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Hardy G, Wong T, Morrissey H, Anderson C, Moltu SJ, Poindexter B, Lapillonne A, Ball PA. Parenteral Provision of Micronutrients to Pediatric Patients: An International Expert Consensus Paper. JPEN J Parenter Enteral Nutr 2021; 44 Suppl 2:S5-S23. [PMID: 32767589 DOI: 10.1002/jpen.1990] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/04/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Micronutrients (vitamins and trace elements) are essential to all nutrition. For children and neonates who are dependent upon nutrition support therapies for growth and development, the prescribed regimen must supply all essential components. This paper aims to facilitate interpretation of existing clinical guidelines into practical approaches for the provision of micronutrients in pediatric parenteral nutrition. METHODS An international, interdisciplinary expert panel was convened to review recent evidence-based guidelines and published literature to develop consensus-based recommendations on practical micronutrient provision in pediatric parenteral nutrition. RESULTS The guidelines and evidence have been interpreted as answers to 10 commonly asked questions around the practical principles for provision and monitoring of micronutrients in pediatric patients. CONCLUSION Micronutrients are an essential part of all parenteral nutrition and should be included in the pediatric nutrition therapy care plan.
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Affiliation(s)
- Gil Hardy
- Ipanema Research Trust, Auckland, New Zealand
| | - Theodoric Wong
- Consultant Pediatric Gastroenterologist, Women's and Children's Hospital, Birmingham, UK
| | - Hana Morrissey
- School of Pharmacy and Pharmaceutical Science, Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
| | - Collin Anderson
- Pharmacy, Intermountain Healthcare Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Sissel J Moltu
- Department of Neonatology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Brenda Poindexter
- Department of Pediatrics, Cincinnati Children's Hospital and Medical Centre, Cincinnati, Ohio, USA
| | | | - Patrick A Ball
- School of Pharmacy and Pharmaceutical Science, Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
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Carter P, O'Donoghue KJM, Dworzynski K, O'Shea L, Roberts V, Reeves T, Bastounis A, Mugglestone MA, Fawke J, Pilling S. A demonstration of using formal consensus methods within guideline development; a case study. BMC Med Res Methodol 2021; 21:73. [PMID: 33865324 PMCID: PMC8052943 DOI: 10.1186/s12874-021-01267-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 04/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recommendations within guidelines are developed by synthesising the best available evidence; when limited evidence is identified recommendations are generally based on informal consensus. However, there are potential biases in group decision making, and formal consensus methods may help reduce these. METHODS We conducted a case study using formal consensus, to develop one set of recommendations within the Neonatal Parenteral Nutrition guideline being produced for the National Institute for Health and Care Excellence. Statements were generated through identification of published guidelines on several topics relating to neonatal parenteral nutrition. Ten high quality guidelines were included, and 28 statements were generated; these statements were rated by the committee via two rounds of voting. The statements which resulted in agreement were then used to develop the recommendations. RESULTS The approach was systematic and provided transparency. Additionally, a number of lessons were learnt; including the value of selecting the appropriate topic, giving adequate time to the process, and ensuring methodologies are understood by the committee for their value and relevance. CONCLUSION Formal consensus is a valuable option for use within guideline development when specific criteria are met. The approach provides transparent methodology, ensuring clarity on how recommendations are developed.
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Affiliation(s)
- P Carter
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK.
| | - K J M O'Donoghue
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - K Dworzynski
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - L O'Shea
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - V Roberts
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - T Reeves
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - A Bastounis
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
- Division of Epidemiology & Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK
| | - M A Mugglestone
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - J Fawke
- Leicester Neonatal Service, University Hospitals Leicester Infirmary Square, Leicester, LE1 5WW, UK
| | - S Pilling
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
- Camden and Islington NHS Foundation Trust, St Pancras, Hospital, 4 St Pancras Way, London, NW1 0PE, UK
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Hojsak I, Chourdakis M, Gerasimidis K, Hulst J, Huysentruyt K, Moreno-Villares JM, Joosten K. What are the new guidelines and position papers in pediatric nutrition: A 2015-2020 overview. Clin Nutr ESPEN 2021; 43:49-63. [PMID: 34024560 DOI: 10.1016/j.clnesp.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/01/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nutrition related publications in pediatric population cover wide range of topics and therefore it is usually difficult for clinicians to get an overview of recent nutrition related guidelines or recommendations. METHODS The Special Interest Group (SIG) of Pediatrics of European Society for Clinical Nutrition and Metabolism (ESPEN) performed a literature search to capture publications in the last five years aiming to provide the latest information concerning nutritional issues in children in general and in specific diseases and to discuss progression in the field of pediatric nutrition evidence-based practice. RESULTS Eight major topics were identified as the most frequently reported including allergy, critical illness, neonatal nutrition, parenteral and enteral nutrition, micronutrients, probiotics and malnutrition. Furthermore, it was noted that many reports were disease focused or included micronutrients and were, therefore, represented as tables. CONCLUSION Overall, it has been shown that most reports on nutrition topics in pediatrics were systematic reviews or guidelines/position papers of relevant societies, but many of them basing the conclusion on a limited number of high-quality randomized controlled trials or large observational cohort studies.
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Affiliation(s)
- Iva Hojsak
- Children's Hospital Zagreb, University of Zagreb Medical School, Zagreb, Croatia; University J.J. Strossmayer Medical School, Osijek, Croatia.
| | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece.
