Nutrition support of the pediatric patient with AIDS

Maintaining optimal nutrition in the pediatric patient with Acquired Immune Deficiency Syndrome (AIDS) is challenging, but it may be one of the most effective therapies. Patients experience numerous complications that compromise nutritional status. Infection, fever, diarrhea, feeding problems, and decreased intake all contribute to malnutrition, which in turn predisposes the patient even more to infection and malabsorption. Nutrition assessment should be done routinely so that new problems may be identified and treated. High-calorie, high-protein feedings, vitamin supplementation, and, when necessary, gavage feedings or parenteral nutrition are recommended to improve nutritional status and prevent further deficits. Maintaining optimal nutrition in the pediatric patient with Acquired Immune Deficiency Syndrome (AIDS) poses a significant challenge to the health care team. Patients may experience numerous complications that compromise nutritional status. The patient is at high risk for opportunistic infections, especially of the lungs, central nervous system, gastrointestinal (GI) tract, and skin. Such infections are common causes of morbidity and mortality. Impaired nutritional status may further impair the patient's immunocompetence. A study by Kotler and Gaety demonstrated severe progressive malnutrition in adult AIDS patients, with the lowest measures of lean body mass occurring in those patients close to death at the time of the study. While no studies of children with AIDS have been done to date, we have subjectively observed feeding problems, weight loss, and malnutrition in most of the patients we have seen.     

Nutrition entérale dans le SIDA compliqué d'atteinte digestive

The tolerance and efficacy of enteral nutrition in patients with AIDS and digestive tract complications were assessed retrospectively in a serie of 17 patients aged 28–57 year. The digestive complications included cryptosporidiosis, CMV colitis and nutrient malabsorption. All the patients were severely malnourished, with a weight loss ranging from 13 to 38 per cent. Enteral nutrition was poorly tolerated in eight patients (47%) because of digestive discomfort (diarrhea) or psychological disturbances. Eleven patients received more than two weeks of enteral nutrition: mean intake 43.2 9.6 keal/kg/day, for 14 to 28 days. There was no significant improvement in most nutritional parameters. Global nutritional status improved in three patients, remained unchanged in six patients, and deteriorated in two patients. In patients with AIDS and digestive involvement, the tolerance and nutritional efficacy of enteral nutrition are poor.     

COPD机械通气患者营养支持研究进展

慢性阻塞性肺疾病(COPD)的患者由于疾病本身的影响造成营养素的摄入不足、吸收不良及消耗量增加等,易导致机体的营养不良。良好的营养状态对COPD患者的预后有着积极的作用,而合理的营养支持有助于改善患者的营养不良状态。在营养支持过程中,营养支持方式及时机的选择、营养配方的选择以及一些特殊营养物质的添加都会直接影响营养治疗的效果。同时,在进行营养治疗过程中,易出现腹胀、腹泻、胃潴留、返流、吸入性肺炎等常见并发症,这些并发症如何处理也会影响患者的预后。营养支持的监测可以为营养治疗方案的调整提供依据,因此应该如何通过相关生化指标的监测来评估营养支持的效果也是一个重要的问题。作者对这些相关问题作一讨论。     

Position of The Canadian Dietetic Association and The American Dietetic Association: nutrition intervention in the care of persons with human immunodeficiency virus infection

The goals of nutrition intervention in HIV disease include early assessment and treatment of nutrient deficiencies, the maintenance and restoration of lean body mass, and support for activities of daily living and quality of life. The maintenance and restoration of nutritional stores is closely interrelated and interdependent with each of the other recommended medical therapies. Therefore, it is vital to the health of persons with HIV/AIDS to have access to the services of a registered dietitian, who is the essential member of the health care team for providing nutrition care (48). The registered dietitian should take an active role in developing nutrition care protocols for HIV/AIDS in their practice setting. The dietetic professional must take responsibility for obtaining and maintaining current knowledge in this area and take the lead in translating current nutrition knowledge and research into practical and realistic nutrition guidelines for the individual with HIV/AIDS. Further research is needed in the area of HIV/AIDS and nutrition. Registered dietitians and other members of the health care team are encouraged to conduct nutrition research in the area of nutrition interventions and outcomes of nutrition therapy. Additionally, government health related agencies, national AIDS-related organizations, and private industry should be encouraged to provide funding sources and support to the issue of research in nutrition related problems and interventions in HIV/AIDS.     

