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Tripodi SI, Bergami E, Panigari A, Caissutti V, Brovia C, De Cicco M, Cereda E, Caccialanza R, Zecca M. The role of nutrition in children with cancer. TUMORI JOURNAL 2023; 109:19-27. [PMID: 35722985 PMCID: PMC9896537 DOI: 10.1177/03008916221084740] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In recent years, the influence of nutrition on the health and growth of children has become increasingly important. The relevance of nutrition is even greater for children who are facing cancer. Malnutrition, within the context of undernutrition and overnutrition, may impact not only the effectiveness of treatments and outcomes, but also the quality of life for patients and their families. In this article, we review nutritional assessment methods for children with cancer, focusing on the specific characteristics of this population and analyze the efficacy of nutritional interventions, which include enteral, parenteral, and nutritional education. From our analysis, two important conclusions emerged: i) there is a need to focus our attention on the nutritional status and the body composition of oncologic children, since these factors have a relevant impact on clinical outcomes during treatment as well as after their conclusion; ii) the support of skilled clinical nutrition personnel would be extremely helpful for the global management of these patients.
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Affiliation(s)
- Serena Ilaria Tripodi
- Paediatric Haematology and Oncology,
Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Serena Ilaria Tripodi, Paediatric
Haematology and Oncology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi
19, Pavia, 27100, Italy.
| | - Elena Bergami
- Paediatric Haematology and Oncology,
Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Arianna Panigari
- Paediatric Haematology and Oncology,
Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Valentina Caissutti
- Clinical Nutrition and Dietetics Unit,
Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlotta Brovia
- Clinical Nutrition and Dietetics Unit,
Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marica De Cicco
- Paediatric Haematology and Oncology,
Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Cell Factory, Fondazione IRCCS
Policlinico San Matteo, Pavia, Italy
| | - Emanuele Cereda
- Clinical Nutrition and Dietetics Unit,
Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit,
Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marco Zecca
- Paediatric Haematology and Oncology,
Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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2
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Zama D, Muratore E, Biagi E, Forchielli ML, Rondelli R, Candela M, Prete A, Pession A, Masetti R. Enteral nutrition protects children undergoing allogeneic hematopoietic stem cell transplantation from blood stream infections. Nutr J 2020; 19:29. [PMID: 32276595 PMCID: PMC7149876 DOI: 10.1186/s12937-020-00537-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/27/2020] [Indexed: 12/18/2022] Open
Abstract
Enteral Nutrition (EN) is recommended as first line nutritional support for patients undergoing Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT), but only few studies exist in the literature which compare EN to Parenteral Nutrition (PN) in the paediatric population. Forty-two consecutive paediatric patients undergoing allo-HSCT at our referral centre between January 2016 and July 2019 were evaluated. Post-transplant and nutritional outcomes of patients receiving EN for more than 7 days (EN group, n = 14) were compared with those of patients receiving EN for fewer than 7 days or receiving only PN (PN group, n = 28). In the EN group, a reduced incidence of Blood Stream Infections (BSI) was observed (p = 0.02) (n = 2 vs. n = 15; 14.3% vs. 53.6%). The type of nutritional support was also the only variable independently associated with BSI in the multivariate analysis (p = 0.03). Platelet engraftment was shorter in the PN group than in the EN group for a threshold of > 20*109/L (p = 0.04) (23.1 vs 35.7 days), but this correlation was not confirmed with a threshold of > 50*109/L. The Body Mass Index (BMI) and the BMI Z-score were no different in the two groups from admission to discharge. Our results highlight that EN is a feasible and nutritionally adequate method of nutritional support for children undergoing allo-HSCT in line with the present literature. Future functional studies are needed to better address the hypothesis that greater intestinal eubyosis maintained with EN may explain the observed reduction in BSI.
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Affiliation(s)
- Daniele Zama
- Paediatric Oncology and Haematology Unit 'Lalla Seràgnoli', Department of Paediatrics, University of Bologna, Sant'Orsola Malpighi Hospital, Via Massarenti, 11, 40138, Bologna, Italy.
| | - Edoardo Muratore
- Paediatric Oncology and Haematology Unit 'Lalla Seràgnoli', Department of Paediatrics, University of Bologna, Sant'Orsola Malpighi Hospital, Via Massarenti, 11, 40138, Bologna, Italy
| | - Elena Biagi
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | | | - Roberto Rondelli
- Paediatric Oncology and Haematology Unit 'Lalla Seràgnoli', Department of Paediatrics, University of Bologna, Sant'Orsola Malpighi Hospital, Via Massarenti, 11, 40138, Bologna, Italy
| | - Marco Candela
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Arcangelo Prete
- Paediatric Oncology and Haematology Unit 'Lalla Seràgnoli', Department of Paediatrics, University of Bologna, Sant'Orsola Malpighi Hospital, Via Massarenti, 11, 40138, Bologna, Italy
| | - Andrea Pession
- Paediatric Oncology and Haematology Unit 'Lalla Seràgnoli', Department of Paediatrics, University of Bologna, Sant'Orsola Malpighi Hospital, Via Massarenti, 11, 40138, Bologna, Italy
| | - Riccardo Masetti
- Paediatric Oncology and Haematology Unit 'Lalla Seràgnoli', Department of Paediatrics, University of Bologna, Sant'Orsola Malpighi Hospital, Via Massarenti, 11, 40138, Bologna, Italy
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3
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McGrath KH. Parenteral nutrition use in children with cancer. Pediatr Blood Cancer 2019; 66:e28000. [PMID: 31535458 DOI: 10.1002/pbc.28000] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 12/28/2022]
Abstract
Multiple disease and treatment-related factors contribute to intestinal insult and influence the nutritional status of children with cancer. Many children with cancer will experience intestinal dysfunction during their cancer journey and children with cancer are a common referral group for inpatient parenteral nutrition. Appropriate use of parenteral nutrition in children with cancer and intestinal failure may alleviate malnutrition and associated risks. However, proper selection of patients, correct parenteral nutrition prescription, and close monitoring is important to avoid unnecessary intestinal failure or parenteral nutrition-related complications, minimize long-term nutritional sequelae or additional costs to health services, and optimize intestinal rehabilitation.
