Stratégies de prise en charge nutritionnelle spécifiques : l'enfant et l'adulte jeune atteints d'un handicap

Handicapped children are at high risk for malnutrition. In this situation nutritional assessment becomes difficult to perform due to musculo-skeletal deformities, patient's collaboration. In any case nutritional indices require simple measures: weight and height. Nutritional care must be presented early to parents in order to start as soon as possible when oral intake does not meet nutritional needs. For the handicapped child, surgery is often a major stress that requires nutritional care before, during and after. Obesity often aggravates the burden of the handicap and does not provide protection against malnutrition. Like in non-handicapped persons nutritional care can improve the outcome and well being of handicapped children.     

Nutrition au cours des radiothérapies et chimiothérapiesNutritional support during cancer chemotherapy and radiotherapy

Nutritional support for cancer patients treated with radiotherapy and chemotherapy are strongly requested with regard to the frequent malnutrition at time of diagnosis. Furthermore, the malnutrition often progresses with adverse effects of therapy and disease progression. Nutritional screening and assessment are essential. Dietetic care is mandatory for patients with malnutrition or at risk of malnutrition when they are still able to eat. But this oral nutritional support is frequently unable to maintain sufficient nutritional intakes with regard to tumour effect or treatment toxicity. Enteral or parenteral nutrition must be provided to patients unable to absorb adequate quantity of nutrients for a prolonged period. The primary goal is to avoid, especially for malnourished patients, further nutritional degradation which can lead to treatment interruptions, complications or increased risk of death. Routine administration of artificial nutrition has been tested during radiotherapy and chemotherapy but results are conflicting and data are missing for severely malnourished patients. No benefits in terms of treatment toxicity, tumour response, risk of complications and finally mortality have been demonstrated for routine use of artificial nutrition. Most decisions for indication of nutritional support, route of administration and quality of artificial nutrition in this field can't rely today on evidence-based medicine. However, artificial nutrition can provide nutrients and hydration necessary to maintain comfort and to improve survival for patients unable to eat sufficient nutrition for a prolonged period.     

Évaluation de l’état nutritionnel péri-opératoire

In surgical patients, malnutrition is associated with an increase in morbidity, mortality, length of stay and health care costs, and has an impact on quality of life. Before surgery, the risk of malnutrition is depending on patient-related factors (age, associated diseases, on-going symptoms, duration of pre-operative hospital stay), surgical procedure, and medical treatment (radiotherapy, chemotherapy, corticoid treatment). The early screening and management of malnutrition are mandatory during the peri-operative period, with the aim to improve post-operative prognosis and clinical outcome. The nutritional assessment is based on the research of weight loss, the calculation of body mass index and the research of an hypoalbuminemia, all of them having a negative impact on postoperative prognosis. The Nutritional Risk Index (NRI) is also of strong prognostic value. We propose a stratification of the nutritional risk indicating several levels of surgical risk. The organization, the planning and the traceability in the medical record of the nutritional assessment should allow optimizing the management and the clinical outcome of surgical patients. The pre-operative consultation of anaesthesia could be the privileged time to perform the screening of malnutrition and to plan its management, if they were not previously performed by the medico-surgical team.     

Nutrition périopératoire chez la personne âgée. Cas particulier de la fracture de l’extrémité supérieure du col du fémur

Emergency surgery is associated with an increase in the risk of malnutrition in the elderly. Thirty to fifty percent of elderly persons admitted to in surgery are malnourished. In patients for which nutritional status is threatened by both the aging process and comorbidities, the surgical intervention represents an additional stress that will induce or worsen malnutrition. Nutritional care must no be delayed. First choice is the oral route, including protein and energy rich nutritional supplements, and must be a part of multidimensional perioperative care It is recommended to reach 30 to 40 kcal tot/kg/day and 1.2 to 1.5 g of proteins/kg/day. It is recommended to prescribe, during the stay in rehabilitation wards after surgery, oral nutritional supplements. This oral supplementation has been shown to be efficacious in malnourished elderly patients: there is weight gain, a lower risk for complications and a lower mortality rate. However, compliance may be reduced in elderly patients with low appetite, especially in case of dementia, or early medical complications. In order to prevent other falls and fractures, it is recommended to look for vitamin D deficiency and to prescribe vitamin D 800–1200 UI/day.     

