Enteral Nutrition in the Critically Ill Child Clinical Nutrition Abstracts Highlights of Clinical Nutrition Week 2007

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ISSN 1815-7262

Science supporting better nutrition

2007 • Volume 3, Issue 2

In this issue Enteral nutrition in the critically ill child Clinical nutrition abstracts Highlights of Clinical Nutrition Week 2007

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CLINICAL NUTRITION HIGHLIGHTS Science supporting better nutrition

2007 • Volume 3, Issue 2

Feature article 2 Enteral nutrition in the critically ill child Edward M. Barksdale, Jr

Clinical nutrition abstracts 11 Cancer 11 Critical care 11 General nutrition 13 Immunonutrition 14 Inflammatory bowel disease 15 Pancreatitis 16 Pediatrics 16 Trauma and burns 17

Highlights of Clinical Nutrition Week 18 28–31 January 2007

Conference calendar 24

Sponsored as a service to the medical profession by the Nestlé Nutrition Institute. Editorial development by CMPMedica. The opinions expressed in this publication are not necessarily those of the editor, publisher or sponsor. Any liability or obligation for loss or damage howsoever arising is hereby disclaimed. Although great care has been taken in compiling and checking the information herein to ensure that it is accurate, the editor, publisher and sponsor shall not be responsible for the continued currency of the information or for any errors, omissions or inaccuracies in this publication. © 2007 Société des Produits Nestlé S.A. All rights reserved. No part of this publication may be reproduced by any process in any language without the written permission of the publisher. CMPMedica Pacific Ltd Unit 901-903, 9th Floor, AXA Centre, 151 Gloucester Road, Wan Chai, Hong Kong T +852 2559 5888 F +852 2559 6910 [email protected] www.asia.cmpmedica.com CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07 10:33 AM Page 2

Enteral nutrition in the critically ill child

Edward M. Barksdale, Jr, MD Robert Izant Endowed Chair and Chief of Pediatric Surgery Professor of Surgery Feature article Rainbow Babies and Children’s Hospital/Case University { Cleveland, Ohio, USA }

Introduction tion may reach 60% in the intensive care unit (ICU), accruing greater metabolic debt and amplifying the Over the last three decades, significant progress in the physiologic insult to these children.4,5 The relationship care of the critically ill child has heightened the aware- of malnutrition to impaired immunity, including reduc- ness of the role of appropriate nutritional support in tions in T cell number and function, phagocytic cell improving survival and long-term outcomes. Sepsis, activity, secretory immunoglobulin A (IgA) responses shock, major trauma and severe inflammation initiate a and complement activation, and deficiencies in vitamins profound sequence of hormonal, metabolic and and trace minerals, is well documented in the litera- immunologic events that may increase resting energy ture.6,7 These impairments translate into an increased requirements by 30–100% (Figure).1-3 This hypermet- risk of infection, poor wound healing and death. In abolic response, combined with the limited energy contrast, overfeeding has been associated with diet-

reserves of children and the high incidence of malnutri- induced thermogenesis, increased CO2 production tion in pediatric critical care admissions, magnifies the leading to prolonged ventilation, and fatty deposition in physiologic impact. Furthermore, in-hospital malnutri- the liver (steatosis).8

Figure. Changes in metabolic rate and nitrogen excretion with various types of physiologic stress

Starvation vs injury: Nitrogen dynamics Resting metabolic expenditure

28 180 Major burns Major burns 24 160 Peritonitis Skeletal trauma 20 140 Skeletal trauma Severe sepsis 16 120 Infection 12 100 Normal range 8 Normal range Nitrogen excretion (g/day)

Elective operation Resting metabolism (In %) Elective operation 4 80

Partial starvation Partial starvation 0 60 Total starvation Total 0 0 10203040 Days 01020304050 Days

Reprinted from Long CL, Schaffel N, Geiger JW, Schiller WR, Blakemore WS. Metabolic Response to Adapted from Long CL, Schaffel N, Geiger JW, Schiller WR, Blakemore WS. Metabolic Response Injury and Illness: Estimation of Energy and Protein Needs from Indirect Calorimetry and to Injury and Illness: Estimation of Energy and Protein Needs from Indirect Calorimetry and Nitrogen Balance. JPEN J Parenter Enteral Nutr 1979:3:452-456 with permission from Nitrogen Balance. JPEN J Parenter Enteral Nutr 1979:3:452-456 with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. does not endorse the use of this material in any form other than its entirety. does not endorse the use of this material in any form other than its entirety. CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2 CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume

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Metabolic response to injury and stress

Several general principles have In the normal physiologic (non-stressed) state, there “ exists a homeostatic balance between caloric intake, Feature article emerged that are increasingly protein synthesis and the energy expenditure required for maintenance, growth and development of the child. guiding management in the ICU: Calories consumed via carbohydrates (60% of total intake), fats (30–35%) and protein (5–10%) are prima- early nutritional intervention; rily utilized for baseline energy needs; excess carbohydrate and fat are stored anabolically as fat in avoidance of overfeeding; and the the liver or the periphery, and excess protein is used to build lean body mass.12,13 Critical illness initiates a preferential utilization of enteral cascade of events that induces a combined hypermetabolic and hypercatabolic state, resulting in major relative to parenteral support. alterations in carbohydrate, fat and protein metabolism and a significant increase in resting energy expenditure (REE) (Figure).4,6,14,15 This ‘stress’ response is mediated by various hormones, growth factors and pro-inflammatory cytokines, such as tumor necrosis factor-α Retrospective reviews indicate that” primary (TNF-α) and interleukin-1β (IL-1β), that may last for a factors leading to poor nutritional outcome are an few days or continue until the inciting condition is inadequate initial nutritional assessment, inaccurate brought under control.12,14 Clinically, this may manifest prediction of energy and protein needs, and inconsistent as fever, leukocytosis and hyperglycemia. During a nutrient delivery during critical illness.9 Despite these period in which nutrition intake is also diminished or observations, few carefully controlled studies exist to absent, these events lead to a ‘wasting syndrome’ most offer evidenced-based guidelines for the nutritional characterized by loss of lean body mass and protein. management of the critically ill child; therefore, much All organ systems are affected by this process, but of the practice currently employed in caring for the the liver and the gut appear to be the primary end-organ pediatric patient is extrapolated from the adult litera- targets. The pleiotropic role of the liver in orchestrating ture. Nevertheless, several general principles have the shift of metabolic events from the normal to hyper- emerged that are increasingly guiding management in metabolic state is an important component of the stress the ICU: early nutritional intervention; avoidance of response.15 Hepatic protein synthesis is redirected away overfeeding; and the preferential utilization of enteral from negative acute-phase proteins (eg, albumin, trans- relative to parenteral support. ferrin, ceruloplasmin, prealbumin and retinol-binding The goals of nutrition interventions in the ICU protein) to positive acute-phase proteins (eg, α-1 anti- should be directed toward the maximal preservation of trypsin, α-1 acid glycoprotein, α-2-macroglobulin and major organ system function during the acute phase of C-reactive protein [CRP]) that are considered to be illness, minimization of the catabolic response and the important in recovery. Proteolysis also supplies amino prompt restoration of the premorbid nutritional state acids that can provide substrate for the cells that will without producing treatment-related complications. enhance the protective immune response.15 Increasing evidence supports early enteral feeding as the The gut is also affected by the stress response, most effective means of achieving these goals in the which may promote intestinal mucosal atrophy and CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume 3, Issue 2 majority of patients.4,10,11 breakdown of mucosal barrier function.16,17 These The purpose of this review is to discuss the role of changes are critical steps in the development of bacter- enteral nutrition in the pathophysiology and treatment ial translocation. Insights into the role of gut-origin of critical illness in the pediatric population, with a sepsis, its effects on the development of the systemic particular emphasis on patients with traumatic brain inflammatory response syndrome (SIRS) and overall injury, burns, cancer and bone marrow transplantation, outcome in the critically ill patient have led to the insti- and pancreatitis. These conditions have been selected tution of early enteral nutrition support to ameliorate because they are common and pose major nutritional these effects. Enteral nutrition improves gastric empty- challenges in pediatric critical care. ing, enhances intestinal motility, positively alters gut

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one of the principal by-products of carbohydrate metabolism, is produced in excess during overfeeding. Compensatory increases in the ventilatory rate to remove excess CO place significant physiologic The goals of nutrition 2 “ demands on an already debilitated patient population interventions in the ICU should be and may precipitate respiratory insufficiency and failure.8 Excess protein delivery has also been shown in adults to exacerbate this condition and increases sensi-

Feature article directed toward the maximal tivity to CO2. Furthermore, administration of excess preservation of major organ protein may lead to azotemia, hyperammonemia and hypernatremia secondary to hypertonic dehydration system function during the acute related to increased free water losses.9 Replacing one third of carbohydrate-based calories with lipid will effectively reduce CO production, lipogenesis and phase of illness, minimization of 2 ventilatory rate.8 These observations indicate the need the catabolic response and the for appropriate nutritional intervention in the care of the critically ill child to avoid problems with prompt restoration of the malnutrition or overfeeding. In addition, avoiding the inappropriate use of TPN will also aid in preventing gut premorbid nutritional state compromise through maintenance of gastrointestinal barrier function and stimulation of gut-associated without producing treatment- lymphoid tissue. related complications. Nutrition assessment

The nutritional assessment of patients admitted to the ICU is an important component of care and should be comprehensive enough to not only identify those ” patients at risk of adverse outcomes, but also to flora, limits bacterial translocation, reduces aspiration establish a baseline evaluation to guide the ongoing episodes and abrogates the stress response.18 nutritional plan of care.19 Studies indicate that this is Multiple metabolic disturbances also occur as a frequently neglected in the evaluation of new admissions consequence of excess carbohydrate or caloric intake in to the pediatric ICU (PICU) due to factors such as time the critically ill child. The metabolic threshold for these constraints and more urgent acute medical concerns.20 deleterious effects varies with patient age, premorbid This evaluation should document the baseline status (ie, nutritional status and disease severity. Major individual somatic and visceral protein levels, fat stores, vitamin, differences may also exist between patients relative to mineral and trace element levels, REE), identify deficien- their metabolic requirements during the acute stress cies (or excesses) and provide a monitoring tool to gauge response. Excess carbohydrate intake or delivery results effectiveness of intervention. Specific focus in the critical in hyperinsulinemia, lipogenesis, hypertriglyceridemia, care setting should emphasize identification of patients decreased fatty acid oxidation, reduced ketogenesis, and with or at risk of malnutrition. Acute and chronic increased glucose oxidation. Elevated portal vein protein energy malnutrition (PEM) is present in 10–65% insulin-to-glucagon ratios and serum levels of hepatic of children admitted to the PICU.4,9-11 PEM, defined as enzymes secondary to hepatocellular injury are both a weight for age, weight for height or height for age related to excess carbohydrate intake and result in less than the 3rd or 5th percentile, or a weight less than hepatic steatosis during acute metabolic stress and 90% of ideal (per Waterlow criteria), results from the sepsis.8 Morphologic changes, including cholestasis and aggregate effects of inadequate protein intake, nutrient steatosis, may occur as early as 5 days following the loss, and increased nutrient and caloric needs.4 This initiation of total parenteral nutrition (TPN). manifests as deficits in muscle and organ protein, and Significant ventilatory impairments occur as a conse- lipid reserves. Similarly, obesity is increasingly recog- quence of excess carbohydrate intake with or without nized as a premorbid risk factor that negatively impacts

21 excessive caloric administration. Carbon dioxide (CO2), outcomes in the PICU. CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2 CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume

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Table 1. Nutritional assessment of the critically ill child

COMPONENT GUIDELINES I. History Medical history Should be detailed Feature article Diagnosis Assess ± effects on metabolic rate Medications Prescribed and over-the-counter Supplements Nutritional, herbal Allergies Environmental and food-related Diet history Assess adequacy, risk for deficiencies, premorbid malnutrition (>10% weight loss) II. Anthropometrics Height Knee-height measurement, arm span, segmental measures Weight Calculate weight-for-height ratio, % ideal body weight Head circumference If <2 years of age Triceps skinfold (TSF) To assess body fat stores Mid arm circumference (MAC) Use to determine somatic protein stores (Mid arm muscle area [MAMA]) III. Body composition Bioimpedance analysis (BIA) Dual energy X-ray Use to measure lean body mass, fat mass, bone density absorptiometry (DEXA) IV. Biochemical profile Basic metabolic panel (BMP) Use to assess hydration, renal function Sodium (Na) 2–6 mEQ/kg/d; ↑ needs diuretic therapy, SIADH; ↓ needs fluid overload Potassium (K) 2–3 mEQ/kg/d; ↑ needs refeeding syndrome, diuretics; ↓ needs renal failure Chloride (Cl) 2–4 mEQ/kg/d; ↑ needs gastric losses (NG tube or vomiting) ↑ ↑ Bicarbonate (HCO3) 2–5 mEQ/kg/d; needs small bowel drainage; needs diarrhea, renal wasting Blood urea nitrogen (BUN) ↑ levels suggest renal dysfunction, excess protein load Creatinine (Cr) ↑ levels suggest renal dysfunction Glucose ↑ levels suggest diabetes or glucose intolerance Liver function tests Assess hepatic function Alkaline phosphatase ↑ in bone disease or biliary obstruction Aspartate aminotransferase ↑ in hepatocellular injury, ie, trauma, drugs, toxins, TPN Alanine aminotransferase ↑ in hepatocellular injury, ie, trauma, drugs, toxins, TPN Lactate dehydrogenase Normal range varies with age of child; elevations imply hepatic injury Total bilirubin ↑ intra- or extrahepatic ductal obstruction, ie, decreased secretion Albumin ↓ levels may suggest liver synthetic dysfunction or malnutrition Total protein ↓ levels present with loss of visceral and somatic protein stores Triglyceride level Complete blood count (CBC) To help identify micronutrient deficiencies Hemoglobin/Hematocrit (Hgb/Hct) ↓ levels in anemia from chronic disease, iron deficiency, malnutrition Platelet count Thrombocytopenia may indicate hepatic dysfunction or bone marrow failure Mean corpuscle volume (MCV) Prothrombin time (PT) Prolongation indicative of coagulopathy, possibly secondary to hepatic synthetic dysfunction Minerals and trace elements Calcium 1–2.5 mEQ/kg/d; ↓ levels cause tetany Phosphorus 0.5–1 mmoL/kg/d; ↓ levels cause weakness Magnesium 0.3–0.5 mEQ/kg/d; ↓ levels cause seizures Iron ↓ levels cause anemia Zinc 2–5 mg/d (normal plasma level 90–110 µg/dL); ↓ levels acrodermatitis, diarrhea, poor healing

