Nutritional immunomodulation in critically ill children with acute lung injury: feasibility and impact on circulating biomarkers.

Objective: Respiratory failure caused by acute lung injury or acute respiratory distress syndrome is associated with significant morbidity in children. Enteral nutrition enriched with eicosapentaenoic acid, gamma-linolenic acid and antioxidants (eicosapentaenoic acid + gamma-linolenic acid) can safely modulate plasma phospholipid fatty acid profiles, reduce inflammation, and improve clinical outcomes in adults. There is little information regarding the use of enteral eicosapentaenoic acid + gamma-linolenic acid to modulate plasma phospholipid fatty acid profiles in children. We sought to determine if continuous feeding of enteral nutrition containing eicosapentaenoic acid, gamma-linolenic acid, and antioxidants was feasible in critically ill children with acute lung injury or acute respiratory distress syndrome. We further evaluated the impact of such an approach on the alteration of plasma phospholipid fatty acid concentrations. Design: Prospective, blinded, randomized, controlled, multicenter trial. Setting: PICU. Patients: Twenty-six critically ill children (age 6.2 +/- 0.9 yr, PaO2/FIO2 185 +/- 15) with the diagnosis of acute lung injury or acute respiratory distress syndrome. Interventions: Mechanically ventilated children received either eicosapentaenoic acid + gamma-linolenic acid or a standard pediatric enteral formula. Clinical, biochemical, plasma fatty acid, and safety data were assessed at baseline, study days 4 and 7. Measurements and Main Results: At baseline, there were no significant differences in the two study groups. Both groups met enteral feeding goals within 30 hrs and had similar caloric delivery. There were no differences in formula tolerance as measured by serum chemistries, liver and renal function, and hematology studies after 7 days of feeding either eicosapentaenoic acid + gamma-linolenic acid or pediatric enteral formula. On study day 4 and 7, plasma phospholipid fatty acid profiles in the eicosapentaenoic acid + gamma-linolenic acid group showed a significant increase in anti-inflammatory circulating markers. Conclusions: Providing enteral nutrition with eicosapentaenoic acid + gamma-linolenic acid to critically ill children with lung injury was feasible and caloric goals were met within 30 hrs. This feeding protocol effectively modulated plasma phospholipid fatty acid concentrations to reflect an anti-inflammatory profile. This study provides data to inform future outcome studies using enteral eicosapentaenoic acid + gamma-linolenic acid in children with lung injury. (Pediatr Crit Care Med 2013; 14:e45-e56)