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Shrivastava S, Shaw K, Lee M, Reitich P, Hunter S, Klosterman M, Sathe M. Association of in-line digestive enzyme cartridge with enteral feeds on improvement in anthropometrics among pediatric patients with cystic fibrosis. Nutr Clin Pract 2024; 39:903-910. [PMID: 38493301 DOI: 10.1002/ncp.11142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Approximately 85% of patients with cystic fibrosis (CF) have exocrine pancreatic insufficiency (EPI) with 10% requiring supplemental nighttime enteral tube feedings. Administration of pancreatic enzyme replacement therapy (PERT) with nighttime feedings is fraught with challenges. RELiZORB (Alcresta Therapeutics, Inc), an in-line lipase cartridge, delivers PERT continuously with enteral feedings. Outcomes related to the use of this in-line lipase cartridge are lesser known. This project evaluated anthropometrics related to in-line lipase cartridge use among pediatric patients with CF already receiving oral PERT therapy prior to nighttime enteral feedings. METHODS Retrospective chart review was performed on 29 patients with CF and EPI receiving supplemental tube feedings and utilizing in-line lipase cartridge for a continuous 12 month period between 2015 and 2019. Anthropometrics were evaluated 12 months before and after initiation of in-line lipase cartridge. RESULTS Compared with mean height z score at 6-months pre-in-line lipase cartridge, mean height z score at 6-months post-in-line-lipase cartridge (adjusted mean difference [AMD] = 0.2540; 95% CI = [0.0487, 0.4592]; P = 0.0153) and mean height z score at 12-months post-in-line lipase cartridge (AMD = 0.2684; 95% CI = [0.0203, 0.5166]; P = 0.0340) were significantly higher. Mean weight z score at 12-months post-in-line-lipase-cartridge neared statistical significance compared with 6-months pre-in-line lipase cartridge (AMD = 0.2816; 95% CI = [-0.0003, 0.5634]; P = 0.0502) when excluding seven patients with advanced lung disease (forced expiratory volume in the first second of expiration of 40%). Weight-for-length or body mass index did not significantly differ compared with pre-in-line lipase cartridge. CONCLUSION Use of in-line lipase cartridge with enteral feeds improved anthropometrics, especially height, in pediatric patients with CF.
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Affiliation(s)
- Samarth Shrivastava
- Department of Pediatrics, Division of Combined Internal Medicine and Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Karyn Shaw
- Pediatric Clinical Nutrition, Children's Health, Dallas, Texas, USA
| | - MinJae Lee
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Patricia Reitich
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Stacie Hunter
- Pediatric Clinical Nutrition, Children's Health, Dallas, Texas, USA
| | - Mary Klosterman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Meghana Sathe
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Berry AJ, Bilbo A. Exocrine pancreatic insufficiency and pancreatic exocrine replacement therapy in clinical practice. Nutr Clin Pract 2024; 39 Suppl 1:S78-S88. [PMID: 38429965 DOI: 10.1002/ncp.11124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/02/2024] [Accepted: 01/07/2024] [Indexed: 03/03/2024] Open
Abstract
Exocrine pancreatic insufficiency (EPI) is a complex condition that disrupts normal digestion and absorption. Patients with EPI may suffer from mild to debilitating malabsorption with a constellation of symptoms that can have a significant effect on quality of life and nutrition status. Pancreatic enzyme replacement therapy (PERT) is effective and safe to treat EPI and is the standard of care for this condition. A wide variety and various forms of these products exist, as well as numerous guidelines and recommendations. Obtaining PERT for patients can oftentimes be cost prohibitive. Determining the presence and extent of EPI can be challenging and patient specific, making it difficult for practitioners. This narrative review will explore these issues, as well as several disease states potentially affected by EPI, and review current management strategies.
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Affiliation(s)
- Amy J Berry
- Department of Clinical Nutrition, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Amy Bilbo
- Department of Clinical Nutrition, Medical University of South Carolina, Charleston, South Carolina, USA
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Wilschanski M, Munck A, Carrion E, Cipolli M, Collins S, Colombo C, Declercq D, Hatziagorou E, Hulst J, Kalnins D, Katsagoni CN, Mainz JG, Ribes-Koninckx C, Smith C, Smith T, Van Biervliet S, Chourdakis M. ESPEN-ESPGHAN-ECFS guideline on nutrition care for cystic fibrosis. Clin Nutr 2024; 43:413-445. [PMID: 38169175 DOI: 10.1016/j.clnu.2023.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Nutritional status is paramount in Cystic Fibrosis (CF) and is directly correlated with morbidity and mortality. The first ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with CF were published in 2016. An update to these guidelines is presented. METHODS The study was developed by an international multidisciplinary working group in accordance with officially accepted standards. Literature since 2016 was reviewed, PICO questions were discussed and the GRADE system was utilized. Statements were discussed and submitted for on-line voting by the Working Group and by all ESPEN members. RESULTS The Working Group updated the nutritional guidelines including assessment and management at all ages. Supplementation of vitamins and pancreatic enzymes remains largely the same. There are expanded chapters on pregnancy, CF-related liver disease, and CF-related diabetes, bone disease, nutritional and mineral supplements, and probiotics. There are new chapters on nutrition with highly effective modulator therapies and nutrition after organ transplantation.
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Affiliation(s)
- Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Anne Munck
- Cystic Fibrosis Centre, Hopital Necker-Enfants Malades, AP-HP, Paris, France
| | - Estefania Carrion
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sarah Collins
- CF Therapies Team, Royal Brompton & Harefield Hospital, London, UK
| | - Carla Colombo
- University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Dimitri Declercq
- Cystic Fibrosis Reference Centre, Ghent University Hospital and Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Elpis Hatziagorou
- Cystic Fibrosis Unit, 3rd Pediatric Dept, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Jessie Hulst
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics and Department of Nutritional Sciences, The University of Toronto, Toronto, Canada
| | - Daina Kalnins
- Department of Clinical Dietetics, The Hospital for Sick Children, Toronto, Canada
| | - Christina N Katsagoni
- Department of Clinical Nutrition, Agia Sofia Children's Hospital, Athens, Greece; EFAD, European Specialist Dietetic Networks (ESDN) for Gastroenterology, Denmark
| | - Jochen G Mainz
- Brandenburg Medical School, University Hospital. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Carmen Ribes-Koninckx
- Pediatric Gastroenterology and Paediatric Cystic Fibrosis Unit. La Fe Hospital & La Fe Research Institute, Valencia, Spain
| | - Chris Smith
- Department of Dietetics, Royal Alexandra Children's Hospital, Brighton, UK
| | - Thomas Smith
- Independent Patient Consultant Working at Above-disease Level, UK
| | | | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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4
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Sasanfar B, Toorang F, Salehi-Abarghouei A. Effects of n-3 polyunsaturated fatty acid supplementation on appetite: a systematic review and meta-analysis of controlled clinical trials. Syst Rev 2024; 13:44. [PMID: 38281014 PMCID: PMC10821539 DOI: 10.1186/s13643-023-02430-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 12/11/2023] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND The current studies explore the effect of omega-3 polyunsaturated fatty acids (PUFAs) on appetite. OBJECTIVE To examine the effect of omega-3 polyunsaturated fatty acids (n-3 PUFAs) on appetite using a systematic review and meta-analysis of controlled clinical trials (CTs). PATIENTS AND METHODS Online databases including PubMed, Scopus, ISI Web of Science, and Google Scholar were searched up to January 2022. A random-effects model was used to compare the overall standardized mean difference in appetite scores between n-3 PUFAs supplemented and control individuals. RESULTS Fifteen eligible CTs with 1504 participants (872 for n-3 PUFA supplementation and 632 for placebo groups) were included in our systematic review. The meta-analysis showed no significant difference in overall appetite score between n-3 PUFAs supplemented and control groups (standardized mean difference [SMD] = 0.458, 95% confidence interval [CI] - 0.327, 1.242, P value = 0.25). However, the n-3 PUFA supplementation significantly increased the desire to eat (SMD = 1.07, 95% CI 0.116, 2.029, P = 0.02) compared to control. CONCLUSION Although we found no effect of omega-3 supplementation on overall appetite score, it modestly increases the desire to eat. Further CTs evaluating the effect of PUFAs on appetite are still needed to confirm these findings.
