Minimal enteral nutrition

Although parenteral nutrition has been used widely in the management of sick very low birth weight infants, a smooth transition to the enteral route is most desirable. Trophic feeding is the practice of feeding small volume of enteral feeds in order to stimulate the development of the immature gastrointestinal tract of the preterm infant. This practice has also been termed as minimal enteral nutrition (MEN). MEN improves gastrointestinal enzyme activity, hormone release, blood flow, motility and microbial flora. Clinical benefits include improved milk tolerance, greater postnatal growth, reduced systemic sepsis and shorter hospital stay. There is currently no evidence of any adverse effects following MEN. MEN can be commenced in neonates on ventilation and total parenteral nutrition. A protocol of giving MEN has been presented here.     

Nutritional support of the pediatric surgical patient.

This review discusses the important developments in pediatric surgical nutrition over the past year. Sepsis and total parenteral nutrition-associated cholestasis remain complex problems for patients on total parenteral nutrition. Investigations suggest that total parenteral nutrition may compromise bactericidal activity, increasing the risk of sepsis. Sepsis possibly sensitizes the liver to cholestatic injury. Small volume enteral feeds may restore immune system function. Current research does not support an association between phytosterols in parenteral lipid solutions and total parenteral nutrition-associated cholestasis. Methionine has been identified as a potential hepatotoxin. Ursodeoxycholic acid and S-adenosyl-L-methionine are the most promising treatments of total parenteral nutrition-associated cholestasis. Small bowel transplant is now a reasonable option for patients with irreversible intestinal failure. Patient and graft survival rates have improved with FK-506 (Tacrolimus) immunosuppression. Isolated intestinal grafts have the best survival rate (92% at 1 year). Most surviving graft recipients are weaned off of total parenteral nutrition. The Cox Proportional Hazard model may help to identify candidates for small bowel transplant. This equation predicts the duration of dependence on total parenteral nutrition. Patients with irreversible intestinal failure can then be referred for early small bowel transplantation.     

Gut Hormones and 'Minimal Enteral Feeding'

ABSTRACT. Previously we have identified multiple surges in plasma concentrations of gut hormones post-natally in enterally fed term and preterm infants. In this study on 104 preterm infants we have shown that such surges are induced after ingestion of very small quantities of human milk. Whereas 6-day-old exclusively parenterally fed infants showed no postnatal elevation in enteroglucagon, gastrin, GIP, motilin and neurotensin, infants recovering from hyaline membrane disease who had received restricted enteral nutrition had similar hormone surges to those seen in well infants on full enteral feeds. Significant elevations in enteroglucagon, gastrin and GIP occurred after a cumulative mean enteral feed volume since birth of only 24 ml (12 ml/kg body weight) had been consumed and after a mean total intake of 96 ml (50 ml/kg) the response was maximal. Greater feed volumes were required to produce a neurotensin or motilin surge, but even these volumes were substantially lower than those required for full enteral feeding. In view of the proposed roles of gut hormones in the adaptation to extrauterine nutrition these data have implications for mammalian biology and raise the possibility that 'minimal enteral feeding' might have a clinical therapeutic role in infants undergoing prolonged parenteral nutrition.     

Optimising nutrition of preterm and term infants in the neonatal intensive care unit

Optimum nutrition leads to improved long-term neurodevelopmental outcomes in both preterm and term infants admitted to the neonatal intensive care (NICU). This review delineates the phases of nutritional management from full parenteral nutrition, transitioning to enteral nutrition and on to full enteral feeds. It describes the essential components of best nutritional care in the neonatal periods and provides practical tips in the management of nutrition in these infants. The authors make recommendations for care based on national and international guidelines and personal expertise of working in a tertiary NICU.     

