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。     

Severe,persistent, and fatal T‐cell immunodeficiency following therapy for infantile leukemia

We describe five cases of children who completed chemotherapy for infantile acute lymphoblastic leukemia (ALL) and soon after were diagnosed with severe T‐cell, non‐HIV immunodeficiency, with varying B‐cell and NK‐cell depletion. There was near absence of CD3⁺, CD4⁺, and CD8⁺ cells. All patients developed multiple, primarily opportunistic infections. Unfortunately, four patients died, although one was successfully treated by hematopoietic stem cell transplantation. These immunodeficiencies appeared to be secondary to intensive infant ALL chemotherapy. Our report highlights the importance of the early consideration of this life‐threatening immune complication in patients who received chemotherapy for infantile ALL.     

T-lymphocyte subsets in HIV-infected and high-risk HIV-uninfected adolescents: retention of naive T lymphocytes in HIV-infected adolescents. The Adolescent Medicine HIV/AIDS Research Network

BACKGROUND: The capacity of the immune system of adolescents to generate and repopulate naive and memory cell populations under conditions of normal homeostasis and human immunodeficiency virus (HIV) infection is largely unknown. OBJECTIVE: To assess lymphocyte subsets in HIV-infected and high-risk HIV-negative adolescents. DESIGN: The Reaching for Excellence in Adolescent Care and Health Project of the Adolescent Medicine HIV/AIDS Research Network recruits a cohort of HIV-infected and high-risk HIV-uninfected adolescents, aged 13 to 18 years 364 days, into a study of biomedical and behavioral features of HIV infection as seen in the context of full availability of primary care and HIV-related consultative services. Lymphocyte phenotypes were determined using standard 3-color flow cytometry. SETTING: The Reaching for Excellence in Adolescent Care and Health Project is carried out at 16 clinical sites in 14 urban areas. PARTICIPANTS: T-lymphocyte subsets are reported in 192 HIV-positive and 78 HIV-negative youths. RESULTS: For HIV-positive subjects, the total CD4+ cell count and the percentage of CD4+ cells are decreased when compared with those of the HIV-negative controls (P<.001). The reduction in total CD4+ cells reflects a loss of naive, and memory, CD4+ cells compared with HIV-negative youths. Human immunodeficiency virus-infected adolescents, many of whom have been infected recently (ie, those with CD4+ cell counts > or =0.500 x 10(9)/L [500/microL]), have a significant increase in naive CD8+ cells compared with HIV-negative youths (P<.01). There also is a significant increase in memory CD8+ cells at all strata of total CD4+ cells compared with HIV-negative youths (P<.01). The increase in naive CD8+ cells in those subjects with CD4+ cell counts of 0.500 x 10(9)/L or greater is a unique finding in this cohort. CONCLUSIONS: This study demonstrates high levels of naive CD8+ cells in response to HIV infection in adolescents with CD4+ cell counts of 0.500 X 10(9)/L or greater. The presence of high levels of naive CD8+ cells suggests functioning thymic tissue in some adolescents infected with HIV. Furthermore, the normal level of naive CD4+ cells in adolescents with CD4+ levels of 0.500 x 10(9)/L or greater provides additional support for the concept of a more robust immune system in HIV-infected adolescents compared with HIV-infected adults. These observations suggest that the immune system of HIV-infected adolescents may be capable of better responses to neoantigens and cytotoxic T-lymphocyte responses to HIV than the immune system of infected children or adults. Human immunodeficiency virus-infected adolescents may have an immune system that is capable of reconstitution following highly active antiretroviral therapy.     