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Affiliation(s)
- Bahareh Sasanfar
- Research Center for Food Hygiene and Safety, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Department of Nutrition, School of Public Health, Faculty of Health, Shahid Sadoughi University of Medical Sciences, P O Box 8915173160, Yazd, Iran
- Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran
- Student Research Committee, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Fatemeh Toorang
- Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran
- Departments of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Amin Salehi-Abarghouei
- Research Center for Food Hygiene and Safety, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
- Yazd Cardiovascular Research Center, Non-Communicable Diseases Research Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
- Department of Nutrition, School of Public Health, Faculty of Health, Shahid Sadoughi University of Medical Sciences, P O Box 8915173160, Yazd, Iran.
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Sankararaman S, Schindler T. Exocrine Pancreatic Insufficiency in Children - Challenges in Management. Pediatric Health Med Ther 2023; 14:361-378. [PMID: 37908317 PMCID: PMC10615098 DOI: 10.2147/phmt.s402589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/13/2023] [Indexed: 11/02/2023] Open
Abstract
Cystic fibrosis (CF) is the leading etiology for exocrine pancreatic insufficiency (EPI) in children, followed by chronic pancreatitis, Shwachman-Diamond syndrome, and other genetic disorders. Management of EPI in children poses several unique challenges such as difficulties in early recognition, lack of widespread availability of diagnostic tests and limited number of pediatric-specific pancreatic centers. Pancreatic enzyme replacement therapy is the cornerstone of EPI management and in young children difficulties in administering pancreatic enzymes are frequently encountered. Patients with EPI also should be screened for fat-soluble vitamin deficiencies and receive appropriate supplementation. Among disorders with EPI in children, CF is the relatively well-studied condition, and most management recommendations for EPI in children come from expert consensus and conventional practice guidelines. The impact of EPI can be greater in children given their high metabolic demands and rapid growth. Early diagnosis and aggressive management of EPI prevent consequences of complications such as malnutrition, fat-soluble vitamin deficiencies, and poor bone health and improve outcomes. Management by multi-disciplinary team is the key to success.
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Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, Department of Pediatrics, UH Rainbow Babies & Children’s Hospital / Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Teresa Schindler
- Division of Pediatric Pulmonology, Department of Pediatrics, UH Rainbow Babies & Children’s Hospital, Cleveland, OH, USA
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6
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Tsikis ST, Fligor SC, Hirsch TI, Mitchell PD, Pan A, Moskowitzova K, Whitlock AE, Loring G, First E, Nedder A, Gura KM, Puder M. A Digestive Cartridge Reduces Parenteral Nutrition Dependence and Increases Bowel Growth in a Piglet Short Bowel Model. Ann Surg 2023; 278:e876-e884. [PMID: 36924229 PMCID: PMC10481911 DOI: 10.1097/sla.0000000000005839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
OBJECTIVE To determine whether the use of an immobilized lipase cartridge (ILC) to hydrolyze fats in enteral nutrition (EN) reduces parenteral nutrition (PN) dependence in a porcine model of short bowel syndrome with intestinal failure (SBS-IF). BACKGROUND SBS-IF occurs after intestinal loss resulting in malabsorption and PN dependence. Limited therapeutic options are available for achieving enteral autonomy. METHODS Eleven Yorkshire piglets underwent 75% jejunoileal resection and were randomized into control (n=6) and treatment (n = 5) groups. PN was initiated postoperatively and reduced as EN advanced if predefined clinical criteria were fulfilled. Animals were studied for 14 days and changes in PN/EN calories were assessed. Intestinal adaptation, absorption, and nutrition were evaluated at the end of the study (day 15). Comparisons between groups were performed using analysis of covariance adjusted for baseline. RESULTS ILC animals demonstrated a 19% greater reduction in PN calories ( P < 0.0001) and higher mean EN advancement (66% vs 47% of total calories, P < 0.0001) during the 14-day experiment. Treatment animals had increased intestinal length (19.5 vs 0.7%, P =0.03) and 1.9-fold higher crypt cell proliferation ( P =0.02) compared with controls. By day 15, ILC treatment resulted in higher plasma concentrations of glucagon-like peptide-2 ( P = 0.02), eicosapentaenoic acid ( P < 0.0001), docosahexaenoic acid ( P = 0.004), vitamin A ( P = 0.02), low-density lipoprotein ( P = 0.02), and high-density lipoprotein ( P = 0.04). There were no differences in liver enzymes or total bilirubin between the two groups. CONCLUSIONS ILC use in conjunction with enteral feeding reduced PN dependence, improved nutrient absorption, and increased bowel growth in a porcine SBS-IF model. These results support a potential role for the ILC in clinical SBS-IF.