Aggressive nutrition for preterm infants--benefits and risks

Very preterm infants frequently develop growth failure while in neonatal units. Guidelines for protein and energy requirements have recently been revised to consider the fetal reference related to lean body mass and protein gain, rather than weight gain, with revised protein intakes up to 4.4 g/kg/day at 26 to 30 weeks gestation. To limit growth failure, parenteral nutrition (PN) with relatively high protein and lipid needs to be commenced on day one. Early PN should be accompanied by minimal enteral feeds at 5-20 ml/kg/day with enteral feeds being steadily and carefully increased. Mother's own milk is the feed of choice and fortification schedules need to be revised to better meet new guidelines. Providing early PN and grading of enteral feeds with human milk to full feeds and then fortification to meet revised guidelines should improve growth and development, reduce infection rates and avoid the risks associated with rapid catch-up growth.     

Enterale Ernährung von Frühgeborenen

To a large extent postnatal growth failure is caused by inadequate postnatal nutrition. Postnatal growth failure is associated with poor brain growth, low IQ, coronary heart disease and hypertension. Growth failure is a marker of poor neurocognitive outcome. Owing to safety concerns, parenteral nutrition is started too late and advanced too slowly, and enteral nutrition is started too late, withheld too often and advanced too slowly. The immediate postnatal priority is to reestablish the fetal condition of full parenteral nutrition as fast as possible and gradually introduce enteral nutrition. In the present paper early enteral feeding of preterm infants is reviewed with especial reference to nutritional needs, markers of early feeding tolerance, feeding techniques and supplementation of feeds.     

Complications of short bowel syndrome

Short bowel syndrome is the commonest reversible cause of intestinal failure. Most of the children are started on parenteral nutrition (PN) after surgery to enable growth and allow time for intestinal adaptation i.e. a process whereby the shorter length of bowel is able to achieve complete function as if the entire length of bowel is present. With advances in management a majority of children with short bowel syndrome are able to discontinue PN and establish on full enteral feeds. This article mainly focuses on the complications of short bowel syndrome that need to be avoided in order for intestinal adaptation to progress and the child to be established on enteral feeds/oral diet.     

Neonatal nutrition: a brief review

Background  With increasing survival of extremely premature infants, emphasis is now focused on the quality of these survivors’ lives. Possibly the most important factor in the premature’s ability to survive in the NICU and thrive is the ability to replicate in utero growth through enteral and parenteral nutrition. Data Sources  Current literature and review articles were retrieved from PubMed and personal files of the authors. Results  The use and complications of the various components of total parenteral nutrition (TPN) were reviewed. The composition of appropriate enteral feeds for the premature was reviewed as was the difficulties associated with the establishment of adequate enteral feeds in the premature infants. Conclusions  Early initiation of amino acids in TPN and timely increases in the components of TPN can improve the caloric intake of prematures. Enteral feeds, particularly of breast milk, may be started within the first few days of life in all but hemodynamically unstable prematures. Newer lipid preparations show promise in reversing the hepatic damage of TPN associated cholestatic jaundice.     

Feeding growth restricted preterm infants with abnormal antenatal Doppler results

Absence or reversal of end diastolic flow (AREDF) in the umbilical artery is associated with poor outcome, and elective premature delivery is common. Feeding these infants is a challenge. They often have poor tolerance of enteral feeding, and necrotising enterocolitis may develop. This review explores current practice to see if there is evidence on which to base guidelines. The incidence of necrotising enterocolitis is increased in infants with fetal AREDF, especially when complicated by fetal growth restriction. Abnormalities of splanchnic blood flow persist postnatally, with some recovery during the first week of life, providing justification for a delayed and careful introduction of enteral feeding. Such a policy exposes babies to the risks of parenteral nutrition, with no trials to date showing any benefit of delayed enteral nutrition. Trials are required to determine the optimum timing for introduction of enteral feeds in growth restricted infants with fetal AREDF.     

