Magnetic Resonance–Guided Nasogastric Feeding Tube Placement for Neonates: A Preclinical Study

Background: Establishing postnatal nutrition delivery is challenging in neonates with immature sucking and swallowing ability. Enteral feeding is the gold standard for such patients, but their small size and fragility present challenges in nasogastric (NG) feeding tube placement. Feeding tubes are typically placed with x‐ray guidance, which provides minimal soft tissue contrast and exposes the baby to ionizing radiation. This research investigates magnetic resonance (MR) guidance of NG feeding tube placement in neonates to provide improved soft tissue visualization without ionizing radiation. Materials and Methods: A novel feeding tube incorporating 3 solenoid coils for real‐time tracking and guidance in the MR environment was developed. The feeding tube was placed 5 times in a rabbit with conventional x‐ray guidance to assess mechanical stability and function. After x‐ray procedures, the rabbit was transferred to a neonatal MR system, and the tube was placed 5 more times. Results: In procedures guided by x‐ray and MR, the feeding tube provided sufficient mechanical strength and functionality to access the esophagus and stomach of the rabbit. MR imaging provided significantly improved soft tissue contrast versus x‐ray, which aided in proper tube guidance. Moreover, MR guidance allowed for real‐time placement of the tube without the use of ionizing radiation. Conclusions: The feasibility and benefits offered by an MR‐guided approach to NG feeding tube placement were demonstrated. The ability to acquire high‐quality MR images of soft tissue without ionizing radiation and a contrast agent, coupled with accurate 3‐dimensional device tracking, promises to have a powerful impact on future neonatal feeding tube placements.     

Post‐pyloric feeding tube placement in critically ill patients: Extending the scope of practice for Australian dietitians

Aim

To determine whether the placement of a post‐pyloric feeding tube (PPFT) can be taught safely and effectively to a critical care dietitian.

Methods

This is a prospective observational study conducted in an adult intensive care unit (ICU). The intervention consisted of 19 attempts at post‐pyloric intubation by the dietitian. The 10 ‘learning’ attempts were performed by the dietitian under the direction of an experienced (having completed in excess of 50 successful tube placements) user. A subsequent nine ‘consolidation’ attempts were performed under the responsibility of the intensive care consultant on duty. The primary outcome measures were success (i.e. tip of the PPFT being visible in or distal to the duodenum on X‐ray) and time (minutes) to PPFT placement. Patients were observed for adverse events per standard clinical practice.

Results

A total of 19 post‐pyloric tube placements were attempted in 18 patients (52 (23–70) years, ICU admission diagnoses: trauma n = 4; respiratory failure n = 3; and burns, pancreatitis and renal failure n = 2 each). No adverse events occurred. Most (75%) patients were sedated, and mechanically ventilated. Prokinetics were used to assist tube placement in 11% (2/19) of attempts, both of which were successful. Placement of PPFT was successful in 58% (11/19) of attempts. Whilst training, the success rate was 40% (4/10) compared with 78% (7/9) once training was consolidated (P = 0.17). In the successful attempts, the mean time to placement was 11.0 minutes (3.9–27.1 minutes).

Conclusions

A dietitian can be trained to safely and successfully place PPFT in critically ill patients.     

Successful Identification of Anatomical Markers and Placement of Feeding Tubes in Critically Ill Patients via Camera‐Assisted Technology with Real‐Time Video Guidance

Background: Enteral feeding via feeding tube (FT) provides essential nutrition support to critically ill patients or those who cannot intake adequate nutrition via the oral route. Unfortunately, 1%–2% of FTs placed blindly at bedside enter the airway undetected (as confirmed by x‐ray), where they could result in adverse events. Misplaced FTs can cause complications including pneumothorax, vocal cord injury, bronchopleural fistula, pneumonia, and death. X‐ray is typically performed to confirm FT placement before feeding, but may delay nutrition intake, may not universally identify misplacement, and adds cost and radiation exposure. Methods: A prospective case series was conducted to evaluate a novel FT with a camera to provide real‐time visualization, guiding placement. The primary end point was the clinician's ability to identify anatomical markers in the gastrointestinal tract and/or airway using the camera. Results: The Kangaroo Feeding Tube with IRIS Technology tube was placed in 45 subjects with 1 misplaced tube; 3 placements were postpyloric, with the remainder gastric. Clinicians correctly identified the stomach in 44 of 45 placements at a median depth of 60.0 cm (range 45.0–85.0 cm). A stomach image was obtained in 42 subjects (93.3%). Agreement between camera image and radiographic confirmation of placement was 93% (P = .014) with small deviations in recognizing stomach vs small bowel. No device‐related adverse events occurred. Conclusions: Direct visualization of the stomach using a camera‐equipped FT can assist with FT placement, help avoid misplacements, and with further studies to evaluate the safety of eliminating confirmatory x‐ray before feeding, could potentially preclude the need for radiographic confirmation.     

