Influence of Age and Type of Underlying Disease on Complications Related to Home Enteral Nutrition

Background: No data about the influence of age and underlying diseases on home enteral nutrition (HEN)–related complications are reported in the literature. Herein, we retrospectively investigated this issue by analyzing HEN‐related complications in a cohort of consecutive patients grouped according to the underlying disease and age. Material and Methods: We reviewed the medical records of 101 patients referring to our team in 2007–2010 to obtain patients’ demographic data, age, nutrition status, duration of HEN treatment, and type of HEN‐related complications. They were divided in cancer and neurologic patients and subgrouped on the basis of their age. HEN‐related complications were expressed as complication rates. Results: Patients with neurological diseases suffered a significantly higher number of complications as compared with cancer patients (P = .04). Age did not significantly influence complication rates. The mechanical complications were the most frequent. The majority of HEN‐related complications were resolved at home. Conclusion: Our data strongly suggest that HEN‐related complications are influenced by underlying diseases and not by age. In neurologic patients, dementia, loss of autonomy, and the different therapies administered by PEG probably play an important role in increasing the number of HEN‐related complications as compared with cancer patients. The most frequent complications can be managed at home, reducing the costs of hospitalizations and discomfort for the patient.     

Two-year follow-up of the 'Families for Health' programme for the treatment of childhood obesity

Background The high prevalence of obesity in children in the UK warrants continuing public health attention. ‘Families for Health’ is a family‐based group programme for the treatment of childhood obesity. Significant improvements in body mass index (BMI) z‐score (?0.21, 95% CI: ?0.35 to ?0.07, P= 0.007) and other health outcomes were seen in children at a 9‐month follow‐up. Aim To undertake a 2‐year follow‐up of families who attended ‘Families for Health’ in Coventry, to assess long‐term outcomes and costs. Methods ‘Families for Health’ is a 12‐week programme with parallel groups for parents and children, addressing parenting skills, healthy lifestyles and emotional well‐being. The intervention was delivered at a leisure centre in Coventry, England, with 27 overweight or obese children aged 7–13 years (18 girls, 9 boys) and their parents, from 21 families. A ‘before‐and‐after’ evaluation was completed with 19 (70%) children followed up at 2 years. The primary outcome was change in BMI z‐score from baseline; secondary outcomes were children's quality of life, parent–child relationships, eating/activity habits and parents' mental health. Costs to deliver the intervention and to families were recorded. Results Mean change in BMI z‐score from baseline was ?0.23 (95% CI: ?0.42 to ?0.03, P= 0.027) at the 2‐year follow‐up and eight (42%) children had a clinically significant reduction in BMI z‐score. Significant improvements were seen in children's quality of life and eating habits in the home, while there were sustained reductions in unhealthy foods and sedentary behaviour. Fruit and vegetable consumption and parent's mental health were not significantly different at 2 years. Costs of the programme were £517 per family (£402 per child), equivalent to £2543 per unit reduction in BMI z‐score. Conclusions Improvements in BMI z‐score and certain other outcomes associated with the ‘Families for Health’ programme were sustained at the 2‐year follow‐up. ‘Families for Health’ is a promising new childhood obesity intervention, and a randomized controlled trial is now indicated.     

Outcomes of Infants With Home Tube Feeding: Comparing Nasogastric vs Gastrostomy Tubes

Background: The aim of this study was to determine the tube‐related complications and feeding outcomes of infants discharged home from the neonatal intensive care unit (NICU) with nasogastric (NG) tube feeding or gastrostomy (G‐tube) feeding. Materials and Methods: We performed a chart review of 335 infants discharged from our NICU with home NG tube or G‐tube feeding between January 2009 and December 2013. The primary outcome was the incidence of feeding tube–related complications requiring emergency department (ED) visits, hospitalizations, or deaths. Secondary outcome was feeding status at 6 months postdischarge. Univariate and multivariate analyses were conducted. Results: There were 322 infants discharged with home enteral tube feeding (NG tube, n = 84; G‐tube, n = 238), with available outpatient data for the 6‐month postdischarge period. A total of 115 ED visits, 28 hospitalizations, and 2 deaths were due to a tube‐related complication. The incidence of tube‐related complications requiring an ED visit was significantly higher in the G‐tube group compared with the NG tube group (33.6% vs 9.5%, P < .001). Two patients died due to a G‐tube–related complication. By 6 months postdischarge, full oral feeding was achieved in 71.4% of infants in the NG tube group compared with 19.3% in the G‐tube group (P < .001). Type of feeding tube and percentage of oral feeding at discharge were significantly associated with continued tube feeding at 6 months postdischarge. Conclusion: Home NG tube feeding is associated with fewer ED visits for tube‐related complications compared with home G‐tube feeding. Some infants could benefit from a trial home NG tube feeding.     

