Fortifier and Cream Improve Fat Delivery in Continuous Enteral Infant Feeding of Breast Milk

Premature and high-risk infants require accurate delivery of nutrients to promote appropriate growth. Continuous enteral feeding methods may result in significant fat and micronutrient loss. This study evaluated fat loss in enteral nutrition using current strategies for providing high-risk infants fortified human milk (HM). The fat content of HM was measured by IR analyzer in a simulated feeding system using the Kangaroo ePump™ and the MedFusion™ 2010 pump. Comparisons in fat loss were made between HM, HM supplemented with donor HM-derived fortifier Prolacta + H²MF™ (H²MF), and HM supplemented with H²MF and donor HM-derived cream ProlactCR™ (cream). When using the Kangaroo ePump™, the addition of H²MF and cream to HM increased fat delivery efficiency from 75.0% ± 1.2% to 83.7% ± 1.0% (p < 0.0001). When using the MedFusion™ 2010 pump, the addition of H²MF to HM increased fat delivery efficiency from 83.2% ± 2.8% to 88.8% ± 0.8% (p < 0.05), and the addition of H²MF and cream increased fat delivery efficiency to 92.0% ± 0.3% (p < 0.01). The addition of H²MF and cream to HM provides both the benefits of bioactive elements from mother’s milk and increased fat delivery, making the addition of H²MF and cream an appropriate method to improve infant weight gain.     

Establishing Early Enteral Nutrition With the Use of Self‐Advancing Postpyloric Feeding Tube in Critically Ill Children

Introduction: Early nutrition support is an integral part of the care of critically ill children. Early enteral nutrition (EN) improves nitrogen balance and prevents bacterial translocation and gut mucosal atrophy. Adequate EN is often not achieved as gastric feeds are not tolerated and placing postpyloric feeding tubes can be difficult. Spontaneous transpyloric passage of standard feeding tubes without endoscopic intervention or use of anesthesia can range from 30%?80%. The authors report on their experience with a 14Fr polyurethane self‐advancing jejunal feeding tube in a pediatric population. These tubes have been used in the adult population with success, but to the authors’ knowledge, there have been no reports of its use in the pediatric age group. Case Series: The authors present 7 critically ill patients 8–19 years old, admitted to the pediatric intensive care unit, in whom prolonged recovery, inability to tolerate gastric feeds, and dependence on ventilator were predicted at the outset. The jejunal feeding tube was successfully placed on first attempt at the bedside in all 7 patients within the first 24 hours without the use of a promotility agent or endoscopic intervention. Nutrition goal achieved within 48 hours of feeding tube placement was reported for each patient. This case series demonstrates that children fed via the small bowel reached their nutrition goal earlier and did not require parenteral nutrition. Conclusion: The self‐advancing jejunal feeding tube can be used effectively to establish early EN in critically ill children.     

A Novel Approach to Improving Fat Delivery in Neonatal Enteral Feeding

Continuous infusion systems used for enteral nutrition support in the neonatal intensive care unit deliver as little as 60% of the fat in human milk to the neonate. This study determined the effect of mixing common feedings for preterm infants in the feeding bag and tubing on fat losses during enteral feeding. Laboratory models were developed to assess the contribution of various mixing techniques to delivered fat content. Fat content was measured periodically during feeding and compared to baseline measurements. A multistage approach incorporating a feeding bag inverter and a tubing circulation loop delivered >90% of milk fat when used in conjunction with a commercial continuous infusion system. With unfortified human milk, this approach delivered 91.9% ± 1.5% of fat content over a one hour feed, significantly greater (p < 0.01) than 77.5% ± 2.2% delivered by continuous infusion controls (Mean ± SEM). With fortified human milk, this approach delivered 92.1% ± 2.4% of fat content, significantly greater (p < 0.01) than 79.4% ± 1.0% delivered by a non-adapted infusion system (Mean ± SEM). Mixing human milk during continuous infusion improves fat delivery, which may improve nutrition and growth outcomes in low birth weight neonates.     

