Nutritional requirements in a hospitalized or surgical pediatric patient provide a unique challenge. Pediatric patients respond more rapidly to severe illnesses and stress to the body because of decreased energy stores.

Adequate provision of nutrition requires careful nutritional assessment, determination of energy needs, and appropriate route of administration (eg, enteral or parenteral).

Although parenteral nutrition (PN) in adult patients has been described in the literature as early as the 1600s, Dr William C Heird and colleagues reported the first successful and safe administration of PN in infants in 1972.¹

Energy expenditure increases during periods of stress to the body, but the change is variable. Considerations in feeding route should be made based on the clinical course of the patient, the anticipated length of fasting, the underlying function of the GI (gastrointestinal) tract and nutritional status of the patient, and the degree of nutritional intake at baseline.²

Since then, advances in both enteral and parenteral modes of nutrition have optimized nutrition in the surgical pediatric patient.

Enteral feeds are preferred over parenteral feeds because they most closely resemble the normal physiologic activity of the GI tract.

PN involves delivery of nutrients intravenously; therefore, it is nonphysiological because nutrients bypass the liver. This can put patients at risk for liver dysfunction and cholestasis.²

Bypassing the GI tract can cause structural and functional changes, such as thinning of the mucosa, blunting of the villi, and increased bacterial translocation.³

Additionally, early initiation of PN may affect infants’ development of eating behaviors later in life.⁴

Not only do enteral feeds decrease risk of complications in pediatric patients but also they are less expensive and easier to administer.⁵

For these reasons, enteral nutrition is preferred over PN whenever possible. However, oftentimes critically ill and surgical pediatric patients are at risk for malnourishment in the hospital setting, so PN is sometimes necessary.

PN may be given to complement enteral feeding, or it may substitute enteral feeds, known as total parenteral nutrition (TPN).

PN is appropriate in children when enteral feeding is either not tolerated or unable to meet the patient’s energy needs.

In neonates, PN can begin within 48 to 72 hours of birth if the enteral route cannot be used.

In older infants and children, PN should only be used if a fasting period of 5 or more days is anticipated.⁶