Self‐Insertion of a Nasogastric Tube for Home Enteral Nutrition

Background: Enteral tube feeding can be a source of discomfort and reluctance from patients. We evaluated for the first time the tolerability of self‐insertion of a nasogastric (NG) tube for home enteral nutrition (EN). Materials and Methods: All patients requiring enteral tube feeding for chronic diseases were enrolled in a therapeutic patient education (TPE) program at Nancy University Hospital. Results: In our department, between November 2008 and August 2012, 66 patients received EN with an NG tube. Twenty‐nine of 66 had self‐insertion of the NG tube (median age, 44 years), 17 had an anatomical contraindication, and 20 were excluded because of cognitive disability or language barrier or refusal. Twenty‐eight of 29 patients completed the TPE program. One patient died of pancreatic cancer in palliative care during the study. Median follow‐up was 20 months (interquartile range [IQR], 4–31). Median gain weight was 3.1 kg (IQR, 1.8–6.0) (P = .0002). Median duration of self‐insertion of the NG tube was 3 months (IQR, 2–5), and it was well tolerated by all 29 patients. Two patients described minor adverse events: abdominal pain and nausea for 1 patient and epistaxis leading to temporary discontinuation of EN for another patient. A group of 10 consecutive patients previously had a long‐term NG tube for EN. If they had the choice between a self‐inserted NG tube and a long‐term NG tube, all 10 patients reported they would prefer to start again with the self‐inserted NG tube. Conclusion: This pilot study suggests that self‐insertion of an NG tube may be efficacious and well tolerated in patients receiving EN for chronic conditions.     

Thirty‐Day Readmission Rate Is High for Hospitalized Patients Discharged With Home Parenteral Nutrition or Intravenous Fluids

Background: Reducing hospital readmissions decreases healthcare costs and improves quality of care. There are no published studies examining the rate of, and risk factors for, 30‐day readmissions for patients discharged with home parenteral support (HPS). Objective: Determine the rate of 30‐day readmissions for patients discharged with HPS and whether malnutrition and other demographic or clinical factors increase the risk. Materials and Methods: Retrospective review of patients discharged with HPS from the Cleveland Clinic between July 1, 2013, and June 30, 2014, and followed by the Cleveland Clinic Home Nutrition Support Service. Results: Of the 224 patients studied, 31.6% (n = 71) had unplanned readmissions within 30 days of hospital discharge. Of these, 21.1% (n = 15) were HPS related, with catheter‐related bloodstream infection (n = 5) and dehydration (n = 5) the most common. The majority of patients (84.4%) were diagnosed with malnutrition, but the presence or degree did not influence the readmission rate (P = .41). According to univariable analysis, patients with an ostomy (P = .037), a small bowel resection (P = .002), a higher HPS volume at discharge (P < .001), and a shorter period between HPS consult and hospital discharge (P < .026) had a lower risk of 30‐day readmission than their counterparts. On multivariable analysis, patients had a higher risk of 30‐day readmission if they had a history of heart disease (P = .048) and for every 1‐unit increase in white blood cells (P = .026). Conclusions: Patients discharged with HPS have a high 30‐day readmission rate, although most readmissions were not related to the HPS itself. The presence and degree of malnutrition were not associated with 30‐day readmissions.     

