Metabolic vs Nutrition Support

It is now generally accepted that early feeding post injury exerts a positive effect on outcome in the critically ill, despite the fact that many of these patients are well nourished or even overnourished on admission. One possible mechanism is that early feeding post injury may have a positive influence on the duration and intensity of the systemic inflammatory response, especially when coupled with intensive insulin therapy to maintain normoglycemia at <150 mg/dL. Current clinical nutrition guidelines recommend early enteral nutrition providing full nutrition requirements in the critically ill patient; however, in the first week post injury, exclusive enteral feeding is typically inadequate, particularly in protein. A potentially new and different therapeutic goal to modulate the systemic inflammatory response might be more effectively accomplished for the first week post injury by hypocaloric feedings (~9–18 kcal/kg or 50%–75% resting metabolic expenditure) principally as intravenous dextrose but with at least 1 g/kg protein as intravenous amino acids to provide early metabolic support. This proposed regime, along with intensive insulin therapy to maintain glucose homeostasis, should promote the protein synthetic component of the postinjury inflammatory response while reducing net protein catabolism. A formal trial of early metabolic support in the acutely injured should be safe, easy to execute, and potentially efficacious, with subsequent improvement in the inflammatory state and, it is hoped, clinical outcomes.     

Defining Pediatric Malnutrition

Lack of a uniform definition is responsible for underrecognition of the prevalence of malnutrition and its impact on outcomes in children. A pediatric malnutrition definitions workgroup reviewed existing pediatric age group English‐language literature from 1955 to 2011, for relevant references related to 5 domains of the definition of malnutrition that were a priori identified: anthropometric parameters, growth, chronicity of malnutrition, etiology and pathogenesis, and developmental/ functional outcomes. Based on available evidence and an iterative process to arrive at multidisciplinary consensus in the group, these domains were included in the overall construct of a new definition. Pediatric malnutrition (undernutrition) is defined as an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes. A summary of the literature is presented and a new classification scheme is proposed that incorporates chronicity, etiology, mechanisms of nutrient imbalance, severity of malnutrition, and its impact on outcomes. Based on its etiology, malnutrition is either illness related (secondary to 1 or more diseases/injury) or non–illness related, (caused by environmental/behavioral factors), or both. Future research must focus on the relationship between inflammation and illness‐related malnutrition. We anticipate that the definition of malnutrition will continue to evolve with improved understanding of the processes that lead to and complicate the treatment of this condition. A uniform definition should permit future research to focus on the impact of pediatric malnutrition on functional outcomes and help solidify the scientific basis for evidence‐based nutrition practices.     

Does Genetic Predisposition Influence Surgical Results of Operations for Obesity?

Background: There is a familial predisposition to obesity. We wished to document the incidence of obesity (BMI > 40 kg m⁻²) in the immediate relatives (parents and siblings) of obese patients who were candidates for gastric restrictive surgery. We determined if a familial predisposition to obesity would influence the surgical results. Methods: The height, weight and BMI were obtained in 1841 relatives of obese patients and in 1059 relatives of normal weight controls. The results of gastric surgery after 52.9 ± 23.1 months were obtained in 44 patients with a familial history of obesity and in 34 patients without a familial history. Results: Patients presenting with a BMI > 40 kg m⁻² were 24.541 times more likely to have a first degree relative with morbid or super obesity than individuals in the control group. Mothers were twice as likely to be severely obese as fathers. A successful result (BMI < 35 kg m⁻² or less than 50% excess weight) occurred 52.9 ± 23.1 months in 77% of patients with a family history of obesity and in 73% of patients without a familial predisposition (p = 0.79). Conclusions: There is a strong familial predisposition to obesity but over one-half of the immediate family members of obese patients have a BMI < 30 kg m⁻². Gastric restrictive surgery induces satiety and produces a successful outcome regardless of familial predisposition. Patients who undergo surgery have a remarkably stable weight over the year prior to operation, suggesting they are defending a markedly elevated BMI.     

Nutrition Algorithms for Infants with Hypoplastic Left Heart Syndrome; Birth through the First Interstage Period

Failure to thrive is common in infants with hypoplastic left heart syndrome and its variants and those with poor growth may be at risk for worse surgical and neurodevelopmental outcomes. The etiology of growth failure in this population is multifactorial and complex, but may be impacted by nutritional intervention. There are no consensus guidelines outlining best practices for nutritional monitoring and intervention in this group of infants. The Feeding Work Group of the National Pediatric Cardiology Quality Improvement Collaborative performed a literature review and assessment of best nutrition practices from centers participating in the collaborative in order to provide nutritional recommendations and levels of evidence for those caring for infants with single ventricle physiology.     

The Association Between Home Parenteral Nutrition and Patients With FAP‐Associated Intra‐Abdominal Desmoids

Background: Intra‐abdominal desmoid tumors (IADTs) are a common complication of familial adenomatous polyposis (FAP). Treatment is not standardized for advanced disease. Medical and surgical treatments may be ineffective in preventing complications, which can cause intestinal failure. Home parenteral nutrition (HPN) can be a life‐saving treatment in these patients. The aim of this study was to investigate the association with HPN in FAP‐IADTs. Methods: A retrospective review of FAP patients with IADTs at the Cleveland Clinic (CC) between 1980 and 2009 was performed. Patients and tumor characteristics were retrieved from the CC Jagelman Registry for Inherited Neoplasms and CC HPN database. Inclusion criteria were FAP‐IADTs and 6‐month follow up at CC. Exclusion criteria were <6‐month follow‐up, lack of 3‐dimensional lesion or sheet desmoid, and/or incomplete medical records. Kaplan‐Meier curves were analyzed for HPN and non‐HPN groups. Results: One hundred fifty‐four patients were included and divided into 2 groups: HPN (n = 41, 26.6%) and non‐HPN (n = 113, 73.4%). The HPN group was more likely to have advanced‐stage disease and significantly higher incidence of chronic abdominal pain, narcotic dependency, bowel obstruction, ureteral obstruction, deep vein thrombosis, pulmonary embolism, fistulae, and sepsis (P < .05). The need for HPN represented a strong predictor of mortality (5‐year survival HPN = 72% vs non‐HPN = 95%), but duration of HPN did not affect mortality. Conclusion: HPN, although a life‐saving treatment, is an independent poor prognostic factor associated with high morbidity and mortality.