The nutritional intake supplied by enteral formulae used in older children (aged 7–12 years) on home tube feeds

Background:  In the UK, patients aged 6–12 years contribute more than one-third of children on home enteral tube feeds (HETF). Many enteral feeds are given to this age group. The present study aimed to investigate the formula with the best nutritional composition for children aged 7–12 years on HETF by comparing the nutrient intake of three feed types; a paediatric feed (PF) for 1–6 year olds, an adult feed (AF), and a feed for children (OCF) aged 7–12 years.
Methods:  Twenty-five HETF children aged 7–14 years (median 10 years) were given a 6.3 kJ mL⁻¹ enteral feed designed for 7–12 year olds (or weighing 21–45 kg) for 9 months. Nutrient intakes on the 7–12-year-old feed were compared with baseline feed (paediatric n  = 10; or adult n  = 15).
Results:  At baseline, the PF failed to meet 100% of the reference nutrient intake (RNI) for three of 19 (16%) of the nutrients studied, whereas AF provided in excess of 250% of the RNI for six of 19 (32%) of the nutrients. During the trial, the nutrients on the OCF were two of 19 (11%) <100% and four of 19 (21%) >250% of the RNI. Only seven of 10 (70%) children on a PF met at least 100% of the UK RNI for calcium, compared to 17 of 19 (89%) on the OCF.
Conclusions:  It is important to offer older children an enteral feed that provides an optimal level of nutrients to meet their nutritional requirements. Feeds designed for 7–12-year-old children more closely meet nutrient requirements than paediatric or adult formulae, but require further modification to fully meet the nutritional needs of this group.     

Improved nutritional management reduces length of hospitalization in intractable diarrhea

Sixteen patients were managed by one of two specific refeeding protocols to compare the efficacy of two enteral formulas in the nutrition restoration of infants with intractable diarrhea (IDI). The protocols outlined specific nutritional therapy including transition from parenteral to enteral nutrition; concentration, volume, and steps of advancement of formulas. Patient progress was monitored daily. Average length of stay, number of days on parenteral nutrition support, and number of formula changes for the IDI protocol groups were compared with a retrospective chart audit group of 29 IDI patients. The protocol groups had substantially fewer days of parenteral nutrition support, significantly fewer formula changes (p less than 0.01), and fewer days of hospitalization. The differences resulted in $14,750 of charges saved per protocol patient.     

Parenteral nutrition. Do dietitians have a role? Results of the Parenteral and Enteral Nutrition Group survey

Aim: To examine the role of the nutrition support dietitian in parenteral nutrition (PN).
Methods: Two postal surveys were sent to members of the Parenteral and Enteral Nutrition Group (PENG) in 1993 and 1995. The questionnaires were designed to examine four key areas of dietetic practice in PN.
Results: Response rates of 73% in 1993 and 75% in 1995 were achieved. In 1993, a minority of dietitians, only 5%, assumed total responsibility for the formulation of parenteral nutrition regimens. In 1995 this figure had risen to 14%. However, 83% of nutrition support dietitians wanted to increase their involvement in PN. Results from the 1995 survey showed that 42% of dietitians felt that education at undergraduate level was inadequate, whilst 58% felt education at postgraduate level could be improved.
Conclusion: Both surveys raised a number of issues concerning present prescribing practices of PN in the UK. There appears to be little practical clinical nutrition education concerning PN either in the medical, dietetic or pharmaceutical curriculum. This may indicate that present prescribing practices are suboptimal. Because dietitians are involved in nutritional assessment and calculation of nutritional requirements it would seem sensible that dietitians should have a greater prescribing role in PN. In order to become competent advisors in this area, more must be done to improve education for dietitians at the undergraduate and postgraduate levels, otherwise the opportunity to be actively involved in this area may be lost.     

Delivery of Enteral Nutrition after the Introduction of Practice Guidelines and Participation of Dietitians in Pediatric Critical Care Clinical Teams

