Journal of Pediatric Surgery 50 (2015) 60–63

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Enteral nutrition in neonatal and pediatric extracorporeal life support: A

survey of current practice
Thomas J. Desmarais a,b, Yan Yan c, Martin S. Keller a, Adam M. Vogel a,⁎
a
Division of Pediatric Surgery, Washington University School of Medicine in Saint Louis, Saint Louis, MI, United States
b
Geisel School of Medicine at Dartmouth, Hanover, NH, United States
c
Department of Surgery, Washington University School of Medicine in Saint Louis, Saint Louis, MI, United States

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: The purpose of this study was to characterize enteral (EN) nutrition practices in neonatal and pediatric
Received 29 September 2014 patients receiving extracorporeal life support (ECLS).
Accepted 6 October 2014 Methods: A Web-based survey was administered to program directors and coordinators of Extracorporeal Life
Support Organization centers providing neonatal and pediatric ECLS. The survey assessed patient and clinical fac-
Key words: tors relating to the administration of EN.
Extracorporeal life support
Results: A total of 122 responses (122/521, 23.4%) from 96 institutions (96/187; 51.3%) were received. One
ECLS
ECMO
hundred fifteen provided neonatal or pediatric ECLS, and 84.2% reported utilizing EN during ECLS. 55% and
enteral 71% of respondents provide EN ‘often’ or ‘always’ for venoarterial and venovenous ECLS, respectively. EN was
nutrition reported as given ‘often’ or ‘always’ by 24% with increased vasopressor support, 53% with “stable” vasopressor
critical care support, and 60% with weaning of vasopressor support. Favorable diagnosis for providing EN includes respiratory
distress syndrome, pneumonia, asthma, trauma/post-operative, pulmonary hemorrhage, and infectious cardio-
myopathy. Vasopressor requirement and underlying diagnosis were the primary or secondary determinant of
whether to provide EN 81% and 72% of the time. 38% reported an established protocol for providing EN.
Conclusion: EN support is common but not uniform among neonatal and pediatric patients receiving ECLS. ECLS
mode, vasopressor status, and underlying diagnosis play an important role in the decision to provide EN.
© 2015 Elsevier Inc. All rights reserved.

1. Background intestinal absorptive function, increased bacterial translocation, central-

line infections, hyperglycemia, and cholestasis [7].
Extracorporeal Life Support (ECLS) utilizes a series of established and Delivery of EN may be avoided because of concerns regarding
evolving technologies to deliver life saving treatment to critically ill inadequate intestinal perfusion and non-occlusive mesenteric ischemia
patients with reversible cardiac and pulmonary failure [1]. Malnutrition with the development of necrotizing enterocolitis, intestinal ischemia,
in critically ill patients is extremely common and is associated with perforation, or gastrointestinal hemorrhage. Despite these concerns,
increased mortality and morbidity including impaired immune function, hypoperfusion related intestinal complications while on ECLS remain
impaired ventilator drive, prolonged ventilator dependence, and an unproven risk. Several small studies have documented the feasibility
increased infections [2]. Consequently, adequate nutrition is essential and safety of EN in ECLS patients in the neonatal, pediatric, and adult
to minimize physiologic complications of critical illness and to promote populations [7–13]. Additionally, current guidelines for providing nutri-
patient recovery. tional support of neonates simultaneously supported with ECLS recom-
Enteral nutrition (EN) is the preferred method of caloric, protein, and mend initiating enteral feeds when patients are clinically “stable” [14].
micronutrient delivery and has been shown to reduce sepsis-associated The optimum route for delivery of nutrition in neonates and children
morbidity and cost, improve intestinal immunologic function, and receiving ECLS is not well established and practice patterns have not
improve nitrogen balance in critically ill patients [3–5]. Alternatively, been described. The goal of this study is to characterize current practice
parenteral nutrition (PN) has been used to deliver daily caloric, protein, patterns of the administration and delivery of EN at centers treating
and micronutrient requirements [6], but is associated with several neonatal and pediatric ECLS patients.
complications including intestinal villus hypoplasia, reduction of
2. Methods

