ISSN 1815-7262

CLINICAL HIGHLIGHTS Science supporting better nutrition 2010 • Volume 6, Issue 3

In this issue Diagnosing and treating cow’s milk Clinical nutrition abstracts 32nd ESPEN Congress

CLINICAL NUTRITION HIGHLIGHTS Science supporting better nutrition 2010 • Volume 6, Issue 3

Feature article 2 Diagnosing and treating cow’s milk protein allergy Professor Christophe Dupont

Health economic perspective 8 Economic estimates of the burden of cow’s milk protein allergy: A literature review

Clinical nutrition abstracts 9 Cancer 9 Critical care 9 12 Immunonutrition 13 Nutrition support 14 15

Highlights of 32nd ESPEN Congress 18 5–8 September 2010

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. © 2010 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. 2 CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 Feature article eea wrig ate hv teeoe eeoe recom- developed therefore have parties working Several decrease the risk of complications, such as impaired growth. and diets elimination inappropriate on infants of number potential nutritionalcompromiseisprevented. that ensure to caregivers for required is elimination the avoidance of CMP. A careful prescription and explanation of distress or constipation. The mainstay of CMPA treatment is not usually considered as a cause of such symptoms as infant is it where settings care primary in missed easily therefore is (CMPA) allergy protein milk Cow’s eczema. symptoms chronic to GI from range Symptoms onset. delayed with onset, to a wide array of non–IgE-mediated , usually immediate with usually allergies, (IgE)-mediated E globulin immuno- well-recognized the from extends manifestations clinical of range The system. respiratory and tract (GI) tinal gastrointes- skin, the as such organs affecting children, in reactions adverse of cause the be can (CMP) protein milk Cow’s diet. “balanced” a of part as childhood throughout used for complementary feeding and is commonly consumed widely is formulas, infant most of basis the is milk Cow’s I. Introduction the riskofcomplications, suchas of CMPA willreducethenumber elimination dietsanddecrease Accurate and early diagnosis of CMPAof diagnosis early the and reduce Accurate will Accurate andearlydiagnosis of infants oninappropriate cow’s milkproteinallergy impaired growth Diagnosing andtreating Hôpital Necker–EnfantsMalades Professor ChristopheDupont Pediatric Paris, France o cu feunl, ih h peec o io deficiency iron of presence the with frequently, occur to deficiencies from CMPA are unknown. Iron deficiency seems may clusteraccordingtocertainpatterns. tricians. to pedia- general and care primary assist specifically algorithm, an including recommendations, develop to consensus convened was force task such one CMPA; of treatment and diagnosis the for guidelines or mendations shown in Tables 1 and 2, respectively.Tables2, in and shown 1 as frequency, or symptoms’, ‘alarm as to referred severity, to according understanding better for panel consensus the by classified were and numerous, are CMPA of Symptoms II. SymptomsofCMPA the consensuspanelmembers. of opinion consensus and experience clinical the as well as ature and existing national recommendations and standards, liter the of review comprehensive a on based were which Reproduced General toinfection) (unrelated tract Respiratory Skin Gastrointestinal tract Organ involvement CMPA asthepossiblecause in combinationwithitemslistedtable2), indicatingsevere Table 1. Alarmsymptomsandfindings(canbefoundaloneor CMPA,’ cow BMJ PublishingGroupLtd. al,Y, VandenplasInfants, et h ln-em osqecs f oeta nutritional potential of consequences long-term The s milkproteinallergy. 1 ’ Cow of Management and Diagnosis the for Guidelines from hs ril wl rve tee recommendations, these review will article This volume 92, pages 902-908, 2007, with permission from permission with 2007, 902-908, pages 92, volume Child Dis Arch Anaphylaxis obstruction withdifficultybreathing orbronchial Acute laryngoedema iron deficiency anemia hypoalbuminemia orfailuretothrive with dermatitis orsevereatopic Exudative orseverecolitis enteropathy Endoscopic/histologically confirmed Hypoalbuminemia macroscopic bloodloss Iron deficiency anemiaduetooccultor and/or refusaltofeedvomiting Failure tothriveduechronicdiarrhea Symptoms andfindings 1 Symptoms of CMPAof Symptoms Ml Poen leg in Allergy Protein Milk s - Feature article CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 3

2 eosino- eosinophilic These infants suffer from rectal 3,4,6 3,4,7 In gut eosinophilic disorders the key characteristic protein-induced proctocolitis is considered a Food protein-induced enteropathy usually presents Food protein-induced enterocolitis syndrome (FPIES) IgE-mediated IgE-mediated to egg, CMP and/or peanuts. During the episode of eczema, the causal role of an impaired impaired an of role causal the eczema, of episode the During skin barrier increases the likelihood of allergen sensitization route. via the cutaneous is eosinophilic infiltration, which can lead to esophagitis (EE). This occurs more frequently in boys than in girls, and is manifested by nausea, sometimes or pain epigastric and vomiting impaction, food with intes- other of those overlap symptoms gastroenteritis; philic diseases GI eosinophilic with patients Pediatric diseases. tinal have evidence of food allergy, especially to cow’s milk and egg. The role of aeroallergen particularly sensitivity, in EE, the of content eosinophilic the in variations by determined is esophageal mucosa according to season. Non–IgE-mediated disorders Non–IgE-mediated disorders affect mainly young infants, chronic more are and tract, GI the to isolated commonly are in nature. type of eosinophilic GI disorder, but involves only a non– IgE-mediated mechanism. It is generally present in the first few months of life, due to food passing from the maternal breast milk. in the first few months life of steatorrhea, with non-bloody malabsorption, diarrhea, and failure to thrive. distension abdominal edema, to lead Protein may enteropathy losing and anemia. The other differential causes of enteropathy, including infection, diagnosis metabolic must causes, consider lymphangiectasia and celiac disease. Biopsy shows small bowel villous increased injury, crypt length and intra- epithelial lymphocytes. The disease usually resolves by the age of 2 years. bleeding but appear healthy edema and mucosal shows which colonoscopy, are requires diagnosis growing well. The with stripes of mucosa exhibiting bleeding and clusters of by spontaneously resolve Symptoms infiltration. eosinophilic the age of 1 year. of months 3 first the during infants in seen commonly most is babies. breastfed in delayed be might development its but life, Ingestion of CMP triggers severe symptoms of prolonged projectile vomiting that develop within a few hours feeding. after During long-term or milk, infants may intermittent experience severe vomiting and ingestion diarrhea of that can lead to dehydration, lethargy, acidosis and methe- moglobinemia with high peripheral leukocyte counts; the infants may appear to have sepsis. Oral challenge should be lead reactions of 20% about because caution with performed to shock. Diarrhea may s Milk Protein Allergy in 2-4 is a chronic inflam- chronic a is eczema atopic Symptoms regurgitation Frequent Vomiting Diarrhea Constipation perianal rash) (with/without Blood in stool anemia Iron deficiency Atopic dermatitis (angioedema) Swelling of lips or eye lids Urticaria unrelated to acute infections, drug intake or other causes Runny media) nose (otitis Chronic cough Wheezing distress or colic (wailing/ Persistent irritable for ≥3 h per day) at least 3 days/ week over a period of >3 weeks immunological basis for their - classi Arch Dis Child volume 92, pages 902-908, 2007, with permission from 2-5 from Guidelines for the Diagnosis and Management of Cow’ s milk protein allergy. This relationship is part of the well-established and 2 Categories of allergic reactions Categories of allergic reactions to CMP Infants, Vandenplas Y, et Infants, Vandenplas Y, al, BMJ Publishing Group Ltd. show in general one or more of the listed symptoms. * Infants with CMPA cow’ CMPA, Reproduced Table 2. Most frequent symptoms of CMPA* Most frequent symptoms 2. Table Organ involvement tract Gastrointestinal Skin Respiratory tract (unrelated to infection) General follow several hours after consumption of CMP in associ- ation with other target organ responses (eg, urticaria and bronchial asthma), as well as during systemic anaphylaxis in atopic patients. strong association between eczema and IgE-mediated food Up allergy. to 64% of infants whose eczema first developed before 3 months of age have a high risk for concomitant CMP “sensitive” eczema or eczema “sensitive” CMP two in IgE serum raised with associated disorder skin matory thirds of cases, allergen sensitization and a family history of atopy. Mixed IgE-mediated and cell-mediated disorders and/or ”eosinophilic gastroenteropathies” IgE-mediated symptoms Immediate GI hypersensitivity or “gastrointestinal - anaphy laxis” affects both infants and children, with acute onset of nausea and colicky abdominal pains within a few minutes and up to 2 hours after food ingestion. Diagnosing CMP-induced adverse reactions requires a clear understanding of the III. fication, with diagnostic modalities varying according classification. to anemia in some cases leading to a diagnosis of CMPA, as well as failure to thrive. 4 CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 Feature article gold standard for milk feeding in infant nutrition. However,nutrition. infant in feeding milk for standard gold the is Breastfeeding infants. breastfed in occur may CMPA Management ofCMPA inbreastfedinfants an aminoacidformula(AAF). Infants with severe symptoms should preferably be fed using allergy.IgE-mediated have to likely are vomiting immediate and urticaria eyes, and/or lips the of angio-oedema as such symptoms with presenting Infants initiated. be should diet to elimination “mild diagnostic a as and CMPA, considered suspected is moderate” case the 1) Table in listed (as Figure 1. If the infant does not present with alarm symptoms in shown as infants symptoms, of severity the formula-fed to according differs for intervention recommended The Management ofCMPA informula-fedinfants IV. Figure 1. AlgorithmforthediagnosisandmanagementofCMPA informula-fed infants Reproduced from Guidelines for the Diagnosis and Management of Cow’s Milk Protein Allergy in Infants, Vandenplas Y, et al, AAF, amino acid formula; CMP, cow’s milk protein; CMPA, cow’s milk protein allergy; eHF, extensive hydrolyzed formula; IgE, immunoglobulin E; RAST, radioallergosorbent test. diagnosis andtreatment Clinical approachtoCMPA Others(rare) • General: persistentdistressorcolic(≥3h • nose, Respiratory: runny chroniccough, • Dermatological: dermatitis, atopic swelling • Gastrointestinal: frequentregurgitation, • symptoms: One ormoreofthefollowing CMPASuspicion ofmildtomoderate observation under clinical milkformula Cows Open challenge** and monitor Resume CMPindiet No CMPA symptoms 3 days/weekoveraperiodof>3weeks least per daywailing/irritable)at toinfection) wheezing (allunrelated other causes toacuteinfections,unrelated drugintakeor of lipsoreyelids(angioedema), urticaria iron deficiency anemia (with/without perianalrash), bloodinstool, vomiting, diarrhea, constipation Improvement Therapeutic extensivehydrolyzed Therapeutic formula (eHF)for2to4weeks* Elimination diet Elimination Maintain CMP elimination dietuntil9–12months Maintain CMPelimination diet with AAF* Elimination Elimination of age, least6months and forat No improvement Suspicion ofcow’s (CMPA) milkproteinallergy CMPA symptoms or Resume CMP Blood: totalIgE, • Skintests: pricktest, • Consider thefollowing: Testing forCMPA in diet Family (riskfactor) history • Clinicalfindings • Clinical assessment CMP specific IgE(RAST)for testforCMP patch of CMPA of tions. Clinicians can consider skin prick tests or determination a personaleliminationdiet. adopts she if breastfeeding continue can she that mother the reassuring and diagnosis accurate an on relies infants these Treating occur. 1) Table in (listed symptoms alarm unless breast via transferred milk. Exclusive or partial breastfeeding should be continued, CMP to reactions clinical repro- ducible show infants breastfed exclusively of 0.5% about examination. and disease, atopic have parents if increases infant the in atopy of risk the since history, family hensive case, every in present are all not although of analysis careful a numerous, are which 2), CMPA(Tablesand of 1 symptoms on relies work-up diagnostic The The diagnosticwork-up Arch Dis Child diagnostic procedures diagnostic Pediatric specialist for aminimal2–4weeks* Amino acidformula(AAF) diet Elimination None of the classic allergy tests is considered diagnostic No improvement challenge Repeat Repeat . All techniques exhibit both strengths and limita and strengthsboth exhibittechniques All . volume 92, pages 902-908, 2007, with permission from BMJ Publishing Group Ltd. 1 Systemicreactions: shock–needs anaphylactic • Respiratory: acutelayngoedemaorbronchial • Dermatological: orsevereatopic exudative • Gastrointestinal: failuretothriveduechronic • symptoms: One ormoreofthefollowing Suspicion ofsevereCMPA immediate referraltohospitalformanagement immediate obstruction withdifficultybreathing failure tothriveorirondeficiency anemia withhypoalbuminemia-anemiaor dermatitis colitis or severeulcerative endoscopic/histologically confirmedenteropathy (hypoalbuminemia); enteropathy occult ormacroscopicbloodloss;protein-losing refusal tofeed;irondeficiency anemiadueto diarrhea, and/or and/orregurgitation/vomiting ** According toresultsofcontrol Dependingoncost/benefitratio Aminoacidformula(AAF) * testing in IgE-mediated allergy testing inIgE-mediated drink eHF and/or ifthechildrefusesto challenge Pediatric specialist Improvement and pediatric specialist pediatric Referral to careful physical careful n compre- a on - Feature article CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 5 12 The 13 (eHFs). extensively hydrolyzed formulas 11 continuing breastfeeding as long as possible Educating patients and treating Educating patients and treating emergency situations It is important to recognize and to respond allergic reactions Parents when and other caregivers they of the child, occur. even occasional caregivers, educated and should equipped with be priate the emergency appro- treatment. This includes an antihistamine and, epinephrine if auto-injector. indicated, Preparing an individualized emergency plan is necessary. an For children with mild-to-moderate CMPA who are metabolic disorders; metabolic abnormalities; anatomical celiac disease; other enteropathies; especially cystic fibrosis; pancreatic insufficiency, non-immunological reactions to food, such as secondary lactose intolerance; allergic reactions to other food allergens, molds, such fur, animal as such substances, other or as wheat, soy, eggs, dust; malignancy; or GI and urinary tract infections. infections, particularly European Commission has limited the content of immuno- These hydrolysates are made of cow’s milk proteins that have that proteins milk cow’s of made are hydrolysates These undergone a process combining heating and hydrolysis, so that peptidic remains have a molecular weight mostly below 1,500 Daltons (Da), and always below 5,000 Da. Nutritional options for elimination diets In the case of being CMPA diagnosed while the child is still being breastfed, is of course the first choice. If symptoms the child while develops CMPA being breastfed, which is common situation, then not the mother needs to start the an elimi- most increased appropriate an by accompanied herself, diet nation intake in calcium. CMP-induced anaphylaxis requires early administration of sponta- settle may nature milder a of Reactions epinephrine. neously, or after the administration of an Some situations antihistamine. may require the administration of costeroids. The coexistence corti- of asthma may be a major risk factor for the occurrence of more severe allergic reactions to milk cow’s and requires the appropriate treatment in the emergency plan. not being breastfed, elimination of CMP should start with the introduction of The composition of the hydrolyzed formulas must meet the 25 of 1999/21/EC Directive Commission the of requirements purposes. medical special for dietary on 1999 March • • • • • • • • • 4,10 Figure 3. Cow’s milk patch test (right), milk patch test (right), Cow’s Figure 3. compared to control (left) However, published values establishing thresholds CMPA in formula-fed infants CMPA challenge procedures remain Referral to a specialist is mandatory in severe cases. The clinician should also assess whether the child Allergen elimination diets and challenge procedures Allergen elimination diets and 8,9 treatment of mild-to-moderate the standard for diagnosis and Figure 2. Cow’s milk skin milk Cow’s 2. Figure compared to prick test, negative ones for diagnosis of active CMPA are only partially reliable, due for of are reliable, diagnosis only active CMPA partially to lack of published data and probably manifestations. also clinical and age to childrens’ to according variations by radioallergosorbent test (RAST) of specific IgE levels using using levels IgE specific of (RAST) test radioallergosorbent by results positive with extracts, CMP whole or milk cow’s fresh prick Skin 2). (Figure CMPA IgE-mediated in only observable infants; young in including age, any at performed be can tests with decreases with specificity age, while increases sensitivity age. Patch tests help in the diagnosis of non–IgE-associated reactions (Figure 3). SpecificIgE havemeasurements gained in popularity with the recent increase in sensitivity of the assay. A differential diagnosis must not be overlooked, and may include: suffers from concurrent conditions: gastroesophageal reflux, especially in infants younger than may 1 be year, associated with, or induced constipation CMPA; by, may be related to but in most cases is due only to motor imbalances. CMPA remain the standard for diagnosis and treatment of mild-to- in formula-fed infants. Following an elimi- moderate CMPA is milk for IgE specific blood of measurement the diet, nation preferable to avoid a severe adverse reaction in a child with IgE-mediated symptoms. 6 CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 Feature article of age. monthsreplaceformulasadapted infant6before notshould highindividual susceptibility. However, a exhibitsgoat’s which CMP,orsheep’s milk to reactivity cross of absence an is there providing intake calcium boosting by benefit provide erance. hence,these children maymisdiagnosedbe CMP;with lactose intol of traces to react may children allergic highly some cases). (probablyallergicalsosoyCMPAofnot 30%tothan lessis months,6 providing thanthat there evidenceis olderthatthechild with children in used be may and available also are it uuly edn t rmsin Hwvr i cnrs to contrast in However, remission. to leading usually diet, elimination an under spontaneously resolves usually CMPA and dietary reintroduction of CMP Prognosis: Potential for resolution of CMPA dients present in foodstuffs. allergenic ingreregarding labelling the rules the defines EC, 2000/13/ Directive amending 2003/89/EC Directive, Union European A albumin. serum lactalbumin, whey,caseinates, casein, proteins, milk cow’s label: the on terms following productindicatedpresenceatheTheis inof CMPany ofby diet. the eliminatedfrom be mustcontaining milk,products industrial all and products, dairy other cheese, and Milk, cream butter, parents. to explained carefully be to needs diet elimination CMP the CMPA, of diagnosis Following CMPA Complementary feeding in patients with condition seems severe, or if a child refuses to thedrink if the choice eHF.first a indicatedas also is AAFAAF. Anan of symptomsand catch-up growth may be obtained with the use resolution of eczema, atopic severe or thrive to failurewith gastroenteroproctitis IgE-mediated in particularly eHF, to symptomstenceof underfeedingeHF suggestiveis allergy of persisproteinadopted:thecomponent,thenanywhen is of manifestations are the most likely non–IgE-associatedreactions. other An AAF, and deprived GI peptides; these in present content ofnitrogen-containingsubstances. total the of 1% than less to hydrolysates in proteins reactive used, since the infant may develop nutritional deficiencies. be thereforeshouldnutritionalinfantnotandmeet needs to improperly called chestnut,“milks”. or These coconut almond, products rice, from are made “juices”totally eg, unsuitable adapted for the treatment of CMPA.treatmentof the foradapted are they that indicate studies several countries, and some in ats my e osmd y hs wt CP, but CMPA, with those by consumed be may Lactose inappropriate are products used widely of number A Goat’s and sheep’s milk and other dairy products mayproducts dairyother Goat’ssheep’s andand milk iepoen ae hydrolysates based Rice-protein Somechildren may, however, residualreactto allergens 16-18

