A stepwise approach to the development of a local protocol for nutritional support in critically ill children
https://doi.org/10.24884/2078-5658-2026-23-3-145-154
Abstract
Nutrition support is an important part of the complex therapy of critically ill children. A literature review of scientific publications shows that enteral nutrition (EN) is the preferred method of nutritional support for those with a functioning gastrointestinal tract. Despite the development of numerous national and international clinical guidelines and algorithms over the past decades, nutrition remains controversial.
The objective was to substantiate a stepwise approach in the development of a local protocol for nutritional support in the pediatric intensive care unit. This review does not focus on neonates and infants. A total of 50 publications were included.
A stepwise approach to creating a local protocol includes: assessment of nutritional status and timing of enteral feeding initiation; determination of target energy and protein requirements, nutrient delivery methods, and monitoring of nutritional tolerance.
A modern nutrition strategy in the pediatric NICU is active nutritional therapy based on proven algorithms, early use of enteral feeding, and continuous monitoring of gastrointestinal function. Given the nutritional recommendations, further clinical research and the development of standardized nutrition protocols in pediatric practice remain urgent tasks.
About the Authors
O. E. Mitkinov
Dorzhi Banzarov Buryat State University
Russian Federation
Russian Federation
Mitkinov Oleg E., Dr. of Sci. (Med.), Associate Professor, Head of the Department of Postgraduate Education, Institute of Medicine
24a, Smolina str., Ulan-Ude, 670000
A. S. Belkova
Dorzhi Banzarov Buryat State University
Russian Federation
Russian Federation
Belkova Anna S., Postgraduate Student, Department of Hospital Surgery
24a, Smolina str., Ulan-Ude, 670000
References
1. Aleksandrovich Yu. S., Aleksandrovich I. V., Pshenisnov K. V. Screening methods for assessing nutritional risk in hospitalized children. Vestnik intensivnoi terapii, 2015, vol. 3, pp. 24–31. (In Russ.).
2. Borovik T. E., Fomina M. V., Yatsyk S. P. et al. Enteral nutritional support for children with surgical pathology in the perioperative period. Rossiyskiy Pediatricheskiy Jurnal, 2023, vol. 26, no. 3, pp. 168–177. (In Russ.). http://doi.org//10.46563/1560-9561-2023-26-3-168-177.
3. Glebova E. S., Ivanova-Davydova E. V., Amcheslavsky V. G. Indirect calorimetry as an objective method for assessing the energy needs of patients in critical conditions. Detskaya kchirurgia, 2019, vol. 23, no. 6, pp. 329–334. (In Russ.). http://doi.org/10.21320/1818-474X-2022-2-120-128.
4. Kuligin A. V., Kapralov S. V., Kolokolov O. V. et al. Metabolism in critically ill patients. Sovremennye problemy nauki i obrazovaniya, 2022, vol. 4. (In Russ.). http://doi.org/10.17513/spno.31849.
5. Leiderman I. N., Gritsan A. I., Zabolotskikh I. B. et al. Perioperative nutritional support. Guidelines of the Federation of Anesthesiologists and Resuscitators. Vestnik intensivnoy terapii imeni A. I. Saltanova, 2021, vol. 4, pp. 7–20. (In Russ.). http://doi.org/10.21320/1818-474X-021-4-7-20.
6. Lisitsa I. A., Zavyalova A. N., Aleksandrovich Yu. S. Practical aspects of organizing enteral nutrition for patients in pediatric intensive care units. Part 1. Choosing a feeding method. Children’s Medicine of the North-West, 2024, vol. 12, no. 4, pp. 39–57. (In Russ.). https://doi.org/10.56871/CmN-W.2024.50.45.003.
7. Lisitsa I. A., Zavyalova A. N., Aleksandrovich Yu. S. et al. Practical aspects of organizing enteral nutrition for patients in pediatric intensive care units. Part 2. Textural changes and care features during enteral nutrition. Children’s Medicine of the North-West, 2024, vol. 12, no. 4, pp. 58–72. (In Russ.). https://doi.org/10.56871/CmN-W.2024.25.55.004.
8. Luft V. M., Lapitsky A. V., Sergeeva A. M. Organizational aspects of nutritional support for patients in a multidisciplinary emergency hospital. Messenger of anesthesiology and resuscitation, 2024, vol. 21, no. 1, pp. 88–94. (In Russ.). https://doi.org/10.24884/2078-5658-2024-21-1-88-94.