The Washington University in St. Louis School of Medicine Institu-

⁎ Corresponding author at: Division of Pediatric Surgery, Washington University School
of Medicine in St. Louis, One Children's Place, Suite 5S40, Saint Louis, MO 63110, United
tional Review Board (#201302094) approved this study. The Extracor-
States. Tel.: +1 314 454 6022; fax: +1 314 454 2442. poreal Life Support Organization (ELSO) is an international consortium
E-mail address: [email protected] (A.M. Vogel). of health care professions and scientists who are dedicated to the

http://dx.doi.org/10.1016/j.jpedsurg.2014.10.030
0022-3468/© 2015 Elsevier Inc. All rights reserved.
 T.J. Desmarais et al. / Journal of Pediatric Surgery 50 (2015) 60–63 61

development and evaluation of novel therapies for support of failing Twenty-five respondents reported that there was at least one factor
organ systems [15]. Contact information for ECLS program directors considered more important at their institution than the four factors
and coordinators was obtained from participating centers identified discussed above. In the free response space provided, the most com-
on the ELSO Web site. The survey was administered through the monly listed factors included bowel functionality [14], severity of illness
REDCap electronic data capture tool hosted at Washington University [2], lactic acidosis [2], presence of central cannulation [2], and cardiac
in St Louis [16]. A link to the survey was sent electronically on June 4, arrest [2]. Other reasons included: “presence of feeding tube prior to
2013, with reminders sent on June 17, 2013, and again on July 8, heparinization” and “unit preference.”
2013. The thirteen question Web-based survey was designed to assess Forty-four of the respondents declared that there is a preferred
nutritional implementation and delivery practices in neonatal and anatomic site for the delivery of enteral feeds during ECLS. Of those
pediatric patients on ECLS. The survey (see Appendix A) sought to reporting a preferred site for delivery of enteral feeds, 18 (41%) reported
determine factors that might influence EN implementation such as ‘gastric’ as the preferred site, while 26 (59%) reported ‘post pyloric’ as
ECLS mode, patient diagnosis, vasopressor support, and pharmacologic the preferred site.
paralysis as well as administration preferences (gastric vs. post-pyloric Thirty-six respondents, 38% of those answering the question, reported
and institutional unit-based “feeding” protocols). that their institution had an established protocol for managing enteral
The data were compiled anonymously and analyzed as a composite. nutrition on ECLS. Fourteen respondents reported a pediatric only
Responses are reported as ranges for continuous data and percentages protocol, three a neonatal only protocol, and nineteen reported having
for categorical data. Write-in answers are reported as direct quotes or both pediatric and neonatal protocols.
grouped by theme.
4. Discussion

3. Results The results of our survey indicate that the vast majority of ECLS
program directors and coordinators at ELSO centers provide EN to
Surveys were sent to 521 individuals from 187 institutions. One neonatal and pediatric patients receiving ECLS. Significant variability
hundred twenty-two responses (23.4%) were received representing appears to exist with regard to the patient and cincal parameters that
96 institutions (51.3%). Of the 122 responses, 115 individuals reported dictate the decision to initiate EN. ECLS patients are often the most
providing neonatal or pediatric ECLS at the 90 centers they represented. critically ill and may gain significant benefit from EN [14]. However,
Of these centers, 68.8% are located in the United States, 5.6% in the there have been no rigorous, prospective studies investigating the role
United Kingdom, and the remaining centers come from fifteen of EN on outcome in ECLS patients.
other countries. The relationship of ECLS and the initiation of EN on gastrointestinal
One hundred fourteen individuals continued the survey, and 96 physiology has been explored in patients receiving ECLS. An analysis
(84.2%) reported providing enteral nutrition (EN), while 18 (15.8%) of a cohort of 16 neonatal VA ECLS patients showed an overall increase
reported not providing enteral nutrition to their patients on ECLS. As in intestinal permeability [10]. The initiation of enteral nutrition to
summarized in Table 1, respondents were asked to rate how often seven patients did not result in any additional changes in intestinal
their center provides EN to children on ECLS based on ECLS mode, permeability. Therefore, although intestinal integrity in ECLS patients
patient diagnosis, level of vasopressor support, and pharmacologic may be compromised, it does not appear to deteriorate with EN. The
paralysis. Respondents were also asked to rank which of these four results of intestinal hormone response (gastrin, cholecystokinin, and
categories would be considered the most important when deciding peptide-YY) to enteral nutrition in neonates supported on VA ECLS
whether or not to provide EN (Table 2). have also been evaluated in twelve patients and compared to twelve

Table 1
Utilization of enteral nutrition based on ECLS mode, diagnosis, vasopressor status, and paralysis.