The Association Between Home Parenteral Nutrition and Patients With FAP‐Associated Intra‐Abdominal Desmoids

Background: Intra‐abdominal desmoid tumors (IADTs) are a common complication of familial adenomatous polyposis (FAP). Treatment is not standardized for advanced disease. Medical and surgical treatments may be ineffective in preventing complications, which can cause intestinal failure. Home parenteral nutrition (HPN) can be a life‐saving treatment in these patients. The aim of this study was to investigate the association with HPN in FAP‐IADTs. Methods: A retrospective review of FAP patients with IADTs at the Cleveland Clinic (CC) between 1980 and 2009 was performed. Patients and tumor characteristics were retrieved from the CC Jagelman Registry for Inherited Neoplasms and CC HPN database. Inclusion criteria were FAP‐IADTs and 6‐month follow up at CC. Exclusion criteria were <6‐month follow‐up, lack of 3‐dimensional lesion or sheet desmoid, and/or incomplete medical records. Kaplan‐Meier curves were analyzed for HPN and non‐HPN groups. Results: One hundred fifty‐four patients were included and divided into 2 groups: HPN (n = 41, 26.6%) and non‐HPN (n = 113, 73.4%). The HPN group was more likely to have advanced‐stage disease and significantly higher incidence of chronic abdominal pain, narcotic dependency, bowel obstruction, ureteral obstruction, deep vein thrombosis, pulmonary embolism, fistulae, and sepsis (P < .05). The need for HPN represented a strong predictor of mortality (5‐year survival HPN = 72% vs non‐HPN = 95%), but duration of HPN did not affect mortality. Conclusion: HPN, although a life‐saving treatment, is an independent poor prognostic factor associated with high morbidity and mortality.     

How Close Are We to Achieving Energy and Nutrient Goals for Very Low Birth Weight Infants in the First Week?

Background: Emerging evidence suggests intakes of protein and energy as early as the first week of life in preterm very low birth weight (VLBW) infants are associated with improved neurodevelopment. In response, many neonatal intensive care units (NICUs) have launched new, more aggressive early feeding guidelines. The aim of this study was to evaluate enteral and parenteral energy and macronutrient intakes during the first postnatal week in VLBW infants admitted to NICUs that have introduced more aggressive early feeding guidelines. Materials and Methods: Estimated energy and macronutrient intakes were prospectively collected from VLBW infants fed exclusively mother's own milk and/or parenteral nutrition and compared with expert recommendations. Days to reach full enteral feeds (150 mL/kg/d) and discharge anthropometrics were examined. Results: By days 6 and 7, median protein and lipid intakes, respectively, reached recommended values (3.5 and 3.0 g/kg/d). However, by day 8, many infants remained below recommended intakes for protein (34%), lipid (34%), carbohydrate (68%), and energy (71%). Late‐onset sepsis was associated with a decreased likelihood of reaching full enteral feeds on any given day (hazard ratio, 0.2; 95% confidence interval, 0.1–0.5; P ≤ .0009). There was no significant relationship between week 1 nutrient intakes and anthropometrics at discharge. Conclusion: Despite the introduction of more aggressive early feeding guidelines and improved energy and nutrient intakes compared with literature values, many VLBW infants remain below recommended nutrition goals in the first week.     

High folate levels in Aboriginal children after subsidised fruit and vegetables and mandatory folic acid fortification

Objective : To evaluate the impact of a fruit and vegetable (F&V) subsidy program for disadvantaged Aboriginal children in Australia, implemented alongside the introduction of mandatory folic acid fortification of bread‐making flour. Methods : A before‐and‐after evaluation was undertaken of a F&V subsidy program at three Aboriginal community‐controlled health services in New South Wales. The program provided a weekly box of subsidised F&V linked to preventive health services and nutrition promotion for families. In this analysis, red blood cell (RBC) folate was assessed together with self‐reported dietary intake at baseline and 12 months later in a cohort of 125 children (aged 0–17 years). Results : No children had low RBC folate at baseline or at follow‐up; however, 33 children (26%) exceeded the reference range of RBC folate at baseline and 38 children (30%) exceeded the reference range at follow‐up. Mean RBC folate levels increased substantially in children at follow‐up (mean RBC folate z‐score increased +0.55 (95%CI 0.36–0.74). Change in F&V intake (p=0.196) and mean bread intake (p=0.676) were not statistically significant predictors for change in RBC folate levels. Conclusions : RBC folate levels increased among these disadvantaged Aboriginal children following mandatory folic acid fortification and participation in a subsidised F&V program. Even before mandatory folic acid fortification, none of these children had low RBC folate. Implications : The effect on health of mandatory fortification of foods with folate is not clear, hence, ongoing population‐based monitoring of folate levels to assess the impact of mandatory folic acid fortification is important.     