关注危重患儿肠外营养规范应用

肠外营养（PN）是危重患儿肠功能衰竭或肠内喂养障碍时的主要营养支持治疗方法。准确评估危重患儿的营养状况及能量需求有助于更好地实施PN策略。最佳的PN时机尚未确定,但目前倾向于晚期开始。“全合一”是推荐的肠外营养模式。在危重成人患者中,已经不同程度地推荐使用药理营养素,但在儿科还须更深入的研究。     

Reducing bacterial contamination of enteral feeds

OBJECTIVE: It has previously been shown that microbial contamination of enteral feeds given to children in hospital and at home is common. This study therefore examined the effects of improvements in the enteral feeding protocol, coupled with an intensive staff training programme, on bacterial contamination. METHODS: The enteral feeding protocol was modified by: priming the feeding set on an alcohol treated metal tray, spraying the bottle opener and top with 70% alcohol, wearing non-sterile disposable gloves, and filling the feeding reservoir with feed for up to 24 hours' use rather than only four hours. Daily feeds samples were collected from 16 inpatients and home patients on enteral nutrition at the start and end of feeding. Seventy seven samples were cultured. Results were compared with previously published control data. RESULTS: Enteral feed contamination rates were reduced significantly from 62% to 6% of feeds given at home (p < 0.001), and from 45% to 4% of feeds given in hospital (p < 0.001). CONCLUSIONS: This study highlights the importance of using an appropriate enteral feeding protocol, and of regular staff training in reducing contamination rates of enteral feeds to an acceptable level.     

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??Parenteral nutrition has become a mainstay in the treatment of critically ill children with intestinal or conditions that preclude enteral feeding. Accurate assessment of nutritional status and energy requirements in critically ill children will help to better implement the strategy of parenteral nutrition. The timing of the optimal parenteral nutrition has not been determined??and at present the supplementary parenteral nutrition tends to be started at a later stage. “All in one” is recommended for parenteral nutrition. Pharmacological nutrients have been recommended in critically ill adult patients with different levels??but more extensive research is still needed in critically ill children.     

Changing trends in feeding policies for ventilated preterm infants

In 1987 and 1994 all UK regional neonatal intensive care units were questioned about their feeding policies for the ventilated preterm infant. Between 1987 and 1994 there was an increase in the use of milk feeds (59 versus 71%), fortified breast milk (5 versus 72%) and low birthweight formula (41 versus 69%) whilst use of donor breast milk declined (56 versus 22%). Units that gave enteral feeds used significantly less parenteral nutrition ( p < 0.05). Overall there was a tendency towards greater uniformity in feeding policies.     

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问肠内营养的开展尚无共识.目的 探讨亚低温治疗期问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,按照亚低温治疗期问是否行肠内营养分为...     

Protein-losing enteropathy in an infant with a lymphangiomyoma

A 3-month-old girl with intractable diarrhoea had protein-losing enteropathy secondary to a lymphangiomyoma. This is the first reported case of lymphangiomyoma in an infant. As enteral feeds were not tolerated, she was maintained on parenteral nutrition for 2 months. Pancreatic enzyme supplementation produced a rapid clinical improvement and normalization of serum albumin level. Weaning was subsequently tolerated and the vitamin, mineral, and trace element deficiencies improved. Subsequent recurrence was associated with normal pancreatic function and has proved refractory to treatment.     

Initial nutritional management of the preterm infant

Postnatal nutrition has a large impact on long-term outcome of preterm infants. Evidence is accumulating showing even a relationship between nutrient supply in the first week of life and later cognitive development in extremely low birth weight infants. Since enteral nutrition is often not tolerated following birth, parenteral nutrition is necessary. Yet, optimal parenteral intakes of both energy and amino acids are not well established. Subsequently, many preterm infants fail to grow well, with long-term consequences. Early and high dose amino acid administration has been shown to be effective and safe in very low birth weight infants, but the effect of additional lipid administration needs to be defined.     