Variable N (%) Never (%) Occasionally (%) Some (%) Often (%) Always (%)

VA ECLS 96 (100) 4 (4.1) 24 (25) 15 (15.6) 37 (38.5) 16 (16.7)

VV ECLS 91 (94.8) 2 (2.2) 13 (14.3) 11 (12) 37 (40.7) 28 (30.8)
Neonatal diagnoses
Meconium aspiration 75 (78.1) 17 (22.7) 14 (18.7) 10 (13.3) 18 (24) 16 (21.3)
PPHN 75 (78.1) 13 (17.3) 18 (24) 10 (13.3) 18 (24) 16 (21.3)
Respiratory distress syndrome 80 (83.3) 12 (24) 16 (20) 11 (13.8) 23 (28.8) 18 (22.5)
Sepsis 83 (86.5) 17 (20.5) 16 (19.3) 16 (19.3) 24 (29) 10 (12)
Congenital diaphragmatic hernia 77 (80.2) 36 (46.8) 14 (18.2) 12 (15.6) 10 (13) 5 (6.5)
Congenital cardiac disease 85 (88.5) 13 (15.3) 24 (28.2) 19 (22.3) 16 (18.8) 13 (15.3)
Pediatric diagnosis
Pneumonia 87 (90.6) 2 (2.3) 15 (17.2) 10 (11.5) 31 (35.6) 29 (33.3)
Asthma 73 (76.0) 2 (2.7) 12 (16.4) 8 (11) 26 (35.6) 25 (34.2)
ARDS 86 (89.6) 2 (2.3) 15 (17.4) 13 (15.1) 28 (32.6) 28 (32.6)
Trauma/postoperative 75 (78.1) 4 (5.3) 11 (14.7) 19 (25.3) 24 (32) 17 (22.7)
Pulmonary hemorrhage 81 (84.4) 6 (7.4) 14 (17.3) 15 (18.5) 21 (26) 25 (30.9)
Infectious cardiomyopathy 83 (86.5) 5 (6) 16 (19.3) 12 (14.5) 32 (38.6) 18 (21.7)
Congenital cardiac disease 86 (89.6) 9 (10.5) 20 (23.3) 19 (22.1) 23 (26.7) 15 (17.4)
Cardiac arrest 84 (87.5) 17 (20.2) 17 (20.2) 17 (20.2) 21 (25) 12 (14.3)
Rhabdomyolysis 65 (67.7) 13 (20) 13 (20) 11 (17) 13 (20) 15 (23)
Bone marrow transplant 60 (62.5) 20 (33.3) 5 (8.3) 13 (21.7) 12 (20) 10 (16.7)
Hematologic transplant 53 (55.2) 17 (32) 5 (9.4) 11 (20.8) 10 (18.9) 10 (18.9)
Vasopressor agent status
Increasing support 93 (96.9) 39 (42) 17 (18.3) 15 (16.1) 18 (19.4) 4 (4.3)
“Stable” support 92 (95.8) 8 (8.7) 25 (27.2) 10 (10.9) 32 (34.8) 17 (18.5)
Weaning support 87 (90.6) 5 (5.7) 18 (20.7) 12 (14) 32 (36.8) 20 (23)
Pharmacologic Paralysis 92 (95.8) 18 (19.6) 19 (20.7) 13 (14.1) 28 (30.4) 14 (15.2)

Reports the responses of survey participants who were asked to rate how often their institution provided enteral nutrition for patients on extracorporeal life support.
ECLS: extracorporeal life support; VA: venoarterial, VV: venovenous, ECLS: extracorporeal life support, PPHN: persistent pulmonary hypertension of the newborn.
62 T.J. Desmarais et al. / Journal of Pediatric Surgery 50 (2015) 60–63

Table 2
The importance of mode, vasopressors, paralysis, and diagnosis when considering enteral nutrition for patients on extracorporeal life support.

Variable Respondents, N (%) First (%) Second (%) Third (%) Fourth (%)

ECLS mode 89 (92.7) 7 (7.9) 8 (9) 30 (33.7) 44 (19.4)

Vasopressor requirements 89 (92.7) 38 (42.7) 34 (38.2) 13 (14.6) 4 (4.5)
Pharmacologic paralysis 89 (92.7) 9 (10.1) 18 (20.2) 28 (31.5) 34 (38.2)
Underlying diagnosis 92 (95.8) 39 (42.4) 27 (29.3) 16 (17.4) 10 (10.9)

“First” represents most important.