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Affiliation(s)
- Kathleen H McGrath
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Australia.,Intestinal Failure and Clinical Nutrition Group, Murdoch Children's Research Institute, Melbourne, Australia
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The Use of Jejunal Tube Feeding in Children: A Position Paper by the Gastroenterology and Nutrition Committees of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition 2019. J Pediatr Gastroenterol Nutr 2019; 69:239-258. [PMID: 31169666 DOI: 10.1097/mpg.0000000000002379] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Jejunal tube feeding (JTF) is increasingly becoming the standard of care for children in whom gastric tube feeding is insufficient to achieve caloric needs. Given a lack of a systematic approach to the care of JTF in paediatric patients, the aim of this position paper is to provide expert guidance regarding the indications for its use and practical considerations to optimize its utility and safety. METHODS A group of members of the Gastroenterology and Nutrition Committees of the European Society of Paediatric Gastroenterology Hepatology and Nutrition and of invited experts in the field was formed in September 2016 to produce this clinical guide. Seventeen clinical questions treating indications and contraindications, investigations before placement, techniques of placement, suitable feeds and feeding regimen, weaning from JTF, complications, long-term care, and ethical considerations were addressed.A systematic literature search was performed from 1982 to November 2018 using PubMed, the MEDLINE, and Cochrane Database of Systematic Reviews. Grading of Recommendations, Assessment, Development, and Evaluation was applied to evaluate the outcomes.During a consensus meeting, all recommendations were discussed and finalized. In the absence of evidence from randomized controlled trials, recommendations reflect the expert opinion of the authors. RESULTS A total of 33 recommendations were voted on using the nominal voting technique. CONCLUSIONS JTF is a safe and effective means of enteral feeding when gastric feeding is insufficient to meet caloric needs or is not possible. The decision to place a jejunal tube has to be made by close cooperation of a multidisciplinary team providing active follow-up and care.
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McGrath KH, Evans V, Yap J. Indications and Patterns of Use for Parenteral Nutrition in Pediatric Oncology. JPEN J Parenter Enteral Nutr 2019; 44:632-638. [DOI: 10.1002/jpen.1685] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/03/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Kathleen H. McGrath
- Department of Gastroenterology and Clinical Nutrition The Royal Children's Hospital Melbourne Australia
- Intestinal Failure and Clinical Nutrition Group Murdoch Children's Research Institute Melbourne Australia
| | - Victoria Evans
- Department of Gastroenterology and Clinical Nutrition The Royal Children's Hospital Melbourne Australia
| | - Jason Yap
- Department of Gastroenterology and Clinical Nutrition The Royal Children's Hospital Melbourne Australia
- Department of Paediatrics The University of Melbourne Melbourne Australia
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McGrath KH, Hardikar W. Gastrostomy tube use in children with cancer. Pediatr Blood Cancer 2019; 66:e27702. [PMID: 30854790 DOI: 10.1002/pbc.27702] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 01/14/2023]
Abstract
Children with cancer are at risk of malnutrition, which can impair critical childhood processes of growth and development and contribute to poor health outcomes. Enteral nutrition can effectively ameliorate malnutrition or weight loss in children with cancer; however, published nutrition support algorithms contain minimal specific information on gastrostomy tube use, and current literature is limited. Decisions about gastrostomy tube insertion in children with cancer can be challenging. Consideration of gastrostomy tube insertion is only appropriate in children with long-term dependence on enteral nutrition, particularly when nasogastric tube insertion is predicted or proven to be problematic. Specific indications for patient selection are unclear, and referring clinicians may be unaware of important absolute and relative contraindications. Complications are predominantly minor in nature; however, reported rates are high. Morbidity must be weighed carefully against the need and anticipated duration of enteral nutrition support, and further research in this area is needed.
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Affiliation(s)
- Kathleen H McGrath
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Australia.,Intestinal Failure and Clinical Nutrition Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Winita Hardikar
- Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
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Abstract
Pediatric patients require specialized attention and have diverse demands for proper growth and development, and thus need a different approach and interest in nutritional assessment and supply. Enteral nutrition is the most basic and important method of nutritional intervention, and its indications should be identified. Also, the sites, modes, types, and timing of nutritional intervention according to the patient's condition should be determined. In addition, various complications associated with enteral nutrition supply should be identified, and prevention and treatment are required. This approach to enteral nutrition and proper administration can help in the proper growth and recovery of pediatric patients with nutritional imbalances or nutritional needs.