An Improved Method for Collecting Breath From 3‐ to 7‐Year‐Old Children

Breath sampling and analysis provide healthcare professionals with a practical, noninvasive diagnostic measurement for children with a variety of gastrointestinal (GI) disorders. New biomarkers found in human breath have been investigated and provide the opportunity to diagnose bacterial overgrowth and other underlying causes of GI dysfunction. Although several protocols have been described previously regarding breath sampling, few have demonstrated the feasibility of collection in young children. This communication introduces a simple game that allows for 3‐ to 7‐year‐old children to practice breath exhalation to give a proper breath sample in a relaxed and comfortable environment. The technique described offers clinicians a creative approach for obtaining breath samples from a child by reducing the apprehension and anxiety associated with the research and clinical environment.     

Outcomes of Infants With Home Tube Feeding: Comparing Nasogastric vs Gastrostomy Tubes

Background: The aim of this study was to determine the tube‐related complications and feeding outcomes of infants discharged home from the neonatal intensive care unit (NICU) with nasogastric (NG) tube feeding or gastrostomy (G‐tube) feeding. Materials and Methods: We performed a chart review of 335 infants discharged from our NICU with home NG tube or G‐tube feeding between January 2009 and December 2013. The primary outcome was the incidence of feeding tube–related complications requiring emergency department (ED) visits, hospitalizations, or deaths. Secondary outcome was feeding status at 6 months postdischarge. Univariate and multivariate analyses were conducted. Results: There were 322 infants discharged with home enteral tube feeding (NG tube, n = 84; G‐tube, n = 238), with available outpatient data for the 6‐month postdischarge period. A total of 115 ED visits, 28 hospitalizations, and 2 deaths were due to a tube‐related complication. The incidence of tube‐related complications requiring an ED visit was significantly higher in the G‐tube group compared with the NG tube group (33.6% vs 9.5%, P < .001). Two patients died due to a G‐tube–related complication. By 6 months postdischarge, full oral feeding was achieved in 71.4% of infants in the NG tube group compared with 19.3% in the G‐tube group (P < .001). Type of feeding tube and percentage of oral feeding at discharge were significantly associated with continued tube feeding at 6 months postdischarge. Conclusion: Home NG tube feeding is associated with fewer ED visits for tube‐related complications compared with home G‐tube feeding. Some infants could benefit from a trial home NG tube feeding.     

Pediatric Outpatient Feeding Clinic

Background: Feeding disorders occur commonly in the pediatric population and vary in severity from picky eating to extreme food selectivity. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, 10th Revision provide more inclusive diagnostic criteria for feeding disorders, but little is known about the actual referral population to an outpatient feeding clinic. In this investigation, the nutrition status, reason for referral, and related exploratory questions of outpatient referrals are detailed. Materials and Methods: Children aged 1–18 years were eligible for enrollment. Survey data collected included demographics, prior diagnoses, parental/caretaker complaint, mealtime duration, referral source, and food repertoire. Exploratory questions examined the impact of the feeding disorder on immediate family. Results: Ten percent of participants had a weight‐for‐height z score or body mass index score of ≤?2. The most common parental/caretaker chief complaint were poor nutrition, food refusals, and poor weight gain. The food repertoire included 15 or fewer items (7%), between 15 and 25 items (18%), or greater than 25 items (75%). The most positive responses to exploratory questions were mealtime frustration, lack of understanding by other family members, lack of access to appropriate treatment in a timely fashion, and inability to meet the child's feeding needs. Conclusion: Most referred infants and children were not undernourished. Despite this finding, most parents/caretakers were concerned about inadequate nutrition status and poor weight gain. Feeding disorders have an adverse effect on immediately family members. Revised diagnostic criteria should facilitate better identification of the broad spectrum of feeding disorders.     

