A.S.P.E.N. position paper: recommendations for changes in commercially available parenteral multivitamin and multi-trace element products

Method validation of an inductively coupled plasma mass spectrometry (ICP-MS) assay for the analysis of magnesium, copper and zinc in red blood cells

Background

Laboratory measurements of trace elements such as magnesium (Mg), copper (Cu), and zinc (Zn) in red blood cells (RBCs) are essential for assessing nutritional status and diagnosing metal toxicity. The purpose of this study was to develop and validate an ICP-MS method for quantifying these elements in RBCs.

Methods

Packed RBCs were aliquoted and diluted in an alkaline diluent solution containing internal standards, 0.1 % Triton X-100, 0.1 % EDTA, and 1 % ammonium hydroxide. The resulting diluted specimen was analyzed using inductively coupled plasma mass spectrometry (ICP-MS) to quantitatively determine the levels of Mg, Cu, and Zn. The method underwent validation for accuracy, precision, method comparison, linearity, analytical sensitivity, and carryover. Additionally, retrospective data were analyzed, and non-parametric reference intervals were calculated.

Results

Accuracy and linearity fell within the expected range of ≤±15 % for all analytes. Within-run, between-run, and total imprecision were ≤15 % coefficient of variation. All other validation experiments met the established acceptance criteria. Retrospective data analysis was conducted on patient samples using the method. The application of Tukey's HSD test for multiple comparisons revealed statistically significant mean differences (p < 0.05) in Mg, Cu, and Zn concentrations between all pairwise groups of age and sex, except for the mean Cu concentration in adult males versus females and the mean Mg concentrations in adult versus minor males.

Conclusions

The presented method was successfully validated and met the criteria for clinical use. Retrospective data analysis of patient results demonstrated the method's suitability for assessing nutritional deficiency and toxicity.

Sleep and home parenteral nutrition in adults: A narrative review

Infusions of home parenteral nutrition (HPN) are often cycled at night coinciding with sleep episodes. Adult consumers of HPN are known to experience poor sleep attributed to frequent awakenings and long durations of wakefulness after falling asleep. Consequently, most consumers do not meet recommendations for sleep duration and quality or daytime napping. The primary underlying pathophysiology resulting in sleep problems is nocturia; however, other factors also exist, including disruptions caused by medical equipment (ie, pump alarms), comorbid conditions, dysglycemia, and medication use. Early guidance on sleep is imperative because of the central role of sleep in physical health and wellbeing, including mitigating complications, such as infection risk, gastrointestinal problems, pain sensitivity, and fatigue. Clinicians should routinely inquire about the sleep of their patients and address factors known to perturb sleep. Nonpharmacologic opportunities to mitigate sleep problems include education on healthy sleep practices (ie, sleep hygiene); changes in infusion schedules, volumes, rates, and equipment; and, possibly, behavioral interventions, which have yet to be examined in this population. Addressing comorbid conditions, such as mood disorders, and nutrition deficiencies may also help. Pharmacologic interventions and technological advancement in HPN delivery are also needed. Research on sleep in this population is considered a priority, yet it remains limited at this time.

Micronutrient deficiencies in inflammatory bowel disease: an incidence analysis

BACKGROUND

Micronutrient deficiencies associated with malnutrition in patients with inflammatory bowel disease (IBD) can lead to complications including anemia, coagulopathy, poor wound healing, and colorectal cancer. This study aimed to investigate micronutrient deficiencies (copper, vitamins A, B 9 , E, and K) in IBD patients and highlight associated symptoms to aid in the recognition of micronutrient deficiencies.

METHODS

A retrospective electronic chart review was performed on adults diagnosed with Crohn's disease or ulcerative colitis hospitalized at a tertiary care center for IBD flare between January 2013 and June 2017. Patients with serum or whole blood micronutrient levels were included. Pregnant and incarcerated patients were excluded.

