Enteral Feeding in Children on Noninvasive Ventilation Is Feasible, but Clinicians Remain Fearful*

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Delivering adequate nutrition to meet the child’s energy goals in critical illness is vital, with enteral nutrition (EN) the preferred route. Yet, many barriers exist, in organizational processes, patient factors, and clinician fears, which prevent the timely delivery of EN (1–3). Canarie et al (4) in a large (n = 444) retrospective six U.S. PICU study found that noninvasive ventilation (NIV) was the most significant treatment factor that delayed the initiation of EN. The use of (and options for) NIV has increased markedly in the last decade in both within PICUs and within the hospital in general (5), so reluctance to enterally feed children on NIV has become a concern. NIV of course is used as both a step-up and a step-down treatment to support the child’s own respiratory efforts and reduce the need for intubation and invasive ventilation. Children presenting with severe bronchiolitis form the largest subgroup of critically ill children requiring NIV. However, nutrition guidelines based on evidence are elusive. Current guidelines simply recommend nasogastric feeds or IV fluids for infants with a diagnosis of bronchiolitis who cannot maintain hydration orally, but there is no evidence to any being more beneficial (6). Still, clinician fears predominantly relate to the theoretical need for escalation of respiratory support and intubation, while on NIV therapy, with a potential risk of vomiting, aspiration, and pneumonia.
Therefore, it is timely that Leroue et al (7) in this issue of Pediatric Critical Care Medicine have examined the practice of delivering EN in a group of children on NIV. This single-center, retrospective cohort study included 562 children, 69% under 5 years old and virtually all (98%) with a medical diagnosis receiving different types of NIV. At the time when EN was commenced, NIV was delivered with continuous positive airway pressure, biphasic positive airway pressure (BiPAP), and high-flow nasal cannula, in 13%, 32%, and 42% respectively, with a few children weaned off NIV before EN commenced. More than half (57%) required escalation of their respiratory support during the PICU admission. The unit had local nutrition guidelines (as recommended by American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines [8]), which were followed by a PICU nutrition support team. These consisted of a proactive nutritional strategy, in favor of early EN (oral or via jejunal tube). Consequently, they found that in 64% of children, EN was initiated within 24 hours of admission, and 67% children did achieve their estimated energy goals during their PICU stay (median 2 d). This was predominantly by oral feeding (54%) or by transpyloric feeding (30%). In their multivariate analysis, they found that two factors were independently associated with the likelihood of not initiating early EN in the first 24 hours: the need of higher NIV support (use of BiPAP) and the use of continuous sedation (all with dexmetomidine). Of note, 12% children suffered adverse events (54 pneumonia and five aspiration pneumonia), which is considerably lower than that reported in the adult literature (9) but still a concern. The retrospective design did not allow for further analysis of these complications, and no link with nutrition could be investigated. The lack of any clearly defined diagnostic criteria for ventilator-associated pneumonia in this study (7) is another limitation, which authors have acknowledged. In the children fed by transpyloric route, there were multiple x-rays required (median two per patient) and a number of tube misplacements, so although transpyloric feeding may appear the obvious choice in terms of reducing risk of aspiration, it is not ideal.

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