中国新生儿营养支持临床应用指南

该指南目的是建立能够反映当前最佳临床实践,循证的营养支持指南,为临床实践和进一步的临床研究方向提供参考。该指南参考了大量已发表的相关文献,在此基础上,由来自各相关学科的多位专家起草、审阅并反复修改而成。目标人群为早产儿、低体重出生儿等危重新生儿。指南分为肠内营养、肠外营养、肠内肠外营养联合应用三部分。当经口喂养无法满足患儿需要量时,应给予肠内或肠外营养支持。如果患儿存在胃肠道功能障碍,肠外营养是唯一选择。指南最后给出了肠内肠外营养联合应用的计算公式。     

营养支持对高营养风险患儿临床结局的影响

目的探讨营养支持对有高营养风险患儿临床结局的影响。方法应用改良的儿科营养不良筛查评分法(STAMP),对连续入院的1 296例患儿进行营养风险筛查评分,并分析营养支持对临床结局的影响。结果 1 296例住院患儿中,379例STAMP评分≥4分,高营养风险检出率为29.24%。304例患儿纳入进一步分析,其中85例(27.96%)有营养支持。营养支持患儿中,37例肠外营养支持(PN),23例肠内营养支持(EN),25例PN和EN联合应用;EN、PN、PN和EN联合应用比较,人均和日均营养支持费用的差异有统计学意义(P均0.001);EN的人均和日均费用均为最低。与无营养支持患儿比较,营养支持患儿感染发生率有所降低,但差异无统计学意义(P=0.095);无营养支持患儿抗感染治疗费用高于有营养支持患儿,抗生素治疗费用也明显高于有营养支持患儿,差异均有统计学意义(P均0.001)。无营养支持、EN、PN、PN+EN四组间住院费用差异有统计学意义(P=0.003),而四组间住院时间差异无统计学意义(P=0.213)。结论改良的STAMP评分作为儿科患者营养风险筛查工具简单实用;不同的营养支持方式费用存在差异;营养支持可有效改善临床结局,特别是减少感染和降低抗感染治疗费用。     

Nutritional practices and outcome of extremely premature infants

We analyzed the records of 182 newborns with birth weights under 1000 g, who survived longer than seven days, to determine risk factors for subacute mortality and morbidity. Statistical analysis using logarithm-linear modeling was used to identify complex interactions and to minimize confounding. Nosocomial infection, necrotizing enterocolitis, male gender, and chronic lung disease (CLD) were identified as independent risk factors for subacute mortality. Male gender and CLD were associated with increased mortality only among patients who received parenteral nutrition (PN). Moreover, PN, rather than enteral nutrition (EN), was a risk factor for delayed growth, nosocomial infection, and CLD. Delayed initiation of EN was associated with decreased necrotizing enterocolitis risk only among male infants with birth weights under 775 g. Our results do not support elective withholding of EN in other groups of extremely low-birth-weight infants. We conclude that indications for PN and for withholding initiation of EN in very-very-low-birth-weight infants need to be established by prospective studies.     

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??Parenteral nutrition (PN) is an essential and often life-saving treatment for infants and children who cannot be adequately fed orally or enterally, to prevent or correct malnutrition, and to sustain appropriate growth. PN is more costly and can induce severe complications than oral nutrition or EN. The complications is reduced by a meticulous mornitoring, establishment of a multidisciplinary nutrition support team, avoidance of unbalanced or excessive substrate supplies, strict hygiene measures to reduce catheter infections, and forceful enhancement of enteral feeding where possible to limit the amount and duration of PN.     

肠外营养监测及并发症处理

肠外营养（PN）是不能通过口或肠道为患儿提供足够营养时,所采取的一项挽救生命的治疗措施,可预防或改善营养不良,并保证患儿的生长发育需要。相比经口喂养或肠内营养,PN花费多,并可引起严重并发症。因此,需要严密监测,建立多学科的营养支持团队,避免所提供的营养不均衡或营养过度,严格进行无菌操作,以减少导管相关感染,有可能的情况下尽可能强化肠内营养,减少PN的量和时间。     

