Artificial nutrition: dilemmas in decision-making

Training in Paediatric Clinical Nutrition Across Europe: A Survey of the National Societies Network (2016-2019) of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition

OBJECTIVES/BACKGROUND

Disease-related malnutrition is common in patients with chronic diseases and has detrimental effects, therefore, skills in nutrition care are essential core competencies for paediatric digestive medicine. The aim of this survey, conducted as part of a global survey of paediatric gastroenterology, hepatology and nutrition (PGHN) training in Europe, was to assess nutrition care-related infrastructure, staff, and patient volumes in European PGHN training centres.

METHODS

Standardized questionnaires related to clinical nutrition (CN) care were completed by representatives of European PGHN training centres between June 2016 and December 2019.

RESULTS

One hundred training centres from 17 European countries, Turkey, and Israel participated in the survey. Dedicated CN clinics exist in 66% of the centres, with fulltime and part-time CN specialists in 66% and 42%, respectively. Home tube feeding (HTF) andhome parenteral nutrition (HPN) programmes are in place in 95% and 77% of centres, respectively. Twenty-four percent of centres do not have a dedicated dietitian and 55% do not have a dedicated pharmacist attached to the training centre. Even the largest centres with >5000 outpatients reported that 25% and 50%, respectively do not have a dedicated dietitian or pharmacist. Low patient numbers on HTF and HPN of <5 annually are reported by 13% and 43% of centres, respectively.

CONCLUSIONS

The survey shows clear differences and deficits in Clinical Nutrition training infrastructure, including staff and patient volumes, in European PGHN training centres, leading to large differences and limitations in training opportunities in Clinical Nutrition.

Enteral Nutrition in Pediatric Patients

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.

Bridging the Continuum: Nutrition Support in Palliative and Hospice Care

Clinicians and patients in today's technically focused healthcare environment are often faced with decisions of what should be done vs what could be done. The decision to provide or not provide nutrition support during palliative care and hospice care requires an understanding of and respect for patient wishes, an appreciation for the expectations of the patient and family, and open and effective communication. There can be confusion and disagreement concerning what nutrition therapies should be continued and which ones stopped. These decisions can be facilitated by answering the question: When do the burdens of nutrition support outweigh the benefit to the patient? The patient, family members, and healthcare providers should openly discuss and agree upon the goals of nutrition support during palliative care and hospice care.

Initiating artificial nutrition support: a clinical judgement analysis

BACKGROUND

Variations in the practice of artificial nutrition are partly a result of the judgements of clinicians. Little is known about these judgements, the decision processes used or the quality of the decisions that arise. The methodology of clinical judgement analysis describes and explains judgemental differences between clinicians and offers a window into why clinician choices sometimes fail to correspond with current best practice guidelines.

METHODS

A clinical judgement analysis with 27 clinicians using two judgement tasks was carried out. Clinicians expressed their 'likelihood of feeding' and 'whether or not they would initiate artificial nutrition support' in response to 54 patient scenarios. Measures of agreement between clinicians, the degree of linear reasoning employed, their judgemental consistency and concordance with National Institute for Health and Clinical Excellence (NICE) guidelines were assessed.

RESULTS

Clinicians' judgements varied substantially both in the amount of information employed and the weighting given to information. Clinicians had only moderate agreement with NICE recommendations and overestimated the need for artificial nutrition support. Suboptimal judgements were consistently applied by clinicians. When clinicians reasoned in more linear ways, their judgements and decisions improved.

CONCLUSIONS

Overestimating the need for artificial nutritional support may inflate health service costs and increase risks for patients unnecessarily. A better understanding by clinicians of the information needed (as well as how to use it) for artificial nutrition support initiation may help improve clinical decision-making.

Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN committee on nutrition

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.

Extrauterine growth retardation in premature infants in Shanghai: a multicenter retrospective review

Intrauterine growth retardation (IUGR) represents the degree of body growth and development decided by genes and by placental function. Extrauterine growth retardation/restriction (EUGR) refers to severe nutritional deficits during the first weeks of life that result in growth that is less than expected based on intrauterine growth rates (growth values < or =10th percentile of intrauterine growth expected in accordance with the estimated gestational age). The deficits affect not only weight but also head circumference and height. As is well known, a nutrition support team (NST) is a multidisciplinary team comprised of physicians, nurses, dietitians, pharmacists, social workers, and medical technologists who provide nutritional management. In this study, we review 2,015 premature infants (1,209 boys and 806 girls) from four hospitals in the Shanghai area from January 1, 2003 to December 31, 2006, two of which had NSTs. The overall incidence of EUGR was 56.8% assessed by weight, while the incidence of IUGR was 26.1%. Higher incidence of EUGR was associated with lower birth weight, but higher gestational age. There was a significant relationship between EUGR incidence and NST availability (chi(2) = 60.630, p < 0.001), though there was no similar finding for IUGR incidence. The incidence of EUGR was 44% in NST hospitals and 62.6% in non-NST hospitals. According to logistic regression, the following five factors were related to EUGR: male gender, gestational age at birth, birth weight, length of hospital stay, and NST availability. NSTs reduced the risk of EUGR by a magnitude of 0.47. EUGR remains a serious problem in premature infants in Shanghai, but NSTs can reduce EUGR incidence.