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, College of Medicine, Veterinary and Life Sciences, Royal Hospital for Sick Children, University of Glasgow, Glasgow, United Kingdom.
| | - Jessie Hulst
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics and Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Koen Huysentruyt
- Department of Pediatric Gastroenterology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | | | - Koen Joosten
- Department of Pediatric Intensive Care, Sophia Children's Hospital - Erasmus Medical Center, Rotterdam, the Netherlands.
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Vettleson KL, Larson HJ, Mohamed MW, Grindeland CJ, Muzzy Williamson JD. Micronutrient Monitoring and Management in Parenteral Nutrition-Dependent Premature Neonates: A Case Series. J Pediatr Pharmacol Ther 2021; 26:200-204. [PMID: 33603585 DOI: 10.5863/1551-6776-26.2.200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/22/2020] [Indexed: 11/11/2022]
Abstract
We present a prospective case series of 3 premature neonates with abnormal vitamin A, vitamin E, and selenium levels after being managed on prolonged parenteral nutrition (PN). All 3 patients experienced gastrointestinal complications including spontaneous intestinal perforation, necrotizing enterocolitis, and/or short bowel syndrome. Additionally, all 3 patients developed PN-associated liver disease, which required the use of a mixed lipid emulsion and a fish oil-based lipid emulsion for a short period of time. We evaluated the micronutrient levels of these patients after they had been receiving PN for 1 to 2 months. After the early identification of these abnormalities, we promptly attempted to correct the levels through supplementation and restriction, as appropriate. One barrier we experienced in the treatment of these patients was the conflicting guidance of daily micronutrient dosing in PN and when to evaluate levels in premature infants from the European and American pediatric nutrition organizations, the European Society for Paediatric Gastroenterology Hepatology and Nutrition and the American Society for Parenteral and Enteral Nutrition. Additionally, after we assessed micronutrient levels, we experienced a lack of guidance on how to adjust dosing and when to monitor subsequent levels.
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Eveleens RD, Witjes BCM, Casaer MP, Vanhorebeek I, Guerra GG, Veldscholte K, Hanff LM, Cosaert K, Desmet L, Vlasselaers D, Maebe S, Bernard B, Van den Berghe G, Verbruggen SCAT, Joosten KFM. Supplementation of vitamins, trace elements and electrolytes in the PEPaNIC Randomised Controlled Trial: Composition and preparation of the prescription. Clin Nutr ESPEN 2021; 42:244-251. [PMID: 33745587 DOI: 10.1016/j.clnesp.2021.01.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIMS Following the results of the paediatric early versus late parenteral nutrition in critical illness (PEPaNIC) multicentre, randomised, controlled trial, the new ESPGHAN/ESPEN/ESPR/CSPEN and ESPNIC guidelines recommend to consider withholding parenteral macronutrients for 1 week, while providing micronutrients, in critically ill children if enteral nutrition is insufficient. Critically ill children are suspected to be vulnerable to micronutrient deficiencies due to inadequate enteral nutrition, increased body's demands and excessive losses. Hitherto, micronutrient requirements in PICU are estimated based on recommended daily intakes for healthy children and expert opinion. We aimed to provide an overview of the current practice of micronutrient administration and practical considerations in the three participating centres of the PEPaNIC study, and compare these therapies with the recommendations in the new ESPGHAN/ESPEN/ESPR/CSPEN guidelines. METHODS We describe the current composition and preparation of the prescribed parenteral micronutrients (consisting of vitamins, trace elements and electrolytes) in the three centres (Leuven, Rotterdam and Edmonton) that participated in the PEPaNIC RCT, and compare this per micronutrient with the ESPGHAN/ESPEN/ESPR/CSPEN guidelines recommendations. RESULTS The three centres use a different micronutrient supplementation protocol during the first week of critical illness in children, with substantial differences regarding the amounts administered. Leuven administers commercial vitamins, trace elements and electrolytes in separate infusions both in 4 h. Rotterdam provides commercial vitamins and trace elements simultaneously via 8-h infusion and electrolytes continuously over 24 h. Lastly, Edmonton administers commercial vitamins and institutionally prepared trace elements solutions in 1 h and electrolytes on demand. Comparison with the ESPGHAN/ESPEN/ESPR/CSPEN guidelines yields in differences between the recommendations and the administered amounts, which are most substantial for vitamins. CONCLUSION The practice of intravenous micronutrient administration differs substantially between the three PEPaNIC centres and in comparison with the current guideline recommendations. This deviation is at least partially explained by the inability to provide all recommended amounts with the currently available commercial products and by the lack of strong evidence supporting these recommendations.
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Affiliation(s)
- Renate D Eveleens
- Intensive Care, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Bregje C M Witjes
- Department of Clinical Pharmacology and Pharmacy, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Michael P Casaer
- Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - Ilse Vanhorebeek
- Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - Gonzalo Garcia Guerra
- Department of Paediatrics, Intensive Care Unit, University Alberta, Stollery Children's Hospital, Edmonton, Canada
| | - Karlien Veldscholte
- Intensive Care, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Lidwien M Hanff
- Department of Pharmacy, Princess Maxima Centre for Paediatric Oncology, Utrecht, the Netherlands
| | - Katrien Cosaert
- Department of Pharmacy, University Hospitals KU Leuven, Leuven, Belgium
| | - Lars Desmet
- Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - Dirk Vlasselaers
- Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - Sofie Maebe
- Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - Britney Bernard
- Department of Paediatrics, Intensive Care Unit, University Alberta, Stollery Children's Hospital, Edmonton, Canada
| | - Greet Van den Berghe
- Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - Sascha C A T Verbruggen
- Intensive Care, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Koen F M Joosten
- Intensive Care, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands.