The Impact of Glutamine Dipeptide–Supplemented Parenteral Nutrition on Outcomes of Surgical Patients

Objective: To evaluate the impact of glutamine dipeptide–supplemented parenteral nutrition (GLN‐PN) on clinical outcomes in surgical patients. Methods: MEDLINE, EMBASE, Web of Science, and the Cochrane Controlled Clinical Trials Register were searched to retrieve the eligible studies. The studies were included if they were randomized controlled trials that evaluated the effect of GLN‐PN and standard PN on clinical outcomes of surgical patients. Clinical outcomes of interest were postoperative morbidity of infectious complication, mortality, length of hospital stay, and cost. Statistical analysis was conducted by RevMan 4.2 software from the Cochrane Collaboration. Results: Fourteen randomized controlled trials (RCTs) (N = 587) were included in this meta‐analysis. The results showed that glutamine dipeptide significantly reduced the length of hospital stay by around 4 days in the form of alanyl‐glutamine (weighted mean difference [WMD] = ?3.84; 95% confidence interval [CI] ?5.40, ?2.28; z = 4.82; P < .001) and about 5 days in the form of glycyl‐glutamine (WMD = ?5.40; 95% CI ?8.46, ?2.33; z = 3.45; P < .001). The overall effect indicated a significant decrease in the infectious complication rates of surgical patients receiving GLN‐PN (risk ratio = 0.69; 95% CI 0.50, 0.95; z = 2.26; P = .02). Conclusion: GLN‐PN was beneficial to postoperative patients by shortening the length of hospital stay and reducing the morbidity of postoperative infectious complications.     

Dietary Management of Blood Glucose in Medical Critically Ill Overweight and Obese Patients: An Open‐Label Randomized Trial

Background: Enteral nutrition (EN) increases hyperglycemia due to high carbohydrate concentrations while providing insufficient protein. The study tested whether an EN formula with very high‐protein‐ and low‐carbohydrate‐facilitated glucose control delivered higher protein concentrations within a hypocaloric protocol. Methods: This was a multicenter, randomized, open‐label clinical trial with parallel design in overweight/obese mechanically ventilated critically ill patients prescribed 1.5 g protein/kg ideal body weight/day. Patients received either an experimental very high‐protein (37%) and low‐carbohydrate (29%) or control high‐protein (25%) and conventional‐carbohydrate (45%) EN formula. Results: A prespecified interim analysis was performed after enrollment of 105 patients (52 experimental, 53 control). Protein and energy delivery for controls and experimental groups on days 1–5 were 1.2 ± 0.4 and 1.1 ± 0.3 g/kg ideal body weight/day (P = .83), and 18.2 ± 6.0 and 12.5 ± 3.7 kcals/kg ideal body weight/day (P < .0001), respectively. The combined rate of glucose events outside the range of >110 and ≤150 mg/dL were not different (P = .54, primary endpoint); thereby the trial was terminated. The mean blood glucose for the control and the experimental groups were 138 (?SD 108, +SD 177) and 126 (?SD 99, +SD 160) mg/dL (P = .004), respectively. Mean rate of glucose events >150 mg/dL decreased (Δ = ?13%, P = .015), whereas that of 80–110 mg/dL increased (Δ = 14%, P = .0007). Insulin administration decreased 10.9% (95% CI, ?22% to 0.1%; P = .048) in the experimental group relative to the controls. Glycemic events ≤80 mg/dL and rescue dextrose use were not different (P = .23 and P = .53). Conclusions: A very high‐protein and low‐carbohydrate EN formula in a hypocaloric protocol reduces hyperglycemic events and insulin requirements while increasing glycemic events between 80–110 mg/dL.     