19 14,15 r as available also are

Soy-basedformulas - - - ;

of milk and dairy products, even as teenagers. have “residual disease” and cannot tolerate a “normal” actually CMPA intake of free be to considered children some that CMPA with early GI symptoms has a better prognosis. however,childhood; inrhinoconjunctivitis laterand asthma developmentdevelopmentreactionsandfoodsotherof toof IgE-mediated withsymptomsassociated increasedpersistence,isanof withrisk CMPA proteins. milk soluble to than casein allergicto more is childthe allergicdiseases;and and symptomswaslong; thechild exhibits multiple foodallergies of onset the and CMP the of consumption between of periodcommencement the disease; atopic familial severe of child will fall into the first or the second category. residuala disease.currentlydatacan No predictwhether the categorycases,childmaintainfallsthosetheintothewhoof dairyWesternintakemilkandproductsofa in otherdiet.In usual thecorresponds amounttolerate.Sometimestothis to theydeterminecan amountthethatCMPchildtheof ableis carefullyfollowprogressivethis reintroduction thatphaseso sometimes delayed, 1 month be after the mayOFC. Parents reaction must therefore A be instructed OFC. to the follows be rechallenged before 1 year of age. CMPAnotshould longer,of lasttype this childrenwith and could symptomsother manifestationsand skin withCMPA lengemay be suggested from 9months of age. IgE-dependent digestive manifestations, duration may be short, and a rechal early,caseof non–IgE-dependent CMPA withpredominantly the allergyexample,treatment.infood Formainstays of the lenging the child in order to detect tolerance to CMP is Rechalone of data. preceding the on based given be may mation maintainastrict elimination diet, even though some approxi to needwillchild a caregiverlonghowparentor informthe ously restrict their dairy intake. eatingdairyproducts, whichusually leadsspontanethemto when nausea and/or pain abdominal diarrhea, report may years. 3 of age the by cases of 90% and 70% between in occurring incomplete, and slow be may process this thinking,general epoi, e te eua b cide t et e fo, a food, new eat to children by refusal the ie, Neophobia, Difficulties in refeeding the child with CMPA been published on OFC in children. possibility of a severe reaction. Several recommendations have reintroduction such should for be discussed with protocol parents and caregivers, The as dairythere is home.the and at milk products of reintroduction gradual a by followed hospitalunit,daycare a cow’sin provocationtomilk test or challengefood(OFC)oral an given is child the thatmended CMPA may not resolve completely. It has been showncompletely.resolvebeen nothas CMPA mayIt h porsie enrdcin f M a home at CMP of reintroduction progressive The eoe icniun te lmnto de, t s recom is it diet, elimination the discontinuing Before Thus, in clinical practice, it is not possible to predict and 20 hs s atclry h cs i tee s history a is there if case the particularly is This 22 21 These children - - - - -

Feature article CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 7 - - J Allergy Allergy J 2006;61:1238- Allergy J J Allergy Clin Immunol J J Pediatr Gastroenterol Nutr Eur Eur Ann Allergy Clin Immunol 2002;13(Suppl 15):23-28. 2002;13(Suppl 2008;121:343-347. 2004;59:980-987. Longo G, Barbi E, Berti I, et al. Specific oral tolerance induction in induction tolerance oral Specific al. et I, Berti E, Barbi G, Longo reactions. milk-induced cow’s severe very with children De Boissieu D, Dupont C. Sublingual immunotherapy for cow’s a milk report. preliminary allergy: protein Dupont C, Kalach N, Soulaines P, et al. Cow’s milk epicuta Clin Immunol Clin 1239. neous immunotherapy in a children: pilot trial accept of safety, ability and impact on allergic reactivity. 2010;125:1165-1167. Meglio Meglio P, Bartone E, Plantamura M, et al. A protocol in milk allergy. with desensitization children cow’s IgE-mediated for oral Allergy Rancé F, Rancé Deschildre et A, F, F, Villard-Truc al. Oral food challenge in children: an expert review. 2009;41:35-49. Kokkonen Kokkonen Tikkanen J, S, Savilahti E. Residual intestinal disease after milk allergy in 2001;32:156-161. infancy. Høst Høst A, Halken S, Jacobsen et HP, al. Clinical course of cow’s childhood. in diseases atopic and allergy/intolerance protein milk Immunol Allergy Pediatr Directive Directive 2003/89/EC of the European Parliament and of Council of the 10 November 2003 amending Directive 2000/13/EC as regards indication of the ingredients present in (2003). Official foodstuffs Journal of the European Union of 25 November http://eur-lex.europa.eu/LexUriServ/ at: Available 308/15. L 2003. Accessed LexUriServ.do?uri=OJ:L:2004:024:0058:0064:EN:PDF. 2010. 7, November

24. 25. 26. 23. 22. 21. 20. 19. Acta Acta children with CMPA J J Pediatr In press. In It is the joint responsibility of It is the joint responsibility Several challenges remain, especially in severe cases, in cases, severe in especially remain, challenges Several doctors and other clinicians to doctors and other clinicians 2001;8:1226-1233. appropriate care is delivered to appropriate care is delivered Pediatr Pediatr Allergy Immunol Arch Pédiatr Arch 1997;100:444-451 are properly informed, and that the are properly informed, ensure that parents and caregivers ensure that parents and V. Conclusions V. pediatric in issue key a is CMPA of symptoms the Recognizing practice. Yet, identification ofCMPA is difficult, requiring pediatricians to keep in mind the protein aspect of CMPA as a cause of symptoms. Once largely overlooked, CMPA is now recognized as a well defined clinical condition. The increased has recognition arisen of from CMPA the work of nutrition by formula adapted of development the researchers, recommendations providing bodies scientific and companies, management of this condition. for the diagnosis and those with long-lasting conditions, and because of the possi- bility of serious adverse events. It is the joint responsibility of doctors and other clinicians to ensure that parents and caregivers are properly informed, and that the appropriate specialty to Referral CMPA. with children to delivered is care cases. clinicians may be warranted in difficult Arch Pediatr Arch 2006;36:311-316.

- - - - - 23,24 2006;42:352-361. J Allergy Clin Immunol Clin Allergy J Clin Exp Allergy Exp Clin 2008;121:1062-1068. 2008;121:1062-1068. 1993;82: 314-319. 1993;82: Reche Reche M, Pascual C, Fiandor A, et al. The effect of a partially hydrolysed formula based on rice protein in the treatment infants with of cow’s milk protein allergy. Goulet I, Axelsson C, Agostoni on Nutrition; Committee ESPGHAN O, et al. Soy protein infant formulae and follow-on formulae: a commentary by the ESPGHAN Committee on Nutrition. Bhatia J, Greer F; American Academy of Pediatrics Committee feeding. infant in formulas soy protein-based of Use Nutrition. on Pediatrics 2010;21:577-585. Committee on Nutrition of the et A, formulas Soybean-based Briend Bresson A, al. French JL, Bocquet Society of Pediatrics. French]. [in nutrition infant in Gastroenterol Nutr Paediatr A R, et Bernardini rice-based al. hydrolysed A, Restani P, Fiocchi formula is a tolerated by milk with allergy: children multi- cow’s study. centre Commission Commission Directive 1999/21/EC of 25 March 1999 on dietary of Journal Official (1999) the foods for purposes medical special European Communities of 7 April 1999. L 91/29. Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:199 2010. December 8 Accessed 9:091:0029:0036:EN:PDF. Aggett PJ, Haschke F, Heine W, et al. ESPGAN Committee on Nutrition Comment on antigen-reduced infant formulae. Dupont C, Chouraqui JP, de Boissieu D, et al. Comité de Comité nutrition et al. de D, Boissieu JP, Chouraqui C, Dupont de diététique charge en Prise pédiatrie. de française Société la de vache. de lait du protéines aux l’allergie and adolescents. adolescents. and

15. 17. 18. 16. 14. 12. 13. 11. Pathol Hum J J Biol Regul 2010;95:134- J J Allergy Clin Immunol J J Allergy Clin Immunol 2009,9:371–377. 1997;100:444-451. 2009;45:481-486. an to adaptation food allergy from a 25 2007;92:902-908. Arch Arch Dis Child Educ Pract Ed J Allergy Clin Immunol Clin Allergy J 2008;22:27-33. 26 J Paediatr Child Health Child Paediatr J Curr Op Allergy Clin Immunol Clin Allergy Op Curr Arch Dis Child Dis Arch Using Using these techniques several authors describe inter This is also called “immunotherapy”, which is probably probably is which “immunotherapy”, called also is This Allen KJ, Davidson GP, Day AS, et milk of AS, Management Day al. cow’s Davidson Allen GP, KJ, protein allergy in infants and young children: an expert panel perspective. Odze RD, Bines J, Leichtner AM, et al. Allergic proctocolitis in study. biopsy clinicopathologic a prospective infants: 1993;24:668–674. enterocolitis A. Food protein-induced A, Muraro Nowak-Wegrzyn syndrome. Ronchetti Ronchetti R, Jesenak M, Barberi S, atopy et patch tests with food and inhalant al. allergens. Reproducibility of Homeost Agents Homeost 2005;116:1321-1326. Sampson HA, Ho DG. Relationship children in challenges between food positive of risk food-specific the and IgE concentrations Kalach N, MD, Soulaines P, de Boissieu D, Dupont C. A pilot study study pilot A C. Dupont D, Boissieu de P, Soulaines MD, N, Kalach of the usefulness and safety of a ready-to-use atopy patch test (APT) (Diallertest®) versus a during comparator cow’s milk (Finn allergy Chamber®) in children. Vandenplas Vandenplas Y, Koletzko S, Isolauri E, et al. Guidelines for diagnosis the and management of cow’s milk infants. protein allergy in cow’s managing and Identifying al. et N, Shah R, Meyer G, Toit du milk protein allergy. 144. Sicherer SH, Sampson HA. Food allergy. 2):S116-S125. Suppl 2010;125(2 Sampson HA, Ho DG. Relationship children in challenges between food positive of risk food-specific the and IgE concentrations adolescents. and