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56
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Schwahn B. Fosdenopterin: a First-in-class Synthetic Cyclic Pyranopterin Monophosphate for the Treatment of Molybdenum Cofactor Deficiency Type A. Neurology 2021. [DOI: 10.17925/usn.2021.17.2.85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Copper and Copper/Zinc Ratio in a Series of Cystic Fibrosis Patients. Nutrients 2020; 12:nu12113344. [PMID: 33143143 PMCID: PMC7692365 DOI: 10.3390/nu12113344] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 10/25/2020] [Accepted: 10/28/2020] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis (CF) patients require a stable and sufficient supply of micronutrients. Since copper is an essential micronutrient for human development, a cross-sectional study was carried out to investigate the serum copper levels, serum copper/zinc (Cu/Zn) ratios, and their relationship with nutritional indicators in a group of CF patients. Anthropometric, biochemical, and dietary measurements, an abdominal ultrasound, and respiratory and pancreatic tests were conducted. Seventeen CF patients were studied (10 females, 59%), 76.5% of whom were ∆F580. Their mean serum copper (113 ± 23 μg/dL) was normal, and there was only one teenager with hypocupremia (6%) and two children with hypercupremia (18%). A significant association between serum copper and zinc levels was discovered. The Cu/Zn ratio was higher than 1.00 for 94% of patients, which is an indicator of an inflammation status. There was no significant correlation between the serum copper concentrations and respiratory and pancreatic function, respiratory colonization, and the results of the abdominal ultrasound. Linear regression analysis showed that serum copper had a positive association with both the Z-score body mass index (BMI) and mean bone conduction speed (BCS). Therefore, since 94% of CF patients had a Cu/Zn ratio > 1.00, this factor must alert us to consider the risk of zinc deficiency and high inflammatory response. The measurement of serum zinc alone does not show one’s zinc status. However, the Cu/Zn ratio may be an indicator of zinc deficiency and the inflammatory status of CF patients.
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Abstract
Iatrogenic manganese (Mn) neurotoxicity is a safety concern in neonates receiving parenteral nutrition (PN). Prior studies suggest Mn contamination of PN ingredients represents an unintended source of Mn delivery. In order to determine the relative contribution of unsourced Mn to total Mn exposure in neonatal PN, this study measured Mn concentrations in neonatal PN solutions using inductively coupled plasma mass spectrometry. Solutions prepared using a standard fixed dose neonatal multiple trace element product were compared with test solutions prepared using individual trace element ingredients not including Mn. The standard solutions (n = 6) contained a mean (SD) Mn concentration of 56.63 μg/L (0.94), compared with 6.04 μg/L (0.39) in the test solutions without added Mn (n = 6). This study suggests that neonatal PN contains significant quantities of Mn not intentionally added during PN preparation. Further studies are needed to identify individual ingredient sources of unintentional Mn, and the feasibility of Mn omission strategies.
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Effects of High-Dose Selenium Supplementation on Oxidative Stress and Inflammatory Markers in Critically Ill Children After Gastrointestinal Surgery: A Randomized Clinical Trial. IRANIAN JOURNAL OF PEDIATRICS 2020. [DOI: 10.5812/ijp.102118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: Pediatric observational studies have indicated that most critically ill children have low serum selenium level, which is associated with the increased incidence of multiple organ failure and deteriorated clinical outcomes. Selenium plays a key role in the endogenous antioxidant defense mechanism and inflammatory pathways. Objectives: The present study aimed to assess the effects of high-dose selenium supplementation on the improvement of inflammatory and oxidative stress indices, as well as clinical outcomes, in pediatric patients with severe oxidative stress and inflammation following major gastrointestinal surgeries. Methods: This prospective, single-blind, randomized, parallel group superiority trial was conducted at the pediatric intensive care unit (PICU) of Akbar Pediatric Hospital in Mashhad, Iran in 2019. Patients were assigned to the supplementation (high-dose selenium: 20 µg/kg/d) and control groups (placebo with the recommended dietary allowance doses of selenium) using stratified blocks. Among 72 eligible critically ill children after gastrointestinal surgery, 66 patients completed the study. Inflammatory markers were measured and compared between the groups, including high-sensitivity C-reactive protein (hsCRP), interleukin 1 beta (IL-1β), prooxidant-antioxidant balance (PAB) assay, and clinical outcomes. Data analysis was performed in SPSS version 20 using the intention-to-treat approach. Results: Only 14 patients had optimal serum selenium concentrations before the surgery and PICU admission. At the end of the study, 90.6% of the patients (n = 29) in the intervention group and 100% (n = 34) of those in the placebo group had suboptimal serum selenium levels (< 50 ng/mL). Although supplementation with high-dose selenium decreased the inflammatory markers in the post-surgical critically ill children (-18 mg/mL and -37.5 pg/mL for hsCRP and IL-1β, respectively), the administered dose could not improve the serum glutathione peroxidase (GPx) concentrations as the selenium functional marker, as well as the PAB assay as the single test to assess the balance/imbalance of the oxidants and antioxidants simultaneously. Additionally, clinical outcomes such as infections, length of ICU stay, and 28-day mortality did not improve after the intervention. Conclusions: According to the results, high-dose selenium supplementation (20 µg/kg/d) in the post-surgical critically ill children could improve the serum inflammatory markers. However, the changes were suboptimal with no significant effects of the serum GPx concentrations, antioxidant defense system, and clinical outcomes.