Total parenteral nutrition by a nutrition support team: improved quality of care

Most of the studies that have examined the effect of nutrition support teams (NST) on the quality of total parenteral nutrition (TPN) have found reductions in the frequency of metabolic and central venous catheter related complications. Previous studies have not examined the patterns of nutrient delivery (eg, calories and protein) when TPN is provided either by a primary physician or by a NST. We compared the quality of TPN care provided by our NST or by primary physicians utilizing nonspecialized hospital personnel and resources. As expected, catheter complications were significantly less frequent in NST patients. Assessment of nutritional status and nutrient requirements as well as nitrogen balance were performed and documented significantly more often in NST patients. In addition, nutritional goals for calories and protein were achieved and positive nitrogen balance documented more often in NST patients. The need to consult the NST physician to utilize the NST was not well received by primary attending and resident physicians and resulted in nonuse of the team. In the future, modification of NST policies will be explored to encourage greater utilization of the NST without compromising the high standard of nutrition care delivered by the NST.     

Effect of home total parenteral nutrition on body composition in patients with acquired immunodeficiency syndrome

Malnutrition occurs commonly in patients with acquired immunodeficiency syndrome (AIDS). The efficacy of nutritional support is unknown. A prospective, longitudinal study was conducted to determine the effect of prolonged total parenteral nutrition on body composition in 12 AIDS patients. Five patients were malnourished because of problems with food intake or absorption, while seven had systemic infections, with or without a malabsorption syndrome. The AIDS patients gained body weight and body fat content in response to total parenteral nutrition, while mean body cell mass, estimated as total body potassium content, was unchanged. However, all five patients with altered intake or absorption had significant repletion of body cell mass which was significantly different from the patients with systemic infections. Calorie and nitrogen intake did not differ between the two groups. It is concluded that body mass repletion is possible in AIDS patients in whom malabsorption is the major pathogenetic factor in producing malnutrition and is less successful in patients with serious ongoing systemic diseases. Thus, the response to nutritional support is dependent on the particular clinical circumstances.     

Inflammatory bowel disease: nutritional implications and treatment

It is clear that the nutritional state of patients with inflammatory bowel disease is often impaired and that the provision of nutritional support results in an improvement in nutritional state of these patients. Improvement in nutritional status can be achieved as effectively with enteral as with parenteral nutrition. The nutritional support appears to have no primary therapeutic effect in patients with ulcerative colitis. With regard to nutritional support in Crohn's disease, parenteral nutrition should be restricted to use as supportive rather than primary therapy. Available information now seems to suggest that most of the benefits of parenteral nutrition in Crohn's disease are related to improvement in nutritional state rather than as primary therapy, and its use should be restricted to treatments of specific complications of Crohn's disease, such as intestinal obstruction, related to stricture formation or short bowel syndrome following repeated resection. The present available evidence indicates that defined elemental diets may have a primary therapeutic role in the management of first acute attacks of Crohn's disease when there is a need to improve the nutritional status of patients with inflammatory bowel disease as an adjunct to primary drug therapy. Enteral nutrition is as efficacious as parenteral nutrition; moreover, it is safer to administer and more cost-effective.     

Arbre décisionnel du soin nutritionnel

Undernutrition is a frequent complication of acute and chronic diseases, and is correlated with disease prognosis and patients’ quality of life. Undernutrition has a major impact on health care costs. Screening of undernutrition and nutritional care are recommended in current clinical practice and the identification of undernutrition-related costs is of prime importance. The management of nutritional care depends on nutritional risk and status, protein and energy needs, and spontaneous oral intake. The goal of nutritional care is to avoid the onset of malnutrition in patients at risk, and in undernourished patients to prevent its worsening and to correct it. Three different levels of nutritional intervention do exist: dietary counseling and oral nutritional supplements, enteral nutrition, and in case of enteral nutrition's contra-indications, intolerance or insufficiency, total or supplemental parenteral nutrition. The choice of feeding routes depends mainly on the expected duration of nutrition support. In every case, nutritional strategy should be regularly re-evaluated and adapted according to nutritional efficacy and disease evolution.     

