Stratégie de prise en charge nutritionnelle de l'enfant et de l'adolescent (Nutrition orale, entérale, parentérale)

Children are especially threatened by malnutrition, because of the high protein-energy cost of growth. Any nutritional deficiency is the source of protein energy malnutrition, which compounds the problems of underlying disease. The protein-energy cost of catch-up growth is particularly high, and should lead to a rigorous adjustment of nutritional supply to prevent metabolic disorders associated with refeeding syndrome (directly related to the homeostatic change secondary to severe protein energy malnutrition). If the gastrointestinal tract can be used for refeeding, it should be used (oral or enteral nutrition). When the gastrointestinal tract is unable to meet the protein and energy requirements, parenteral nutrition is required. Catch-up growth may be achieved by using appropriate nutritional support.     

Éducation des familles et de l'enfant en nutrition artificielle à domicile

The techniques of artificial nutrition came of age since the seventies (1969 for enteral nutrition and 1973 for parenteral nutrition). Artificial nutrition has considerably modified the outcome of a great number of children with severe digestive tract pathologies or many other disorders making impossible or ineffective oral food administration. There are currently two techniques of artificial nutrition: enteral nutrition (the most physiological using the digestive tract) and parenteral nutrition (by central venous line, more demanding and more complications). Home parenteral and enteral nutrition emerged with new realities: increase in the number of children needing a nutritional assistance, increase in the number of indications and a constant need to make autonomous the child and the family leading to a better quality of life. The best care for these children needs a multidisciplinary approach (physicians, nurses, dieteticians, pharmacists, speech therapist, psychologists…) and a close relation between primary care and hospital. This also requires a significant investment of parents who are sometimes assisted by private nurses. Parents are thus educated with techniques of enteral nutrition and parenteral nutrition: use of the material, training with the care, learning the action to be taken in case of problem. They have thus a role of caregiver: heavy responsibility necessary to the return at home of their child. The educational role of the hospital team thus takes a paramount importance with the aim to provide an optimal home return and the most adequate care by the family.     

Nutrition artificielle entérale versus parentérale au cours des pancréatites aiguës

Artificial nutrition is useful in acute pancreatitis with a poor prognosis (Ranson ≥ 3). The choice between enteral and parenteral nutrition has been a matter of debate, because of the stimulating effect of some substrates secretion. According to studies of in animals and healthy volunteers, TPN is safe, even with lipid emulsions and enteral nutrition is safe if administration is performed in the jejunum. Lipids must be avoided if nutrition is administrated in the gastric or duodenal site. Effectiveness is the same and safety is identical, but parenteral nutrition can lead to catheter sepsis.     

Rôle du foie dans le métabolisme des nutriments en nutrition artificielle

The liver is a prominent organ in nutritional homeostasis. Due to unique metabolic properties, it plays a main role in the metabolism of the three macronutrients ‘as well as the micronutrients’ (vitamins and minerals) storage. Although it represents only 2.5% of the body mass, it consumes 20% of total resting energy expenditure and a similar percentage of the amino acid mixture absorbed via the gut during and after a meal. Due to a peculiar vascularization (portal vein, the entire gastrointestinal venous flux is directed towards the liver with all hydrosoluble nutrients, only water-unsoluble lipids being excluded from this obligatory ‘first-pass mechanism’). Since it is the location for glycogen storage, VLDL synthesis and ketogenesis, the liver is crucial in the fed-to-fasted metabolic alternation. While fat is not physiologically stored in the liver, it is a very important organ in lipid metabolism. Except immunoglobulins, all plasma proteins are synthetised by the liver together with the constitutive proteins, explaining that it is a very powerful organ for protein synthesis. Finally, due to a very active amino acid metabolism, the liver can reshape the amino acid-mixture coming from the gut in the absorptive state. Such a phenomenon has a major implication in the nutritional physiology of amino acid metabolism according to the route: enteral or parenteral. Indeed, in the latter case the remodelling by the liver does not occurs.     

Supplémentation en vitamine K lors de la nutrition parentérale chez l’enfant

The supplementation of vitamin K is necessary for total parenteral nutrition (TPN) patient to avoid hemorrhagic risk. In home TPN and to simplify the children administration, the vitamin K could be added once or twice monthly in admixtures. The aim of this work was to evaluate the vitamin K stability (20 mg/L) in usual conditions of administration (binary or ternary mixtures, at room temperature and at artificial light for 24 hours) and at storage (binary mixtures protected from light, at 4 °C for 12 hours). Each step of the study was performed with quantification using HPLC method coupled with UV detection at 244 nm on five TPN bags. The results of this study show that the vitamin K was stable for 24 hours at light exposure and at room temperature in binary mixture (96.6%) also ternary (99.8%). The vitamin K was stable at 4 °C for 12 days (98.4%). This work shows that vitamin K can be added directly in TPN and could avoid painful intramuscular injection. Such nutritional admixtures could be prepared beforehand and allow administration at home. This practice is actually consensual in gastro-enterology department at Necker University Hospital. A clinical and biologic monitoring is essential.     