Intensive Nutrition in Acute Lung Injury

Background: Despite extensive use of enteral (EN) and parenteral nutrition (PN) in intensive care unit (ICU) populations for 4 decades, evidence to support their efficacy is extremely limited. Methods: A prospective randomized trial was conducted evaluate the impact on outcomes of intensive medical nutrition therapy (IMNT; provision of >75% of estimated energy and protein needs per day via EN and adequate oral diet) from diagnosis of acute lung injury (ALI) to hospital discharge compared with standard nutrition support care (SNSC; standard EN and ad lib feeding). The primary outcome was infections; secondary outcomes included number of days on mechanical ventilation, in the ICU, and in the hospital and mortality. Results: Overall, 78 patients (40 IMNT and 38 SNSC) were recruited. No significant differences between groups for age, body mass index, disease severity, white blood cell count, glucose, C‐reactive protein, energy or protein needs occurred. The IMNT group received significantly higher percentage of estimated energy (84.7% vs 55.4%, P < .0001) and protein needs (76.1 vs 54.4%, P < .0001) per day compared with SNSC. No differences occurred in length of mechanical ventilation, hospital or ICU stay, or infections. The trial was stopped early because of significantly greater hospital mortality in IMNT vs SNSC (40% vs 16%, P = .02). Cox proportional hazards models indicated the hazard of death in the IMNT group was 5.67 times higher (P = .001) than in the SNSC group. Conclusions: Provision of IMNT from ALI diagnosis to hospital discharge increases mortality.     

Handgrip Strength at Admission and Time to Discharge in Medical and Surgical Inpatients

Background and Objective: Handgrip strength is a relevant marker of functional status and is also a component of nutrition assessment. The simplicity of this measurement supports its usefulness as a tool to predict who will likely take longer to hospital discharge. The aim of this study was to quantify the association between sex‐specific handgrip strength at hospital admission and time to discharge alive. We intended to include a group of diverse diagnoses and to compare medical and surgical wards, taking into account the potential confounders’ effect of patients’ characteristics and severity of disease. Subjects and Methods: Prospective study in 2 public acute‐care general hospitals in Porto, Portugal, in 2004. Handgrip strength was evaluated using a handgrip dynamometer in a probability sample of 425 patients from medical and surgical wards. The association between baseline handgrip strength and time to discharge was evaluated using survival analysis with discharge alive as the outcome and deaths and transfers being censored. Results: In medical wards, women with high admission handgrip strength had a very short hospital stay (all had been discharged by the sixth day), and among men, patients with low handgrip strength had a particularly longer stay (approximately 50% were discharged after 15 days of hospitalization). In surgical wards, an increasing length of stay with decreasing handgrip strength quartiles was also observed in both sexes. Conclusions: Lower handgrip strength at hospital admission was associated with a longer time in the hospital, in patients of both sexes, in medical and surgical wards. Although this association was explained in part by age, height, education level, cognitive status, and disease severity, its direction remained unchanged regardless of the aforementioned factors.     

Impact of Early Sodium Supplementation on Hyponatremia and Growth in Premature Infants

Background: We tested the hypothesis that sodium supplementation in early preterm infants prevents late‐onset hyponatremia and improves growth without increasing common morbidities during birth hospitalization. Materials and Methods: This was a randomized, masked controlled trial of 4 mEq/kg/d of sodium (intervention) versus sterile water (placebo) from days‐of‐life 7 to 35 in infants born at <32 weeks corrected gestational age. The primary outcome was weight gain in the first 6 weeks of life. Secondary outcomes included weekly serum sodium concentrations, growth in body length and head circumference, and complications of prematurity during birth hospitalization. Results: Fifty‐three infants with an average corrected gestational age of 28.5 ± 2.4 weeks were randomized. Infants receiving the intervention had fewer (P = .012) reports of serum sodium concentrations <135 mmol/L and greater velocity of weight gain during the study period, mean (SD) 26.9 (3.1) vs 22.9 (4.7) g/kg/day, P = .012. At 6 weeks of age, infants <28 weeks' gestation who received sodium supplementation had greater percentage weight change from birth, mean (SD) 193% (22%) vs 173% (10%), P = .041, and maintained fetal reference birth percentile for body weight more often (P = .002) compared with infants receiving placebo. Growth in length and head circumference was not significantly different between study arms. No increase in common prematurity‐related morbidities was detected in infants who received supplemental sodium chloride. Conclusion: Sodium supplementation of enteral feedings in very premature infants averts hyponatremia and enhances weight gain.     