RESULTS

A total of 611 IBD patients (440 Crohn's disease, 171 ulcerative colitis) met the inclusion criteria. Micronutrients were assessed in a subset of IBD patients (copper: 12.3%, A: 10.1%, B 9  : 95.9%, E: 10.3%, and K: 4.6%). Overall, 10.1% of patients had micronutrient deficiencies. The proportion of patients with copper, A, B 9 , E, and K deficiencies were 25.4, 53.3, 1.9, 23.7, and 29.4% for Crohn's disease and 50, 52.9, 1.2, 43.8, and 18.2% for ulcerative colitis, respectively. The most common symptoms or historical features associated with micronutrient deficiency were anemia (copper, B 9 ), muscle weakness (copper, E) thrombocytopenia, fatigue (copper, B 9 ), diarrhea (B 9 ), dry skin, hyperkeratosis, pruritus, significant weight loss, elevated C-reactive protein (A), bleeding, and osteoporosis (K).

CONCLUSION

Micronutrient deficiencies are common in IBD patients, yet they are not routinely assessed. Copper, vitamins A, E, and K deficiencies are particularly underrecognized. Associated historical features should raise suspicion and prompt assessment and treatment.

Role of Peripheral Parenteral Nutrition Composition on Clinical Outcomes in Patients Undergoing Gastrectomy or Colectomy: A Phase III Indian Clinical Trial

Aims and background

Various types of parenteral nutritional products exist, each with specific formulations designed to meet the diverse nutritional needs of patient's post-abdominal surgery. Here, two different parenteral nutrition (PN) solutions BFLUID and NUTRIFLEX PERI are compared in terms of therapeutic efficacy and safety profile.

Materials and methods

A prospective, multi-center, randomized, parallel-group, non-inferiority Phase III clinical trial compared two PN solutions namely BFLUID (N = 78) and NUTRIFLEX PERI (N = 72) in 150 patients undergoing gastrectomy or colectomy. Primary endpoints included length of hospital stay while secondary endpoints included assessment and comparison of length of ICU/HDU stay, assessment of incidents of infections and mortality, change in blood levels of vitamin B1, change in nutritional parameters, thrombophlebitis, pain at the injection site, and recording of adverse events (AEs).

Results

There was no significant difference in terms of length of hospital stay, length of ICU/HDU stay as well as changes in nutritional parameters from baseline and change in blood levels of vitamin B1 from baseline. Both study groups exhibited comparability in terms of AEs, pain at the injection site, and the incidence of phlebitis. There was no significant difference in the number and severity of adverse events reported in both groups. Additionally, no signs of infection were observed in patients from either group.

Conclusion

The trial successfully demonstrated the non-inferiority of BFLUID to NUTRIFLEX PERI. Moreover, the results indicated that PN enriched with high levels of branched-chain amino acids (BCAAs), essential amino acids (EAAs), and thiamine is both safe and efficacious for adult patients undergoing gastrectomy or colectomy.

How to cite this article

Goyal A, Pathak A, BS Madhu, Soni H, Bhatt K, Raju KVVN, et al. Role of Peripheral Parenteral Nutrition Composition on Clinical Outcomes in Patients Undergoing Gastrectomy or Colectomy: A Phase III Indian Clinical Trial. Indian J Crit Care Med 2024;28(9):871-878.

ESPEN practical guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease

BACKGROUND AND AIMS

Hospitalized patients often have acute kidney disease (AKD) or chronic kidney disease (CKD), with important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, the possible impact on nutritional requirements cannot be neglected. On this regard, the present guideline aims to provide evidence-based recommendations for clinical nutrition in hospitalized patients with KD.

METHODS

The standard operating procedure for ESPEN guidelines was used. Clinical questions were defined in both the PICO format, and organized in subtopics when needed, and in non-PICO questions for the more general topics. The literature search was from January 1st, 1999 until January 1st, 2020. Each question led to one or more recommendation/statement and related commentaries. Existing evidence was graded, as well as recommendations and statements were developed and agreed upon in a multistage consensus process.