Provision of optimal nutrition is often difficult to achieve in the critically ill child, but can improve with better nutritional support practices. This study evaluated the joint impact of the introduction of enteral feeding practice guidelines and participation of dietitians in daily ward rounds on enteral nutrition (EN) intake and practices in children in intensive care. Nutritional intake and EN practices were audited before (period A) and after (period B) the introduction of enteral feeding practice guidelines and participation of dietitians in daily ward rounds in a pediatric intensive care unit. Information was collected on a daily basis and nutritional intake was compared with predefined targets and the United Kingdom dietary reference values. There were 65 patients and 477 nutritional support days in period A and 65 patients and 410 nutritional support days in period B. Basal metabolic rate (BMR) energy requirements were achieved in a larger proportion of nutritional support days in period B (BMR achieved [% nutritional support days]; period A: 27% vs period B: 48.9%; P<0.001). In patients admitted for nonsurgical reasons, median energy, protein, and micronutrient intake improved significantly. In the same group, the percentage of daily fluid intake delivered as EN increased post implementation (period A: median=66.8%; interquartile range=40.9 vs period B: median=79.6%; interquartile range=35.2; P<0.001). No significant changes were seen in patients admitted for corrective heart surgery. Implementation of better EN support practice can improve nutritional intake in some patients in critical care, but can have limited benefit for children admitted for corrective heart surgery.     

Implementation of an electromagnetic imaging system to facilitate nasogastric and post-pyloric feeding tube placement in patients with and without critical illness

Background:  Artificial nutrition support is required to optimise nutritional status in many patients. Traditional methods of placing feeding tubes may incur clinical risk and financial costs. A technique facilitating placement of nasogastric and post-pyloric tubes via electromagnetic visual guidance may reduce the need for X-ray exposure, endoscopy time and the use of parenteral nutrition. The present study aimed to audit use of such a system at initial implementation in patients within an acute NHS Trust.
Methods:  A retrospective review was undertaken of dietetic and medical records for the first 14 months of using the Cortrak® system. Data were collected on referral origin, preparation of the patient prior to insertion, placement success rates and need for X-ray. Cost analysis was also performed.
Results:  Referrals were received from primary consultants or consultant intensivists, often on the advice of the dietitian. Fifty-nine percent of patients received prokinetic therapy at the time of placement. Thirty-nine tube placements were attempted. Sixty-nine percent of referrals for post-pyloric tube placement resulted in successful placement. X-ray films were requested for 22% of all attempted post-pyloric placements. Less than half of nasogastric tubes were successfully passed, although none of these required X-ray confirmation. The mean cost per tube insertion attempt was £111.
Conclusions:  This system confers advantages, particularly in terms of post-pyloric tube placement, even at this early stage of implementation. A reduction in clinical risk and cost avoidance related to X-ray exposure, the need for endoscopic tube placement and parenteral nutrition have been achieved. The implementation of this system should be considered in other centres.     

肠外瘘病人肠内营养支持临床应用研究

目的：观察肠内营养在肠外瘘病人应用的时机、条件、途径及肠内营养制品的选择,研究肠内营养在肠外瘘病人中的作用。方法：收集１７０例肠外瘘病人诊断、住院总天数及全肠外营养（ＴＰＮ）、全肠内营养（ＴＥＮ）、肠内＋肠外营养（ＰＮ＋ＥＮ）、经口饮食的天数,计算不同营养支持方法期间,非蛋白质热量、蛋白质的供给量和并发症的发生率。收集ＴＰＮ、ＴＥＮ支持前和支持后满１５天病人的血清白蛋白浓度。另对４０例肠外瘘病人进行为期１５天的前瞻性观察,了解肠内营养对白蛋白、前白蛋白、转铁蛋白、纤维连结蛋白、总蛋白、球蛋白和肝酶谱的影响。结果：１７０例病人的总住院天数为１３５５３天,其中１６４人曾使用ＴＰＮ６０４０天（４４．６％）;１２９人使用ＴＥＮ３６７６天（２７．１％）;８３人使用肠内＋肠外营养４８９天（３．６％）;１２８人经口饮食２３３     

Early nutritional therapy: the role of enteral and parenteral routes

PURPOSE OF REVIEW: Early nutrition is defined as the initiation of nutritional therapy within 48 h of either hospital admission or surgery. However, optimal timing for initiation of nutritional therapy through either enteral or parenteral routes remains poorly defined with the existing data. We reviewed the recent literature investigating the role of early enteral and parenteral nutrition in critical illness and perioperative care. RECENT FINDINGS: Recent studies in both trauma/surgical and nonsurgical patients support the superiority of early enteral over early parenteral nutrition. However, late commencement of enteral feeding should be avoided if the gastrointestinal tract is functional. Both prolonged hypocaloric enteral feeding and hypercaloric parenteral nutrition should be avoided, although the precise caloric target remains controversial. SUMMARY: Early enteral nutrition remains the first option for the critically ill patient. However, there seems to be increased favor for combined enteral-parenteral therapy in cases of sustained hypocaloric enteral nutrition. The key issue is when the dual regimen should be initiated. Although more study is required to determine the optimal timing to initiate a combined enteral-parenteral approach, enteral nutrition should be initiated early and parenteral nutrition added if caloric-protein targets cannot be achieved after a few days.     