Establishing Decision Trees for Predicting Successful Postpyloric Nasoenteric Tube Placement in Critically Ill Patients

Background

Despite the use of prokinetic agents, the overall success rate for postpyloric placement via a self‐propelled spiral nasoenteric tube is quite low.

Methods

This retrospective study was conducted in the intensive care units of 11 university hospitals from 2006 to 2016 among adult patients who underwent self‐propelled spiral nasoenteric tube insertion. Success was defined as postpyloric nasoenteric tube placement confirmed by abdominal x‐ray scan 24 hours after tube insertion. Chi‐square automatic interaction detection (CHAID), simple classification and regression trees (SimpleCart), and J48 methodologies were used to develop decision tree models, and multiple logistic regression (LR) methodology was used to develop an LR model for predicting successful postpyloric nasoenteric tube placement. The area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of these models.

Results

Successful postpyloric nasoenteric tube placement was confirmed in 427 of 939 patients enrolled. For predicting successful postpyloric nasoenteric tube placement, the performance of the 3 decision trees was similar in terms of the AUCs: 0.715 for the CHAID model, 0.682 for the SimpleCart model, and 0.671 for the J48 model. The AUC of the LR model was 0.729, which outperformed the J48 model.

Conclusion

Both the CHAID and LR models achieved an acceptable discrimination for predicting successful postpyloric nasoenteric tube placement and were useful for intensivists in the setting of self‐propelled spiral nasoenteric tube insertion.     

Verification of an electromagnetic placement device compared with abdominal radiograph to predict accuracy of feeding tube placement

Background: Use of an electromagnetic placement device (EMPD) facilitates placement of feeding tubes at the bedside. Standard practice for verification of feeding tube placement is via radiographic confirmation. The purpose of this research study was to assess the accuracy of placement of small‐bore feeding tubes (SBFTs) as determined by EMPD interpretation compared with that of abdominal radiograph verification by a radiologist. Methods: This multicenter prospective study enrolled patients requiring bedside feeding tube placement. SBFTs were placed by an experienced investigator using the EMPD. Two abdominal radiographs were then obtained: one after initial SBFT placement and an additional radiograph after injection of contrast. Documentation of location based on clinician interpretation using the EMPD was then compared with radiologist interpretation. Results: The final sample size was 194 patients, including 18 pediatric patients. Patient age ranged from 12 days to 102 years. Median time for tube placement was 12 minutes. Of the 194 patients, only 1 patient had data showing discrepancies between the original EMPD verification and the final abdominal radiograph interpretation, providing a 99.5% agreement. No patient experienced complications during SBFT placement, and 15 patients had inadvertent airway placement that was avoided with the use of the EMPD. Conclusions: There was a high percentage of agreement between EMPD and radiologic interpretation after contrast injection. The EMPD aided in avoiding inadvertent airway placement, with no patient complications. This device can be used safely at the bedside to facilitate placement of feeding tubes, leading to the delivery of early enteral nutrition.     