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Risk of Iodine Deficiency in Extremely Low Gestational Age Newborns on Parenteral Nutrition. Nutrients 2020; 12:nu12061636. [PMID: 32492945 PMCID: PMC7352251 DOI: 10.3390/nu12061636] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/03/2022] Open
Abstract
Iodine is an essential component of thyroid hormones, which play a critical role in neurodevelopment. The iodine status of pregnant women and their newborns is not checked routinely. Extremely Low Gestational Age Newborns do not receive Iodine supplementation while on parenteral nutrition (PN). We measured urine iodine levels and thyroid function tests in 50 mother–infant dyads at birth, at 1 week, 1, 2, 3 months and near discharge. We correlated maternal and neonatal urine iodine levels with thyroid functions and measured iodine levels in milk and PN. In our study, 64% of mothers were iodine deficient at the time of delivery, their free T4 levels were 0.48 (0.41–0.54) ng/dL with normal thyroid-stimulating hormone (TSH). Iodine levels were thirty-fold higher in extremely low gestational age newborns (ELGAN) exposed to iodine comparing to full terms (p < 0.001), but this effect lasted <1 week. At 1 month of age, ELGAN on PN developed iodine deficiency (p = 0.017) and had high thyroglobulin levels of 187 (156–271) ng/mL. Iodine levels improved with enteral feeds by 2 months of age (p = 0.01). Iodine deficiency is prevalent among pregnant women and ELGAN; in particular, those on PN are at risk of hypothyroidism. Iodine supplementation during pregnancy and postnatally should be considered to avoid iodine deficiency.
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61
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Wendel D, Ho BE, Kaenkumchorn T, Horslen SP. Advances in non-surgical treatment for pediatric patients with short bowel syndrome. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1770079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Danielle Wendel
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Beatrice E. Ho
- Department of Pharmacy, Seattle Children’s Hospital, Seattle, WA, USA
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Tanyaporn Kaenkumchorn
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Simon P. Horslen
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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63
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Srikrishnaraj A, Chambers K, South C, Arppe Robertson M, Vresk L, Tedesco-Bruce A, Haliburton B, Yanchis D, Belza C, Zietsma J, Benec J, Carricato M, Kean P, Avitzur Y, Wales PW, Harrison D, Courtney-Martin G. Trace Elements' Contamination of Pediatric Parenteral Nutrition Solutions in Canada: A Cause for Concern. JPEN J Parenter Enteral Nutr 2020; 45:347-356. [PMID: 32338772 DOI: 10.1002/jpen.1836] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Trace elements' (TEs) contamination of parenteral nutrition (PN) solutions is an ongoing concern. The aims of this study were 1) to measure actual TE concentrations in PN admixtures compared with ordered concentrations and 2) compare TE intake with current recommendations. METHODS PN admixtures from discarded bags were collected from patients receiving home PN and on inpatient wards. Samples were collected from 72 patients (39 inpatients, 33 receiving home PN). Age, percentage energy intake from PN, and PN orders were collected from patients' charts. PN samples were analyzed for TEs, including chromium (Cr) and manganese (Mn), and concentration measurements compared with ordered concentrations and current recommendations. RESULTS Measured Cr and Mn concentrations were higher than ordered concentrations: 5.3 ± 1.7 vs 2.8 ± 1.5 µg/L; P < 0.0001 and 11.9 ± 5.9 vs 0.00 µg/L; P < 0.0001, respectively. Chromium contamination alone accounted for over 100% of current recommendations for patients 0-12 months and between 63% and 92% for children >1 year. Contamination of Mn provided all the measured Mn in PN admixtures, since Mn is excluded from PN orders at our institution. Between 70% and 120% of current Mn recommendations were met from contamination. CONCLUSIONS Cr should be excluded from PN admixtures for children 0-12 months and only one-fourth the current recommendation should be added for pediatric patients >1 year. Manganese should also be excluded from PN admixture for pediatric patients but plasms monitoring 2-3 times per year is recommended for those on long-term PN.