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Affiliation(s)
- Savas T. Tsikis
- Vascular Biology Program, Boston Children’s Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Scott C. Fligor
- Vascular Biology Program, Boston Children’s Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Thomas I. Hirsch
- Vascular Biology Program, Boston Children’s Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Paul D. Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Amy Pan
- Vascular Biology Program, Boston Children’s Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Kamila Moskowitzova
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Ashlyn E. Whitlock
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | | | | | - Arthur Nedder
- Animal Care Resources Children’s Hospital, Boston Children’s Hospital, Boston, MA
| | - Kathleen M. Gura
- Department of Pharmacy and the Division of Gastroenterology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Mark Puder
- Vascular Biology Program, Boston Children’s Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
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7
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Leonard A, Bailey J, Bruce A, Jia S, Stein A, Fulton J, Helmick M, Litvin M, Patel A, Powers KE, Reid E, Sankararaman S, Clemm C, Reno K, Hempstead SE, DiMango E. Nutritional considerations for a new era: A CF foundation position paper. J Cyst Fibros 2023; 22:788-795. [PMID: 37230807 DOI: 10.1016/j.jcf.2023.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/13/2023] [Accepted: 05/13/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To provide interim advice and considerations to the CF Community around CF nutrition in the current era. METHODS The Cystic Fibrosis (CF) Foundation organized a multidisciplinary committee to develop a Nutrition Position Paper based on the rapidly changing nutrition landscape in CF, due in part to widespread use of cystic fibrosis transmembrane regulator highly effective modulator therapy (HEMT). Four workgroups were formed: Weight Management, Eating Behavior/Food Insecurity, Salt Homeostasis and Pancreatic Enzyme use. Each workgroup conducted their own focused review of the literature. RESULTS The committee summarized current understanding of issues pertaining to the four workgroup topics and provided 6 key take-aways around CF Nutrition in the new era. CONCLUSION People with CF (pwCF) are living longer, particularly with the advent of HEMT. The traditional high fat, high calorie CF diet may have negative nutritional and cardiovascular consequences as pwCF age. Individuals with CF may have poor diet quality, food insecurity, distorted body image, and an higher incidence of eating disorders. An increase in overweight and obesity may lead to new considerations for nutritional management, given potential effects of overnutrition on pulmonary and cardiometabolic parameters.
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Affiliation(s)
- Amanda Leonard
- The Johns Hopkins Children's Center, Baltimore, MD, United States of America.
| | - Julianna Bailey
- The University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Amanda Bruce
- University of Kansas Medical Center, Kansas City, Kansas United States of America
| | - Shijing Jia
- University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Adam Stein
- Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Judith Fulton
- Children's Hospital Colorado, Aurora, Colorado, United States of America
| | - Meagan Helmick
- Community Advisor to the Cystic Fibrosis Foundation, Bethesda, Maryland, United States of America
| | - Marina Litvin
- Division of Endocrinology, Metabolism and Lipid Research. Washington University School of Medicine. St. Louis, MO, United States of America
| | - Alpa Patel
- Nationwide Children's Hospital, Columbus Ohio, United States of America
| | - Kate E Powers
- Albany Medical Center, Albany, New York, United States of America
| | - Elizabeth Reid
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | | | - Cristen Clemm
- Cystic Fibrosis Foundation, Bethesda, Maryland United States of America
| | - Kim Reno
- Cystic Fibrosis Foundation, Bethesda, Maryland United States of America
| | - Sarah E Hempstead
- Cystic Fibrosis Foundation, Bethesda, Maryland United States of America
| | - Emily DiMango
- Columbia University Irving Medical Center, New York, New York, United States of America
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Klepper CM, Moore J, Gabel ME, Fleet SE, Kassel R. Pediatric formulas: Categories, composition, and considerations. Nutr Clin Pract 2023; 38:302-317. [PMID: 36815542 DOI: 10.1002/ncp.10954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/29/2022] [Accepted: 12/31/2022] [Indexed: 02/24/2023] Open
Abstract
Formulas, liquid nutrition, may be consumed orally or via a feeding tube to provide partial or complete nutrition that a given individual could not obtain using natural food stuffs in their native form. A wide range of commercially available formulas exist, which may be used as sole-source nutrition or in conjunction with other foods. Physicians and dietitians must understand the nature of and indications for specific formulas to treat diseases, provide complete nutrition to patients, and avoid harm. Products vary in macronutrient and micronutrient content and calorie concentration among many other factors. They are formulated specifically for patients of specific ages, correlating to nutritional needs and medical diagnoses. Additionally, formula availability, insurance coverage, mode of consumption, physiologic tolerance, and caregiver preference influence formula selection. Caregivers may also make their own pediatric formulas. We review commercial and homemade pediatric formulas.
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Affiliation(s)
- Corie M Klepper
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Joseph Moore
- Department of Clinical Nutrition and Lactation, Children's of Alabama, Birmingham, Alabama, USA
| | - Megan E Gabel
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Rochester Medical Center, Rochester, New York, USA
| | - Sarah E Fleet
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel Kassel
- Department of Pediatrics, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA.,Division of Gastroenterology, Hepatology and Nutrition, Birmingham, Alabama, USA
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9
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Freedman SD, Zaworski K, Pierzynowska K, Pierzynowski S, Gallotto R, Sathe M, Borowitz DS. Validation of an omega-3 substrate challenge absorption test as an indicator of global fat lipolysis. PLoS One 2023; 18:e0284651. [PMID: 37155649 PMCID: PMC10166528 DOI: 10.1371/journal.pone.0284651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/05/2023] [Indexed: 05/10/2023] Open
Abstract
INTRODUCTION The coefficient of fat absorption (CFA) quantifies fat that remains in stool after digestion and is not a direct measure of lipolysis. CFA has been used to assess treatment of pancreatic insufficiency but does not correlate with pancreatic enzyme replacement therapy dose. We explored use of an omega-3 substrate absorption challenge test as a sensitive test of lipolysis and absorption. METHODS We studied a novel microbially-derived lipase (SNSP003) employing an established surgical model commonly used to study the uptake of macronutrients, the exocrine pancreatic insufficient pig. Pigs were fed a high-fat diet and given a standardized omega-3 substrate challenge to test the effect of lipolysis on its absorption. Blood was drawn at 0, 1, 2, 4, 6, 8, 12, and 24 hours following the substrate challenge and was analyzed for omega-3 and total fat levels (c14:c24). SNSP003 was also compard to porcine pancrelipase. RESULTS The absorption of omega-3 fats was significantly increased following administration of 40, 80 and 120 mg SNSP003 lipase by 51% (p = 0.02), 89%, (p = 0.001) and 64% (p = 0.01), respectively, compared to that observed when no lipase was administered to the pigs, with Tmax at 4 hours. The two highest SNSP003 doses were compared to porcine pancrelipase and no significant differences were observed. Both doses increased plasma total fatty acids (141% for the 80 mg dose (p = 0.001) and 133% for the 120 mg dose (p = 0.006), compared to no lipase) and no significant differences were observed between the SNSP003 lipase doses and porcine pancrelipase. CONCLUSION The omega-3 substrate absorption challenge test differentiates among different doses of a novel microbially-derived lipase and correlates with global fat lipolysis and absorption in exocrine pancreatic insufficient pigs. No significant differences were observed between the two highest novel lipase doses and porcine pancrelipase. Studies in humans should be designed to support the evidence presented here that suggests the omega-3 substrate absorption challenge test has advantages over the coefficient of fat absorption test to study lipase activity.
