Supplement: survey questions part 1 (survey) and part 2 (point-prevalence) Part 1: survey General information 1. What is your country of work? 2. What is the name of your institution? 3. What type of hospital do you work in? general hospital university hospital children’s hospital (non-university) university-children’s hospital other, specify 4. What is your profession? pediatric intensivist anesthesiologist pediatrician surgeon dietician/nutritionist Nurse/nurse practitioner 5. How many years of experience do you have working in a PICU? 1-5 20 >20 6-10 11- 6. What type of a PICU do you work in? multidisciplinary/mixed surgical cardiac medical other, specify 7. Is the PICU combined with an adult ICU or a neonatal ICU? Not combined adult Both neonatal and adult 8. What is the number of ICU beds in your unit? 1-10 11-20 neonatal 21-30 >30 9. What is the average number of admissions in your unit per year? 10. On average, what percentage of your patients are mechanically ventilated at some stage during their PICU course? <25% 25-50% >50-75% >75% Nutritional assessment and demands 1. Is there a pediatric nutrition support team or unit in your institution? No Yes a. If yes: This nutritional team consists of: pediatric intensivist anesthesiologist pediatrician surgeon dietician nurse pharmacist other b. If yes: How often is this team visiting the PICU? daily except weekends & bank holidays > 1x a week 1-4x/month 6-12 x/year < 6x/year other 2. Is there a nutritional protocol used in your PICU? No Yes a. If Yes: This protocol contains information about (yes/no): i. Assessment of energy requirements ii. Assessment of protein requirements iii. Assessment and management of gastric residual volume iv. Administration of type of enteral formula v. Administration of amount of enteral formula vi. Administration of composition of parenteral nutrition vii. Administration of amount of parenteral nutrition b. If yes: Is an age- (or weight-) differentiated nutritional protocol used in your PICU? No Yes, for parenteral nutrition Yes, for enteral nutrition Yes, for both parenteral and enteral nutrition c. If No:Who is responsible for assessment of nutritional demands? Nutritional team pediatric intensivist anesthesiologist pediatrician dietician pharmacist other (specify ______) 3. How are the basal energy requirements of your patients in your PICU estimated? Harris-Benedict equation Schofield equation for weight Schofield equation for weight and height WHO White Talbot Don’t know other (specify _____) 4. What weight is used in the calculation of energy requirements? Estimated body weight Actual body weight Ideal body weight (growth chart) No weight used other 5. Are correction factors applied to resting energy expenditure to estimate total energy expenditure? Fever Specific diagnosis Growth Catch-up growth Absorption Blood parameters No correction factors used other 6. Is nutritional status monitored… (yes/no) a. On admission b. During PICU course/stay c. At discharge 7. How is nutritional status monitored? weight height upper arm/leg circumference head circumference skin fold thickness blood parameters not other (specify) 8. How much of the prescribed energy intake do you think a child in your PICU actually receives per day on the 2nd day? and on the 4th day? >90% 76-90% 51-75% 3150% <30% 9. Is indirect calorimetry used to measure resting energy requirements? NO YES, only in mechanical ventilated patients YES, in mechanical ventilated and non-ventilated patients (canopy mode) If Yes a. Which machine/device is used for indirect calorimetric measurements? Deltatrac Quark RMR Other b. When using indirect calorimetry, how long does a measurement take? <1 hour 1-5 hours 5-24 hours c. When is the first indirect calorimetric measurement performed? As soon as ventilator settings are appropriate Weight loss Expected stay > 4 days other d. When are consecutive indirect calorimetric measurements performed? Not, single measurement 4-7x/week 1-3x/week 1-3x/month On indication Other e. Is the prescribed energy intake adjusted