A substantial number of children in critical care are malnourished on admission, and many of them can deteriorate further during treatment due to the metabolic response to injury, surgery, or disease [1,2]. Optimal nutritional support during the ICU stay can minimize nutrient deficits and delay the establishment of malnutrition during critical illness [3]. An important aspect of nutrition strategy for the severely ill is the appropriate delivery of enough nutrients via the enteral route. However, enteral nutrition has several associated problems. Delays in starting feeds, insufficient feed increases, recurring disruptions, perceived feed intolerance, and failure to meet energy targets are a few examples of it. After EN is successfully established during critical illness, enteral feedings are often discontinued for varying periods for diagnostic or therapeutic interventions.4,5,6 (B) Frequent interruptions in enteral nutrient delivery affect clinical outcomes secondary to the suboptimal provision of calories. Treating doctors may have control over these periprocedural disruptions, and up to a quarter of them can be avoided.32, 33(thesis) The objective of this study was to assess the adequacy of enteral nutrition practices during PICU treatment at MGMMCH Aurangabad. We analyzed nutrient intake in critically ill children and factors responsible for inadequate delivery of enteral nutrition, such as delayed EN and interruptions. We also evaluated the frequency of avoidable factors and their impact on nutrient delivery. (6)

A cross-sectional observational study was conducted in the PICU. MGM Medical College and Hospital Aurangabad over a six months period. The study was started after approval from the institutional ethical committee. Inclusion criteria Infants and children from 1 month to 18 years were admitted to the PICU for more than 24 hours. and were on enteral feeds were enrolled. Exclusion criteria Children with malabsorption syndromes were excluded. Data collection Data were collected from the time of initiation of feed until the patient either reached full feed for 7 consecutive days or was discharged from the PICU. The baseline characteristics of all enrolled cases including, detailed anthropometric measurements were taken, and nutritional assessment was performed as per WHO Guidelines. To calculate the calorie requirement, the Schofield (weight) formula was used, wherein BMR is considered the direct way of measuring REE (resting energy expenditure) and an indirect way of calculating the daily calorie requirement. The timing of starting EN after PICU admission was noted. If it was started more than 48 hrs, after admission, the reason for the delay was noted. Interruptions in enteral feeding, their number, the duration of each episode of interruptions, and their causes were noted, and the reasons behind feeding interruptions were further analyzed as avoidable and nonavoidable causes. Statistical analysis Continuous variables were expressed as medians with interquartile ranges and analyzed with nonparametric statistics (Mann–Whitney tests) for differences between groups. Categorical data are presented as counts and percentages, and differences between groups were explored with the chi-squared test or Fisher's exact test. Ethics statement This study protocol was approved by the MGM ECRHS (MGM ECRHS/2019/60, Date 10.10.2019). Written informed consent was obtained from the parents before enrolment in the study.