esting results, with a complete tolerance achieved in approxi achieved tolerance a with complete results, esting mately 30% of cases after around 1 year of treatment. 5. 6. 7. 8. 10. 9. However, the maintenance of tolerance requires the body to be be to body the requires tolerance of maintenance the However, major the has technique This allergen. the to exposed regularly reactions severe of risk the reducing substantially of advantage disad the has also but allergen, the of ingestion accidental after vantage of inducing potentially severe reactions during the is recommended technique this therefore, process; therapeutic use now attempts Other centers. specialized to restricted be to the route, sublingual technique used for respiratory allergens, and also the epicuta the also and allergens, respiratory for used technique route. neous References 1. 2. 3. 4. a a more appropriate term. leads Immunotherapy to either a “tolerance”, the final state of to non-reactivity the allergen independent of its regular reactivity. of use, threshold the increases whereas simply “desensitization” zation”. “Forcing” “Forcing” the lack of CMP tolerance using an “induction of tolerance” technique is gaining interest in food doses low milk very by giving is started the process allergy. Basically, with orally, gradual increases aiming at inducing “desensiti New treatments for CMPA: Desensitization Desensitization CMPA: for treatments New common characteristic of children aged 2–10 years, might be might years, 2–10 aged of children characteristic common been has diet elimination an when pronounced or likely more from food suffered having Children by imposed food allergy. a than to foods new try reluctant more sometimes are allergy sibling. Several factors non-allergic may increase neophobia, to adhering of difficulty the symptoms, of severity the as such meals. of monotony the and diet elimination the Health economic 8 CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 perspective the condition in the first year vary from Estimates for the total direct treatments costs to manage countries. different in estimated were CMPA managing of costs indirect and direct total the simulations, and h Wrd leg Organization. Allergy World the of initiative an through developed were which exists, A series of national guidelines on the treatment of CMPA allergic reactions among children in developed countries. managing and identifying of importance the on tioners consensus in the scientific literature and amongst practi- of cow’s milk protein allergy (CMPA). Yet, there is large burden societal the on published been have studies Few Nestlé NutritionInstitute Health EconomicsManager Dr Patrick Detzel milk proteinallergy:Aliteraturereview Economic estimatesoftheburdencow’s Health economic perspective (eg, physical and social impacts) of CMPA on families. on CMPA of impacts) social and physical (eg, costs soft the of magnitude of order an get to disorder it is illustrative to use studies on this more prevalent skin Thus, AD. of forms severe to moderate with associated dermatitis (AD). A large majority of CMPA cases will be atopic on literature the at look to is CMPA of impact allergic an for care reaction episode. to work off time as such costs, indirect high associated the to due children affected the of caregivers other and parents by carried are costs the vary in each country, the modeling indicates that most of n nutilzd countries. industrialized in 2–3%) (approximately rate incidence low rather the to related be might CMPA on data burden cost societal up to€1,587intheUnitedKingdom case (€) costs per treatment All societal case (€) costs per treatment Direct Source: studiesbyGuestetal. costspercaseoffournational Calculated cow’s milkproteinallergy Table. Estimateddirecttreatmentcostsformanaging n niet a t gap h pyia o social or physical the grasp to way indirect An factors different of costs economic the Although Africa South 2,332 – Australia 755 2 ae o dcso models decision on Based – 1 h rltv lc of lack relative The Kingdom United 4 1,587 (Table). €525 in Finland – 3 Finland 525 – 3

tially higher than for the average child with asthma. with child average the for than higher tially substan- is AD severe or moderate with child a of care Similarly, costs. Su financial et al. and estimated that the episode financial costs AD in the the for care to taken time workdays, of loss deprivation, sleep were families major factors contributing to the increased stress for the children andtheirfamilies. CMPA among of burden financial and social, personal, the reduce to help should and potential of have CMPA, management of the for implementation protocols care widespread science-based as such treatment, with associated outcomes health improve to Strategies CMPA.of burden total the of perspective partial a only is CMPA to related AD therefore, like disorders skin hospitalization); at looking to lead can (which tract respiratory the and anemia) diarrhea, vomiting, tation, (regurgi- tract gastrointestinal the as such organs, other involves often but disorders, skin with associated only not is CMPA including children. affected the problems, among irritability, behavioral and parents among guilt of feelings include families impacting burden of forms other costs, indirect and direct these to addition f hlrn ih oeae o eee D a signifi- was cantly greater than that of mellitus. AD severe to moderate with children of care the with associated stress family that found Kemp 6. 5. 4. 3. 2. 1. References cost. ArchDisChild 1997;76:159-162. JC,Su Kemp AS, VarigosGA, Nolan TM.financial and family eczema:the Atopic on impact its nomics 2003;21:105-113. Kemp AS. Cost of of illness of atopic dermatitis in children: impact a societal perspective. budget and implications Resource intheUK. JF. milk allergy cow managing JMedEcon2010;13:119-128. Guest G, Lack E, Nagy E, Sladkevicius new of impact budget Opin 2008;24:1167-1177. and implications resource Finland.in allergy milk cow of management the the for guidelines reimbursement Modelling E. Valovirta J, Guest 2002;2:217-225. Heine RG, Elsayed S, Hosking CS, Hill DJ. Cow’s milk allergy in infancy. 2010;21(Suppl 21):1-125. guidelines.(DRACMA) allergy cow’smilk against action for rationale and diagnosis (WAO) Organization Allergy World al. et H, Schünemann J, Brozek A, Fiocchi Pediatr Allergy Immunol Pediatr Allergy Curr Opin Clin Immunol Pharmacoeco- Curr Med Res Med Curr 5 The 6 In Clinical nutrition

abstracts CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 9 -

CRITICAL CARE

Parenteral nutrition versus enteral nutrition in severe acute pancreatitis Acta Cir Bras 2010 Oct;25(5):449-454. Linhares MM. A, Goldenberg Azevedo JR, de Araújo GF, de Vieira JP, Brazil. University of Maranhao, Federal Surgical Department, PURPOSE: To compare the enteral nutritional support effect in severe acute pancreatitis, with of parenteral versus respect to efficacy, safety, morbidity, mortality and length of hospitalization. METHODS: The study was comprised of 31 patients, divided into a parenteral and group an (n enteral group = (n 16) = 15), who for met abdominal severity tomography criteria (Balthazar classes C, E). The D, patients were and compared by demographics, disease antibiotic etiology, prophylaxis, use or not of somatostatin, nutritional support, complications and disease progression. There was no RESULTS: statistical difference in the average duration of nutritional support, somatostatin, or antibiotics in the two groups. Imipenem was the drug prophylaxis of of pancreatic choice infections for in both groups. More Br J Nutr 2010 Sep;104(6):872-877. Kaanders JH, Lintz-Luidens H, KH, Wei EL, Rasmussen-Conrad van den Berg MG, Merkx MA. Radboud Department of Gastroenterology and – Dietetics (367), Netherlands. The Nijmegen, Centre, University Nijmegen Medical Clinical research shows that necessary to prevent in nutritional head and intervention neck cancer is patients undergoing radiotherapy. The adjusted was study to the care of present value assess individually objective nutritional standard of to compared the a by counselling 2007, and 2005 between conducted study, prospective A (SC). energy optimal (IDC, counselling dietary individual compared (standard nurse an by SC to requirement) protein and nutritional counselling). Endpoints were weight loss, (BMI) (5% and weight malnutrition loss/month) before, during and after the significant patients A Thirty-eight treatment. groups. two over distributed evenly included were treatment the after months 2 found was loss weight in decrease patients in Malnutrition SC. with compared IDC for 0.03) = (P with IDC over decreased time, while increased malnutrition and early with SC intensive in (P patients = Therefore, 0.02). clini produces dietitian a by counselling dietary individualized cally relevant effects in neck terms and of head weight decreasing loss with and patients in SC with compared malnutrition radiotherapy. undergoing cancer -

CANCER

CLINICAL NUTRITION ABSTRACTS 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 in this section were selected from a search on clinical National LibraryThe abstracts included of site at www.nlm.nih.gov. Web PubMed may be accessed via the National Library of Medicine. Comparison of the effect of individual dietary counselling and of standard nutritional care on weight loss in patients with head and neck cancer undergoing radiotherapy BACKGROUND: Plasma lower arginine in patients with which cancer, indicates that arginine concentrations are may be disturbed in these supplementation patients. has Arginine been associated with positive effects on antitumor mechanisms and has been shown to tumor reduce growth and to prolong survival. Furthermore, prognosis of the patients with head and neck cancer disappointing. remains Insufficient intake frequently leadsmortality and morbidity to mal- high to contributes which nutrition, rates. OBJECTIVE: The aim of this study was to assess the long-term effects of perioperative arginine supplementation cancer. neck and head with patients malnourished severely in DESIGN: In this trial, double-blind, we randomized, randomly controlled assigned patients with head and 32 neck cancer to receive severely 1) standard malnourished perioperative enteral nutrition (n = supplemented perioperative enteral 15) nutrition (n = or 17). The 2) arginine- primary outcome was long-term (≥10 y) survival. Secondary locoregional of appearance long-term the included outcomes recurrence, distant metastases, and second primary tumors. RESULTS: No significant differences in baseline character Am J Clin Nutr 2010 Nov;92(5):1151-1156. DJ, Kuik Leemans CR, Langius JA, MA, van Bokhorst-de van der Schueren Buijs N, Leeuwen PA. van MA, Vermeulen Netherlands. Amsterdam, MB VU University Medical Center, Departments of , Perioperative arginine-supplemented nutrition in Perioperative arginine-supplemented with head and neck cancer malnourished patients survivalimproves long-term istics were observed between groups. The group receiving arginine-enriched nutrition had a significantly better overall survival (P = 0.019) and better disease-specific survival (P = a had group arginine-supplemented the Furthermore, 0.022). significantly better locoregional recurrence-free survival (P = distant of occurrence the in difference significant No 0.027). metastases or occurrence of a second primary Perioperative CONCLUSION: groups. tumor the between observed was arginine-enriched enteral nutrition significantly improved the long-term overall survival and long-term disease-specific cancer. neck and head with patients malnourished in survival Clinical nutrition 10 CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 abstracts cohort study of patients admitted to the surgical intensive intensive surgical the to admitted patients of study cohort in those prospective A to METHODS: patients. (EN) equivalent nutrition enteral are and TGC by ameliorated complications are PN-related that hypothesized practice. authors (TGC) The control glucose tight most predates although literature described, well are illness critical in (PN) BACKGROUND: The infectious risks of Texas, USA. Department ofSurgery, Universityof Texas SouthwesternMedicalCenter, Dallas, K,Matsushima Cook A, Tyner T, Tollack L, Williams R, LemaireS, Friese R, Frankel H. Am JSurg2010Sep;200(3):386-390. unabated bytightglucosecontrol Parenteral nutrition: A clear andpresentdanger support team. nutritional multidisciplinary a or dietitian a as such sional, profes- healthcare nutrition dedicated a without difficult be can the implementation and interpretation of correct ill, support critically nutritional on guidelines have many groups produced expert although and understated tolerance be physical cannot and metabolic to according provision nutrient changing of importance The utilization. substrate responses inflammatory and metabolism improving favorably in promise great show excessive attenuate to the have potential that acids fatty n-3 as such nutrients with New feeds tubes. feeding bowel small or drugs prokinetic with versial. Gastric dysfunction problems can often be overcome anti-diarrheal drugs; however, the use of probiotics is contro- and feeds peptide or fiber with treated be can Diarrhea unit. care intensive the in common is emptying, gastric delayed in increase and recovery. immobility Physical intolerance of feeding, such as diarrhea or and stress less metabolic give during to optimal seem would it generally but harmful be can macronutrients underfeeding and overfeeding Both mass. lean of loss rapid to lead can and nutrients utilize to ability the change metabolism, alter will sepsis or , by induced response inflammatory The procedure. complex very a is but mortality even and morbidity reduce to potential the has correctly them Feeding eat. to unable or malnourished are unit care intensive the in patients Many United Kingdom. Department ofNutritionandDietetics, LiverpoolUniversityHospital, Royal Liverpool, Turner P. Proc NutrSoc2010Nov;69(4):574-581. solutions intensive careunit: Keychallengesandpractical Providing optimalnutritionalsupportonthe parenteral nutritionalsupport. to compared complications septic fewer with associated is support nutritional Enteral CONCLUSION: group. enteral the in none and group parenteral the in deaths three were There groups. two the in hospitalization of length average in difference no was There 0.006). = (P group parenteral the in frequent more significantly were tissue, pancreatic the of infections and sepsis catheter as such complications, tious Infec- 0.10). = (P significant statistically not was difference complications occurred in the parenteral group, although the

patients. unit care intensive surgical among complications for infectious factor risk significant a still is PN TGC, of mentation imple successful the Despite CONCLUSIONS: 0.03). = P infection bloodstream (CI)1.14–17.49; interval 95% 4.48; confidence ratio, (odds catheter-related a having the of in odds increase >4-fold a with associated was PN model, regression logistic multivariate a In PN. of administration the with associated significantly was infection bloodstream catheter-related and infection bloodstream of incidence the Nonetheless, 0.002). = P mg/dL, 125.6 vs (118.2 patients daily for the lower were PN for than values the group EN glucose Mean studied. were patients fifty-five hundred One RESULTS: use. PN and outcomes infectious between ation associ the explore to used was regression multi logistic and variate Univariate mg/dL. 110 to 80 was target TGC patients. EN and PN comparing conducted, was unit care Intensive CareUnit, Hospital GeneralUniversitariode Alicante, Alicante, Spain. Martinez M, Menendez-Mainer A, Solera-SuarezM, Sanchez-Payá J. Acosta-Escribano J, Fernández-Vivas M, GrauCarmona T, J, Caturla-Such Garcia- Intensive CareMed2010Sep;36(9):1532-1539. trial traumatic braininjury: A prospective, randomized Gastric versustranspyloricfeedinginsevere ventilated critically illpatients? the negative nitrogen balanceinmechanically Can anadequateenergyintake beabletoreverse in severeTBIpatients. of incidence the overall and late reduces pneumonia and improves nutritional efficacy route transpyloric the delivered through nutrition Enteral CONCLUSIONS: 0.003). = P 0.04–0.6, CI (95% 0.2 OR residuals, gastric increased of incidence lesser had and 0.01) < P 84%, vs (92 group GF the to compared diet of amounts higher received group TPF no significant differences in other nosocomial infections. The pneumonia, OR 0.3 (95% CI 0.1–0.7, P = 0.01). There were (SOFA).RESULTS: of incidence lower a had group TPF The and stay score assessment failure ICU organ sequential stay,and of hospital (GIC), length ventilation, mechanical complications on days gastrointestinal enteral nutrition-related were outcomes Secondary pneumonia. associated Primary outcome was the incidence of early and ventilatory- kg/d. N g 0.2 of intake nitrogen a and requirements energy calculated of kcal/kg/d 25 with diet, same the received They VENTION: Patients were randomized to TPF or GF groups. followed until discharge or 30 days after admission. INTER- were Patients were and admission ICU after h 24 first 2008. the within included December and 2007 April between TBI for admitted patients adult CHI four and hundred One PATIENTS: hospital. university a of unit AND care in intensive an study DESIGN randomized (TBI). open-label, Prospective, patients SETTING: injury brain traumatic severe in pneumonia ventilator-associated of incidence to the regard with (GF) feeding gastric with compared (TPF) feeding transpyloric of efficacy the evaluate To PURPOSE:

