Changes in global nutrition practices in critically ill children and the impact of emerging evidence: a secondary analysis of the Pediatric International Nutrition Studies (PINS), 2009-2018

Background The timeline of the three Pediatric International Nutrition Studies (PINS) coincided with the publication of 2 major guidelines for the timing of parenteral nutrition (PN) and recommended energy and protein delivery dose. Objective The study's main objective was to describe changes in the nutrition delivery practice recorded in PINS 1 and 2 (conducted in 2009 and 2011, pre-exposure epoch) versus PINS 3 (conducted in 2018,post-exposure epoch), in relation to the published practice guidelines. Design This study is a secondary analysis of data from a multi-center prospective cohort study. Participants /setting. Data from 3650 participants, aged 1 month to 18 years, admitted to 100 unique hospitals that participated in three PINS was used for this study. Main outcome measures The time in days from PICU admission to the initiation of PN and enteral nutrition (EN) delivery were the primary outcomes. Prescribed energy and protein goals were the secondary outcomes. Statistical analyses performed A frailty model with a random intercept per hospital with stratified baseline hazard function by region for the primary outcomes and a mixed-effects negative binomial regression with random intercept per hospital for the secondary outcomes. Results The proportion of patients receiving EN (88.3% vs. 80.6%, p-value<0.001) was higher, and those receiving PN (20.6% vs. 28.8%, p-value<0.001) was lower in the PINS3 cohort compared to PINS1-2. In the PINS3 cohort, the odds of initiating PN during the 1st 10 days of PICU admission were lower, compared to the PINS1-2 cohort (HR=0.8, CI=[0.67-0.95], p-value=0.013); and prescribed energy goal was lower compared to the PINS1-2 cohort (IRR=0.918, CI=[0.874-0.965], p=0.001). Conclusions The likelihood of initiation of PN delivery significantly decreased in the first ten days post-admission in the PINS3 cohort compared to PINS1-2. Energy goal prescription in mechanically ventilated children significantly decreased in the post-guidelines epoch compared to the pre-guidelines epoch.