ECLS: extracorporeal life support.

ECLS patients receiving PN and eight patients not receiving ECLS of 70% by 7 days without major adverse event. Finally, a retrospective,
support [17]. This analysis showed that hormone levels were signifi- single-center review of 31 VA and 55 VV ECLS patients from 2007 to
cantly higher in patients receiving enteral nutrition and shown to be 2012 found an overall nutritional adequacy of 80% using a standard
equivalent to age matched controls not being supported with ECLS. feeding protocol including prokinetic agents. Of note, patients who re-
These studies demonstrate that utilizing EN on ECLS patients does not ceived continuous renal replacement therapy in conjunction with ECLS
appear to adversely impact intestinal physiology and should not be had a later initiation of feeds, longer time to first bowel movement,
used as a reason to withhold EN. and more feeding intolerance. The use of paralysis and sedation did not
Previous studies have demonstrated, feasability, safety, and potential appear to influence feeding tolerance. These studies demonstrate that a
benefits of enteral nutrition in ECLS patients. A comprehensive retro- focus on early intiation of EN using standardized feeding protocols to
spective review of 29 consecutive pediatric patients supported with address advancing feeds as well as feeding intolerance is safe and
ECLS compared those who received EN with those who received PN well tolerated.
[7]. The groups were similar in baseline characteristics including ECLS Not surprisingly, our survey results demostrate that a patient's
mode – although VV ECLS was more common in both groups. There underlying diagnosis as well as vasopressor support are important
were no complications associated with the utilization of enteral factors in a physician's decision to implement EN. The literature does
nutrition. The authors found no difference between the groups in the not support the concept that the presence of EN, vasoactive medica-
time needed to achieve caloric goals, a cost savings of $170 per day in tions, and ECLS predisposes to an inadequate splanchnic circulation
the EN group, and a non-statistically significant survival benefit with and subsequent gastrointestinal complication such as necrotizing
EN. In a study comparing 16 neonates receiving EN to 35 neonates enterocolitis. Simarly, there does not appear to be a relationship
receiving PN, no differences were found in the rate of septic or other between ECLS mode and the presence of pharmacologic paralysis with
complications [13]. The groups were matched for diagnosis, all patients negative outcomes. Although underlying diagnosis seemed to have the
received VA ECLS, and all but two patients had received vasoactive greatest importance in the decision to start EN, there was a wide
medications. A five-year, single-center retrospective review of neonates variablility among individual diagnoses. The most obvious response
receiving VA ECLS provides additional insight into factors impacting was the strong disinterest in initiating EN in neonates with congenital
the decision to initiate EN [8]. Thirty-five of 112 neonates with congenital diaphragmatic hernia. However, the presence of intrathoracic gas-
diaphragmatic hernia were not considered for EN. Of 77 patients trointestinal conents and the potential for tension physiology in this
considered for EN, 10 did not receive EN for hemodynamic instability, a diagnosis represent a physiologically plausible risk and a legitimate
short ECLS run, history of gastric retention, or clinician’s preference. reason for withholding EN. Other diagnoses, particularly in the absense
The remaining 67 patients had EN initiated according to a standard of “clinical stability,” lack a biologically plausible a priori reason for
feeding protocol. Of note, 87% of patients had a gastric feeding tube witholding EN. However, since most respondents “always” or “often”
while the remainder had a trans-pyloric feeding tube. Most patients provide EN to patients receiving ECLS, the survey results are consistent
received vasopressors and there was no relationship between vaso- with current guidelines of providing nutritional support for neonates
pressor use and discontinuation of EN. No major complications including supported with ECLS that recommend initiating enteral feeds in “stable”
bilious vomiting, blood-stained stools, or abdominal distention were patients [14].
identified. Additionally, approximately 80% of these patients were There are several limitations to the survey and its interpretation. The
receiving EN while concomitantly receiving vasoactive medications overall response to the survey was low and therefore a large number of
after they reached a “stable state.” The authors reported no detectable institutions' practice patterns and biases may not be identified. The high
clinical impact on gut function and no correlation with gastric residuals percentage of respondents reporting providing enteral nutrition to
in these patients. These studies suggest that the routine use of enteral patients receiving ECLS may reflect such a responder bias. The survey
feeding in patients receiving VA ECLS is feasible, well tolerated, and was sent to program directors and coordinators of ELSO centers and
not deleterious. represents their individual practice patterns and their perception of
Although not a specific focus of this survey, multiple studies of the their institutions' practice; their responses may not accurately reflect
use of EN in adult ECLS may add additional perspective to the neonatal additional ECLS provider practices. We hypothesize that respondents
and pediatric populations. A single-center retrospective review of 27 reporting an institutional feeding protocol for patients receiving ECLS
patients receiving VV ECLS for acute respiratory failure found that 96% (38% of centers) may suggest a less-than-enthusiastic institutional
received EN using a unit-based feeding protocol with the liberal use of trend towards initiating EN. Since this was a voluntary survey, there
prokinetic agents (95% by 48 hours) [11]. This cohort had 80% “tolerance” was no opportunity to verify actual nutritional delivery practices.
by two days and no serious adverse events (pulmonary aspiration, Finally, the nature of the survey did not make it feasible to collect addi-
nosocomial pneumonia, intestinal ischemia, gastroinestinal bleeding, tional important clinical data such as: nutritional adequacy; timing
or other gastrointestinal complications). A second single-center retro- of initiation of EN and rate of increase to goal; barriers to continuous
spective series of 48 patients (35 VA ECLS and 13 VV ECLS) from 2005 delivery of EN, and important outcome data such as gastrointestinal
to 2007, found that overall, 94% received EN with 69% of patients complications, infections, sepsis, fluid balance, duration of mechanical
receving EN as their sole nutritional source [9]. In this group, 71% ventilation, and mortality.
received prokinetic agents and average nutritional adequacy while on This study represents a first step to evaluate center-specific practice
ECLS was 55%. Again, no adverse events were identified. A prospective and bias toward providing EN to critically ill neonates and children
observational study of 7 adult cardiothoracic VA ECLS patients (all receiving ECLS. A more detailed, multicenter retrospective analysis is
were receiving multiple vasporessor agents) found nutritional adequacy needed to describe the relationship of important clinical and nutritional
 T.J. Desmarais et al. / Journal of Pediatric Surgery 50 (2015) 60–63 63