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2 - c

), had an acute physiology and 2 metric. RESULTS: Three RCTs with 2 I and t-tests were used to describe teristics; the population agreement charac- between raters the was kappa statistic. evaluated RESULTS: On using admission, the average patient was 50.4 (±14.2) years of age, mass index: 29.0 ± 9.2 kg/m overweight (body Early enteral nutrition reduces mortality in trauma Early enteral nutrition reduces mortality A meta-analysis patients requiring intensive care: of randomised controlled trials [Epub ahead of print] Injury 2010 Jul 7. Sweetman EA. Simpson F, Heighes PT, Doig GS, New South Sydney, University of Sydney, Northern Clinical School, Intensive Care, Australia. Wales, INTRODUCTION: To determine whether the of early provision standard enteral nutrition (EN) confers treatment benefits to adult trauma patients who require intensive care. MATERIALS AND METHODS: MEDLINE and EMBASE were searched. Hand citation review of retrieved guidelines and systematic reviews was undertaken and academic and industry experts were contacted. Methodologically sound randomized controlled trials (RCTs) conducted trauma patients in requiring intensive care that adult compared the delivery of standard EN, provided within 24 h to of injury, standard care were was included. conducted on The clinically primary outcomes, meaningful which analysis included patient-oriented mortality, functional status and quality of life. Secondary analyses regurgitation, pneumonia, bacteraemia, sepsis considered and multiple vomiting/ organ dysfunction syndrome. Meta-analysis was conducted using an analytical method known to minimise bias in the presence of sparse events. The impact of heterogeneity was assessed using the objective of this investigation was to determine if nutritional nutritional if determine to was investigation this of objective status could be reliably classified using assessment (SGA) in mechanically ventilated subjective(MV) patients. global SUBJECTS/METHODS: Fifty-seven patients requiring MV >48 h in a university-affiliatedmedical ICU were evaluated in this cross-sectional study over a 3-month period. Nutri- tional status was categorized independently by two regis- tered using SGA. Frequencies, means (+ s.d.), 126 participants were found to be free from major flaws and flaws major from free be to found were participants 126 early of provision The analysis. primary the in included were chronic health evaluation II score of 24 (±10) and respiratory and (±10) 24 of score II evaluation health chronic as categorized were patients of 29) = (n percent Fifty failure. malnourished. Agreement between raters was 95% before consensus, reflecting near perfectand agreement excellent (k reliability. Patients = categorized 0.90) as malnour ished were more often admitted to the hospital floor before the ICU (n = 32; 56%), reported decreased dietary intake wasting muscle of signs exhibited and 0.02) = P 46%, vs (69 (45 vs 7%, P < 0.001, respectively) and fat loss (52 vs 7%, P < 0.001, respectively) on physical exam when compared SGA CONCLUSIONS: individuals. nourished normally with can serve as a reliable nutrition assessment technique detecting malnutrition in for patients requiring Its MV. routine use should be incorporated into future studies and clinical practice.

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× 100) and the NB were -1 ). A high rate (53%) of inadequate energy -1 and NB was observed (r = 0.670; P = 0.007). CONCLUSION: CONCLUSION: 0.007). = P 0.670; = (r observed was NB and The results show a high rate of inadequate EI and negative NB, and equilibrium between EI and EE may improve NB. require- energy the adjust to used be can calorimetry Indirect ments in the critically ill patients. estimated and associated with kcal/d, 268 ± 1,515 was EE mean The each RESULTS: coefficient. other by Spearman and most of the patients (11/14) presented a negative NB (-8.2 ± 4.7 g.d intake was found, and a positive correlation between EI EE EI between correlation positive a and found, was intake BACKGROUND/OBJECTIVES: The detection of malnu- trition in the intensive care unit (ICU) is critical to appro- priately address its contribution on outcomes. The primary Eur J Clin Nutr 2010 Nov;64(11):1358-1364. Braunschweig CA. Gurka DP, SJ, Peterson Sheean PM, School of Feinberg Northwestern University, Department of Preventive Medicine, USA. Illinois, Chicago, Medicine, Nutrition assessment: The reproducibility of The Nutrition assessment: subjective global assessment in patients requiring mechanical ventilation A systematic review of the address literature pertinent was clinical performed questions to regarding management in the setting of acute spinal nutritional cord injury (SCI). Specific metabolicchallenges are present following spinal cord The injury. acute stage is characterized by a reduction in metabolic as activity, well as a negative nitrogen balance that cannot be corrected, even monitored with accurately be aggressive to need nutritional demands Metabolic support. to avoid overfeeding. Enteral feeding is nasogastric, possible, the not is feeding optimal oral When route SCI. following followed by nasojejunal, then by percutaneous endoscopic is suggested. if necessary, gastrostomy, Acute management of nutritional demands after Acute management of nutritional demands spinal cord injury [Epub ahead of print] 26. Aug J Neurotrauma 2010 Christie S. Singer S, Casha S, Thibault-Halman G, Division of , Capital District Health Authority , Halifax Infirmary, Halifax, Halifax, Halifax Infirmary, Authority , Capital District Health Division of Neurosurgery, Canada. Nova Scotia, Division of Intensive Care, Department of Surgery and Anatomy, Faculty of Medicine of Medicine Faculty Anatomy, Department of Surgery and Care, Division of Intensive Brazil. Ribeirão Preto, of São Paulo, of Ribeirão Preto-University PURPOSE: Adequate energy provision and nitrogen losses treatment for essentials are patients ill critically of prevention energy evaluate to were study this of aims The recovery. and expenditure (EE) and nitrogen balance (NB) of critically ill patients, to classify adequacy of energy intake (EI), and to verify adequacy of EI capacity to reverse the negative NB. METHODS: Seventeen patients from an intensive care unit calorimetry Indirect period. 24-hour a within evaluated were was performed to calculate patient’s EE and Kjeldhal urinary for nitrogen analysis. The total EI and protein intake were calculated from the standard parenteral and nutrition enteral infused. Underfeeding was characterized 90% or as less and EI overfeeding as 110% The or adequacy greater of the of EI EE. (EI EE 2010 Sep;25(3):445-450. J Crit Care A. Basile-Filho Garcia RW, JS, Marchini JP, Monteiro Japur CC, Clinical nutrition 12 CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 abstracts outcomes. Thus, larger therapeutic doses of specific specific of doses therapeutic larger relevant Thus, clinically improve outcomes. to agents pharmacologic as serve to appear doses, therapeutic in given when nutrients, metab for some that vital known now is it But, as repair. and growth, olism, viewed been has nutrition tionally, Tradi nutrients. ability acting the on pharmacologically key also provide to but on provided only are not “pharmaco- calories hinge of many how may area nutrition the Adequate in nutrition.” especially care, critical in nutrition in clinical period we are in a At present, “revival” Aurora, Colorodo, USA. Department of , Denver SchoolofMedicine, UniversityofColoradoat Wischmeyer PE, HeylandDK. Crit CareClin2010Jul;26(3):433-441, vii. The futureofcriticalcarenutritiontherapy patients intheICU. of outcome clinical the improve could nutrition enteral and parenteral of combination the that show to warranted are studies Clinical requirements. is energy meeting in insufficient nutrition enteral when deficiencies nutritional of onset prevent could nutrition parenteral Supplemental ICU. the in nutrition parenteral of use the reconsider to come has time control is obtained and hyperalimentation avoided. Thus, the glycemic a if ICU the in patients in morbidity infectious and on mortality effect significant no has nutrition parenteral all-in-one that suggests evidence Recent outcome. clinical worse a with correlated is deficit protein-energy subsequent and requirements, the energy of coverage insufficient associated with frequently is alone nutrition enteral However, 1980s. the in ICU the in care nutritional of standard gold the as nutrition parenteral replaced alone nutrition enteral tract, gastrointestinal the on effects beneficial its of Because principle. all-in-one nutrition the to according parenteral administered not when was period a hyperglycemia at overnutrition to and related were effects detrimental These associated with increased mortality and is infectious morbidity. nutrition parenteral total of use the that indicate early 1990s and 1980s the intensive in published the Studies (ICU). in unit care commonly implemented been since has and 1960s the in developed was nutrition parenteral Total Nutrition Unit, GenevaUniversityHospital, Geneva, Switzerland. Thibault R, PichardC. Crit CareClin2010Jul;26(3):467-480, viii. improve outcomes? Parenteral nutritionincriticalillness: Canitsafely 0.04–0.91, CI 95% 0.20, = (OR mortality in reduction significant a with associated was EN multi-center trial. large a of conduct the by confirmed be should meta-analysis this of results The small. was size trial and low was quality trial overall promising, is mortality in reduction statistically significant a of detection the Although reduction. CONCLUSION: amortality analytical of confir different presence a the a confirmed and method using analysis conducted sensitivity analysis A matory pooled. be could

I 2 = 0). No other outcomes other No 0). = - - - on how to administer the right nutrients, in the right right the in patients. ill nutrients, critically to time right right the at amounts, the administer answers to to lead how will on nutritional of study the in principles pharma research clinical and clinical biology, basic molecular cology, of use The to hypotheses. underway these are test or planned are trials multicenter Large given. is drug a like much components, separate as admin istered be also can pharmaconutrients Specific be provided. cannot calories enteral adequate when patients at-risk in be used may route by parenteral Supplementation route. enteral the involve via It will preferentially nutrition nutrition patients. early ICU administering of at-risk future in the that outcome thought is on effect has stay (ICU) significant unit a care intensive the in protein and early calories delivered Recent of number states. the that disease imply or also data injury deficiencies specific acute by on replace to brought required be may nutrients people anditsimportancetohealth Assessment andmanagementofnutritioninolder nursing homes [ArticleinSpanish] supplement in malnourishedelderlypatients in Effect ofanoralhyperproteic nutritional meet dailyrequirements. be considered in patients at high risk or in patients unable to should feeding enteral or supplements Oral attention. and care special require impairment cognitive or physical with Patients treated. be must isolation, social and medication , illness, chronic as such causes, underlying and approach, holistic a requires Management practice. clinical in used commonly being Tool Screening Universal trition Malnu- the risk, at patients treat and identify to important is assessment Nutritional people. older in malnutrition of etiology complex the in role a play all illness, psychological and diseases chronic as such aging, of changes pathologic addition In taste. and smell of senses diminish and emptying level, and changes in fluid electrolyte regulation, delay gastric hormonal and cytokine in changes as mass, body lean reduced such functions, physiological and a biological with in coupled decline reduced which, have expenditure, energy often and people appetite Older mortality. and rates, readmission hospital higher surgery, from recovery delayed healing, wound poor function, cognitive reduced anemia, impaired status, is functional muscle function, decreased bone mass, immune dysfunction, and in: decline population a this with in associated increasing is malnutrition prevalence of The process. aging the older affects the and in population health of element important an is Nutrition United Kingdom. Adult andElderlyMedicine, NevillHallHospital, Abergavenny, Wales, Ahmed T, HaboubiN. Clin Interv Aging 2010 Aug 9;5:207-216.

GERIATRICS - - Clinical nutrition abstracts CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 13 - - - - ), ), related orphan g t), and interleukin-17F (IL-17F) were were (IL-17F) interleukin-17F and t), g immune-enhancing diets enriched with arginine, omega-3 fatty fatty omega-3 arginine, with enriched diets immune-enhancing which and acids, RNA resection, for 5 operative days before was prolonged after operative resection by enteral infusion. postop early received group postoperative the in patients Ten no with formula enriched same the of infusion enteral erative Tenpatientsin beforeresection. nutrition operative artificial the control group received total postop nutrition parenteral The eratively. primary endpoint was immune responses; the was endpoint the rate secondary complications. of infectious A Concanavalin (Con A)- or RESULTS: phytohemagglutinin killer natural and proliferation lymphocyte (PHA)-stimulated group perioperative the in higher significantly were activity cell expression (mRNA) RNA Messenger groups. other the in than levels of T-bet, interferon-gamma (IFN- (ROR gammat receptor significantly higher in the perioperative infectious of group rate the than group, perioperative in the In groups. the other was complications reduced significantly compared with that immuno Perioperative in CONCLUSION: the groups. other nutrition reduced after immunosuppression stress-induced a major stressful operative resection. The modulation of Th1/ Th2 and differentiation Th17 response may play important effect. immunologic this in roles Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Thomas Jefferson University, Division of Pulmonary and Critical Care Medicine, USA. Pennsylvania, Philadelphia, Immunonutrition in high-risk surgical patients: patients: Immunonutrition in high-risk surgical of the literature A systematic review and analysis Enteral Nutr 2010 Jul-Aug;34(4):378-386. JPEN J Parenter Zaloga GP. Marik PE, BACKGROUND: Immunomodulating diets (IMDs) have been demonstrated to modulate improve inflammation. However, immune the clinical function these diets benefitin patients undergoing elective surgery is contro- of and versial. The goal of this meta-analysis the was impact of to IMDs determine on the clinical outcomes of patients high-risk undergoing elective review surgery. included prospective, controlled, METHODS: clinical trials that The compared the clinical outcome of elective surgical patients enteral control a or IMD an receive to randomized were who and IMD of type the to according stratified were Studies diet. abstracted were Data IMD. the of initiation the of timing the on study design, study size, patient population, and IMD used. The outcomes of interest were the acquisition of new infections, wound complications, length of (LOS), hospital and mortality. stay Meta-analytic techniques were used to analyze the data. relevant Twenty-one RESULTS: studies were identified, which included a total of Immunonutrition significantly 1,918 patients. reduced the risk of acquired infections, wound complications, and LOS. The similar was effect treatment mortality The groups. both in 1% was rate regardless of the timing of the commencement of the IMD. The benefits of immunonutrition required both arginine and fish oil. CONCLUSIONS: An immunomodulating enteral diet containing increased amounts of both arginine and fish oil should be considered in all high-risk patients undergoing deter be cannot timing optimal the Although surgery. major