Pulmonary complications of 9931 narrow-bore nasoenteric tubes during blind placement: a critical review

Introduction: A critical review of the pulmonary complications associated with blind placement of narrow‐bore nasoenteric tubes (NETs) is discussed. Preventive measures and placement techniques are addressed to decrease patient morbidity and mortality. Methods: A thorough database review was conducted to identify all randomized controlled and retrospective trials specifically addressing pulmonary complications from narrow‐bore NET placement. Five unique studies, comprising more than 9900 NET placements, were identified. On the basis of the literature reviewed, the authors identified 3 major complications associated with blind NET placement: patient mortality directly resulting from NET misplacement, incidence of tracheopulmonary malpositioning, and correlation between NET misplacement and mechanical ventilation. Results: Of the 9931 NET placements reviewed, there were 187 total improper tube placements in the tracheobronchial tree, which translates to a 1.9% mean overall malposition rate. Of these 187 misplacements, there were 35 (18.7%) reported pneumothoraces, at least 5 of which resulted in patient death. NET malpositioning was reported in 13%–32% of subsequent repositioning attempts. This increased risk exposes the patient population to a cumulative mortality from tracheobronchial malpositioning approaching >20%. Unexpectedly, of the 187 total misplacements, 113 (60.4%) of the patients were mechanically ventilated. Conclusions: Practitioners need to be aware of the potential for pulmonary complications associated with blind NET placement. Changes in institutional protocol should be considered to minimize unnecessary risks. As with any procedure, experienced personnel should be primarily used for tube placement and responsible for assisting others with less familiarity to learn the proper methods.     

Placement of a Magnetic Small Bowel Feeding Tube at the Bedside

Background: Current methods of achieving postpyloric enteral access for feeding are fraught with difficulties, which can markedly delay enteral feeding and cause complications. Bedside tube placement has a low success rate, often requires several radiographs to confirm position, and delays feeding by many hours. Although postpyloric enteral tubes can reliably be placed in interventional radiology (IR), this involves greater resource utilization, delays, cost, and inconvenience. We assessed the utility of bedside enteral tube placement using a magnetic feeding tube (Syncro‐BlueTube; Syncro Medical Innovations, Macon, GA, USA) as a means to facilitate initial tube placement. Methods: We recorded the time to insertion, location of tube, success rate, and need for radiographs in a series of patients given magnetic feeding tubes (n = 46) inserted by our hospitalist service over an 8‐month interval. Results: Of the 46 attempted magnetic tube placements, 76% were successfully placed in the postpyloric position, 13% were in the stomach, and 11% could not be placed. In 83% of the magnetic tubes, only 1 radiograph was needed for confirmation. The median time to placement was 12 minutes (range, 4–120 minutes). Conclusion: The use of a magnetic feeding tube can increase the success rate of bedside postpyloric placement, decrease the time to successful placement, and decrease the need for supplemental radiographs and IR.     

Bedside electromagnetic-guided feeding tube placement: an improvement over traditional placement technique?

BACKGROUND: Registered dietitian/registered nurse (RD/RN) teams were created to place small bowel feeding tubes (SBFT) at the bedside in intensive care unit (ICU) patients using an electromagnetic tube placement device (ETPD). The primary objective of this study was to evaluate the safety of placing feeding tubes at the ICU bedside using an ETPD. Secondary outcomes included success rate, cost, and timeliness of feeding initiation. METHODS: Data were collected prospectively on 20 SBFT blind placements in ICU patients (control group). After implementing a protocol for RD/RN teams to place SBFTs with an ETPD, 81 SBFTs were placed (study group). Complications, success rate, number of x-rays after tube placement, x-ray cost, and time from physician order to initiation of feedings were compared between the groups. RESULTS: No adverse events occurred in either group. Successful SBFT placement was 63% (12/19) in the control group and 78% (63/81) in the study group (not significant, NS). The median time between physician order for tube placement and feeding initiation decreased from 22.3 hours (control group) to 7.8 hours (study group, p = .003). The median number of x-rays to confirm correct placement was 1 in the study group compared with 2 in the control group (p = .0001), resulting in a 50% decrease in the mean cost for x-rays. CONCLUSIONS: No adverse events occurred with the implementation of bedside feeding tube placement using an ETPD. In addition, SBFT placement with an ETPD by designated ICU RD/RN teams resulted in lower x-ray costs and more timely initiation of enteral feedings compared with blind placement.     