新生儿体外膜氧合救治下肠内营养和肠外营养11例病例系列报告

目的 观察危重症新生儿接受体外膜氧合（ECMO）救治技术下肠内营养（EN）和肠外营养（PN）的耐受性和安全性。方法 回顾性收集复旦大学附属儿科医院2015年8月10日至2020年3月31日收入PICU接受ECMO治疗的新生儿，排除经心外科讨论为复杂性、难治性先天性心脏病（不论是否行手术治疗）的新生儿，所有患儿均接受了静脉-动脉ECMO治疗，同时采用PN联合EN支持治疗。采集人口学资料（胎龄、出生体重、性别等），PN和EN支持开始时间、每天PN和EN用量及维持时间以及相关并发症，营养相关实验室检查（生化检查和电解质等），加EN时应用的血管活性药物剂量和种类、呼吸支持时间和预后。结果 11例危重新生儿进行了ECMO辅助治疗，均接受PN支持,9例接受EN支持,无NEC发生，8例存活者中7例出院体重均＞P10(WHO标准)。ECMO期间均合并血小板减少和低磷血症，6例发生胆汁淤积，合并低钙血症10例、低镁血症5例。ECMO联合间歇连续性肾脏替代治疗（CRRT）较不联合CRRT直接胆红素（μmol·L-1）更高，差异有统计学意义［70.0（32.4-182.4） vs 13.7（11.2~-15.7），P =0.015］。结论 接受ECMO辅助的危重新生儿EN联合PN治疗安全、可行，但需临床严密观察和监测相关实验室指标。     

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??The total parenteral nutrition??TPN?? or supplemental PN??SPN?? are necessary and safe for patients with contraindications of enteral nutrition??EN?? or patients with EN failing to reach caloric targets. But the PN start time is controversial and the related research findings are conflicting. In terms of current research??in low-risk patients PN can be delayed for 7 days. In high-risk patients the PN starting 3 days after admissicn is reasonable. At the same time??daily nutritional assessment and metabolic status monitoring are important.     

Short bowel syndrome and intestinal failure in infants and children

Children with short bowel syndrome (SBS), and resultant intestinal failure (IF), represent a unique and challenging patient population for paediatric health professionals. The number of infants requiring prolonged parenteral nutrition (PN) for SBS continues to increase. The need for often complex PN and enteral nutrition (EN) regimens requires the formation of a multidisciplinary nutrition support team (NST) with specialist expertise. The achievement of enteral adaptation and weaning from PN can take up to several years, necessitating delivery of PN at home (HPN). The complications of PN, namely recurrent sepsis and intestinal failure associated liver disease (IFALD) limit survival in this group. While medical and nutritional therapies for SBS and IF remain limited, advancing surgical techniques may help improve adaptation in the long-term SBS. Intestinal transplantation also continues to play a role for patients with irreversible SBS, IF and advanced IFALD. The optimum design of regional services for SBS in children remains controversial; however the standardization of care and dissemination of skills through managed clinical networks will enable a cohesive approach to patient management.     

Nutrition support in a surgical patient

Nutrition has very important role to play during health and disease state in human beings. Neonates and younger children are more prone to develop nutritional deficiencies. They have very critical reserves and are rapidly growing. Any surgical insult leads to multiple nutritional problems. Careful planning of nutritional management in a surgical patient is mandatory. Nutritional support should start from the day when the child develops the surgical condition to withstand stress of disease and surgical procedure. In the postoperative period nutritional support should start as early as possible. Start with small amount and build up gradually till the normal enterai nutrition (EN) is tolerated. When EN is not tolerated parenteral nutrition (PN) should be considered. Parenteral nutrition on short term basis is very important to tide over the crisis due to postoperative complications. Parenteral nutrition on long term basis is required in short bowel syndrome resulting from resection of large part of the gut. During PN, enterai nutrition should be continued in small amounts in order to maintain the integrity of mucosal lining of the gut. Enterai nutrition is more physiological and can provide adequate amount of immunonutrients, minerals and vitamins.     

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??Sepsis is one of important reasons for the death of children in intensive care unit. Although anti-infection and active symptomatic treatment are the key to treatment??whether nutrition support is rational and effective or not can also affect clinical prognosis. Sepsis children are in stress status??so nutrition support needs to meet the demand for energy??protein and other nutrients without increasing the burden of organs. Although intestinal function is damaged because of systemic infection??enteral nutrition??EN?? is still the first choice by actively creating conditions. If the EN is not enough??supplemental parenteral nutrition??PN?? should be given. In the process of nutrition support??immune nutrients can be added to regulate immune function and attenuate inflammation.     

婴幼儿短肠综合征的院内营养支持疗效观察

目的探讨肠内肠外营养支持对短肠综合征(SBS)患儿的治疗作用。方法回顾性分析2013年11月至2015年1月在本院进行营养治疗的7例短肠综合征患儿临床资料,观察营养支持对患儿体重增长和血清白蛋白、血红蛋白、尿素氮、胆红素等生化指标的影响。结果 7例患儿中,体重增长满意2例,体重变化不明显4例,体重下降明显1例。营养支持前后患儿生化指标无明显变化。结论及时有效的营养支持,可减少短肠综合征患儿的体重丢失,维持营养相关生化指标的合理水平,改善疾病预后。     

