Nutritional management of the infant with cystic fibrosis

Nutraceutical Approach for the Management of Cystic Fibrosis

Background:

Cystic fibrosis is an autosomal recessive monogenic disease marked by a mutation in the cystic fibrosis transmembrane conductance regulator gene. Cystic fibrosis transmembrane conductance regulator gene mutations affect respiratory, digestive and reproductive functions and impede bicarbonate, bile acid and sweat secretion. Moreover, the current trend indicates that CF is no longer only a paediatric disease; but has progressively become a disease that also affects adults. This calls to address the condition with an appropriate nutraceutical approach.

Objective:

The study aims to find and collate nutritional targets in the management of Cystic Fibrosis.

Method:

Studies highlighting the benefits of nutrients or nutraceuticals in the management of Cystic Fibrosis were included from previously published research articles (1971 to 2020). Data including nutrients, nutraceuticals, study design, study model, sample size, age, dose and duration of the dose of the supplement were extracted from the studies included and explored to understand their role.

Results:

About 26 studies are being included in the present review. It was found that nutrient interventions comprising nutraceuticals including dietary fibre, proteins and amino acids (taurine, arginine, glutathione), fats (medium-chain triglycerides, polyunsaturated fatty acids (omega-3 fatty acids)), phytochemicals (apigenin, genistein, quercetin, curcumin, allicin, beta-carotene, Pulmonaria officinalis L, Epigallocatechin-3-gallate), micronutrients including vitamin A, vitamin D, vitamin K, magnesium and zinc in addition to antioxidants exhibit improvement in the symptomatic condition of cystic fibrosis patients.

Conclusion:

The advent of nutraceuticals in the food industry and studies indicating their promising benefits have paved a path for targeted therapies in cystic fibrosis.

The data and characteristics of the human milk banks in mainland China

BACKGROUND

Human milk banks (HMB) have been established for over 100 years in North America and Europe. This study aimed to describe and summarize the operation and characteristics of the HMBs in mainland China since the first nonprofit HMB operated in 2013.

METHODS

Operation of HMB in mainland China is based on the standards and guidelines of the Human Milk Banking Association of North America and some countries in Europe and was modified to meet the needs and circumstances in China such as donation only in the local HMB by medical staff. We reviewed the descriptive data of these 14 HMBs and the clinical characteristics of recipients, the eligible milk donors and the donor milk retrospectively.

RESULTS

In mainland China, from March 2013 to December 2016, 14 nonprofit HMBs were developed and operational in public hospitals except one and located in the south, east, north and northwest of mainland China. In total, 2680 eligible donors donated 4608.2 L of breast milk. The mean age of these donors was 29.4 years with 60.6% receiving college education and 90.6% term delivery. A total of 4678 recipients including preterm infants (n = 2990, 63.9%), feeding intolerance (n = 711, 15.2%), maternal illness (n = 345, 7.4%), serious infection (n = 314, 6.7%), necrotising enterocolitis (n = 244, 5.2%), post-surgery (n = 38, 0.8%) and others (n = 36, 0.8%). The rate of discarded raw milk was only 4.4% because of hepatitis B and C or cytomegalovirus positivity.

CONCLUSIONS

HMB has been developing rapidly in mainland China. Donor human milk was used not only for preterm infants but also for other ill children. But the sustainability of milk banking needs proper management and more financial support by relative health authorities and the government.

Fibrose cística: uma abordagem clínica e nutricional

A fibrose cística é a doença genética letal mais comum em populações caucasianas e é caracterizada por infecções crônicas e recorrentes do pulmão, insuficiência pancreática e elevados níveis de cloro no suor. É uma doença de herança autossômica recessiva causada pela mutação no gene do Regulador da Condutância Transmembrana da Fibrose Cística, que induz o organismo a produzir secreções espessas e viscosas que obstruem os pulmões, o pâncreas e o ducto biliar. Muitos pacientes apresentam insuficiência pancreática, que leva a má-absorção de nutrientes especialmente de proteínas e lipídeos e a complicações gastrintestinais tais como prolapso retal, síndrome da obstrução intestinal, constipação e cirrose hepática. A fibrose cística normalmente é diagnosticada na infância, pelos programas de triagem neonatal ou pelo teste do suor. Devido aos vários sistemas envolvidos e à variabilidade e cronicidade da doença, uma abordagem multidisciplinar é essencial para auxiliar o paciente e sua família a compreenderem a doença e aderirem ao tratamento. A terapia atual da fibrose cística inclui a manutenção do estado nutricional, a remoção das secreções das vias aéreas com fisioterapia e mucolíticos, o uso de antibióticos para prevenção e tratamento de infecções, a prescrição de suplementos energéticos, dietas hiperlípidicas e hiperprotéicas, bem como a suplementação de minerais e vitaminas lipossolúveis. O objetivo deste trabalho foi realizar breve revisão de literatura sobre os aspectos clínicos e nutricionais da fibrose cística.

