records
Tool/Data Collection
Method
Data Analysis  Statistical analysis
Findings/Discussion  Those who were classified in the groups of underweight or obese had a higher
risk for infection and lower likelihood of hospital discharge
 The highest mortality rate was for underweight children, as well as fewer
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INTEGRATED REVIEW
ventilator free hospital days.
Appraisal/Worth to Patients who are ventilated suffering from malnutrition is prevalent in PICU.
practice Anthropometric variables might allow for more effective screening of patients who
are in the groups of risk for poor outcomes.

APA Citation Author Fivez, T., Kerklaan, D., Mesotten, D., Verbruggen, S., Wouters, P., Vanhorebeek, I.,
Qualifications Debaveye, Y., Vlasselaers, D., Desmet, L., Casaer, M., Guerra, G., Hanot, J., Joffe,
A., Tibboel, D., Joosten, K. & Van den Berghe, G. (2016). Early versus late
parenteral nutrition in critically ill children. The New England Journal of Medicine,
374(4). doi: 10.1056/NEJMoa1514762
 Fivez, T. - MD
 Kerklaan, D. – MD
 Mesotten, D. – MD, PhD
 Verbruggen, S. – MD, PhD
 Wouters, P. – MD, PhD
 Vanhorebeek, I. – MD, PhD
 Debaveye, Y. – MD, PhD
 Vlasselaers, D. – MD, PhD
 Desmet, L. – MD, PhD
 Casaer, M. – MD, PhD
 Guerra, G. – MD, PhD
 Hanot, J. – MD, PhD
 Joffe, A. – MD, PhD
 Tibboel, D. – MD, PhD
 Joosten, K. – MD, PhD
 Van den Berghe, G. – MD, PhD
Background/Problem Background: There are many trials based upon benefits of early parenteral nutrition
Statement in adults, but less in pediatrics.
Problem statement: To examine the effects of early parenteral nutrition within 24
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hours and seven days to determine effects of patient outcomes.
Conceptual/Theoretica None
l Framework

Design/ Design: Quantitative, multicenter, randomized, controlled trial

Method/Philosophical Philosophical underpinnings: None
Underpinnings

Sample/ Setting/Ethical Sample: 1440 critically ill pediatric patients

Considerations Setting: PICUs
Ethical considerations: approved by ethics committee, consent was obtained by
parents/legal guardians of patients
Major Variables  New acquired infection
Studied (and their  Duration of ICU stay
definition), if  Parenteral nutrition initiation time
appropriate
Measurement Measurement tool: medical records
Tool/Data Collection Data collection:
Method
Data Analysis  Statistical analysis
 70% power

Findings/Discussion  Late-PN had a 10.7% increase in new infections while early-PN had a 18.5%
in new infections
 Late-PN had a shorter ICU stay
 Late-PN was associated with a shorter duration of mechanical ventilation
Appraisal/Worth to Withholding parenteral nutrition for one week is crucial in maintaining good patient
practice outcomes for critically ill pediatric patients,
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INTEGRATED REVIEW
APA Citation Author van Puffelen, E., Jacobs, A., Verdoorn, C., Joosten, K., van den Berghe, G., Ista, E. &
Qualifications Verbruggen, S. (2019). International survey of de-implementation of initiating
parenteral nutrition in paediatric intensive care units. BMC Health Services Research,
19(379). doi: 10.1186/s12913-019-4223-x.
 van Puffelen, E. - Department of Paediatrics and Paediatric Surgery, Erasmus
MC – Sophia Children’s Hospital, University Medical Centre Rotterdam,
Rotterdam, the Netherlands
 Jacobs, An. - Department of Cellular and Molecular Medicine, Clinical
Division and Laboratory of Intensive Care Medicine, University Hospitals
KU Leuvan, Leuvan, Belgium.
 Verdoom, C. - Department of Paediatrics and Paediatric Surgery, Erasmus
MC – Sophia Children’s Hospital, University Medical Centre Rotterdam,
Rotterdam, the Netherlands.
 Joosten, K. - Department of Paediatrics and Paediatric Surgery, Erasmus MC
– Sophia Children’s Hospital, University Medical Centre Rotterdam,
Rotterdam, the Netherlands.
 van den Burghe, G. - Department of Cellular and Molecular Medicine,
Clinical Division and Laboratory of Intensive Care Medicine, University
Hospitals KU Leuvan, Leuvan, Belgium.
 Ista, E. - Department of Paediatrics and Paediatric Surgery, Erasmus MC –
Sophia Children’s Hospital, University Medical Centre Rotterdam,
Rotterdam, the Netherlands. Department of Internal Medicine, Nursing
Science, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The
Netherlands.
 Verbruggen, S. - Department of Paediatrics and Paediatric Surgery, Erasmus
MC – Sophia Children’s Hospital, University Medical Centre Rotterdam,
Rotterdam, the Netherlands.
Background/Problem Background: Starting parenteral nutrition (PN) in critically ill children is inferior to
Statement holding the PN during the first seven days was found in the PEPaNIC study.
Problem statement: The study examines the degree of early de-implementation of
starting PN in the first week in PICUs and the barriers for de-implementation.
Conceptual/theoretica  The article used the PEPaNIC study to investigate de-implementation of
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l Framework nutrition in pediatric intensive care patients.
Design/ Design: Quantitative cross-sectional study used in 43 Pediatric Intensive Care units
Method/Philosophical (PICUs)
Underpinnings Method: Online survey
Philosophical underpinnings: none
Sample/ Sample: 87 responses from members of the World Federation of Pediatric Intensive
Setting/Ethical and Critical Care Societies.
Considerations Setting: PICUs
Ethical considerations: Institutional Review Board of the Erasmus MC in Rotterdam
approved the protocol and waived the need for consent
Major Variables  De-implementation: the act of not implementing a protocol
Studied (and their  Degree of de-implementation
definition), if  Current nutritional practice
appropriate  Factors affecting de-implementation
Measurement Measurement tool: LimeSurvey GmbH version 2.06lts
Tool/Data Collection Data collection method: Survey/Questionnaire
Method