小儿慢性腹泻营养支持治疗分析

目的研究营养支持治疗在慢性腹泻治疗的有效性。方法回顾性研究2012年7月至2014年7月48例慢性腹泻患儿资料,病例根据年龄分为1岁组(27例)和≥1岁组(21例);将27例合并营养不良的患儿分为肠内营养(EN)组(10例)、部分肠外营养组(PPN+EN)(16例)、完全肠外营养(TPN)组(1例)。分析不同年龄组及不同治疗方式患儿的治疗过程和结局。结果 48例患儿中,短肠综合征、病毒性肠炎、肠道手术、吸收不良综合征等为较常见病因,50%(24例)病因不明。在入院营养评定方面,1岁组的中度体重低下患儿所占比例高于≥1岁组(P0.05)。EN组年龄别体质指数Z评分(BAZ)由治疗前的-2.2±1.5增加至治疗后的-1.8±1.0(P=0.040),所供能量由治疗前的每日46±17 kcal/kg增加至每日83±32 kcal/kg(P=0.012);PPN+EN组的年龄别体重Z评分(WAZ)由治疗前的-3.3±2.0增加至-2.8±1.8(P=0.044),BAZ由治疗前的-2.8±1.4增加至-2.0±1.4(P=0.012)。TPN组仅1例,经治疗后腹泻症状改善。接受营养治疗的27例患儿中,4例未好转,其余患儿症状缓解、营养状况改善。结论在慢性腹泻的治疗过程中,肠内及肠外营养治疗作为综合治疗的一部分,可有效改善营养状况,缓解腹泻症状。     

Chinese guidelines for the assessment and provision of nutrition support therapy in critically ill children

Background

This document represents the first evidence-based guidelines to describe best practices in nutrition therapy in critically ill children (>?1 month and <?18 years), who are expected to require a length of stay more than 2 or 3 days in a Pediatric Intensive Care Unit admitting medical patients domain.

Methods

A total of 25,673 articles were scanned for relevance. After careful review, 88 studies appeared to answer the pre-identified questions for the guidelines. We used the grading of recommendations, assessment, development and evaluation criteria to adjust the evidence grade based on the quality of design and execution of each study.

Results

The guidelines emphasise the importance of nutritional assessment, particularly the detection of malnourished patients. Indirect calorimetry (IC) is recommended to estimate energy expenditure and there is a creative value in energy expenditure, 50 kcal/kg/day for children aged 1–8 years during acute phase if IC is unfeasible. Enteral nutrition (EN) and early enteral nutrition remain the preferred routes for nutrient delivery. A minimum protein intake of 1.5 g/kg/day is suggested for this patient population. The role of supplemental parenteral nutrition (PN) has been highlighted in patients with low nutritional risk, and a delayed approach appears to be beneficial in this group of patients. Immune-enhancing cannot be currently recommended neither in EN nor PN.

Conclusion

Overall, the pediatric critically ill population is heterogeneous, and an individualized nutrition support with the aim of improving clinical outcomes is necessary and important.

     

肠内营养在儿童胰腺外伤治疗中的应用

目的 探讨肠内营养在儿童胰腺外伤治疗中的应用效果.方法 回顾性分析2003年6月至2010年10月首都医科大学附属北京儿童医院收治的胰腺外伤患儿临床资料.记录损伤程度、营养制剂及使用方式,有无营养相关并发症及转归.结果 25例胰腺外伤患儿中,12例应用肠内营养.肠内营养患儿中.Ⅱ级损伤4例,1例手术;Ⅲ级损伤7例,1例...     

Intravenous nutrition for the pediatric patient.

Nutritional management of infants and children differs from that of adults because of the extra requirements for growth and the limitations of physiological immaturity. Although parenteral nutrition (PN) is an accepted practice and a potentially life-saving therapy for pediatric patients who cannot be fed through their gastrointestinal tract, it is associated with the risk of serious metabolic, mechanical, and infectious complications. Candidates for PN should be selected according to well-defined indications, with initial nutritional assessment and with careful attention given to fluid, electrolyte, vitamin, trace element, and caloric requirements. Total calories should be administered so that the nonprotein-calorie to gram-nitrogen ratio is in the range of 150 to 250:1. Although short-term supplemental nutritional support can be administered through a peripheral vein, long-term total PN is best delivered by central venous access. PN should be initiated and monitored in accordance with well-established protocols. The lowest complication rate and highest cost-effectiveness are achieved by an interdisciplinary team that includes one or more nurses, dietitians, pharmacists, and physicians. The development of safe, reliable, and miniaturized intravenous pumps with built-in monitors has made home parenteral nutrition possible and desirable in selected patients.     

