Comprehensive Modified Diet Simplifies Nutrition Management of Adults with Short-Bowel Syndrome

Short-bowel syndrome (SBS) is a complex condition resulting from massive surgical resection of the intestinal tract. Nutrient malabsorption and metabolic alterations occur as a function of the portions of bowel removed and the length of remaining bowel segment. The nutrition management of SBS is challenging; many dietary restrictions are described, but inconsistently, throughout the literature. We compiled the restrictions and developed a comprehensive diet to reestablish adult patients with SBS on oral intake after surgery. Our purpose was to simplify the task of instructing patients with SBS in a diet that restricts all categories of food substances that may be poorly absorbed: fat, lactose, insoluble fiber, oxalates, and concentrated sweets. Suggestions to increase the transit time of ingested foods are included with the diet. Patients are taught the SBS diet after surgery and have bimonthly contact with the dietitian after leaving the hospital. Categories of restricted food substances, such as lactose, may be attempted and added back to the diet if they are tolerated. Bowel adaptation enhances tolerance to various dietary components over time. If sufficient bowel adaptation occurs, some patients are eventually able to return to an unrestricted diet. J Am Diet Assoc. 1998;98:309–315.     

Nutrition Support in Critically Ill Children: Underdelivery of Energy and Protein Compared with Current Recommendations

Critically ill children are at high risk for developing nutritional deficiencies, and hospital undernutrition is known to be a risk factor for morbidity and mortality in children. This study's aims were to examine current nutrition practices and the adequacy of nutrition support in the pediatric intensive care unit (PICU). This retrospective chart review included 240 PICU patients admitted to PICU for longer than 48 hours and documented all intravenous (IV), parenteral, and enteral energy and protein for the first 8 days. Basal metabolic rate and protein requirements were estimated by Schofield equation and the American Society for Parenteral and Enteral Nutrition Clinical Guidelines, respectively. Moderate/severe acute malnutrition was defined as weight for age greater than ?2 z scores, and moderate/severe chronic malnutrition (growth stunting) was defined as height for age greater than ?2 z scores, using 2000 Centers for Disease Control and Prevention growth charts. During the first 8 days of PICU stay, the actual energy intake for all patient-days was an average of 75.7%±56.7% of basal metabolic rate and was significantly lower than basal metabolic rate (P<0.001); the actual protein intake for all patient-days met an average of 40.4%±44.2% of protein requirements and was significantly lower than the American Society for Parenteral and Enteral Nutrition guidelines (P<0.001). Delivery of energy and protein were inadequate on 60% and 85% of patient-days, respectively. Only 75% of estimated energy and 40% of protein requirements were met in the first 8 days of PICU stay. These data demonstrate a high prevalence of critically ill children who are not meeting their recommended levels of protein and energy. In order to avoid undernutrition of these children, providers must conduct ongoing assessment of protein and energy intake compared with protein and energy requirements.     

Nutrition Recommendations Update: Dietary Fats and Children

This is a report of the Joint Working Group of the Canadian Paediatric Society and Health Canada.* Published with permission from the Health Protection Branch, Health Canada.     

Enteral Nutrition Support in Burn Care: A Review of Current Recommendations as Instituted in the Ross Tilley Burn Centre

Failure to adequately address the increased levels of inflammatory mediators, catecholamines and corticosteroids central to the hypermetabolic response post burn injury can lead to catastrophic results. One of the most important perturbations is provision of adequate and early nutrition. The provision of the right balance of macro and micronutrients, along with additional antioxidants is essential to mitigating the hypermetabolic and hypercatabolic state that results following a burn injury. As it is now widely accepted that enteral feeding is best practice for the burn population research has been more closely examining the individual components of enteral nutrition support. Recently fat to carbohydrate ratios, glutamine and antioxidants have made up the balance of this focus. This paper provides a review of the most recent literature examining each of these components and discusses the practices adopted in the Ross Tilley Burn Centre at Sunnybrook Health Sciences Centre.     

A Comparison of Postoperative Early Enteral Nutrition with Delayed Enteral Nutrition in Patients with Esophageal Cancer

We examined esophageal cancer patients who received enteral nutrition (EN) to evaluate the validity of early EN compared to delayed EN, and to determine the appropriate time to start EN. A total of 208 esophagectomy patients who received EN postoperatively were divided into three groups (Group 1, 2 and 3) based on whether they received EN within 48 h, 48 h–72 h or more than 72 h, respectively. The postoperative complications, length of hospital stay (LOH), days for first fecal passage, cost of hospitalization, and the difference in serum albumin values between pre-operation and post-operation were all recorded. The statistical analyses were performed using the t-test, the Mann-Whitney U test and the chi square test. Statistical significance was defined as p < 0.05. Group 1 had the lowest thoracic drainage volume, the earliest first fecal passage, and the lowest LOH and hospitalization expenses of the three groups. The incidence of pneumonia was by far the highest in Group 3 (p = 0.019). Finally, all the postoperative outcomes of nutritional conditions were the worst by a significant margin in Group 3. It is therefore safe and valid to start early enteral nutrition within 48 h for postoperative esophageal cancer patients.     

