Managing children and adolescents on parenteral nutrition: challenges for the nutritional support team

Optical Identification of Parenteral Nutrition Solutions Exploiting Refractive Index Sensing

Parenteral artificial nutrition (PAN) is a lifesaving treatment for a large population of patients affected by different diseases, and it consists of intravenous injection of nutritive fluids by means of infusion pumps. Wrong PAN solutions are, unfortunately, often administered, thus threatening the patients' well-being. Here, we report an optofluidic label-free sensor that can distinguish PAN solutions on the basis of their volumetric refractive index (RI). In our system, a monochromatic light beam, generated by a laser diode, travels obliquely through a transparent, square-section polystyrene channel, is then back-reflected by a mirror, and finally exits the channel in a position that depends on the filling fluid RI. The displacement of the output light spot ΔXexperim is easily detected with a linear, 1-D position sensitive detector (PSD). We initially calibrated the sensor with water-glucose solutions demonstrating a sensitivity S = ΔXexperim/Δn = 13,960 µm/RIU. We then clearly distinguished six commercial PAN solutions, commonly administered to patients. To the best of our knowledge, this is the first reported healthcare sensing platform for remote contactless recognition of PAN fluids, which could be inserted into infusion pumps to improve treatment safety, by checking the compliance to the prescription of the fluid actually delivered to the patient.

The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients

Parenteral nutrition (PN) is a complex and specialized form of nutrition support that has revolutionized the care for both pediatric and adult patients with acute and chronic intestinal failure (IF). This has led to the development of multidisciplinary teams focused on the management of patients receiving PN: nutrition support teams (NSTs). In this review we aim to discuss the historical aspects of IF management and NST development, and the practice, composition, and effectiveness of multidisciplinary care by NSTs in patients with IF. We also discuss the experience of two IF centers as an example of contemporary NSTs at work. An NST usually consists of at least a physician, nurse, dietitian, and pharmacist. Multidisciplinary care by an NST leads to fewer complications including infection and electrolyte disturbances, and better survival for patients receiving short- and long-term PN. Furthermore, it leads to a decrease in inappropriate prescriptions of short-term PN leading to significant cost reduction. Complex care for patients receiving PN necessitates close collaboration between team members and NSTs from other centers to optimize safety and effectiveness of PN use.

Factors Impacting on Eating in Pediatric Intestinal-Transplant Recipients: A Mixed-Methods Study

BACKGROUND

No empirical data are found examining why eating may be difficult for some children and not others following intestinal transplant. This study aimed to describe the eating behaviors and nutrition intake of intestinal-transplant-recipient children and examine factors that may impact on their eating.

METHODS

Caregivers of all (n = 34) intestinal-transplant recipients <18 years of age in the United Kingdom were invited to participate in this mixed-methods study comprising questionnaires, a 3-day food diary and interviews. Questionnaires included the Children's Eating Behaviour Questionnaire and demographic/nutrition-related items. Analysis was by descriptive statistics using SPSS. Semistructured telephone interviews explored caregiver perceptions of their child's eating. Analysis was thematic.

RESULTS

Nine caregivers were recruited and completed the questionnaire and food diary. Eight of these were interviewed. Home tube feeding was required by 77% (n = 7) of children post transplant, 56% (n = 5) were "food avoidant", and median energy intake was 93% (range, 61%-137%) of requirements. The findings revealed complex, interrelated positive and negative medical, caregiver, and child-related influences on eating. Learning to eat at the recommended age and having positive and significant pretransplant eating experiences appeared protective, whereas receiving nothing by mouth and having aversive experiences were barriers.

CONCLUSION

This study provides the first empirical evidence of factors that may influence eating after intestinal transplant in children. The findings suggest promoting eating pretransplant, when the negative physical consequences can be managed, may be protective, and there may be eating-difficulty predictors that could be used to facilitate targeted interventions.