Copper 200–500 µg/d (normal plasma level 80–163 µg/dL); ↓ levels leucopenia, anemia, CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume 3, Issue 2 poor healing Selenium 30–40 µg/d (normal plasma level 50–150 µg/dL); ↓ levels cause muscle tenderness, kwashiorkor Vitamins A ↓ (deficiency) scaly skin, night blindness D ↓ rickets, craniotabes, tetany E ↓ peripheral neuropathy, ataxia, nystagmus ↓ B12 pernicious anemia, neuropathy Folate ↓ macrocytic anemia

NG, nasogastric; SIADH, syndrome of inappropriate antidiuretic hormone; TPN, total parenteral nutrition

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Table 2. Resting energy expenditure equations

Age Gender WHO23 Schofield24 0–3 years Male 60.9 W – 54 0.17 W + 1.517 H – 617.6 Female 61 W – 51 16.25 W + 1.0232 H – 413.5 3–10 years Male 22.7 W + 495 19.6 W + 0.1303 H + 414.9 Female 22.5 W + 499 16.97 W + 161.8 H + 371.2

Feature article 10–18 years Male N/A 16.3 W + 0.1372 H + 515.5 Female N/A 8.365 W + 4.65 H + 200.0

H, height; W, weight

The nutrition assessment should consist of a child have been empirically adjusted to account for the complete history (medications, growth and development, theoretically increased caloric needs of the hypermeta- diet and activity), biophysical evaluation (height, weight, bolic child in the PICU, but most overestimate true height:weight ratio, anthropometrics) and biochemical calorie/energy needs. REE, as measured by indirect profile, and the establishment of a customized nutritional calorimetry, reveals that the hypermetabolic response is plan of care. Consideration of the use of indirect less than predicted by these equations. Many PICUs calorimetry in the PICU setting may allow for a more may not have the resources to perform indirect tailored regimen. This assessment allows for stratification calorimetry, or it may be difficult to perform in the non- of patients at greatest risk of adverse outcomes and facil- intubated child. It is also not accurate in children who

itates targeting of timely therapeutic interventions. weigh less than 5 kg, have a fraction of inspired O2 Frequent and dynamic re-evaluation and assessment of >60%, or endotracheal tube leakage >10%. Several these interventions allows them to be customized to avoid equations exist that allow REE to be estimated at base- under- or overfeeding. A summary of the major compo- line and in the stressed state; the Harris-Benedict, nents of the nutritional assessment are listed in Table 1; Talbott, World Health Organization, Schofield and more detailed information on nutritional assessment can Curreri equations provide a starting point for estimat- be obtained from the references. ing energy needs (Table 2).22-25 Most studies suggest that dynamic clinical judgment and reassessment should be Nutrition support the principal tools utilized to guide the ongoing adequacy of nutritional support therapy. Nutrition for the critically ill child involves the provision of nutrients, calories and fluids that meets the Traumatic brain injury patient’s dynamic requirements for the preservation of tissue integrity (ie, prevention of muscle and visceral Brain injury is the primary cause of traumatic death in protein degradation) and fulfillment of the energy children in developed nations, with an annual incidence supply to meet organ needs and prevent major system of approximately 3,000 deaths in the United States dysfunction (ie, cardiovascular, pulmonary and alone. The magnitude of the burden of traumatic brain immune). The establishment of a uniform approach in injury (TBI) in pediatrics is much greater considering children mandates a thorough understanding of disease that in the United States each year approximately pathophysiology, the beneficial and adverse effects asso- 400,000 children will suffer injury and, of these, nearly ciated with therapeutic interventions, the complications 30,000 will require hospitalization.26,27 Many of these of the disease and the options for the provision of nutri- children will develop cognitive impairments that require tion support. The goals of therapy are to rapidly replete rehabilitation or result in long-term disability. TBI is the protein deficits that occur as result of catabolism, associated with significant hypermetabolism, the degree restore normal physiology and homeostasis, decrease of which depends on the extent of injury and the injury-related morbidity and mortality, and facilitate treatment (ie, neuromuscular paralysis, hypothermia, physical growth in the recovery phase. etc).27,28 Compelling evidence indicates that early enteral Lack of consensus exists on the appropriate equa- support has both short- and long-term benefits, associ- tion to estimate REE in the critically ill child. Many of ated with a reduction in infectious complications in the equations used to assess energy needs in the healthy patients with TBI. Although data regarding the CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2 CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume

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optimal nutritional management of TBI in the PICU electrolyte measurements should be monitored meticu- are sparse and somewhat conflicting relative to lously and appropriate supplementation given with survival, emerging evidence regarding a reduction in caution in these patients to maintain optimum sodium morbidity supports aggressive initiation of enteral levels between 135 and 145 mEq/L.30-32

nutrition. Following initial stabilization, enteral nutri- During the acute phase of brain injury, the synthe- Feature article tion support is ideally commenced within 72 hours of sis of visceral proteins (negative acute-phase reactants, admission, with progression to full feeding over the next such as albumin, prealbumin and transferrin) are down- 48 hours.26 regulated to shift toward the production of acute-phase Gastrointestinal disturbances – gastroesophageal reactants, such as CRP and α-1–acid glycoproteins, that reflux and delayed gastric emptying – associated with are necessary for wound healing and immune response.33 brain injury often challenge this approach. Monitoring of serum CRP and prealbumin levels may Gastroesophageal reflux, a common occurrence in TBI, herald trends in injury recovery versus overt malnutri- predisposes patients to aspiration and pneumonia. tion. Serial measurements of serum CRP should Following head trauma in adults, delayed gastric empty- decrease and prealbumin should rise when catabolism ing is observed in 50% during the first 2 weeks and subsides and anabolism begins. Hence, advancement to 25% during the first 4 weeks.29 The etiology of both full caloric feeds may be targeted during this phase of these conditions is most likely mediated centrally by the recovery. Elevated protein requirements up to twice the effects of increased intracranial pressure on the recommended daily allowance may be indicated during medullary centers that control vagal nerve function. the anabolic phase of recovery from severe brain injury. Metoclopramide has been demonstrated to be beneficial This is emerging as a tool to manage calorie delivery in in this population. The potential for gastrointestinal this population.4 disturbances in the patient with head injury makes the small bowel a better site for feeding. Post-pyloric feed- Burns ing regimens are generally uniformly employed in most high volume pediatric neurosurgical ICUs. Burn injury is associated with the greatest hypermetab- The central nervous system regulates fluid and olism of all traumatic conditions and nutrition support electrolyte balance through the hypothalamic- has formed the foundation of modern care. Large burns neurohypophyseal axis. Fluid and electrolyte shifts, (≥20% total body surface area) may induce a hyper- common following severe brain injury, make the metabolic phase lasting more than 4 weeks from the routine monitoring of weight changes and serum initial injury.34,35 Burns are associated with an exagger- protein levels an unreliable parameter for dynamic ated catabolic response relative to other critical nutritional assessment and monitoring.30 Sodium injuries, while loss of lean body mass, decreased host dysregulation, either through iatrogenic or pathologic defenses and abnormal immune responses are also processes, may exacerbate brain injury and worsen magnified.35 The REE may increase by up to 100% prognosis. Excessive free water administration depending on the depth and extent of burn injury.36 The via intravenous fluids or formula may lead to Curreri formula is the most commonly used formula to cerebral edema and increased intracranial pressure. estimate total calorie requirements in children with Alternatively, excess sodium administration from burns.25 The route of nutrient delivery is significantly enteral or parenteral sources may lead to hyper- affected by the medical status of the patient. Extreme natremic cerebral dehydration, which can be hemodynamic lability, use of pressors and the presence fatal. Patients with TBI are at risk of developing of other medical conditions may preclude the safe initi- the syndrome of inappropriate antidiuretic hormone ation of enteral feeding. Parenteral nutrition may be an (SIADH) or cerebral salt-wasting syndrome. effective metabolic bridge until the gut may be utilized. CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume 3, Issue 2 Antidiuretic hormone (ADH) or vasopressin produced Even during these brief periods of TPN use, alteration by the posterior pituitary leads to renal sodium preser- in intestinal flora, disruption of mucosal barrier func- vation, decreased urine sodium levels and urinary tion and impaired immunity may occur. If feasible, concentration. Lack of sufficient ADH causes excessive dual-feeding with small amounts of enteral nutrition salt and dilute urine loss. This may be treated with may be advantageous, as gut-mediated sepsis plays a fluid replacement and ADH administration with major role in the morbidity and mortality of burn desmopressin (DDAVP). Many of the enteral formulas patients in the PICU. Most centers aim to initiate lack adequate sodium to meet these increased needs enteral feeding following the return of intestinal and supplementation is necessary. Serum and urine peristalsis to assure ileus resolution, and decrease

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vomiting and aspiration risk. Slow increases to meet During the last decade, bone marrow transplan- the target calorie and nutrient goals by 5–7 days post- tation (BMT) has emerged as an aggressive therapy in injury are generally well tolerated using this overall the treatment of several malignant and non-malignant therapeutic strategy. conditions. BMT is frequently associated with a Glutamine-supplemented formulas have recently reversible multisystem organ failure that results in been shown to attenuate the effects on intestinal barrier major nutritional sequelae, including protein-energy function.37,38 Although data with regard to the duration malnutrition, and vitamin and trace element deficien- of therapy are limited, it appears clear that optimum cies. In many patients, transient intestinal failure may Feature article doses ranging from ~0.35–0.57 g/kg of body weight per be associated with impaired nutritional status that day for at least 5 days are of some benefit and without lasts for up to 1 year after BMT. One component of apparent clinical toxicity in adults. The addition of transient intestinal failure associated with BMT is glutamine to pediatric formulas in a similar dose range protein-losing enteropathy, in which protein is lost appears to be indicated.39 Increased tissue and urinary through an inflamed and abnormal intestinal losses of zinc and copper are also associated with ther- mucosa.47 The effects of radiation, chemotherapy, mal injury, and require meticulous monitoring and graft-versus-host disease (GVHD) and viral infection supplementation. These micronutrients are critical for may contribute individually or in concert to this bone matrix formation (osteogenesis), bone mineraliza- process.41 Impairments in vitamin, mineral and trace tion, prevention of bone resorption and wound healing element metabolism and absorption associated with (collagen cross-linking).40 chemotherapy and BMT are also quite common. The most commonly observed among these include

Cancer and bone marrow thiamine and vitamins K and B12. The levels of the transplantation minerals and trace elements magnesium, copper, zinc and selenium are frequently found to be low in this Considerable controversy exists within the literature as population of patients. Attention to these potential to the incidence of malnutrition among children diag- deficiencies should be addressed through routine nosed with cancer. It appears that diagnosis (ie, serologic monitoring and appropriate nutritional hematologic versus solid tumor), clinical stage and supplementation (Table 1).41 If feasible, the initiation socioeconomic factors, among several other variables, of enteral nutrition has been associated with may impact the presence and degree of malnutrition fewer biochemical zinc and selenium deficiencies at initial diagnosis and following therapy.41-43 than TPN.48 Chemotherapy, radiation and surgery have major adverse effects on the nutritional status of pediatric Pancreatitis patients. Multiple determinants influence the etiology of malnutrition in this population, and may be categorized Acute pancreatitis is an inflammatory process that into three major groups: involves the pancreas, peripancreatic tissues and occa- 1) Increased energy needs; sionally remote organs, and is increasing in frequency 2) Impaired caloric consumption; and in children.49,50 Although the initiating event remains to 3) Increased energy losses. be identified, the pathophysiology of acinar cell injury A hypermetabolic state analogous to that seen in leading to activation of trypsin from its precursor major trauma or sepsis, with the release of pro-inflam- trypsinogen and subsequent pancreatic autodigestion matory factors and tumor-associated cytokines as is well described.51 In the vast majority of cases, this is detailed above, may increase the metabolic demands a local process that typically resolves within a few and REE. However, some of these increased metabolic days with minimal pancreatic or remote organ demands may be offset by the associated decrement in dysfunction. However, in severe cases, this local physical activity that occurs in these chronically ill process may activate a cascade of pathophysiologic patients.44-46 Changes in oral food intake may occur as events that leads to the development of SIRS with a result of treatment-related complications, such as extensive pancreatic necrosis, intestinal ischemia, mucositis, dysphagia, emesis, food aversion and bacterial translocation, respiratory distress, multisys- anorexia. Direct radiation or chemotherapy effects on tem organ failure and, potentially, death. Fortunately, the intestinal mucosa leading to diarrhea, protein-losing the full SIRS response is seldom seen in children, enteropathy and malabsorption may contribute to but an attenuated form of the systemic process increased energy losses.4 may occur.51,52 CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2 CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume

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Enteral nutrition was long considered to have decision-making to stop feeding in the presence of adverse effects on the management of patients with worsening clinical signs and symptoms.52,53 There are acute pancreatitis, secondary to the stimulation of few reported controlled studies in children with acute pancreatic enzymatic activity precipitating further pancreatitis; however, many centers are adapting the

53,54 autodigestion. In fact, ‘gut rest’ has long been strategy of initiating early enteral nutrition. Meta- Feature article considered the standard of care for patients with analyses of multiple reports in the adult literature acute pancreatitis. Emerging evidence in adult litera- allow some general conclusions to be drawn that may ture challenges this old paradigm and supports the likely be applicable in pediatrics. Enteral nutrition premise that enteral nutrition via a nasojejunal feed- may be safely administered to patients with acute ing tube with a semi-elemental diet (a high-protein, pancreatitis within 48 hours of presentation using a low-fat formulation) is superior to parenteral nutri- radiographically- or endoscopically-placed flexible tion.55 Furthermore, the early initiation of enteral nasojejunal feeding tube. In the absence of pain or support may not only be tolerated but therapeutic in clinical symptoms of worsening pancreatitis, enteral acute pancreatitis. Studies show that enterally-fed support may be advanced to goal feeds as tolerated patients with severe pancreatitis had significantly over 2–4 days.55,56 fewer septic episodes and total complications, and a lower risk of multisystem organ failure and SIRS.55,56 Summary Furthermore, there were significant reductions in length of hospitalization and cost of care.55,56 The The increased recognition of the role that malnutrition provision of trophic enteral nutrition attenuates the plays as an adverse prognostic factor in critically ill SIRS response by improving splanchnic blood flow, children has led to greater focus on the importance of inhibiting immune effector cell activation, decreasing premorbid nutritional status and post-morbid nutri- cytokine production, enhancing intestinal motility tional support. Emerging evidence supports the and bile salt recirculation, and decreasing bacterial initiation of early enteral feeding to enhance long-term overgrowth.54 outcomes in most pediatric critical illnesses. Trophic Although many studies suggest a superior role feeds are ideally initiated within 48–72 hours, or as for enteral versus parenteral nutrition support in soon as the disease process is stabilized or ileus patients with pancreatitis, some caution must be resolves. Typically, feeding is advanced to full support employed in the clinical setting. Enteral, even elemen- over a 3–5-day period with dynamic attention to tal, feeding may in some patients stimulate changes in the metabolic requirements to avoid over- pancreatitis, but this may be minimized by very distal or underfeeding. Estimates of the caloric/energy and jejunal feeding tube placement and judicious clinical protein needs may be made using standard equations adjusted for age, injury severity and associated medical therapies (eg, neuromuscular paralysis). New insights into the pathophysiology of the hypermetabolic syndrome, protein energy malnutrition and gut mucosal physiology are changing old paradigms of withholding enteral nutrition support in the PICU that Emerging evidence supports were predicated on concerns about risks of aspiration “ and gut injury. Evidence demonstrating faster recovery, the initiation of early enteral shorter ventilatory courses, fewer septic complications, decreased length of stay and lower costs in feeding to enhance long-term selected patients receiving early enteral feeds is being CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume 3, Issue 2 reported for many diagnoses. The use of small, flexible outcomes in most pediatric feeding tubes, a variety of available elemental or semi- elemental formulas and the judicious use of critical illnesses. promotility agents are facilitating this new approach to care. Further advances in our understanding of the hypermetabolic syndrome coupled with new formula developments may usher in a new paradigm of enteral ” nutrition as therapy in critical illness. 9 CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07 10:33 AM Page 10

References

1. Long CL, Schaffel N, Geiger JW, Schiller WR, expert consultation. Geneva: World Heath but mostly missed. Eur J Pediatr 1991;150:318- Blakemore WS. Metabolic response to injury and Organization; 1985:WHO Technical Report Series 322. illness: estimation of energy and protein needs No 724. 45. Barr RD, Gibson BE. Nutritional status and from indirect calorimetry and nitrogen balance. 24. Schofield WN. Predicting basal metabolic rate, cancer in childhood. J Pediatr Hematol Oncol JPEN J Parenter Enteral Nutr 1979;3:452-456. new standards and review of previous work. 2000;22:491-494. 2. Briassoulis G, Zavras N, Hatzis T. Malnutrition, Hum Nutr Clin Nutr 1985;39(suppl 1):5-41. 46. Picton SV. Aspects of altered metabolism in chil- nutritional indices, and early enteral feeding in 25. Curreri PW, Luterman A. Nutritional support of dren with cancer. Int J Cancer Suppl 1998; critically ill children. Nutrition 2001;17:548-557. the burned patient. Surg Clin North Am 1978; 11:62-64. 3. Border JR, Hassett J, LaDuca J, et al. The gut 58:1151-1156. 47. Reilly JJ, Weir J, McColl JH, Gibson BE. origin septic states in blunt multiple trauma (ISS 26. Redmond C, Lipp J. Traumatic brain injury in the Prevalence of protein–energy malnutrition at = 40) in the intensive care unit. Ann Surg 1987; pediatric population. Nutr Clin Pract 2006; diagnosis in children with acute lymphoblastic 206:427-448. 21:450-461. leukemia. J Pediatr Gastroenterol Nutr 1999; Feature article 4. Irving SY, Simone SD, Hicks FW, Verger JT. 27. Michaud LJ, Rivara FP, Longstreth WT Jr, Grady 29:194-197. Nutrition for the critically ill child: enteral and MS. Elevated initial blood glucose levels and 48. Papadopoulou A. Nutritional considerations in parenteral support. AACN Clin Issues Adv Pract poor outcome following severe brain injuries in children undergoing bone marrow transplanta- Acute Crit Care 2000;11:541-558. children. J Trauma 1991;31:1356-1362. tion. Eur J Clin Nutr 1998;52:863-871. 5. Oosterveld MJ, Van Der Kuip M, De Meer K, De 28. Adelson PD, Bratton SL, Carney NA, et al. 49. Nydegger A, Couper RT, Oliver MR. Childhood Greef HJ, Gemke RJ. Energy expenditure and Guidelines for the acute medical management of pancreatitis. J Gastroenterol Hepatol 2006; balance following pediatric intensive care unit severe traumatic brain injury in infants, children, 21:499-509. admission: a longitudinal study of critically ill and adolescents. Chapter 18. Nutritional 50. DeBanto JR, Goday PS, Pedroso MR. Acute children. Pediatr Crit Care Med 2006;7:147-153. support. Pediatr Crit Care Med 2003; pancreatitis in children. Am J Gastroenterol 6. Smith MK, Lowry SF. The hypercatabolic state. 4(3 suppl):S68-S71. 2002;97:1726-1731. In: Shils ME, Olson JA, Shike M, Ross CA, eds. 29. Ott L, Young B, Phillips R, et al. Altered gastric 51. Werlin SL, Kugathasan S, Frautschy BC. Modern Nutrition in Health and Disease. 9th ed. emptying in the head-injured patient: relation- Pancreatitis in children. J Pediatr Gastroenterol Philadelphia: Williams & Wilkins; 1999:1555- ship to feeding intolerance. J Neurosurg Nutr 2003;37:591-595. 1568. 1991;74:738-742. 52. Oliver MR, Ranuh R, Heine RG, Gegati-Levy R, 7. Bistrian BR, Blackburn GL, Scrimshaw NS, Flatt 30. Rhoney DH, Parker D Jr. Considerations in fluid Crameri J. The changing incidence of acute JP. Cellular immunity in semistarved states in and electrolytes after traumatic brain injury. pancreatitis in children: a 10-year experience in hospitalized adults. Am J Clin Nutr 1975; Nutr Clin Pract 2006;21:462-478. Melbourne. J Pediatr Gastroenterol Nutr 28:1148-1155. 31. Agha A, Thornton E, O’Kelly P, et al. Posterior 2004;39(suppl 1):S167. 8. Chwals WJ. Overfeeding the critically ill child: pituitary dysfunction after traumatic brain injury. 53. Weizman Z. An update on diseases of the fact or fantasy? New Horiz 1994;2:147-155. J Clin Endocrinol Metab 2004;89:5987-5992. pancreas in children. Curr Opin Pediatr 1997; 9. de Oliveira Iglesias SB, Leite HP, Santana 32. Berkenbosch JW, Lentz CW, Jimenez DF, Tobias 9:494-497. e Meneses JF, de Carvalho WB. Enteral nutrition JD. Cerebral salt wasting syndrome following 54. Weber CK, Adler G. From acinar cell damage in critically ill children: are prescription and brain injury in three pediatric patients: sugges- to systemic inflammatory response: current delivery according to their energy requirements? tions for rapid diagnosis and treatment. Pediatr concepts in pancreatitis. Pancreatology 2001; Nutr Clin Pract 2007;22:233-239. Neurosurg 2002;36:75-79. 1:356-362. 10. Briassoulis G, Venkataraman S, Thompson AE. 33. Wilcockson DC, Campbell SJ, Anthony DC, 55. Marik PE, Zaloga GP. Meta-analysis of parenteral Energy expenditure in critically ill children. Crit Perry VH. The systemic and local acute phase nutrition versus enteral nutrition in patients with Care Med 2000;28:1166-1172. response following acute brain injury. J Cereb acute pancreatitis. BMJ 2004;328:1407-1410. 11. Pollack MM. Nutritional support of children in Blood Flow Metab 2002;22:318-326. 56. McClave SA, Greene LM, Snider HL, et al. the intensive care unit. In: Suskind R, Lewinter- 34. Carlson DE, Cioffi WG Jr, Mason AD Jr, Comparison of the safety of early enteral vs Suskind L, eds. Textbook of Pediatric Nutrition. McManus WF, Pruitt BA Jr. Resting energy parenteral nutrition in mild acute pancreatitis. 2nd ed. New York: Raven Press; 1993:207-216. expenditure in patients with thermal injuries. JPEN J Parenter Enteral Nutr 1997;21:14-20. 12. Taylor RM, Preedy VR, Baker AJ, Grimble G. Surg Gynecol Obstet 1992;174:270-276. Nutritional support in critically ill children. Clin 35. Milner EA, Cioffi WG, Mason AD, McManus WF, Nutr 2003;22:365-369. Pruitt BA Jr. A longitudinal study of resting 13. Teitelbaum D, Coran AG. Perioperative nutri- energy expenditure in thermally injured patients. tional support in pediatrics. Nutrition 1998; J Trauma 1994;37:167-170. 14:130-142. 36. Mochizuki H, Trocki O, Dominioni, L, et al. 14. Bursztein S, Elwyn DH, Askanazi J. Energy Mechanism of prevention of postburn hyperme- metabolism and indirect calorimetry in critically tabolism and catabolism by early enteral feeding. ill and injured patients. Acute Care 1988- Ann Surg 1984;200:297-310. 1989;14-15:91-110. 37. Long C. Energy expenditure of major burns. J 15. Jeschke MG, Barrow RE, Herndon DN. Extended Trauma 1979;19(11 suppl):904-906. hypermetabolic response of the liver in severely 38. Peng X, Yan H, You Z, Wang P, Wang S. Effects burned pediatric patients. Arch Surg 2004; of enteral supplementation with glutamine gran- 139:641-647. ules on intestinal mucosal barrier function in 16. Stechmiller JK, Treloar D, Allen N. Gut dysfunc- severe burned patients. Burns 2004;30:135-139. tion in critically ill patients: a review of the 39. Zhou YP, Jiang ZM, Sun YH, et al. The effect of literature. Am J Crit Care 1997;6:204-209. supplemental enteral glutamine on plasma 17. Swank GM, Deitch EA. Role of the gut in multiple levels, gut function, and outcome in severe organ failure: bacterial translocation and perme- burns: a randomized double-blind, controlled ability changes. World J Surg 1996;20:411-417. clinical trial. JPEN J Parenter Enteral Nutr 18. Schears GJ, Deutschman CS. Common nutri- 2003;27:241-245. tional issues in pediatric and adult critical care 40. Windle EM. Glutamine supplementation in criti- medicine. Crit Care Clin 1997;13:669-690. cal illness: evidence, recommendations, and 19. Bettler J, Roberts KE. Nutrition assessment of implications for clinical practice in burn care. J the critically ill child. AACN Clin Issues Burn Care Res 2006;27:764-772. 2000;11:498-506. 41. Voruganti VS, Klein GL, Lu HX, et al. Impaired 20. Hendricks K. Nutritional assessment. In: Baker zinc and copper status in children with burn SB, Baker RD, Davis A, eds. Pediatric Enteral injuries: need to reassess nutritional require- Nutrition. New York: Chapman & Hall; 1997:105- ments. Burns 2005;31:711-716. 118. 42. Sala A, Pencharz P, Barr RD. Children, cancer, 21. Miller J, Rosenbloom A, Silverstein J. Childhood and nutrition – A dynamic triangle in review. obesity. J Clin Endocrinol Metab 2004;89:4211- Cancer 2004;100:677-687. 4218. 43. Brennan B, Ross JA, Barr RD. On nutritional 22. Talbot FB. Basal metabolism standards for chil- status and cancer in children. Cancer Strategy dren. Am J Dis Child 1938;55:455-459. 1999;1:195-202. 23. World Health Organization. Energy and protein 44. Smith DE, Stevens MC, Booth IW. Malnutrition at CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2 CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume requirements: Report of a joint FAO/WHO/UNU diagnosis of malignancy in childhood: common