9. Tretyakova E. P., Shen N. P., Suchkov D. V. Evaluation of pediatric patients’ readiness to increase the volume of enteral nutrition in case of gastrointestinal dysfunction. Meditsinskiy almanakch, 2019, no. 5-6(61), pp. 42–45. (In Russ.). http://dx.doi.org/10.21145/2499-9954-2019-5-36-38.
10. Shmakov A. N., Aleksandrovich Yu. S., Stepanenko S. M. Protocol. Nutrition therapy for children in critical conditions. Anesteziologiya i reanimatologiya, 2017, vol. 62, no. 1, pp. 14–23. (In Russ.). http://dx.doi.org/10.18821/0201-7563-2017-62-1-14-23.
11. Balakrishnan B., Flynn-O’Brien K. T., Simpson P. M. et al. Enteral nutrition initiation in children admitted to pediatric intensive care units after traumatic brain injury // Neurocritical Care. – 2019. – Vol. 30. – P. 193–200. http://doi.org/10.1007/s12028-018-0597-6.
12. Bechard L. J., Duggan C., Touger-Decker R. et al. Nutritional status based on body mass index is associated with morbidity and mortality in mechanically ventilated critically ill children in the PICU // Critical Care Medicine. – 2016. – Vol. 44, № 8. – P. 1530–1537. http://doi.org/10.1097/CCM.0000000000001713.
13. Bechard L. J., Staffa S. J., Zurakowski D. et al. Time to achieve delivery of nutrition targets is associated with clinical outcomes in critically ill children // American Journal of Clinical Nutrition. – 2021. – Vol. 114, № 5. – P. 1859–1867. http://doi.org/10.1093/ajcn/nqab244.
14. Blaser A. R., Padar M., Mändul M. et al. Development of the Gastrointestinal Dysfunction Score (GIDS) for critically ill patients. A prospective multicenter observational study (iSOFA study) // Clinical Nutrition. – 2021. – Vol. 40. – P. 4932–4940. http://doi.org/10.1016/j.clnu.2021.07.015.
15. Brown A. M., Carpenter D., Keller G. et al. Enteral nutrition in the PICU: current status and ongoing challenges // Journal of Pediatric Intensive Care. – 2015. – Vol. 4, № 2. – P. 111–120. http://doi.org/10.1055/s-0035-1559806.
16. Chourdakis M., Hecht C., Gerasimidis K. et al. Malnutrition risk in hospitalized children: use of 3 screening tools in a large European population // American Journal of Clinical Nutrition. – 2016. – Vol. 103, № 5. – P. 1301–1310. http://doi.org/10.3945/ajcn.115.110700.
17. Compher C., Bingham A. L., McCall M. et al. Guidelines for the provision of nutrition support therapy in the adult critically ill patient: the American Society for Parenteral and Enteral Nutrition // Journal of Parenteral and Enteral Nutrition. – 2022. – Vol. 46, № 1. – P. 12–41. http://doi.org/10.1002/jpen.2267.
18. Deane A. M., Ali Abdelhamid Y., Plummer M. P. et al. Are classic bedside exam findings required to initiate enteral nutrition in critically ill patients: emphasis on bowel sounds and abdominal distension // Nutrition in Clinical Practice. – 2021. – Vol. 36. – P. 67–75. http://doi.org/10.1002/ncp.10610.
19. Dhochak N., Singh A., Malik R. et al. Acute gastrointestinal injury in critically ill children: Impact on clinical outcome // Journal of Paediatric and Child Health. – 2022. – Vol. 58. – P. 649–654. http://doi.org/10.1111/jpc.15804.
20. Gerasimidis K., Macleod I., Maclean A. et al. Performance of the novel Paediatric Yorkhill Malnutrition Score (PYMS) in hospital practice // Clinical Nutrition. – 2011. – Vol. 30. – P. 430–435. http://doi.org/10.1016/j.clnu.2011.01.015.
21. Hamilton S., McAleer D. M., Ariagno K. et al. A stepwise enteral nutrition algorithm for critically ill children helps achieve nutrient delivery goals // Pediatric Critical Care Medicine. – 2014. – Vol. 15, № 7. – P. 583–589. http://doi.org/10.1097/PCC.0000000000000179.
22. Haney A., Burritt E., Babbitt C. J. The impact of early enteral nutrition on pediatric acute respiratory failure // Clinical Nutrition ESPEN. – 2018. – Vol. 26. – P. 42–46. http://doi.org/10.1016/j.clnesp.2018.04.017.