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Affiliation(s)
- Steven D Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Kamil Zaworski
- Department of Animal Physiology, The Kielanowski Institute of Animal Physiology and Nutrition, Polish Academy of Sciences, Jabłonna, Poland
| | - Kateryna Pierzynowska
- Department of Animal Physiology, The Kielanowski Institute of Animal Physiology and Nutrition, Polish Academy of Sciences, Jabłonna, Poland
- Department of Biology, Lund University, Lund, Sweden
- Synspira Therapeutics, Inc., Framingham, MA, United States of America
| | - Stefan Pierzynowski
- Department of Biology, Lund University, Lund, Sweden
- Anara AB, Trelleborg, Sweden
- Department of Medical Biology, Institute of Rural Health, Lublin, Poland
| | - Robert Gallotto
- Synspira Therapeutics, Inc., Framingham, MA, United States of America
| | - Meghana Sathe
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern/Children's Health, Dallas, TX, United States of America
| | - Drucy S Borowitz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States of America
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10
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Fat digestion using RELiZORB in children with short bowel syndrome who are dependent on parenteral nutrition: Protocol for a 90-day, phase 3, open labeled study. PLoS One 2023; 18:e0282248. [PMID: 36857339 PMCID: PMC9977023 DOI: 10.1371/journal.pone.0282248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/03/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Short bowel syndrome (SBS) is a leading cause of intestinal failure resulting in parenteral nutrition (PN) dependence and nutritional deficiencies. Long-term PN use is associated with the development of sepsis and intestinal failure-associated liver disease. Achieving enteral autonomy is the optimal way to prevent these complications. In SBS, the decreased intestinal length, bile acid deficiency, and rapid transit time contribute to fat malabsorption and continued PN dependence. We propose the use of an immobilized lipase cartridge (ILC; RELiZORB) that connects in-line with enteral feed tubing sets and is designed to breakdown the majority of fats provided in enteral nutrition (EN). Preclinical studies have demonstrated both improved fat and fat-soluble vitamin absorption with ILC use in a porcine model of SBS. To evaluate the clinical applicability of these findings, we designed a phase 3, open labeled, single center, clinical trial to determine the safety, tolerability, and efficacy of the RELiZORB enzyme cartridge when used daily with EN for 90 days. METHODS The patient population will include PN dependent children with SBS, aged 2-18 years. The primary outcome is the change in PN calories from baseline, assessed weekly throughout the study. Changes in growth Z-scores, 72-hour fecal fat and coefficient of fat absorption, plasma fatty acids and fat-soluble vitamins will also be evaluated. Assessment of change in continuous outcomes will be made using the area under the curve, expressed as a percent change relative to baseline, calculated over study day 7 to 90 (AUC7-90). The incidence of adverse events will be monitored and summarized by system organ class. DISCUSSION If successful, RELiZORB may offer a safe alternative to reducing PN dependence and achieving enteral autonomy in pediatric intestinal failure. These results would be clinically significant given the clear association between long-term PN use and complications in SBS. TRIAL REGISTRATION ClinicalTrials.gov NCT03530852; registered on May 21st, 2018, last update posted on September 14th, 2022.
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11
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Wilson A, Altman K, Schindler T, Schwarzenberg SJ. Updates in Nutrition Management of Cystic Fibrosis in the Highly Effective Modulator Era. Clin Chest Med 2022; 43:727-742. [PMID: 36344077 DOI: 10.1016/j.ccm.2022.06.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Attainment and maintenance of good nutrition has been an important aspect of management in cystic fibrosis (CF) for decades. In the era of highly effective modulator therapy for CF, the quality of the nutrients we recommend is increasingly important. Our therapy must support our patients' health for many years beyond what we previously thought. Preventing cardiovascular disease, reducing hyperlipidemia, and optimizing lean body mass for active, longer lives now join the long-standing goal of promoting lung function through nutrition. This chapter summarizes recent developments in nutrition in people with CF, with an eye to the evolution of our practice.
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Affiliation(s)
- Alexandra Wilson
- Cystic Fibrosis Clinical Research, Clinical Research Services, National Jewish Health, 1400 Jackson Street, K333, Denver, CO 80206, USA
| | - Kimberly Altman
- Gunnar Esiason Adult Cystic Fibrosis and Lung Center, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Terri Schindler
- Pediatric Pulmonology, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital
| | - Sarah Jane Schwarzenberg
- Department of Pediatrics; University of Minnesota Masonic Children's Hospital, Academic Office Building, 2450 Riverside Avenue South AO-201, Minneapolis, MN 55454, USA.
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12
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Borowitz D, Brooks JF, Aliaj E, Gallotto D. Community Perspective on Pancreatic Enzyme Replacement Therapy in Cystic Fibrosis. J Pediatr Gastroenterol Nutr 2022; 75:e94-e97. [PMID: 36070542 DOI: 10.1097/mpg.0000000000003606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
People with cystic fibrosis (CF) and exocrine pancreatic insufficiency must take pancreatic enzyme replacement therapy (PERT) to prevent malnutrition and gastrointestinal (GI) symptoms. Finding better ways to manage GI complaints is a high priority for the CF community. We fielded a survey to assess the perspective of people affected by CF regarding symptoms attributed to and challenges associated with current PERT, to identify factors that affect participation in PERT studies, and to understand attitudes toward an outcome measure that could be an alternative to the coefficient of fat absorption test. Persistent GI symptoms are commonly ascribed to PERT. Minimizing time commitment and maximizing patient safety were factors affecting participation in research. We demonstrate 4 generalizable ways to incorporate patient experience early in the research process to aid in development of new medications and help improve study enrollment.
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Affiliation(s)
- Drucy Borowitz
- From the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | | | - Enid Aliaj
- the Cystic Fibrosis Foundation, Bethesda, MD
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13
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The Use of the RELiZORB Immobilized Lipase Cartridge in Enterally-Fed Children With Cystic Fibrosis. TOP CLIN NUTR 2022. [DOI: 10.1097/tin.0000000000000300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Tsikis ST, Fligor SC, Secor JD, Yu LJ, Pan A, Mitchell PD, Loring G, First E, Nedder AP, Grammer RM, Pattison B, Gura KM, Puder M. An in-line digestive cartridge increases enteral fat and vitamin absorption in a porcine model of short bowel syndrome. Clin Nutr 2022; 41:1093-1101. [PMID: 35413571 PMCID: PMC9050916 DOI: 10.1016/j.clnu.2022.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND & AIMS Short bowel syndrome (SBS) occurs after intestinal loss resulting in parenteral nutrition dependence and micronutrient deficiencies, which may lead to life-limiting complications. ALC-078 is a cartridge containing immobilized lipase that connects in-line with enteral feeding sets and digests fats in enteral nutrition (EN). In this study, we evaluate the efficacy of ALC-078 to improve fat and nutrient absorption in a porcine SBS model. METHODS Fifteen male Yorkshire piglets were assessed. Animals were randomized to no intestinal resection (n = 5), 75% resection (n = 5), or 75% resection + ALC-078 (n = 5). After recovery, animals were treated for 14 days. Piglets received 60% of nutrition from continuous EN and 40% from chow. The degree of fat malabsorption was determined by the coefficient of fat absorption (CFA) following a 72-h stool collection. Body weight, fat-soluble vitamins, and nutritional markers were assessed. RESULTS Adverse events were similar across the three groups (P = 1.00). ALC-078-treated animals had similar weight gain compared to resected piglets. Resected animals had a lower CFA compared to unresected controls (79.3% vs. 95.2%, P = 0.01) while there was no significant difference in the ALC-078 animals (87.1% vs. 95.2%, P = 0.19). Between Study Days 1 and 15, ALC-078 animals had increased concentrations of vitamin D (12.2 vs. 8.7 ng/mL, P = 0.0006), and vitamin E (4.3 vs. 2.5 mg/L, P = 0.03). These markers did not significantly change in untreated resected animals. CONCLUSION ALC-078 increases the absorption of fat-soluble vitamins and may improve fat malabsorption. Future studies should determine whether ALC-078 can reduce PN dependence and if these findings translate to human patients with SBS.