to the measured energy expenditure? NO f. YES Is the Respiratory Quotient (RQ) used? No Yes, to decide if a patient is over/underfed Yes, to decide if the balance between carbohydrate/lipid intake is adequate Yes, to decide if the measurement is valid Other 10. The protein target used in your PICU is closest to the following guideline: ASPEN (0-2 years 2-3 g/kg/d, 2-13 years 1,5-2 g/kg/d, 13-18 years 1,5 g/kg/d) ESPEN/ESPGHAN (neonates 1,5-3 g/kg/d, 2 months-3 years 1-2,5 g/kg/d, 3-18 years 1-2 g/kg/d, critically ill 3 /kg/d) National Recommended Daily Allowances (RDA) (NL: neonates 1,8 g/kg/d, 1-12 months 1,2 g/kg/d, > 1 year 0,9 g/kg/d) 11. What is the (parenteral) lipid target used in your PICU (g/kg/day)? < 1.5 g/kg/d 1.5 tot 2.5 g/kg/d 2.5-3.5 g/kg/d > 3.5 g/kg/d No idea Other Enteral nutrition (EN) 1. What is the (average) target time for starting enteral feeds after PICU admission? No target time, depends on the attending physician’s choice <6 hours 6-12 hours 13-24 hours 25-48 hours >48 hours 2. In your opinion, how many days (average) post-admission would you be able to feed patients exclusively by enteral route in your PICU? <2 days 2-3 days 4-5 days 67 days >7 days 3. What is the preferred route for EN administration? Jejunal duodenal gastric no preference 4. How is a post-pyloric tube inserted? By endoscopy insertion Echographic Other By fluoroscopy Blind 5. How is a post-pyloric tube position controlled? Radiographic Biochemical indicators Not Other 6. Are intermittent or continuous feedings preferred? a. In ventilated patients: intermittent continuous no preference b. In non-ventilated patients intermittent continuous no preference c. In patients fed by gastric tube intermittent continuous no preference d. In patients fed by post-pyloric tube: intermittent continuous no preference 7. For what reasons is enteral feeding stopped or decreased? High gastric residuals Abdominal distension or pain Diarrhoea Vomiting Reduced or altered bowel sounds Haemodynamic instability Use of muscle relaxants Frequent procedures requiring fasting Surgical post-op orders other (specify 8. Are prokinetic agents used? No Yes, if a child is not tolerating feeds Yes, in every patient with a feeding tube Other 9. Is use of stress ulcer prophylaxis common in your unit? No Yes, in all PICU patients Yes, if a child is on mechanical ventilation Yes, in every patient with coagulopathy Yes, if a child is on steroids other Parenteral nutrition (PN) 1. How much glucose is administered during the first 12-24 hours of admission: < 10KG and 10-30KG and >30 KG: 2-4 mg/kg/min 4-6 mg/kg/min 6-8 mg/kg/min 8-10 mg/kg/min 2. How do you define hypoglycemia in your PICU? < 4,4 mmol/L (<80 mmg/dl) < 3,9 mmol/L (,70 mg/dl) < 2.8 mmol/L (<50 mg/dl) < 2,2 mmol/L (<40 mg/dl) <1,7 mmol/L (<30 mg/dl) other 3. At what glucose level is extra glucose administered (bolus or increased intake)? < 3,9 mmol/L (<70 mg/dl) < 2.8 mmol/L (,50 mg/dl) < 2,2 mmol/L (,40 mg/dl) <1,7 mmol/L (<30 mg/dl) other 5. Is the definition of hypoglycemia age or weight-dependent? No Yes 4. Is there a protocol for hyperglycemia treatment available? No Yes 5. What is the target blood glucose level in your PICU patients? <10 mmol/L (<180 mg/dl) <8 mmol/L (<144 mg/dl) <6 mmol/L (<108 mg/dl) <5 mmol/L (<90 mg/dl) 2.8-4.4 mmol/L (age < 1 year) 3.9-5.5 mmol/L (age 1-16 y) 6. Is the target blood glucose..? a. age/weight-dependent? No Yes b. different for certain patient populations (e.g. brain injury)? No Yes 7. At what point would you start PN in a child (expected to be) intolerable to enteral feeds? < 24 hours < 48 hours 2-4 days 4-7 days >7 days other 8. When enteral nutrition is provided but is insufficient to meet target goals, would PN be added? No Yes, always Yes, if enteral nutrition covers < 80% of target calories Yes, if enteral nutrition covers < 50% of target calories other 9. If PN is given in combination with EN at what moment (percentage of nutritional target achieved by EN) is PN stopped? If enteral nutrition covers 100% of target calories If