Factors Affecting Spontaneous Closure of Gastrocutaneous Fistulae After Removal of Gastrostomy Tubes in Children With Intestinal Failure

Background: Children with intestinal failure (IF) frequently require gastrostomy tubes (GTs) for long‐term nutrition support. Risk factors for persistent gastrocutaneous fistulae (GCFs) in pediatric patients with IF are largely unknown but may include underlying nutrition status and duration of indwelling GT. Materials and Methods: Records of patients with IF having undergone GT removal and allowed a trial at spontaneous closure were reviewed. Nonparametric continuous variables were analyzed using the Wilcoxon rank sum test. Post hoc analysis was performed to identify the optimal threshold of GT duration predicting probability of spontaneous closure identified using receiver operating characteristic curve analysis. Results: Fifty‐nine children with IF undergoing GT removal were identified. Spontaneous closure occurred in 36 (61%) sites, while 23 (39%) underwent operative closure at a median 67 days after GT removal. The duration of indwelling GT was significantly shorter in the spontaneous closure group (11.5 vs 21 months, P = .002). Of 33 GT indwelling for ≤18 months, 28 (85%) closed spontaneously, compared with only 9 of 26 (35%) with duration >18 months (P < .001). With GCF persisting beyond 7 days, only 21% (6/28) of sites closed spontaneously, but this dropped to 6% (1/18) of cases with concurrent GT duration >18 months. Conclusions: Of the risk factors evaluated, only prolonged GT duration was associated with an increased likelihood of failure to close spontaneously. It is significantly less likely in pediatric patients with IF in whom GCF persists >7 days, particularly if the duration of GT is >18 months. Relatively earlier operative closure should be considered in this group.     

Relationship Between Amino Acid and Energy Intake and Long‐Term Growth and Neurodevelopmental Outcomes in Very Low Birth Weight Infants

Background: Inadequate nutrition may contribute to adverse neurodevelopmental and growth outcomes in very low birth weight (VLBW) infants. Materials and Methods: A retrospective cohort study was conducted of infants born weighing <1250 g between 2009 and 2010 in a tertiary neonatal intensive care unit. The aim was to investigate whether there was a correlation between the amount of amino acid and calories received in the first 4 weeks of life and neurodevelopment and growth at 2 years. Results: Parenteral amino acid intake in week 2 of life correlated with higher language and motor scores on the 2‐year Bayley Scales of Infant and Toddler Development Third Edition (Bayley III). Conversely, higher total amino acid intake during week 1 of life (≥1.5 g/kg/d) was associated with a shorter duration of hospitalization, shorter intensive care stay, fewer days receiving mechanical ventilation, fewer days receiving supplemental oxygen, and a lower incidence of chronic lung disease (CLD). Higher caloric intake in the first 4 weeks correlated strongly with shorter duration of hospitalization, shorter intensive care stay, fewer days on the ventilator, and fewer days receiving supplemental oxygen. In patients with CLD, week 1 and 2 parenteral and total amino acid intake correlated with higher cognitive and motor scores on the Bayley III at 2 years old. Weeks 1–4 amino acid and calorie intake correlated with fewer days on the ventilator, fewer days of supplemental oxygen, and fewer days of hospitalization. Conclusion: Amino acid intake within the first weeks of life correlated positively with neurodevelopmental outcomes at 2 years, and patients with CLD were found to be particularly at risk. Caloric intake may affect protein accretion.     

Continuous versus Intermittent Enteral Tube Feeding for Critically Ill Patients: A Prospective,Randomized Controlled Trial

The appropriate strategy for enteral feeding remains a matter of debate. We hypothesized that continuous enteral feeding would result in higher rates of achieving target nutrition during the first 7 days compared with intermittent enteral feeding. We conducted an unblinded, single-center, parallel-group, randomized controlled trial involving adult patients admitted to the medical intensive care unit who required mechanical ventilation to determine the efficacy and safety of continuous enteral feeding for critically ill patients compared with intermittent enteral feeding. The primary endpoint was the achievement of ≥80% of the target nutrition requirement during the first 7 days after starting enteral feeding. A total of 99 patients were included in the modified intention-to-treat analysis (intermittent enteral feeding group, n = 49; continuous enteral feeding group, n = 50). The intermittent enteral feeding group and continuous enteral feeding group received 227 days and 226 days of enteral feeding, respectively. The achievement of ≥80% of the target nutrition requirement occurred significantly more frequently in the continuous enteral feeding group than in the intermittent enteral feeding group (65.0% versus 52.4%, respectively; relative risk, 1.24; 95% confidence interval, 1.06–1.45; p = 0.008). For patients undergoing mechanical ventilation, continuous enteral feeding significantly improved the achievement of target nutrition requirements.     