Adequate Nutrition May Get You Home

Background: Macronutrient deficit in the surgical intensive care unit (ICU) is associated with worse in‐hospital outcomes. We hypothesized that increased caloric and protein deficit is also associated with a lower likelihood of discharge to home vs transfer to a rehabilitation or skilled nursing facility. Materials and Methods: Adult surgical ICU patients receiving >72 hours of enteral nutrition (EN) between March 2012 and May 2014 were included. Patients with absolute contraindications to EN, <72‐hour ICU stay, moribund state, EN prior to surgical ICU admission, or previous ICU admission within the same hospital stay were excluded. Subjects were dichotomized by cumulative caloric (<6000 vs ≥6000 kcal) and protein deficit (<300 vs ≥300 g). Baseline characteristics and outcomes were compared using Wilcoxon rank and χ² tests. To test the association of macronutrient deficit with discharge destination (home vs other), we performed a logistic regression analysis, controlling for plausible confounders. Results: In total, 213 individuals were included. Nineteen percent in the low‐caloric deficit group were discharged home compared with 6% in the high‐caloric deficit group (P = .02). Age, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II), and initiation of EN were not significantly different between groups. On logistic regression, adjusting for BMI and APACHE II score, the high‐caloric and protein‐deficit groups were less likely to be discharged home (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.08–0.96; P = .04 and OR, 0.29; 95% CI, 0.0–0.89, P = .03, respectively). Conclusions: In surgical ICU patients, inadequate macronutrient delivery is associated with lower rates of discharge to home. Improved nutrition delivery may lead to better clinical outcomes after critical illness.     

Follow-up phone calls increase nutrient intake estimated by three-day food diaries in 13-year-old participants of the Raine study

Aim: Our primary objective was to determine the effect of follow‐up phone calls on estimated nutrient intakes obtained by three‐day food diaries from 13‐year‐old adolescents. Methods: Food diaries were recorded using household measures and entered into a dietary analysis software program, before and after follow up by telephone. A sample of 340 participants aged 13 years born into the Western Australian Pregnancy Cohort (Raine) Study, a population‐based longitudinal cohort followed from 16 to 20 weeks' gestation to 13 years of age (current follow up). After face‐to‐face instruction, participants completed three‐day food diaries at home and returned them by post. Follow‐up telephone calls were made to each participant to improve data collection response and to verify missing details in the food diaries. Nutrient intakes before and after telephone follow up were compared using Student's t‐tests in spss . Results were also compared with those of the Child and Adolescent Physical Activity and Nutrition survey. Results: Follow‐up phone calls significantly increased the estimated intake of total kilojoules, water, total carbohydrates, sugars and magnesium (P < 0.05). Conclusion: These results indicate the importance of follow‐up phone calls to obtain missing details in three‐day food diaries completed by adolescents.     

Transitioning Preterm Infants From Parenteral Nutrition: A Comparison of 2 Protocols