RESULTS

The present guideline provides 32 evidence-based recommendations and 8 statements, defining how to assess nutritional status, how to define patients at risk, how to choose the route of feeding, and how to integrate nutrition with KRT. In the final online voting, a strong consensus was reached in 84% at least of recommendations and 100% of statements.

CONCLUSION

The presence of KD in hospitalized patients identifies a highly heterogeneous group of subjects with widely varying nutrient needs and intakes. Considering the high nutritional risk related with this clinical condition, an individualized approach consisting of nutritional status evaluation and monitoring, frequent evaluation of nutritional requirements, and careful integration with KRT should be planned to avoid both underfeeding and overfeeding. Practical recommendations and statements were developed, aiming at defining suggestions for everyday clinical practice in the individualization of nutritional support in this patient setting. Literature areas with scarce or without evidence were also identified, thus requiring further basic or clinical research.

Vitamin K: a potential missing link in critical illness-a scoping review

BACKGROUND

Vitamin K is essential for numerous physiological processes, including coagulation, bone metabolism, tissue calcification, and antioxidant activity. Deficiency, prevalent in critically ill ICU patients, impacts coagulation and increases the risk of bleeding and other complications. This review aims to elucidate the metabolism of vitamin K in the context of critical illness and identify a potential therapeutic approach.

METHODS

In December 2023, a scoping review was conducted using the PRISMA Extension for Scoping Reviews. Literature was searched in PubMed, Embase, and Cochrane databases without restrictions. Inclusion criteria were studies on adult ICU patients discussing vitamin K deficiency and/or supplementation.

RESULTS

A total of 1712 articles were screened, and 13 met the inclusion criteria. Vitamin K deficiency in ICU patients is linked to malnutrition, impaired absorption, antibiotic use, increased turnover, and genetic factors. Observational studies show higher PIVKA-II levels in ICU patients, indicating reduced vitamin K status. Risk factors include inadequate intake, disrupted absorption, and increased physiological demands. Supplementation studies suggest vitamin K can improve status but not normalize it completely. Vitamin K deficiency may correlate with prolonged ICU stays, mechanical ventilation, and increased mortality. Factors such as genetic polymorphisms and disrupted microbiomes also contribute to deficiency, underscoring the need for individualized nutritional strategies and further research on optimal supplementation dosages and administration routes.

CONCLUSIONS

Addressing vitamin K deficiency in ICU patients is crucial for mitigating risks associated with critical illness, yet optimal management strategies require further investigation.

IMPACT RESEARCH

To the best of our knowledge, this review is the first to address the prevalence and progression of vitamin K deficiency in critically ill patients. It guides clinicians in diagnosing and managing vitamin K deficiency in intensive care and suggests practical strategies for supplementing vitamin K in critically ill patients. This review provides a comprehensive overview of the existing literature, and serves as a valuable resource for clinicians, researchers, and policymakers in critical care medicine.

Evidence and Perspectives for Choline Supplementation during Parenteral Nutrition-A Narrative Review

Choline is an essential nutrient, with high requirements during fetal and postnatal growth. Tissue concentrations of total choline are tightly regulated, requiring an increase in its pool size proportional to growth. Phosphatidylcholine and sphingomyelin, containing a choline headgroup, are constitutive membrane phospholipids, accounting for >85% of total choline, indicating that choline requirements are particularly high during growth. Daily phosphatidylcholine secretion via bile for lipid digestion and very low-density lipoproteins for plasma transport of arachidonic and docosahexaenoic acid to other organs exceed 50% of its hepatic pool. Moreover, phosphatidylcholine is required for converting pro-apoptotic ceramides to sphingomyelin, while choline is the source of betaine as a methyl donor for creatine synthesis, DNA methylation/repair and kidney function. Interrupted choline supply, as during current total parenteral nutrition (TPN), causes a rapid drop in plasma choline concentration and accumulating deficit. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) defined choline as critical to all infants requiring TPN, claiming its inclusion in parenteral feeding regimes. We performed a systematic literature search in Pubmed with the terms "choline" and "parenteral nutrition", resulting in 47 relevant publications. Their results, together with cross-references, are discussed. While studies on parenteral choline administration in neonates and older children are lacking, preclinical and observational studies, as well as small randomized controlled trials in adults, suggest choline deficiency as a major contributor to acute and chronic TPN-associated liver disease, and the safety and efficacy of parenteral choline administration for its prevention. Hence, we call for choline formulations suitable to be added to TPN solutions and clinical trials to study their efficacy, particularly in growing children including preterm infants.