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Affiliation(s)
- S T Tsikis
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA
| | - S C Fligor
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA
| | - J D Secor
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA
| | - L J Yu
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA
| | - A Pan
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA
| | - P D Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - G Loring
- Alcresta Therapeutics, Newton, MA 02462, USA
| | - E First
- Alcresta Therapeutics, Newton, MA 02462, USA
| | - A P Nedder
- Animal Care Resources Children's Hospital, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - R M Grammer
- Animal Care Resources Children's Hospital, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - B Pattison
- Animal Care Resources Children's Hospital, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - K M Gura
- Department of Pharmacy and the Division of Gastroenterology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - M Puder
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA.
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Borowitz D, Aronoff N, Cummings LC, Maqbool A, Mulberg AE. Coefficient of Fat Absorption to Measure the Efficacy of Pancreatic Enzyme Replacement Therapy in People With Cystic Fibrosis: Gold Standard or Coal Standard? Pancreas 2022; 51:310-318. [PMID: 35695742 PMCID: PMC9257055 DOI: 10.1097/mpa.0000000000002016] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/02/2022] [Indexed: 12/10/2022]
Abstract
OBJECTIVES We sought data on the validity, reliability, responsiveness, and feasibility of the coefficient of fat absorption (CFA) as a measure of pancreatic enzyme replacement therapy (PERT) efficacy in people with cystic fibrosis (pwCF) and reviewed the literature for alternative measures. METHODS We searched PubMed for the Medical Subject Heading cystic fibrosis and the key words cystic fibrosis, fat absorption, CFA, and fecal fat imbalance; historical articles; and citations in bibliographies. RESULTS The lower the CFA, the greater its variability; thus, it is less variable in healthy individuals who have higher CFA than pwCF. In addition, the test-retest values for CFA are more variable in pwCF than the general population. There is no correlation between CFA and body mass index or PERT dose but CFA is related to gastrointestinal signs and symptoms. Research-quality CFA studies are expensive, time consuming, and odious to pwCF and research staff. Sparse stool tests, breath tests, and blood tests of fat absorption have been studied as potential alternatives to CFA to measure PERT efficacy. CONCLUSIONS Based on the evidence, we conclude that CFA as a measure of the efficacy of PERT is more of a "coal standard" than a gold standard; developing suitable alternatives should be a priority.
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Affiliation(s)
- Drucy Borowitz
- From the Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences
| | - Nell Aronoff
- University Libraries, University at Buffalo, Buffalo, NY
| | - Linda C. Cummings
- Department of Internal Medicine, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Asim Maqbool
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Freswick PN, Reid EK, Mascarenhas MR. Pancreatic Enzyme Replacement Therapy in Cystic Fibrosis. Nutrients 2022; 14:nu14071341. [PMID: 35405954 PMCID: PMC9003370 DOI: 10.3390/nu14071341] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 11/16/2022] Open
Abstract
While typically considered a pulmonary disease, cystic fibrosis patients develop significant nutritional complications and comorbidities, especially those who are pancreatic insufficient. Clinicians must have a high suspicion for cystic fibrosis among patients with clinical symptoms of pancreatic insufficiency, and pancreatic enzymatic replacement therapy (PERT) must be urgently initiated. PERT presents a myriad of considerations for patients and their supporting dieticians and clinicians, including types of administration, therapy failures, and complications.
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Affiliation(s)
- Peter N. Freswick
- Helen DeVos Children’s Hospital, Grand Rapids, MI 49503, USA
- Correspondence:
| | - Elizabeth K. Reid
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (E.K.R.); (M.R.M.)
| | - Maria R. Mascarenhas
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (E.K.R.); (M.R.M.)
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Hendrix SJ, Flume PA, First ER, Stone AA, Van Buskirk M. Improvements in anthropometric measures and gastrointestinal tolerance in patients with cystic fibrosis by using a digestive enzyme cartridge with overnight enteral nutrition. Nutr Clin Pract 2022; 37:344-350. [PMID: 35199869 PMCID: PMC9415120 DOI: 10.1002/ncp.10831] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Patients with cystic fibrosis (CF) and pancreatic insufficiency are at risk for suboptimal fat absorption, inability to maintain weight, poor growth, and increased gastrointestinal (GI) symptoms due to malabsorption. Enteral nutrition (EN) is used to supplement caloric intake and requires pancreatic enzyme replacement for effective digestion. We evaluated the relationship between long‐term use of an in‐line digestive enzyme cartridge with EN and changes in anthropometric measures and GI symptoms in patients with CF. Methods This is a single‐center, retrospective case review of patients with CF using a digestive enzyme cartridge with EN. Data were collected from the patient medical records and included weight, height, body mass index, EN regimen, and reported GI symptoms. Results Thirteen pediatric and five adult patients with a mean age of 12.6 years used a digestive enzyme cartridge with EN for a period of 3–27 months. Most patients (n = 14) had been using oral digestive enzymes with EN before using the digestive enzyme cartridge, whereas four started from the onset of EN. The indications to convert from oral enzymes to the digestive enzyme cartridge included poor growth (72.2%) and poor tolerance of EN (69.2%). There was a reduction in reported GI symptoms after initiating use of the digestive enzyme cartridge. After 12 months of digestive cartridge use, there were improvements in anthropometrics. Conclusions This real‐world experience with prolonged use of a digestive enzyme cartridge with EN demonstrated improved clinical outcomes and a reduction in GI symptoms in patients with CF.
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Affiliation(s)
- Sara J Hendrix
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Patrick A Flume
- Medical University of South Carolina, Charleston, South Carolina, USA
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Lahiri T, Sullivan JS. Recent advances in the early treatment of cystic fibrosis: Bridging the gap to highly effective modulator therapy. Pediatr Pulmonol 2022; 57 Suppl 1:S60-S74. [PMID: 34473419 DOI: 10.1002/ppul.25660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/22/2021] [Accepted: 09/01/2021] [Indexed: 11/08/2022]
Abstract
Highly effective modulator therapy (HEMT) for cystic fibrosis (CF) has been touted as one of the greatest advances to date in CF care. As these therapies are now available for many older children and adults with CF, marked improvement of their nutritional status, pulmonary and gastrointestinal symptoms has been observed. However, most infants and younger children are not current candidates for HEMT due to age and/or cystic fibrosis transmembrane conductance regulator (CFTR) mutation. For these young children, it is essential to provide rigorous monitoring and care to avoid potential disease sequelae while awaiting HEMT availability. The following article highlights recent advances in the care of infants and young children with CF with regard to surveillance and treatment of nutritional, pulmonary, and gastrointestinal disorders. Recent clinical trials in this population are also reviewed.