Place de l'impédancemétrie dans le dépistage de la dénutrition à l'hôpitalBio-impedance analysis: Screening of denutrition in hospitalized patients

The prevalence of malnutrition is high in patients and tends to worsen during the hospital stay. In the absence of one reliable method to evaluate patients, the assessment of nutritional status is based on a global approach. Body composition measurement by bio-impedance analysis (BIA) is one of these approaches. Body composition measurements can detect malnutrition or abnormal hydration. Fat free mass, fat mass, and total body water are the main body compartments that are evaluated. Determination of abnormal body composition can then guide nutritional support. The reliability of BIA depends on the equation used to predict body composition and the parameters included in the formula (weight, height, sex, age, race, etc.). These parameters allow to minimize measurement errors. Thus, formula developed for specific populations allow to evaluate the nutritional status with reasonable error rates. BIA has been found to be inaccurate with abnormal distribution of body compartments (ascites, dialysis, lypodystrophy, etc.) or extreme weights (cachexia, obesity). Multi-frequency or segmental BIA was developed to overcome hydration abnormalities and variations in body geometry. However, these techniques require further validation. The BIA seems to have some limitations. This review aims to assess the reliability of BIA to detect protein-calorie malnutrition at hospital admission or during nutritional follow-up of patients.     

Nutrition en cancérologie : aspects pédiatriquesNutrition and cancer in children

Cancer is associated with a high risk of malnutrition in children. This risk is different from one tumor to another, at the time of diagnosis and at any time of the disease course. Numerous tumor-related and treatment-related factors are involved. High dose-chemotherapy, with its specific side effects is particularly deleterious. Growth curves are of major interest for the long-term follow up of the nutritional status in children. The systematic use of nutritional risk scores is recommended, in order to improve prevention and early treatment of malnutrition. Nutritional supplies should meet the high protein and energy needs associated with cancer and its treatments. Oral and tube-feeding should be used preferably, according to digestive function. Peripheral parenteral nutrition may serve only as a complementary, short-term nutritional support. Central lines are required for all total and/or long term parenteral nutrition periods. Whatever the nutritional support, it can help to fulfil chemotherapy programmes, with benefit on remission duration and survival.     

Stratégies de dépistage de la dénutrition chez l''enfant hospitalisé

Metabolic stress modifies homeostasis, therefore nutrient's metabolism and nutritional needs. Stress is a risk factor of malnutrition, which increases morbidity and short-term mortality, and, in the child, can threaten long-term growth. Nutritional assessment is difficult in critically ill children. Nutritional support must be undertaken early as possible, especially in malnourished children and with severe agression. Enteral nutrition must be privileged. Parenteral nutrition is indicated when enteral nutrition is impossible, badly supported or insufficient to satisfy needs. Monitoring must be rigorous because aggression increases the risk of metabolic complications.     

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.     

Dénutrition périnatale : prise en charge nutritionnelle spécifique du nouveau-né

Malnutrition is quite rare in neonates. However perinatal malnutrition occurs in two situations. Fetal malnutrition leading to intra-uterine growth retardation with a birth weight below the lower limit for gestational age. On the other hand a postnatal relative malnutrition ("extra-uterine" growth retardation) which occurs mainly in preterm neonates. Both these situations need specific nutritional care after birth but also during the first years of life as there is probably a relationship between post-natal nutrition and health in adults (Barker hypothesis).     

Outils et procédures de dépistage de la dénutrition et de son risque en milieu hospitalierTools and procedures for screening for malnutrition and its associated in risks in hospital

Malnutrition affects on average 20–50% of hospital inpatients and its negative repercussions in terms of morbi-mortality have been fully documented. Although this state of affairs is well known, there is little screening for malnutrition in hospitals. There is no single parameter indicating malnutrition, which instead has to be diagnosed based on anthropometric and biological data, and by multi-factorial indices of nutritional risk. Screening adapted to each of the four main classes of hospital care, acute medicine and surgery, intensive care, geriatrics and paediatrics needs to be systematically performed for every inpatient. To make malnutrition screening a natural part of the practice of care, we need to design training courses, which highlight the benefits in terms of length of stay, morbi-mortality and cost.     

Conséquences de la dénutrition chez l'enfant et l'adolescent. Mortalité, morbidité, conséquences médicoéconomiques

In the developed countries, the sick children are at risk of protein-energy malnutrition (PEM). Marasmus is the most common form of severe PEM in such children. Its major characteristics are low muscle and fat masses with the presence of marked facial, axillary and inguinal skinfolds. Furthermore the marastic children are irritable and depressed. When the PEM is moderate, which is more frequent, the affected children present a failure to thrive. Severe and moderate PEM have multiple functional consequences on different systems and organs with an impact on mortality, morbidity and costs. In this paper, the functional consequences on the immune system, digestive tract, liver, lung, heart, kidney, skin, bone and brain are passed in review. To end, some comments are done about the particularities of PEM in mental anorexia and obesity.     