Influence of Dietitians in Preventing Parenteral Nutrition Prescription Errors in Children

BACKGROUND

The purpose of this study is to determine whether direct involvement by dietitians in parenteral nutrition (PN) ordering resulted in a reduction in PN prescriptions errors.

METHODS

A prospective audit of PN prescriptions was undertaken at a pediatric hospital over 50 weeks. Prescriptions for PN that had dietitian involvement (dietitian group) were compared with prescriptions in which dietitians were not directly involved (nondietitian group). The number of total prescriptions, the number of prescriptions with errors, and the types of errors from both groups were recorded. Errors were classified into "dietitian-preventable errors" and "nondietitian-preventable errors." Comparisons were made between prescriptions with and without errors, between dietitian-preventable and nondietitian-preventable errors, and between the dietitian and nondietitian groups per error type.

RESULTS

The total number of PN prescriptions was 725 (from 45 patients) and 471 (from 66 patients) for the dietitian and nondietitian groups, respectively. The nondietitian group was more likely than the dietitian group to prescribe PN incorrectly-18.0% (85 of 471) vs 12.4% (90 of 725; P = .007)-with the nondietitian group having 1.5-times more PN prescriptions with errors (risk ratio = 1.5, 95% CI: 1.1-1.9). The total number of prescription errors was 126 and 146 for the dietitian and nondietitian groups, respectively. The dietitian group was less likely than the nondietitian group to be associated with dietitian-preventable errors: 65.9% (83 of 126) vs 87.0% (127 of 146; risk ratio = 1.3, 95% CI: 1.1-1.5; P < .0001).

CONCLUSION

Dietitian input into prescription of PN reduced the number of prescriptions with errors.

Paediatric Home Parenteral Nutrition in the Czech Republic and Its Development: Multicentre Retrospective Study 1995-2011

Background: Treatment quality and outcomes of paediatric home parenteral nutrition (HPN) program during its development in the Czech Republic. Methods: A retrospective study of patients receiving HPN from May 1995 till June 2011. Results: Sixty-six patients were treated in 8 centres. In 48 patients, long-term PN began in the first year of life and in 35 of them in the first month. Sixty children had gastrointestinal and 6 had non-gastrointestinal disease. In a majority of the patients, the Broviac catheter was used. Thirty-two (48.5%) patients were weaned from PN after 1-117 months, 21 (32.8%) continued on HPN after 7-183 months, and 13 (19.7%) patients died, all on PN. The mortality in patients with primary gastrointestinal disease was significantly lower than in patients with non-gastrointestinal disease. Thirty-one paediatric patients were receiving HPN for 14,480 catheter days in 2009-2010. Fourteen patients had 23 Catheter Related Blood Stream Infections (CRBSI) episodes. The incidence of CRBSI in 2009-2010 was 1.58/1,000 catheter days. Conclusion: Submitted data showed that even in the absence of expert centres, patient care may achieve results comparable to countries with well-developed HPN program. A majority of Czech HPN patients are at present treated in specialized centres, following the most desirable pattern of care.

Educational outcomes associated with providing a comprehensive guidelines program about nursing care of preterm neonates receiving total parenteral nutrition

Poor understanding or practice of Total Parenteral Nutrition (TPN) causes devastating complications. Therefore, good Neonatal Intensive Care Unit (NICU) nursing care for preterm neonates and close monitoring of complications is essential for successful TPN therapy. The study was conducted in NICU at Ain Shams University Hospital in Cairo, Egypt, using a quasi-experimental research design with prepost intervention assessments. Data was collected using a self-administered questionnaire sheet and an observation checklist (prepost format) and developed a comprehensive guidelines program about nursing care of TPN of preterm neonates. Results revealed that the program had a significant positive impact on nurses' knowledge and practice outcomes.