Définition et évolution du statut nutritionnel au cours d'une greffe osseuse allogénique (15 malades): Rôle de la nutrition parentérale et de l'apport azoté

Our work concerned 15 patients (9 males, 6 females) with a mean age of 29.5 years, having a hematologic malignant disease and undergoing allogenic bone marrow transplantation.We studied :

1. The metabolic disorders induced by the conditioning regimen (chemotherapy and total body irradiation) pregraft accompanying cytolysis (day −7, −5, −2).

2. The corrective effect of a total parenteral nutrition introduced 2 days before the transplantation and pursued during 30 days post-graft (day −2 to day 30).

3. The interest of a high calorie intake (BEE × 2) and, after randomisation, of a variable nitrogen intake (24% of the total calorie intake for group A [8 patients] and 14% for group B [7 patients]). The patient characteristics of these two groups were closely comparable. Urinary parameters were studied daily (3-methylhistidine, cratinine, nitrogen) and blood parameters weekly (transferrin, pre-albumin, albumin, retinol binding protein).

We observed globally :

-- An excellent result of the nutritional support without significant weight loss;

-- protein catabolism stopped with a recovery of synthesis of RBP after day 7 and pre-albumin from day 7;

-- a decrease in muscle catabolism.

The randomized study showed :

-- a significant difference in nitrogen excretion between group A and group B;

-- earlier and better protein synthesis recovery in group A, particularly with regard to RBP and pre-albumin.

In conclusion, we recommend for the patients undergoing bone marrow transplantation :

-- nutritional support should be introduced before the conditioning regimen;

-- a high calorie intake (BEE × 2) with a nitrogen intake between 14% and 24% of the total calorie intake;

-- cyclic parenteral nutrition should be pursued during the second and third month post-graft.

La nutrition artificielle en periopératoire chez le patient diabétique

The diabetic patients are at high risk of malnutrition. One recommends seeking specific deficiencies (zinc, selenium, vitamins C and E) for malnourished diabetic patients. For the perioperative cares, one recommends to cover their protein needs and their caloric needs and to accordingly optimize the antidiabetic treatment. One should probably use oral supplements or enteral nutrition products with a low glycemic index. The presence of diabetic gastroparesis can make it difficult or dissuade enteral nutrition. The incidence of gastroparesis justifies gastric residue control, the use of prokinetic, and nutrition in postpyloric site. An equivalent parenteral carbohydrate intake has a hyperglycaemic effect more important than with the oral or enteral way. It is recommended to use an infusion pump in diabetic patients to administer parenteral nutrition. Daily use of lipid emulsions is recommended in this context.     

Les complications hépatiques de la nutrition parentérale chez l'adulte

Parenteral nutrition-associated liver disease is a frequent and sometimes life-threatening event. The usual presentation consists of chronic cholestasis, which can evolve within months to years to extensive fibrosis and cirrhosis. Histologic lesions are very similar to those observed in cholestatic liver diseases such as primary biliary cirrhosis and sclerosing cholangitis, and can lead to terminal liver failure and portal hypertension. Pathogenic factors involved in these complications are still poorly understood. Patient-dependent factors include very short bowel syndrome and chronic bacterial overgrowth. Nutrition-dependent factors, easy to correct, are hypercaloric parenteral feeding and, especially in Europe, excess fat, the threshold of which is 1 g · kg⁻¹ · d⁻¹ with ω-6 fat emulsions. It is fundamental to decrease the overall frequency of these complications in patients with long-term intestinal failure in order to avoid a combined liver-intestine transplantation. Preventive measures may combine limitation of parenteral fat intake and treatment of putative patient-dependent factors. Ursodeoxycholic acid and taurine-enriched solutions might be promising treatments for such patients.     

Maladies alcooliques du foie et dénutrition

The aim of this study is to try to answer to four questions from a literature review.

1) What is the prevalence of malnutrition in alcoholic patients with and without liver disease?

2) Is nutritional status independently correlated with survival in patients with alcoholic cirrhosis?

3) Is nutritional supplementation useful in patients with severe liver disease?

4) What energy substrate and nitrogen sources should be used for intravenous nutrition in patients with cirrhosis?

The answers to these questions are:

1) The prevalence of malnutrition in alcoholic patients depends on definition of the studied population. The objective assessment of nutritional status by quantitative clinical and biological parameters is difficult.

2) It has not been demonstrated that nutritional status has an independent prognostic value in patients with alcoholic cirrhosis.

3) The effectiveness of supplementary parenteral nutrition on survival and nutritional status of patients with severe alcoholic liver disease has not been proved.

4) Neither fat emulsions nor conventional amino acids solutions are contraindicated in patients with cirrhosis when parenteral nutrition is necessary.

Complications hépatiques de la nutrition artificielle chez l'enfant : stratégies thérapeutiques

Parenteral nutrition-associated complications in children can result in the deterioration of hepatic structure and function which ultimately leads to cirrhosis. The frequency and prevalence of these complications are difficult to clarify; moreover, their presentation is polymorphous (lithiasis, steatosis, cholestasis, fibrosis) and nonspecific. Patients at risk need to be clearly identified, since preventive intervention and treatment can slow down the disease's progression. However, when intestinal functions become severely impaired with absolute dependency on parenteral nutrition, intestinal transplantation becomes the sole treatment.