Diarrhea and Weight Loss After Bone Marrow Transplantation in Children

To define the determinants of diarrhea after bone marrow transplantation (BMT) and its nutritional sequelae, the medical records of 20 consecutive children (median age, 9 years; 13 boys and 7 girls) undergoing BMT at Children's Hospital in Birmingham, UK were surveyed. All patients who received total body irradiation (TBI) required parenteral nutrition (PN). Seventy-eight percent of TBI patients and 73% of children who received allografts developed diarrhea compared with only 27% of non-TBI patients and 22% of those who received auto grafts (P < 0.05). Ninety percent of children with diarrhea required PN. Duration of PN in these children was longer than in those without diarrhea who requested PN (P < 0.05). Despite PN, weight loss at discharge was still greater in the study group (P < 0.05). Diarrhea was associated with a significant fall in serum albumin (P < 0.005). Diarrhea and weight loss occur in children after BMT despite active PN support. Pretransplant TBI and the we of all grafts are important determinants of these complications.     

新生儿缺氧缺血性脑病亚低温治疗期间开展肠内营养的回顾性非随机对照研究

背景：亚低温是新生儿缺氧缺血性脑病（HIE）的有效治疗措施,目前国内外对亚低温期间肠内营养的开展尚无共识。 目的：探讨亚低温治疗期间开展肠内营养的安全性。 设计：回顾性非随机对照研究。 方法：2019年1月至2020年6月重庆医科大学附属儿童医院新生儿中心诊断为HIE并实施亚低温治疗的患儿,按照亚低温治疗期间是否行肠内营养分为开奶组和禁奶组,收集患儿的一般情况、临床表现、实验室检查、诊断及治疗等情况,肠内营养开奶日龄、开奶种类、奶量和喂养方式。 主要结局指标：住院期间NEC的发生率。 结果：95例HIE患儿进入分析,开奶组51例,禁奶组44例。①开奶组患儿腹胀发生率低于禁奶组(P=0.047),两组呕吐、血便和抽搐发生率差异无统计学意义。②两组患儿在生后1 h内血气分析、入院首次血常规、头颅超声提示出血、头颅MR异常差异均无统计学意义。③开奶组平均静脉营养治疗时间和平均住院时间均短于禁奶组（P均＜0.001）;两组NEC、喂养不耐受等合并症发生率差异无统计学意义。④开奶组患儿中,60.8%以配方奶开奶,41.1%为日龄1 d开奶,初始平均奶量为19.1 mL·kg-1·d-1,68.6%患儿亚低温期间未加奶。开奶组中1例发生了NEC(Ⅰ期),保守治疗后好转,无死亡病例。 结论：亚低温期间早期开始微量肠内营养,可减少腹胀的发生,缩短静脉营养治疗时间及住院时间,不增加NEC的发生风险。     

Tube feeding and bone marrow transplantation

BACKGROUND: Children undergoing bone marrow transplantation (BMT) have poor oral intake during the transplant period, caused mainly by the intensive therapy used for their conditioning. Nutritional support (NS) is almost always needed. Whenever possible, tube feeding (TF) is preferred to parenteral nutrition (PN) because its more physiologic and causes fewer complications. However, children undergoing BMT are usually parenterally fed. We, therefore, studied whether TF was tolerated in children undergoing BMT and whether the nutritional intake was adequate in comparison to PN. PROCEDURE: Two groups were compared: TF (n = 12) and PN (n = 22). If intolerance for TF occurred, additional or total PN was given. Nutritional status, intake, complications, and costs were assessed. RESULTS: Both groups had an adequate nutritional status and reached 85% of their nutritional requirements. TF was possible in 62% of the NS days and three children could be exclusively fed with TF. A longer pre-transplant duration of TF seemed to increase the enteral tolerance. Gastrointestinal symptoms were equally frequent in TF as in PN, but cholestasis was less frequent in TF. The mean nutritional cost per child in the TF group was 440 US dollars less than in the PN group. CONCLUSIONS: TF is possible and equal in efficacy to PN in children undergoing BMT, and may have budgetary benefits.     

新生儿围手术期的营养支持

目的评估新生儿围手术期应用胃肠外营养(PN)支持的临床疗效,为营养支持的合理运用提供依据。方法对30例围手术期新生儿进行营养评估,营养不良者在肠内营养的基础上辅以PN,总结PN的组成、供给量、配制顺序、使用途径,并监测体质量、实验室指标、预后及防治并发症。结果 30例病例中,26例痊愈,4例好转。PN治疗后,患儿体质量、血浆白蛋白较前略有增加(P均<0.05),肝转氨酶、黄疸、血脂、尿素氮、前白蛋白、总胆汁酸均无明显变化。结论 PN支持方案安全、有效,实施方便;对于蛋白质营养不良新生儿围手术期的PN支持,应适当增加氨基酸的供给量。