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IMMUNONUTRITION helper T (Th17) cell response, and infectious complication rate rate complication infectious and response, cell (Th17) T helper Thirty patients METHODS: after pancreaticoduodenectomy. were into divided who pancreaticoduodenectomy underwent received group perioperative the in patients Ten groups. three BACKGROUND: BACKGROUND: The mechanisms of immunonutrition on understood. poorly still are complications infectious reducing determine to designed was study randomized prospective This whether immunonutrition influences the following factors: cell-mediated immunity, differentiation of T helper type 1 (Th1) and Th2 cells, interleukin (IL)-17-producing CD4 Surgery 2010 Sep;148(3):573-581. A, Kato Ohtsuka M, H, Yoshidome Shimizu H, Kimura F, Furukawa K, Suzuki D, Miyazaki M. H, Yoshitomi Chiba University Graduate School of Medicine, Department of , Japan. Chiba, Effects of perioperative immunonutrition on T helper type 1 (Th1)/ cell-mediated immunity, response after Th17 and Th2 differentiation, pancreaticoduodenectomy INTRODUCTION: INTRODUCTION: Nutritional problems develop - compli cations in geriatric patients and increase and their mortality. morbidity Hyperproteic nutritional supplements one are of the options OBJECTIVES: To assess to the beneficial effect improve and tolerance nutritional deficiencies. of one hyperproteic nutritional supplement High (Ensure Plus Protein, Abbott Laboratories, S.A.) in malnour 2010 Jul-Aug;25(4):549-554. Nutr Hosp Navarro Rubio J, Navarro Calero J, Soler C, Pou JA, Veira Antonio De Ordóñez J, M. Ventura López S, Marcos Olivares Hospital Universitario Marqués de Valdecilla, Santander, Spain. Santander, Valdecilla, Marqués de Hospital Universitario ished subjects over 65 years. METHODS: Observational, prospective, open, multicenter included We study. malnour ished subjects over 65 years living in nursing homes located or <92 score GNRI as considered was Malnutrition Spain. in BMI <19. Before inclusion, we obtained signed consent informed of patients or received Ensure Plus High Protein for 8 weeks. The primary their relatives. GNRI. and BMI weight, in observed changes All were endpoints participants RESULTS: We analyzed 255 evaluable per-protocol the patients for 243 and analysis (ITT) valid intention-to-treat for (PP) analysis; 69% (n = 172) were female and 31% (n = 77) male. The average protein amount administered was 51 g/d. At the end of the study, statistically significant differences (P < 0.001) were found in weight, BMI and compared to GNRI baseline, both in when the ITT and the PP analysis. The average weight increase was (mean ± SE) 2.86 ± 0.13 kg for PP analysis; 80% of participants (n = 202) achieved a a had analysis) PP (39.5% patients 96 and kg >1 gain weight hyper a of addition The CONCLUSIONS: >7%. gain weight proteic oral nutritional supplement contributes positively in improving the nutritional status of our study malnourished geriatric patients in terms of significant increaseweight, BMI and GNRI. in body Clinical nutrition 14 CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 abstracts formula reduced the likelihood of diarrhea. As retrospective As diarrhea. FODMAP of likelihood the reduced formula lower a on initiated being while development, diarrhea predicted independently duration nutrition enteral than any other formula. CONCLUSIONS: Length of stay and this formula was its FODMAP content, being 47–71% lower 0.029; estimated OR 0.18). The only ofdeveloping characteristic unique to in risk = (P 1.5 Isosource on initiated patients in seen was diarrhea reduction five-fold than greater model, a regression alogistic through variables influencing for adjusting After stay 2.1). (OR days use antibiotic >11 of and duration 4.0) (OR nutrition length enteral 4.2), with (OR days associated >21 was diarrhea analysis Univariate showed diarrhea. had 61% receiving patients nutrition, 160 enteral Of g/d. 36.5 to 10.6 from ranged levels FODMAP Formula RESULTS: content. polyols) and mono-saccharides and di- oligo-, (fermentable FODMAP and fiber osmolality, to according classified were Formulas 2003 year to 2008. the Clinical and demographic from data were selected extracted. randomly and coding ICD-10-AM by identified were nutrition histories enteral receiving Medical inpatients of METHODS: composition. formula to attention specific with nutrition enteral receiving patients in ToAIM: unknown. diarrhea with associated factors identify remain causes the nutrition, enteral complicates commonly diarrhea that recognized is it Although BACKGROUND: Department ofMedicine, MonashUniversity, BoxHill, Victoria, Australia. Halmos EP, MuirJG, BarrettJS, DengM, ShepherdSJ, GibsonPR. Aliment Pharmacol Ther 2010Oct;32(7):925-933. (FODMAP) contentoftheformula by thepoorlyabsorbedshort-chaincarbohydrate Diarrhoea duringenteralnutritionispredicted and providea“roadmap”forthepractitioner. issues controversial more the of some clarify to means a as reviewed is adults in immunonutrition of use for guidelines practice clinical evidence-based recent addition, critical In with illness. associated immunity acquired and innate in which immune nutrients can be used to modulate alterations by mechanisms the discusses article This thera- modality. peutic a as immunonutrition of use widespread more the has led to concern among clinicians that in turn has curtailed inappropriately.used are potential nutrients immune when harm This suggested have meta-analyses several However, illness. critical medical and surgical with patients of subsets effects on immune function has been shown to be beneficial in Dietary supplementation with nutrients that have physiologic Department ofMedicine, Chicago, UniversityofIllinoisat Chicago, Illinois, USA. Mizock BA. Nutrition 2010Jul-Aug;26(7-8):701-707. Immunonutrition andcriticalillness: An update be initiatedpreoperativelywhenfeasible. immunonutrition that suggested study,is this it from mined

NUTRITION SUPPORT

nevninl td ivsiaig OMP i enteral in formula isindicated. FODMAPs investigating study interventional an relationship, cause-effect a support not does evaluation the developmentofguidelinesshouldbeadvanced. burden, economic increasing an also cause wounds, especially chronic wounds, Because evolved. has standard golden no far thus but guidelines develop to approaches some are There notice. special deserves that process complex very a indeed is healing Wound applicable. if supple- quickly, start mentation to necessary is patients of status nutritional the of survey close a reason surgery.that or For injury as after such stress of phases catabolic in geriatric patients and in patients common very is Malnutrition patients. ished malnour and undernourished for challenging very be can This reserves. protein and stores energy body from released usually is cells new of building the for energy The needed. is energy much process wound-healing the During wounds. non-delayed wound healing and prevention for of the development of essential chronic is good wound the and of documentation management wound local Therefore, routine. wounds. chronic Chronic in wounds demand many resources in the clinical result daily can this negatively, affected is process wound-healing various the If factors. extrinsic on and intrinsic forward depending progress phases the can through it backward process; and linear healing a always wound not However, is components. specific that events require certain by and into characterized is divided proliferative, Each (inflammatory, maturation). be can phases that different process three a is healing Wound University ClinicofSurgery, Paracelsus MedicalUniversity, Salzburg, Austria. Wild T, Rahbarnia A, KellnerM, SobotkaL, Eberlein T. Nutrition 2010Sep;26(9):862-866. Basics innutritionandwoundhealing end-stage liverdisease. in strategies treatment and status, nutritional assess to used methods malnutrition, of causes the addresses article This population. patient this in outcomes clinical improve can oral through feeding parenteral or feeding, tube enteral supplementation, deficiencies nutrient of compli- Correction malnutrition-associated cations. prevent to intervention appropriate allow to important is diagnosis Early outcomes. clinical affects adversely and cause, of irrespective disease, liver end-stage in common is malnutrition Protein-calorie UniversityHospital,Emory Atlanta, Georgia, USA. Nutrition andMetabolicSupportService, DepartmentofPharmaceuticalServices, Zhao VM, Ziegler TR. Crit CareNursClinNorth Am 2010Sep;22(3):369-380. Nutrition supportinend-stageliverdisease Missouri, USA. Division ofGastroenterology, University ofMissouriSchoolMedicine, Columbia, NM,Szary Arif M, ML, Matteson Choudhary A, PuliSR, BechtoldML. J ClinGastroenterol2010 Aug 20. [Epubaheadofprint] A meta-analysis percutaneous endoscopicgastrostomy placement: Enteral feedingwithinthree hoursafter

- Clinical nutrition abstracts CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 15 - - PEDIATRICS

Effect of early enteral nutrition on morbidity and Effect of early enteral nutrition on mortality in children with burns Burns 2010 Nov;36(7):1067-1071. Mansouri F. Khorasani EN, Mashhad, Kermanshah University of Medical Sciences, Department of Pediatrics, Iran. Khorasan, Burns increase the metabolic demands can lead of to severe weight the loss and body increased risk and of death. Early enteral support is believed to improvetinal, immunological,gastrointes nutritional and metabolic responses criticalto injury; thispremisehowever, needinisfurtherof substantiation by definitive data. This researchexamineeffectivenessthe aimedsafetyearlyandenteralof feeding to in pediatric patients suffering from ANDMETHODS: burns. Thisclinical trial wascarried MATERIALSoutwith a totalnumber688 childrenof withburns hospitalized thein BurnDepartment across 2-yeara period (September 2002– September 2004). The two subjects groups. A were total of randomized322 patients venousresuscitation, intoreceived in accordance onlywith current treatment intra protocols, in the first 48 h and were considered as the late enteral nutrition group (LEN group); 366nourished patients early were enteral such nutrition that both group groups received (EEN similar in the group), first amounts 48 h. Initiation of of enteral fluidnutrition commenced between 3 and 6 were hkept in the following unit until thethey were discharged. burn.management Wound did The not vary patientsbetween groups. RESULTS: our study, Inthe mean age was 5 ± 3 years in the LEN group and 5 ± 3.5 years in the EEN group. Hot liquids were the most common cause of burns in both groups.percentage The of mean burn was reported as 20 ±group 13 and in22 ±the 15 LEN in the EEN group. Meanhospitalization duration of was 16.4 ± 3.7 and 12.6 days ± 1.3 in in the the EEN group LEN for groupcured 0.05).patients A total (Pof 40 < patients (12%) in the LEN group and 31 patients (8.5%) in the EEN group expired (P CONCLUSION:< 0.05). Our research showed that EEN decreases duration of hospitalization and mortality in children with burns. unwell patient. The literature suggests that theequations are fairly accurate predicted compared to measured energy expenditure in free living obese patients before these findings cannot directlybe However, bariatricsurgery. and after applied to those obese patients experiencing complications of bariatric surgery, who will be acutely unwell exhibiting inflammatory response. It is therefore necessary to refer to the literature on energy expenditure in hospitalized obese patients, to help guide practice. More research examining the energy and protein needing requirements nutrition of support obese following patients urgently bariatric required. surgery is

- - - - 72 ≤ 3 h) ≤ 3 h) after ≤ 72 hours, or number ≤ 72 hours,72 andsignificant 3 h) and delayed or next ≤ ≤ 3 hours after PEG placement ≤ measure of inconsistency. RevMan 5.0 2 I

of significant gastric residual volumes at day 1. was utilized for statistical analysis. RESULTS: Five studies (n = 355) met the inclusion criteria. No significantences differ were noted between early ( day feedings for patient complicationsconfidence interval (CI), 0.39–1.53; P = 0.47], [ORdeath in 0.78; 95% numberand0.40), = 0.18–1.99;CI,P 95%0.60; (ORhours of significant gastric residual volume during1.46; 95% dayCI, 0.75–2.84; 1P = (OR 0.27). No publication andbias no significant heterogeneity were noted. CONCLU SIONS: Early tube feeding hasnosignificant differences to delayed or next-day feeding in respect to complications, death in This review details the practicalities of providing nutrition support to obese patients who followingbariatric experience surgeryhighlightsandnutri the ofsome complications Proc Nutr Soc 2010 Nov;69(4):536-542. Segaran E. Trust, Imperial College Healthcare Hospital, St Mary’s Department of Dietetics, United Kingdom. London, Provision of nutritional support to those Provision of nutritional support to complications following bariatric experiencing surgery tional challenges encountered by this Bariatric group of surgery patients. to cantly treat increased internationally over morbid the past decade obesitywith hospital admissions has rising annually. signifi The gastric bypass is currently the most commonly performed procedure. complication Therate can be up to 16%, with a considerableproportion having nutritional implications. The treatment can involve avoidance of oral diet and nutrition ie, support, enteral or parenteral nutrition. Opposition to nutrition of aims theclarify to useful is encountered.Itbe cansupport nutritionsupport, these being: the avoidance of overfeeding and its consequences, preservation of lean body mass and promotion of healing. Evidence suggests that hypoenergic nutrition is not harmful and may Thereis alack of consensus regarding the optimum actuallymethod be beneficial. to predict the nutritional requirements in the obese acutely percutaneous endoscopic gastrostomy abstractsrecent anddatabasesmedical (PEG) Various METHODS: placement. from major conference proceedings were searched (8/09). Only RCTs on adult subjects that compared early versus ( delayed or next-day feedings after PEG were placement included. Meta-analysis was performed using pooled estimatescomplications,of death increases in the number of postprocedural gastric residual volume during day 1 using odds ratio (OR) with the fixed and random effects models. Heterogeneity was assessed by calculating the BACKGROUND: Traditionally, tube feedings have delayed been after gastrostomy placement to the next day up and to 24 hours various postprocedure. randomized clinical However, trials results (RCTs) indicate feeding from may be earlier an option. Therefore, we conducted a meta- analysis to analyze the effect of earlier feedings ( Clinical nutrition 16 CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 abstracts pretation ofanthropometric dataneedatailored approach. inter and status nutritional of assessment children, talized hospi- in syndromes and conditions medical of diversity the of Because admission. during malnutrition developing for risk at children identify to available are tools screening New status. nutritional of interpretation appropriate for used be conditions and syndromes, specific growth references should country- specific growth references. For children with specific medical with compared rates malnutrition of estimation under and over- of risk a is there but reference as used be The new World Health Organization child-growth charts can but has a few advantages in the general pediatric population. malnutrition acute of definition the for used be also can age for index respectively.mass malnutrition, Body chronic and height-for-age and Weight-for-heightstandard deviation scores are used for classification for acute data. prevalence interpreting when account into taken be to have that issues current describe to is review this of purpose The conditions. clinical and disease underlying with children in especially prevalent, very still is children hospitalized in Malnutrition Hospital, Rotterdam, The Netherlands. Department ofPediatrics, Pediatric IntensiveCare, ErasmusMC-SophiaChildren’s Joosten KF, HulstJM. Nutrition 2010 Aug 12. [Epubaheadofprint] Current issues Malnutrition inpediatrichospitalpatients: cow’s milk-freediet. a followed have or follow who children in concern of are adhered to. Low intakes of D, calcium, and well riboflavin was CMA with diagnosed children of diet elimination therapeutic milk The of CONCLUSIONS: reintroduction diet. the at into age products the to nor studied factor sociodemographic other any to related neither was diet the to Adherence dietitian/nutritionist. a by information tional nutri- of absence the of because possibly diet, their in CMP of amounts small often more had children monosensitized and Older cases. the of 85% in accuracy extreme with child RESULTS: The families adhered to the elimination diet of the the ageatreintroductionofmilkproductsinchild’s diet. assess to studied were records food Subsequent to. adhered was diet elimination the strictly how define to studied were CMA with diagnosed children 267 of records food study, cohort birth a From SUBJECTS/METHODS: recovery. of age and adherence the with associated factors the evaluate to to and diet elimination the CMA, to adherence of degree the assess of diagnosis a with children of diet the terizing charac- at aimed study This diet. the from (CMP) proteins for cow’s milk allergy (CMA) is the elimination treatment of all cow’s milk basic The BACKGROUND/OBJECTIVES: Department ofPublicHealth, UniversityofHelsinki, Helsinki, Finland. Simell O, IlonenJ, KnipM, Virtanen SM. Tuokkola J, KailaM, Kronberg-KippiläC, SinkkoHK, Klaukka T, PietinenP, Veijola R, Eur JClinNutr2010Oct;64(10):1080-1085. milk intothediet therapeutic eliminationdietandreintroductionof Cow’s milkallergyinchildren: Adherence toa