Total parenteral nutrition in bone marrow transplantation: a clinical evaluation

Bone marrow transplantation (BMT) is associated with severe metabolic stress secondary to anorexia, mucositis, enteritis, and infection. We compared nutritional parameters and clinical outcomes of 22 patients who received prophylactic total parenteral nutrition (TPN) to those of 22 controls, matched for age and diagnosis, who received nutritional support ad libitum. Over the 5-week study period, the TPN group averaged caloric intakes greater than 1.5 X basal energy expediture (BEE) per day and gained 2.5% of body weight; the control group averaged less than 0.9 X BEE and lost 3.7% of body weight. Visceral protein status as reflected by serum albumin was not different. Engraftment of donor marrow cells was 3 days earlier (p less than 0.01) in the TPN group than in the controls, despite there being no significant difference in the number of marrow cells each group received. There was no difference in the two groups' clinical outcomes; mortality, duration of hospital stay, and incidences of sepsis, graft-versus-host disease, and return of malignancy were equivalent. Thus, patients who received prophylactic TPN engrafted sooner than patients who did not; however, overall clinical outcome was unaffected by TPN. Controlled studies of prophylactic TPN are indicated for the BMT patient population.     

Use of probiotics in HIV-infected children: a randomized double-blind controlled study

HIV/AIDS is an infection characterized by immune cell dysfunction and subsequent immunodeficiency, as well as intestinal disorder. Probiotics are live microbial feed supplements that beneficially affect the host animal by improving intestinal microbial balance and promoting health benefits. The goals of this study were to determine whether the use of probiotics could improve the immune response determined by CD4 cells mm(-3) counts and reduce liquid stool episodes. A randomized double-blind controlled trial with 77 HIV-infected children (2-12 years), divided into two groups: one receiving probiotics (formula containing Bifidobacterium bifidum with Streptococcus thermophilus -2.5 x 10(10) colony forming units) and the other, a standard formula (control group), for 2 months. The CD4 counts (cells mm(-3)) were collected at the beginning and end of the study. The quality and number of stools were assessed by a questionnaire (watery to normal stool consistency). There was an increase in the mean CD4 count in the probiotics group (791 cells mm(-3)) and a small decrease in the control group (538 cells mm(-3)). The change from baseline in mean CD4 cell count was +118 cells mm(-3) vs. -42 cells mm(-3) for children receiving the probiotic formula and control formula, respectively (p = 0.049). A similar reduction in liquid stool consistency in both the groups (p < 0.06), with a slight enhancement in the probiotics group, was observed, but without significant difference (p < 0.522). The incidence of loose-soft stools showed a small decrease in both groups (p < 0.955) and there was an increase in the incidence of normal stool consistency in both the groups (p < 0.01). Our study showed that probiotics have immunostimulatory properties and might be helpful in the treatment of HIV-infected children.     

Host defense abnormalities associated with HIV infection

Infection with human immunodeficiency virus (HIV) impairs immune function. Most abnormalities in host defense associated with HIV infection are due to helper T-cell dysfunction. Studies defining these abnormalities in the HIV-infected patient have largely been done in adults. A more complete understanding of the immunodeficiency that occurs in infants and young children congenitally infected with HIV awaits further study of their immune function and the effect this virus has on the developing immune system.     

Short stature as the primary manifestation of monosymptomatic celiac disease.

It is generally accepted that celiac disease (CD) must always be taken into consideration when dealing with children manifesting growth failure. It is therefore important to have laboratory tests capable of detecting patients who should undergo intestinal biopsy. Auxological and endocrine parameters, bone age, some nutritional indices (hemoglobin, serum iron, calcium, total protein, and albumin), and anti-gliadin antibodies (AGA) IgA and IgG and 1-h blood xylose levels were evaluated in 49 children of short stature. On the basis of the intestinal biopsy, 29 (59.1%) patients affected by CD were found. When patients with atrophic and normal intestinal mucosa were compared, significant differences in the frequency of pathological values of hemoglobinemia, serum iron, AGA, and 1-h blood xylose levels were found, whereas no difference was observed in the levels of serum calcium, total protein, and albumin. Bone age was delayed in 81% of the celiac patients and in 47% of the controls. In particular, AGAs were found in 27 of 29 celiac patients and in three control subjects who showed a low level of one of the two antibodies. The results of our study demonstrate that AGA (IgA and IgG), together with 1-h blood xylose, hemoglobinemia, serum iron, and family history of CD determination, are extremely useful for screening patients of short stature. This type of screening cannot, however, replace the intestinal biopsy because such tests cannot be completely sensitive and specific.     