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Affiliation(s)
- Dae Yong Yi
- Department of Pediatrics, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
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Gonzales F, Bruno B, Alarcón Fuentes M, De Berranger E, Guimber D, Behal H, Gandemer V, Spiegel A, Sirvent A, Yakoub-Agha I, Nelken B, Duhamel A, Seguy D. Better early outcome with enteral rather than parenteral nutrition in children undergoing MAC allo-SCT. Clin Nutr 2017; 37:2113-2121. [PMID: 29097037 DOI: 10.1016/j.clnu.2017.10.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/23/2017] [Accepted: 10/05/2017] [Indexed: 10/18/2022]
Abstract
There is no consensus on the type of nutritional support to introduce in children undergoing allogeneic stem cell transplantation (allo-SCT) after myeloablative conditioning (MAC). This retrospective, multicenter, observational study compared the early administration of enteral nutrition (EN group, n = 97) versus parenteral nutrition (PN group, n = 97) in such patients with matching for important covariates. The primary endpoint was the study of day 100 overall mortality. The early outcome at day 100 was better in EN group regarding mortality rate (1% vs. 13%; p = 0.0127), non relapse mortality (1% vs. 7%; p = 0.066), acute GVHD grades II-IV (37% vs. 54%; p = 0.0127), III-IV (18% vs. 34%; p = 0.0333) and its gut localization (16% vs. 32%; p = 0.0136). Platelet engraftment was better in EN group than in PN group for the threshold of 20 G/L (97% vs. 80% p < 0.0001) and 50 G/L (92% vs. 78%, p < 0.0001). The length of stay was shorter in EN group (28 vs. 52 days, p < 0.0001). There were no differences between the two groups regarding the polynuclear neutrophil engraftment, infection rate or mucositis occurrence. These results suggest that, in children undergoing MAC allo-SCT, PN should be reserved to the only cases when up-front EN is insufficient or impossible to perform.
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Affiliation(s)
- F Gonzales
- Univ. Lille, CHU Lille, Hématologie Pédiatrique, Hôpital Jeanne de Flandre, F-59000 Lille, France
| | - B Bruno
- Univ. Lille, CHU Lille, Hématologie Pédiatrique, Hôpital Jeanne de Flandre, F-59000 Lille, France
| | - M Alarcón Fuentes
- Univ. Lille, CHU Lille, Hématologie Pédiatrique, Hôpital Jeanne de Flandre, F-59000 Lille, France
| | - E De Berranger
- Univ. Lille, CHU Lille, Hématologie Pédiatrique, Hôpital Jeanne de Flandre, F-59000 Lille, France
| | - D Guimber
- Univ. Lille, CHU Lille, Gastro-Entérologie, Hépatologie et Nutrition Pédiatrique, Hôpital Jeanne de Flandre, F-59000 Lille, France
| | - H Behal
- Univ. Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, Unité de biostatistiques, F-59000 Lille, France
| | - V Gandemer
- CHU Rennes, Service d'Onco-Hématologie Pédiatrique, Hôpital Sud, Rennes, France
| | - A Spiegel
- CHU Strasbourg, Service d'Hématologie et d'Oncologie Pédiatrique, Hôpital Hautepierre, Strasbourg, France
| | - A Sirvent
- CHU Montpellier, Unité d'Onco-Hématologie Pédiatrique, Montpellier, France
| | - I Yakoub-Agha
- Univ. Lille, CHU de Lille, Maladies du Sang, Hôpital Claude Huriez, F-59000 Lille, France
| | - B Nelken
- Univ. Lille, CHU Lille, Hématologie Pédiatrique, Hôpital Jeanne de Flandre, F-59000 Lille, France
| | - A Duhamel
- Univ. Lille, CHU Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, Unité de biostatistiques, F-59000 Lille, France
| | - D Seguy
- Univ. Lille, Inserm, CHU Lille, Service de Nutrition, U995 - LIRIC - Lille Inflammation Research International Center, F-59000 Lille, France.
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Capriati T, Nobili V, Stronati L, Cucchiara S, Laureti F, Liguori A, Tyndall E, Diamanti A. Enteral nutrition in pediatric intestinal failure: does initial feeding impact on intestinal adaptation? Expert Rev Gastroenterol Hepatol 2017; 11:741-748. [PMID: 28562106 DOI: 10.1080/17474124.2017.1335196] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Primary IF can be due to impaired gut length or impaired gut function; short bowel syndrome (SBS) is the leading cause of IF. In IF patients complete enteral starvation should be avoided whenever possible and enteral/oral nutrition (EN/ON) should be employed at the maximum tolerated amount in each phase of the clinical evolution of IF. Intraluminal nutrients have stimulatory effects on epithelial cells and on trophism that enhance intestinal adaptation. Areas covered: Evidence for nutritional interventions in pediatric IF is limited and of poor quality. Clinical practice in SBS feeding are more 'experience-based' rather than 'evidence-based' and this dearth of clinical evidence is partly due to the rarity of this condition. This review updates knowledge concerning the impact of the initial diet with EN/ON in neonatal onset SBS in the process of bowel adaption. Expert commentary: Human milk resulted the preferred starting diet and it is generally combined with amino-acids (AAs) in Northern America and with hydrolyzed proteins (HFs) in Europe; polymeric diet is rarely employed. HFs were not more effective than AAs in promoting intestinal adaptation.
