Is Undernutrition Associated With Deterioration of Outcomes in the Pediatric Intensive Care Unit (PICU): Systematic and Meta-Analysis Review

Abstract

Background and aim: Undernutrition (UN) may negatively impact clinical outcomes for hospitalized patients. The relationship between UN status at pediatric intensive care unit (PICU) admission and clinical outcomes is still not well-reported. This systematic meta-analysis review evaluated the impact of UN at admission to PICU on clinical outcomes, including mortality incidence, length of stay (LOS), and the need for and length of time on mechanical ventilation (MV).

Methods: A search was conducted using relevant and multi-medical databases from inception until January 2022. We considered studies that examined the link between UN at PICU admission and clinical outcomes in patients aged 18 years or younger. Pooled risk difference estimates for the PICU outcomes were calculated using a random-effects model.

Result: There were a total of 10,638 patients included in 17 observational studies; 8,044 (75.61%) and 2,594 (24.38%) patients, respectively, were normal-nourished (NN) and undernourished (UN). In comparison to NN patients, UN patients had a slightly higher risk of mortality (RD = 0.02, P = 0.05), MV usage (RD = 0.05, P = 0.02), and PICU LOS (RD = 0.07, P = 0.007). While the duration of MV was significantly longer in UN than in NN (RD = 0.13, P < 0.0001). Sensitivity analysis of UN classification cohorts with a z-score < -2 or in the 5%, patetints age up to 18 years, and mixed diagnose for PICU admission demonstrated a 6-fold increase in the probability of PICU LOS in UN patients compared to NN patients (RD = 0.06, 95% CI = 0.01, 0.12). UN patients have a higher risk of MV usage RD = 0.07, 95% CI = 0.00, 0.14) in studies involving cohorts with a mixed primary diagnosis for PICU admission.

Conclusion: In PICU, UN is linked to mortality incidence, longer PICU stay, MV usage, and duration on MV. The primary diagnosis for PICU admission may also influence clinical outcomes. Determining the prevalence of UN in hospitalized patients, as well as the subgroups of patients diagnosed at the time of admission, requires more research. This may help explain the relationship between nutritional status and clinical outcomes in PICU patients.

Keywords: length of stay; mortality incidence; nutrition status; pediatric intensive care unit; the need for and length of time on mechanical ventilation; undernutrition.

Figure 1

PRISMA flow diagram employed in the literature search process to identify articles that met the inclusion criteria for this systematic review.

Figure 2

Forest plots of pooled (A) estimation RD of mortality incidence between PICU patients with undernutrition and normal nutrition. (B) Funnel plots assessing for publication bias in studies reporting estimation mortality RD between undernutrition and normal nutrition. CI, confidence interval.

Figure 3

Forest plots of pooled estimation risk difference of MV usage between UN and NN patients. CI, confidence interval.

Figure 4

Forest plots of pooled (A) estimation risk difference, (B) standardized mean difference of PICU LOS between undernutrition and normal nutrition patients. CI, confidence interval.

Figure 5

Forest plots of pooled (A) estimation risk difference, (B) standardized mean difference of prolonged use of MV between undernutrition and normal nutrition PICU patients. CI, confidence interval.