What are the recommendations for feeding a 4-year-old child with Acute Respiratory Distress Syndrome (ARDS) who is intubated?

Feeding Management for an Intubated 4-Year-Old Child with ARDS

Initiate enteral nutrition through a nasogastric tube within the first 48 hours of ARDS diagnosis, preferably as early as possible after hemodynamic stabilization, and do not withhold feeding solely because the child is on vasoactive medications. 1

Route and Timing of Nutrition

Enteral nutrition is the preferred method of feeding and should be started early in the PICU course. 1

• Use a gastric tube (nasogastric or orogastric) rather than a post-pyloric feeding tube as the initial route of enteral feeding. 1
• Post-pyloric feeding should only be performed in patients with documented gastric intolerance after prokinetic treatment or in patients at high risk for aspiration. 1
• Parenteral nutrition may be withheld for the first 7 days of PICU admission if enteral nutrition can be provided. 1
• The prone position does not represent a contraindication for enteral nutrition and should not delay feeding. 1

Hemodynamic Considerations

Do not withhold enteral feeding solely based on vasoactive-inotropic medication administration. 1

• Enteral feeding is not contraindicated in children with septic shock or ARDS after adequate hemodynamic resuscitation who no longer require escalating doses of vasoactive agents or in whom weaning of vasoactive agents has started. 1
• This represents a critical shift from older practice patterns that delayed feeding in hemodynamically unstable children. 2

Energy and Protein Goals

Determine energy expenditure using indirect calorimetry when available to guide precise calorie targets. 1

• If indirect calorimetry is unavailable, use VO2 from pulmonary arterial catheter or VCO2 from the ventilator rather than predictive equations, as equations tend to overestimate needs. 1
• Administer hypocaloric nutrition (not exceeding 70% of energy expenditure) in the early phase of acute illness (first 3 days), then increase to 80-100% after day 3. 1
• If using predictive equations, prefer hypocaloric nutrition (below 70% estimated needs) over isocaloric nutrition for the first week due to risk of overfeeding. 1
• Both overfeeding and underfeeding prolong duration of mechanical ventilation in children, making precise calorie goals essential. 2

Feeding Advancement Strategy

The evidence does not provide a clear recommendation on whether to use early hypocaloric/trophic feeding followed by slow advancement versus early full enteral feeding. 1

• Early and adequate enteral nutrition is associated with improved 60-day survival after pediatric critical illness. 2
• Early enteral nutrition (≥25% of calculated energy goal within first 48 hours) is associated with lower PICU mortality, shorter PICU length of stay, and more ventilator-free days in children with PARDS. 3
• Despite guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10, primarily due to perceived feeding intolerance and reluctance to feed during hemodynamic instability. 2

Monitoring and Tolerance

Do not routinely measure gastric residual volumes as a marker of feeding tolerance. 1

• Do not routinely use prokinetic agents for treatment of feeding intolerance. 1
• Monitor for clinical signs of feeding intolerance rather than relying on gastric residual volume measurements. 1

Supplementation and Additives

Avoid routine supplementation with specialized nutrients in children with ARDS:

• Do not use specialized lipid emulsions. 1
• Do not use selenium supplementation. 1
• Do not use glutamine supplementation. 1
• Do not use arginine supplementation. 1
• Do not use zinc supplementation. 1
• Do not use ascorbic acid (vitamin C) supplementation. 1

Common Pitfalls to Avoid

• Delaying enteral nutrition due to vasoactive medication use is not supported by evidence and may worsen outcomes. 1
• Excessive fluid restriction can interfere with the ability to provide sufficient nutritional intake and should be balanced against nutritional needs. 2
• Routine measurement of gastric residual volumes leads to unnecessary interruptions in feeding without improving outcomes. 1
• Using post-pyloric tubes as first-line feeding access is not recommended; start with gastric tubes. 1
• Inadequate delivery of enteral nutrition due to perceived intolerance contributes to malnutrition, with one out of every two children in the PICU developing or worsening malnutrition. 2