Experience of post-pyloric feeding in seriously ill patients in clinical practice

BACKGROUND: Maintaining nutrition is an integral part of patient care and when it is possible enteral nutrition is regarded as superior to parenteral nutrition. Post-pyloric feeding may enable enteral feeding to be maintained in patients who cannot tolerate nasogastric feeding. The success of post-pyloric feeding in routine clinical practice is uncertain. METHODS: One hundred and forty six consecutive patients who had 150 separate episodes of post-pyloric feeding were identified. Casenotes were reviewed to assess indication for post-pyloric feeding, prior use of alternative methods of feeding, success of achieving nutritional requirements and patient outcome. RESULTS: A post-pyloric tube was successfully placed in 138 (92%) and nutritional requirements were met by post-pyloric feeding alone in 124 (83%). Post-pyloric feeding was used for between 2 and 254 days (median 14 days). Conditions for which post-pyloric feeding was used to administer nutritional support included burn injury, pancreatitis, sepsis, post-operative gastric stasis, bone marrow transplantation and chemotherapy induced vomiting. Fifty (33%) patients had an attempt at nasogastric feeding and 33 (22%) were on total parenteral nutrition before post-pyloric feeding was commenced. There was one major complication of a jejunal ulcer bleed in the series. Minor complications included displacement of the nasojejunal tube and failure to absorb feed related to gastrointestinal dysfunction. CONCLUSIONS: Post-pyloric feeding can be successfully used to maintain enteral nutrition in patients who would otherwise require parenteral nutrition.     

Feeding the gut early after digestive surgery: results of a nine-year experience

BACKGROUND AND AIMS: Early enteral nutrition (EEN) after surgery should be preferred to parenteral feeding, but its clinical use is limited for concerns about possible gastrointestinal (GI) adverse effects and feeding tube-related complications. Thus we evaluated our experience focusing on safety and tolerance of early postoperative jejunal feeding and possible risk factors for gastrointestinal adverse effects. METHODS: 650 subjects treated with EEN after major digestive surgery for cancer were prospectively studied. EEN was started within 12 hours after operation via a naso-jejunal (NJ) feeding tube or a catheter-feeding jejunostomy. The rate of infusion was progressively increased to reach the nutritional goal (25 kcal/kg/day) within the 4th postoperative day. Rigorous treatment protocols for diet delivery and EEN-related GI adverse effects were applied. RESULTS: 402 patients had a jejunostomy and 248 patients a NJ tube. EEN-related GI adverse effects were observed in 194/650 patients (29.8%). In 136/194 patients, these events were successfully handled by treatment protocols. Overall the nutritional goal was achieved in 592/650 patients (91.1%). Fifty-eight (8.9%) subjects had to be switched to parenteral feeding because of refractory intolerance to EEN. Intra-abdominal surgical complications and low serum albumin (<30 g/L) were the two major factors affecting tolerance. Severe jejunostomy-related complications occurred in 7/402 (1.7%) patients. EEN-related mortality was 0.1% (1/650). CONCLUSIONS: The use of the gut early after surgery is safe and well-tolerated and it should represent the first choice for nutritional support in this type of patients.     

Optimal nutritional support

There is ongoing debate about the respective roles of enteral and parenteral nutrition. The present short review suggests that these two feeding modalities are not mutually exclusive and that optimal nutritional support may necessitate the concomitant administration of enteral together with parenteral nutrition.     

Artificial nutrition support for patients in the Cambridge Health District

This paper describes the results of a one-year prospective survey of patients who received artificial enteral and parenteral nutritional support at home and in the hospitals of the Cambridge Health District. Enteral tube feeding accounted for most of the artificial nutritional support provided both in hospital and in the community. The findings of the study suggest that nutritional support is an important adjunct to the treatment of serious clinical disorders, and that the care of such patients can be improved by the establishment of a multidisciplinary enteral and parenteral nutrition team. Suggestions are made for establishing a structured home nutritional service.     

