SJ Moltu et al JPGN 2021; 73: 274-289. Full Text: Nutritional Management of the Critically Ill Neonate: A Position Paper of the ESPGHAN Committee on Nutrition

Background: The authors of this position paper are trying to modulate the treatment recommendations based on the PEPaNIC trial. This “large randomized trial, the Early versus Late Parenteral Nutrition in the Pediatric Intensive Care Unit (PEPaNIC) trial, showed that withholding parenteral nutrition (PN) during the first week of acute illness improved early outcomes as compared to PN initiated during the first 24 hours after admission in children [Fivez T, Kerklaan D, Mesotten D, et al. Early versus late parenteral nutrition in critically ill children. N Engl J Med 2016; 374:1111–1122] ⁽⁷¹⁾. Effects were similar in the subgroup of 209 term-born neonates recruited to the trial ⁽⁷²⁾. Despite this finding, many clinicians appear reluctant to limit early nutritional support due to (1) concerns about possible harm by not providing adequate nutrients during the first week of critical illness, particularly in neonates and undernourished children ⁽⁷³⁾, and (2) the belief that exogenous dietary protein provision is essential during critical illness ⁽⁷³⁾.”

Key recommendations:

• In preterm infants, available evidence does not support any significant changes to current guidelines, which recommend that critically ill preterm infants should receive nutritional support started at (or reduced to) the minimal amount needed to cover basal metabolic rate and basic macronutrient needs during the early acute phase ^{(26,27,129,149)}. For many preterm infants, this means that they will need PN.

• In critically ill term neonates, initiation of PN within 24 hours is not routinely recommended; however, considering the limitations of the PEPaNIC trial and the observed low risk of long-term harm from early PN in critically ill neonates, the ESPGHAN-CoN does NOT support a change towards withholding parenteral nutritional support for 7 days as standard nutritional care. This position paper suggests considering careful initiation of nutritional support, including micronutrients, just below or at predicted REE after 48–72 hours… when adequate enteral nutrition is not feasible

My take: Particularly in preterm infants, adequate nutrition should not be withheld due to their very limited reserves. In term critical infants, these guidelines offer a logical approach until more studies are available.

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