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Affiliation(s)
| | - Kathryn Chambers
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Courtney South
- Research Institute, The Hospital for Sick Children, Toronto, Canada
| | | | - Laura Vresk
- Research Institute, The Hospital for Sick Children, Toronto, Canada
| | | | - Beth Haliburton
- Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Dianna Yanchis
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Christina Belza
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Jordan Zietsma
- Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Joanna Benec
- Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Megan Carricato
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Penni Kean
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Debra Harrison
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Glenda Courtney-Martin
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada.,Faculty of Kinesiology, University of Toronto, Toronto, Canada.,Department of Nutritional Sciences, University of Toronto, Toronto, Canada
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64
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Marino LV, Valla FV, Beattie RM, Verbruggen SCAT. Micronutrient status during paediatric critical illness: A scoping review. Clin Nutr 2020; 39:3571-3593. [PMID: 32371094 PMCID: PMC7735376 DOI: 10.1016/j.clnu.2020.04.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/06/2020] [Accepted: 04/14/2020] [Indexed: 01/06/2023]
Abstract
Background No evidence based recommendations for micronutrient requirements during paediatric critical illness are available, other than those arising from recommended nutrient intakes (RNI) for healthy children and expert opinion. Objectives The objective of this review is to examine the available evidence from micronutrient status in critically ill children considering studies which describe 1) micronutrient levels, 2) associations between micronutrient levels and clinical outcome, and 3) impact on clinical outcome with micronutrient supplementation during PICU admission. Design Scoping review. Eligibility criteria Any study which used a qualitative and quantitative design considering causes and consequences of micronutrient levels or micronutrient supplementation during paediatric critical illness. Sources of evidence NICE Healthcare Databases Advanced Search website (https://hdas.nice.org.uk/) was used as a tool for multiple searches, with a content analysis and charting of data extracted. Results 711 records were identified, 35 were included in the review. Studies evaluated serum micronutrient status was determined on admission day in majority of patients. A content analysis identified (n = 49) initial codes, (n = 14) sub-categories and (n = 5) overarching themes during critical illness, which were identified as: i) low levels of micronutrients, ii) causes of aberrant micronutrient levels, iii) associations between micronutrients levels and outcome, iv) supplementation of micronutrients. Conclusion During critical illness, micronutrients should be provided in sufficient amounts to meet reference nutrient intakes for age. Although, there is insufficient data to recommend routine supplementations of micronutrients at higher doses during critical illness, the ‘absence of evidence should not imply evidence of absence’, and well designed prospective studies are urgently needed to elucidate paediatric micronutrient requirements during critical illness. The absence of reliable biomarkers make it challenging to determine whether low serum levels are reflective of a true deficiency or as a result redistribution, particularly during the acute phase of critical illness. As more children continue to survive a PICU admission, particularly those with complex diseases micronutrient supplementation research should also be inclusive of the recovery phase following critical illness.
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Affiliation(s)
- L V Marino
- Department of Dietetics/Speech & Language Therapy, NIHR Biomedical Research Centre Southampton, University Hospital Southampton NHS Foundation Trust and School of Health Sciences, University of Southampton, Southampton, UK.
| | - F V Valla
- Paediatric Intensive Care Unit, Hôpital Femme Mère Enfant, CarMEN INSERM UMR 1060 Hospices Civils de Lyon, Lyon-Bron, France
| | - R M Beattie
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, NIHR Biomedical Research Centre Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - S C A T Verbruggen
- Intensive Care, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
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Parenteral Zinc Intake in Newborns With Jejunostomy or Ileostomy: Results of a Monocentric Cohort Study. J Pediatr Gastroenterol Nutr 2020; 70:521-526. [PMID: 31880665 DOI: 10.1097/mpg.0000000000002596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The aim of the study was to assess zinc status of newborns with parenteral nutrition with or without a small bowel stoma, to determine the incidence of zinc deficit, and to determine the clinical factors associated with plasma zinc levels. METHODS Monocentric cohort study including all liveborn infants receiving zinc parenteral intake at 500 μg · kg · day and who benefited from at least 1 plasma zinc assessment during hospitalization. RESULTS Sixty-eight dosages of zinc were performed in 50 newborns, divided into 3 groups (no stoma = 26, jejunostomy = 11, ileostomy = 13). Thirty-seven of the 50 infants were born preterm. The mean ± standard deviation plasma zinc was 14.9 ± 4.3 μmol/L and was similar among the 3 groups. Sixty-four percent, 3%, and 34% of zinc values were within, below, and above the normal range, respectively. In infants with jejunostomy, only 1 plasma zinc value (5%) was below the reference range. Plasma zinc levels were negatively correlated with stoma output (r = -0.449; P = 0.013). In contrast to patients with limited intestinal losses (ie, no stoma and ileostomy groups) no association between zinc levels and postmenstrual age was observed in infants with a jejunostomy suggesting that 500 μg · kg · day was adequate not only in preterm infants but also in term infants with a jejunostomy. CONCLUSION Plasma zinc levels decrease significantly with the increase of stoma output volume of newborns with small bowel stoma. Zinc deficit was prevented in newborns with a small bowel stoma receiving of 500 μg · kg · day of parenteral zinc.