Perioperative nutrition in malnourished surgical cancer patients - a prospective, randomized, controlled clinical trial

Background & aims

Malnourished surgical patients are supposed to benefit from perioperative nutrition. It is unclear, however, whether enteral intervention really surpasses the parenteral one, and whether the modification of standard formula matters. The aim of the study was to evaluate the clinical value of the route and type of perioperative nutritional support.

Methods

A group of 167 malnourished patients (91 M, 76 F, mean age 61.4 years) operated between June 2001 and December 2008 was randomly assigned during postoperative period to four groups according to nutritional intervention: enteral and parenteral, standard or immunomodulating. All patients received parenteral nutrition before surgery for 14 days, which provided homogenous groups for the postoperative evaluation. The trial was designed to test the hypothesis that enteral nutrition and/or immunonutrition can reduce the incidence of postoperative complications.

Results

The incidence of individual complications was comparable among all four groups (p > 0.05). Infectious complications occurred in 23 of 84 patients with standard diets and in 20 of 83 patients receiving immunomodulatory formula (odds ratio 0.84; 95% CI 0.42 to 1.69). There were no significant differences in infectious complications’ ratio in patients receiving enteral (24/84 patients) and parenteral formulas (19/83 patients). Neither immunomodulating formulas nor enteral feeding significantly affected the length of hospitalization, overall morbidity and mortality rates.

Conclusions

Results demonstrated that postoperative nutritional intervention generates comparable results regardless of the route and formula used and that preoperative intervention is of the utmost importance.The study was registered in the Clinical Trials Database – number: NCT 00558155.     

Eating disorder management in hospital patients: Current practice among dietitians in Australia

Aim:  To examine dietetic practice during the management of eating disorders in inpatient and daypatient settings.
Methods:  A survey was sent to dietitians working in the clinical management of eating disorders within Australia. Thirty-six qualified dietitians including all dietitians working at the specialist units in Australia participated in the study.
Results:  Most dietitians aim to meet patients' nutritional requirements by food alone without artificial feeding. High-energy supplements are the preferred method of increasing energy intake to eating disorder patients. Nasogastric feeding was a standard feeding practice for anorexia nervosa reported by one-third of dietitians. Total parenteral nutrition was not considered an option for nutritional rehabilitation. In the treatment of anorexia nervosa, variable energy intakes for individual patients were prescribed aiming for weight gain of up to 1.0 kg/week in inpatients and 0.5 kg/week in outpatients.
Conclusion:  In Australia, there is no standard nutritional management for anorexia and bulimia nervosa. This survey establishes a baseline for nutritional management and practice of dietitians working with patients with eating disorders. Further research is needed regarding use of nasogastric feeding, and weight gain targets in anorexia nervosa.     

The impact of nutritional support on appetite and food intake

Artificial nutrition (enteral tube feeding and parenteral nutrition) is increasingly being used in hospital and community settings to provide short- and long-term nutritional support to a diverse range of patients with acute and chronic conditions. Despite these methods of feeding being used either in cojunction with diet, or as a sole source of nutrition, the issue of their satiating ability has previously been largely overlooked. The consensus that emerges from this review is that nutrients provided by enteral tube feeding or parenteral nutrition are not as effective as orally ingested nutrients at relieving appetite sensations or suppressing food intake. When artificial nutritional support is used as the sole source of nutrition, distressing appetite sensations may occur, even if full nutrient requirements are met by enteral tube or parenteral feeding. When used as a supplement to ad libitum food intake, enteral tube feeding and parenteral nutrition only partially suppress oral intake, and total energy intake is increased. The mechanisms responsible for the poorer satiating ability of artificial feeding methods, relative to food intake, are not clearly understood, but the bypassing of the upper gastrointestinal tract and associated cephalic phase response by these methods of nutrient delivery may be important.     

Clinical trial of a paediatric enteral feed

A paediatric enteral feed, Paediasure, was given to children aged 1–8 years needing nutritional support. Those who had more than 60% of their energy from Paediasure were included in the trial which ran for 1–3 months. Anthropometric measurements were done at the start and at the end of the trial. Nutritional evaluations of Paediasure were made and compared with other enteral feeds.
It was found that children's growth was satisfactory on Paediasure, that it was well tolerated and palatable if given orally. Paediasure has a high-nutrient density so when given at low volumes (which are required for overweight and some very underweight patients) the recommended nutrient intakes (RNI) are more likely to be met than if other enteral feeds are used.     