Parenteral nutrition in clinical practice: International challenges and strategies

PURPOSE

Parenteral nutrition (PN) is an established therapy when oral/enteral feeding is not sufficient or is contraindicated, but nevertheless PN remains a complex, high-alert medication that is susceptible to errors that may affect patient safety. Over time, considerable progress has been made to make PN practices safer. The purpose of this article is to address ongoing challenges to improve the PN use process from prescription to administration and monitoring, and to outline practical aspects fostering the safety, quality, and cost-effectiveness of PN, as discussed at the International Safety and Quality of PN Summit.

SUMMARY

Opportunities to improve the PN use process in clinical practice include the promotion of inter-disciplinary communication, vigilant surveillance for complications, staff education to increase competency, and more consistent use of advanced technologies that allow automated safety checks throughout the PN process. Topics covered include considerations on PN formulations, including the value of intravenous lipid emulsions (ILEs), trends in compounding PN, the current and future role of market-authorized multi-chamber PN bags containing all 3 macronutrients (amino acids, glucose/dextrose, and ILE) in the United States and in Europe, and strategies to cope with the increasing global problem of PN product shortages.

CONCLUSION

This review outlines potential strategies to use in clinical practice to overcome ongoing challenges throughout the PN use process, and ultimately promote PN patient safety.

A scoping review of parenteral requirements (macronutrients, fluid, electrolytes and micronutrients) in adults with chronic intestinal failure receiving home parenteral nutrition

INTRODUCTION

Home parenteral nutrition (HPN) prescriptions should be individualised in adults with chronic intestinal failure (IF). The aims of the review were to explore HPN requirements and available guidelines and to determine whether adults (≥ 18 years) receive recommended parenteral nutrient doses.

METHODS

Online databases searches identified empirical evidence (excluding case-reports), reviews and guidelines (Published 2006-2024 in English language). Additional reference lists were hand-searched. Older studies, cited in national guidelines were highlighted to map evidence source. Two reviewers screened 1660 articles independently, with 98 full articles assessed and 78 articles included (of which 35 were clinical studies). Citation tracking identified 12 older studies.

RESULTS

A lack of evidence was found assessing parenteral macronutrient (amounts and ratios to meet energy needs), fluid and electrolyte requirements. For micronutrients, 20 case series reported serum levels as biomarkers of adequacy (36 individual micronutrient levels reported). Studies reported levels below (27 out of 33) and above (24 out of 26) reference ranges for single micronutrients, with associated factors explored in 11 studies. Guidelines stated recommended parenteral dosages. Twenty-four studies reported variable proportions of participants receiving HPN dosages outside of guideline recommendations. When associated factors were assessed, two studies showed nutrient variation with type of HPN administered (multichamber or individually compounded bags). Five studies considered pathophysiological IF classification, with patients with short bowel more likely to require individualised HPN and more fluid and sodium.

CONCLUSIONS

This review highlights substantial evidence gaps in our understanding of the parenteral nutritional requirements of adult receiving HPN. The conclusions drawn were limited by temporal bias, small samples sizes, and poor reporting of confounders and dose. Optimal HPN nutrient dose still need to be determined to aid clinical decision-making and further research should explore characteristics influencing HPN prescribing to refine dosing recommendations.