Stratégies de prise en charge nutritionnelle spécifiques : l'enfant en cancérologie

In children with cancer, malnutrition may antedate the diagnosis or be a result of aggressive chemotherapeutic regimens. The prevalence of malnutrition at diagnosis is related to the type of tumour and the extent of the disease, ranging from < 10% in patients with standard-risk acute lymphoblastic leukaemia to 50% in children with advanced neuroblastoma. The pathogenis of the energy imbalance that underlies the development of malnutrition is complex, including increased breakdown of fat and protein as well as energy-consumptive changes in carbohydrate metabolism (Cori cycle). Despite several confounding factors (different definitions of nutritional status and the wide variety of measures used for its assessment), studies have shown decreased tolerance of chemotherapy associated with altered metabolism of antineoplastic drugs, increased infection rates, altered quality of life and possibly poor clinical outcome in malnourished patients. In this article, we review guidelines for the nutritional management of a child with cancer and we purpose an algorithm for nutritional support.     

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.     

Nutrition périopératoire : protocoles de soins

Based on texts written by experts, the objective of this paper is to propose a practical approach to nutrition for clinicians, according to the nutritional status of patients and the evaluation of surgical risk. Any patient with a nutritional grade greater than or equal to 2 should benefit from nutritional support. Indeed, current data confirm that preoperative and early nutritional support in surgery at risk can reduce significantly postoperative morbidity for patients with non-malnourished (immunonutrition in cancer surgery GI), and the morbidity and mortality in malnourished patients (enteral nutrition when possible). A preoperative oral intake is recommended 2 to 3 hours before elective surgery for clear fluids and 6 hours for a light meal. Moreover, a preoperative oral intake of carbohydrates (maltodextrin 12.5%) is recommended (except in diabetic patients). Postoperatively, early oral feeding (within 24 hours) is recommended in the absence of cons to surgery. Glutamine is recommended in case of postoperative complications.     

Évaluation et prise en charge des troubles de la déglutition

Swallowing is a complex phenomenon, allowing per os feeding but with a protection of respiratory tract. Swallowing disorders are frequent, involve liquids, solids or theses two textures, and are mainly caused by neurological or otorhinolaryngological diseases. They may have severe consequences, like an alteration of quality of life for patients or their relatives, an increased risk of aspiration, of malnutrition or dehydration, and finally a possible decrease of survival. Assessment includes careful questioning and physical examination. The reference complementary investigation is videofluoroscopic evaluation. Nutritional assessment is mandatory. Taking care of swallowing disorders in a multidisciplinary manner is recommended, with interventions of physician, speech therapist, dietician, sometimes dentist or surgeon, and needs a strong contribution of the paramedical staff and the patient relatives. Enteral nutrition is recommended when repeated or severe respiratory complications occur, when the nutritional status is altered in spite of feeding enrichment, modulations of textures or use of oral nutritional supplements, or when the meals are too long.     

Prévalence et conséquences de la dénutrition dans l'insuffisance respiratoire chronique

From large series of patients with COPD, the prevalence of malnutrition can be estimated at 25% taking a cut-off value for Body Mass Index (BMI) less than 20 kg/m², and 35% for a body weight less than 90% of the ideal body weight. Data are very scarce for the other causes of respiratory failure. Malnutrition is a feature of emphysema. There is a well established correlation between height related body weight and FEV1, and TCO: it is not possible to assert that malnutrition is lither a cause or a consequence of the altered respiratory function. Nutritional status is a predictor for the capacity of exercise, independently of the alteration of respiratory function. There is probably a link between malnutrition and the performance of respiratory muscles. The prognostic influence of malnutrition in chronic respiratory failure is well established, with the best survival rates for overweight patients.     

Mécanismes de la dénutrition chez l'enfant et l'adolescent

Malnutrition in child and adolescent is observed in various situations where there is an imbalance between the food intakes and caloric and proteic needs. Child is particularly vulnerable because its reserves are weak and its high caloric and proteic needs because of its growth. Various mechanisms leading to malnutrition were brought back and correspond to distinct clinical entities. The situations of malnutrition by exclusive mechanism of intake deficiency meet primarily in third world where they can take the form of starvation, extreme adaptive situation with prolonged fast. During situations known as of aggression like severe sepsis, polytraumatism, extended burn, surgery, malnutrition can settle quickly. Mechanism brought back in situation of acute aggression is defined classically like related to hypermetabolism with hypercatabolism. Kwashiorkor, another type of caloric and proteic malnutrition concerning child in third world, cannot be regarded as a simple caloric and proteic deficiency. It currently seems that a deficiency at the same time in macronutriments and micronutriments plays a part in genesis of this pathology. The glutathion seems in particular, to play a fundamental part in the kwashiorkor's pathophysiology. The most documented hypothesis relates imbalance between production of free radicals and mechanisms of defence. Mechanisms of repair would be insufficient, and persistence of membrane deteriorations would cause anomalies observed in kwashiorkor like oedema, hepatic overload, neurological disorders and diarrhoea.