Data Analysis  IBM SPSS statistics version 24

Findings/Discussion  PN withheld in 12% for first week

 PN partially withheld by 40%
 No de-implementation by 37%
 Reasons for not de-implementing: concerns on holding amino acids, safety of
children who are malnourished, consequences in the long term waiting on
updates for nutritional guidelines
 Needs for increasing awareness, addressing the intervention questions and
having international guidelines for de-implementation of harmful care

Appraisal/Worth to Healthcare workers should be aware of the harmful effects of implementing nutrition
practice in PICU patients and that there is a lack of guidelines for healthcare workers to
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follow.

APA Citation Author van Puffelen, E., Hulst, J., Vanhorebeek, I., Dulfer, K., Van den Burghe, G., Joosten,
Qualifications K. & Verbruggen, S. (2020). Effect of late versus early initiation of parenteral
nutrition on weight deterioration during PICU stay: Secondary analysis of the
PEPaNIC randomised controlled trial. Clinical Nutrition, 39, 104-109. doi:
10.1016.j.clnu.2019.02.014
 van Puffelen, E. - Department of Paediatrics and Paediatric Surgery, Intensive
Care Unit, Erasmus MC – Sophia Children’s Hospital, University Medical
Center Rotterdam, Rotterdam, the Netherlands.
 Hulst, J. - Department of Paediatrics and Paediatric Surgery, Intensive Care
Unit, Erasmus MC – Sophia Children’s Hospital, University Medical Center
Rotterdam, Rotterdam, the Netherlands.
 Vanhorebeek, I. - Department of Cellular and Molecular Medicine, Clinical
Division and Laboratory of Intensive Care Medicine, University Hospitals
KU Leuven, Leuven, Belgium.
 Dulfer, K. - Department of Paediatrics and Paediatric Surgery, Intensive Care
Unit, Erasmus MC – Sophia Children’s Hospital, University Medical Center
Rotterdam, Rotterdam, the Netherlands.
 Van den Burghe, G. - Department of Cellular and Molecular Medicine,
Clinical Division and Laboratory of Intensive Care Medicine, University
Hospitals KU Leuven, Leuven, Belgium.
 Joosten, K. - Department of Paediatrics and Paediatric Surgery, Intensive
Care Unit, Erasmus MC – Sophia Children’s Hospital, University Medical
Center Rotterdam, Rotterdam, the Netherlands.
 Verbruggen, S. - Department of Paediatrics and Paediatric Surgery, Intensive
Care Unit, Erasmus MC – Sophia Children’s Hospital, University Medical
Center Rotterdam, Rotterdam, the Netherlands.
Background/Problem Background: Children in a critically ill condition are at risk for weight deterioration.
Statement There is much controversy over initiating parenteral nutrition (PN) in this population
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and its effect on this patient outcome.
Problem statement: The study assessed the effect of withholding PN for seven days
and its effect on z-score change in the Pediatric Intensive Care Unit (PICU) and
clinical outcomes.
Conceptual/theoretica Secondary analysis of the PEPaNIC study
l Framework

Design/ Design: Quantitative randomized, controlled trial

Method/Philosophical Method: Examination of z scores
Underpinnings Philosophical underpinnings: none

Sample/ Sample: 470 patients with longitudinal z scores on admission (anthropometric

Setting/Ethical measurements) and on the last day in PICU
Considerations Setting: PICU
Ethical considerations: The institutional ethical review boards of all the participating
centers approved the study while written informed consent was obtained the parents
or legal guardian of each patient.
Major Variables  Z scores
Studied (and their  Weight deterioration
definition), if  Early discharge from PICU
appropriate  Risk of new infections
Measurement Measurement tool: Z-scores
Tool/Data Collection Data collection method: medical records
Method

Data Analysis  Z score

 Medical records
Findings/Discussion  Enteral nutrition was equal in the early-PN and late-PN group
 Less weight z-score was associated with: lower infection risk, higher
likelihood of earlier discharge from PICU alive.
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 Change in weight z-score did not differ among both groups
 Weight deterioration during PICU stay was connected to worse clinical
outcocmes. Withholding PN for 7 days did not cause weight z-score
deterioration during PICU stay.
Appraisal/Worth to This study brings new data to PICUs and the effects of PN in critically ill children.
practice There is a requirement for more research on this topic, as the measurement of body
composition did have some limitations.