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.

Design: 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.

Keywords: adequacy; children; energy; enteral nutrition; mortality; parenteral nutrition; protein.

© 2015 American Society for Nutrition.

Figures

FIGURE 1

Daily cumulative protein intake adequacy in relation to the day since admission to the PICU in mechanically ventilated children (n = 1245). Adequacy = amount delivered ÷ goal prescribed × 100. Mean protein prescribed in this cohort was 1.9 g/kg per day. PICU, pediatric intensive care unit.

FIGURE 2

Relation between enteral protein adequacy and 60-d mortality in relation to the severity of illness at admission in mechanically ventilated children (n = 1245). Adequacy equals the delivered amount as a percentage of prescribed goal. *Significantly lower mortality than in reference category of <20%, P < 0.01 (Fisher’s exact test). The interaction between the severity of illness and protein intake adequacy was significant, P = 0.014 (Wald’s test = 8.62 on 2 df).

FIGURE 3

Median and interquartile values of protein intake adequacy (as a percentage of the prescribed goal) in survivors and nonsurvivors: a cohort of mechanically ventilated children (n = 1245).

FIGURE 4

Linear relation between enteral protein intake adequacy (as a percentage of the prescribed goal) as a continuous variable and 60-d mortality in a cohort of mechanically ventilated children (n = 1245).