parameters to clinically meaningful outcomes. Such a study could provide enteral nutrition in a patient? [yes/no] (if yes go to question 8, if
information on best practices and inform multi-center, collaborative, pro- no continue to question 9)
spective trials comparing different nutritional strategies. This is essential 8. Please use the space provided to let us know what that factor is.
for improving morbidity and mortality in this patient population. [blank space]
9. At your center, is there a preferred anatomic site for the delivery of
Acknowledgments enteral feeds? [yes/no] (if yes go to 10; if no go to 11)
10. What is the preferred anatomic site for delivering enteral feeds at
Thomas J. Desmarais was supported by a Doris Duke Charitable your center?
Research Foundation Grant to Washington University in Saint Louis. a. Gastric
The authors wish to acknowledge the Extracorporeal Life Support b. Post pyloric
Organization for their support as well as Mrs. Susan Phillips for her crit- c. Other (free text response available)
ical review of the manuscript.
11. Does your center have an established protocol for managing enteral
nutrition for pediatric or neonatal patients on ECLS?
Appendix A. Nutritional Support in Neonatal and Pediatric
a. Pediatric only
Extracorporeal Life Support Survey
b. Neonatal only
c. Both
1. Institution represented by participant
d. Neither
2. Does your center ever administer enteral nutrition to children on
ECLS? [yes/no] (if yes, continue to question 3; if no, go to question 13) 12. Please use the space provided to report any further details that you
3. Please rate how often your center uses enteral nutrition in the feel would lead to a better understanding of how and when you use
following ECLS modes: enteral nutrition. [blank space]
a. Veno-arterial (VA) ECLS [never, occasionally, some, often, always] 13. Would you be interested in participating in a prospective trial
b. Veno-venous (VV) ECLS [never, occasionally, some, often, always] comparing enteral versus parenteral feeding in the child supported
4. Please rate how often your center utilizes enteral nutrition for the with ECLS? [yes/no]
following diagnoses: For each diagnosis- [never, occasionally,
some, often, always]
a. Neonatal diagnoses References
i. Meconium aspiration
ii. Persistent pulmonary hypertension [1] Zwischenberger JB, Bartlett RH, Extracorporeal Life Support Organization. ECMO:
extracorporeal cardiopulmonary support in critical care. Ann Arbor, MI: Extracorporeal
iii. Respiratory distress syndrome Life Support Organization; 1995 717.
iv. Sepsis [2] Heyland DK, Dhaliwal R, Drover JW, et al. Canadian clinical practice guidelines for
v. Congenital diaphragmatic hernia nutrition support in mechanically ventilated, critically ill adult patients. JPEN J
Parenter Enteral Nutr 2003;27(5):355–73.
vi. Congenital cardiac disease [3] de Lucas C, Moreno M, Lopez-Herce J, et al. Transpyloric enteral nutrition reduces
b. Pediatric diagnoses the complication rate and cost in the critically ill child. J Pediatr Gastroenterol
i. Pneumonia Nutr 2000;30(2):175–80.
[4] Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international
ii. Asthma guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med
iii. Acute respiratory distress syndrome 2008;36(1):296–327.