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Affiliation(s)
- Thomas Lahiri
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
| | - Jillian S Sullivan
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
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Alves AA, De Queiroz AAAE, Jorge Soares CR, de Queiroz AAA. Microfluidic caging lipase in hyperbranched polyglycerol microcapsules for extracorporeal treatment of enzyme pancreatic insufficiency. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2021; 32:2349-2368. [PMID: 34428382 DOI: 10.1080/09205063.2021.1971820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Lipase cartridges are currently the mainstay of treatment to improve fat absorption related to pancreatic insufficiency (PI) in patients receiving enteral nutrition feedings. Enzyme immobilization is an essential prerequisite for designing lipase cartridges systems for efficient enzymatic fat hydrolysis. A microfluidic approach has been adopted to produce lipase (LIP) caged in hyperbranched polyglycerol microcapsules (HPGly). The resulting HPGly-LIP microcapsules are spherical and had an average diameter of 29 µm with monomodal size distribution. The optimum conditions determined by artificial neural networks were HPGly concentration of 10 wt.%, LIP loading of 20% (wt) and total flow rate in microfluidic cell of 1.0 mL/h. Under these conditions, the maximum capacity of the LIP that can be microencapsulated is around 85% with respect to the HPGly concentration of 10 wt.% and total flow rate in microfluidic cell of 1.0 mL/h. This resultant HPGly-LIP exhibited Michaelis-Menten coefficients of 1.138,14 mM (Km) and 0.49 U/mg (Vmax) showing higher activity compared to free LIP. Finally, the robust HPGly-LIP microcapsules showed excellent recyclability. The in vitro Analysis of the HPGly-LIP cytotoxicity showed that microcapsules had no cytotoxic effect to L929 fibroblasts cells and behaved very similar to the negative control. These features will be useful for the facile construction of biocatalytic systems with high efficiency, excellent recyclability and adequate biocompatibility for treatment of patients with PI receiving enteral nutrition feedings.
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Affiliation(s)
- Andressa Aparecida Alves
- Doctorate Post-Graduate Scholarship in Materials for Engineering/Biomaterials (CAPES), Federal University of Itajubá (UNIFEI), Itajubá-Minas Gerais, Brazil
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Sathe MN, Patel D, Stone A, First E. Evaluation of the Effectiveness of In-line Immobilized Lipase Cartridge in Enterally Fed Patients With Cystic Fibrosis. J Pediatr Gastroenterol Nutr 2021; 72:18-23. [PMID: 33165085 DOI: 10.1097/mpg.0000000000002984] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pancreatic insufficiency occurs in most patients with cystic fibrosis (CF) contributing to malnutrition. In the United States, 3600 patients with CF require enteral feeding (EF). Oral pancreatic enzymes are commonly used with EF, despite not being designed or approved for this use. An immobilized lipase cartridge (ILC) for extracorporeal digestion of enteral feedings was developed. The sponsor provided it to patients via a structured program, which we evaluated to assess the effectiveness of the ILC on nutritional status. METHODS The program provided the ILC to patients prescribed the device while reimbursement efforts were ongoing. Baseline anthropometric data were obtained and subsequent measurements of height, weight, and body mass index (BMI) were collected at 6 and 12 months. RESULTS Inclusion criteria were met by 100 patients (age = 0--45 years). Over 12 months of use in patients >2 years of age (n = 93), there were significant improvements seen in height and weight z-scores with improvement trend seen in BMI. The frequency of achieving the 50th percentile increased steadily for weight and BMI from baseline to 12 months but not for height. CONCLUSIONS This evaluation of a program to assist patient access to ILC demonstrates that better growth is possible over standard of care. The association of ILC use with significant improvements in anthropometric parameters over a 12-month period in people with CF demonstrates the effectiveness of ILC as rational enzyme therapy during enteral feedings.
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Affiliation(s)
- Meghana N Sathe
- University of Texas Southwestern and Children's Health Dallas, Dallas, TX
| | - Dhiren Patel
- St. Louis University and Cardinal Glennon Children's Medical Center, St. Louis, MO
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21
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Shaikhkhalil AK, Freeman AJ, Sathe M. Variations in Nutrition Practices in Cystic Fibrosis: A Survey of the DIGEST Program. Nutr Clin Pract 2020; 36:1247-1251. [PMID: 33242217 DOI: 10.1002/ncp.10605] [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: 03/31/2020] [Accepted: 10/18/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Evidence-based management of gastrointestinal (GI) and nutrition manifestations of cystic fibrosis (CF) is limited, and practice variations have not been studied. METHODS Thus, a survey was developed with the purpose of evaluating current nutrition practices of CF-focused gastroenterologists, specifically utilizing awardees and mentors of the Cystic Fibrosis Foundation (CFF) Developing Innovative GastroEnterology Specialty Training (DIGEST) Program. Topics included appetite stimulation, tube feeding (TF), and aspects of nutrition assessment, specifically urine sodium and essential fatty acid (EFA) status. RESULTS The response rate was 61% (22/36). About half (55%; 12/22) of respondents had 5-10 years of experience in GI, and 23% (5/22) had >10 years. In regard to appetite stimulation, the majority used cyproheptadine; however, duration and pattern of prescribing varied. Variation was noted in TF management pertaining to tube placement, formula choice, and prescribing pancreatic enzyme replacement therapy with overnight TF. The majority did not check EFAs or urine sodium. Treatment for deficiencies in EFA or abnormal urine sodium was inconsistent. CONCLUSION The survey reveals wide variation in management of some aspects of nutrition-related manifestations of CF among experienced providers. This reflects the need for research to provide evidence-based guidelines.
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Affiliation(s)
- Ala K Shaikhkhalil
- Division of Gastroenterology Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Alvin J Freeman
- Division of Pediatric Gastroenterology, Hepatology, and Nutritio, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Meghana Sathe
- Division of Pediatric Gastroenterology and Nutrition, UT Southwestern, Children's Health Dallas and Plano, Dallas, Texas, USA
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22
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Boullata JI, Clarke JL, Stone A, Skoufalos A, Nash DB. Optimizing Clinical and Cost Outcomes for Patients on Enteral Nutrition Support for Treatment of Exocrine Pancreatic Insufficiency: Proceedings from an Expert Advisory Board Meeting. Popul Health Manag 2020; 22:S1-S10. [PMID: 31066618 PMCID: PMC6537119 DOI: 10.1089/pop.2019.0042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Joseph I Boullata
- 1 Department of Nutrition Sciences, Drexel University, Philadelphia, Pennsylvania.,2 Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Janice L Clarke
- 3 Jefferson College of Population Health, Philadelphia, Pennsylvania
| | - Archie Stone
- 4 Alcresta Therapeutics, Inc., Newton, Massachusetts
| | - Alexis Skoufalos
- 3 Jefferson College of Population Health, Philadelphia, Pennsylvania
| | - David B Nash
- 3 Jefferson College of Population Health, Philadelphia, Pennsylvania
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Overview of Immobilized Enzymes' Applications in Pharmaceutical, Chemical, and Food Industry. Methods Mol Biol 2020; 2100:27-63. [PMID: 31939114 DOI: 10.1007/978-1-0716-0215-7_2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The use of immobilized enzymes in industry is becoming a routine process for the manufacture of many key compounds in the pharmaceutical, chemical, and food industry. Some enzymes like lipases are naturally robust and efficient, can be used for the production of many different molecules, and have found broad industrial applications. Some more specific enzymes, like transaminases, have required protein engineering to become suitable for applications in industrial manufacture. For all enzymes, the possibility to be immobilized and used in a heterogeneous form brings important industrial and environmental advantages such as simplified downstream processing or continuous process operations. Here, we present a series of large-scale applications of immobilized enzymes with benefits for the food, chemical, pharmaceutical, cosmetics, and medical device industries, some of them hardly reported before.