Fat‐Modified Breast Milk Resolves Chylous Pleural Effusion in Infants With Postsurgical Chylothorax but Is Associated With Slow Growth

Background: Chylothorax occurs in ~3%–5% of infants undergoing cardiac surgery. Standard treatment requires discontinuation of breast milk feeding, due to the abundance of long‐chain triglycerides and transition to a medium‐chain triglyceride (MCT)–based formula. Objective: To determine the effectiveness of fat‐modified breast milk (MBM) for the treatment of chylothorax compared with MCT formula. Materials and Methods: Infants diagnosed with chylothorax following surgery for congenital heart disease between January 2008 and December 2009 at The Hospital for Sick Children were eligible for this nonrandomized open‐label study. Treatment infants (n = 8) received mother's own milk that had been modified by removing the fat layer via centrifugation and adding MCT, nutrients, and essential fatty acids to provide an estimated 74 kcal/100 mL and 1.4 g/100 mL protein (MBM group). Control infants (n = 8) received an MCT formula (MCT group). The feeding intervention was a minimum of 6 weeks after chest tube removal per The Hospital for Sick Children standard chylothorax treatment protocol. Results: Daily volume and duration of chest tube drainage were not different between the MBM and MCT groups. While there was no statistically significant difference in rates of weight gain (g/d) between feeding groups, infants in the MBM group, who tended to be younger, experienced a decline in mean weight (P = .04) and length (P = .01) for age z scores. Conclusion: Fat‐modified breast milk resolved chylothorax; however, strategies to address poor growth need to be developed and evaluated in larger trials prior to widespread clinical adoption of this novel treatment.     

Placement of a Magnetic Small Bowel Feeding Tube at the Bedside

Background: Current methods of achieving postpyloric enteral access for feeding are fraught with difficulties, which can markedly delay enteral feeding and cause complications. Bedside tube placement has a low success rate, often requires several radiographs to confirm position, and delays feeding by many hours. Although postpyloric enteral tubes can reliably be placed in interventional radiology (IR), this involves greater resource utilization, delays, cost, and inconvenience. We assessed the utility of bedside enteral tube placement using a magnetic feeding tube (Syncro‐BlueTube; Syncro Medical Innovations, Macon, GA, USA) as a means to facilitate initial tube placement. Methods: We recorded the time to insertion, location of tube, success rate, and need for radiographs in a series of patients given magnetic feeding tubes (n = 46) inserted by our hospitalist service over an 8‐month interval. Results: Of the 46 attempted magnetic tube placements, 76% were successfully placed in the postpyloric position, 13% were in the stomach, and 11% could not be placed. In 83% of the magnetic tubes, only 1 radiograph was needed for confirmation. The median time to placement was 12 minutes (range, 4–120 minutes). Conclusion: The use of a magnetic feeding tube can increase the success rate of bedside postpyloric placement, decrease the time to successful placement, and decrease the need for supplemental radiographs and IR.     