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CLINICAL NUTRITION ABSTRACTS

hospital length of stay and ICU, length of stay regression CANCER trees were calculated. RESULTS: Both groups were underfed with 50% of goal met in surgical ICU and 56% of goal met in medical ICU. Medical ICU patients received less propofol Modulation of lipid rafts by Ω-3 fatty acids in and significantly less dextrose-containing intravenous fluids inflammation and cancer: Implications for use when compared to surgical ICU patients (p = 0.013). From of lipids during nutrition support regression analysis, approaching full nutrient requirements

Nutr Clin Pract 2007 Feb;22(1):74-88. during ICU stay was associated with greater hospital length Clinical nutrition

Siddiqui RA, Harvey KA, Zaloga GP, Stillwell W. of stay and ICU length of stay. For combined groups, if % abstracts Methodist Research Institute, Cellular Biochemistry, Indianapolis, Indiana, goal was ≥82%, the estimated average value for ICU length USA. of stay was 24 days; whereas, if the % goal was <82%, the Current understanding of biologic membrane structure and average ICU length of stay was 12 days. This relationship function is largely based on the concept of lipid rafts. Lipid held true for hospital length of stay. CONCLUSIONS: rafts are composed primarily of tightly packed, liquid- Medical and surgical ICU patients were insufficiently fed ordered sphingolipids/cholesterol/saturated phospholipids during their ICU stay when compared with registered dieti- that float in a sea of more unsaturated and loosely packed, tian recommendations. Medical ICU patients received liquid-disordered lipids. Lipid rafts have important clinical earlier nutrition support, on average more enteral nutrition, implications because many important membrane-signaling with fewer kilocalories supplied from lipid-based sedatives proteins are located within the raft regions of the and intravenous fluid relative to surgical ICU patients. membrane, and alterations in raft structure can alter activ- Based upon length of stay, the data suggest that the most ity of these signaling proteins. Because rafts are lipid-based, severely ill patient may not benefit from delivery of full their composition, structure, and function are susceptible to nutrient needs in the ICU. manipulation by dietary components such as ω-3 polyunsaturated fatty acids and by cholesterol depletion. We review Effect of nutritional support on glucose control how alteration of raft lipids affects the raft/nonraft localiza- Curr Opin Clin Nutr Metab Care 2007 Mar;10(2):210-214. tion and hence the function of several proteins involved in Seematter G, Tappy L. cell signaling. We focus our discussion of raft-signaling Service of Anaesthesiology, University Hospital of Canton de Vaud (CHUV), Lausanne, Switzerland. proteins on inflammation and cancer. PURPOSE OF REVIEW: There is evidence that maintaining a normal glycemia level in critically ill patients has beneficial effects on outcome. Strategies aimed at lowering glycemia CRITICAL CARE are based on the understanding of mechanisms regulating glucose metabolism. RECENT FINDINGS: Activation of AMP protein kinase in skeletal muscle and in the liver leads Feeding practices of severely ill intensive care to a reduction in glucose production, a stimulation of unit patients: An evaluation of energy sources and glucose uptake, and a lowering of glycemia. These mecha- clinical outcomes nisms appear to be activated during exercise, or by the J Am Diet Assoc 2007 Mar;107(3):458-465. endogenous adipokine adiponectin. Alterations in Hise ME, Halterman K, Gajewski BJ, Parkhurst M, Moncure M, Brown JC. adiponectin concentrations during critical illness may thus The University of Kansas Medical Center, Department of Dietetics and play a role in the metabolic stress responses. In addition, Nutrition, Kansas City, Kansas, USA. AMP-activated protein kinase is the target for drugs OBJECTIVE: The quantity of nutrition that is provided to (metformin, thiazolidinediones), which may be of interest in intensive care unit (ICU) patients has recently come under the intensive care unit. Besides insulin, plasma glucose

more scrutiny in relation to clinical outcomes. The primary concentrations may be lowered by hypocaloric feeding, or CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume 3, Issue 2 objective of this study was to assess energy intake in severely by feeding 'diabetic' formula with low glucose content and ill ICU patients and to evaluate the relationship of energy supplemented with fructose. Whether such approaches lead intake with clinical outcomes. DESIGN: Prospective cohort to beneficial effects comparable to those observed with study. SUBJECTS/SETTINGS: Seventy-seven adult surgery insulin remains to be established. SUMMARY: Recent find- and medical ICU patients with length of ICU stay of at least ings regarding the molecular mechanisms underlying glucose 5 days. STATISTICAL ANALYSES PERFORMED: transport and metabolism are summarized, and potential Student's t test and χ2 tests were used to examine ICU popu- strategies other than insulin are outlined which may lations. To determine the relationship of patient variables to contribute to lowering glycemia in critically ill patients.

The abstracts included in this section were selected from a search on clinical nutrition and related topics of the PubMed database of the United States National Library of Medicine. PubMed may be accessed via the National Library of Medicine Web site at www.nlm.nih.gov.

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Effect of an enteral diet supplemented with a commenced and 6-hourly nasogastric aspirates were specific blend of amino acid on plasma and performed. If a gastric residual volume ≥250 mL recurred muscle protein synthesis in ICU patients on treatment, open-label, combination therapy was given. Patients were studied for 7 days. Successful feeding was Clin Nutr 2007 Feb;26(1):30-40. defined as 6-hourly gastric residual volume <250 mL with Mansoor O, Breuillé D, Béchereau F, Buffiére C, Pouyet C, Beaufrére B, Vuichoud J, Van't-Of M, Obled C. a feeding rate ≥40 mL/h. MEASUREMENTS AND MAIN RCO Département d'anesthésie-réanimation, CHU, 63000 Clermont-Ferrand, RESULTS: Demographic data, blood glucose levels, and France. use of inotropes, opioids, and benzodiazepines were simi- BACKGROUND & AIM: Polytrauma patients are charac- lar between the two groups. After 24 hours of treatment, terized by a negative nitrogen balance and muscle wasting. both monotherapies reduced the mean gastric residual Standard nutrition is relatively inefficient to improve muscle volume (metoclopramide, 830 ± 32 mL to 435 ± 30 mL, protein turnover. The aim of this study was to investigate the p < 0.0001; erythromycin, 798 ± 33 mL to 201 ± 19 mL, effect of enteral nutrition (EN) supplemented with specific p < 0.0001) and improved the proportion of patients amino acids on protein metabolism in polytrauma patients. with successful feeding (metoclopramide = 62% and METHODS: In a double-blind study, 12 polytrauma erythromycin = 87%). Treatment with erythromycin was patients were randomized to receive EN supplemented with more effective than metoclopramide, but the effectiveness either a mixture of cysteine, threonine, serine and aspartate of both treatments declined rapidly over time. In patients abstracts (AA patients) or alanine at isonitrogenous levels (Ala who failed monotherapy, rescue combination therapy Clinical nutrition patients). An intravenous infusion of Ŀ-[1-13C]-leucine was was highly effective (day 1 = 92%) and maintained its performed in the fed state between day 9 and 12 post-injury effectiveness for the study duration (day 6 = 67%). (Df) in patients and in a group of healthy volunteers (n = 8) High pretreatment gastric residual volume was associated (EN+Ala) to measure whole body leucine kinetics, plasma with poor response to prokinetic therapy. CONCLU- and muscle protein synthesis rates. Nitrogen balance, SIONS: In critical illness, erythromycin is more effective 3-methyl histidine excretion were measured from day 3 to than metoclopramide in treating feed intolerance, but the Df. RESULTS: The contribution of total plasma proteins to rapid decline in effectiveness renders both treatments whole body protein synthesis was greatly increased, from suboptimal. Rescue combination therapy is highly effec- 11% in healthy volunteers to about 25% in polytrauma tive, and further study is required to examine its role as the patients. AA supplementation had no effect on nitrogen first-line therapy. balance, leucine kinetics or plasma protein synthesis in patients. In contrast, the urinary excretion of 3-methyl histi- Hypocaloric feeding of the critically ill dine tended to decrease along the study in the AA Nutr Clin Pract 2006 Dec;21(6):617-622. supplemented group compared to an increase in the Ala Boitano M. group. Muscle protein synthesis tended to be higher in the Clinical Nutrition, Scripps Memorial Hospital–Encinitas, Encinitas, AA group than in the Ala group (46%, p = 0.065). California, USA. CONCLUSION: During injury, an increased supply of During critical illness, the stress response causes acceler- cysteine, threonine, serine and aspartate could be able to ated gluconeogenesis and lipolysis, leading to better cover the specific amino acid requirements, thus hyperglycemia and elevated serum triglyceride levels. The resulting in improved muscle protein synthesis without traditional nutrition support strategy of meeting or exceed- impairment of acute-phase protein synthesis. ing calorie requirements may compound the metabolic alterations of the stress response. Hypocaloric nutrition Erythromycin is more effective than support has the potential to provide nutrition support metoclopramide in the treatment of feed without exacerbating the stress response. Studies have intolerance in critical illness shown hypocaloric nutrition support to be safe and to Crit Care Med 2007 Feb;35(2):483-489. achieve nitrogen balance comparable with traditional regi- Nguyen NQ, Chapman MJ, Fraser RJ, Bryant LK, Holloway RH. mens. Benefits shown include improved glycemic control, Department of Gastroenterology, Hepatology and General Medicine, Royal decreased intensive care unit (ICU) length of stay (LOS), Adelaide Hospital, and University Department of Medicine, University of and decreased ventilator days and infection rate; however, Adelaide, South Australia, Australia. not all studies have produced identical results. Providing OBJECTIVE: This study aimed to a) compare the efficacy adequate dietary protein has emerged as an important of metoclopramide and erythromycin in the treatment of factor in efficacy of the hypocaloric regimen. Although it feed intolerance in critical illness; and b) determine the is inconclusive, currently available research suggests that a effectiveness of "rescue" combination therapy in patients nutrition support goal of 10–20 kcal/kg of ideal or who fail monotherapy. DESIGN: Randomized controlled adjusted weight and 1.5–2 g/kg ideal weight of protein trial. SETTING: Level III mixed medical and surgical may be beneficial during the acute stress response. Well- intensive care unit. PATIENTS: Ninety mechanically venti- designed, randomized, controlled studies with adequate lated, medical patients with feed-intolerance (gastric sample size that evaluate relevant clinical outcomes such as residual volume ≥250 mL). INTERVENTIONS: Patients mortality, ICU LOS, and infection while controlling for received either metoclopramide 10 mg intravenously four factors such as glycemic control, severity of illness, incor- times daily (n = 45) or erythromycin 200 mg intravenously poration of calories from all sources, in addition to feeding twice a day (n = 45) in a double-blind, randomized fash- regimens, are needed to definitively determine the effects

CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2 CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume ion. After the first dose, nasogastric feeding was of hypocaloric nutrition support.

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Feeding the critically ill obese patient: The role of Nutritional requirements may change with PD progression hypocaloric nutrition support or after surgical therapy for PD. Patients and caregivers Respir Care Clin N Am 2006 Dec;12(4):593-601. may benefit from counseling by a dietician who is knowl- Miller JP, Choban PS. edgeable about the nutritional risks and needs of PD. Mount Carmel Health System, Columbus, Ohio, USA. Regularly inquire about dysphagia symptoms, and consider speech therapy consultation for clinical and modi- Obesity and its many metabolic and physiologic comorbidi- fied barium-swallowing evaluations and management ties are becoming more common. Thus, a strategy to recommendations. Although non-oral delivery options of approach the nutritional needs of obese critically ill patients dopaminergic therapy are increasing, severe dysphagia is warranted. The adverse effect of obesity on the respiratory may warrant percutaneous endoscopic gastrostomy tube system is well established. The obesity may be an inciting placement for nutritional support and more reliable PD event or merely an additional burden in the obese critically medication dosing. Analyze vitamin B and D concentra- ill patient. A strategy of hypocaloric nutrition support 12 tions at regular intervals. Both vitamins are frequently avoids the many detrimental effects of overfeeding and has

deficient in elderly persons but may not be routinely Clinical nutrition been considered for all critically ill patients. In the obese

checked by primary care physicians. Record over-the- abstracts patient, the strategy addresses the additional problem of the counter and nutritional supplement medications at each excessive fat store and has the additional benefit of fat visit, and assist patients in periodically re-evaluating their reduction while sparing lean body mass. In the patient with potential benefits, side effects, drug interactions, and costs. normal renal and hepatic function, hypocaloric nutrition To date, clinical trials of antioxidant vitamins and nutri- support simplifies care and may improve outcome. tional supplements have provided insufficient evidence to Nutrition support for the long-term ventilator- support routine use for PD in the clinic. Data from several clinical trials of antioxidant vitamins/nutritional supple- dependent patient ments are expected in the near future. Consider altering Respir Care Clin N Am 2006 Dec;12(4):567-591, vi. medication dosing in relation to meals to help with mild to Cresci G, Cue JI. moderate motor fluctuations. Patients with severe motor Surgical Nutrition Service, Department of Surgery, Medical College of Georgia, Augusta, Georgia, USA. fluctuations may benefit from adapting the 5:1 carbohydrate-to-protein ratio in their daily meals and snacks. This article discusses issues related to nutrition support for Following a "protein redistribution" diet is logistically the critically ill (CCI), especially those who are dependent more difficult and less palatable, and therefore less on ventilators for long periods. A large and growing popu- frequently recommended. To ensure adequate protein lation of patients survives acute critical illness only to intake, a registered dietician should supervise patients who become CCI with profound debilitation, weeks to months of follow either of these diets. hospitalization, and often permanent dependence on mechanical ventilation and other life-sustaining modalities. Despite resource-intensive treatment, outcomes for the CCI Successful new method of extracorporeal remain poor. Topics addressed in this article include percutaneous endoscopic gastrostomy (E-PEG) neuroendocrine profiles in CCI patients, allostatic overload, Surg Endosc 2007 Apr 3; [Epub ahead of print]. causes of prolonged mechanical ventilation, and the metab- Toyama Y, Usuba T, Son K, Yoshida S, Miyake R, Ito R, Tsuboi K, Kashiwagi H, olism of chronic ventilator dependence. The article also Tajiri H, Yanaga K. Department of Surgery, Jikei University School of Medicine, Kashiwa, Chiba, describes issues related to assessing the nutrition, determin- Japan. ing nutrition requirements, and deciding the route of nutrient delivery for CCI patients. BACKGROUND: Although percutaneous endoscopic gastrostomy (PEG) has become popular for patients with swallowing disorders as a nutrition support or a decom- pressant of gastrointestine, perioperative complications associated with PEG have not decreased, especially peris- GENERAL NUTRITION tomal infections. To reduce peristomal infections, we designed a new method of gastrostomy by extracorporeal approach under endoscopic observation, named as extra- Nutritional therapies in Parkinson's disease corporeal PEG (E-PEG). METHODS: Experimental studies