Carbohydrate Versus Fat in the Dietary Treatment of Short-Bowel Syndrome

The importance of the human colon in energy salvage has been documented again in a recent clinical study. Patients with short-bowel syndrome can be divided into two groups: those with colon and those without colon in continuity. While a high-carbohydrate, low-fat diet appears to be of nutritional benefit to the former group, dietary restrictions and reduction of fat intake are not effective in reducing intestinal energy loss in the latter group.     

Early Enteral Nutrition Is Associated With Lower Mortality in Critically Ill Children

Background: The purpose of this study was to examine the association of early enteral nutrition (EEN), defined as the provision of 25% of goal calories enterally over the first 48 hours of admission, with mortality and morbidity in critically ill children. Methods: We conducted a multicenter retrospective study of patients in 12 pediatric intensive care units (PICUs). We included patients aged 1 month to 18 years who had a PICU length of stay (LOS) of ≥96 hours for the years 2007–2008. We obtained patients’ demographics, weight, Pediatric Index of Mortality–2 (PIM2) score, LOS, duration of mechanical ventilation (MV), mortality data, and nutrition intake data in the first 4 days after admission. Results: We identified 5105 patients (53.8% male; median age, 2.4 years). Mortality was 5.3%. EEN was achieved by 27.1% of patients. Children receiving EEN were less likely to die than those who did not (odds ratio, 0.51; 95% confidence interval, 0.34–0.76; P = .001 [adjusted for propensity score, PIM2 score, age, and center]). Comparing those who received EEN to those who did not, adjusted for PIM2 score, age, and center, LOS did not differ (P = .59), and the duration of MV for those receiving EEN tended to be longer than for those who did not, but the difference was not significant (P = .058). Conclusions: EEN is strongly associated with lower mortality in patients with PICU LOS of ≥96 hours. LOS and duration of MV are slightly longer in patients receiving EEN, but the differences are not statistically significant.     

肠内外营养在妊娠剧吐治疗中的应用

妊娠剧吐不利于母亲和胎儿的健康,提供足够的营养支持是治疗的主要措施。本文简要介绍近年肠内外营养在妊娠剧吐治疗中的应用情况,旨在为正确选择何种营养途径提供新的思路。     

早期肠内营养支持对ARDS患者的免疫功能影响

目的观察早期肠内营养支持对ARDS患者的免疫功能影响以及对最终死亡率的影响.方法ARDS患者在开始机械通气分为肠内营养组和对照组,肠内营养组在机械通气当天即通过鼻胃管或鼻肠管给予鼻饲合成营养素,对照组则延迟至7天以后应用肠内营养.然后统计各项指标情况.结果治疗两周后及存活者出院时观察组与对照组相比在总蛋白、淋巴细胞数量、以及CD3和CD4水平均有明显升高,而CD8变化不大.肠内营养组与对照组相比在机械通气时间(平均12.8±2.1天、17.6±3.6天)、住ICU时间(平均21.5±4.6天、31.5±3.4天)均明显缩短.两组最终病死率有明显差异,肠内营养组为27.8%,对照组为35.7%.两组营养支持相关并发症发生率无明显差异.结论早期肠内营养支持可提高ARDS患者的免疫功能,提高总蛋白水平,降低最终病死率,缩短机械通气时间和住ICU时间,从而降低患者的医疗费用.     

Enteral Nutrition in Dementia: A Systematic Review

The aim of this systematic review is to evaluate the role of enteral nutrition in dementia. The prevalence of dementia is predicted to rise worldwide partly due to an aging population. People with dementia may experience both cognitive and physical complications that impact on their nutritional intake. Malnutrition and weight loss in dementia correlates with cognitive decline and the progress of the disease. An intervention for long term eating difficulties is the provision of enteral nutrition through a Percutaneous Endoscopic Gastrostomy tube to improve both nutritional parameters and quality of life. Enteral nutrition in dementia has traditionally been discouraged, although further understanding of physical, nutritional and quality of life outcomes are required. The following electronic databases were searched: EBSCO Host, MEDLINE, PubMed, Cochrane Database of Systematic Reviews and Google Scholar for publications from 1st January 2008 and up to and including 1st January 2014. Inclusion criteria included the following outcomes: mortality, aspiration pneumonia, pressure sores, nutritional parameters and quality of life. Each study included separate analysis for patients with a diagnosis of dementia and/or neurological disease. Retrospective and prospective observational studies were included. No differences in mortality were found for patients with dementia, without dementia or other neurological disorders. Risk factors for poor survival included decreased or decreasing serum albumin levels, increasing age or over 80 years and male gender. Evidence regarding pneumonia was limited, although did not impact on mortality. No studies explored pressure sores or quality of life.     