Optimal Nutrition Parameters for Neonates and Infants with Congenital Heart Disease

Congenital heart defects are known causes of malnutrition. Optimal nutritional management is paramount in improving short and long-term prognosis for neonates and infants with congenital heart malformations, as current strategies target preoperative and postoperative feeding requirements. Standardized enteral and/or parenteral feeding protocols, depending on the systemic implications of the cardiac defect, include the following common practices: diagnosing and managing feeding intolerance, choosing the right formula, and implementing a monitoring protocol. The latest guidelines from the American Society for Parenteral and Enteral Nutrition and the European Society of Paediatric and Neonatal Intensive Care, as well as a significant number of recent scientific studies, offer precious indications for establishing the best feeding parameters for neonates and infants with heart defects.     

Artificial nutrition support in hospitals in the United Kingdom - 1991: Second national survey

Objective - to determine current clinical practice of nutrition support in hospitals in the UK and to determine whether there have been any apparent changes in practices since 1988. Design - An 81 question survey about enteral and parenteral nutriton was sent to all District Dietitians registered with the British Dietetic Association. Information was collected additionally from pharmacists and clinicians. Results - 61.2% of questionnaires distributed were completed and returned. 32.5% of respondents had access to nutrition support teams, compared with 27% in 1988. The documentation of usage of nutrition support was poor, only 33% being able to accurately quantify administation of enteral nutrition, and 53% parenteral nutrition. Since 1988 the number of respondents using peripheral parenteral nutrition had doubled to 15%. Those using percutaneous gastrostomies had increased from 6% to 74%. Those using respiratory enteral diet formulations had quadrupled to 33%. There have been no other apparent major changes in nutrition support practice in the UK, in the last 3 years. Conclusions - Despite increasing awareness about the role of artificial nutrition support, and the value of Nutrition Support Teams there has been little or no progress in the provision or monitoring of support in the last 3 years. This has important implications when considering audit of such practices.     

Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a prospective, randomized controlled trial

BACKGROUND: The purpose of this study was to compare gastrointestinal tolerance to two enteral feeding protocols in critically ill patients. METHODS: A prospective, randomized controlled trial, that involved 96 consecutive patients expected to stay in the intensive care unit for > or =3 days and who had no contraindications to enteral feeding. The patients were randomized to either the current protocol (group I; gastric residual volume threshold, 150 mL, optional prokinetic) or proposed feeding protocol (group II; gastric residual volume threshold 250 mL, mandatory prokinetic). Gastrointestinal intolerance was recorded as episodes of high gastric residual volume, emesis, or diarrhea. The time to reach the goal rate of feeding and the percentage of nutritional requirements received during the study period were also recorded. RESULTS: Nineteen of 36 patients (19/36 = 0.53) in group I had one or more episodes of high gastric residual volume, compared with 10 of 44 patients (10/44 = 0.23) in group II (p < .005). There was no statistical difference between the two protocols with regards to emesis, diarrhea, or the total episodes of intolerance. The patients in group II reached their goal rates on average in 15 hours and received 76% of their nutritional requirements, compared with 22 hours and 70% in group I; however, these differences were not statistically significant. CONCLUSIONS: The incidence of enteral feeding intolerance was reduced by using a gastric residual volume of 250 mL along with the mandatory use of prokinetics. The study showed a trend of improved enteral nutrition provision and reduced the time to reach the goal rate in group II. These improvements support the adoption of the proposed feeding protocol for critically ill patients.     

Nutritional support in acute pancreatitis

PURPOSE OF REVIEW: This review explores the role of enteral and parenteral nutrition in severe acute pancreatitis and discusses the potential benefits of glutamine, omega-3 fatty acids, arginine and selenium together with probiotics and prebiotics in these patients. In addition, the method of refeeding during the convalescent period is also examined. RECENT FINDINGS: A complex picture is emerging in which enteral nutritional support may be important early in the course of the disease with parenteral nutrition being used more as a backup and possibly only after the systemic inflammatory response has peaked. Nasogastric feeding, sometimes supplemented by parenteral nutrition, is as efficacious as nasojejunal feeding. An individualized approach, in which strategies of nutritional support are tailored to patient response, is gaining currency. Data regarding specialized formulae are mixed but the use of prebiotics is showing promise and is worthy of further exploration. In the convalescent period, preliminary data also indicate that the risk of pain developing is no greater if a light diet is instituted rather than clear fluids. SUMMARY: Nutritional support in acute pancreatitis remains challenging and controversial with a number of different and unexpected approaches, including the use of nasogastric feeding and dual enteral and parenteral nutrition support, being adopted in recent clinical trials.