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Thomassen RA, Kvammen JA, Sæland C, Kjeserud C, Eikeland J, Juliusson PB, Bentsen BS, Henriksen C. Micronutrients in paediatric Intestinal Failure Patients receiving home parenteral nutrition. Clin Nutr 2020; 39:3452-3460. [PMID: 32204976 DOI: 10.1016/j.clnu.2020.02.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/24/2020] [Accepted: 02/28/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Children with intestinal failure (IF) receive parental nutrition to ensure adequate growth and development. The aim of this study was to assess micronutrient status in paediatric IF patients receiving home parenteral nutrition (HPN) in comparison to a group of healthy children. METHODS An observational cross-sectional study was performed at Oslo University Hospital and at the Department of Nutrition, University of Oslo from January to September 2017. All children with IF, aged two to 18 years, were invited to participate. A reference group of healthy children was recruited through social media advertisement. Dietary intake was assessed by a four-day food record, and enteral and parenteral provision was recorded. Blood samples were analysed for vitamins, minerals and haematology to assess iron status. Two spot urine samples from each subject were analysed for iodine concentration (UIC) and creatinine. RESULTS Nineteen children with IF and 50 healthy children were included. The mean age of the participants was 10.0 years. IF-patients received a median of 76% of their estimated energy requirements from parenteral nutrition (PN). Recommended intake (RI) for iodine from the diet was reached by 16% of IF patients and 28% of healthy children. In the IF group there was a significant positive correlation between UIC and the percentage of iodine intake from oral diet and enteral nutrition support (r = 0.57, p = 0.03). Although the IF patients had a median parenteral iodine supply of more than twice the ESPGHAN recommendation, the median UIC was 89 μg/L indicating insufficient iodine status. This may suggest that the ESPGHAN recommendation for iodine in paediatric parenteral nutrition is too low. The healthy children had sufficient iodine status according to the median UIC (133 μg/L). IF patients had significantly lower total provision of iron compared to the healthy children, 4,9 vs 8,4 mg/day (p = 0.01) with 21% of IF patients and 28% of healthy children reaching RI for iron. The prevalence of anaemia was higher in IF patients than in the healthy children (40 vs.10%, p = 0.016). CONCLUSION The study indicates an insufficient iodine and iron status among paediatric IF patients. Iodine status was associated with enteral provision and patients had insufficient status even if they received the ESPGHAN recommendation of iodine. TRIAL IDENTIFICATION NUMBER Clinical Trials AEV2017/1. 2016/391/REK sør-øst B.
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Affiliation(s)
- Rut Anne Thomassen
- Oslo University Hospital, Department of Paediatric Medicine, Oslo, Norway.
| | | | - Camilla Sæland
- University of Oslo, Department of Nutrition, Institute of Basic Medical Sciences, Faculty of Medicine, Oslo, Norway
| | - Christina Kjeserud
- University of Oslo, Department of Nutrition, Institute of Basic Medical Sciences, Faculty of Medicine, Oslo, Norway
| | - Joakim Eikeland
- Oslo University Hospital, Department of Medical Biochemistry, Oslo, Norway
| | - Petur Benedikt Juliusson
- University of Bergen, Department of Clinical Science, Bergen, Norway; Norwegian Institute of Public Health, Department of Health Registries, Bergen, Norway
| | | | - Christine Henriksen
- University of Oslo, Department of Nutrition, Institute of Basic Medical Sciences, Faculty of Medicine, Oslo, Norway
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[Neonatal parenteral nutrition formulation: where are we?]. NUTR HOSP 2020; 38:11-15. [PMID: 33155472 DOI: 10.20960/nh.02903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Introduction: the introduction of parenteral nutrition in preterm infants has meant a major advance in their prognosis, being the last few years very fruitful in terms of publication of guidelines in this area. Objectives: to know the formulation and preparation procedures of neonatal parenteral nutrition (NPN) in Spanish hospitals. Methods: a multi-centre survey was conducted in Pharmacy Services on the aforementioned processes. Results: fifty-five hospitals met inclusion criteria. Electronic prescription systems were use by 51 %, 65.5 % always formulated individually, while 34.4 % had predesigned formulas. Tricameral preparations were used by 13.0 %. In 52.7 % of cases, first day nutrition was prepared on demand, starting before 8 hours of life in 88.1 % of cases. Inorganic phosphate was the first option in 10.4 %, vitamins, trace elements and zinc were added daily in 92.7 %, 90.9 % and 70.9 % of cases, respectively. NPN including lipids in the same bag was formulated by 45.4 % of the hospitals, compared to 34.5 % where it was administered separately in all cases. In 50.9 % of hospitals they never added heparin to their NPN. The 89.1 % used photoprotected bags. The stability of the admixture varied from 24 hours to 15 days. Conclusion: the elaboration of the PPN in Spain is subject to great variability. There is controversy regarding the use of heparin and ternary mixtures, which is reflected in the variability of clinical practice.
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van der Louw E, Aldaz V, Harvey J, Roan M, van den Hurk D, Cross JH, Auvin S. Optimal clinical management of children receiving ketogenic parenteral nutrition: a clinical practice guide. Dev Med Child Neurol 2020; 62:48-56. [PMID: 31313290 PMCID: PMC6916385 DOI: 10.1111/dmcn.14306] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2019] [Indexed: 12/23/2022]
Abstract
AIM To give evidence-based recommendations on the application of ketogenic diet parenteral nutrition (KD-PN) in emergency situations. METHOD An international group of experts (n=14) researched the literature and distributed a survey among 150 expert centers. International accepted guidelines (European Society for Clinical Nutrition and Metabolism/European Society for Paediatric Gastroenterology Hepatology and Nutrition and the American Society for Parenteral and Enteral Nutrition) and handbooks for parenteral nutrition were considered general standards of care. RESULTS In the literature, we identified 35 reports of patients treated by KD-PN. International guidelines and handbooks provided some conflicting information. Twenty-four expert teams from nine countries responded to the survey, reflecting the limited clinical experience. INTERPRETATION This paper highlights 23 consensus-based recommendations for safe and effective KD-PN (e.g. diet initiation, calculation, application, monitoring, and evaluation) based on the best evidence available and expert opinions. WHAT THIS PAPER ADDS In acute settings, ketogenic diet therapy (KDT) can be administered parenterally. Parenteral administration of KDT should be started only at the intensive care unit. Initiate ketogenic parenteral nutrition stepwise to the highest ratio possible with the lowest level of complications. Evaluate the risk-benefit ratio of parenteral administration continuously. Restart enteral feeding as soon as appropriate.
