Arvid Wretlind Lecture 2024 optimal nutrition in critically ill children: Could less be more?

This article reflects my journey over the past several decades in challenging the long-held dogma that critically ill children should receive aggressive nutritional support—particularly high protein intake—early in the course of illness to counteract catabolism and promote anabolism. For many years, this belief dominated clinical practice, under the assumption that early and maximal nutritional delivery would improve outcomes in this vulnerable population. However, as new evidence began to emerge, this approach was called into question. The multicenter PEPaNIC (Early versus Late Parenteral Nutrition in the Pediatric Intensive Care Unit) randomized controlled trial was a pivotal step in addressing this issue. By investigating causality, the trial demonstrated that early supplementation of insufficient or contraindicated enteral nutrition with parenteral nutrition during the first week of admission to the pediatric intensive care unit (PICU) did not lead to improved clinical outcomes. In contrast, tolerating a temporary macronutrient deficit appeared to be both safe and potentially beneficial, challenging the foundational assumptions of early aggressive nutritional intervention.