Compulsory medical rural placements: senior student opinions of early-year experiential learning

Objective: The aim of this study was to determine senior medical student (year 3–5) opinions of their early‐year (year 1–2) rural placement. Design: We assessed the impact of MBBS early‐year rural placements through a follow up of this cohort in their later years using a cross‐sectional questionnaire. Setting: The questionnaire was administered to year 3–5 medical students at their clinical school. Participants: There were 97 participants (49% response rate) in the study. Twenty‐nine per cent were male and 71% were female; 44% were from a rural background and 56% were from a metropolitan background; 48% were year 3 students, 32% were year 4 students and 20% were year 5 students; and 59% of the students were, at the time, situated at a rural clinical school and 41% were at a metropolitan clinical school. Main outcome measure: Closed‐ended questions were quantified and statistically analysed. Open‐ended responses were thematically analysed to determine what their experience of early‐year rural placements were like. Results: Seventy‐nine per cent of students considered the year 1 placement length as ‘about right’. Overall, most students found year 1 rural placements positive and grasped the placement aims and objectives. Most students were also pleased with year 2 rural placements, mainly due to the clinical aspects. Conclusions: Medical students appear to prefer shorter early‐year rural placements and understand the benefits and importance of such placements. They also have a desire for greater clinical exposure during these early‐year placements.     

Use of Temporary Enteral Access Devices in Hospitalized Neonatal and Pediatric Patients in the United States

Background: Temporary enteral access devices (EADs), such as nasogastric (NG), orogastric (OG), and postpyloric (PP), are used in pediatric and neonatal patients to administer nutrition, fluids, and medications. While the use of these temporary EADs is common in pediatric care, it is not known how often these devices are used, what inpatient locations have the highest usage, what size tube is used for a given weight or age of patient, and how placement is verified per hospital policy. Materials and Methods: This was a multicenter 1‐day prevalence study. Participating hospitals counted the number of NG, OG, and PP tubes present in their pediatric and neonatal inpatient population. Additional data collected included age, weight and location of the patient, type of hospital, census for that day, and the method(s) used to verify initial tube placement. Results: Of the 63 participating hospitals, there was an overall prevalence of 1991 temporary EADs in a total pediatric and neonatal inpatient census of 8333 children (24% prevalence). There were 1316 NG (66%), 414 were OG (21%), and 261 PP (17%) EADs. The neonatal intensive care unit (NICU) had the highest prevalence (61%), followed by a medical/surgical unit (21%) and pediatric intensive care unit (18%). Verification of EAD placement was reported to be aspiration from the tube (n = 21), auscultation (n = 18), measurement (n = 8), pH (n = 10), and X‐ray (n = 6). Conclusion: The use of temporary EADs is common in pediatric care. There is wide variation in how placement of these tubes is verified.     

Occupational therapy students' contribution to occasions of service during practice placements in health settings

Introduction: Currently in the Australian higher education sector, the productivity benefits of occupational therapy clinical education placements are a contested issue. This article will report results of a study that developed a methodology for documenting time use during placements and investigated the productivity changes associated with occupational therapy clinical education placements in Queensland, Australia. Supervisors’ and students’ time use during placements and how this changed for supervisors compared to pre‐ and post‐placement is also presented. Methods: Using a cohort survey design, participants were students from two Queensland universities, and their supervisors employed by Queensland Health. Time use was recorded in 30 minute blocks according to particular categories. Results: There was a significant increase in supervisors’ time spent in patient care activities (F = 94.011_{2,12.37 df}, P < 0.001) between pre‐ and during placement (P < 0.001) and decrease between during and post‐placement (P < 0.001). Supervisors’ time spent in all non‐patient care activities was also significant (F = 4.580_{2,16 df}, P = 0.027) increasing between pre‐ and during placement (P = 0.028). There was a significant decrease in supervisors’ time spent in placement activities (F = 5.133_{2,19.18 df}, P = 0.016) from during to post‐placement. Students spent more time than supervisors in patient care activities while on placement. Discussion: A novel method for reporting productivity and time‐use changes during clinical education programs for occupational therapy has been applied. Supervisors spent considerable time in assessing and managing students and their clinical education role should be seen as core business in standard occupational therapy practice. This paper will contribute to future assessments of the economic impact of student placements for allied health disciplines.     