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Affiliation(s)
- Teresa Capriati
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
| | - Valerio Nobili
- b Liver Res Unit , IRCCS, Bambino Gesu Children Hosp , Rome , Italy
| | - Laura Stronati
- c Department of Pediatrics , Universita degli Studi di Roma La Sapienza Facolta di Medicina e Psicologia , Rome , Italy
| | | | - Francesca Laureti
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
| | - Alessandra Liguori
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
| | - Elaine Tyndall
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
| | - Antonella Diamanti
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
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Doctor A, Zimmerman J, Agus M, Rajasekaran S, Wardenburg JB, Fortenberry J, Zajicek A, Typpo K. Pediatric Multiple Organ Dysfunction Syndrome: Promising Therapies. Pediatr Crit Care Med 2017; 18:S67-S82. [PMID: 28248836 PMCID: PMC5333132 DOI: 10.1097/pcc.0000000000001053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To describe the state of the science, identify knowledge gaps, and offer potential future research questions regarding promising therapies for children with multiple organ dysfunction syndrome presented during the Eunice Kennedy Shriver National Institute of Child Health and Human Development Workshop on Pediatric Multiple Organ Dysfunction Syndrome (March 26-27, 2015). DATA SOURCES Literature review, research data, and expert opinion. STUDY SELECTION Not applicable. DATA EXTRACTION Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities. DATA SYNTHESIS Summary of presentations and discussion supported and supplemented by relevant literature. CONCLUSIONS Among critically ill children, multiple organ dysfunction syndrome is relatively common and associated with significant morbidity and mortality. For outcomes to improve, effective therapies aimed at preventing and treating this condition must be discovered and rigorously evaluated. In this article, a number of potential opportunities to enhance current care are highlighted including the need for a better understanding of the pharmacokinetics and pharmacodynamics of medications, the effect of early and optimized nutrition, and the impact of effective glucose control in the setting of multiple organ dysfunction syndrome. Additionally, a handful of the promising therapies either currently being implemented or developed are described. These include extracorporeal therapies, anticytokine therapies, antitoxin treatments, antioxidant approaches, and multiple forms of exogenous steroids. For the field to advance, promising therapies and other therapies must be assessed in rigorous manner and implemented accordingly.
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Affiliation(s)
- Allan Doctor
- Departments of Pediatrics (Critical Care Medicine) and Biochemistry, Washington University in Saint Louis
| | - Jerry Zimmerman
- Department of Pediatrics (Critical Care Medicine), University of Washington, Seattle, WA
| | - Michael Agus
- Department of Pediatrics (Critical Care Medicine), Harvard University, Boston, MA
| | - Surender Rajasekaran
- Department of Pediatrics (Critical Care Medicine), Michigan State University, Grand Rapids, MI
| | | | - James Fortenberry
- Department of Pediatrics (Critical Care Medicine), Emory University, Atlanta, GA
| | - Anne Zajicek
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, NICHD
| | - Katri Typpo
- Department of Pediatrics (Critical Care Medicine), University of Arizona, Phoenix, AZ
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11
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Wilson B, Typpo K. Nutrition: A Primary Therapy in Pediatric Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:108. [PMID: 27790606 PMCID: PMC5061746 DOI: 10.3389/fped.2016.00108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/20/2016] [Indexed: 12/18/2022] Open
Abstract
Appropriate nutrition is an essential component of intensive care management of children with acute respiratory distress syndrome (ARDS) and is linked to patient outcomes. One out of every two children in the pediatric intensive care unit (PICU) will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies. Early and adequate enteral nutrition (EN) is associated with improved 60-day survival after pediatric critical illness, and, yet, despite early EN guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10. Inadequate delivery of EN is due to perceived feeding intolerance, reluctance to enterally feed children with hemodynamic instability, and fluid restriction. Underlying each of these factors is large practice variation between providers and across institutions for initiation, advancement, and maintenance of EN. Strategies to improve early initiation and advancement and to maintain delivery of EN are needed to improve morbidity and mortality from pediatric ARDS. Both, over and underfeeding, prolong duration of mechanical ventilation in children and worsen other organ function such that precise calorie goals are needed. The gut is thought to act as a "motor" of organ dysfunction, and emerging data regarding the role of intestinal barrier functions and the intestinal microbiome on organ dysfunction and outcomes of critical illness present exciting opportunities to improve patient outcomes. Nutrition should be considered a primary rather than supportive therapy for pediatric ARDS. Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric ARDS. In this review, we examine the current evidence regarding dose, route, and timing of nutrition, current recommendations for provision of nutrition to children with ARDS, and the current literature for immune-modulating diets for pediatric ARDS. We will examine emerging data regarding the role of the intestinal microbiome in modulating the response to critical illness.
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Affiliation(s)
- Bryan Wilson
- Department of Emergency Medicine, University of Arizona College of Medicine , Tucson, AZ , USA
| | - Katri Typpo
- Department of Pediatrics, Steele Children's Research Center, University of Arizona College of Medicine , Tucson, AZ , USA
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12
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Kuiken NSS, Rings EHHM, Havinga R, Groen AK, Tissing WJE. Effect of minimal enteral feeding on recovery in a methotrexate-induced gastrointestinal mucositis rat model. Support Care Cancer 2015; 24:1357-64. [PMID: 26335404 PMCID: PMC4729808 DOI: 10.1007/s00520-015-2911-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/16/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Patients suffering from gastrointestinal mucositis often receive parenteral nutrition as nutritional support. However, the absence of enteral nutrition might not be beneficial for the intestine. We aimed to determine the feasibility of minimal enteral feeding (MEF) administration in a methotrexate (MTX)-induced mucositis rat model and thereby determine the effect of MEF on recovery. METHODS Male Wistar rats were attached to swivel systems from day 1 to 5 after 45 mg/kg MTX IV injection. The MTX group continued ad libitum feeding, and the MTX + MEF group continued ad libitum feeding and received from day 1 to 5 continuously MEF. MEF consisted of 20% of their normal caloric intake. We measured body weight, intake, and plasma citrulline. At day 10, the rats were terminated and villus and crypt length were measured. RESULTS The administration of MEF caused no increased severity of mucositis phenotype, with comparable caloric intake, body weight, and plasma citrulline during mucositis. The recovery of plasma citrulline levels was not different between both groups. At day 7 and 8, the MTX + MEF group gained significantly more weight (p < 0.05 and p < 0.01, respectively), and at day 8 and 9 the total caloric intake was significantly increased (p < 0.01 and p < 0.05, respectively) compared to the MTX group. At day 10, the rats from the MTX + MEF group showed a significant increase in jejunal villus length compared to the MTX group (p < 0.05). CONCLUSIONS This is the first study in which the feasibility of MEF administration during chemotherapy-induced mucositis was determined. This study indicates that MEF administration is feasible during mucositis and suggests that MEF accelerates recovery after MTX-induced mucositis.