Immunological evaluation in the early diagnosis of prenatal or perinatal HIV infection.

A longitudinal evaluation was carried out of the clinical, infective, and immunological progress of 34 children (who were aged 6 to 68 months--mean 25 months at the time of writing) born to 31 mothers infected with human immunodeficiency virus (HIV), over a mean observation period of 13.4 months. Clinical symptoms, not always clearly related to HIV became apparent in 11 children, and preceding immune abnormalities were documented in two of them. In eight children culture for HIV was positive, and six of these were symptomatic. No cancers were diagnosed and none of the children died. Immune abnormalities including hypergammaglobulinaemia, IgG subclass deficiency, low serum IgA concentration, antibody deficiency, a decrease in the number of CD4+(T helper) cells, and defective cellular responses to antigens, were found in seven of the children in whom culture for HIV was positive; in two of four who had symptoms and in all four who were symptom free and in whom culture was negative for HIV but in whom HIV antibodies persisted and who were older than 15 months; and in three of nine who were symptom free and in whom culture was negative with loss of HIV antibodies. We conclude that serological diagnosis alone may be misleading and that additional immunological assessment may help to identify affected children. Analysis of humoral and cellular responses to antigens used for vaccination such as tetanus toxoid by measurement of specific antibodies and skin testing are simple and helpful in clinical practice.     

A prospective randomized clinical trial of total parenteral nutrition in children with cancer

A prospective randomized clinical trial was undertaken to test the efficacy of total parenteral nutrition (TPN) among previously untreated children receiving abdominal/pelvic irradiation with or without adjuvant chemotherapy who were at risk for weight loss, malnutrition, and complications from treatment. Children were evaluated by weight/height determinations, anthropomorphic measurements, and laboratory studies. TPN was associated with an improved nutritional status during therapy as compared with control patients on ad libitum intake. However, when TPN was discontinued, weight declined and there were no differences among treated and control patients detected at three-month follow-up. Likewise there was no obvious effect from TPN on tolerance to therapy in the adequately nourished child. TPN as initial supportive therapy should be reserved for those children who are malnourished or marginally malnourished at the time of presentation. Close nutritional assessment during treatment is essential since approximately 25% of children undergoing abdominal/pelvic radiotherapy with chemotherapy can be expected to become malnourished during an initial course of therapy.     

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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.     

Immunization of HIV-infected children with varicella vaccine

OBJECTIVE: To determine the safety and immunogenicity of varicella vaccine in children with human immunodeficiency virus (HIV) infection. Children (n = 41) who were mildly affected by HIV (Centers for Disease Control and Prevention stage N1 or A1) and had no history or serum antibody indicative of prior varicella infection were immunized with two doses of live attenuated varicella vaccine. RESULTS: A minority of the vaccine recipients had mild local or systemic reactions. Vaccination had no effect on the clinical stage of HIV or the HIV RNA plasma load. CD4 cell percentage and CD4 cell count were marginally decreased at week 4 after the first vaccination; this effect was no longer present at week 8 after vaccination. Two months after the second dose of vaccine, 60% of vaccine recipients had anti-varicella antibody in their serum, and 83% had a positive lymphocyte proliferation assay response to varicella antigen. CONCLUSION: On the basis of its safety and immunogenicity, varicella vaccine should be considered in the childhood vaccines given to mildly affected HIV-infected children.     