Fifty patients admitted to the PICU during the study period were included in the study who met the study criteria. The study cohort (Table 1) consisted of an approximately equal proportion of male and female patients. They had a median age of 2.25 yrs. and a mean length of ICU stay of 5.5 days. Only 17 (34%) had normal nutritional status at admission. The rest had varying degrees of malnutrition (table 1). Respiratory problems were the most common causes of ICU admission 13(26), followed by neurologic problems 10 (20) and Congenital heart defect 06 (12). The median length of ICU stay was 5.5 ( ) days. 5 (16.7%) children required mechanical ventilation and the median duration of mechanical ventilation was days. Nutritional therapy in any form was started on the day of admission in 60% of the patients, after 48 hours in 9%patients, and after 72 hrs 6% (Table 2). The mean time from PICU admission to starting enteral nutrition was 32.5 hrs. Time to reach 50% and 70% of energy goals was significantly more in patients with EN feeds started 24 hrs after admission. The majority of patients with delayed enteral feeding had a neurological illness with a GCS score of less than 8. A total of 118 interruptions to EN were identified. Total hours of interruptions to enteral nutrition were 85 days (2048 hrs) out of a total of 390 days (9360 hrs) of PICU stay, which means 21.8% of total PICU stay was without EN due to interruptions. The mean hrs of interruption per patient was 40.96. Enteral feeding was interrupted due to various reasons in almost all patients. A total of 619 hrs of interruptions were due to (30.9) altered sensorium due to CNS diseases, 504 hrs (24) were due to respiratory distress, 492 hrs (61.5) were due to RT aspirates, 292 hrs surgical procedure, 164 were due to diagnostic procedures, 163 hrs it was due to radiological investigations mainly MRI. After analysing the causes of interruptions, it was found that 82.23% were avoidable interruptions, 17.67% were avoidable interruptions, and 17 (56.7%) of pts achieved prescribed energy goals during their PICU stay. The mean time to achieve 50% of the calorie goal in the study population was 3.71 days; it was 4.8 to reach 70% and 5.93 to achieve 100% calorie goals. Table 1: Baseline characteristics of the study group subjects BASELINE CHARACTERISTICS VALUE Median age (in months) 2.25 (11.5) Male: female 1: 1.7 Weight; median (kg) 5.1 Height; median (cm) 58 PICU length of stay; median (iqr) (days) 5.5 Mechanically ventilated, n (%) 5 (16.7%) Grade of malnutrition on admission(>5yrs) i) Adequately Nourished 06% ii) Grade 1 PEM 12% iii) Grade 2 PEM 02% iv) Grade 3 PEM 04% Inference as per WHO classification of malnutrition (<5 yrs.) i) Adequate for age 7% ii) Moderately wasted 7% iii) Moderately wasted and moderately stunted 1% iv) Severely wasted and moderately stunted 1% Severely wasted and severely stunted 02% Table 2: Diagnosis in the study group Diagnosis Median(%) Respiratory illness 13(26) Neurologic/seizures 10 (20) Congenital heart defect 6 (12) Neurosurgery/Trauma 6 (12) sepsis/septic Shock 5 (10) Dengue fever 4 (8) Hemato-Oncology 4 (8) GI surgery 2 (4) Table 3: Evaluation of variables in the study group Variables Value Time taken (hrs) to start EN after PICU admission; Median (IQR) 23.5 (12.3) No. of patients (%) who achieved energy goals during PICU stay 17 (56.7) No. of patients (%) who achieved protein goals during PICU stay 25 (83.3) Time to reach energy intake goal, in days; Median (IQR) 5.5 (3.3) Time to reach protein intake goal, in days; Median (IQR) 4 (2) Table 4: Comparison of details about the interruptions in the study group Interruptions Group Total number of interruptions 283 Hours of interruptions 85 days (2048 hrs ) Mean Hours of interruptions per patient 40.9 Avoidable interruptions (82.23%) Unavoidable interruptions (17.67%) causes Interruptions altered sensorium due to CNS diseases 619 respiratory distress 504 RT aspirates 492 diagnostic procedures 164 to radiological investigations 163 Surgical procedures 292 Table 5: Evaluation of the adequacy of nutritional support in the study group Variables Study group Prescribed goals for daily energy intake (calculated as per Schofield equation); (Kcal/kg/d); Mean (SD) 67 (12) Delivered daily energy intake; (Kcal/kg/d); Mean (SD) 47(11) Prescribed goals for daily protein intake; (gr/kg/d); Mean (SD) 1.8 (0.5) Delivered daily protein intake; (gr/kg/d); Mean (SD) 1.8 (0.4)

Although EN is the preferred mode of nutrient delivery in critically ill patients, barriers to the optimal delivery of enteral nutrients at the bedside persist (7). Several eligible patients are deprived of EN during critical illness because of factors, such as suboptimal prescription, failure to initiate EN early, or frequent and prolonged interruptions to enteral feeding (8,9,10). Delayed initiation and subsequent interruptions are the main contributors to suboptimal EN administration in the PICU. (C) The current clinical guidelines for nutritional support in critically ill children recommend early initiation of EN within the first 24 hours following admission ( ).Early enteral nutrition is essential to reach the desired calorie and protein intake at an early stage. advantages It has been observed that the initiation time of nutrition therapy in the PICU setting is unnecessarily prolonged.6,9,14. Sixty percent of patients in our study were started on enteral nutrients on the first day of admission. However, in 9% of the patients in this study, EN was initiated 48 hr after admission, and 6% of patients received EN after 72 hr of admission. The results of this study are consistent with Taylor et al,13 who reported 59% of patients to be initiated within the first 24 hours of admission, and Mehta et al,9 who reported the mean time to initiation to be 24 hours with a range of 0–3.5 days. It is even though early EN is known to improve clinical outcomes, decrease infection rates, and length of stay and is cost-effective (1, 9-11). Common reasons behind late EN are increased levels of respiratory support, the severity of illness, procedures and gastrointestinal disturbances, and physicians’ ignorance of nutritional requirements (7, 14). Many physicians are reluctant to start EN, especially in critically ill patients, because it is known to be associated with an increased risk of aspiration pneumonia (2). In a study performed by Hosun Lee et al. (8), the most common cause of delayed EN was altered GI motility and hemodynamic instability.3 Jackie Mara et al observed that patients with general surgical problems and congenital heart defects (CHDs) took longer to start EN. In our study, the most common reason for delayed EN was reluctance on the part of physicians in hemodynamic instability patients and the severity of the disease. The problem of feed interruption during EN is well recognized (11)(D). The care of a critically ill patient involves multiple interventions, which often compete with the delivery of EN in the intensive care setting. Elective procedures, unplanned interventions, or diagnostic tests often require a fasting state, requiring interruption of EN. In addition, feeding intolerance or contraindications to enteral feeding related to the disease processes may require feeding to be postponed or discontinued in the PICU. In our study, for various reasons, enteral feeding was interrupted for some duration in a majority of the patients. In 10 patients duration of interruption was less than 12 hrs in rest 40 cases it was more than 12 hrs. The total duration of interruptions to enteral nutrition was 85 days 2048 hrs, and the mean hours of interruptions per patient was 40.9 hrs. Out of total feeding hours 21.8% time was spent without feed due to EN interruptions. Common causes for EN interruptions in our study population were altered sensorium due to CNS diseases and respiratory distress requiring respiratory support followed by feeding intolerance indicated by RT aspirates, surgical procedures, and radiological investigations, mainly MRI. Mehta et al (11), in a prospective observational study of 117 children, found that interruptions occurred in 30% of PICU patients, and 58% of these interruptions were classed as avoidable. A Canadian survey of physicians and dieticians (3) found fasting for procedures to be a major barrier. Fasting for procedures, both in the PICU (such as for extubation) or outside the PICU (for radiological procedures) and to the operating department, are considerable problems for most intensive care patients. No evidence exists regarding "safe" fasting times for critically ill children and specifically which procedures require fasting. The fear driving fasting is potentially having a "full stomach" and the risk of pulmonary aspiration associated with emergency reintubation (if the endotracheal tube became dislodged) (12) (E). Enid E. Martinez et al. conducted a prospective observational study published in 2016. EN intolerance, mechanical ventilation, ICU procedures, radiology investigations and operative procedures, and intravenous feeding are interrupted in 30–42% of PICU patients9. These disruptions could result in 42.4 percent of PICU time spent without food and failure to meet nutrient delivery targets9. However, compared to previous studies, EF was started early in our study population, but the number and duration of interruptions were more. Lyvonne N. Tume et al conducted a study in which 920 pediatric critical care professionals from 57 countries participated in a cross-sectional online survey. (a stumbling block to EN delivery)4. fluid restriction was the most significant barrier for dietitians (69%) compared to delaying meals before procedures (46%) for physicians and insufficient dietician coverage on weekends, nights, and holidays for nurses (44%). LIMITATIONS OF STUDY This was a single-centre study, some of our findings are unlikely to be generalizable due to the small sample size. We did not measure resting energy expenditure in PICU patients due to the unavailability of facilities for it; hence, estimated caloric and volume goals were used to prescribe caloric or volume intake. We did not measure protein intake and excretion in our patients and hence cannot comment on the effect of EN deprivation on protein balance.