Block versus longitudinal integrated clerkships: students’ views of rural clinical supervision

Context

Medical students undertaking longitudinal integrated clerkships (LIC s) train in multiple disciplines concurrently, compared with students in block rotations who typically address one medical discipline at a time. Current research suggests that LIC s afford students increased access to patients and continuity of clinical supervision. However, these factors are less of an issue in rural placements where there are fewer learners. The aim of this study was to compare rural LIC and rural block rotation students’ reported experiences of clinical supervision.

Methods

De‐identified data from the 2015 version of the Australian national rural clinical schools (RCS s) exit survey was used to compare students in LIC s with those in block rotations in relation to how they evaluate their clinical supervisors and how they rate their own clinical competence.

Results

Multivariate general linear modelling showed no association between placement type (LIC versus Block) and reported clinical supervision. The single independent predictor of positive perception of clinical supervisors was choosing an RCS as a first preference. There was also no association between placement type (LIC versus Block) and self‐rated clinical competence. Instead, the clinical supervision score and male gender predicted more positive self‐ratings of clinical competence.

Conclusions

The quality of clinical supervision in block placements and LIC programmes in rural Australian settings was reported by students as equivalent.

     

Bone Mineral Density and Growth in Children Having Undergone Liver Transplantation With Corticosteroid‐Free Immunosuppressive Protocol

Background: Children post–liver transplantation (post‐LTX) are at risk of growth delay and decreased bone mineral density (BMD) secondary to corticosteroid (CS) therapy and suboptimal intake of nutrients important for bone health. The pediatric LTX program at Stollery Children's Hospital introduced a CS‐free LTX regimen in 2003. This retrospective study investigated whether the implementation of a CS‐free protocol resulted in improvements in BMD (dual x‐ray absorptiometry) and growth following LTX. Methods: A retrospective chart review of all children undergoing LTX was conducted. The parameters included repeated measures of anthropometric (weight, weight z score, height, height z score), BMD/bone mineral content (BMC), laboratory variables, graft function (number/severity of rejection), and CS therapy (dose, duration). Results: A total of 39 patients met study inclusion (20 male; n = 28 on CS; n = 11 CS‐free). Mean duration of follow‐up was 5.5 ± 3.3 years. The mean weight and height z scores were ?0.31 ± 0.14 (CS) and 0.22 ± 0.23 (CS‐free; P = .09) and ?0.71 ± 0.13 (CS) and 0.23 ± 0.22 (CS‐free; P = .002), respectively. Lumbar and whole‐body BMD z score less than ?2 were present in 15% and 8% of the cohort, respectively. There were no significant differences between CS and CS‐free in lumbar BMC (22.2 ± 1.4 and 23.4 ± 2.02 g; P = .165) and lumbar BMD (0.57 ± 0.02 and 0.80 ± 0.22 g/cm²; P = .152), respectively. Lumbar BMC (r² = 0.89, P < .05) and whole‐body BMC (r² = 0.93, P < .05) were inversely related to CS dose >0.2 mg/kg/d and positively related to bone age (P < .01). Conclusion: CS therapy in children post‐LTX is associated with reduced BMC and delayed linear growth. Understanding the clinical and nutrition factors influencing bone health is important to optimizing growth and bone health in children post‐LTX.     

One‐Step Insertion of Low‐Profile Gastrostomy in Pediatric Patients vs Pull Percutaneous Endoscopic Gastrostomy

Background: Standard care for initiation of enteral feeding in children has been pull percutaneous endoscopic gastrostomy (pull‐PEG). As an alternative to pull‐PEG, a 1‐step endoscopic procedure for inserting a low‐profile gastrostomy tube “button” has been developed that allows initial placement of a balloon‐retained device. This report presents outcomes of metrics used to compare button placement with pull‐PEG in a pediatric population. Methods: Data were generated from procedural experiences of surgeons on pediatric patients (n = 374) with a variety of clinical indications for gastrostomy. Study population ages ranged from 6 days to 16 years, while weights were from 2–84 kg. Results: The button was successfully placed by the 1‐step procedure in 98% of the respective study population, and median procedural times were 20 and 15 minutes for button and pull‐PEG placements, respectively. Median times to first feeds were equivalent for the 1‐step procedure and pull‐PEG (6 hours), while times to first nutrition feeds were 12.5 and 10 hours, respectively. Stoma site complications within each study group were similar. Healthy stoma proportions were 65.2% and 73.2% in the 1‐step procedure and pull‐PEG groups, respectively, at first follow‐up. Conclusions: Similar study outcomes between the 1‐step procedure and pull‐PEG groups suggest that the former is a feasible alternative to pull‐PEG for initial tube placement in children. The 1‐step method involves a single procedure and reduces patient exposure to anesthesia, operating room time, and the potential for complications compared with a pull‐PEG requirement for multiple procedures.     