Videotoracoscopia como uma opção no tratamento cirúrgico do quilotórax após cirurgia cardíaca pediátrica

OBJETIVO: Avaliar o uso de videotoracoscopia no tratamento cirúrgico do quilotórax após cirurgia para correção de cardiopatias congênitas em crianças. MÉTODOS: Revisamos os prontuários médicos de 3.092 crianças operadas para a correção de cardiopatias congênitas no Instituto do Coração/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (SP) entre fevereiro de 2002 e fevereiro de 2007. RESULTADOS: Das 3.092 crianças, 64 (2,2%) apresentaram quilotórax como complicação pós-operatória. Em 50 (78,1%) dessas, o tratamento clínico foi bem-sucedido, enquanto esse falhou em 14 (21,9%), as quais foram submetidas à ligação do ducto torácico por videotoracoscopia. A ligação do ducto torácico obteve sucesso em 12 pacientes (86%) e falhou em 2 casos, os quais foram resolvidos com medidas clínicas adicionais, como dieta pobre em gorduras e nutrição parenteral. Não houve morbidade ou mortalidade relacionada à operação. Dos 14 pacientes, 5 (35%) faleceram em decorrência de complicações cardíacas ou infecciosas. CONCLUSÕES: A ligadura videoassistida do ducto torácico pode ser realizada com segurança em pacientes gravemente enfermos e com doença cardíaca grave, com resultados favoráveis.

[Is it worth knowing the characteristics of inpatient paediatric parenteral nutrition?]

OBJECTIVE

To describe the characteristics of inpatient parenteral nutrition during 2008 in a tertiary level paediatric hospital. To compare this practice with recent standards.

MATERIAL AND METHODS

Longitudinal, descriptive, and retrospective study of patients under 16 years receiving parenteral nutrition in 2008. Demographic data as well as data of the nutritional support were recorded.

RESULTS

A total of 120 children received parenteral nutrition, of whom 63 were under 2 years, 30 between 3 and 7 years, and 27 older than 7 years. They accounted for 1.6% of all the inpatients during that period. Most frequent indication was gastrointestinal surgery (35.5%), followed by non-surgical gastrointestinal diseases (19.8%). The average composition in the first day of parenteral nutrition was: 63.1kcal/kg (SD: 21.3); volume, 76.6ml/kg (SD: 28.4); carbohydrates 9.6g/kg/d (SD: 3.2); amino acids 2.1g/kg/d (SD: 0.6), and lipids 1.9g/kg/d (SD: 1). The mean duration of parenteral support was 10.5 days (SD: 9.8). Internal jugular vein (34.7%) and femoral vein were the most common intravenous access. The main reason to discontinue parenteral nutrition was transition to oral/enteral feedings. The complication rate was 27.3%.

CONCLUSIONS

There is an interest in evaluating standard practice in parenteral nutrition in order to develop improvement strategies. Infants and toddlers are the principal candidates for parenteral nutrition. Standardisation is one way to decrease errors in its preparation and prescription.

Symposium 6: Young people, artificial nutrition and transitional care. Transition in young people on home parenteral nutrition

Pharmacological, surgical and technological advances have resulted in children now surviving through adolescence into adulthood with conditions that were previously unseen by adult services. Arranging transition for young people on home parenteral nutrition (HPN) to the adult sector is one of greatest challenges for health services that care for young people. Transition is not only a key quality issue for health services, but is a multidimensional process covering psychosocial, educational and vocational aspects. Poorly-planned transition may result in difficulties when young people access adult specialist services. As a consequence, there may be increased risk of non-adherence or lack of follow-up, which carries dangers of morbidity and mortality as well as poor social and educational outcomes. Transition does not end at the exit from the paediatric clinic, but continues into the adult sector, which needs to provide developmentally-appropriate clinical care. Recent Department of Health initiatives are aimed at ensuring that young people do not miss out on healthcare during the transfer between paediatric and adult services. Transfer can be a major, often daunting, event for young people. Parents may also fear transfer and need to learn to 'let go' of some control, which may be particularly difficult with a young person on HPN.