title: Nutrition algorithms and bedside nutrient delivery practices in pediatric intensive care units: an international multicenter cohort study.
abstract: BACKGROUND
  Enteral nutrition (EN) delivery is associated with improved outcomes in critically ill patients. We aimed to describe EN practices, including details of algorithms and individual bedside practices, in pediatric intensive care units (PICUs).
  
  
  METHODS
  Available EN algorithm details from 31 international PICUs were obtained. Daily nutrient intake data from 524 mechanically ventilated patients, 1 month to 18 years old, were prospectively documented, including EN delivery, adjunct therapies, and energy prescription. Practices associated with higher percentage adequacy of EN delivery were determined by regression analysis.
  
  
  RESULTS
  Nine EN algorithms were available. All algorithms defined advancement and EN intolerance; 7 of 9 defined intolerance by gastric residual volume; 3 of 9 recommended nutrition screening and fasting guidelines. Few elements were in agreement with the American Society for Parenteral and Enteral Nutrition and the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition guidelines. Of the 341 patients who received EN exclusively 32.9% received ≥66.6% of prescribed energy on day 7. Percentage adequacy of EN delivered was inversely associated with days to EN initiation (-8.92; P < .001) and hours per EN interruption (-1.65; P = .001) and was not associated with the use of algorithms, promotility agents, or postpyloric feeding.
  
  
  CONCLUSIONS
  A minority of PICUs employ EN algorithms; recommendations were variable and not in agreement with national guidelines. Optimal EN delivery was achieved in less than one-third of our cohort. EN adjunct therapies were not associated with increased EN delivery. Studies aimed at promoting early EN and decreasing interruptions may optimize energy delivery in the PICU.
authors.affiliation: Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: Enid E
authors.initials: EE
authors.lastname: Martinez
authors.forename: Lori J
authors.initials: LJ
authors.lastname: Bechard
authors.forename: Nilesh M
authors.initials: NM
authors.lastname: Mehta
mesh_terms: D000293:Adolescent; D000465:Algorithms; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D016638:Critical Illness / Q000628:therapy; D002149:Energy Intake; D004750:Enteral Nutrition / Q000592:standards*; D055317:Evidence-Based Practice; D005260:Female; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D016014:Linear Models; D008297:Male; D009752:Nutritional Status; D011446:Prospective Studies
keywords: algorithms; energy intake; enteral nutrition; pediatric intensive care units; practice guidelines