Peritonitis after gastrostomy tube replacement: a case series and review of literature

Background: The placement of feeding gastrostomy (G) tubes through a percutaneous endoscopic gastrostomy (PEG) technique has become common because of its simplicity and safety. The majority of the serious complications are reported to occur within a few days of initial tube placement and happen in fewer than 3% of cases. Long‐term reported complications of this procedure include occlusion or breakage of the G‐tube, requiring reinsertion. This report describes the complication of intraperitoneal placement and the development of peritonitis after replacement of an established PEG tube and reviews the pertinent world literature. Methods: A retrospective review of cases of intraperitoneal insertion of replacement G‐tubes was done as well as a Medline search for cases of intraperitoneal insertion of replacement G‐tube or development of peritonitis after replacement tube insertion. Results: Three new cases of inadvertent intraperitoneal insertion of a replacement G‐tube in adult patients with mature tracts are reported. An additional 5 cases have been previously described in adults. Significant morbidity was associated with this complication, and 4 deaths were related to it. Methods used to determine whether the replacement G‐tube was intragastric were not uniform. Conclusions: There have been few reports of intraperitoneal insertion of replacement G‐tubes in patients with mature (>30 days) stoma sites. The cases presented in this report highlight for the clinician the importance of considering this complication, particularly if there are any difficulties with the reinsertion. Prospective studies are needed to determine the frequency of this complication and the optimal protocol for PEG replacement.     

Treating Delayed Gastric Emptying in Critical Illness

Background: We describe experience using the Cortrak nasointestinal feeding tube and prokinetics in critically ill patients with delayed gastric emptying. Methods: Patient cohorts fed via a Cortrak electromagnetically guided nasointestinal tube (EGNT) or 14 French‐gauge nasogastric tube plus prokinetics were retrospectively compared. Results: Of 69 EGNT placements in 62 patients, 87% reached the small intestine. The median percentage of the enteral nutrition goal increased from 19% pre‐EGNT to 80%–100% between days 1 and 10 post‐insertion and was greater than in 58 patients prescribed metoclopramide (40%–87%: days 1–2, 5–7, P ≤ .018) or 38 patients prescribed erythromycin (48%–98%; days 1 and 5, P < .0084). Up to day 10, the cumulative feeding days lost were lower for EGNT (1.06) than for metoclopramide (2.6, P < .02) or erythromycin (3.1, P < .02). The EGNT group had a lower use of prokinetics and lower treatment cost. Conclusion: Most bedside EGNT placements succeed and, compared to nasogastric feeding plus prokinetics, increase enteral nutrition delivery and reduce both cumulative feeding days lost and prokinetic use.     

Small bowel feeding tube placement using an electromagnetic tube placement device: accuracy of tip location

Background: An electromagnetic tube placement device (ETPD) monitors tip position of feeding tubes (FT) during placement in the digestive tract. It helps to avoid airway misplacement and permits positioning into the small bowel (SB). This study compares the overall agreement between FT tip location as determined by an ETPD vs an abdominal radiograph of the kidneys, ureter, and bladder (KUB). Methods: Using an ETPD, A nurse placed postpyloric FTs in ICU patients. We included all patients in whom the ETPD was used for FT placement. Data were prospectively recorded for 255 days on the rate of successful postpyloric placement, ETPD estimated tip location, and KUB location. Results: 860 tubes were placed in 616 patients, 719 (83.6%) of which recorded for ETPD and KUB. According to the KUB, 81% of tubes were in the SB; however, ETPD suggested 89% were beyond the pylorus. There was moderate agreement beyond what could be attributed to chance between KUB and ETPD tip locations (475 [66.1%], κ score 0.62 [95% confidence interval 0.58–0.67]). More tubes by KUB were distal (134[18.6%]) vs proximal (110[15.3%]) to the suspected location by ETPD (P < .0001. Tubes in or distal to the second half of the duodenum, according to ETPD were rarely in the stomach (<1%). No tubes were proximal to the stomach or placed into the airway. Conclusions: The strong agreement between KUB and ETPD, when tubes were believed to be in the second part of the duodenum or beyond, suggests that KUB is necessary only when the FT tip is suspected to be in the proximal duodenum.     