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Affiliation(s)
- Elles van der Louw
- Erasmus MC – Sophia Children's HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
| | | | | | - Marian Roan
- UCSF Benioff Children's HospitalOaklandCAUSA
| | - Dorine van den Hurk
- University Medical Hospital Utrecht Wilhelmina Children's HospitalUtrechtthe Netherlands
| | - J Helen Cross
- UCL Great Ormond Street Hospital for Children NHS TrustLondonUK
| | - Stéphane Auvin
- Hȏpital Universitaire Robert‐DebréAssistance Publique Hȏpitaux de ParisParisFrance
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Leite HP, Koch Nogueira PC, Uchoa KMCB, Carvalho de Camargo MF. Copper Deficiency in Children With Intestinal Failure: Risk Factors and Influence on Hematological Cytopenias. JPEN J Parenter Enteral Nutr 2019; 45:57-64. [PMID: 31637763 DOI: 10.1002/jpen.1728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 09/24/2019] [Accepted: 10/01/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND We investigated to what extent serum copper influences hemoglobin (Hb), neutrophil, and platelet counts and the factors associated with serum copper in children with intestinal failure (IF) who have their micronutrient status monitored according to a standard protocol. METHODS Children with IF admitted to a pediatric intestinal rehabilitation program and receiving home parenteral nutrition (PN) were followed up prospectively. Patients received vitamins and multi-trace elements (TEs) as part of the PN. Copper, iron, zinc, vitamin A, and cobalamin serum levels were routinely monitored at 3-month intervals or monthly when a deficiency was detected. Complete blood counts were performed biweekly. Repeated-measures analyses were used to estimate the effect of explanatory variables on the outcomes. RESULTS Thirteen children with a median time receiving PN of 16.6 months were included. An average of 7 copper measurements per patient were performed; 53.8% of patients had a low serum level at least twice during the follow-up. Eight patients with cholestasis had TEs of PN discontinued. In the multivariable analysis, copper was not associated with Hb levels; an increase of 10 µg/dL in serum copper resulted in an increase of 240/mm3 (95% confidence interval [CI], 18.0-30.1) neutrophils and of 8429/mm3 (95% CI, 466-1219) platelets (P < .001). Time of PN without copper, direct bilirubin levels, and ostomy were associated with lower serum copper. CONCLUSION The increase in serum copper was associated with significant increases in neutrophil and platelet counts. Time without copper in PN, cholestasis, and having an ostomy negatively influenced copper status.
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Affiliation(s)
- Heitor Pons Leite
- Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Paulo Cesar Koch Nogueira
- Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil.,Center for Intestinal Rehabilitation, Hospital Samaritano de São Paulo, São Paulo, São Paulo, Brazil
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Cernat E, Puntis J. Paediatric parenteral nutrition: current issues. Frontline Gastroenterol 2019; 11:148-154. [PMID: 32133114 PMCID: PMC7043071 DOI: 10.1136/flgastro-2018-101127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 02/04/2023] Open
Abstract
Parenteral nutrition transformed the prognosis for infants and children with intestinal failure. Soon after its introduction into clinical care 50 years ago, parenteral nutrition was also rapidly adopted for use in the preterm infant, where immaturity of gastrointestinal motor function precluded enteral feeding. Preterm infants subsequently became the single largest group of patients to be fed in this way. Although the development of scientific knowledge and the lessons of clinical experience have reduced the risk of complications, some of the problems and difficulties associated with this form of nutritional support remain challenging. These include central venous catheter-related sepsis, thrombosis, liver disease, bone disease and metabolic disturbance. In an initiative to promote best practice, guidelines on parenteral nutrition were first published by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition and collaborating organisations in 2005. These were constructed following a thorough review of the scientific literature, allowing a series of evidence-based recommendations to be made. The exercise was repeated just over 10 years later and updated guidelines published in 2018. This review summarises key elements from the new guideline, with a focus on what has changed since 2005.
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Affiliation(s)
- Elena Cernat
- Department of Paediatric Gastroenterology and Nutrition, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - John Puntis
- Department of Paediatric Gastroenterology and Nutrition, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Zemrani B, Bines JE. Monitoring of long-term parenteral nutrition in children with intestinal failure. JGH Open 2019; 3:163-172. [PMID: 31061893 PMCID: PMC6487815 DOI: 10.1002/jgh3.12123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/02/2018] [Accepted: 11/03/2018] [Indexed: 12/19/2022]
Abstract
Pediatric intestinal failure (IF) is a rare and complex condition associated with significant morbidity and mortality. It is defined as the reduction of gut mass or function below the minimal needed for absorption of nutrients and fluid to sustain life and growth. Since the advent of specialized multidisciplinary intestinal rehabilitation centers, IF management has considerably evolved in the last years, but serious complications of long-term parenteral nutrition (PN) can occur. Main complications include intestinal failure-associated liver disease, growth failure, body composition imbalance, central venous access complications, micronutrient deficiencies and toxicities, metabolic bone disease, small intestinal bacterial overgrowth, and renal disease. With improvement in survival rates of patients over the last 20 years, emphasis should be on limiting IF-related comorbidities and improving quality of life. Close monitoring is pivotal to ensuring quality of care of these patients. The care of children with chronic IF should involve a comprehensive monitoring plan with flexibility for individualization according to specific patient needs. Monitoring of children on long-term PN varies significantly across units and is mainly based on experience, although few guidelines exist. This narrative review summarizes the current knowledge and practices related to monitoring of children with IF. The authors also share their 20-year experience at the Royal Children's Hospital in Melbourne Australia on this topic.
