Tube feeding increases the gastric-emptying rate determined by gastroesophageal scintigraphy

Neurological impairment and malnutrition in children: The role of home enteral nutrition in real life

Objective

Recent decades have brought an increased survival of children with Neurologic Impairment (NI) but malnutrition and digestive comorbidity remain important challenges to face. We designed the present study to assess the course of nutritional status following standardized Home Enteral Nutrition (HEN) program and to evaluate impact of changing mode of feeding, as a part of overall multidisciplinary management, on digestive co-morbidity as Gastro-Esophageal Reflux Disease (GERD), Oropharyngeal Dysphagia (OPD), constipation and airway aspiration.

Methods

We performed a retrospective analysis on NI children entered into Institutional HEN program due to NI disorders between January 2011 and 2019. Demographic, anthropometric characteristics (BMI z-score and weight for age z-score) and symptoms (GERD, OPD constipation and airway aspiration) were collected at the enrolment and during the follow up.

Results

We enrolled 402 patients (median age: 39 months); overall survival was 97%. Nutritional status was significantly improved by HEN; in particular growth profile significantly changed within the first 2 years following HEN beginning; GERD and airways aspirations decreased after HEN beginning. Constipation and OPD remained unchanged over time.

Conclusions

Malnutrition and digestive complaints are distinctive features of NI children. Nutritional status improve after 2 years from the beginning of standardized nutritional interventions. Overall multidisciplinary care, including standardized HEN protocols, seems to also impact on GERD and airway aspirations, which can decrease over time. It is possible that constipation and OPD, unchanged over time, are more dependent on underlying diseases than on overall treatments.

Vomiting and Gastric Motility in Early Brain Damaged Children With Congenital Zika Syndrome

OBJECTIVES

This study investigated the occurrence of vomiting and gastric dysmotility in dysphagic children with congenital Zika syndrome (CZS) and assessed possible associations of these findings with the severity of dysphagia and the presence of tube feeding.

METHODS

Forty-six children with CZS were assessed for dysphagia, and the occurrence of vomiting, dietary volume tolerance <15 mL/kg, and feeding time per meal >30 minutes were evaluated. Gastric antrum ultrasonography was used to detect the frequency of contractions and measure antral areas (at fasting and 15 minutes postprandial), from which the gastric emptying rate (GER) was calculated. Antral ultrasonography findings were compared with those of ten healthy controls. Vomiting and gastric motility were compared between CZS patients according to the severity of dysphagia and the requirement for tube feeding.

RESULTS

Overall, 76% (35/46) of children with CZS had moderate-to-severe dysphagia (MSD), among whom 60% (21/35) were tube fed [MSD tube fed (MSDTF)]. Vomiting occurred in 54% (25/46) of children, whereas dietary volume intolerance and prolonged feeding time were observed in 59% (27/46) and 37% (17/46), respectively, most frequently in MSDTF patients. On ultrasound, 61% (28/46) of children with CZS had no antral contractions, whereas 90% (9/10) of controls did. Compared to healthy controls, GER was eight-fold lower in children with CZS and 60-fold lower in MSDTF children.

CONCLUSIONS

In dysphagic children with CZS, vomiting, volume intolerance, and prolonged feeding time were frequent and possibly associated with impaired antral contraction and delayed gastric emptying, especially in cases of severe dysphagia and tube feeding.

Bolus Gastric Feeds Improve Nutritional Delivery to Mechanically Ventilated Pediatric Medical Patients: Results of the COntinuous vs BOlus (COBO2) Multi-Center Trial

BACKGROUND

Comparison of bolus (BGF) versus continuous gastric feeding (CGF) with respect to timing and delivery of energy and protein in mechanically ventilated pediatric patients has not been investigated. We hypothesized that bolus delivery would shorten time to goal nutrition and increase the percentage of goal feeds delivered.

METHODS

Multi-center, prospective, randomized comparative effectiveness trial conducted in seven Pediatric ICUs (PICUs). Eligibility criteria: 1 month - 12 years of age, intubated within 24 hours of PICU admission, expected duration of ventilation at least 48 hours, eligible to begin enteral nutrition within 48 hours.

EXCLUSION CRITERIA

acute or chronic gastrointestinal pathology, or acute surgery.