This study highlights the problems associated with enteral nutrition during the management of a critically ill child. This shows that the nutritional requirements of sick children were seldom achieved in the paediatric critical care unit. EN was often initiated as late after admission and was interrupted in a significant proportion of cases. By taking care of many avoidable delays and interruptions to EN, we can improve nutritional intake. Strategies for reducing avoidable delayed EN and interruptions are required to improve enteral nutrition delivery and the nutritional status of critically ill children.

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Keehn A, O’Brien C, Mazurak V, et al. Epidemiology of interruptions to nutrition support in critically ill children in the pediatric intensive care unit. J Parenter Enteral Nutr 2015; 39:211–217. The prospective study highlights the high frequency of enteral nutrition interruptions in the PICU, with a report of a median of 42.4% of time in the PICU spent without nutrition. Most common reasons for enteral nutrition interruptions included procedures, including extubation and enteral nutrition intolerance. 14. Canarie MF, Barry S, Carroll CL, et al. Risk factors for delayed enteral nutrition in critically ill children. Pediatr Crit Care Med 2015; 16:e283–e289. The multicenter cross-sectional study highlights positive pressure ventilation, severity of illness, procedures, and gastrointestinal disturbances as clinical risk factors for delayed enteral nutrition delivery in the PICU. 15. Martinez EE, Bechard LJ, Mehta NM. Nutrition algorithms and bedside nutrient delivery practices in pediatric intensive care units: an international multicenter cohort study. Nutr Clin Pract 2014; 29:360–367.The multicenter study highlights the prevalence of poor enteral nutrition delivery and enteral nutrition intolerance as a common cause for limited enteral nutrition delivery 16. 63. Hamilton S, McAleer DM, Ariagno K, et al. A stepwise enteral nutrition algorithm for critically ill children helps achieve nutrient delivery goals. Pediatr Crit Care Med 2014; 15:583–589. The pre and postintervention prospective study examined the impact of introducing a stepwise algorithm for enteral nutrition. Following the algorithm implementation, the authors report a decrease in enteral nutrition interruptions, time to reach goal enteral nutrition, reduced use of parenteral nutrition, and an increase in number of patients who reached enteral nutrition goal. 17. 64. Petrillo-Albarano T, Pettignano R, Asfaw M, Easley K. Use of a feeding protocol to improve nutritional support through early, aggressive, enteral nutrition in the pediatric intensive care unit. Pediatr Crit Care Med 2006; 7:340–344 18. Enid E. Martineza,b and Nilesh M. Mehta The science and art of pediatric critical care nutrition Curr Opin Crit Care 2016, 22:316–324 DOI:10.1097/MCC.0000000000000316 Early and optimal enteral nutrition, and specifically optimal protein intake, in critically ill children is associated with improved clinical outcomes.