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Affiliation(s)
- Nicoline S S Kuiken
- Department of Pediatric Oncology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Pediatric Gastroenterology and Hepatology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Edmond H H M Rings
- Department of Pediatrics, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
- Department of Pediatrics, Erasmus Medical Center Rotterdam, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Rick Havinga
- Department of Pediatric Gastroenterology and Hepatology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Albert K Groen
- Department of Pediatric Gastroenterology and Hepatology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Wim J E Tissing
- Department of Pediatric Oncology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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13
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Partial Enteral Nutrition Preserves Elements of Gut Barrier Function, Including Innate Immunity, Intestinal Alkaline Phosphatase (IAP) Level, and Intestinal Microbiota in Mice. Nutrients 2015; 7:6294-312. [PMID: 26247961 PMCID: PMC4555127 DOI: 10.3390/nu7085288] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 05/20/2015] [Accepted: 07/22/2015] [Indexed: 01/28/2023] Open
Abstract
Lack of enteral nutrition (EN) during parenteral nutrition (PN) leads to higher incidence of infection because of gut barrier dysfunction. However, the effects of partial EN on intestina linnate immunity, intestinal alkaline phosphatase (IAP) and microbiota remain unclear. The mice were randomized into six groups to receive either standard chow or isocaloric and isonitrogenous nutritional support with variable partial EN to PN ratios. Five days later, the mice were sacrificed and tissue samples were collected. Bacterial translocation, the levels of lysozyme, mucin 2 (MUC2), and IAP were analyzed. The composition of intestinal microbiota was analyzed by 16S rRNA pyrosequencing. Compared with chow, total parenteral nutrition (TPN) resulted in a dysfunctional mucosal barrier, as evidenced by increased bacterial translocation (p < 0.05), loss of lysozyme, MUC2, and IAP, and changes in the gut microbiota (p < 0.001). Administration of 20% EN supplemented with PN significantly increased the concentrations of lysozyme, MUC2, IAP, and the mRNA levels of lysozyme and MUC2 (p < 0.001). The percentages of Bacteroidetes and Tenericutes were significantly lower in the 20% EN group than in the TPN group (p < 0.001). These changes were accompanied by maintained barrier function in bacterial culture (p < 0.05). Supplementation of PN with 20% EN preserves gut barrier function, by way of maintaining innate immunity, IAP and intestinal microbiota.
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Clinical characteristics associated with postoperative intestinal epithelial barrier dysfunction in children with congenital heart disease. Pediatr Crit Care Med 2015; 16:37-44. [PMID: 25162512 PMCID: PMC4286428 DOI: 10.1097/pcc.0000000000000256] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Children with congenital heart disease have loss of intestinal epithelial barrier function, which increases their risk for postoperative sepsis and organ dysfunction. We do not understand how postoperative cardiopulmonary support or the inflammatory response to cardiopulmonary bypass might alter intestinal epithelial barrier function. We examined variation in a panel of plasma biomarkers to reflect intestinal epithelial barrier function (cellular and paracellular) after cardiopulmonary bypass and in response to routine ICU care. DESIGN Prospective cohort. SETTING University medical center cardiac ICU. PATIENTS Twenty children aged between newborn and 18 years undergoing repair or palliation of congenital heart disease with cardiopulmonary bypass. INTERVENTIONS We measured baseline and repeated plasma intestinal fatty acid-binding protein, citrulline, claudin 3, and dual sugar permeability testing to reflect intestinal epithelial integrity, epithelial function, paracellular integrity, and paracellular function, respectively. We measured baseline and repeated plasma proinflammatory (interleukin-6, tumor necrosis factor-α, and interferon-γ) and anti-inflammatory (interleukin-4 and interleukin-10) cytokines, known to modulate intestinal epithelial barrier function in murine models of cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS All patients had abnormal baseline intestinal fatty acid-binding protein concentrations (mean, 3,815.5 pg/mL; normal, 41-336 pg/mL). Cytokine response to cardiopulmonary bypass was associated with early, but not late, changes in plasma concentrations of intestinal fatty acid-binding protein 2 and citrulline. Variation in biomarker concentrations over time was associated with aspects of ICU care indicating greater severity of illness: claudin 3, intestinal fatty acid-binding protein 2, and dual sugar permeability test ratio were associated with symptoms of feeding intolerance (p < 0.05), whereas intestinal fatty acid-binding protein was positively associated with vasoactive-inotrope score (p = 0.04). Citrulline was associated with larger arteriovenous oxygen saturation difference (p = 0.04) and had a complex relationship with vasoactive-inotrope score. CONCLUSIONS Children undergoing cardiopulmonary bypass for repair or palliation of congenital heart disease are at risk for intestinal injury and often present with evidence for loss of intestinal epithelial integrity preoperatively. Greater severity of illness requiring increased cardiopulmonary support rather than the inflammatory response to cardiopulmonary bypass seems to mediate late postoperative intestinal epithelial barrier function.