A Night Without Stars (Book)

Children with disabilities need adequate nutritional intake to survive and thrive. Many are at risk and in need of nutritional intervention. In this study we evaluated the outcomes of nutrition services for children with disabilities and their families using an integrated model of feeding and nutrition. Thirty-five children and families who received nutrition intervention services participated in the study. Children with disabilities and inadequate nutrition significantly benefited from nutrition interven- tion services. Children increased in weight-for-height ratios. Families reported in- creased alertness for their children with improved nutritional status. Families of children with greater feeding difficulties experienced increased stress and decreased social support. These findings can help families and professionals work in partnership to meet the nutrition needs of children with disabilities and chronic health care problems before a child becomes severely malnourished or a family becomes dys- functional.     

Helping Families Meet the Nutritional Needs of Children With Disabilities: An Integrated Model

Children with disabilities need adequate nutritional intake to survive and thrive. Many are at risk and in need of nutritional intervention. In this study we evaluated the outcomes of nutrition services for children with disabilities and their families using an integrated model of feeding and nutrition. Thirty-five children and families who received nutrition intervention services participated in the study. Children with disabilities and inadequate nutrition significantly benefited from nutrition interven- tion services. Children increased in weight-for-height ratios. Families reported in- creased alertness for their children with improved nutritional status. Families of children with greater feeding difficulties experienced increased stress and decreased social support. These findings can help families and professionals work in partnership to meet the nutrition needs of children with disabilities and chronic health care problems before a child becomes severely malnourished or a family becomes dys- functional.     

Outcome and quality of life in paediatric home parenteral nutrition

In this review the current status of home parenteral nutrition is analysed, with respect to the predictability of weaning from nutritional support and the risk of developing major complications associated with the technique, the loss of vascular access and liver disease. These two complications were evaluated because they represent the more important indication for intestinal transplantation, the availability of which has changed the perspectives of patients and of physicians. Analysis of outcomes from the largest series allows the identification of patients who could be weaned from parenteral nutrition. Important prognostic factors in patients affected by short bowel syndrome are the length and type of the remnant and the time to tolerate enteral feeding. The main complications of therapy are sepsis, thrombosis, nutrient imbalances and liver disease. Sepsis and thrombosis could lead to line replacement and the loss of vascular access. Sepsis no longer represents a major cause of death, but it is a frequent complication. In some patients, it is difficult to assess the risk factors for sepsis, which is possibly related to a poorer outcome. The care of gut failure appears to be the best preventative measure for the occurrence of cholestatic liver disease, but further studies are needed to define the eventual role of lipid emulsion and of specific nutrient deficiency. The quality of life still remains to be studied: because home parenteral nutrition in children has a longer duration, its analysis is mandatory.     

ESPEN Guidelines on Enteral Nutrition: Adult renal failure

Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where normal food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in nephrology patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. Because of the nutritional impact of renal diseases, EN is widely used in nephrology practice. Patients with acute renal failure (ARF) and critical illness are characterized by a highly catabolic state and need depurative techniques inducing massive nutrient loss. EN by TF is the preferred route for nutritional support in these patients. EN by means of ONS is the preferred way of refeeding for depleted conservatively treated chronic renal failure patients and dialysis patients. Undernutrition is an independent factor of survival in dialysis patients. ONS was shown to improve nutritional status in this setting. An increase in survival has been recently reported when nutritional status was improved by ONS.     

Nutritional intervention and quality of life in adult oncology patients

The evaluation of quality of life (QoL) assesses patients' well-being by taking into account physical, psychological and social conditions. Cancer and its treatment result in severe biochemical and physiological alterations associated with a deterioration of QoL. These metabolic changes lead to decreased food intake and promote wasting. Cancer-related malnutrition can evolve to cancer cachexia due to complex interactions between pro-inflammatory cytokines and host metabolism. Beside and beyond the physical and the metabolic effects of cancer, patients often suffer as well from psychological distress, including depression. Depending on the type of cancer treatment (either curative or palliative) and on patients' clinical conditions and nutritional status, adequate and patient-tailored nutritional intervention should be prescribed (diet counselling, oral supplementation, enteral or total parenteral nutrition). Such an approach, which should be started as early as possible, can reduce or even reverse their poor nutritional status, improve their performance status and consequently their QoL. Nutritional intervention accompanying curative treatment has an additional and specific role, which is to increase the tolerance and response to the oncology treatment, decrease the rate of complications and possibly reduce morbidity by optimizing the balance between energy expenditure and food intake. In palliative care, nutritional support aims at improving patient's QoL by controlling symptoms such as nausea, vomiting and pain related to food intake and postponing loss of autonomy. The literature review supports that nutritional care should be integrated into the global oncology care because of its significant contribution to QoL. Furthermore, the assessment of QoL should be part of the evaluation of any nutritional support to optimize its adequacy to the patient's needs and expectations.     