A pilot study exploring the factors that influence the decision to have PEG feeding in patients with progressive conditions

This original pilot study was conducted to explore and understand the factors that influence a patient's decision-making when considering percutaneous endoscopic gastrostomy placement for nonoral nutrition and hydration supplementation. Seven patients living with progressive dysphagic symptoms who had made a decision about percutaneous endoscopic gastrostomy placement were interviewed and their responses analyzed using the constant comparison method. All participants felt they had no option other than to accept the percutaneous endoscopic gastrostomy. The impact of visible physical deterioration and medical opinion were the most powerful influences on patients' decisions. Patients' perception of their involvement in the decision varied. This was linked to the amount and timing of information supplied and support they felt they received. Few patients have prior knowledge of tube feeding and rely heavily on medical advice. Effective communication by healthcare professionals can promote an environment that is supportive of patients' involvement in decisions. Adequate preparation time is vital if patients are to stop feeling uninvolved or peripheral to the decision-making process. Multidisciplinary teams need to address their working practices so that they do not intimidate patients, but rather empower patients in their decision-making.

Adult home parenteral nutrition: a clinical evaluation after a 3-year experience in a Southern European centre

AIM

To evaluate the current use of Home Parenteral Nutrition (HPN) in a Southern European region.

SUBJECTS AND METHODS

A total of 159 (86 m, 73 f) HPN patients, mean age 60.1 +/- 14.2 years, BMI 18.8 +/- 3.3kg/m2, consecutively referred to the Artificial Nutrition outpatient Unit of the Federico II University Hospital in Naples (Italy), from January 2000 to December 2002 and treated for at least 4 weeks. Retrospective evaluation of baseline disease, indications and duration of HPN treatment, type of venous access, complications.

RESULTS

In all, 140 (88%) were cancer and 19 (12%) noncancer patients. Main indications were carcinosis in 68 for total, and hypophagia/dysphagia in 62 patients for partial/integrative (to oral-enteral nutrition) HPN; mean duration of HPN was 81.45 +/- 110.86 days of treatment and infection rate 2.89% in the whole population and 2.66% in the 36 patients treated for more than 3 months. No other major complications have been observed.

CONCLUSION

HPN is confirmed to be a safe and effective treatment when prescribed and administered by a trained team.

Predictive factors of survival in patients with peritoneal carcinomatosis on home parenteral nutrition

OBJECTIVE

We worked to identify predictors of survival in patients with carcinomatosis on home parenteral nutrition (HPN).

METHODS

Survival rate was evaluated in 152 terminal patients (45 men and 107 women) with peritoneal carcinosis on HPN. Selected anthropometric measurements (weight and body mass index), laboratory tests (serum albumin, cholesterol, cholinesterase [CHE], hemoglobin, and lymphocyte count) and clinical variables (ascites, pain, and vomiting) were recorded at baseline. A Karnofsky Performance Status (KPS) was also determined.

RESULTS

Sites of primary cancer were the stomach in 31.6%, ovaries in 27.6%, colorectum in 19.7%, and other in 21.1%. At baseline patients had abnormally low values: 55.3% had a body mass index no greater than 20.0 kg/m2, 40.4% had a serum albumin level lower than 3.0 g/dL, 55.7% had a lymphocyte count no higher than 1200/mm3, 54.6% had a cholesterol level lower than 160 mg/dL, and 63.1% had a CHE level lower than 5400 U/L. Pain, ascites, vomiting, and a KPS score no higher than 40 were observed in 44.1%, 55.3%, 76.3%, and 51.3% of patients, respectively. Survival ranged from 6 to 1269 d (median 45 d). Patients with a KPS score no higher than 40 had shorter survival than did patients with a KPS score of at least 50 (median 28.5 versus 81, P = 0.0001). Multivariate analysis (R2 = 0.152 for the entire model) indicated that KPS (P = 0.01) and CHE (P = 0.034) were significant predictors of survival. Moreover, three different combinations of selected clinical and laboratory variables identified patients who survived fewer than 60 d (high specificity).

CONCLUSIONS

Time of survival widely varied among terminal cancer patients; identification of predictive factors could help to draw up guidelines to improve indications for HPN. In this study, traditional predictors (KPS, albumin, pain, and vomiting) and CHE level appeared to be a useful survival predictor index in incurable patients with peritoneal carcinosis on HPN.

The need for nutrition support teams in pediatric units: a commentary by the ESPGHAN committee on nutrition

The reported prevalence of malnutrition in pediatric hospitals ranges from 15% to 30% of patients, with an impact on growth, morbidity and mortality. Major deficits in nutrition care have been highlighted in European hospitals, and the implementation of nutrition support teams (NSTs) has been suggested as a means to improve malnutrition diagnosis and nutrition care for hospitalized patients. This comment by the ESPGHAN Committee on Nutrition reviews disease related-mechanisms causing malnutrition and consequences of malnutrition and suggests a framework for implementation of NSTs in pediatric units. The recommendations by the Committee on Nutrition include: 1) Implementation of NSTs in hospitals is recommended to improve nutritional management of sick children; 2) The main tasks of the NST should include screening for nutritional risk, identification of patients who require nutritional support, provision of adequate nutritional management, education and training of hospital staff and audit of practice; 3) The NST should be multidisciplinary, with expertise in all aspects of clinical nutrition care; 4) The funds needed to support NSTs should be raised from the health care system; and 5) Further research is needed to evaluate the effects of NSTs in prevention and management of pediatric nutritional disorders, including cost effectiveness in different settings.