Background: Growth in preterm infants is compromised during the transition phase of nutrition, when parenteral nutrition (PN) volumes are weaned with advancing enteral nutrition (EN) feeds, likely due to suboptimal nutrient intakes during this time. We implemented new PN guidelines designed to maintain optimal nutrient intakes during the transition phase and compared growth outcomes of this cohort with a control group. Materials and Methods: A chart review was conducted on infants born <32 weeks’ gestation, before (control group) and after (study group) a new transition PN protocol was implemented in the neonatal intensive care unit. Weight parameters and nutrient intakes were calculated for the transition phase and compared between the 2 groups. Results: Demographic and clinical characteristics of the 2 groups were comparable except for higher rates of sepsis in control group. Weight‐for‐age z scores at birth, at 1 week of life, and at the start of the transition phase were similar. At the end of the transition phase, infants in the study group had significantly higher z scores compared with the control group, even when corrected for sepsis, a difference that persisted at 35 weeks’ gestation. During the transition phase, study infants gained 16.1 ± 4.6 g/kg/d compared with 13.2 ± 5.4 g/kg/d in control group (P < .001). Similar results were observed in the subset of expressed breastmilk–only fed infants (15.9 ± 4.6 g/kg/d in the study group compared with 13.2 ± 5.4 g/kg/d in the control group, P < .004). Conclusion: Optimizing nutrition by the use of concentrated PN during the transition phase to maintain appropriate nutrient intakes improves growth rates in preterm infants.     

Volume‐Based Feeding in the Critically Ill Patient

Introduction: Critically ill patients placed on enteral nutrition (EN) are usually underfed. A volume‐based feeding (VBF) protocol designed to adjust the infusion rate to make up for interruptions in delivery should provide a greater volume of EN than the more common fixed hourly rate‐based feeding (RBF) method. Methods: This single‐center, randomized (3:1; VBF/RBF) prospective study evaluated critically ill patients on mechanical ventilation expected to receive EN for ≥3 days. Once goal rate was achieved, the randomized feeding strategy was implemented. In the VBF group, physicians used a total goal volume of feeds to determine an hourly rate. For the RBF group, physicians determined a constant hourly rate of infusion to meet goal feeds. Results: Sixty‐three patients were enrolled in the study with a mean age of 52.6 years (60% male). Six patients were excluded after randomization because of early extubation. The VBF group (n = 37) received 92.9% of goal caloric requirements with a mean caloric deficit of ?776.0 kcal compared with the RBF group (n = 20), which received 80.9% of goal calories (P = .01) and a caloric deficit of ?1933.8 kcal (P = .01). Uninterrupted EN was delivered for 51.7% of all EN days in VFB patients compared with 54.5% in RBF patients. On days when feeding was interrupted, VFB patients overall received a mean 77.6% of goal calories (while RBF patients received 61.5% of goal calories, P = .001). No vomiting, regurgitation, or feeding intolerance occurred due to VBF. Conclusions: A VBF strategy is safe and improves delivery to better meet caloric requirements than the standard more commonly used rate‐based strategy.     

Metabolic Bone Disease

Background: Metabolic bone disease (MBD) is an important prematurity‐related morbidity, but remains inadequately investigated in extremely low birth weight (ELBW) infants, the group most at risk. The objective was to describe the incidence and associated risk factors of MBD in ELBW infants. Methods: Retrospective analysis of all ELBW infants admitted between January 2005 and December 2010 who survived > 8 weeks. MBD was defined as the presence of osteopenia or rickets in radiographs. Results: Of the 230 infants included in the study, 71 (30.9%) developed radiological evidence of MBD (cases) of which 24/71 (33.8%) developed spontaneous fractures. MBD and fractures were noted at mean postnatal ages of 58.2 ± 28 and 100.0 ± 61 days, respectively. Compared with controls, cases were smaller at birth (664.6 ± 146 g vs 798.1 ± 129 g), more premature (25.0 ± 1.8 vs 26.4 ± 1.9 weeks), more frequently associated with mechanical ventilation, chronic lung disease, parenteral nutrition days, cholestasis, furosemide, postnatal steroids, and antibiotics use (all P < .01). Cases had lower average weekly intake of calcium, phosphorous, vitamin D, protein, and calories during the first 8 weeks of life compared with controls. Cases with MBD, compared with controls, had higher mortality (14.1 vs 4.4%) and longer hospital stay (140.2 ± 51 vs 101.0 ± 42 days; P < .01). Conclusions: MBD remains an important morbidity in ELBW infants despite advances in neonatal nutrition. Further research is needed to optimize the management of chronic lung disease and early nutrition in ELBW infants.