title: Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study.
abstract: BACKGROUND
  The impact of protein intake on outcomes in pediatric critical illness is unclear.
  
  
  OBJECTIVE
  We examined the association between protein intake and 60-d mortality in mechanically ventilated children.
  
  
  METHODS
  In a prospective, multicenter, cohort study that included 59 pediatric intensive care units (PICUs) from 15 countries, we enrolled consecutive children (age: 1 mo to 18 y) who were mechanically ventilated for ≥48 h. We recorded the daily and cumulative mean adequacies of energy and protein delivery as a percentage of the prescribed daily goal during the PICU stay ≤10 d. We examined the association of the adequacy of protein delivery with 60-d mortality and determined variables that predicted protein intake adequacy.
  
  
  RESULTS
  We enrolled 1245 subjects (44% female) with a median age of 1.7 y (IQR: 0.4, 7.0 y). A total of 985 subjects received enteral nutrition, 354 (36%) of whom received enteral nutrition via the postpyloric route. Mean ± SD prescribed energy and protein goals were 69 ± 28 kcal/kg per day and 1.9 ± 0.7 g/kg per day, respectively. The mean delivery of enteral energy and protein was 36 ± 35% and 37 ± 38%, respectively, of the prescribed goal. The adequacy of enteral protein intake was significantly associated with 60-d mortality (P < 0.001) after adjustment for disease severity, site, PICU days, and energy intake. In relation to mean enteral protein intake <20%, intake ≥60% of the prescribed goal was associated with an OR of 0.14 (95% CI: 0.04, 0.52; P = 0.003) for 60-d mortality. Early initiation, postpyloric route, shorter interruptions, larger PICU size, and a dedicated dietitian in the PICU were associated with higher enteral protein delivery.
  
  
  CONCLUSIONS
  Delivery of >60% of the prescribed protein intake is associated with lower odds of mortality in mechanically ventilated children. Optimal prescription and modifiable practices at the bedside might enhance enteral protein delivery in the PICU with a potential for improved outcomes. This trial was registered at clinicaltrials.gov as NCT02354521.
authors.affiliation: Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, and Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; and nilesh.mehta@childrens.harvard.edu.
authors.forename: Nilesh M
authors.initials: NM
authors.lastname: Mehta
authors.affiliation: Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; and.
authors.forename: Lori J
authors.initials: LJ
authors.lastname: Bechard
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, and Harvard Medical School, Boston, MA; and Kingston General Hospital, Kingston, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Zurakowski
authors.affiliation: Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; and.
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Duggan
authors.affiliation: Kingston General Hospital, Kingston, Canada.
authors.forename: Daren K
authors.initials: DK
authors.lastname: Heyland
mesh_terms: D015992:Body Mass Index; D002648:Child; D002675:Child, Preschool; D016638:Critical Illness / Q000401:mortality* / Q000628:therapy*; D004044:Dietary Proteins / Q000008:administration & dosage*; D002149:Energy Intake; D004750:Enteral Nutrition; D005260:Female; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D008297:Male; D011446:Prospective Studies; D064167:Recommended Dietary Allowances; D012121:Respiration, Artificial
chemical_list: D004044:Dietary Proteins
keywords: adequacy; children; energy; enteral nutrition; mortality; parenteral nutrition; protein