静脉补充谷氨酰胺对外科手术新生儿喂养耐受的影响

目的 评价含丙氨酰谷氨酰胺(Ala-Gin)肠外营养(PN)对接受外科手术新生儿喂养耐受的影响.方法 对两家儿童医疗中心2006年1月至2007年1月收治的40例接受外科手术的新生儿进行研究,采用平行、随机、双盲、对照实验,随机分为常规PN组(对照组)和常规PN+Ala-Gln组(研究组),二组各20例,对照组氨基酸的剂量为2～3g·kg-1·d-1;研究组添加0.3g·kg-1·d-1 Ala-Gln双肽,其中Ala-Gln双肽取代了处方中相应氨基酸的量.首要终点指标为术后开始喂养时间,术后达到全肠内喂养天数(标准配方摄入量≥120 ml·kg-1·d-1)、完全脱离肠外营养时间和病死率.结果 研究组和对照组比较,患儿术后开始喂养时间[研究组(8±4)d,对照组(8±5)d]、术后达到全肠内喂养天数[研究组(14±8)次,对照组(15±7)次]以及完全脱离肠外营养时间[研究组(15±8)d,对照组(16±7)d]差异均无统计学意义.对照组有3例死亡,研究组患儿无死亡,病死率通过非意向性分析,二组比较差异有统计学意义,OR值为0.789,95%CI为0.626～0.996.但是通过意向性分析,OR值为0.706,95%CI为0.136～3.658,病死率比较差异没有统计学意义.结论 本研究显示,静脉补充谷氨酰胺未能使接受外科手术的新生儿减少术后开始喂养时间和术后达到全肠内喂养天数,缩短全肠外营养应用时间;但关于是否能够降低患儿病死率,通过意向性分析和非意向性分析的结果有差异,尚需进一步研究.     

Effect of early low-volume enteral substrate on subsequent feeding tolerance in very low birth weight infants

To determine the effect of small enteral feedings on small bowel function, 46 infants with birth weight less than 1500 g, selected on the basis of risk factors for feeding intolerance, were assigned randomly to one of two feeding groups. Group 1 received low-volume enteral feeds (12 ml/kg/day) in addition to parenteral alimentation for 10 days beginning on day 8 of life; group 2 received parenteral alimentation alone until day 18 of life. After this trial period feedings were increased by 15 ml/kg/day in all infants. Four infants (9%) developed necrotizing enterocolitis (one prior to any feeds, two in group 1, and one in group 2); two others were dropped from the study for reasons unrelated to feeding. The remaining 18 infants in group 1 had improved feeding tolerance compared with the 22 in group 2, as manifested by fewer days that gastric residuum totalled more than 10% of feedings (1.3 +/- 0.5 days vs 3.2 +/- 0.6 days, respectively, p less than 0.05) and fewer days that feedings were discontinued because of feeding intolerance (2.7 +/- 0.8 days vs 5.5 +/- 0.9 days, respectively, p less than 0.05). Consequently, 17 of 18 (94%) infants who had received the early low-volume enteral feedings achieved an enteral intake of 120 kcal/kg/day by 6 weeks of life, whereas only 14 of 22 (64%) infants in the delayed feeding group reached this intake (p less than 0.05). Peak total serum bilirubin concentrations were comparable in the two groups. The initiation of hypocaloric enteral substrate as an adjunct to parenteral nutrition improved subsequent feeding tolerance in sick infants with very low birth weight.     

Parenteral nutrition compared with transpyloric feeding.

Fifty nine infants of birthweight less than 1500 g were allocated alternately to initial total parenteral nutrition or to transpyloric feeding. Mortality was similar between the two groups. Ten of the 29 infants in the transpyloric group failed to establish full enteral nutrition during the first week of life. No beneficial effects on growth were shown in infants receiving parenteral nutrition. Acquired bacterial infection was higher in the parenteral group and associated with morbidity and mortality. Conjugated hyperbilirubinaemia occurred only in the parenterally fed infants. The incidence of necrotising enterocolitis was higher in the transpyloric group. Parenteral nutrition does not confer any appreciable benefit and because of greater complexity and higher risk of complications should be reserved for those infants in whom enteral feeding is impossible.