Clinical profile and natural history of children with HIV infection

Objective: As the HIV infection spreads in India, increasing number of children are affected. We report the clinical manifestations, the laboratory parameters and follow up of these children.Methods: We reviewed case records of all children diagnosed as pediatric HIV infection since 1995 in our department at a tertiary care hospital in north India. Since, September 1999, all children with HIV infection registered in our clinic were prospectively followed up. Complete clinical and laboratory evaluation was performed at baseline and thereafter children were followed up. The children were managed according to standard treatment guidelines.Results: 109 children (82 boys, 27 girls) were diagnosed to have HIV infection. The median (range) age at presentation was 48 months (range: 0.75 months—180 months). Eighty one (74.3%) children acquired the infection vertically, Ninety-one (83.5%) children were symptomatic at time of presentation. The common symptoms in the former were failure to thrive (81.3%), recurrent fever (73.6%), diarrhea (50.5%) and recurrent or persistent pneumonia (44%). All children had poor nutritional status at baseline. Of the 67 children who followed up, 36 were receiving antiretroviral drugs (32 received 3 drugs), while families of 31 children did not opt for antiretroviral therapy. Children receiving antiretroviral therapy showed improvement in nutritional parameters.Conclusion: Majority of children with HIV infection presented with various clinical manifestations, poor nutritional status and immunosuppression. Administration of nevirapine based antiretroviral therapy leads to improvement in growth and immune restoration.     

Enteral nutrition is feasible in pediatric stem cell transplantation patients

We aimed to demonstrate whether enteral nutrition (EN) is feasible in daily practice of hematopoietic stem cell transplantation (HSCT).Nutritional records of 100 patients were evaluated. Patients with poor oral intake were fed by EN with tube. A total of 79 patients required nutritional support. Of them, 71 were fed by EN only. Five were fed by EN plus parenteral nutrition (PN),three were fed by PN only. Median duration of EN was 21 days. In the EN only group, 68% gained or maintained their weight. EN should be considered as a feasible option for nutrition support in children undergoing HSCT. Pediatr Blood Cancer 2012; 59: 1327–1329. © 2012 Wiley Periodicals, Inc.     

Effect of total parenteral nutrition on marrow recovery during induction therapy for acute nonlymphocytic leukemia in childhood

Ten well-nourished children with acute non-lymphocytic leukemia (ANLL) were randomly assigned to groups that received (a) total parenteral nutrition (TPN) throughout the period of induction therapy or (b) standard nutritional support. Body mass and skin hypersensitivity reactions were better maintained in experimental patients. Patients on TPN had higher total white blood counts, absolute granulocyte counts, and platelet counts than did control patients during the course. No difference was apparent in the frequency of febrile episodes, or other aspects of the patients' courses. This preliminary report suggests that intensive nutritional support may accelerate the recovery of normal marrow function during induction therapy for ANLL.     

Six Years' Experience of Total Parenteral Nutrition in Children with Hematological Malignancies at a Single Center: Management, Efficacy, and Complications

Total parenteral nutrition (TPN) is an important issue in supportive care of children with leukemia. We studied 131 consecutive children (87 male, 44 female) with hematological malignancies who received TPN at our center from July 1984 to July 1990 with the aim of evaluating the efficacy and complications of TPN. The use of TPN was associated with lack of any alteration of the anthropometric indexes used in this study. The complications were prevalently metabolic, generally mild, and easily controlled. Laboratory monitoring of nutritional status during TPN is probably of little value in this setting. The feasibility of in-ward preparation of TPN by nurses makes TPN possible at low cost provided that patients are selected carefully.     

危重患儿肠屏障功能障碍时如何进行营养支持

肠黏膜屏障损伤是危重患儿常见的病理生理过程,可造成细菌及内毒素移位、肠源性感染,甚至发生多器官功能衰竭.早期诊断肠黏膜屏障损害,积极纠正肠屏障功能障碍,选择适当的营养方式将有助于提高疗效,改善患儿预后.本文就危重患儿肠屏障功能障碍的概念、诊断方法及营养支持的进展等做一阐述.     