enteral nutrition covers > 80% of target calories If enteral nutrition covers > 50% of target calories Other 10. How is PN provided in your institution?: Pharmacy-customized, age/weight specific Commercial mixed bags Other 11. Is it possible to administer PN without a central venous line? No Yes 12. Which lipid emulsion(s) is/are used? Intralipid (Fresenius) Smoflipid (Fresenius) Omegaven (Fresenius) Clinoleic (Baxter) Lipoplus (Braun) Other… 13. What is your policy regarding parenteral lipid administration? Start at maximal dose Start at 50% of maximal dose Dose depends on blood parameters Dose depends on clinical parameters Other… 14. When is lipid administration stopped? Or decreased? Triglycerides > 5 mmol/L Triglycerides 3,5- 5 mmol/L Triglycerides <3,5 mmol/L Fever Sepsis Other 15. When is protein administration stopped? or decreased? Urea < 10 mmol/L Urea 1015 mmol/L Urea > 15 mmol/L Kidney failure Other ….. 16. Do you routinely administer vitamins and trace elements, when no PN is given. No Yes 17. Do you have anything to add to this survey? 18. What’s your name and email-address (for future references, not mandatory) Part 2: point-prevalence Patient number 1: Patient demographics 1. Gender a. Male b. Female 2. Age category a. Neonate (0-1 month) b. Infant (1 month – 1 year) c. Child 1-5 years d. Child 5-10 years e. Child 10-15 years f. Adolescent > 15 years 3. Diagnosis category a. Medical – respiratory b. Medical – neurologic c. Medical – cardiac d. Medical – other e. Surgical – abdominal f. Surgical – cardiac g. Surgical - trauma h. Surgical – neurologic i. Surgical - other General information 1. PICU length of stay at moment of data entry : … days 2. Ventilation at moment of data entry a. Yes, invasive b. Yes, non-invasive c. No 3. Weight used for calculation of requirements: … kg Enteral nutrition details 1. Is enteral nutrition (EN) provided in this patient? 2. If yes: How is enteral nutrition provided? a. Gastric tube b. Duodenal tube c. Jejunal tube d. Other 3. If yes: What type of enteral formula was used for today? (select up to 3) Please also note the volume of enteral nutrition administered. Parenteral nutrition details 1. What type of dextrose infusion (No TPN!) and volume was administered today? (select up to 3) If no dextrose infusion is provided, please go on to the next question 2. Is continuous insulin administered to treat hyperglycemia? a. Yes b. No 3. How is parenteral nutrition provided: a. Commercial mixed bag with dextrose, protein and lipids b. Commercial bags: separated dextrose, protein and lipids c. Commercial bags: combined dextrose and protein, separated lipids d. Handmade/pharmacy made 4. If Commercial mixed bag: what type of parenteral nutrition (commercial mixed bag) was provided and what volume? Type of mixed bag (eg Olimel) Volume (ml/hour) Volume (ml/24 hours) 5. If commercial bags: separated glucose, protein and lipids: What type of dextrose, protein and lipids were provided and what volume? Type of dextrose bag (eg 20% dextrose) Volume (ml/hour) Volume (ml/24 hours) Type of protein (eg primene 10%) Type of lipid (eg intralipid) 6. If commercial bags: combined glucose and protein, separated lipids : What type of dextrose/protein and lipids were provided and what volume Type of dextrose/protein bag (eg clinimix) Type of lipid (eg intralipid) Volume (ml/hour) Volume (ml/24 hours) 7. If handmade/pharmacy made: please provide a description of the different components of the handmade parenteral nutrition and if possible the energy and protein provided in total/day. Only fill out the fields that apply to your handmade PN Type of dextrose Volume (ml/hour) (eg dextrose 20%) Volume (ml/24 hours) Energy provided Protein in kcal/day provided in (NOT per kg) g/day (NOT per kg) Type of protein (eg primene 10%) Type of lipid (eg intralipid) Combined PN (eg dextrose 20%, amino acids 5%) 8. If no parenteral nutrition: Are vitamins/trace elements provided intravenously? a. Yes b. No 9. Do you want to add another patient? If yes same questions for patient 2 and so on…