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Kuiken NSS, Rings EHHM, Tissing WJE. Risk analysis, diagnosis and management of gastrointestinal mucositis in pediatric cancer patients. Crit Rev Oncol Hematol 2014; 94:87-97. [PMID: 25560731 DOI: 10.1016/j.critrevonc.2014.12.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 11/17/2014] [Accepted: 12/11/2014] [Indexed: 12/12/2022] Open
Abstract
Mucositis is a complex inflammatory reaction of the mucous membranes of the alimentary tract upon chemotherapy and radiotherapy treatment in oncology patients. Mucositis can be subdivided in oral and gastrointestinal mucositis (GI mucositis). The damage to the gastrointestinal tract compromises the intestinal function and thereby the nutritional status and the quality of life, and eventually affects survival. The literature on GI mucositis focuses mainly on adults. This review focuses on data available on GI mucositis in pediatric cancer patients. An evaluation of the clinical presentation and consequences of GI mucositis in children is outlined. The review summarizes key issues for clinicians with respect to risk analysis for developing mucositis and the diagnosis of this condition in children. Information on these issues is obtained from clinical trials in children and adults, and from animal models. Diagnostic tools and assessment of severity of GI mucositis in children is elaborated on. Furthermore, the clinical management of the symptoms and consequences of GI mucositis in children, with specific focus on nutritional support, are discussed.
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Affiliation(s)
- Nicoline S S Kuiken
- Department of Pediatric Oncology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, The Netherlands; Department of Pediatric Gastroenterology and Hepatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Edmond H H M Rings
- Department of Pediatrics, Leiden University Medical Center, The Netherlands; Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Wim J E Tissing
- Department of Pediatric Oncology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, The Netherlands.
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Enteral nutrition: a first option for nutritional support of children following allo-SCT? Bone Marrow Transplant 2012; 47:1191-5. [DOI: 10.1038/bmt.2011.248] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN committee on nutrition. J Pediatr Gastroenterol Nutr 2010; 51:110-22. [PMID: 20453670 DOI: 10.1097/mpg.0b013e3181d336d2] [Citation(s) in RCA: 170] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Enteral nutrition support (ENS) involves both the delivery of nutrients via feeding tubes and the provision of specialised oral nutritional supplements. ENS is indicated in a patient with at least a partially functioning digestive tract when oral intake is inadequate or intake of normal food is inappropriate to meet the patients' needs. The aim of this comment by the Committee on Nutrition of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition is to provide a clinical practice guide to ENS, based on the available evidence and the clinical expertise of the authors. Statements and recommendations are presented, and future research needs highlighted, with a particular emphasis placed on a practical approach to ENS.Among the wide array of enteral formulations, standard polymeric feeds based on cow's-milk protein with fibre and age adapted for energy and nutrient content are suitable for most paediatric patients. Whenever possible, intragastric is preferred to postpyloric delivery of nutrients, and intermittent feeding is preferred to continuous feeding because it is more physiological. An anticipated duration of enteral nutrition (EN) exceeding 4 to 6 weeks is an indication for gastrostomy or enterostomy. Among the various gastrostomy techniques available, percutaneous endoscopic gastrostomy is currently the first option. In general, both patients and caregivers express satisfaction with this procedure, although it is associated with a number of well-recognised complications. We strongly recommend the development and application of procedural protocols that include scrupulous attention to hygiene, as well as regular monitoring by a multidisciplinary nutrition support team to minimise the risk of EN-associated complications.
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The Influence of Neocate in Paediatric Short Bowel Syndrome on PN Weaning. J Nutr Metab 2010; 2010. [PMID: 20721339 PMCID: PMC2915748 DOI: 10.1155/2010/297575] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 03/08/2010] [Indexed: 11/17/2022] Open
Abstract
Clinical management of short bowel syndrome remains a multistage process. Although PN is crucial, early introduction of enteral feeding is mandatory. We describe retrospectively 4 patients with an ultrashort bowel who could be weaned off PN on very short terms after introduction of an amino-acid-based formula (Neocate). Patient 1 had congenital short bowel with 50 cm small bowel and 30 cm colon. He had persistent diarrhoea on a semielementary formula. When Neocate was introduced he could be weaned from PN within 6 months. Patient 2 needed multiple surgical interventions because of NEC at D 27. He maintained 40 cm small bowel and an intact colon and remained PN dependent on semielemental formula. After introducing Neocate, PN could be weaned within 3 months. In the next 2 patients, Neocate was introduced as initial enteral feeding after bowel resection following antenatal midgut volvulus. Patient 3 had 20 cm small bowel and an intact colon. PN was weaned after 2 months. Patient 4 had 9 cm small bowel and an intact colon. PN was weaned after 13 months. In all patients Ileocaecal valve (ICV) was preserved. No consensus is reached on the type of formula to use for short bowel syndrome. Compared to recent data in the literature, the weaning period in these 4 patients was significantly shortened on an aminoacid based formula. The reason for this may lie in the antiallergic properties of this formula. We recommend the use of an amino-acid-based formula to induce earlier weaning of PN.