Evaluation of Arsenic and Cobalt Levels in Pediatric Patients Receiving Long-Term Parenteral Nutrition

This study continues the research in which we determined the concentration of aluminum in children receiving long-term parenteral nutrition (LPN). Since our results were interesting, we decided to assay arsenic (As) and cobalt (Co) in the collected material, which, like aluminum, constitute contamination in the mixtures used in parenteral nutrition. Excesses of these trace elements in the human body are highly toxic, and deficiencies, particularly in the case of Co, can lead to various complications. The aim of this study was to determine the impact of LPN in children on their serum levels of As and Co, as well as the excretion of these elements in urine, and to compare them with a control group of healthy children. The study group consisted of 83 children receiving home parenteral nutrition from two Polish centers, while the control group included 121 healthy children. In both groups, the levels of As and Co in serum and urine were measured. The elemental compositions of the samples were determined using inductively coupled plasma mass spectrometry (ICP-MS). It was demonstrated that the children receiving LPN did not have increased As exposure compared to the controls. Greater exposure compared to the control group was shown for Co. In conclusion, children receiving LPN are not exposed to As, and even though the concentrations of Co in serum and urine were higher in the LPN group than in the healthy controls, neither trace element poses a health threat to children requiring LPN.

Iodine status in children with intestinal failure

OBJECTIVES

Children on long-term parenteral nutrition (PN) are at high risk of iodine deficiency (ID). However, most available information comes from cross-sectional studies. We investigated the iodine status, associated factors, and prevalence of hypothyroidism in children with intestinal failure (IF) who were followed up longitudinally.

METHODS

This was a cohort study of children with IF monitored for urine iodine concentration (UIC), iodine intake, serum selenium concentration, and thyroid function in an intestinal rehabilitation program. The outcome variable ID was defined as a UIC value < 100 μg/L. Adjusted generalized estimating equations were used to assess the effects of the exposure variables on the UIC.

RESULTS

Twenty-four patients aged 62.7 (39.1; 79.7) months who received PN for 46.5 (21.5) months were included. The average energy supply was 81.2 kcal/kg/day, 77.6% of which was provided by PN. An average of 5.2 UIC measurements per patient were performed. ID prevalence decreased from baseline (83.3%) to the last assessment (45.8%). Three patients had hypothyroidism secondary to iodine and selenium combined severe deficiency. Iodine intake from enteral or oral nutritional formulas was positively associated with UIC (β = 0.71 [0.35, 1.07]; p < 0.001). Meeting approximately 80% of the estimated average requirement for iodine from nutritional formulas resulted in a greater probability of normal UIC values.

CONCLUSION

ID is highly prevalent in children with IF who receive long-term PN and its frequency decreases with iodine intake from nutritional formulas. Severe combined iodine and selenium deficiencies are associated with the development of hypothyroidism in these patients.

ESPEN practical short micronutrient guideline

BACKGROUND

Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. The importance of MNs in common pathologies is recognized by recent research, with deficiencies significantly impacting the outcome.

OBJECTIVE

This short version of the guideline aims to provide practical recommendations for clinical practice.

METHODS

An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL for the initial guideline. The search focused on physiological data, historical evidence (for papers published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations.

RESULTS

The limited number of interventional trials prevented meta-analysis and led to a low level of evidence for most recommendations. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90 % of votes. Altogether the guideline proposes 3 general recommendations and specific recommendations for the 26 MNs. Monitoring and management strategies are proposed.

CONCLUSION

This short version of the MN guideline should facilitate handling of the MNs in at-risk diseases, whilst offering practical advice on MN provision and monitoring during nutritional support.