23. Irving S. Y., Albert B. D., Mehta N. M., Srinivasan V. Strategies to optimize enteral feeding and nutrition in the critically ill child: a narrative review // Pediatric Medicine. – 2022. – Vol. 5. – P. 9. http://doi.org/10.21037/pm-21-17.
24. Joosten K. Nutritional screening and guidelines for managing the child with faltering growth // European Journal of Clinical Nutrition. – 2010. – Vol. 64. – P. 22–24. http://doi.org/10.1038/ejcn.2010.44.
25. Kratochvíl M., Klučka J., Klabusayová E. et al. Nutrition in pediatric intensive care: a narrative review // Children (Basel). – 2022. – Vol. 11, № 7. – P. 1031. http://doi.org/10.3390/children9071031.
26. Li X., Zou Y., Zuo J. et al. Evaluation of malnutrition risk screening in hospitalized children with digestive system diseases. A single-center cross-sectional study // Frontiers of Pediatric. – 2025. – Vol. 17. – P. 1598962. http://doi.org/10.3389/fped.2025.1598962.
27. Liauchonak S., Hamilton S., Franks J. D. et al. Impact of implementing an evidence-based definition of enteral nutrition intolerance on nutrition delivery: A prospective, cross-sectional cohort study // Nutrition in Clinical Practice. – 2023. – Vol. 38, № 2. – P. 376–385. http://doi.org/10.1002/ncp.10941.
28. Malekiantaghi A., Asna Ashari K., Shabani-Mirzaee H. et al. Evaluation of the risk of malnutrition in hospitalized children by PYMS, STAMP, and STRONGkids tools and comparison with their anthropometric indices: a cross-sectional study // BMC Nutrition. – 2022. – Vol. 21. – P. 33. http://doi.org/10.1186/s40795-022-00525-8.
29. Martinez E. E., Bechard L. J., Brown A. M. et al. Intermittent versus continuous enteral nutrition in critically ill children: A pre-planned secondary analysis of an international prospective cohort study // Clinical Nutrition. – 2022. – Vol. 41, № 12. – P. 2621–2627. http://doi.org/10.1016/j.clnu.2022.09.018.
30. Martinez J., Rodriguez Hovnanian K. M., Martinez E. E. Biomarkers and functional assays of epithelial barrier disruption and gastrointestinal dysmotility in critical illness // A Narrative Review. Nutrients. – 2023. – Vol. 19, № 18. – P. 4052. http://doi.org/10.3390/nu15184052.
31. McCarthy H., Dixon M., Crabtree I. et al. The development and evaluation of the screening tool for the assessment of malnutrition in paediatrics (STAMP) for use by healthcare staff // Journal of Human Nutrition and Dietetics. – 2012. – Vol. 25. – P. 311–318. http://doi.org/10.1111/j.1365-277X.2012.01234.x.
32. Mehta N. M., Bechard L. J., Cahill N. et al. Nutritional practices and their relationship to clinical outcomes in critically ill children. An international multicenter cohort study // Critical Care Medicine. – 2012. – Vol. 40, № 7. – P. 2204–2211. http://doi.org/10.1097/CCM.0b013e31824e18a8.
33. Mehta N. M., Bechard L. J., Zurakowski D. et al. Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study // American Journal of Clinical Nutrition. – 2015. – Vol. 102, № 1. – P. 199–206. http://doi.org/10.3945/ajcn.114.104893.
34. Mehta N. M., Skillman H. E., Irving S. Y. et al. Guidelines for the provision and assessment of nutrition support therapy in the pediatric critically ill patient: Society of critical care medicine and American society for parenteral and enteral nutrition // Journal of Parenteral and Enteral Nutrition. – 2017. – Vol. 41. – P. 706–742. http://doi.org/10.1177/0148607117711387.
35. Meinert E., Bell M. J., Buttram S. 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 // Pediatric Critical Care Medicine. – 2018. – Vol. 19. – P. 345–352. http://doi.org/10.1097/PCC.0000000000001471.
36. Mills K. I., Mehta N. M. Nutritional support in the pediatric ICU // Pediatric Critical Care. Springer. – 2019. – P. 137–154. http://doi.org/10.1007/978-3-319-96499-7_ 8.
37. Nakamura K., Yamamoto R., Higashibeppu N. et al. The Japanese Critical Care Nutrition Guideline 2024 // Journal of Intensive Care. – 2025. – Vol. 13, № 1. – P. 18. http://doi.org/10.1186/s40560-025-00785-z.