- - is more likely after age 5 years. eventually ceased feeds successfully, childrenbut majority of slow CONCLUSIONS: growth. A slow andwith failed weaning associatednotwasthisindex, massbutbody decline in a by commonlyreductionfollowedFeed0.04).was = [1.1–43];P 0.025)=P orto have [1.3–42];taken more 7.4 than yeara to stop (OR (OR 6.9 feeds artificial on be still to likely more oralsupplement drinks. Thosereferred on yearsafter reliantwere5age were two and fed enterally still were seven diet, solelynormalon(0.4–5.4)(range)were(78%) 1.7years,32 reductions.feedmakesupportto Afterfollow-up medianfor extremelyanxious aboutweight loss neededand considerable enteraloften1,987–9,728)feeds.Parentsfromweredaily kJ before(range3,766reductionandmedianofreceivedthey a 4.0(range 0.7–15) years when first seen; 27 (66%) were male over a 5-year period. RESULTS: The children were agedclinic database median for all 41 children referred for feed withdrawal Clinical and anthropometric data retrieved from case notes and successfulwithcessation. feed SUBJECTS METHODS:AND associated factors identify and growth on reduction feed of actions and relieve parental anxiety. AIMS: To assesscombined thewith psychological impact input to improve mealtime inter stimulatehospital,volumetohunger,reductionfeedusing of multidisciplinary provides management which of ‘hard teamto wean’ feedingchildren within aa large children’sdescribe authors The difficult. be may diet normal to transition the BACKGROUND:Enteralfeeding vitalsickinfants,foris but Department of Child Health, University of Glasgow, Glasgow,Wright United CM, Kingdom.Smith KH, Morrison J. Arch Dis Child and failure enteral feeding: Factors associated with success Withdrawing feeds from children on long term disease. beenshown effective forthe treatment ofinflammatory bowel exclusive enteral nutrition and therapy have rest bowel with nutrition parenteral only disease, bowel inflammatory their treat help to diets manipulate patients their manyAlthough canimprove comorbid conditions like osteopenia and anemia. likewise, identifying correcting micronutrient and deficiencies growth; improve can macronutrients Providing morbidity. ative colitis and Crohn’s disease and is associated tritionwith increasedis a common presenting symptom in both pediatricmanagement ulcer of inflammatory bowel disease in children.Nutrition Malnu interventions play a central role in the treatment and Washington, USA. Department of Pediatrics, Seattle Children’s Hospital, UniversityMallon DP, of Washington, Suskind DL. Seattle, Nutr Clin Pract Nutrition in pediatric inflammatory bowel disease Scotia, Canada. Department of Gastroenterology, IWK Health Centre, DalhousieOtley University, AR, Russell Halifax, RK, Day NovaAS. Expert Rev Clin Immunol Crohn’s disease Nutritional therapy for the treatment of pediatric 2010 Jul 23. [Epub ahead of print] 2010 Aug;25(4):335-339.

2010 Jul;6(4):667-676.

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2010 May;64(Suppl 1):S22-S24. May;64(Suppl 2010 2010 May;64(Suppl 1):S5-S7. May;64(Suppl 2010

Nutritional screening and guidelines for managing managing for guidelines and screening Nutritional growth faltering with child the Nutr Clin J Eur MC, R. Meyer Erasmus K, Hospital, Joosten Children’s Sophia Care, Intensive Paediatric of Department Netherlands. The population pediatric hospitalized the in common is Malnutrition malnu define (Joosten and to used Hulst, 2008). cut-offs Across the Europe to the documented according varies prevalence Protein and energy requirements for ‘optimal’ ‘optimal’ for requirements energy and Protein growth catch-up Nutr Clin J Eur Sick for Hospital PB. Institute, Pencharz Research Sciences, Nutritional and Paediatrics of Departments Canada. Ontario, Toronto, Children, considered be can childhood in requirements energy and Protein as being made up of such components as and maintenance growth (Panel on 2002/2005; Report Macronutrients, of a of Report 2004; Consultation, Expert FAO/WHO/UNU Joint a Joint Expert WHO/FAO/UNU 2007). Consultation, This can approach readily be applied to the of question catch-up growth (Report of a Expert Consul Joint WHO/FAO/UNU tation, 2007). depend Enteral nutrition requirements on the acids) (amino protein of absorption and digestion of efficiency and non-protein energy ( and ; 2002/2005). Panel Macronutrients, on malnu that thought disease-associated It trition. is, however, (Joosten children of hospitalized 15–30% about affects trition requirements Nutrient 2008). al., et Pawellek 2008; Hulst, and children growing in higher significantly are weight body kg per al., et (Agostoni lower are stores body whereas adults, in than 2005). This makes the young child more vulnerable to recog early for the requirement the hence of malnutrition, effects Over 2005). al., et (Agostoni treatment appropriate and nition hasemerged ofbody evidence a significant few years, the last inpediatric the screening ofnutritional at efficacy the looking advances have Similarly, population. also been guide of made in development the the and growth faltering of management regard. this in professionals healthcare aid to lines when the digestive tract is functioning, EN support is preferred preferred is support EN functioning, is tract digestive the when of method EN is effective a and safe nutrition. can parenteral and over diseases, pediatric of range wide a for support nutrition in Indica several chronic conditions. undernutrition alleviate by or requirements incapacity include in children nutritional feeding tube for enteral tions meet to inability eat, to ability observed limited frequently (as aspiration of risk high alone, intake oral in neuro-muscular disorders or and psychomotor in metabolism, altered losses, retardation), some nutritional increased support EN of goal The management. disease primary as cases nutri child’s the or improve be to maintain should in children and symptoms gastrointestinal minimizing while status, tional and child the of both of life quality the of improving/maintaining administration easier are advantages Secondary treatments. with caregiver. the compliance better so and medications and rehabilitation; and fluids education for time more preserve pleasure. also for can EN feeding oral encourage to important however, is, it

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2010 May;64(Suppl 1):S17-S21. May;64(Suppl 2010 panied by undernutrition, and when dietary measures are insuf are measures dietary when and undernutrition, by panied of these children, requirements to theficient fulfill nutritional enteral nutrition (EN) may be needed. In clinical practice, Many severe and/or chronic diseases of childhood can be accom be can childhood of diseases chronic and/or severe Many Eur J Clin Nutr Nutr Clin J Eur PB. Flandre Sullivan de Jeanne F, Gottrand Nutrition, and Hepatology Gastroenterology, Pediatric of Department France. Lille, Hospital, University Children Gastrostomy tube feeding: When to start, what to to what start, to When feeding: tube Gastrostomy stop to how and feed Enteral nutrition support (ENS) involves both the delivery of both the delivery involves (ENS) support nutrition Enteral oral specialized of provision the and tubes feeding via nutrients in at with a ENS is patient indicated supplements. nutritional is intake oral when tract digestive functioning a partially least to meet is food of inappropriate or normal intake inadequate Committee the by comment this of aim The needs. patients’ the Gastroen for of Pediatric on Society the Nutrition European Braegger C, Decsi T, Dias JA, Hartman C, Kolacek S, Koletzko B, Koletzko S, Mihatsch Mihatsch S, Koletzko B, Koletzko S, Kolacek C, Hartman JA, Dias ESPGHAN J; T, Goudoever Decsi van C, D, Braegger Turck H, Szajewska R, Shamir J, Puntis L, Moreno W, Nutrition. on Committee Switzerland. Zurich, Hospital, Children’s University and Hepatology, Nutrition terology, is to provide a the and clinical evidence available the on based ENS, to guide practice clinical expertise of the authors. and Statements recommen are and dations needs presented, future research highlighted, to on placed approach a emphasis practical with a particular standard formulations, enteral of array wide the Among ENS. age and fiber with protein cow’s-milk on based feeds polymeric for most are suitable content and nutrient for energy adapted is preferred intragastric possible, Whenever patients. pediatric is feeding intermittent and nutrients, of delivery physiological. postpyloric to more is it because feeding continuous to preferred An duration of anticipated enteral nutrition (EN) exceeding or enterostomy. gastrostomy for 4 is to an 6 indication weeks percuta available, techniques gastrostomy various the Among In the option. first is currently gastrostomy endoscopic neous with satisfaction express and caregivers patients both general, well- of number a with associated is it although procedure, this the devel recommend strongly We complications. recognized that of include protocols opment and procedural application monitoring as regular as well to hygiene, attention scrupulous the to team minimize support nutrition by a multidisciplinary complications. EN-associated of risk Practical approach to paediatric enteral nutrition: A nutrition: enteral paediatric to approach Practical nutrition on committee ESPGHAN the by comment Nutr Gastroenterol Pediatr J Crohn’s disease Crohn’s and colitis ulcerative are lifelong conditions condi with these particular effects for upon nutrition, especially in available children are Various adolescents. and tions but there remains no cure. Over the last decades, exclusive exclusive decades, last the Over cure. no remains there but tions efficacy have to demonstrated been has (EEN) nutrition enteral in the induction of the remission, reviews along article This with benefits. numerous inflammatory and other nutritional disease. Crohn’s in EEN with associated outcomes and benefits along highlighted, are therapy this of mechanisms potential The EEN. of use wider the to barriers are that factors with Highlights of

18 nd CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 32 ESPEN Congress increased thenutrient deficits. wasting severe and REE, highest the had therapy radiation al. et (Ravasco P, deficiencies intake nutrient expenditure and wasting (REE), energy resting increased with history associated are cancer and disease advanced Furthermore, 450). chemotherapy and P,al. (Ravasco et surgery previous intake, duration, nutritional disease location, tumor staging, advanced loss, weight including depletion, nutrition with signifi- associated cantly are to factors individual Various the anorexia’. ‘voluntary promotes develop these as such symptoms of presence The decline. cognitive and depression dysosmia, dysguesia, dysphagia, pain, constipation, diarrhea, satiety, early vomiting, nausea, symptoms, flu-like fatigue, include K. Arends (VanE, anorexia Cutsem to leading cancer of process the discussed Arends and VanCutsem by article functionality.in decrease to leads weakness muscle review A Skeletal theorgans. to spare muscle sacrifices body the as occurs wasting Muscle patients. cancer ambulatory all of and 51% before chemotherapy, and is present in around 80% cancer patients before surgery, 57% before Nutr 2008;27:793-799). al. et is WJ, (Evans morbidity increased and with associated hyperthyroidism, and malabsorption depression, primary mass, muscle of loss age-related distinct starvation, from is Cachexia cachexia. are with breakdown associated frequently protein insulin muscle increased inflammation, and resistance Anorexia, disorders). endocrine (excluding failure growth is children in and for retention) fluid (corrected loss weight is adults in clinical cachexia of prominent feature The mass. of loss without or muscle with of loss by characterized is and illness, underlying with associated syndrome metabolic complex a is Cachexia Nutritional supportincancer Educational LLLsession: cachexia Mechanisms ofwastingincancer P Ravasco (Portugal)P Ravasco 2005;9(Suppl 2):S51-S63). Symptoms 2):S51-S63). 2005;9(Suppl Nurs Oncol J Eur Ravasco explained that weight loss occurs in 75% of all 072:0-1) Nnrsodr to Non-responders 2007;25:308-314). Invest Cancer 5–8 September 2010 • Nice, France Nice, • 2010 September 5–8 32 of Highlights nd 2003;15:443- Radiol) Coll (R Oncol Clin ESPEN Congress ESPEN Clin acr ad nrae lvl o tmr erss factor- necrosis tumor (TNF- of levels intake increased aggressive and nutrient state, cancer, disease decreased advanced with with associated were coupled loss weight Ravasco increased and REE proteins. increased that reported phase colleagues and and acute of REE production increase promote breakdown, fat promote Cytokines E, Cutsem K. (Van Arends cachexia and anorexia with associated indirectly or directly either occur cytokines with may cancer, during inflammation Systemic psyche. and function al. Cancer et P, (Ravasco (QoL) life of quality of and determinants loss independent all are intake weight nutrient decreased location, and staging Cancer anorexia. but QoL changes don’t fully explain cachexia. explain fully don’t changes QoL but anorexia, of absence the Ravasco in occur can lipolysis. cachexia that noted increases which lipase lipoprotein levels of decreased and adipocytes, of lipolysis increased due to are cachexia of demands energy pathway. phase increased for mobilized proteolytic acute the and through gluconeogenesis response liver causes degra dation protein Muscle mortality. to and leading immobility patient degradation, protein increased and synthesis Cachexia (PIF). protein with decreased loss, muscle skeletal factor selective causes inducing proteolysis factor and mobilizing (LMF) also produce and to cells pathways, tumor stimulate anabolic over pathways catabolic favor that products tumor with together work Cytokines wasting. tissue in involved are factors Other loss. cause weight to sufficient not are alone but degradation, muscle to promote acids amino scavenge may proteins phase acute al. et DC, (McMillan mg/L 10 shorter than lower with levels than survival associated are mg/L 101 than higher levels (CRP) protein C-reactive patients, cancer in that reported (Barber survival decreased MD. and loss with weight associated rapid was more response phase acute increased an al. et P, (Ravasco (VEGF) factor growth endothelial vascular and Nutr Cancer Nutr Nutr Clin Pract Clin Nutr Cancer changes life perceptions and may lead to to lead may and perceptions life changes Cancer α 2004;12:246-252), while semi-starvation impairs impairs semi-starvation while 2004;12:246-252), , nelui- (L1, L6 interferon- IL-6, (IL-1), interleukin-1 ), acr J Cancer u J no Nurs Oncol J Eur 2001;41:64-69). Ravasco explained that that explained Ravasco 2001;41:64-69). 2007;13:392-398). Barber noted that that noted Barber 2007;13:392-398). 2002;17:203-209). McMillan et al. al. et McMillan 2002;17:203-209). 2005;9(Suppl 2):S51-S63). 2):S51-S63). 2005;9(Suppl Support Care Care Support γ (IFN- γ α ) - Highlights of 32nd ESPEN Congress CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 19