Percutaneous endoscopic gastrostomy (PEG) tubes are placed in elderly adults in Japan with advanced dementia regardless of expectation of improvement in quality of life

Background

The Japan Geriatrics Society published a guideline on the decision-making process for health care for the elderly in June 2012, noting that withholding or withdrawing feeding tubes are treatment options that should be discussed during the decision-making process. Arguments against the guideline posit that the insertion of a percutaneous endoscopic gastrostomy (PEG) tube feeding may improve quality of life (QOL) for elderly adults and their relatives.

Objectives

The aim of the present study was to explore (a) expected outcomes with PEG tube placement and (b) outcomes from PEG tube feeding in long-term care settings among elderly adults with advanced dementia in Japan.

Design

This study was conducted using a cross-sectional study design.

Setting

A total of 381 hospitals and 985 long-term care facilities provided sets of completed questionnaires.

Participants

There were 1 199 hospital patients and 2 160 long-term care patients aged 65 years or older with PEG tube placement included in the analysis.

Measurements

The nurses or physicians at each hospital provided information on the level of dementia at the time of PEG tube placement and on the expected outcomes of PEG tube feeding for elderly hospital patients. The nurses or other direct care workers at each facility provided information on the level of dementia and outcomes from PEG tube feeding for the long-term care patients.

Results

In the hospital patient group, 62.9% of patients had advanced dementia. PEG tube feeding was expected to prolong survival for 51.1% of hospital patients with advanced dementia. Improved QOL was expected for 39.1% of them. In the long-term care patient group, 61.7% of patients had advanced dementia. The rate of patients enjoying their own lives was lower in long-term care patients who had advanced dementia (4.2%) than in the other patients (16.4%). Approximately 60% of relatives reported satisfaction with the QOL of the patients, both in the long-term care patients with advanced dementia and the other patients.

Conclusion

Our results question the assumption that PEG tube feeding may improve QOL among elderly adults with advanced dementia. The national health policy should explore an approach to help patients, relatives, and practitioners make decisions about feeding options.     

Do the contemporary dietary patterns of children align with national food and nutrient recommendations?

Background

Childhood nutrition is important in optimising growth, development and future health. The present study compared dietary intakes of Australian children aged 4–8 years with (i) Australian Guide to Healthy Eating (AGHE) food group recommendations and (ii) age‐specific Nutrient Reference Values (NRVs), in addition to (iii) describing food group intakes of children meeting key NRVs.

Methods

Data were obtained from a representative sample of children (n = 789) from the National Nutrition and Physical Activity Survey between May 2011 and June 2012. Parent‐reported 24‐h recall dietary data were disaggregated into five core food groups, along with energy‐dense, nutrient‐poor (EDNP) foods, with intakes being compared with AGHE recommendations. Food group intakes were compared for children meeting the NRVs for 10 nutrients used for the development of AGHE food groups. Chi‐squared and t ‐tests were performed to determine differences in food group intakes with P < 0.05 considered statistically significant.

Results

Only one child met the recommended daily servings for all AGHE core food groups and none met both core and energy‐dense, nutrient‐poor (EDNP) food group recommendations. The lowest level of alignment (percentage meeting recommendations) was for vegetables (4.6%) and the highest was for fruit (47.7%). Mean (SD) daily intake of EDNP foods [4.7 (3.2) serves day^?1] accounted for 38.4% of total energy intakes. Children meeting key NRVs (n = 395) consumed greater daily servings of fruit [2.2 (1.7)], dairy [2.2 (1.2)] and EDNP foods [5.0 (3.4)] compared to the total sample (n = 789).

Conclusions

Significant discrepancies exist between contemporary dietary patterns of Australian children and national recommendations. Future AGHE revisions should incorporate greater diversity of consumption patterns, including sub‐categories of EDNP foods.