Curr Treat Options Neurol 2007 May;9(3):198-204. for E-PEG were performed repeatedly using pigs under CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume 3, Issue 2 Evatt ML. general anesthesia to confirm the safety of this procedure Department of Neurology, Movement Disorders Section, Emory University for human use. After approval of institutional ethics School of Medicine, Atlanta, Georgia, USA. review board in our university, thirty patients with prior Advise patients with Parkinson's disease (PD) to consume consent participated in this study. The operation time, the a balanced diet, with special attention to adequate intake incidence rate of complications and the hospital stay were of dietary fiber, fluids, and macro- and micronutrients. compared between E-PEG and ordinary pull-method PEG Regularly reassess patients' nutritional history and anthro- groups. RESULTS: Two patients (6.7%) in E-PEG group pomorphic measures (height and weight), particularly in had postoperative complications, ie, aspiration pneumonia patients with advanced disease. PD-related psychosocial, and surgical site infection. The operation time of E-PEG as well as physical and cognitive, limitations increase group was 5–16 (mean ± SD: 10.3 ± 2.96) min as susceptibility to subacute and chronic malnutrition. compared to 14–37 (mean ± SD: 26.9 ± 8.39) min with

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pull-method PEG. The postoperative hospital day of Usefulness of the MNA in the long-term and acute- E-PEG was within 2 days except for the two complicated care settings within the United States cases. Significant differences in operation time, complica- J Nutr Health Aging 2006 Nov-Dec;10(6):502-506. tion rate and postoperative hospital stay between those Langkamp-Henken B. groups were observed statistically. CONCLUSIONS: These Food Science and Human Nutrition Department, University of Florida, results indicate that E-PEG was safe, tolerable and speedy Gainesville, Florida, USA. when compared ordinary pull-method PEG. The Mini Nutritional Assessment (MNA®) is a tool that was developed for use with elders to provide rapid assess- Update on enteral nutrition support for cystic ment of nutritional risk. Although this screening tool has fibrosis been validated and frequently used in long-term and acute- ® Nutr Clin Pract 2007 Apr;22(2):223-232. care settings in Europe, the MNA has not been used ® Erskine JM, Lingard C, Sontag M. extensively within the United States. The MNA may need Dietetics Program, University of Northern Colorado, School of Natural and to be validated for use within US nursing and acute-care Health Sciences, Greeley, Colorado, USA. facilities because validity may be affected by the acuity of Cystic fibrosis (CF) is an inherited disease affecting the illness, the use of aggressive nutrition support, which respiratory, gastrointestinal, hepatobiliary, and reproduc- makes the scoring of the MNA® difficult, and the age of tive systems. Nutrition status in persons with CF is often patients admitted for care (acute care). Additionally, in abstracts compromised due to increased energy needs, frequent most long-term care settings, a specific screening tool Clinical nutrition infections, pancreatic insufficiency, lung disease, or (Minimum Data Set) is already required to assess resident CF-related diabetes. Maintaining good nutrition status has function including nutritional risk. The MNA® may be been associated with better pulmonary function, reduced more useful in an assisted living facility, where nutrition hospitalizations, and increased longevity. Nutrition screening and assessment tools are not currently in support as oral supplementation (used in >37% of the place, yet maintenance of functional status is important to CF population) or tube feeding (used in >13% of the CF prevent transfer to a nursing facility. population) is often required for children and adults with CF. The purpose of this update is to describe current consensus and evidence for enteral nutrition support guidelines, reported complications of enteral feeding in the IMMUNONUTRITION CF population, evidence of expected outcomes, and to discuss related areas requiring further research. A case report is provided to illustrate potential outcomes Prospective randomized study on perioperative of aggressive enteral support. enteral immunonutrition in laparoscopic colorectal surgery A local nutritional screening tool compared to Surg Endosc 2007 Jul;21(7):1175-1179. malnutrition universal screening tool Finco C, Magnanini P, Sarzo G, Vecchiato M, Luongo B, Savastano S, Bortoliero M, Barison P, Merigliano S. Eur J Clin Nutr 2007 Jan 31; [Epub ahead of print]. Department of Medical and Surgical Sciences, 3rd General Surgery Clinic, Gerasimidis K, Drongitis P, Murray L, Young D, McKee RF. Coloproctological Unit, S. Antonio Hospital, University of Padova, Padova, Human Nutrition Section, Division of Developmental Medicine, University of Italy. Glasgow, Yorkhill Hospitals, Glasgow, United Kingdom. BACKGROUND: Perioperative nutrition for patients OBJECTIVE: The aim of the study was to compare the undergoing colon surgery seems to be effective in reducing Glasgow Nutritional Screening Tool with the Malnutrition catabolism and improving immunologic parameters. A Universal Screening Tool (MUST) recently recommended for relatively low-fiber and highly absorbable diet may facili- use by the British Association for Parenteral and Enteral tate the intestinal cleansing and loop relaxation Nutrition. DESIGN: Comparison-validation study. fundamental for laparoscopic surgery with a lower dose of SETTING: Four adult acute hospitals in Glasgow, UK. iso-osmotic laxative. METHODS: From 1 February 2004 SUBJECTS: All 242 inpatients from a variety of specialties. to 30 July 2005, 28 patients referred to our unit with colon METHODS: Two investigators independently interviewed disease (neoplasms and diverticular disease) amenable to 202 in-patients for the comparison-validation study. Each laparoscopic surgery were prospectively randomized into used a single tool with each patient, using each tool in turn. two groups of 14 patients each. For 6 days preoperatively, Investigators were not aware of each other's assessments. the patients in group 1 were given 750 mL/d of a diet Forty other patients were interviewed by both raters sepa- enriched with arginine, omega-3 fatty acids, and ribonu- rately using the local tool to evaluate inter-rater reliability. cleic acid (RNA) associated with low-fiber foods. They had RESULTS: When compared with MUST as a 'gold stan- 1 day of intestinal preparation with 3 L of iso-osmotic dard', the local tool had a sensitivity of 95.3% and a laxative. On postoperative day 2, they were fed orally with specificity of 64.9%, with moderate agreement between the the same diet. The patients in group 2 preoperatively two tools using kappa test (κ = 0.57). Agreement between received a low-fiber diet. They had 2 days of preparation the raters was substantial (κ = 0.69) with 85% of patients with iso-osmotic laxative (3 L/d). On postoperative day 3, classified the same by both raters. CONCLUSION: The oral nutrition was restored. Intraoperatively, we evaluated Glasgow Nutritional Screening Tool is a valid and reliable loop relaxation and intestinal cleanliness. Clinical trends

CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2 CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume tool that can be used on admission for nutritional screening. were monitored in both groups, as well as adverse reac-

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tions to early nutrition. The nutritional (albumin, prealbumin) and immunologic (lymphocyte subpopulations, INFLAMMATORY BOWEL DISEASE immunoglobulins) biohumoral parameters were evaluated at the first visit, on the day before surgery, on postoperative day 7, and 1 month after surgery. RESULTS: The two Nutritional modulation of the inflammatory groups did not differ in terms of age, gender, distribution response in inflammatory bowel disease – of disease, or baseline anthropometric, biohumoral, or From the molecular to the integrative to immunologic parameters. There was a significant increase the clinical in CD4 lymphocytes on the day before surgery as World J Gastroenterol 2007 Jan;13(1):1-7. compared with baseline parameters (p < 0.05) in group 1, Wild GE, Drozdowski L, Tartaglia C, Clandinin MT, Thomson AB. but not in group 2. There was no statistically significant Department of Medicine, Division of Gastroenterology, McGill University, difference between the two groups in intestinal Montreal, Quebec, Canada. loop relaxation or cleanliness or in postoperative Nutrient deficiencies are common in patients with

infectious complications. CONCLUSIONS: Perioperative inflammatory bowel disease (IBD). Both total Clinical nutrition

immunonutrition proved to be safe and useful in increas- parenteral and enteral nutrition provide important abstracts ing the perioperative immunologic cell response. It may supportive therapy for IBD patients, but in adults contribute toward improving the preparation and relax- these are not useful for primary therapy. Dietary inter- ation of the intestinal loops despite the shorter intestinal vention with omega-3 polyunsaturated fatty acids preparation. contained in fish oil may be useful for the care of IBD patients, and recent studies have stressed the role of PPAR on NFκB activity on the potential beneficial Application of perioperative immunonutrition for effect of dietary lipids on intestinal function. gastrointestinal surgery: A meta-analysis of randomized controlled trials Impact of long-term enteral nutrition Asia Pac J Clin Nutr 2007;16(suppl):253-257. Zheng Y, Li F, Qi B, Luo B, Sun H, Liu S, Wu X. on clinical and endoscopic recurrence Department of General Surgery, Xuanwu Hospital, Capital Medical University, after resection for Crohn's disease: A Beijing, China. prospective, non-randomized, parallel, The aim of this study was to evaluate clinical and controlled study economic validity of perioperative immunonutrition and Aliment Pharmacol Ther 2007 Jan;25(1):67-72. effect on postoperative immunity in patients with gastro- Yamamoto T, Nakahigashi M, Umegae S, Kitagawa T, Matsumoto K. intestinal cancers. Immunonutrition diet supplemented Inflammatory Bowel Disease Centre & Department of Surgery, Yokkaichi Social Insurance Hospital, Yokkaichi, Mie, Japan. two or more of nutrients including glutamine, arginine, ω-3 polyunsaturated fatty acids and ribonucleic acids. BACKGROUND: The impact of enteral nutrition on A meta-analysis of all relevant clinical randomized postoperative recurrence has not been properly exam- controlled trials (RCTs) was performed. The trials ined. AIM: To investigate the impact of enteral compared perioperative immunonutrition diet with stan- nutrition using an elemental diet on clinical and endo- dard diet. We extracted RCTs from electronic databases: scopic recurrence after resection for Crohn's disease. Cochrane Library, MEDLINE, EMBASE, SCI and assessed METHODS: Forty consecutive patients who under- methodological quality of them according to the handbook went resection for ileal or ileocolonic Crohn's disease for Cochrane reviewer in June 2006. Statistical analysis were studied. After operation, 20 patients continu- was performed by RevMan4.2 software. Thirteen RCTs ously received enteral nutritional therapy (EN group), involving 1,269 patients were included. The combined and 20 had neither nutritional therapy nor food results showed that immunonutrition had no significant restriction (non-EN group). In the EN group, enteral effect on postoperative mortality (OR = 0.91, p = 0.84). formula (Elental) was infused through a nasogastric But it had positive effect on postoperative infection rate tube in the night-time, and low-fat foods were taken in (OR = 0.41, p < 0.00001), length of hospital stay (WMD the daytime. All patients were followed up regularly = -3.48, p < 0.00001). Furthermore, it improved immune for 1 year after operation. Ileocolonoscopy was function by increasing total lymphocytes (WMD = 0.40, performed at 6 and 12 months after operation. p < 0.00001), CD4 levels (WMD = 11.39, p < 0.00001), RESULTS: One patient (5%) in the EN group and CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume 3, Issue 2 IgG levels (WMD = 1.07, p = 0.0005) and decreasing seven (35%) in the non-EN group developed clinical IL6 levels (WMD = -201.83, p < 0.00001). At the same recurrence during 1-year follow-up (p = 0.048). Six time, we did not find significant difference in CD8, IL2 months after operation, five patients (25%) in the EN and CRP levels. There were no serious side effects and two group and eight (40%) in the non-EN group developed trials found low hospital cost. In conclusion, perioperative endoscopic recurrence (p = 0.50). Twelve months after diet adding immunonutrition is effective and safe to operation, endoscopic recurrence was observed in six decrease postoperative infection and reduce length of patients (30%) in the EN group and 14 (70%) in the hospital stay through improving immunity of postopera- non-EN group (p = 0.027). CONCLUSIONS: Our tive patients as compared with the control group. Further long-term enteral nutritional therapy significantly prospective study is required in children or critical patients reduced clinical and endoscopic recurrence after resec- with gastrointestinal surgery. tion for Crohn's disease.