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Altman K, McDonald CM, Michel SH, Maguiness K. Nutrition in cystic fibrosis: From the past to the present and into the future. Pediatr Pulmonol 2019; 54 Suppl 3:S56-S73. [PMID: 31715089 DOI: 10.1002/ppul.24521] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/19/2019] [Indexed: 12/13/2022]
Abstract
Nutritional management is an integral part of multidisciplinary care for persons with cystic fibrosis. This review will look at how nutrition care has evolved over time. In addition, we will look at how some newer therapies impact nutrition care.
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Affiliation(s)
- Kimberly Altman
- Gunnar Esiason Adult Cystic Fibrosis and Lung Center, New York Presbyterian/Columbia University Medical Center, New York, New York, United States
| | | | - Suzanne H Michel
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Karen Maguiness
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, United States
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Sankararaman S, Schindler T, Sferra TJ. Management of Exocrine Pancreatic Insufficiency in Children. Nutr Clin Pract 2019; 34 Suppl 1:S27-S42. [DOI: 10.1002/ncp.10388] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology; Department of Pediatrics; UH Rainbow Babies & Children's Hospital; Case Western Reserve University School of Medicine; Cleveland Ohio USA
| | - Teresa Schindler
- Division of Pediatric Pulmonology; Department of Pediatrics; UH Rainbow Babies & Children's Hospital; Cleveland Ohio USA
| | - Thomas J. Sferra
- Division of Pediatric Gastroenterology; Department of Pediatrics; UH Rainbow Babies & Children's Hospital; Case Western Reserve University School of Medicine; Cleveland Ohio USA
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Schwarzenberg SJ, Borowitz D. Challenging barriers to an option for improved provision of enteral nutrition. J Cyst Fibros 2019; 18:447-449. [DOI: 10.1016/j.jcf.2019.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Colombo C, Nobili RM, Alicandro G. Challenges with optimizing nutrition in cystic fibrosis. Expert Rev Respir Med 2019; 13:533-544. [PMID: 31094240 DOI: 10.1080/17476348.2019.1614917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction. Optimizing nutrition remains the cornerstone of therapy for patients with cystic fibrosis (CF) since it is associated with better pulmonary function and survival. However, a significant proportion of patients still fail to achieve normal growth and nutritional status. Areas covered. This review describes the current challenges in providing effective nutritional therapy in CF with a focus on the current issues related to energy imbalance, dietary composition, adherence to nutritional recommendations, pancreatic enzyme replacement therapy, and the effects of modulators of the CF transmembrane conductance regulator. Expert opinion. CF is a multisystemic disease that requires a personalized nutritional approach with accurate evaluation of energy balance. There is an urgent need for evidence-based recommendations on the dietary composition, in consideration of the increasing prevalence of overweight, diabetes and the potential effects of fatty acids on inflammation and immune response. More research into new pancreatic enzyme formulations is also required.
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Affiliation(s)
- Carla Colombo
- a Department of Pathophysiology and Transplantation , Università degli Studi di Milano , Milan , Italy.,b Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Centre , Milan , Italy
| | - Rita Maria Nobili
- b Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Cystic Fibrosis Centre , Milan , Italy
| | - Gianfranco Alicandro
- c Department of Clinical Sciences and Community Health , Università degli Studi di Milano , Milano , Italy
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Grover AS, Freeman AJ, Abu-El-Haija M, Eisses JF, Gardner TB, Liu QY, Lowe ME, Nathan JD, Palermo TM, Singh VK, Trout AT, Uc A, Husain SZ, Morinville VD. Updates in Pediatric Pancreatology: Proceedings of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Frontiers in Pediatric Pancreatology Symposium. J Pediatr Gastroenterol Nutr 2019; 68:e27-e33. [PMID: 30888340 PMCID: PMC6444930 DOI: 10.1097/mpg.0000000000002186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The Pancreas Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition aims to promote awareness of pediatric pancreatic diseases, support clinical and basic science research in the field, educate pediatric gastroenterologists, and advocate on behalf of pediatric patients with pancreatic disorders. At the 2017 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the Pancreas Committee held a full day symposium on pediatric pancreatic diseases, entitled, "Frontiers in Pediatric Pancreatology." The symposium served as a timely and novel academic meeting that brought together individuals with a vested interest in the care of children with pancreatic disorders. The objective of this day-long course was to update practicing gastroenterologists on the latest advances in research, management algorithms, endoscopic therapies, radiographic resources, surgical approaches, and novel drug therapies targeted to pediatric pancreatitis. Presentations were divided into 4 modules: diagnosis, risk factors, and natural history of pancreatitis; pancreatic imaging and exocrine function; management of pancreatitis; and new frontiers in pediatric pancreatitis research. The course fostered a unique ecosystem for interdisciplinary collaboration, in addition to promoting discussion and stimulating new research hypotheses regarding pediatric pancreatic disorders. Oral presentations by experts in various fields of pancreatology led to thought-provoking discussion; in addition, a meet-the-professor luncheon stimulated critical evaluation of current research in pediatric pancreatic diseases, highlighting knowledge gaps and future research endeavors. The current report summarizes the major learning points from this novel symposium focusing on the growing demographic of pediatric pancreatic diseases.