RESULTS

We enrolled 158 mechanically ventilated children between October 2015 and April 2018; 147 patients were included in the analysis (BGF = 72, CGF = 75). The BGF group was slightly older than CGF, otherwise the two groups had similar demographic characteristics. There was no difference in the percentage of patients in each group that achieved goal feeds. Time to goal feeds was shorter in the BGF [Hazard Ratio 1.5 (CI 1.02-2.33); P = 0.0387]. Median percentage of target kilocalories [median kcal 0.78 vs 0.59; p = <.0001], and median percentage of protein delivered [median pro 0.77 vs 0.59; p = <.0001] was higher for BGF patients. There was no difference in serial oxygen saturation index between groups.

CONCLUSION

Our study demonstrated shorter time to achieve goal nutrition via BGF compared to CGF in mechanically ventilated pediatric patients. This resulted in increased delivery of target energy and nutrition. Further study is needed in other PICU populations. This article is protected by copyright. All rights reserved.

Gastric emptying of milk in infants and children up to 5 years of age: normative data and influencing factors

BACKGROUND

Gastric emptying scintigraphy is widely used in infants and children, but there is a lack of age-specific normative data.

OBJECTIVE

The objectives of this retrospective study were: 1) to establish a range of gastric emptying of milk or formula as a surrogate for normal gastric emptying in infants and young children ≤5 years of age, and 2) to investigate the effects of patient age, feeding volume, feeding route and gastroesophageal reflux on gastric emptying.

MATERIALS AND METHODS

The reports of 5,136 gastric emptying studies of children ≤5 years of age performed at Children's National Medical Center from January 1990 to August 2012 were reviewed. Demographic data, 1-h and 3-h gastric emptying values and gastroesophageal reflux status of all patients were stored in a database. Using stringent inclusion and exclusion criteria, the studies of patients as similar to healthy children as possible were selected for this study.

RESULTS

The study group included 2,273 children (57% male) ages 0-59 months (median: 4.6 months). The median 1-h gastric emptying was 43% (interquartile range [IQR] 34-54%). The median 3-h gastric emptying was 91% (IQR 79-98%). Sixty-one percent of patients with 1-h gastric emptying value of <50% had 3-h gastric emptying ≥80%. Gastric emptying was significantly faster in children ≤6 months as compared with all older age groups. In each age group, the median gastric emptying decreased with increasing feeding volume. Gastric emptying was significantly faster in patients fed via combined nasogastric tube and oral routes as compared with those fed exclusively orally. There was no significant difference in gastric emptying of children with and without gastroesophageal reflux.

CONCLUSION

Although there are statistically significant differences in gastric emptying based on age, volume and route of feeding, the data suggest that overall normal liquid gastric emptying in infants and children ≤5 years of age is ≥80% at 3 h. One-hour emptying measurements are not reliable for detecting delayed gastric emptying.

Effect of nasogastric tube on salivagram result in paediatric patients

OBJECTIVE

The aim of this study was to analyse the potential effect of indwelling nasogastric tubes (NGTs) on the positive rate of pulmonary aspiration in the salivagram of paediatric patients.

METHODS

This retrospective study evaluated 290 children suffering from respiratory tract infection with clinical suspicion of pulmonary aspiration (104 cases with NGT and 186 cases without NGT). Among them, 216 had good past health, while 74 had history of oropharyngeal diseases or brain injuries. Tc-DTPA salivagrams were performed to determine whether the risk of pulmonary aspiration was different between patients with and without NGT.

RESULTS

The positive rates of aspiration in salivagram were 32.3% (60/186) and 29.8% (31/104) in the patients without and with NGT, respectively. The positive rates of the two groups had not statistically significant difference [risk ratio (RR) = 0.924; 95% confidence interval (CI): 0.644-1.326; P = 0.666]. Subgroup analyses showed that the patients with good past health had the positive rates of 24.4% (19/78) with NGT and 25.4 % (35/138) without NGT. The two groups had no statistically significant difference (RR = 0.960; 95% CI: 0.592-1.559; P = 0.870). For the patients with underlying diseases, the positive rates were 46.2% (12/26) with NGT and 52.1% (25/48) without NGT. These two groups also demonstrated no statistically significant difference (RR = 0.886; 95% CI: 0.540-1.455; P = 0.626).