Cystic fibrosis: nutritional consequences and management

Life expectancy for patients with Cystic Fibrosis (CF) has steadily improved during the last three decades, and death in childhood is now uncommon. Nutrition is a critical component of the management of CF, and nutritional status is directly associated with both pulmonary status and survival. Expert dietetic care is necessary, and attention must be given to ensuring an adequate energy intake in the face of demands which may be increased by inadequately controlled malabsorption, chronic broncho-pulmonary colonisation by bacteria and fungi, exacerbations of acute lung infection, impaired lung function, and the need for rehabilitation, repair and growth. Pancreatic enzyme replacement therapy (PERT) is needed by up to 90% of CF patients in Northern Europe, where the 'severe' mutation deltaF508 predominates, but a smaller proportion in Mediterranean countries and elsewhere, because pancreatic insufficiency is one of few features of CF which correlate with genotype. Complications of CF including liver disease and CF-related diabetes pose further challenges. In addition, deficiency of specific nutrients including fat soluble vitamins (particularly A, E and K) essential fatty acids and occasionally minerals occur for a variety of reasons. Osteopenia is common and poorly understood. Liver disease increases the likelihood of vitamin D deficiency. Glucose intolerance and diabetes affect at least 25% of CF adults, and the diabetes differs from both types 1 and 2 diabetes mellitus, but it inversely correlates with prognosis. Management consists of anticipating problems and addressing them vigorously as soon as they appear. Supplements of vitamins are routinely given. Energy supplements can be oral, enteral or, rarely, parenteral. All supplements, including PERT, are adjusted to individual needs.

Energy expenditure, nutrition status, and body composition in children with cystic fibrosis

OBJECTIVE

Undernutrition is a frequent complication in patients with cystic fibrosis (CF). Elevated energy requirements have been found to be 4% to 33% higher than in controls in some studies. Whether or not this is caused by a primary defect or energy metabolism is still a matter of controversy. To this end, we assessed energy expenditure, nutrition status, and body composition of clinically stable CF outpatients.

METHODS

Fifteen clinically stable CF patients, ages 2 to 15 y, were paired with 15 healthy control children. Measurements consisted of anthropometry and body composition. Plasma tocopherol, retinol, and hair zinc content were measured. Resting energy expenditure was determined by indirect calorimetry. Physical activity and dietary intake were recorded by recall methods.

RESULTS

Two children were nutritionally at risk according to the weight/height index, eight were normal, three were overweight, and two were obese. Body composition was similar in both groups. Zinc, tocopherol, and retinol levels were low in three, two, and three patients, respectively. Resting energy expenditures were 4.7 MJ/d (1127 +/- 220 kcal/d) in CF children and 4.63 MJ/d (1108 +/- 191 kcal/d) in control children (P = not significant). Physical activity level was sedentary in 86.6% of CF patients; the rest had a light physical activity pattern. Energy intake represented 141% of the estimated daily energy expenditure.

CONCLUSIONS

Non-oxygen-dependent CF children, without acute respiratory infection, had resting energy expenditures comparable to those of matched controls. Total energy expenditure was similar to or slightly lower than that in healthy children. Dietary recommendations for CF patients need to be reassessed.

Nutritional challenges of infants with cystic fibrosis

Nutrition plays an essential role in the management of cystic fibrosis (CF), particularly in infants with their high energy requirement due to rapid growth. Most infants are already malnourished at the time of clinical diagnosis due to an energy imbalance with increased losses and needs not compensated by energy intake. Even in very young asymptomatic CF patients diagnosed by neonatal screening programs, nutritional deficits can be detected in a high proportion of infants, since about half of all CF patients have evidence of pancreatic insufficiency at the time of birth. This review provides recommendations for assessment of the nutritional status at diagnosis and nutritional management including supplementation with pancreatic enzymes during the first year of life.