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Hada M, Omura K, Hirano Y, Watanabe G. Changes in bowel mucosal permeability and wound healing after neoadjuvant chemotherapy. Oncol Lett 2010; 1:161-165. [PMID: 22966276 DOI: 10.3892/ol_00000030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Accepted: 06/29/2009] [Indexed: 11/06/2022] Open
Abstract
Neoadjuvant chemotherapy (NAC) with 5-fluorouracil (5-FU) and cisplatin (CDDP) is a promising approach for locally advanced gastric cancer. We investigated the influence of NAC with 5-FU/CDDP on the permeability of intestinal mucosa and wound healing. Male Sprague Dawley rats were divided into four groups (n=6). Group 1 received saline (control group) and Groups 2-4 were administered preoperative 5-FU/CDDP (NAC groups). The NAC consisted of daily intraperitoneal administration of 5-FU from day 1 to 5 and from day 8 to 12 and intravenous administration of CDDP on days 2 and 9. The rats underwent gastrotomy (1.0 cm) with a laparotomy of 3 cm in length, under general anesthesia. Seven days after surgery, the rats were orally administered with phenolsulfonphthalein (PSP), and the 24-h urinary excretion of PSP was quantified. On postoperative day 8, the bursting pressure (BP) of the gastric suture line and the tensile strength of the abdominal wound were measured. The hydroxyproline (HP) content in the tissue of the abdominal suture line was then measured, and the number of fibroblast cells in the tissue of the gastric suture line was calculated by histopathological examination. The PSP urinary excretion rate was significantly higher in Group 2 in comparison with the other groups (P<0.05), while the BP of a selected gastrorrhaphy region was significantly lower in Group 2 (P<0.05). No significant differences were noted in the HP content. NAC with 5-FU/CDDP disturbs the healing of intestinal anastomoses when the interval between chemotherapy and surgery is insufficient. Neither HP content nor fibroblast counts were correlated with BP. Consequently, NAC appeared to affect the remodeling of collagen fiber. Thus, the integrity of the intestine may play a role in intestinal wound healing.
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Affiliation(s)
- Masahiro Hada
- General and Cardiothoracic Surgery, Kanazawa University, 13-1 Takaramachi, Kanazawa 920-8641
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Suzuki Y, Kawasaki N, Urashima M, Odaira H, Noro T. Total Enteral Nutrition Facilitates Wound Healing Through Preventing Intestinal Atrophy, Keeping Protein Anabolism and Suppressing Inflammation. Gastroenterology Res 2009; 2:224-231. [PMID: 27942279 PMCID: PMC5139746 DOI: 10.4021/gr2009.08.1307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2009] [Indexed: 12/04/2022] Open
Abstract
Background In clinical settings, early total enteral nutrition (TEN) is known to reduce the postoperative complication and infection rate as well as duration of postoperative stay compared with total parenteral nutrition (TPN) in a variety of critical conditions. We aimed to compare effects TEN and TPN on wound healing and explore its possible mechanisms using rat model. Methods Seven days after operation for inserting enteral tube into gastric space for TEN, Sprague-Dawley rats were made burn (15 mm) in the back. Rats were administrated with either TEN (N = 17) or TPN (N = 15) and evaluated condition of wound healing as well as serum/urine immunological and biochemical parameters at 28 days. Results Burned area was significantly reduced in TEN than in TPN group. Although body weight, serum levels of total protein, albumin and transferrin were the same levels between the two groups, urine nitrogen and intestinal atrophy were significant in TPN group. Conversely, weight of small bowel showed positive linear relationship with levels of parameters calculated as follows: [medication nitrogen quantity – (urine nitrogen + feces nitrogen)]/[medication nitrogen – feces nitrogen quantity]. Weights of spleen and tumor necrotizing factor-a levels in serum were higher in TPN than in TEN. Conclusions These results suggest that TEN may facilitate wound healing compared with TPN through preventing intestinal atrophy, keeping protein anabolism and suppressing inflammation.
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Affiliation(s)
- Yutaka Suzuki
- Department of Surgery, International University of Health and Welfare
| | - Naruo Kawasaki
- Department of Surgery, International University of Health and Welfare
| | - Mitsuyoshi Urashima
- Division of Clinical Research & Development, Jikei University School of Medicine
| | - Hironori Odaira
- Department of Surgery, International University of Health and Welfare
| | - Takuji Noro
- Department of Surgery, International University of Health and Welfare
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Reversal of parenteral nutrition-induced gut mucosal immunity impairment with small amounts of a complex enteral diet. ACTA ACUST UNITED AC 2008; 65:360-5; discussion 366. [PMID: 18695472 DOI: 10.1097/ta.0b013e31817c9711] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although parenteral nutrition (PN) prevents progressive malnutrition, lack of enteral nutrition (EN) during PN leads to gut associated lymphoid tissue (GALT) atrophy and dysfunction. Administering a small amount of EN with PN reportedly prevents increases in intestinal permeability. However, its effects on GALT remain unclear. We analyzed the minimum amount of EN required to preserve gut immunity during PN. METHODS Male Institute of Cancer Research mice underwent jugular vein catheter insertion and tube gastrostomy. They were randomized into four groups to receive isocaloric and isonitrogenous nutritional support with variable EN to PN ratios (EN 0, EN 33, EN 66, and EN 100). EN was provided with a complex enteral diet. After 5 days of feeding, the mice were killed and whole small intestines were harvested. GALT lymphocytes were isolated and counted. Their phenotypes were analyzed by flow cytometry. IgA levels of small intestinal washings were analyzed with enzyme-linked immunosorbent assay. RESULTS Body weight changes did not differ between any two of the groups. Peyer's patch lymphocyte numbers increased in proportion to EN amount, whereas lamina propria lymphocyte numbers were significantly higher in the EN 100 than in the EN 0 group, with no marked increases in the EN 33 and EN 66 groups. Small intestinal IgA levels increased EN amount-dependently and reached a plateau at EN 66. CONCLUSIONS A small amount of EN partially reverses PN-induced GALT changes, suggesting beneficial but limited effects on gut mucosal immunity.