CONCLUSION

The positive rate of pulmonary aspiration was relatively high in patients with respiratory tract infection who have underlying diseases but NGT feeding did not affect salivagram accuracy.

Potential prediction of formulation performance in paediatric patients using biopharmaceutical tools and simulation of clinically relevant administration scenarios of nifedipine and lorazepam

AIMS

This study explores the impact of paediatric patient related factors and choice of formulation on the dissolution characteristics of nifedipine and lorazepam, 2 drug substances regularly applied in very young patients and in compounded formulations.

METHODS

Dissolution experiments were designed to reflect clinical practice in a paediatric hospital, with respect to dosage forms, feeding regimens and methods of administration. Solubility studies addressed the influence of age and prandial state. Drug solubility and dissolution experiments were conducted in biorelevant media and adapted age-specific (neonate and infant) media. Dissolution studies were performed with the mini-paddle apparatus and the flow-through cell apparatus.

RESULTS

Dissolution of nifedipine formulations was not affected by age-related changes of the fasted state simulated gastrointestinal fluids, and by disintegration of the formulation before administration. However, a significant difference in nifedipine's dissolution rate from commercial tablets and compounded capsules was observed. The dissolution of lorazepam tablets was affected by fasted- vs fed-state media, but it was deemed less likely to be clinically relevant. The significant effect of fed-state media on nifedipine's solubility was considered to have possible clinical relevance since very young patients are almost continuously in a fed state.

CONCLUSION

The in vitro results obtained from these studies reveal the potential of biorelevant solubility and dissolution studies reflecting clinical practice to predict drug performance in paediatric patients.

Dietary feeding pattern does not modulate the loss of muscle mass or the decline in metabolic health during short-term bed rest

Short periods of bed rest lead to the loss of muscle mass and quality. It has been speculated that dietary feeding pattern may have an impact upon muscle protein synthesis rates and, therefore, modulate the loss of muscle mass and quality. We subjected 20 healthy men (age: 25 ± 1 yr, body mass index: 23.8 ± 0.8 kg/m²) to 1 wk of strict bed rest with intermittent (4 meals/day) or continuous (24 h/day) enteral tube feeding. Participants consumed deuterium oxide for 7 days before bed rest and throughout the 7-day bed rest period. Prior to and immediately after bed rest, lean body mass (dual energy X-ray absorptiometry), quadriceps cross-sectional area (CSA; CT), maximal oxygen uptake capacity (V̇o_2peak), and whole body insulin sensitivity (hyperinsulinemic-euglycemic clamp) were assessed. Muscle biopsies were collected 7 days before, 1 day before, and immediately after bed rest to assess muscle tracer incorporation. Bed rest resulted in 0.3 ± 0.3 vs. 0.7 ± 0.4 kg lean tissue loss and a 1.1 ± 0.6 vs. 0.8 ± 0.5% decline in quadriceps CSA in the intermittent vs. continuous feeding group, respectively (both P < 0.05), with no differences between groups (both P > 0.05). Moreover, feeding pattern did not modulate the bed rest-induced decline in insulin sensitivity (-46 ± 3% vs. 39 ± 3%; P < 0.001) or V̇o_2peak (-2.5 ± 2.2 vs. -8.6 ± 2.2%; P < 0.010) (both P > 0.05). Myofibrillar protein synthesis rates during bed rest did not differ between the intermittent and continuous feeding group (1.33 ± 0.07 vs. 1.50 ± 0.13%/day, respectively; P > 0.05). In conclusion, dietary feeding pattern does not modulate the loss of muscle mass or the decline in metabolic health during 1 wk of bed rest in healthy men.

Evaluation of technetium-99m metastable nanocolloid as an imaging agent for performing milk scans

OBJECTIVE

The aim of this study was to determine whether technetium-99m (Tc) nanocolloid was a suitable alternative tracer for carrying out milk scan studies in pediatric patients.

PARTICIPANTS AND METHODS

Twenty-seven milk scans performed with Tc nanocolloid were retrospectively assessed for identification of significant esophageal hold-up, gastroesophageal reflux, pulmonary aspiration, and gastric emptying (GE). Scans were also assessed for liver, spleen, and bone marrow uptake. GE results were compared with those of 27 randomly selected normal GE studies carried out using Tc tin colloid.