Immune deficiencies in chronic intestinal pseudo-obstruction

Aim: Chronic intestinal pseudo-obstruction has been associated with urinary disorders, myopathy, and ophthalmoplegia in adults and cholelithiasis in children. We observed a high percentage of total-parenteral-nutrition-dependent patients with pseudo-obstruction and recurrent infections requiring gammaglobulin infusions. Methods: AH records for 23 children with chronic intestinal pseudo-obstruction (10 females and 13 males, mean age 9.8 y ± 4.9 y, range 4–24 y) referred for a nutritional evaluation from 1992 to 1995 were reviewed. Chronic intestinal pseudo-obstruction was diagnosed by clinical, radiographic findings and antroduodenal manometry. Intestinal full-thickness biopsies were performed in seven children. Results: Hypogammaglobulinemia was diagnosed in 18 patients (78%): 16 patients had various immunoglobulin deficiencies and 2 had selective antibody deficiency. Intravenous gammaglobulin was administered in 14 patients. Other medical conditions affecting the children are summarized as follows: autonomic dysfunction in 10 patients (43%), recurrent hypoglycemia in 9 (39%), asthma in 9 (39%), cholecystitis in 7 (30%), low serum carnitine level in 6 (26%), urinary dysfunction in 6 (26%), pancreatitis in 5 (22%), behavioral problems in 5 (22%), myopathy in 2 (9%), idiopathic thrombocytopenia in 2 (8%), velopharyngeal insufficiency in 1 (4%), oculocutaneous albinism in 1 (4%), Pierre-Robin syndrome in 1 (4%), and protein C deficiency in 1 (4%). Munchausen syndrome was suspected in two patients. Conclusions: Chronic intestinal pseudo-obstruction appears to be associated with immune deficiencies. It is unclear if the immune deficiencies, intestinal pseudo-obstruction, and the other medical conditions have a common underlying etiology. Repeated infections may be due to impaired immune function in children with chronic intestinal pseudo-obstruction. We recommend screening for immune deficiencies in children with chronic intestinal pseudo-obstruction.     

Long-term home parenteral nutrition in pediatrics: ten years of experience in 102 patients

One hundred two pediatric patients received all or part of their nutritional needs parenterally at home during the past decade. All received total parenteral nutrition (TPN) at night during an 8- to 12-h infusion. Patients with short bowel syndrome (33%), inflammatory bowel disease (23%), chronic intractable diarrhea (15%), chronic idiopathic intestinal pseudo-obstruction syndrome (10%), and malignancy (10%) made up the largest groups. The mean duration of parenteral support was 735 days (range, 90-3650 days); the mean number of catheters per patient was 2.1 (range, 1-8). Twenty-one patients continue to receive full or partial home TPN: four for more than 10 years and seven for more than 5 years. Fifty-one no longer require it and have had healing of mucosa or bowel adaptation. Complications related to administration of fluid and electrolytes were quite rare. Biotin deficiency was recognized once. Thirty-one have died, but only 13 deaths were related to TPN. Sepsis in nine and liver failure in two were the most common causes of death in the TPN-related group. Three of 21 still on home TPN have graduated either from high school or college. All but one of the school age children attend regular school; one attends a school for the medically disabled, another attends a school for the mentally gifted.     

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。     

706例外科住院患儿营养风险筛查及其临床意义

目的：探讨外科住院患儿的营养风险及其与临床结局的相关性,为临床营养管理提供科学依据。方法：应用营养状况和生长风险筛查工具（STRONG）对706例外科住院患儿进行营养风险筛查,同时记录住院期间患儿营养支持情况、感染性并发症发生率、住院时间、术后住院时间以及住院总费用等资料进行分析。结果：706例外科住院患儿中,有11.5%存在高度营养风险,46.0%为中度营养风险,42.5%为低度营养风险;先天性肥厚性幽门狭窄、肠梗阻、先天性心脏病患儿居高度营养风险发生率前3位;婴儿高度营养风险的发生率明显高于其他年龄段患儿（P<0.01）;81例高度营养风险患儿中有52例（64.2%）接受了肠外营养支持;高度营养风险患儿住院期间较低度营养风险患儿更容易出现体重丢失（P<0.05）,其感染性并发症、住院时间、术后住院时间以及住院总费用均明显高于中、低度营养风险患儿（均P<0.01）。结论：外科住院患儿存在中、高度营养风险;营养风险评分对患儿临床结局存在影响;目前外科住院患儿的营养支持仍不规范,需推广住院儿童营养风险筛查并进行规范的营养支持。