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tube removal. The other factors associated with the delivery PANCREATITIS of less than required energy were PIM 2 ≥15%, gastrointestinal complications, dialysis, and use of α-adrenergic vasoactive drugs. The latter was the only variable in multi- Artificial nutrition and acute pancreatitis: A review variate analysis that was associated with not ultimately and update [article in Spanish] achieving energy goal. CONCLUSIONS: The prescription Nutr Hosp 2007 Jan-Feb;22(1):25-37. and delivery of energy were not adequate in >50% of enteral Gento Peña E, Martín de la Torre E, Miján de la Torre A. nutrition days. The gap between the effective administration Servicio de Aparato Digestivo Complejo Asistencial de Burgos, Facultad de and energy requirements can be explained by both under- Medicina, Universidad de Valladolid, Spain. prescription and underdelivery. Administration of Most of acute pancreatitis cases present as mild cases for vasoactive drugs was the only variable independently asso- which nutritional support is not recommended provided the ciated with a low energy supply. patient is able to restart normal oral intake within 5–7 days. By contrast, severe pancreatitis associates metabolic stress Risk factors for gastrointestinal complications in and requires early nutritional support. In these cases, enteral critically ill children with transpyloric enteral nutrition is recommended, which should be supplemented nutrition with parenteral nutrition if needed. Recent studies indicate abstracts that enteral nutrition may improve the course of severe Eur J Clin Nutr 2007 Feb 28; [Epub ahead of print]. Clinical nutrition acute pancreatitis, reduce its complications and promote a López-Herce J, Santiago MJ, Sánchez C, Mencía S, Carrillo A, Vigil D. Pediatric Intensive Care Unit, Preventive and Quality Control Service (DV), quicker improvement from the disease. Most of the patients Gregorio Marañón General University Hospital, Madrid, Spain. tolerate oligomeric nutrition administered as continuous infusion distally to the Treitz's angle. Recent studies show, OBJECTIVE: To study the risk factors for gastrointestinal however, that intragastric perfusion is safe and may be an complications related to enteral nutrition in critically ill chil- adequate therapeutic option in particular patients with acute dren. DESIGN: A prospective, observational study. severe pancreatitis. Besides, specific agents added to the SETTING: Pediatric intensive care unit. SUBJECTS: Five nutrition (immunomodulators and probiotics) seem to hundred and twenty-six critically ill children who received reduce hospital stay and infectious and non-infectious transpyloric enteral nutrition (TEN). METHODS: complications of acute pancreatitis. Univariate and multivariate logistic regression analysis were used to identify risk factors for gastrointestinal complications. RESULTS: Sixty-six patients (11.5%) presented gastrointestinal complications, 33 (6.2%) abdominal disten- PEDIATRICS sion and/or excessive gastric residue, 34 (6.4%) diarrhea, one gastrointestinal bleeding, three necrotizing enterocolitis and one duodenal perforation. Enteral nutrition was defini- Enteral nutrition in critically ill children: Are tively suspended because of gastrointestinal complications in prescription and delivery according to their energy 11 (2.1%) patients. Fifty patients (9.5%) died. Gastrointestinal complications were more frequent in the requirements? patients who died. Death was related to complications of the Nutr Clin Pract 2007 Apr;22(2):233-239. nutrition in only one patient. The frequency of gastro- de Oliveira Iglesias SB, Leite HP, Santana e Meneses JF, de Carvalho WB. intestinal complications was significantly higher in children Pediatric Intensive Care Unit, Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil. with shock, acute renal failure, hypokalemia, hypophosphatemia and in those receiving dopamine, epinephrine and BACKGROUND: The purpose of this study was to compare vecuronium. The stepwise multivariate logistic regression the differences between prescribed and delivered energy analysis showed that the most important factors associated among critically ill children and to identify the factors that with gastrointestinal complications were shock, epinephrine impede the optimal delivery of enteral nutrition in the first at a rate higher than 0.3 µg/kg/min and hypophosphatemia. 5 days of nutrition support. METHODS: In a prospective CONCLUSIONS: The tolerance of TEN in critically ill chil- cohort study, we evaluated 55 critically ill children aged 8.2 dren is good, although the incidence of gastrointestinal ≥ ± 11.4 months (0–162.3 months), who were fed for 2 days complications is higher in patients with shock, acute renal through a gastric or postpyloric tube. The patients were failure, hypokalemia, hypophosphatemia, and those receiv- followed from admission until day 10 of enteral nutrition. ing epinephrine, dopamine, and vecuronium. Prescribed and delivered energy were recorded daily and compared with each other and with the estimated basal metabolic rate (BMR). The Paediatric Index of Mortality 2 Effect of exclusive enteral nutritional treatment on (PIM 2) was used to estimate illness severity. RESULTS: The plasma antioxidant concentrations in childhood ratio of delivered:required energy was <90% in 55.7% of Crohn's disease the enteral nutrition days. Low prescription was the main Clin Nutr 2007 Feb;26(1):51-56. reason for not achieving the energy goal in the first 5 days Akobeng AK, Richmond K, Miller V, Thomas AG. of enteral nutrition. Discrepancies between prescribed and Department of Paediatric Gastroenterology, Booth Hall Children's Hospital, delivered: energy were attributable to interruptions in feed- Manchester, United Kingdom. ing caused by clinical instability, airway management, BACKGROUND & AIMS: Oxidative stress and depletion

CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2 CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume radiologic and surgical procedures, and accidental feeding of antioxidants may play a role in the pathogenesis of

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Crohn's disease (CD). The aim of this study was to deter- first year. Mean Z-score improved from - 2.6 ± 1 at trans- mine the effect of exclusive enteral nutrition, which is plant to - 1.0 ± 0.6 (p < 0.05) after 1 year. Three patients increasingly being used as primary therapy for CD, on (27.2%) had at least one rejection period, which was plasma antioxidant concentrations in children with active treated with steroids alone or in combination. Mean weight CD. METHODS: In a double-blind randomized controlled Z-score 1 year after surgery was - 0.9 ± 0.6 for patients trial, 15 children with active CD (mean age, 11.3 years, without rejection and - 1.24 ± 0.8 for those with at least range 6.8–15.7) attending a pediatric gastroenterology one rejection episode treated with steroids (p > 0.1). Four referral center, were assigned to receive either a standard patients (36%) had at least one catheter-related sepsis polymeric diet (Group S, n=8) or a glutamine-enriched episode. Mean weight Z-score 1 year after surgery was polymeric diet (Group G, n=7) as primary therapy for - 1.01 ± 0.6 for patients without catheter-related sepsis and active CD. Plasma concentrations of selenium, urates, vita- - 1.24 ± 0.8 for those with at least one catheter-related min A, vitamin E, vitamin C, glutathione, and also sepsis episode (p > 0.1). CONCLUSIONS: There was a malondialdehyde (MDA) were measured at baseline and significant improvement in weight Z-score and biochemical

after 4 weeks of exclusive enteral nutritional treatment. nutritional parameters 1 year after receiving a small bowel Clinical nutrition

RESULTS: Mean (95% CI) selenium concentration of the graft. No influence of steroids or catheter-related sepsis on abstracts cohort increased significantly from 0.82 µmol/L (0.72, children's nutritional status was noted 1 year after surgery, 0.91) to 1.14 µmol/L (0.98, 1.3), p < 0.001. There were, although this point will need further evaluation. however, significant reductions in mean concentrations of vitamin C (11.8 mg/L [7.7, 15.8] to 6.5 mg/L [4.5, 8.7], p = 0.01) and vitamin E (11.3 mg/L [10.3, 12.4] to 9.4 mg/L [8.7, 10.1], p = 0.03). The concentrations of vitamin TRAUMA AND BURNS A, urates, glutathione and MDA did not change significantly over the study period. Glutamine supplementation did not have any significant effect on plasma antioxidant Synbiotics, prebiotics, glutamine, or peptide in concentrations. CONCLUSIONS: Significant changes in early enteral nutrition: A randomized study in circulating antioxidant concentrations occurred in children trauma patients with active CD receiving exclusive enteral nutritional treat- JPEN J Parenter Enteral Nutr 2007 Mar-Apr;31(2):119-126. ment. Glutamine supplementation was not beneficial in Spindler-Vesel A, Bengmark S, Vovk I, Cerovic O, Kompan L. improving plasma antioxidant status. University Medical Centre, Ljubljana, Slovenia.

BACKGROUND: Since the hepatosplanchnic region plays Nutritional status after intestinal transplantation a central role in development of multiple-organ failure and in children infections in critically ill trauma patients, this study Eur J Pediatr Surg 2006 Dec;16(6):403-406. focuses on the influence of glutamine, peptide, and syn- Encinas JL, Luis A, Avila LF, Hernandez F, Sarria J, Gamez M, Murcia J, Leal L, biotics on intestinal permeability and clinical outcome. Lopez-Santamaria M, Tovar JA. METHODS: One hundred thirteen multiple injured Department of Pediatric Surgery Service, Hospital Universitario La Paz, patients were prospectively randomized into four groups: Madrid, Spain. group A, glutamine; B, fermentable fiber; C, peptide diet; INTRODUCTION: The management of children receiving and D, standard enteral formula with fibers combined with small bowel grafts involves potentially life-threatening Synbiotic 2000 (Synbiotic 2000 Forte; Medifarm, Sweden), complications that affect their nutritional status. The aim a formula containing live lactobacilli and specific bioactive of this paper was to define these factors and their influence fibers. Intestinal permeability was evaluated by measuring on nutritional outcome. PATIENTS AND METHODS: lactulose-mannitol excretion ratio on days 2, 4, and 7. Patients with intestinal failure (IF) who received an RESULTS: No differences in days of mechanical ventila- isolated small bowel transplantation (SBT) or small tion, intensive care unit stay, or multiple-organ failure bowel/liver transplantation (SBLT) at our hospital during scores were found between the patient groups. A total of the last 6 years were reviewed for weight Z-score, 51 infections, including 38 pneumonia, were observed, biochemical nutritional parameters, total parenteral nutri- with only 5 infections and 4 pneumonias in group D, tion (TPN) weaning, catheter-related sepsis, rejection and which was significantly less than combined infections (p = steroid treatment. RESULTS: Twenty patients, 11 females 0.003) and pneumonias (p = 0.03) in groups A, B, and C. and 9 males, received an SBT or an SBLT and survived the Intestinal permeability decreased only in group D, from CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume 3, Issue 2 postoperative period; in the present study we only included 0.148 (0.056–0.240) on day 4 to 0.061 (0.040–0.099) on 11 children with follow-up periods longer than 1 year. day 7; (p < 0.05). In group A, the lactulose-mannitol excre- Seven males and 4 females with a mean age of 4.5 years tion ratio increased significantly (p < 0.02) from 0.050 (range, 1 to 20 years) received 6 SBLT and 5 SBT. Nine (0.013–0.116) on day 2 to 0.159 (0.088-0.311) on day 7. (82%) were weaned from TPN to an amino-acid or The total gastric retention volume in 7 days was 1,150 peptide enteral formula during the first 6 months after (785–2,395) mL in group D, which was significantly more surgery. During the first year there was a significant than the 410 (382–1,062) mL in group A (p < 0.02), and increase in total protein from 5.11 ± 1.8 mg/dL to 6.1 ± 620 (337–1,190) mL in group C (p < 0.03). CONCLU- 1.5 mg/dL (p < 0.05) and an increase in albumin from 3.8 SIONS: Patients supplemented with synbiotics did better ± 0.9 mg/dL to 4.5 ± 1.1 mg/dL (p < 0.05). There was an than the others, with lower intestinal permeability and increase in weight Z-score in 9 patients (82%) during the fewer infections.