RESULTS

None of the studies had liver, spleen, or bone marrow uptake, and all studies were interpretable. Significant esophageal hold-up and gastroesophageal reflux was observed in 11 and 48% of the patients, respectively. Only one patient had evidence of pulmonary aspiration, and all patients had normal GE at 2 h after radiolabeled milk ingestion. The average rate of GE at 2 h was faster in the Tc nanocolloid group compared with the Tc tin colloid group (8.85% retained±8.96% vs. 15.48% retained±10.52%, P=0.016).

CONCLUSION

Our findings show that Tc nanocolloid is technically a suitable alternative to Tc sulfur colloid for performing milk scans. However, we could not conclude with certainty on the comparison of the GE rates of Tc nanocolloid and Tc tin colloid. This was because of the variability in the two population groups as well as the fact that the milk that was used in each patient was individualized to the patient and was not standardized.

Increased Activity in the Lung Field on Gastroesophageal Scintigraphy Is Not Always Due to Aspiration

Elevated activity in the lung field on gastroesophageal scintigraphy (milk scan) generally indicates aspiration of the gastric content that has refluxed to the pharynx. An 18-year-old man underwent to gastroesophageal scintigraphy to assess the rate of gastric emptying. Increased activity was noted in the left lower lung field during the image acquisition. Careful analysis of the images showed that this activity was caused by hiatal herniation.

Radionuclide Salivagram and Gastroesophageal Reflux Scintigraphy in Pediatric Patients: Targeting Different Types of Pulmonary Aspiration

OBJECTIVE

Both gastroesophageal reflux (GER) scintigraphy and radionuclide salivagram are commonly used in the detection of pulmonary aspiration in pediatric patients. This investigation is to compare the diagnostic value of these 2 imaging methods.

METHODS

This retrospective study included 4186 pediatric patients (aged 1 week to 16 years; mean age, 28 months) who underwent a GER scintigraphy and/or radionuclide salivagram. Detection rate of pulmonary aspiration by the 2 imaging techniques was compared.

RESULTS

The detection rate for pulmonary aspiration in patients undergoing both procedures was 1.9% (5 of 266) for GER scintigraphy and 22.2% (59 of 266) for radionuclide salivagram. Fifty-six of 59 patients with proven aspiration on radionuclide salivagram demonstrated no such findings on GER scintigraphy, whereas 2 of 5 patients with proven aspiration on GER scintigraphy demonstrated no such findings on radionuclide salivagram. In patients who underwent only 1 procedure (either GER scintigraphy or salivagram), the detection rate for pulmonary aspiration was 0.4% (15 of 3551) for GER scintigraphy and 20.3% (75 of 369) for radionuclide salivagram.

CONCLUSIONS

Radionuclide salivagram showed a much higher detection rate for pulmonary aspiration compared with GER scintigraphy. However, this may be related to a significantly higher prevalence of antegrade versus retrograde aspiration in our study population. Our results also suggest that not all episodes of retrograde aspiration can be detected by a radionuclide salivagram, and the requested scan should be tailored to the type of suspected aspiration.

Does age affect gastric emptying time? A model-based meta-analysis of data from premature neonates through to adults

Purpose. Gastric emptying (GE) is often reported to be slower and more irregular in premature neonates than in older children and adults. The aim of this study was to investigate the impact of age and other covariates on the rate of GE. Methods. The effect of age on the mean gastric residence times (MGRT) of liquid and solid food was assessed by analysing 49 published studies of 1457 individuals, aged from 28 weeks gestation to adults. The data were modelled using the nonlinear mixed‐effects approach within NONMEM version 7.2 (ICON, Dublin, Ireland), with evaluation of postnatal age, gestational age and meal type as covariates. A double Weibull function was selected as a suitable model since it could account for the typical biphasic nature of GE. Results. Age was not a significant covariate for GE but meal type was. Aqueous solutions were associated with the fastest emptying time (mean simulated gastric residence time of 45 min) and solid food was associated with the slowest (98 min). Conclusions. These findings challenge the assertion that GE is different in neonates, as compared with older children and adults due to age, and they reinforce the significance of food type in modulating GE. © 2015 The Authors. Biopharmaceutics & Drug Disposition Published by John Wiley & Sons Ltd.