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Mattsson J, Westin S, Edlund S, Remberger M. Poor oral nutrition after allogeneic stem cell transplantation correlates significantly with severe graft-versus-host disease. Bone Marrow Transplant 2006; 38:629-33. [PMID: 16964269 DOI: 10.1038/sj.bmt.1705493] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
It has previously been shown that enteral nutrition has several advantages compared to parenteral nutrition (PN) in critically ill patients. The nutritional history was studied in 231 patients after allogeneic stem cell transplantation (SCT). Parenteral nutrition was given for a median of 10 (0-74) days. Patients with graft-versus-host disease (GVHD) grades III-IV received more PN (median 20, range 0-67) than patients with GVHD grades 0-II (10, 0-74, P=0.016). Eighty-five (37%) patients were not able to eat anything for a median of 4 days (1-37). We found a correlation between the number of days with no oral intake (before the diagnosis of acute GVHD) and the incidence of acute GVHD grades III-IV. In patients with 1-4 days of no oral intake, the incidence of grades III-IV acute GVHD was 6%, in those with 5-9 days it was 17%, and in those with >9 days it was 38%. On multivariate analysis, we found that more than 9 days with no oral intake was associated with acute GVHD grades III-IV (odds ratio 7.66, confidence interval 1.44-40.7, P=0.016). Poor oral intake early after SCT may be associated with an increased risk of developing severe acute GVHD.
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Affiliation(s)
- J Mattsson
- Center for Allogeneic Stem Cell Transplantation, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden.
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Ekelund M, Ekelund M, Qader SS, Hallén M, Ekblad E. Effects of total parenteral nutrition on rat enteric nervous system, intestinal morphology, and motility. J Surg Res 2005; 124:187-93. [PMID: 15820247 DOI: 10.1016/j.jss.2004.10.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2004] [Indexed: 11/24/2022]
Abstract
Total parenteral nutrition (TPN) is often crucial for patients not being able to feed enterally or having intestinal absorptive deficits. Enteral nutrition is, however, frequently regarded vital for maintaining functional and structural intestinal integrity. The aim of this study was to investigate possible effects of TPN on rat distal small intestine compared to enterally fed identically housed controls, regarding the enteric nervous system (ENS), motility in vitro, and morphology. This study shows that motor responses evoked by electrical stimulation or exposure to vasoactive intestinal peptide (VIP), pituitary adenylate cyclase activating peptide-27 (PACAP-27), and nitric oxide (NO) donor were unchanged. By using immunohistochemistry, the numbers of submucous (P < 0.05) and myenteric (P < 0.05) nerve cells were found to increase, expressed as numbers per unit length. The percentage of neurons expressing VIP, PACAP-27, NO-synthase, and galanin remained unchanged, however. By in situ hybridization the number of submucous neurons expressing neuropeptide Y-mRNA was found to decrease (P < 0.05); the other populations were unaltered. Morphometry revealed an increased submucosal thickness (P < 0.05), while intestinal circumference markedly decreased (P < 0.0001) in TPN-treated rats. In conclusion, TPN treatment resulted in reduced intestinal circumference leading to condensation of enteric neurons. No marked changes in neurotransmitter expression of the enteric neurons or in motor activity were noted.
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Alwayn IPJ, Gura K, Nosé V, Zausche B, Javid P, Garza J, Verbesey J, Voss S, Ollero M, Andersson C, Bistrian B, Folkman J, Puder M. Omega-3 fatty acid supplementation prevents hepatic steatosis in a murine model of nonalcoholic fatty liver disease. Pediatr Res 2005; 57:445-52. [PMID: 15659701 DOI: 10.1203/01.pdr.0000153672.43030.75] [Citation(s) in RCA: 168] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Prolonged use of total parenteral nutrition can lead to nonalcoholic fatty liver disease, ranging from hepatic steatosis to cirrhosis and liver failure. It has been demonstrated that omega-3 fatty acids are negative regulators of hepatic lipogenesis and that they can also modulate the inflammatory response in mice. Furthermore, they may attenuate hepatic steatosis even in leptin-deficient ob/ob mice. We hypothesized that omega-3 fatty acid supplementation may protect the liver against hepatic steatosis in a murine model of parenteral nutrition in which all animals develop steatosis and liver enzyme disturbances. For testing this hypothesis, groups of mice received a fat-free, high-carbohydrate liquid diet ad libitum for 19 d with enteral or i.v. supplementation of an omega-3 fatty acid emulsion or a standard i.v. lipid emulsion. Control mice received food alone or the fat-free, high-carbohydrate diet without lipid supplementation. Mice that received the fat-free, high-carbohydrate diet only or supplemented with a standard i.v. lipid emulsion developed severe liver damage as determined by histology and magnetic resonance spectroscopy as well as elevation of serum liver function tests. Animals that received an i.v. omega-3 fatty acid emulsion, however, showed only mild deposits of fat in the liver, whereas enteral omega-3 fatty acids prevented hepatic pathology and led to normalization of liver function tests. In conclusion, whereas standard i.v. lipid emulsions fail to improve dietary-induced steatotic injury to the liver, i.v. supplementation of omega-3 fatty acids partially and enteral supplementation completely protects the liver against such injury.
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Affiliation(s)
- Ian P J Alwayn
- Department of Surgery and the Vascular Biology Program, The Children's Hospital, Boston, MA 02115, USA
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