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Highlights of Clinical Nutrition Week 28–31 January 2007 • Phoenix, Arizona, USA

Keynote Address – sepsis and implementing the bundles can reduce mortality Translating research to the rates from 43% to 26% (Gao F, et al. Crit Care 2005;9: bedside: Doing the right thing R764-R770). and making a difference Dr Levy challenged ASPEN to rise above academic MM Levy debate and develop consensus recommendations for nutri- Providence, RI, USA tion interventions, identify interventions that are not being Despite the extraordinary hard work and best intentions of performed, and develop methods for changing bedside nutri- caregivers, the quality of health care delivered is unreliable tion practice. and has the potential to harm thousands of patients every day (McGlynn EA, et al. N Engl J Med 2003;348:2635- Surviving sepsis: Effective clinical 2645). A large gap exists between clinicians’ perceptions of weapons their use of evidence-based medicine and actual practice. R Fields, P Posa, J Wooley Data from clinical trials are not consistently applied to prac- Ann Arbor, MI, USA

Nutrition Week tice and evidence-based protocols are underused, resulting in The Surviving Sepsis Campaign promotes a four-tier

Highlights of Clinical adverse outcomes (Soumerai SB, et al. JAMA 1997;277:115- approach to achieve a 25% reduction in mortality from 121. ARDS Network. N Engl J Med 2000;342:1301-1308. sepsis within 5 years: Pronovost PJ, et al. J Crit Care 2004;19:158-164). 1) Gain commitment throughout the organization from Studies show that guideline-based processes can administration to clinicians that severe sepsis must be assess care and improve outcomes. Care bundles are power- managed early and aggressively; ful tools used to standardize care. A care bundle is a group 2) Implement early screening tools and identify triggers for of interventions related to a disease process that when treatment; executed together result in better outcomes than when 3) Implement evidence-based sepsis care bundles; and implemented individually. Providing each element of care 4) Measure process and outcomes changes. within a bundle leads to more reliable care for patients Built-in screening tools and triggers throughout the (www.ihi.org/IHI/topics/reliability). Hospitals that have care continuum facilitate early and rapid identification of implemented central line care bundles have nearly elimi- patients by recognizing that “time is tissue” (Levy MM, et nated catheter-related bloodstream infections, providing al. Crit Care Med 2005;33:2194-2201). compelling evidence that such protocols are effective Two sepsis care bundles, based on evidence-based (Pronovost P, et al. N Engl J Med 2006;355:2725-2732. guidelines, provide specific recommendations that hospitals Berenholtz SM, et al. Crit Care Med 2004;32:2014-2020). can take to initiate rapid changes in the way sepsis is The 100,000 Lives Campaign, a well-publicized managed. The Sepsis Resuscitation Bundle recommends Institute for Healthcare Improvement (IHI) initiative involv- early antibiotic therapy and aggressive therapy to maintain ing more than 3,100 hospitals across the United States, adequate blood pressure. The Sepsis Management Bundle resulted in 122,000 lives saved and demonstrated that includes administering low-dose steroids for septic shock, hospitals could significantly improve care by implementing administering recombinant human activated protein C six changes proven to save lives. The campaign has been (rhAPC), and maintaining tight glucose control and low expanded with the goal of saving 5 million lives over the tidal volume ventilation. Protocols, guidelines and standard- next 2 years. ized sets of standing physician orders drive care. The Surviving Sepsis Campaign is a worldwide Enteral nutrition helps maintain tight glucose control campaign to reduce mortality rates in patients with sepsis by during sepsis and should start as soon as the patient is 25% in 5 years. The campaign utilizes sepsis management hemodynamically stable. Pressor support does not preclude bundles developed on evidence-based guidelines and involves enteral feedings in hemodynamically stable patients. Indirect a multifaceted approach to bring the guidelines to the calorimetry is the gold standard to determine calorie bedside. Powerful data are emerging showing that identifying requirements. Goals are ≤100% of measured resting energy CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2 CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume

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expenditure (MREE) during the shock and catabolic phases options for anorectic patients who are still able to eat (Wood of sepsis and 100–130% MREE during the anabolic phase P, Vogen BD. Geriatr Nurs 1998;19:192-194). of critical illness (McClave SA, et al. JPEN J Parenter A better understanding by healthcare professionals of Enteral Nutr 2003;27:16-20). the role food and eating play in quality of life will improve care for patients on long-term PEN. More research that President’s Address – addresses food and nutrition issues is needed to assess and Food for thought: It’s more improve quality of life (Baxter JP, et al. Br J Nutr 2005;94: than nutrition 633-638). MF Winkler Providence, RI, USA Use of immune-modulating Food and the rituals that surround eating serve many impor- formulas to treat critically tant social purposes that extend far beyond merely meeting ill children nutritional needs. They enhance quality of life by giving P Goday people physical comfort, a sense of security and the feeling Milwaukee, WI, USA that they belong (Walker A. Food, Culture, and Society Recent studies in Greece and Chile compared immuno- 2005;8:161-180). enhancing formulas (IEF) with conventional early enteral Conversely, a diminished ability to enjoy food, stress- nutrition in critically ill children. One study in a pediatric

ful eating problems, unpleasant experiences and decreased intensive care unit (ICU) in Greece randomized 50 children Highlights of Clinical autonomy can negatively impact quality of life. to receive IEF or a control formula (Briassoulis G, et al. Nutrition Week Dietary restrictions and changes in dietary behavior, Nutrition 2005;21:799-807). The study found IEF were not especially those caused by disease and its treatment, are as well tolerated as conventional early enteral nutrition, but highly stressful to both patients and their families (McGrath their use was feasible in children. Mortality and length of P. Cancer Pract 2002;10:94-101). During the course of stay did not differ between the two groups, though the IEF disease, food develops different meanings. Psychosocial group showed trends toward increased nutritional indices meaning may be associated with positive feelings of well- and antioxidant catalysts and fewer nosocomial infections. being or negative feelings of sorrow. Physiological meaning Appropriate modifications for specific age populations might may be associated with positive feelings of comfort or nega- improve formula tolerability and benefits among children. tive feelings of burden. Fatigue and lack of appetite give rise The same group compared nutritional and metabolic to feelings of deprivation because of missing both eating and measures along with various other outcomes (survival, the related social environment, and may lead to a loss of length of stay, and ventilator days) in 40 mechanically venti- personal identity. Family members are also affected by the lated children with severe head injury receiving an IEF vs a loss of social interaction at meals and changes in their loved regular formula (Briassoulis G, et al. Pediatr Crit Care Med ones (Jacobsson A, et al. J Adv Nurs 2004;46:514-522). 2006;7:56-62). Interleukin-8 levels were lower in the IEF Similarly, patients who are dependent on long-term group than in the regular formula group (p < 0.04), and parenteral and enteral nutrition (PEN) experience decreased the IEF group had fewer positive gastric cultures quality of life. They express conflicting emotions about (p < 0.02). However, there was no difference in nosocomial nutrition support; viewing it, on one hand, as their lifeline infections, length of stay, length of mechanical ventilation, and, on the other hand, they experience psychosocial or survival, and, thus, no additional advantage of IEF over distress with decreased physical, psychological and social regular early enteral nutrition. function. They report infusion-related complications, Supplemental enteral arginine had no effect on meta- lifestyle adaptations, feelings of low self-worth and isola- bolic response in children admitted to a pediatric burn center tion, drug dependency, and sleep disturbance. Many also in Chile (Marin VB, et al. Nutrition 2006;22:705-712). There experience hunger, and anger over food restrictions. were no differences in levels of interleukin-1 or -6, tumor- CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume 3, Issue 2 (Brotherton A, et al. J Hum Nutr Diet 2006;19:355-367. necrosis factor (TNF)-α, C-reactive protein, prealbumin, Winkler MF, et al. JPEN J Parenter Enteral Nutr 2005;29: albumin or glucose; however, nitrogen-stimulated lymphocyte 162-170). proliferation did improve. Researchers concluded that the Strategies to reduce stress for patients on PEN and benefits of arginine supplementation for the immune system their families include offering choices whenever possible, do not appear to be related to a metabolic response. tailoring the feeding system to the patient, and mimicking Based on work with immune-enhancing diets in adults the usual home mealtime. Comfort foods, which trigger past and the few available pediatric studies, glutamine and associations and evoke feelings of caring and healing, and antioxidants show the most promise for immune-modulat- ‘happy hour’ beverages, presented in a social milieu, are ing formulas for children.

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Pancreatitis in critically ill children Excess calories are another significant cause of MA Corkins hyperglycemia and, during stress, can further increase Indianapolis, IN, USA the metabolic demands of acute injury and increase Pancreatitis in children has multiple etiologies, including mortality (Alaedeen DI, et al. J Pediatr Surg 2006; trauma, structural anomalies, drug use, viral illnesses, 41:239-244). Therefore, calorie intake should not hereditary disorders, complications of multisystem exceed demand during acute metabolic response in criti- disorders, and idiopathic triggers (Benifla M, Weizman cally ill pediatric patients. Z. J Clin Gastroenterol 2003;37:169-172). The mortal- During the catabolic response to injury, a child’s ity rate of severe pancreatitis is 2–10% in children. A caloric requirements drop markedly as somatic growth pediatric-specific scoring system has been developed stops. The younger the child is, the more significant to predict severity of pancreatitis in children and guide is this effect due to the relatively greater rate of clinical therapy (DeBanto JR, et al. Am J Gastroenterol growth. Critically ill children frequently require 2002;97:1726-1731). mechanical ventilation, and are sedated and main- In mild pancreatitis, oral feedings can be started tained in temperature-controlled environments. with caution when symptoms begin to improve and Together, these factors substantially reduce energy amylase and lipase levels begin to decrease. Enzyme needs. In one study of critically ill children, actual levels do not have to be normal to begin feedings. measured energy expenditure averaged 50% of In the pediatric patient who has more severe predicted requirement (Chwals WJ, et al. J Surg Res pancreatitis but not an ileus, controversy exists on 1988;44:467-472). whether to begin enteral feedings within 24 hours or to Using indirect calorimetry to measure energy wait 3–4 days. Patients with severe acute pancreatitis expenditure and providing only basal caloric support

Nutrition Week and the presence of an ileus require parenteral nutrition can avoid overfeeding children during acute metabolic

Highlights of Clinical support until they begin to improve. stress. In the absence of indirect calorimetry, published As ileus resolves, patients should receive jejunal feed- basal energy requirements based on age, weight and ings to minimize pancreatic stimulation, though it gender offer reasonable guidelines for basal energy is difficult to obtain nasojejunal tube placement in requirements. Equations that incorporate metabolic children. A meta-analysis of six studies of adult patients stress variables (such as body temperature) provide a with pancreatitis who received enteral feedings showed more accurate alternative to current predictive methods better results compared with patients who received in assessing energy requirements of ventilated, critically parenteral nutritional (lower incidence of infection, reduced ill children (White MS, et al. Crit Care Med 2000;28: need for surgical intervention and fewer hospital days) 2307-2312). (Marik PE, Zaloga GP. BMJ 2004;328:1407-1410); however, pediatric data remain sparse. Bowel sounds: Are they worth One randomized trial showed better outcomes waiting for? with semi-elemental feedings in severe pancreatitis than RG Martindale with polymeric feedings (Tiengou LE, et al. JPEN J Portland, OR, USA Parenter Enteral Nutr 2006;30:1-5). There are no stud- Bowel sounds traditionally have been used as evidence ies on IEF in children with acute pancreatitis. that the bowel is functional and it is ‘safe’ to start enteral feeding. Interestingly, this long-held belief is not Acute injury response and supported by evidence. In critically ill or postoperative nutritional support in critically patients, no firm evidence is available to support with- ill infants holding enteral feedings until bowel sounds are heard. WJ Chwals Bowel function and bowel sounds usually return Cleveland, OH, USA quickly after abdominal surgery (Shibata Y, et al. Hyperglycemia in the pediatric patient with sepsis is World J Surg 1997;21:806-809). associated with increased morbidity and mortality, and Ileus, or postoperative bowel dysfunction, results longer length of hospital stay (Hall NJ, et al. J Pediatr from a sequence of events that activate proinflamma- Surg 2004;39:898-901). The acute metabolic stress tory cytokines and mediators in the muscularis of the response to injury contributes to hyperglycemia by bowel, which alter normal peristalsis and motility inducing a cascade of metabolic events, which increase (Kalff JC, et al. Ann Surg 2003;237:301-315). blood sugar levels, enhance gluconeogenesis, suppress The occurrence and duration of ileus vary widely insulin production, and promote insulin resistance. in the ICU setting due to heterogeneity in the popula- CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2 CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume

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tion, ie, variation in stressors, medications and co- This led investigators to focus on changes in gut, morbidities. Patients with pancreatitis, ongoing peritoneal and systemic immunity. While glutamine and peritonitis, and increased intracranial pressure develop various peptides and hormones were shown to prevent ileus more frequently, and dysmotility commonly TPN-induced gut atrophy, they did not affect bacterial persists longer in these disease states. translocation. This indicated that intestinal barrier Ileus is optimally managed by correcting elec- dysfunction and bacterial translocation during intra- trolyte abnormalities, maintaining meticulous glycemic venous feeding are related to factors other than gut control, and minimizing the use of agents known to atrophy (Helton WS, Garcia R. Arch Surg 1993;128: decrease gut motility. 178-183). Many studies support the benefits of early enteral Later observations showed TPN impairs a variety feedings (<48 hours). Artinian and colleagues recently of macrophage functions and increases TNF release, reported a decrease in mortality when patients are fed endotoxin transport across the gut wall, and death in within 48 hours (Chest 2006;129:960-967). It is impor- rodents injected with endotoxin. TPN is associated with tant to evaluate the entire clinical situation, but, in increased activation of the sympathetic nervous system general, feedings should be held only in patients with and increased incidence of fatty liver (Helton WS, et al. high-pitched tingling bowel sounds and nausea, as this Arch Surg 1995;130:209-214. Johnson KM, et al. Arch may indicate ileus and an obstructive pattern. Surg 1995;130:1294-1299).

