Enteral Nutrition Initiation in Children Admitted to Pediatric Intensive Care Units After Traumatic Brain Injury
Traumatic brain injury (TBI) is the leading cause of death and long-term disability among injured children. Early feeding has been shown to improve outcomes in adults, with some similar evidence in children with severe TBI. We aimed to examine the current practice of initiation of enteral nutrition in children with TBI and to evaluate the risk factors associated with delayed initiation of enteral nutrition.
This retrospective, multicenter study used the Pediatric Trauma Assessment and Management Database including all children with head trauma discharged from five pediatric intensive care units (PICU) at pediatric trauma centers between January 1, 2013 and December 31, 2013. We compared demographics, injury and procedure data, time to initiation of nutrition, and injury and illness severity scores between patients who received enteral nutrition early (≤ 48 h) and late (> 48 h). Fisher’s exact and Mann–Whitney U tests compared discrete and continuous variables. Univariate and multivariable analyses evaluated variables associated with delayed initiation of feeding. Outcomes of interest included mortality, complications, ventilator days, hospital and ICU length of stay, and functional status at ICU discharge.
In the 416 patients in the study, the overall mortality was 2.6%. The majority of patients (83%; range 69–88% between five sites, p = 0.0008) received enteral nutrition within 48 h of PICU admission. Lower Glasgow Coma Scale scores and higher Injury Severity Score (ISS) were independently associated with delayed initiation of enteral nutrition. Delayed enteral nutrition was independently associated with worse functional status at PICU discharge (p = 0.02) but was not associated with mortality or increased length of stay.
Children with severe TBI and higher ISS were more likely to have delayed initiation of enteral nutrition. Delayed enteral nutrition was an independent risk factor for worse functional status at ICU discharge for the entire cohort, but not for the severe TBI group.
KeywordsTraumatic brain injury Children Pediatric intensive care Enteral nutrition Outcomes Trauma Pediatric
Dr. Balakrishnan conceptualized the study, interpreted the data analysis, wrote the first draft and edited the manuscript. Dr. Flynn-O’Brien created the PTAM database used for the study and was involved in data interpretation and manuscript edits. Dr. Simpson and Ms. Dasgupta provided statistical data analysis and edited the manuscript. Dr. Hanson conceptualized the study, interpreted the data analysis and edited the manuscript.
Source of support
This project was, in part, supported by a 2014 Childress Foundation grant. Dr. Katherine T Flynn-O’Brien received fellowship support from the National Institute of Child Health and Human Development (T32-HD057822) during the preparation of this paper. VPS data were provided from the VPS, LLC. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the Childress Institute, or VPS, LLC.
Compliance with Ethical Standards
Conflict of interest
The authors have no conflicts of interest relevant to this article to disclose.
- 1.Langlois JA. Traumatic brain injury in the United States: assessing outcomes in children, summary and recommendations. Atlanta: National Center for Injury Prevention and Control, Center for Disease Control and Prevention; 2001.Google Scholar
- 5.Mehta NM, Bechard LJ, Zurakowski D, et al. Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study. Am J Clin Nutr. 2015;102(199–206):10.Google Scholar
- 9.Meinert E, Bell MJ, Buttram S, Kochanek PM, Balasubramani GK, Wisniewski SR, et al. Initiating nutritional support before 72 hours is associated with favorable outcome after severe traumatic brain injury in children: a secondary analysis of a randomized, controlled trial of therapeutic hypothermia. Pediatr Crit Care Med. 2018;19(4):345–52.CrossRefGoogle Scholar
- 10.ACS TQIP. Best practices in management of traumatic brain injury. Jan 2015.Google Scholar
- 23.Phillips R, Ott L, Young B, Walsh J. Nutritional support and measured energy expenditure of the child and adolescent with head injury. J Neurosurg. 1987;67:846Y851.Google Scholar