iv. Trauma/postoperative [5] Kreymann KG, Berger MM, Deutz NE, et al. ESPEN guidelines on enteral nutrition:
intensive care. Clin Nutr 2006;25(2):210–23.
v. Pulmonary hemorrhage [6] Singer P, Berger MM, Van den Berghe G, et al. ESPEN guidelines on parenteral
vi. Infectious cardiomyopathy nutrition: intensive care. Clin Nutr 2009;28(4):387–400.
vii. Congenital cardiac [7] Pettignano R, Heard M, Davis R, et al. Total enteral nutrition versus total parenteral
nutrition during pediatric extracorporeal membrane oxygenation. Crit Care Med
viii. Cardiac arrest
1998;26(2):358–63.
ix. Rhabdomyolysis [8] Hanekamp MN, Spoel M, Sharman-Koendjbiharie I, et al. Routine enteral nutrition in
x. Bone marrow transplant neonates on extracorporeal membrane oxygenation. Pediatr Crit Care Med 2005;6
xi. Hematologic stem cell transplant (3):275–9.
[9] Lukas G, Davies AR, Hilton AK, et al. Nutritional support in adult patients receiving
5. Please rate how often your center uses enteral nutrition in the extracorporeal membrane oxygenation. Crit Care Resusc 2010;12(4):230–4.
following situations: [10] Piena M, Albers MJ, Van Haard PM, et al. Introduction of enteral feeding in neonates
a. Patient on vasopressor agent(s) on extracorporeal membrane oxygenation after evaluation of intestinal permeability
changes. J Pediatr Surg 1998;33(1):30–4.
i. Requiring increased support [never, occasionally, some, [11] Scott LK, Boudreaux K, Thaljeh F, et al. Early enteral feedings in adults receiving
often, always] venovenous extracorporeal membrane oxygenation. JPEN J Parenter Enteral Nutr
ii. “Stable” support [never, occasionally, some, often, always] 2004;28(5):295–300.
[12] Umezawa Makikado LD, Flordelis Lasierra JL, Perez-Vela JL, et al. Early enteral nutri-
iii. Weaning support [never, occasionally, some, often, always] tion in adults receiving venoarterial extracorporeal membrane oxygenation: an
b. Pharmacologically paralyzed [never, occasionally, some, observational case series. JPEN J Parenter Enteral Nutr 2013;37(2):281–4.
often, always] [13] Wertheim HF, Albers MJ, Piena-Spoel M, et al. The incidence of septic complications
in newborns on extracorporeal membrane oxygenation is not affected by feeding
6. Please rank the following variables on their importance when route. J Pediatr Surg 2001;36(10):1485–9.
considering initiation of enteral nutrition? [most important to [14] Jaksic T, Hull MA, Modi BP, et al. A.S.P.E.N. clinical guidelines: nutrition support of
least important] neonates supported with extracorporeal membrane oxygenation. JPEN J Parenter
Enteral Nutr 2010;34(3):247–53.
a. ECLS mode
[15] Extracorporeal Life Support Organization. Available from: http://www.elsonet.org/.
b. Vasopressor requirement [16] Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)—a
c. Pharmacologic paralysis metadata-driven methodology and workflow process for providing translational
d. Underlying diagnosis research informatics support. J Biomed Inform 2009;42(2):377–81.
[17] Hanekamp MN, Spoel M, Sharman-Koendjbiharie M, et al. Gut hormone profiles in
7. At your center, is there a factor considered more important than critically ill neonates on extracorporeal membrane oxygenation. J Pediatr
those in question 6 when deciding whether or not to initiated Gastroenterol Nutr 2005;40(2):175–9.