Enteral Nutrition in Pancreaticoduodenectomy: A Literature Review

Pancreaticoduodenectomy (PD) is considered the gold standard treatment for periampullory carcinomas. This procedure presents 30%–40% of morbidity. Patients who have undergone pancreaticoduodenectomy often present perioperative malnutrition that is worse in the early postoperative days, affects the process of healing, the intestinal barrier function and the number of postoperative complications. Few studies focus on the relation between enteral nutrition (EN) and postoperative complications. Our aim was to perform a review, including only randomized controlled trial meta-analyses or well-designed studies, of evidence regarding the correlation between EN and main complications and outcomes after pancreaticoduodenectomy, as delayed gastric emptying (DGE), postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), length of stay and infectious complications. Several studies, especially randomized controlled trial have shown that EN does not increase the rate of DGE. EN appeared safe and tolerated for patients after PD, even if it did not reveal any advantages in terms of POPF, PPH, length of stay and infectious complications.     

Infant Nutrition and Later Health: A Review of Current Evidence

There is a growing recognition of the need for a lifecourse approach to understanding the aetiology of adult disease, and there is now significant evidence that links patterns of infant feeding to differences in health outcomes, both in the short and longer term. Breastfeeding is associated with lower rates of infection in infancy; in high-income populations, it is associated with reductions in blood pressure and total blood cholesterol, and lower risks of obesity and diabetes in adult life. Breastfeeding rates are suboptimal in many countries, and strategies to promote breastfeeding could therefore confer important benefits for health at a population level. However, there are particular challenges in defining nutritional exposures in infancy, including marked social gradients in initiation and duration of breastfeeding. In recent studies of low and middle-income populations of children and young adults, where the influences on infant feeding practice differ, beneficial effects of breastfeeding on blood pressure, BMI and risk of diabetes have not been confirmed, and further information is needed. Little is currently known about the long-term consequences of differences in the timing and nature of the weaning diet. Future progress will depend on new studies that provide detailed prospective data on duration and exclusivity of breastfeeding together with appropriate characterisation of the weaning diet.     

重型颅脑损伤患者的早期肠内营养支持

我科自１９９７年起对３０例重型颅脑损伤患者应用肠内营养支持，效果良好，报告如下。一般资料本组３０例，均经临床及头颅CT扫描证实为重型颅脑损伤，男２１例，女９例；年龄１２～７２岁；GCS评分３～８分；损伤类型：开放型颅脑损伤２例，闭合性颅脑损伤２８例，其中硬膜外血肿８例，硬膜下血肿６例，脑内血肿６例，开颅手术２０例；并发症：腹泻２例，腹胀呕吐２例。营养支持方法伤后４８h将鼻胃管插入胃内，病人取头高位３０°左右，同时给予胃复安１０mg，每隔８h肌注，烦躁患者给予冬眠药物镇静，插入胃管后回抽胃液无消化道出血…     

基于证据的糖尿病营养治疗推荐标准

营养治疗是糖尿病综合治疗的基础。美国糖尿病学会于2002年提出基于证据的糖尿病营养推荐量标准和治疗原则。改善患者代谢状况，包括控制体重、血糖、血脂、血压及肾功能等，是确保治疗成功的关键。     

Enteral Nutrition for Feeding Severely Underfed Patients with Anorexia Nervosa

Severe undernutrition nearly always leads to marked changes in body spaces (e.g., alterations of intra-extracellular water) and in body masses and composition (e.g., overall and compartmental stores of phosphate, potassium, and magnesium). In patients with severe undernutrition it is almost always necessary to use oral nutrition support and/or artificial nutrition, besides ordinary food; enteral nutrition should be a preferred route of feeding if there is a functional accessible gastrointestinal tract. Refeeding of severely malnourished patients represents two very complex and conflicting tasks: (1) to avoid “refeeding syndrome” caused by a too fast correction of malnutrition; (2) to avoid “underfeeding” caused by a too cautious rate of refeeding. The aim of this paper is to discuss the modality of refeeding severely underfed patients and to present our experience with the use of enteral tube feeding for gradual correction of very severe undernutrition whilst avoiding refeeding syndrome, in 10 patients aged 22 ± 11.4 years and with mean initial body mass index (BMI) of 11.2 ± 0.7 kg/m². The mean BMI increased from 11.2 ± 0.7 kg/m² to 17.3 ± 1.6 kg/m² and the mean body weight from 27.9 ± 3.3 to 43.0 ± 5.7 kg after 90 days of intensive in-patient treatment (p < 0.0001). Caloric intake levels were established after measuring resting energy expenditure by indirect calorimetry, and nutritional support was performed with enteral feeding. Vitamins, phosphate, and potassium supplements were administered during refeeding. All patients achieved a significant modification of BMI; none developed refeeding syndrome. In conclusion, our findings show that, even in cases of extreme undernutrition, enteral feeding may be a well-tolerated way of feeding.