Fecal Transplantation Successfully Treats Recurrent D‐Lactic Acidosis in a Child With Short Bowel Syndrome

D‐lactic acidosis can occur in patients with short bowel syndrome (SBS) when excessive malabsorbed carbohydrate (CHO) enters the colon and is metabolized by colonic bacteria to D‐lactate. D‐lactate can be absorbed systemically, and increased serum levels are associated with central nervous system toxicity manifested by confusion, ataxia, and slurred speech. Current therapy, usually directed toward suppressing intestinal bacterial overgrowth and limiting ingested CHO, is not always successful. Fecal transplantation, the infusion of donor feces into a recipient's intestinal tract, has been used for decades to treat recurrent Clostridium difficile infection, and case reports document its use in the successful treatment of constipation, diarrhea, and abdominal pain. The exact mechanism of action is unknown, but it is surmised that the alteration of the intestinal microbiome, as well as the reintroduction of potential beneficial microbes, helps mediate disease. Here we present the case of a child with SBS and recurrent, debilitating D‐lactic acidosis, which was successfully treated with fecal transplantation.     

Oleanolic Acid Improves Gut Atrophy Induced by Parenteral Nutrition

Background: Nutrition support with parenteral nutrition (PN) is associated with gut atrophy. Prior studies have shown improvement with enteral chenodeoxycholic acid, a dual agonist for the farnesoid X receptor (FXR) and bile acid receptor TGR5. We hypothesized that gut growth is induced by TGR5 activation, and gut atrophy during PN administration could be prevented with the TGR5‐specific agonist oleanolic acid (OA). Methods: Neonatal pigs were implanted with duodenal and jugular vein catheters. Animals were provided equi‐nutritious PN or enteral swine milk. A PN subgroup received enteral OA at 50 mg/kg/d. Results: PN caused marked gut atrophy compared with enterally fed (EN) control animals. OA treatment led to preservation of gut mass demonstrated grossly and histologically. The mean ± SD gut weight as a percentage of body weight was 4.30 ± 0.26 for EN, 1.92 ± 0.06 for PN (P < .05, EN vs PN), and 3.39 ± 0.79 for PN+OA (P < .05, PN+OA vs PN). Mean ± SD gut density (g/cm) was 0.31 ± 0.03 for EN, 0.18 ± 0.03 for PN (P < .05 EN vs PN), and 0.27 ± 0.01 for PN+OA (P < .05 PN+OA vs PN). Histologically, a markedly decreased villous to crypt ratio was noted with PN, and OA significantly prevented this decrease. The mean ± SD v/c ratio was 3.51 ± 0.59 for EN, 1.69 ± 0.10 for PN (P < .05, EN vs PN), and 2.90 ± 0.23 for PN+OA (P < .05, PN+OA vs PN). Gut TGR5 messenger RNA expression was significantly elevated with OA treatment compared with both PN and EN. Conclusion: The bile acid–activated G protein–coupled receptor TGR5 agonist OA prevented gut atrophy associated with PN.     

Patient and Family Caregivers’ Experiences of Living With a Jejunostomy Feeding Tube After Surgery for Esophagogastric Cancer

Background:Jejunostomy feeding tubes (JFTs) can be used to provide nutrition support to patients who have had surgery for esophagogastric cancer. Although previous research reports how patients cope with a gastrostomy tube, little is known about the impact of having a JFT. The aim of this qualitative study was to explore how patients and their informal caregivers experience living with a JFT in the first months following surgery. Methods: Participants were purposively sampled from a cohort of patients recruited to a trial investigating home enteral nutrition vs standard care after esophagogastric surgery for cancer. The sampling framework considered age, sex, and marital status. Informal caregivers were also invited to participate. Interviews were audio recorded, transcribed verbatim, and anonymized. Inductive thematic analysis was used to identify key themes related to living with a JFT. Results: Fifteen patient interviews were conducted; 8 also included a family caregiver. Analysis of the data resulted in 2 main themes: “challenges” and “facilitators” when living with a JFT. While “physical effects,” “worries” and “impact on routine” were the main challenges, “support,” “adaptation” and “perceived benefit” were what motivated continuation of the intervention. Conclusion: Findings suggest that participants coped well with a JFT, describing high levels of compliance with stoma care and the feeding regimen. Nonetheless, disturbed sleep patterns and stoma‐related problems proved troublesome. A better understanding of these practical challenges, from the patient and family caregiver perspective, should guide healthcare teams in providing proactive support to avoid preventable problems.