- 1998;34:503- 2009;96:197-205). 2009;96:197-205). Eur Eur J Cancer 2004;90:996-1002). Fearon 2004;90:996-1002). Br Br J Surg 2005;23:1431-1438). Similarly, Similarly, 2005;23:1431-1438). 1980;69:491-497). Hendry and and Hendry 1980;69:491-497). Am Am J Metab Physiol Endocrinol Br Br J Cancer Am J Am Med J Clin Oncol Clin J 2005;19:422-424). Moses et 2005;19:422-424). al. found that the made no to of difference duration stay hospital or 2 2000;46:813-818). Nutrition counseling on protein intake intake protein on counseling Nutrition 2000;46:813-818). FASEB FASEB J G Grecu (Romania) Benefits and limitations of conventional nutrition support for cancer patients K Fearon (United Kingdom) Clinical priorities for solving nutritional problems Nutritional support in ICU patients Upper gastrointestinal Upper (GI) gastrointestinal cancer is the cancer most lung by likely cancer followed loss, weight with associated be to type al. et WD, (Dewys patients, cancer colorectal 1,035 among that found colleagues having a body mass index (BMI) less than or greater than 20 kg/m physical activity level of cancer patients was very low, and that that and low, very was patients cancer of level activity physical regimen an or exercise maintain to it implement is important (Moses et AW, al. that concluded weight loss impacts and treatment outcomes benefit ONS of use the including regimens nutrition cancer; in alone. feeding by wasting reverse to difficult is it but QoL, 509). Beattie et al. found that progressive weight loss occurred occurred loss weight progressive that found al. et Beattie 509). after discharge; however, patients randomized to postoperative oral receive nutritional supplementation (ONS) had than and QoL and morbidity less status nutritional improved et AH, al. (Beattie supplementation receive not did who those Gut was during with radiotherapy associated increased sustained oral intake, increased QoL scores and maintained function al. et P, (Ravasco intervention with a high protein ONS and limited QoL oral and scores intakes, function. improved dietary instructions nutrition conventional of efficacy the to block partial a is There the partial whether and questioned Fearon in support cancer, mediators, catabolic inflammation, to secondary be may block decreased physical activity and increased age, all working together to cause suboptimal response to nutrition support in cancer cachexia. Barber et al. looked at fibrinogen total rate, and synthetic the needed to strategies inflam modulate mation (Barber MD, et al. found and that colleagues Cuthbertson 2000;279:E707-714). the elderly have to therefore, anabolic resistance; counteract this, protein increased intake is D, required (Cuthbertson et al. Andreyev et al. found that in patients with GI cancer and weight weight and mortality (Hendry cancer PO, GI et with al. patients in that found al. et Andreyev loss, rate response to and decreased treatment these patients received 1 outcomes month less survival of and than chemotherapy those decreased without QoL furthermore, loss; weight HJ, et al. (Andreyev were poorer - - Clin J Clin Oncol 2010;18:265- 2002;10:385- 2009;9:489-498). 2010;142:531-543). Laviano 2005;2:158-165). Decreased Cell Metab Cell Support Care Cancer Support Care Cancer Nat Clin Pract Oncol The regulation of food intake is controlled by the The traditional view of cachexia is that cancer Ravasco Ravasco commented that the wasting seen during 2010;29:154-159). Cancer anorexia A Laviano (Italy) matory response causes serotoninet al. release (Laviano A, fatty acid oxidation in the brain may decrease appetite. In contrast, n-3 fatty acids can decrease cytokine levels, and may increase appetite. Serotonin levelswith branched-chain amino canacids, and ghrelin can increase be lowered the activity of anti-anorexic neurons to increase appetite. A recent paper showed that in animal models, pharmaco logical blockade of the Act RIIB pathway reversed cancer cachexia (Zhou X, et al. concluded by stating that the most effective way anorexiato is to eradicatetreat the tumor. 388). Lasheen and examinedWalsh the impact of anorexia on mortality, and found that no survival anorexia or of weight patients loss was with significantlypatients longer than with the (Lasheen Walsh D.W, cancer anorexia-cachexia syndrome During cancer anorexia, there is hypothalamus an insensitivity to of peripheral the signals, while the inflam The definition of anorexiapatientscancerlung ofdiagnosis,50–60% aboutsatiety’.At is ‘pathologically persistent have reduced appetite. following QoLa 20% decrease in nutrient intake and decreased function scores appetite.Earlysatietyassociatedisincreased anwith ofrisk decrease death (Walsh D, et al. 272).Muscaritoli colleaguesand developedassessscaleto a nausea, vomiting, satiety, and change in taste and smell to help identify at-risk patients (Muscaritoli M, Nutr et al. hypothalamus (Woods SC. 2005;23:1431-1438). anorexia leads to weight describedthe emerging lossview; cancer cachexia is secondary and cachexia. to Ravasco metabolic changes, anorexia, systemiccatabolic inflammation, factors, progression. cytokine The evidence argues production, for earlyindividualized the nutritional counselingadjunctive integration anas and of tumor therapyto the oncology team approach for cancer therapy and patient management (Ravasco P, et al. cancer influences the patient’s clinical course and significantly and course clinical patient’s the influences cancer decrease A mortality. and morbidity prognosis, poor indicates in QoL, functional capacity and physical activity, together with an impaired immune function, treatment-related result morbidity in and increased decreased with a decreased treatment radiotherapy and chemotherapy, tolerance to survival. response and decreased Highlights of

20 nd CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 32 ESPEN Congress that the thermogenic effect of food (an increased energy energy increased (an food of effect thermogenic the that S, (Henneberg al. fever et to lead may overfeeding and 864), al. et is P, nutrition (Nardo parenteral administered when overfed often are Patients S, et al. (Dissanaike calories teral paren average increased and calories parenteral maximum increased include ICU the in infections bloodstream oping versus measured al. Nutr of et C, (Faisy benefits expenditure energy the estimated discussed and 223) al. et KG, (Kreymann ICU the in needs energy for guidelines ESPEN the reviewed Hiesmayr ICU. the from discharged are they once intake protein and calorie increasing for dations recommen need patients that concluded Grecu mortality. 6-month to related was admission upon status nutritional (Dardaine 52% al. was et V, discharge ICU after months 6 rate mortality the that found hours 24 least at mechanical for by ventilation treated and ICU the to admitted patients by D, et al. and problem, a (O’Meara be is administered goal of 50% calorie only 10, day to continues feedings enteral in nutrition enteral A, et of al. (Reintam initiation earlier to lead may which residuals, gastric of that instead intolerance, food used determine be found to could pressure colleagues intra-abdominal of and measurement Reintam provided. rarely nutrition parenteral supplemental with nutrition, enteral start to hours 46.5 took it an average, On 2010;38:395-401). received al. et patients NE, (Cahill of intake protein 60% adequate only adequate and an reached intake, patients energy of 59% only that found survey 2010 medicine care critical The al. 2008;36:296-327). et RP, (Dellinger 2008 of Sepsis Campaign Surviving Guidelines: ICU the Often in Nutrition mentioned therapy. not ICU. is ‘adjuvant’ the an in considered is support nutrition nutrition to impediments al. Care et I, Crit J (Khalid Am vasopressors of stable doses is decreasing patient on or ventilated the when hours) 48 (within nutrition enteral early giving by reduced be can hospital mortality vasopressors, on patients ICU unstable In 509). al. et S, (Villet on outcomes impact clinical negative a has feeding patients. hypocaloric (ICU) Prolonged unit care intensive for support adequate and nutrition early providing to impediments are There M Hiesmayr (Austria) Hiesmayr M ICU the in care and nutrition in Homeostasis 037:4-4) Srn rs fcos o devel for factors risk Strong 2003;78:241-249). ln Nutr Clin Am J Crit Care Am J Crit A Grar Soc Geriatr Am J 2010;19:261-268). Grecu reviewed the the reviewed Grecu 2010;19:261-268). 1991;10:266-271). Hiesmayr explained explained Hiesmayr 1991;10:266-271). Crit Care Crit 2008;17:53-61). A study in elderly in elderly A study 2008;17:53-61). 2008;12(4):R90). Interruption Interruption 2008;12(4):R90). 2001;49:564-570); impaired impaired 2001;49:564-570); Crit Care Crit ln Nutr Clin Clin Nutr Clin Clin Nutr Clin 2007;11:R114). 2007;11:R114). Med Care Crit 2008;27:858- Med Care Crit 2005;24:502- 2006;25:210- Am J Clin Clin J Am - - -

lactic acidosis. lactic prevent to thiamine of provision and only goal, energy of at 50% feeding begin electrolytes, monitoring screening, include which Kingdom, United the from recommendations NICE the and syndrome refeeding prevent to how reviewed Hiesmayr IBW/d. kcal/kg 20 average an with kcal/d 1,300 1,000– was ICU the in intake energy average The results. NutritionDay ICU the reviewed Hiesmayr overweight. or be should intake the on depending adjusted whether the patient is under-, normal provided; 0–3), be days can (on kcal/kg/d initially 20–35 expenditure possible energy not measure is it to if that explained are Hiesmayr decreased. when mg/kg/d 3.5 keep under to intake important is lipid It cause. the be may overnutrition mL/kg/min, >150 is ventilation minute and >1 is quotient CO contrib a increases rate be metabolic increased may factor.addition, In uting protein) for 20–30% of expenditure 1767). However, the use of parenteral nutrition was was death. of nutrition risk increased an parenteral with of associated use the However, parenteral 1767). and al. et enteral G, (Elke mixed nutrition or often parenteral patients these received shock, septic or patients 415 sepsis in severe that with found ICUs German 454 of study gastric al. with et mL JC, Med that 500 (Montejo to effects increased revealed adverse be no could nutrition volume patients residual ICU enteral 329 in study receiving A organ syndrome. multiple of dysfunction development the in involved communicate, are and bacteria commensal and system immune CM. Coopersmith JA, Shock (Clark ‘crosstalk’ intestinal and less stays nutrition. enteral than often ICU during provided was nutrition parenteral while coma, a in or ventilation mechanical receiving those stay, and expected a long with patients to administered was nutrition Enteral nutrition. parenteral or enteral receiving patients than sick less were and stay of length a shorter had ONS receiving patients ICU that found 2010 of survey ICU since surveys were conducted in the mid-1990s (Berger (Berger mid-1990s the al. et MM, in conducted were surveys ICU the since in increased has nutrition enteral of use the decreased and has use nutrition Parenteral 1999;25:95-101). al. received et JC, patients (Preiser of support 67% nutrition only that revealed that ICUs European of survey a from results earlier reviewed Preiser JC Preiser (Belgium) Preiser JC nutrition parenteral and enteral oral, to Barriers 2 production and minute ventilation. When respiratory respiratory When ventilation. minute and production 2010;36:1386-1393). A 1-day point-prevalence point-prevalence 1-day A 2010;36:1386-1393). Preiser discussed the effects of gut starvation starvation gut of effects the discussed Preiser 2007;28:384-393). The intestinal epithelium, epithelium, intestinal The 2007;28:384-393). Nutrition 1997;13:870-877). The NutritionDay NutritionDay The 1997;13:870-877). Crit Care Med Care Crit Med Care Intensive 2008;36:1762- Intensive Care Care Intensive -

Highlights of 32nd ESPEN Congress CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 21

12 12 Am J Clin Nutr Am J Clin Nutr Cochrane Database Syst Rev Am J Clin Nutr 2003;78:496-497). Vitamin J Nutr 2008;138:5-11). A Cochrane meta-analysis It is estimated that in excess of 10–25% of the Gastrointestinal diseases can lead to reduced Vitamin D in the older adult – What is needed, what is safe and where can I get it? K Cashman (Ireland) absorption. Supplementation with calcium and B and D is recommended for at-risk elderly (Lichtenstein AH, et al. found that protein and energy supplementation improved nutrient intake and reduced mortality in subjects undernourished (Milne AC, et al. 2009;(2):CD003288). Volkert concluded her presentation by stating that if natural sources of consumed nutrients in sufficient cannot amounts, be supplementation may be indicated. ng/mL. Therefore, vitamin D deficiencyhuge issue. Andersen and colleagues measured is potentially a What is needed? D Vitamin has the ‘classical’ role of supporting calcium and bone homeostasis. Gross vitamin D deficiency is manifested circulating A adults. in osteomalacia and children in rickets as 1,25(OH)D level <25 nmol/L indicates (Zittermann A. severe deficiency D levels influence osteoporosis risk, since vitamin D levels affect intestinal calcium absorption, parathyroid hormone levels, bone turnover, bone density (BMD), bone strength and fracture risk (Holick MF. 2004;80:1678S-1688S). Recently, vitamin studied for D its effects on cardiovascular disease, respiratory has been disease, diabetes, and cancer, autoimmune diseases. Recent discussion has been focused on the effect of vitamin D on non-skeletal diseases. the However, evidence for the effects defin- as not currently is disease non-skeletal on D vitamin of itive or as strong as for the skeletal conditions. population, in winter, have vitamin D minimum levels threshold below of the 25 nmol/L places these people at risk for or metabolic bone disease, while 10 ng/mL, which 50–60% of the population have levels <50 nmol/L or 20 (aged >65 years); 1,680 vs 2,030 kcal for men and 1,460 vs 1,700 kcal for women. Vitamin also failed and to meet recommendations. mineral The InChianti intakes study found that in elderly subjects, the lowest quintile of vitamin D intake was associated with more than double the risk of frailty (odds ratio = 2.35; 95% CI 1.48–3.73). (Bartali B, et Med Sci 2006;61:589-593). al. J Gerontol A Biol Sci bioavailabilty of nutrients, and 32% of older adults (van gastric Asselt DZ, et al. atrophy affects 1998;68:328-334). Decreased gastric acid together bacterial overgrowth reduces calcium, iron and with vitamin B J Nutr 2008;138:5-11). Low Am J Clin Nutr 2008;87:150-155). The German 1995;62:30-39). In another study, dietary study, another In 1995;62:30-39). Nutr Clin J Am DVolkert (Germany) Nutrient needs of the older adult – Are they really different? nutrient intake and reduced bioavailability in older people result in poor nutritional status, which may lead to physical impairment and cognitive decline with dence. The mean energy intake of nursing home residents loss in of indepen- Germany was below that of community-based older adults Volkert Volkert discussed age-related physiologic affect nutrition, including changes altered taste and smell, that delayed GI of response and production altered and emptying, gastric hormones including cholecystokinin, ghrelin, and anorexia leptin the of syndrome – the as to referred are these together of aging. A decreased lean body mass is observed, followed by decreased basal metabolic energy and intake energy decreased subsequent with rate activity, (BMR) and physical needs. Nutrient needs of the older health, adult functional may and vary nutritional status. with The Nationwide Food Consumption Study II in Institute Germany 2008, (Max-Rubner - http://www.mri.bund.de/fileadmin/Veroef fentlichungen/Archiv/Einzelthemen_Publikationen/nvs_ergebnisbericht_teil2-v2.pdf. Accessed 19 November 2010) found that in subjects aged 65–80 years the caloric intake of men decreased by 450 kcal/d to an average 2,130 kcal/d, and in women by 220 kcal/d to 1,700 kcal/d compared with in decreased intake Protein years. 25–34 aged adults younger Indeed, g/d. 60 to women in and g/d 76 of average an to men 14–15% of German older adults do not meet recommended protein requirements. Castaneda and colleagues reported that sedentary women lost muscle mass and strength when provided with a low protein diet (0.45 g/kg/d), but when provided with more protein (0.92 g/kg/d) muscle mass and et C, (Castaneda improved even or maintained were strength al. older change; muscle lean with associated was intake protein participants with the highest protein intake (1.1 g/kg/d) had 40% less loss of lean body mass over (Houston g/kg/d) (0.7 3 intake protein lowest the with years subjects than those DK, et al. Nationwide Food Consumption Study folic calcium, fiber, found intake, recommended the reached protein that while acid, and vitamins D and E were below the recommended do people older of more or thirds two Germany, In amounts. and g/d) (21–30 fiber of amount recommended the reach not calcium (1,000 mg/d) and 14–15% do not achieve recom- mended protein intake. More than 80% of consume less older vitamin D people than the recommended amount of recommended the than folate less consume 40% and µg/d, 10 older the that showed also Study III NHANES The µg/d. 400 population consumed inadequate amounts of vitamins E, D and K (Lichtenstein AH, et al. NNI Satellite Symposium Satellite NNI Highlights of