Dénutrition et affections neuromusculaires de l''adulte et de l''adolescent

Patients with neuromuscular diseases have protein malnutrition related to the muscle mass decrease. When associated with a decrease in food intake below requirements, patients become cachectic. Respiratory complications are then frequent and severe. In case of respiratory distress, the acute stress might aggravate the protein loss which will be particularly difficult to restore if the muscular activity is reduced. Although there are no curative therapies for neuromuscular diseases but all symptomatic treatments are useful in maintaining function and quality of life; therefore the prevention of malnutrition is essential. Nutritional care is difficult because of the lack of norms for body composition and protein and energy requirements. The nutritional support must take into account the swallowing difficulties, the digestive and polyvisceral involvement and the natural history of the disease. The nutritional support is usually enteral. Feeding through a gastrostomy tube, feasable at home, has improved the quality of life of the patient. Parenteral nutrition is prescribed for limited periods for surgery or acute respiratory failure.     

Malnutrition in patients with AIDS

Malnutrition is a frequent problem in persons infected with the human immunodeficiency virus. The origin of malnutrition in patients with AIDS may be multifactorial. The primary mechanisms include disorders of food intake, alterations in intermediary metabolism, and nutrient malabsorption. Attention to the problems of malnutrition in patients with AIDS is of paramount importance because the timing of death in these patients may be more closely related to degree of body cell mass depletion than to any specific underlying infection. Nutritional support can improve nutritional status in selected patients, and repletion of body cell mass may be associated with functional improvement. Early assessment, attention to nutritional requirements, and prompt intervention can minimize wasting and replete body cell mass. This article examines the evidence for malnutrition in patients with AIDS, reviews the studies of nutritional support, and presents an approach to the management of malnutrition in AIDS.     

An audit of the provision of parenteral nutrition in two acute hospitals: team versus non-team

Studies have indicated that provision of artificial nutritional support services by a multidisciplinary nutrition support team results in significant health benefits and cost savings. An audit was conducted to compare the provision of parenteral nutrition in two hospitals, one with a nutrition support team and one without, with published standards for nutritional care. In the hospital with the nutrition support team there was greater use of nutritional assessment, the energy content of prescribed regimens and energy intake of patients was closer to estimated requirements and the incidence of some metabolic complications was lower. It has been recommended that a nutrition support team should be formed in the hospital that currently has no such facility.     

Position of the American Dietetic Association: liberalized diets for older adults in long-term care

It is the position of the American Dietetic Association (ADA) that the quality of life and nutritional status of older residents in long-term care facilities may be enhanced by a liberalized diet. The Association advocates the use of qualified dietetics professionals to assess and evaluate the need for medical nutrition therapy according to each person's individual medical condition, needs, desires, and rights. One of the major determinants among the predictive factors of successful aging is nutrition. Long-term care includes a continuum of health services ranging from rehabilitation to supportive care. Nutrition care for older adults in long-term settings must meet two goals: maintenance of health through medical care and maintenance of quality of life. However, these goals often seem to compete, resulting in the need for a unique approach to medical nutrition therapy (MNT). Typically, MNT includes assessment of nutritional status and development of an individualized nutrition intervention plan that frequently features a theraperutic diet appropriate for managing a disease or condition. MNT must always address medical needs and individual desires, yet for older adults in long-term care this balance is especially critical because of the focus on maintaining quality of life. Dietetics professionals must help residents and health care team members assess the risks versus the benefits of therapeutic diets. For frail older adults, overall health goals may not warrant the use of a therapeutic diet because of its possible negative effect on quality of life. A diet that is not palatable or acceptable to the individual can lead to poor food and fluid intake, which results in weight loss and undernutrition, followed by a spiral of negative health effects. Often, a more liberalized nutrition intervention that allows an older adult to participate in his or her diet-related decisions can provide for the person's nutrient needs and allow alterations contingent on medical conditions while simultaneously increasing the desire to eat and enjoyment of food. This ultimately decreases the risks of weight loss, undernutrition, and other potential negative effects of poor nutrition and hydration.     