Estado nutricional e ingestão alimentar de pessoas com fibrose cística

A mucoviscidose é uma doença que afeta o estado nutricional por interferir na ingestão e absorção adequadas de nutrientes. Este estudo avaliou 22 pacientes mucoviscidóticos atendidos no Ambulatório de Nutrição do Hospital Infantil Joana de Gusmão em Florianópolis, SC, no período de agosto de 1998 a janeiro de 1999. O estado nutricional foi determinado através de medidas antropométricas e dados de consumo alimentar. Quanto ao estado nutricional, 42,9% dos menores de 2 anos e 28,6% dos maiores de 10 anos estavam desnutridos; na faixa etária de 2 a 10 anos não houve nenhuma criança desnutrida. Quanto ao consumo alimentar, 33,3% atingiram a recomendação de energia e 95,2% atingiram a recomendação de proteína. Podemos concluir que a mucoviscidose afeta o estado nutricional das crianças em períodos críticos de crescimento e desenvolvimento, e que a qualidade da dieta destes pacientes pode ser melhorada através de um cuidado nutricional adequado.

[Protein requirements in children during states of stress. Committee on Nutrition of the French Society of Pediatrics]

Acute and chronic stress conditions affecting critically ill children are characterized by severe protein breakdown and growth failure. This paper describes the disorders of protein metabolism, and gives recommendations for protein and energy intakes during stress conditions in children.

Cystic fibrosis: nutritional consequences and management

Malnutrition is an adverse prognostic factor in cystic fibrosis, influencing the course of pulmonary disease and correlating inversely with survival. A positive energy balance between energy intake and the combination of total energy expenditure, energy losses and growth-related energy cost is essential to maintain normal nutritional status. Before starting nutritional supplementation, it is important to rule out pathological conditions that may have a deleterious effect on nutritional status: persistent exocrine pancreatic insufficiency, chronic bacterial pulmonary colonization, impaired glucose tolerance, specific nutritional deficits and associated disorders leading to a decrease of energy intake. Several methods are available, ranging from boosted oral nutrition to behavioural intervention, oral supplementation, enteral nutrition and, rarely, parenteral nutrition. The use of elemental nutrients for either oral supplementation or enteral nutrition seems of no nutritional benefit and is more expensive than conventional polymeric nutrients. Provided that the goals of the nutritional supplementation are fulfilled, simpler is often better.

Nutrition and cystic fibrosis

Cystic fibrosis is commonly associated with energy deficiency in children and adults. Chronic undernutrition will lead to failure to thrive, wasting, and stunting of linear growth; nutrition and survival are intimately related in cystic fibrosis. These problems can simply be considered as energy imbalance, and management centers on restoration of energy balance. Specific nutrient deficiencies, such as fat soluble vitamins, are common in cystic fibrosis. Recent work has highlighted problems with bone density and also the prevalence of vitamin K deficiency. Management of nutritional problems can be complex, and injudicious treatment can further worsen the situation, as the relationship between high daily doses of pancreatic enzymes and the development of fibrosing colonopathy illustrates.

Cystic fibrosis--an Indian perspective on recent advances in diagnosis and management

Cystic fibrosis (CF) is a common inherited disorder in caucasians. The estimated incidence of CF in Asians varies from 1:10,000 to 1:12,000. Indian data is restricted to few case reports. The gene for CF is located on the long arm of chromosome 7 at position 7q13. There are more than 300 identified mutations in CF. The basic defect in CF is a mutational change in the gene for chloride conductance channel. Failure of chloride conductance by epithelial cells leads to dehydration of secretions that are too viscid and difficult to clear. The disease is characterized by abnormal secretions in the respiratory, gastrointestinal and reproductive tract and sweat glands. The common clinical manifestations include meconium ileus in neonatal period, recurrent lower respiratory tract infections (pseudomonas pneumonia, bronchiectasis), steatorrhoea, azoospermia, and in late stages hepatobiliary and endocrine pancreatic dysfunctions. The diagnosis of disease is established by clinical criteria and sweat chloride concentration more than 60 mEq/L. Facilities for DNA diagnosis of common CF mutations are now available in India. The treatment of CF includes early diagnosis, daily clearance of respiratory passages, appropriate antibiotic therapy, aerosolised recombinant human DNase and antibiotics, and nutritional supplementation. The latter include changes in diet composition, pancreatic enzyme supplementation and vitamins and trace mineral supplementation. Gene therapy for the pulmonary manifestations is being tried in a number of centres abroad. Other considerations include heart lung transplantation and ameloride inhalation therapy.