22 nd CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 32 ESPEN Congress 6 I) Adre R e al. et R, (Andersen IU) 160 current The dietary intakes. intake in Europe is dailysomewhere around 3–4 recommendedµg/d (120– achieve not do canned tuna), and some fortified foods. However, food sources and mackerel salmon, as (such fish wild-caughtoilyinclude vitaminDproduction by the skin. Food sources of vitamin D recommendsunscreenpreventcancer,skinto blocksthisbut living closer to the equator, especially in winter. Dermatologiststhoseforthanlessmuch synthesis is vitamin sun theDfrom Adre R e al. et R, (Andersen March to February during countries European four from years) 71.8 age mean 221; = (n women elderly and years) 12.6 age mean 199; = (n girls adolescent in levels D vitamin hn h si o a one pro. o pol wo live who people For >40 person. younger a of skin the than synthesis vitamin efficientD less at 25% isadultolder an of following exposure to ultraviolet B radiation; however, the skin synthesizedskinCashmantheexplainedis vitamin inthatD Where canIgetit? foods (Zadshir A, et al. et(Zadshir foodsA, fortifiedfrom D vitamintheir of 60% aroundreceive could 541). fortification can have a huge impact. In the US, a person (32–40 ng/mL). circulating levels below the higher cutoffs of 80–100 nmol/L levels below this goal. Over 90% of the population will have then it is estimated that 50–60% of the population will have goal, as recently suggested, is at least 50 nmol/L (20 ng/mL), D vitamin the If women. the of 17% and girls the of 37% in present were ng/ml 10 or nmol/L <25 levels D Vitamin 40 µg/d (1,600 IU). 80 abovenmol/L (32 ng/mL) then the levelsdietary intake should be nearly D achieveabovelevelsto is goalthe consumed. Ifbeshould D vitamin for is 50 nmol/L goal (20 ng/mL), then at the least 25 µg/d (1,000 IU) if vitamin However, 9 µg (360 IU)/d was required to achieve >25 al.nmol/L et (10 ng/mL). selected(CashmanwintercutoffsaboveduringKD,levels D dietary vitamin D requirements necessary to maintain 25(OH) 15 µg/d (600 IU) in the US. Cashman and colleaguesEuropeand in IU) (400µg/d studied 10 years) are 65 adults>(aged the population. The current vitamin D recommendations for older recommendedand what’s being consumed, on average, in the 2038; Hannon EM, et al. al. et A, (Flynn Finland) in µg/d 7.6 to Ireland µg/d 3 to Spain in µg/d 1.1 (range: levels recommended to intake D vitamin mean the intake in women, but in Europe is not raising D vitamin of adequacy the improved Ireland fortification in European Doctors (CPME) of recommended Committee that Standing the frail The elderly intake. D vitamin for dations th latitude ineither thenorthern orsouthern hemispheres, ay gnis r crety eeautn recommen re-evaluating currently are agencies Many Cashman stated that there is a huge gap between what’s m Ci Nutr Clin J Am od ur Res Nutr Food u J ln Nutr Clin J Eur 2009;89:1366-1374). Approximately Ethn DisEthn Br J Nutr u J ln Nutr Clin J Eur 2009;53:10.3402/fnr.v53i0. 2005;15:S5-97-101). Food 2007;97:1177-1186). 2005;59:533-541). 2005;59:533- -

that used vitamin D doses >250 µg/d (10,000 IU vitamin D toxicity (hypercalcemia) in trials conducted in healthy adults Technol Assess2007;158:1-235). al. et A, Cranney 2008;88:582S-586S; Nutr Clin Bone 2004;35:375-382): factors which double the risk of hip fracture (Kanis JA, et al. seven are there that explained Rizzoli 1997;103:12S-17S). C. (Cooper living daily out of activity carry one to least at unable are patients fracture hip all of 80% year, 1 after Moreover, 2002;13:731-737). Int al. Osteoporos et A, (Trombetti fracture hip a experiencing of year 1 within die patients of 20–25% Approximately fracture. hip a suffer will men Swiss seven in one and women Swiss five in one Approximately 20%. about less, is it men For 1308). K. (Lippuner 50% is about fracture osteoporotic of type 50-year-old any a experiencing woman of probability lifetime the Switzerland, In R, et al. et R, (Viethintakes D vitamin higher of safety the investigate that published been have studies new 1997, Since studies. three on recommendations their based IU), (2,000 µg/d 50 of D vitamin of level tolerable American upper the the defined that committee (IOM), Medicine of Institute the 1997, In What issafe? • • • vitamin Dintakeinclude: minimum thresholdof25nmol/L. a maintain to populations most in low too are D vitamin of intakes dietary since required, are elderly the in status D vitamin improve to strategies that stated Cashman 2010. in later recommendations revised release to expected is IOM The intake. higher a with safety shown have that studies of number increasing the to due revised be may D vitamin of 250 µg/d (Hathcock JN, et al. of limit upper revised a of selection confident the supports be/policy. Accessed 19 November 2010). Europein (20 ng/mL) blood levels (CMPE. nmol/L 50 least at achieve to IU/d), (600–800 µg/d 15–20 providedvitaminsupplementbe withaD containing leastat R Rizzoli (Switzerland) Rizzoli R nutrition of role and treatment causes, Prevalence, adult: older the in facture Hip Vitamin Dsupplementation Vitamin D fortification of food (mandatory or voluntary) foods D-rich vitamin naturally-occurring of intake Improving Hathcock summarized that: collectively, the absence of Suggested public health strategies to correct low dietary level upper recommended the that explained Cashman 2001;73:288-294; Jones G. Jones 2001;73:288-294; Nutr Clin J Am ; 24 October242009.Available ; http://www.cpme.at: 2009;5:1304- Suisse Med Rev Am J Clin Nutr 2007;85:6-18). Vitamin D nutritional policy m Med J Am Evid Rep Evid Am J Am 3 )

Highlights of 32nd ESPEN Congress CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 23 - - - Nutr Clin 1999;69:1202- 1997;94:14930- Endocrinol Endocrinol Metab

J Clin Endocrinol Metab Metab Endocrinol Clin J Nestlé Nutrition. not Am J Clin Nutr Clin J Am 2002;18:20-25). 2002;18:20-25). 2001;48:198-205). Am Am J Physiol 2006;22:738-743). However, when when However, 2006;22:738-743). Gut 1991;53:821-825). The elderly lose fat The elderly 1991;53:821-825). Nutrition 1998;275:E249-E258). No differences No in differences 1998;275:E249-E258). 2004;18:1586-1587). Other 2004;18:1586-1587). research has Proc Proc Natl Acad Sci U S A Nutrition 1997;65:489-495). FASEB FASEB J Schneider concluded that the specific metabolic Volpi Volpi and colleagues reported that muscle protein Among Among healthy volunteers, protein pulse feeding Am Am J Physiol Am Am J Clin Nutr Insulin resistance extraction leucine) (eg, acid amino splanchnic Increased Anorexia of aging Resistance to nutrients a. b. No Magic Bullet The views expressed in this newsletter are of the presenters and participants, 14935). 14935). Schneider commented that acid/base disorders may micro while elderly the of mass muscle and bone the decrease features of aging include: 1. 2. 3. fat oxidation are observed between young and older subjects subjects and older young between are observed fat oxidation al. et W, (Aberg non-diabetic, non-stressed individuals were provided with total parenteral nutrition, glucose oxidation was impaired and greater fat oxidation occurred among al. et R, (Al-Jaouni older patients compared elderly the in feeding mixed to resistant was synthesis al. et E, (Volpi subjects younger with responses blunted displayed elderly The 2000;85:4481-4490). lower and signaling anabolic impaired with to meal, a mixed protein synthesis. Guillet et al. reported that in the and the elderly hyperaminoacidemia, with occurred hyperinsulinemia acids amino and insulin to synthesis protein muscle of response is impaired and may be responsible for sarcopenia (Guillet C, et al. 1208; Arnal absorbed MA, quickly et more is al. protein Whey 2000;278:E902-E909). (‘fast’ protein) than casein (‘slow’ protein) in healthy adults (Boirie et Y, al. nutrient deficienciesmay be due to decreased intake and/or absorption. Hopkins reported on changes to the GI micro biota with increasing age; reduction of protective bifidobac disease increased an to related be may bowel large the in teria al. et MJ, (Hopkins risk shown that among older subjects, twice as much leucine was as twice leucine much subjects, older among that shown not and extraction, splanchnic for gut and liver the to diverted as much leucine was to available the et muscle (Boirie al. Y, Nutr Clin J Am increased with meal midday the at retention protein improves al. et MA, (Arnal mass free fat Healthy elderly volunteers have lower energy expenditure and and expenditure energy lower have volunteers elderly Healthy less lean body mass than healthy young L, adults (Vaughan et al. free mass and fat preserve mass during while illness, fat free al. et SM, (Schneider young the in preserved is mass 2002;21:499-504). Gallagher et al. reported that D, (Gallagher expenditure energy muscles resting of 22% for account et al.

- J J Nutr Health Aging 2009;90:1674-1692). 2010;29:78-83). For 2010;29:78-83). a 1998;128:801-809; Tkatch L, et 1998;128:801-809; Clin Clin Nutr ) , , which increases intestinal calcium 2 3 Am Am J Clin Nutr 1999;69:147-152). High protein ONS 1992;11:519-525). Reduced IGF-1 Reduced levels 1992;11:519-525). Ann Ann Intern Med Rizzoli Rizzoli explored the role of protein malnutrition, in Low BMI (<25 kg/m BMI (<25 Low History of prior fracture History of of hip fracture Family history (current) (past or current) Steroid prescription Alcohol (> 2 servings/d) Rheumatoid arthritis Am Am J Clin Nutr J J Am Coll Nutr SM Schneider (France) Specific metabolic features Furthermore, Furthermore, a higher risk of associated with total animal protein intake (Munger RG, et hip fracture is al. inversely can reduce the rate of BMD decline following hip fracture, in resulting shorter stays (Schürch in hospitals rehabilitation MA, et al. and and phosphorus absorption and renal tubular phosphorus reabsorption. The aromatic amino acids, found products, increase in IGF-1 production. In dairy a study in healthy older women (aged 66–79 years) fed an isocaloric diet, the resulted weight/d) body g/kg vs 0.92 (0.45 diet protein lower in a 30% decrease in IGF-1 and type I muscle fibersectional cross area (Castaneda C, et al. 2000;4:85-90). A recent meta-analysis found that 2–4% of BMD variance can be explained by dietary protein intake (Darling AL, et al. al. are are often seen in patients with recent hip fracture, and are related to low protein intake. A recent study reported that use of a high protein ONS, to deliver 20 g/d supplemental protein, in hip fracture patients increased IGF-1 levels over 7 days (Chevally T, et al. given BMD, the risk of hip fracture increases with age. Forty Forty age. with increases of the risk hip fracture BMD, given from hospital to admitted are patients fracture hip of percent nursing homes, and patients with hip fractures are particu larly undernourished. Rizzoli concluded by summarizing that that summarizing by concluded Rizzoli undernourished. larly dietary protein for requirements the elderly are high, at 1.2 g/kg/d. The decreased incidence of hip fractures in Geneva to may be 1990) an since related improvement (2% decrease homes. nursing in living women elderly of status nutritional in of the to the emergence be may also related observation This in decrease the and mid-1990s, the in bisphosphonates of use homes. nursing in living women of number the Schneider Schneider explained that there is resistance to refeeding in and a need to features. the look elderly, at metabolic specific Educational session: Specialized nutrition in the elderly 1. 2. 3. 4. 5. 6. 7. particular the role of insulin-like growth factor-1 (IGF-1). IGF-1 increases muscle and bone synthesis of 1,25(OH)D mass, and stimulates 24 CLINICAL NUTRITION HIGHLIGHTS • 2010 • Volume 6, Issue 3 Conference calendar Conference

Conference 2011 April March January Web site:www.alape-upconference.org Association ofLatinAmericanPediatrics(ALAPE) Organizer: Panama City, Panama 7–10 April2011 1 Web site:www.amda.com/education/ltcmedicine.cfm America MedicalDirectors Association Organizer: Tampa, Florida,USA 24–27 March 2011 Long Term Care Medicine2011 Web site:www.dysphagiaresearch.org/ Dysphagia Research Society Organizer: San Antonio,Texas, USA 3–5 March 2011 (DRS) AnnualMeeting 2011 DysphagiaResearch Society Web site:www.nutritioncare.org/cnw American SocietyforParenteral andEnteralNutrition Organizer: Vancouver, BritishColumbia,Canada 30 January–1February2011 Clinical NutritionWeek 2011 Web site: Philippine SocietyofGeriatricMedicine Organizer: Cebu, Philippines 19–21 January2011 2011 Asia-Pacific GeriatricConference Web site:www.sccm.org Society ofCriticalCare Medicine(SCCM) Organizer: San Diego,California,USA 15–19 January2011 40 st ALAPEUpdatesinPediatrics th CriticalCare Congress www.geriatricsphilippines.org/Cebu2011.html Calendar 2011 Calendar Research JointMeeting 2011 & AsianSocietyforPediatric Pediatric AcademicSocieties’ Web site:www.agingconference.org American SocietyonAging Organizer: San Francisco,California,USA 26–30 April2011 on Aging Conference oftheAmericanSociety Aging inAmerica:the2011Annual Web site:www.iaggbologna2011.com/ Geriatrics, European Region AssociationofGerontologyInternational and Organizer: Bologna, Italy 14–17 April2011 Ageing forallEuropeans (II) Congress: HealthyandActive VII European International Web site:www.pas-meeting.org Pediatric Research Pediatric AcademicSocieties&AsianSocietyfor Organizer: Denver, Colorado,USA 30 April–3May2011