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Affiliation(s)
- Boutaina Zemrani
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical NutritionThe Royal Children's HospitalMelbourneVictoriaAustralia
| | - Julie E Bines
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical NutritionThe Royal Children's HospitalMelbourneVictoriaAustralia
- Murdoch Children's Research InstituteMelbourneVictoriaAustralia
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Jonckheer J, Vergaelen K, Spapen H, Malbrain MLNG, De Waele E. Modification of Nutrition Therapy During Continuous Renal Replacement Therapy in Critically Ill Pediatric Patients: A Narrative Review and Recommendations. Nutr Clin Pract 2018; 34:37-47. [PMID: 30570180 PMCID: PMC7379206 DOI: 10.1002/ncp.10231] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Introduction Nutrition is an important part of treatment in critically ill children. Clinical guidelines for nutrition adaptations during continuous renal replacement therapy (CRRT) are lacking. We collected and evaluated current knowledge on this topic and provide recommendations. Methods Questions were produced to guide the literature search in the PubMed database. Results Evidence is scarce and extrapolation from adult data was often required. CRRT has a direct and substantial impact on metabolism. Indirect calorimetry is the preferred method to assess resting energy expenditure (REE). Moderate underestimation of REE is common but not clinically relevant. Formula‐based calculation of REE is inaccurate and not validated in critically ill children on CRRT. The nutrition impact of nonintentional calories delivered as citrate, lactate, and glucose during CRRT must be considered. Quantifying nitrogen balance is not feasible during CRRT. Protein delivery should be increased by 25% to compensate for losses in the effluent. Fats are not removed by CRRT and should not be adapted during CRRT. Electrolyte disturbances are frequently present and should be treated accordingly. Vitamins B1, B6, B9, and C are lost in the effluent and should be adapted to the effluent dose. Trace elements, with the exception of selenium, are not cleared in relevant quantities. Manganese accumulation is of concern because of potential neurotoxicity. Conclusion Current recommendations regarding nutrition support in pediatric CRRT must be extrapolated from adult studies. Recommendations are provided, based on the weak level of evidence. Additional research on this topic is warranted.
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Affiliation(s)
- Joop Jonckheer
- Intensive Care Department, University Hospital Brussels, Brussels, Belgium
| | - Klaar Vergaelen
- Pediatric Intensive Care Unit, University Hospital Brussels, Brussels, Belgium
| | - Herbert Spapen
- Intensive Care Department, University Hospital Brussels, Brussels, Belgium
| | - Manu L N G Malbrain
- Intensive Care Department, University Hospital Brussels, Brussels, Belgium.,Pediatric Intensive Care Unit, University Hospital Brussels, Brussels, Belgium
| | - Elisabeth De Waele
- Intensive Care Department, University Hospital Brussels, Brussels, Belgium.,Department of Nutrition, University Hospital Brussels, Brussels, Belgium
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ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition. Clin Nutr 2018; 37:2303-2305. [DOI: 10.1016/j.clnu.2018.05.029] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 11/19/2022]
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Zemrani B, McCallum Z, Bines JE. Trace Element Provision in Parenteral Nutrition in Children: One Size Does Not Fit All. Nutrients 2018; 10:E1819. [PMID: 30469420 PMCID: PMC6266164 DOI: 10.3390/nu10111819] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 11/16/2018] [Accepted: 11/18/2018] [Indexed: 12/16/2022] Open
Abstract
Routine administration of trace elements is recognised as a standard of care in children requiring parenteral nutrition. However, there is a lack of global consensus regarding trace elements provision and dosing in pediatric parenteral nutrition. This review provides an overview of available evidence regarding trace elements supply and posology in parenteral nutrition in neonates and children. Trace elements provision in children should be tailored to the weight and clinical condition of the child with emphasis on those at risk of toxicity or deficiency. Based on current evidence, there is a need to review the formulation of commercial solutions that contain multiple-trace elements and to enable individual trace elements additives to be available for specific indications. Literature supports the removal of chromium provision whereas manganese and molybdenum supplementation are debated. Preterm neonates may have higher parenteral requirements in iodine, selenium and copper than previously recommended. There is growing support for the routine provision of iron in long-term parenteral nutrition. Further studies on trace elements contamination of parenteral nutrition solutions are needed for a range of trace elements.
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Affiliation(s)
- Boutaina Zemrani
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, 3052 Melbourne, Australia.
| | - Zoe McCallum
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, 3052 Melbourne, Australia.
- Department of Pediatrics, University of Melbourne, 3010 Melbourne, Australia.
| | - Julie E Bines
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, 3052 Melbourne, Australia.
- Department of Pediatrics, University of Melbourne, 3010 Melbourne, Australia.
- Murdoch Children's Research Institute, 3052 Melbourne, Australia.
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