38. Quiroz-Olguin G., Gutierrez-Salmean G., Posadas-Calleja J. G. et al. The effect of enteral stimulation on the immuneresponse of the intestinal mucosa and its application in nutritional support // Europe Journal of Clinical Nutrition. – 2021. – Vol. 75, № 11. – P. 1–7. http://doi.org/10.1038/s41430-02100877-7.
39. Rohani P., Alimadadi H., Mirrahimi B. et al. Nutrition section position statement and clinical practice recommendations for children admitted to intensive care unit // Innovative Journal of Pediatric. – 2022. – Vol. 32, № 3. – e119824. http://doi.org/10.5812/ijp-119824.
40. Sermet-Gaudelus I., Poisson-Salomon A. S., Colomb V. et al. Simple pediatric nutritional risk score to identify children at risk of malnutrition // American Journal of Clinical Nutrition. – 2000. – Vol. 72. – P. 64–70. http://doi.org/10.1093/ajcn/72.1.64.
41. Singer P., Blaser A. R., Berger M. M. et al. ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit // Clinical Nutrition. – 2023. – Vol. 42, № 9. – P. 1671–1689. http://doi.org/10.1016/j.clnu.2023.07.011.
42. Tume L. N., Valla F. V., Joosten K. et al. Nutritional support for children during critical illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism, endocrine and nutrition section position statement and clinical recommendations // Intensive Care Medicine. – 2020. – Vol. 46, № 3. – P. 411–425. http://doi.org/10.1007/s00134-019-05922-5.
43. van Puffelen E., Hulst J. M., Vanhorebeek I. et al. Effect of late versus early initiation of parenteral nutrition on weight deterioration during PICU stay: Secondary analysis of the PEPaNIC randomised controlled trial // Clinical Nutrition. – 2020. – Vol. 39, № 1. – P. 104–109. http://doi.org/10.1016/j.clnu.2019.02.014.
44. van Puffelen E., Hulst J. M., Vanhorebeek I. et al. Outcomes of delaying parenteral nutrition for 1 week vs initiation within 24 Hours among undernourished children in pediatric intensive care: A subanalysis of the PEPaNIC randomized clinical trial // JAMA Network Open. – 2018. – Vol. 1, № 5. – e182668. http://doi.org/10.1001/jamanetworkopen.2018.2668.
45. Vanhorebeek I., Verbruggen S., Casaer M. P. et al. Effect of early supplemental parenteral nutrition in the paediatric ICU: a preplanned observational study of post-randomisation treatments in the PEPaNIC trial // Lancet Respiratory Medicine. – 2017. – Vol. 5, № 6. – P. 475–483. http://doi.org/10.1016/S2213-2600(17)30186-8.
46. White M., Lawson K., Ramsey R. et al. Simple nutrition screening tool for pediatric inpatients // Journal of Parenteral and Enteral Nutrition. – 2016. – Vol. 40. – P. 392–398. http://doi.org/10.1177/0148607114544321.
47. Wong J. J., Han W. M., Sultana R. et al. Nutrition delivery affects outcomes in pediatric acute respiratory distress syndrome // Journal of Parenteral and Enteral Nutrition. – 2017. – Vol. 41. – P. 1007–1013. http://doi.org/10.1177/0148607116637937.
48. Xu Y., Jiang Y., Guo M. et al. Efficiency analysis of nutritional screening tools for children with congenital heart disease: a retrospective observational study // Frontiers in Nutrition. – 2025. – Vol. 30, № 12. – 1572805. http://doi.org/10.3389/fnut.2025.1572805.
49. Yi D. Y. Enteral nutrition in pediatric patients // Pediatric gastroenterology hepatology and nutrition. – 2018. – Vol. 21, № 1. – P. 12–19. http://doi.org/10.5223/pghn.2018.21.1.12.
50. Zhu X. M., Qian S. Y., Lu G. P. et al. Chinese guidelines for the assessment and provision of nutrition support therapy in critically ill children // World Journal of Pediatrics. – 2018. – Vol. 14, № 5. – P. 419–428. http://doi.org/10.1007/s12519-018-0175-1.
Review
For citations:
Mitkinov O.E., Belkova A.S. A stepwise approach to the development of a local protocol for nutritional support in critically ill children. Messenger of ANESTHESIOLOGY AND RESUSCITATION. 2026;23(3):145-154. (In Russ.) https://doi.org/10.24884/2078-5658-2026-23-3-145-154
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