Rhoades Lecture. Effect of infection on nutrient requirements.

All infections, no matter how mild, decrease nutrient intakes and increase nutrient losses even when subclinical. The losses include decreased intestinal absorption, direct loss of nutrients in the gut, internal diversion for metabolic responses to infection and increased basal metabolic rate when fever is present. In this way, infection influences not only protein and energy status but also that of most other nutrients. The clinical importance of these consequences of infection depends on the prior state of the individual, the nature and duration of the infection, and the diet of the individual during the infection, particularly dietary intake during the convalescent period and whether full recovery takes place before another infection occurs. In industrialized countries particular attention must be paid to the nutrition of hospitalized patients inasmuch as they are frequently debilitated by their primary disease, morbidity, and nutritional status. Morbidity and mortality are increased by nosocomial infections to which the poorly nourished individual is more susceptible.     

Comment réaliser et surveiller une nutrition postopératoire ?

Nutritional supply is necessary in post operative patients who can not assure a normal oral feeding, equivalent to 60 % of their needs, in the 9 days following surgical procedure. In a normal well-feed population, nutritional supply in a shorter post-operative period is whithout influence on mortality and morbidity. On the other hand in undernourished patients nutritional support seems to decrease morbidity. However, the definition of this group using simple means remains difficult. After elective surgery, comparison between total parenteral nutrition and enteral nutrition does not show any important difference. However in the case of post tranmatic surgery, infectious morbidity and intensive care and hospital stays are lower when enteral nutrition is used. The lack of difference following elective surgery is likely due to a small number of patients and the low rate of complications. Enteral nutritional support must be chosen when ever possible. Currently, it is not possible to affirm the porportion of each nutrient when nutrition is performed at the post-operative phase. Optimal glucose supply is around 4 to 6 mg/kg/min and the calorie to nitrogen ratio from 200 to 150/1. Some specific nutrient seem to be of interest especially alpha keto glutarate which can be theoretically employed as a substitute for glutamine. This substrate seems to decrease septic complications and delay of wound healing.Nutritional assessment and effectiveness of feeding regimen is very difficult during the post-operative phase. Only, the confrontation of several methods allows to have a good approach of the nutritional status. Among visceral proteins, transthyretin has the highest sensitivity and predictive specificity during a stable inflammatory process. Muscle strength and bio electrical impedance measurements seem of interest but need further studies. Subjective assessment at the preoperative period remains the best method of nutritional assessment but requires trained observers.     

Preterm nutrition and neurodevelopmental outcomes

Survival of preterm infants has been steadily improving in recent years because of many recent advances in perinatal and neonatal medicine. Despite these advances, the growth of survivors does not reach the ideal target level of the normal fetus of the same gestational age. Postnatal weight gain is often not achieved because extrauterine growth has higher energy requirements than intrauterine growth, due to the intensive care environment, illness and inadequate nutrition. Although many other factors influence infant brain development, including family socioeconomic and educational background, the role of nutrition is considerable and fortunately, amenable to intervention. In the preterm neonate, the brain is the most metabolically demanding organ, consuming the largest proportions of energy and nutrient intake for its function and programmed growth and maturation. Weight gain, linear and head circumference growth are all markers of nutritional status and are independently associated with long-term neurodevelopment. Brain development is not only the result of nutrients intake, but in addition, of the interaction with growth factors which depend on adequate nutrient supply and overall health status. This explains why conditions such as sepsis, necrotizing enterocolitis and chronic lung disease alter the distribution and accretion of nutrients thereby suppressing growth factor synthesis. In this review, we will focus on the direct role of nutrition on neurodevelopment, emphasizing why it should be started without delay. The nutritional requirements of the preterm infant will be discussed, followed by the effects of general nutritional interventions and specific nutrients, as well as the role of nutritional supplements on neurodevelopment. The primordial role of human breast milk, breast milk fortifiers and human milk oligosaccharides will be discussed in detail. We will also examine the role of nutrition in preventing neonatal complications which can affect neurodevelopment in their own right.