Otherwise, bowel sounds are not useful as the only Studies have identified changes in gut luminal Highlights of Clinical indicator of bowel dysfunction. In the majority of bacterial ecology and changes in the pathogenecity of Nutrition Week patients, feedings should be started after adequate Enterobacteriaceae during periods of stress and resuscitation and not be delayed due to the absence of parenteral feeding (Lyte M, et al. Biochem Biophys Res bowel sounds or flatus. Prokinetics are not recom- Commun 1997;232:682-686). These offer greater insight mended or required to initiate early enteral feedings. into the pathophysiology associated with increased inci- Evaluate patient tolerance to feedings by monitoring dence of infection in patients dependent on parenteral nasogastric tube output, distention, pain, glycemic nutrition. control, diarrhea and pneumatosis (Kozar RA, et al. J Surg Res 2002;104:70-75). Advance feedings based on Mechanisms by which intestinal the patient’s clinical condition, not on evidence from bacteria sense host stress and bowel sounds. nutritional status and respond accordingly Observations over 20 years on JC Alverdy the effects of TPN on the Chicago, IL, USA gastrointestinal mucosal barrier: New studies show intestinal bacteria have the ability to Have we been barking up the detect when a host is under extreme physiologic stress wrong tree? and respond to changes in their microenvironment by WS Helton enhancing their virulence genes (Wu L, et al. Science New Haven, CT, USA 2005;309:774-777). These changes in bacterial gene Parenteral nutrition is associated with increased expression may be responsible for the high incidence of susceptibility to infection, caused by changes in fatality from Pseudomonas aeruginosa, a hospital- gastrointestinal (GI) mucosal defense and bacterial acquired pathogen. translocation. Early work in understanding the mecha- Patients with systemic inflammatory response nism of action focused on changes in the anatomy and syndrome (SIRS) have changes in the normal gut physiology of the GI system, including villus morphol- microflora and much higher levels of pathogenic CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume 3, Issue 2 ogy, pancreatic exocrine function, gut hormones and Staphylococcus and Pseudomonas spp than healthy gut permeability. Studies showed total parenteral volunteers (Shimizu K, et al. J Trauma 2006;60:126- nutrition (TPN) was associated with increases in endo- 133). During stress, inflammation, or nutrient depletion, toxin transport across the small bowel (Gonnella PA, the P aeruginosa outer membrane protein, OprF, binds et al. Eur J Cell Biol 1992;59:224-247), increased gut specifically to cytokine interferon-gamma (IFN-γ) and counter-regulatory hormones and cytokine response upregulates production of lethal virulence factor PA-1 (Fong YM, et al. Ann Surg 1989;210:449-456), and (Wagner VE, et al. Trends Microbiol 2006;14:55-58). gut atrophy. However, none of the changes seen Once activated, PA-1 acts as a pathogen in the gut, erod- explained why bacterial translocation occurs. ing the protective barrier of the intestinal tract. Potent

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endotoxins of the pathogen can then cross the gut wall nutrition induces recovery of immunologic function to the bloodstream where they are transported to the (Ikeda S, et al. Ann Surg 2003;237:677-685. Genton L, et lung and adhere to lung tissue, resulting in lethal al. JPEN J Parenter Enteral Nutr 2005;29:44-47). systemic sepsis. Thus, the endotoxin alone is not responsible for death in critically ill and immunocompromised Initiation and management of patients; rather mortality is related to the degree of nutrition support in the patient stress which triggers upregulation of the endotoxin’s with cancer virulence genes (Laughlin RS, et al. Ann Surg 2000;232: C Anastasio 133-142). Valley Stream, NY, USA New research is focused on developing mechanisms Perioperative nutrition support that is adequate in quality, that interfere with the host-to-bacterial signaling path- quantity and duration has a positive effect on patients way, thereby rendering the bacteria insensitive to host with GI cancer who are moderately to severely malnour- stress. By using substances that act as an intestinal mucin ished. These findings are consistent with ASPEN’s and prevent bacteria from adhering to the intestinal guidelines for nutrition support in adults with cancer. epithelium, it may be possible to protect against Intensive nutrition counseling by a dietitian using a Pseudomonas. Such a mechanism would contain rather standard protocol and oral supplements, if required, than eliminate potential pathogens, and may decrease resulted in statistically less weight loss and improved antibiotic usage and the incidence of virulent nosocomial quality of life in patients with head and neck and GI infections. cancer compared with the usual practice of giving general advice and a nutrition booklet (Isenring EA, et al. Br J Nutrition and mucosal immunity Cancer 2004;91:447-452).

Nutrition Week KA Kudsk In the most comprehensive study to date, periopera-

Highlights of Clinical Madison, WI, USA tive nutrition support that provided 25 non-protein In trauma patients, enteral feeding significantly reduces calories/day reduced surgical complications and mortality the complications of pneumonia compared with intra- in moderately or severely malnourished GI cancer patients venous feedings. Both route of administration and type of (Wu GH, et al. World J Gastroenterol 2006;21:2441- nutrition influence antibacterial respiratory tract immu- 2444). This study was the first to look at patients who nity (King BK, et al. Ann Surg 1999;229:272-278). achieved and maintained full feedings. Dr Kudsk suggests that there is an immunologic A nutrition pathway that includes early and regular link between the GI and respiratory tracts – the common nutrition assessment, enteral nutrition intervention and mucosal immune hypothesis (Kudsk KA. Am J Surg multidisciplinary nutrition care results in improved treat- 2003;185:16-21). Secretory immunoglobulin A (IgA) is ment tolerance for patients with esophageal cancer the principal specific immunologic defense at mucosal receiving chemoradiation (Odelli C, et al. Clin Oncol [R surfaces. It produces antibodies that bind to bacteria in Coll Radiol] 2005;17:639-645). the intestine and other sites, such as the respiratory tract, Nutritional supplements containing eicosapentaenoic preventing bacteria from attaching and, hence, causing acid (EPA) have been shown to be beneficial in malnour- infection. The principal anatomic site for immunologic ished patients. EPA interferes with mechanisms implicated sensitization is within the small intestine. in the pathogenesis of cancer cachexia, and has been asso- The route and type of nutrition affects the size and ciated with reversal of cachexia and improved survival function of most of the molecules involved in the produc- (Argiles JM. Eur J Oncol Nurs 2005;9[suppl 2]: S39-S50). tion of IgA. These include T and B cells, which are sensitized to produce IgA, and gut-associated lymphoid The challenge of nutritional tissue (GALT), which is the site of T and B cell activation intervention for the dialysis patient (Janu P, et al. Ann Surg 1997;225:707-715). Nutrition E Moore also affects adhesion molecules that direct unsensitized Parma, OH, USA T and B cells to the activation site, as well as most of the Malnutrition affects up to half of all chronic dialysis molecules in the GALT, especially the cytokines IL-4 and patients and is an important predictor of mortality, but IL-10. Each is critical to intact mucosal immunity. the efficacy of nutrition support interventions in dialysis Parenteral nutrition reduces the mass and function patients has been poorly studied (Mehrotra R, Kopple of most molecules in the GALT. These changes reduce the JD. Annu Rev Nutr 2001;21:343-379). production of IgA, which, in turn, negatively impacts both Oral supplements and enteral nutrition have been the gut and respiratory tract. On the other hand, enteral shown to be safe and efficacious in patients with chronic CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2 CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume

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kidney disease receiving maintenance dialysis. In a small Nutr 2005;29:S10-S11. Dickerson RN, et al. Nutrition retrospective analysis of chronic hemodialysis (HD) 2002;18:241-246). patients, enteral tube feeding resulted in improved Rubinson et al found feeding less than 25% of recom- biochemical data and/or weight gain (Holley JL, Kirk J. mended energy intake increases risk for nosocomial J Ren Nutr 2002;12:177-182). Hypophosphatemia was bloodstream infection (Rubinson L, et al. Crit Care Med common and suggests that a non-renal enteral formula 2004;32:350-357). Thus, there appears to be a minimum may be useful to prevent hypophosphatemia in some level of feeding to minimize risk. patients. Current guidelines for underfeeding call for feeding A recent meta-analysis of 18 studies suggests that early, within 24 hours of admission; providing 33–66% of enteral support significantly increases serum albumin calculated needs for 3–5 days; and increasing feeding to concentrations and improves total dietary intake with 100% of calculated needs over the next 3–5 days. little effect on serum phosphate and potassium (Stratton RJ, et al. Am J Kidney Dis 2005;46:387-405). Few stud- Scientific Paper Session – ies reported clinical outcome, and there was insufficient Abstract of Distinction information to compare disease-specific versus standard formulas, or enteral versus parenteral nutrition. Early enteral feeding of the open Results of studies on enteral nutrition in peritoneal abdomen – nutritional provision,

dialysis (PD) patients are less conclusive. One case study fistulae preventer, and abdomen Highlights of Clinical showed long-term tube feeding of a high-calorie, high- closer? Nutrition Week protein, low electrolyte formula was well tolerated and BR Collier resulted in improved albumin levels and weight gain Nashville, TN, USA (Patel MG, Raftery MJ. J Renal Nutr 1997;7:208-211). This study evaluated the effect of early enteral feedings, In contrast, a retrospective analysis of 10 PD patients initiated within 4 days of admission, in patients with open who required placement of percutaneous endoscopic abdomens after celiotomy. The study included 57 patients gastrostomy (PEG ) feeding tubes suggested PEG feeding who underwent celiotomy and subsequently required an is associated with frequent complications (Fein PA, et al. open abdomen for at least 3 days, survived to discharge and Adv Perit Dial 2001;17:148-152) PEG placement prior had available nutrition data. Seventy-nine percent of to PD initiation appears to be safe. However, patients patients had suffered blunt trauma; 21% had suffered gun who require PEG placement after PD has begun are at shot wounds. higher risk of peritonitis and should be given antifungal In the study group, 53% (30 of 57) had early enteral prophylaxis and maintained on HD for longer than nutrition initiated and met 53% of calorie goal by day 4. 6 weeks after PEG placement. Two of the 30 patients (6.7%) with early enteral feeding developed fistulae, compared with 5 of 27 (18.5%) of the Permissive underfeeding in the group with later feedings who formed fistulae. There were critically ill patient no differences in mean injury severity scores, abdominal N Huff, L Tritt abbreviated injury scores, initial base deficits, and initial Indianapolis, IN, USA transfusion requirements. Seventy-seven percent (23 of 30) Permissive underfeedings, or the use of hypocaloric, high- of patients with early enteral feedings had the abdominal protein enteral or parenteral nutrition, may significantly cavity closed early, defined as within 8 days of initial improve outcomes in critically ill patients (Dickerson RN. surgery; while 10 of 17 (59%) patients with later feedings Curr Opin Clin Nutr Metab Care 2005;8:189-196). were closed early (p = 0.002). Underfeeding may reduce cytokine and inflammatory This study showed that early initiation of enteral responses, attenuate impact of exposure to toxins, and nutrition with open abdomen care trends toward a lower CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume 3, Issue 2 reduce hyperglycemia, seen when patients receive 100% of fistulae rate and is associated with earlier closure of the estimated needs during the initial phase of inflammation. abdominal cavity. Reduced nutrient intake can also maintain GI tract integrity. Recent studies in critically ill patients show short-term The views expressed in this newsletter are of the presenters and participants, not Nestlé Nutrition. permissive underfeeding of 9–18 kcal/kg/d, or 33–66% of estimated needs, is associated with fewer infections and ventilator days, and shorter lengths of stay than with The next Clinical Nutrition Week will be held on 10–13 February 2008 in Chicago, Illinois, USA. higher levels of calorie intake (Krishnan JA, et al. Chest Further information may be found at www.nutritionweek.org. 2003;124:297-305. Ash JL, et al. JPEN J Parenter Enteral

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Conference Calendar 2007

September 12th Congress of the Parenteral and Enteral Nutrition Society of Asia 29th European Society for Clinical (PENSA) Nutrition and Metabolism (ESPEN) Congress 17–20 October 2007 Manila, Philippines 8–11 September 2007 Organizer: Prague, Czech Republic PHILSPEN Secretariat Organizer: Tel: +632 723 0101 local 5714 MCI Suisse SA Fax: +632 725 6868 Tel: +41 22 339 9580 E-mail: [email protected] Fax: +41 22 339 9601 Web site: www.pensa2007.org E-mail: [email protected] Web site: www.espen.org 20th North American Society for Pediatric Gastroenterology, 43rd Annual Meeting of the European Hepatology, and Nutrition (NASPGHAN) Association for the Study of Diabetes Annual Meeting (EASD) 25–27 October 2007 17–21 September 2007 Salt Lake City, Utah, USA Amsterdam, The Netherlands Organizer: Organizer: NASPGHAN Eurocongres Conference Management Tel: +1 215 233 0808 Tel: +31 20 679 3411 Fax: +1 215 233 3918 Fax: +31 20 673 7306 E-mail [email protected] E-mail: [email protected] Web site: www.naspghan.org Web site: www.easd.org

39th Annual Congress of the ADA Food & Nutrition Conference & International Society of Paediatric Expo (FNCE) 2007 Oncology (SIOP) 29 September – 2 October 2007 Philadelphia, Pennsylvania, USA 29 October – 3 November 2007 Mumbai, India Conference Calendar Conference Organizer: American Dietetic Association Organizer: Tel: +1 312 899 0040 Varriance Conferences and Events E-mail: [email protected] Tel: +91 22 2438 1068 Web site: www.eatright.org/FNCE2007 Fax: +91 22 2438 5021 E-mail: [email protected] Web site: www.varriance.com/siop2007 October 20th European Society of Intensive November Care Medicine (ESICM) Annual 2007 Annual Conference of the British Congress Association for Parenteral and Enteral 7–10 October 2007 Nutrition (BAPEN) Berlin, Germany 27–28 November 2007 Organizer: Harrogate, United Kingdom ESICM Congress Manager Tel: +32 2 559 0355 Organizer: Fax: +32 2 527 0062 Sovereign Conference E-mail: [email protected] Tel: +44 (0) 1527 518 777 Web site: www.esicm.org Fax: +44 (0) 1527 518 718 E-mail: [email protected] Web site: www.bapen.org.uk CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2 CLINICAL NUTRITION HIGHLIGHTS • 2007 Volume

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