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Affiliation(s)
- Amit S Grover
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Alvin J Freeman
- Childrens' Healthcare of Atlanta, Division of Gastroenterology, Hepatology and Nutrition, Emory University, Atlanta, GA
| | - Maisam Abu-El-Haija
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - John F Eisses
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Timothy B Gardner
- Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Quin Y Liu
- Cedars-Sinai Medical Center, Digestive Diseases Center, Los Angeles, CA
| | - Mark E Lowe
- Department of Pediatrics, Children's Hospital of St. Louis, Washington University School of Medicine, St. Louis, MO
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Johns Hopkins Medical School, Baltimore, MD
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Aliye Uc
- Stead Family Children's Hospital, University of Iowa, Iowa City, IA
| | - Sohail Z Husain
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Veronique D Morinville
- Division of Pediatric Gastroenterology and Nutrition, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Stevens J, Wyatt C, Brown P, Patel D, Grujic D, Freedman SD. Absorption and Safety With Sustained Use of RELiZORB Evaluation (ASSURE) Study in Patients With Cystic Fibrosis Receiving Enteral Feeding. J Pediatr Gastroenterol Nutr 2018; 67:527-532. [PMID: 30074573 PMCID: PMC6155360 DOI: 10.1097/mpg.0000000000002110] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/22/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Pancreatic insufficiency (PI) and malabsorption of fats lead to reduced caloric intake, inability to maintain weight, and increased gastrointestinal symptoms. Thus, enteral nutrition (EN) is used in patients with cystic fibrosis (CF) and poor nutritional status. The current study evaluated safety, tolerability, and improvement of fatty acid (FA) status in red blood cell (RBC) membranes, a marker of long-term FA absorption, with an in-line digestive cartridge (RELiZORB) that hydrolyzes fat in enteral formula. METHODS Patients with CF receiving EN participated in a multicenter, 90-day open-label study during which RELiZORB was used with overnight EN. The primary endpoint was change over time in RBC uptake of docosahexaenoic acid (DHA)+ eicosapentaenoic acid (EPA). Gastrointestinal symptoms were collected to evaluate safety and tolerability. Several clinical and anthropometric parameters were also assessed throughout the study. RESULTS A total of 36 subjects completed the study with a mean age of 13.8 years, body mass index of 17.7 and 6.2 years mean use of overnight EN. Fat absorption significantly improved as shown by increased RBC levels of DHA+EPA, improved ω-6/ω-3 ratio, and increased plasma levels of DHA+EPA. RELiZORB use was not associated with any unanticipated adverse events. CONCLUSIONS RELiZORB use was found to be safe, well tolerated, and resulted in increased levels of FAs in RBCs and plasma. This is the first prospective study to show EN can improve FA abnormalities in CF. Because improvement in omega-3 levels has been shown to help pulmonary and inflammatory status as well as anthropometric parameters in CF, RELiZORB may have important long-term therapeutic benefits in patients with CF.
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Affiliation(s)
| | | | | | - Dhiren Patel
- Division of Gastroenterology and Department of Pediatrics Saint Louis University School of Medicine, St. Louis, MO
| | | | - Steven D. Freedman
- Department of Medicine and Division of Translational Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Giguere-Rich C, Mathew A, Reid E, Autore K, Guill MF. Use of an In-line Digestive Cartridge With Enteral Nutrition Improves the Weight Trajectory of 2 Children With Cystic Fibrosis Complicated by Another Medical Diagnosis. Nutr Clin Pract 2018; 33:286-294. [PMID: 29658186 DOI: 10.1002/ncp.10080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This clinical observation describes the enteral nutrition (EN) management of 2 toddlers at high nutrition risk due to cystic fibrosis (CF), exocrine pancreatic insufficiency, and comorbid medical conditions. The first case report describes a boy with severe malabsorption after intestinal resection. The second case report reviews a boy with CF and neuroblastoma. When pancreatic enzyme replacement therapy with EN was not effective or appropriate, use of an in-line digestive cartridge was initiated. While using the digestive cartridge, both children showed improvements in their anthropometric measures. This observation reviews the nutrition management throughout their clinical course and describes the use of a digestive cartridge with EN.
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Affiliation(s)
| | - Amy Mathew
- Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Elizabeth Reid
- Children's Hospital of Philadelphia, Cystic Fibrosis Center, Philadelphia, Pennsylvania, USA
| | - Kimberly Autore
- Medical Science Liaison, Alcresta Therapeutics, Inc., Newton, Massachusetts, USA
| | - Margaret F Guill
- Department of Pediatrics, Geisel School of Medicine at Dartmouth Dartmouth-Hitchcock Medical Center, New Hampshire, USA
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Ratchford TL, Teckman JH, Patel DR. Gastrointestinal pathophysiology and nutrition in cystic fibrosis. Expert Rev Gastroenterol Hepatol 2018; 12:853-862. [PMID: 30019967 DOI: 10.1080/17474124.2018.1502663] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cystic fibrosis (CF) is a severe, progressive, multisystemic disease that is caused by mutations in the cystic fibrosis transmembrane conductance regulator gene. Optimizing nutrition is critical, as higher growth parameters are associated with better pulmonary function and outcomes, but unfortunately patients with this disease are prone to malnutrition, growth failure, and vitamin deficiencies. The purpose of this review is to provide a timely highlight of the physiologic processes and outcome data to support today's management strategies, as well as review these principles themselves. Areas covered: This review covers the background of the importance of vigilant attention to nutrition and growth in these patients, the underlying physiology leading to an abnormal gastrointestinal tract and its role in CF malnutrition, and current evaluation and management strategies to address nutrition in CF. Analysis of up-to-date relevant literature was performed using PubMed. Expert commentary: Advances in research and clinical developments over the years have improved knowledge of this disease as well as patient outcomes. Of particular importance is optimizing nutrition especially in the early stages of life, as well as accounting for the markedly abnormal CF intestinal milieu when addressing the gastrointestinal and nutritional needs of these patients.
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Affiliation(s)
- Thomas L Ratchford
- a Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition , Saint Louis University School of Medicine , Saint Louis , Missouri , USA
| | - Jeffrey H Teckman
- a Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition , Saint Louis University School of Medicine , Saint Louis , Missouri , USA
| | - Dhiren R Patel
- a Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition , Saint Louis University School of Medicine , Saint Louis , Missouri , USA
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Sullivan JS, Mascarenhas MR. Nutrition: Prevention and management of nutritional failure in Cystic Fibrosis. J Cyst Fibros 2018; 16 Suppl 2:S87-S93. [PMID: 28986026 DOI: 10.1016/j.jcf.2017.07.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/06/2017] [Accepted: 07/07/2017] [Indexed: 12/21/2022]
Abstract
Close monitoring of nutritional status is critical to the overall health of a patient with CF. As part of routine CF care, measurement of weight and height (and calculation of weight/length or BMI as appropriate) should be performed and analyzed at each visit. Early recognition of nutritional risk is imperative and evaluation with a multidisciplinary team should be performed to assess for caloric intake, caloric malabsorption, and other causes of poor weight gain and growth. Many tools are available to use for intervention, including oral supplementation, behavioral interventions, medications, nutritional therapies, and enteral tube feeding.
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Affiliation(s)
- Jillian S Sullivan
- Department of Pediatrics, University of Vermont Children's Hospital, Burlington, VT, USA.
| | - Maria R Mascarenhas
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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35
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Singh VK, Schwarzenberg SJ. Pancreatic insufficiency in Cystic Fibrosis. J Cyst Fibros 2017; 16 Suppl 2:S70-S78. [DOI: 10.1016/j.jcf.2017.06.011] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 06/30/2017] [Accepted: 06/30/2017] [Indexed: 12/19/2022]
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