The fluorosis conundrum: bridging the gap between science and public health

Fluorosis, a chronic condition brought on by excessive fluoride ingestion which, has drawn much scientific attention and public health concern. It is a complex and multifaceted issue that affects millions of people worldwide. Despite decades of scientific research elucidating the causes, mechanisms, and prevention strategies for fluorosis, there remains a significant gap between scientific understanding and public health implementation. While the scientific community has made significant strides in understanding the etiology and prevention of fluorosis, effectively translating this knowledge into public health policies and practices remains challenging. This review explores the gap between scientific research on fluorosis and its practical implementation in public health initiatives. It suggests developing evidence-based guidelines for fluoride exposure and recommends comprehensive educational campaigns targeting the public and healthcare providers. Furthermore, it emphasizes the need for further research to fill the existing knowledge gaps and promote evidence-based decision-making. By fostering collaboration, communication, and evidence-based practices, policymakers, healthcare professionals, and the public can work together to implement preventive measures and mitigate the burden of fluorosis on affected communities. This review highlighted several vital strategies to bridge the gap between science and public health in the context of fluorosis. It emphasizes the importance of translating scientific evidence into actionable guidelines, raising public awareness about fluoride consumption, and promoting preventive measures at individual and community levels.

Use of Total Parenteral Nutrition (TPN) as a Vehicle for Drug Delivery

Total Parenteral Nutrition (TPN) is a method of providing nutrients directly into the bloodstream for individuals who are unable to meet their nutritional needs through the normal digestive process or gastrointestinal system. It provides macronutrients and micronutrients in a single container, reducing handling and contamination risks and making it more cost-effective. TPN has the potential to be used as a drug delivery system, with applications in combination therapies, personalized medicine, and integrating advanced technologies. It can enhance drug dosage precision and provide nutritional assistance, potentially reducing hospitalization and improving patient outcomes. However, implementing new applications requires thorough testing and regulatory approval. TPN could be particularly useful in pediatric and geriatric care and could also contribute to global health by combating malnutrition in areas with limited medical resources. Healthcare professionals prepare a sterile solution tailored to each patient's nutritional needs, and administration involves a central venous catheter. However, the simultaneous administration of medications with PN admixtures can result in pharmacological incompatibility, which can impact the stability of the oil-in-water system. The European Society for Clinical Nutrition and Metabolism and the American Society for Parenteral and Enteral Nutrition recommendations advise against including non-nutrient drugs in PN admixtures due to safety concerns. This review focuses on the utilization of Total Parenteral Nutrition (TPN) as a method for delivering drugs. It discusses the benefits and difficulties associated with its commercial application and offers suggestions for future research endeavors.

Nutrition guidelines for preterm infants: A systematic review

BACKGROUND

There is no consensus on optimal nutrition for preterm infants, leading to substantial practice variation. We aimed to assess the quality of nutrition guidelines for preterm infants, the consistency of recommendations, and the gaps in recommendations.

METHODS

We searched databases and websites for nutrition guidelines for preterm infants before first hospital discharge, which were endorsed, prepared, or authorized by a regional, national, or international body, written in English, and published between 2012 and 2023. Two reviewers independently screened articles and extracted the recommendations. Four reviewers appraised the included guidelines using Appraisal of Guidelines, Research, and Evaluation II.

RESULTS

A total of 7051 were identified, with 27 guidelines included, 26% of which were high in quality. Most guidelines lacked stakeholder involvement and rigor of development. We found considerable variation in recommendations, many of which lacked details on certainty of evidence and strength of recommendation. Recommendations for type of feed and breastmilk fortification were consistent among high-quality guidelines, but recommendations varied for intakes of almost all nutrients and monitoring of nutrition adequacy. Different guidelines gave different certainty of evidence for the same recommendations. Most gaps in recommendations were due to very low certainty of evidence.

CONCLUSION

Future development of nutrition guidelines for preterm infants should follow the standard guideline development method and ensure the rigorous process, including stakeholders' involvement, to improve the reporting of strength of recommendation, certainty of evidence, and gaps in recommendation. Evidence is needed to support recommendations about macro and micronutrient intakes, breastmilk fortification, and markers on adequacy of intake of different nutrients.

Consequences of Disturbing Manganese Homeostasis

Manganese (Mn) is an essential trace element with unique functions in the body; it acts as a cofactor for many enzymes involved in energy metabolism, the endogenous antioxidant enzyme systems, neurotransmitter production, and the regulation of reproductive hormones. However, overexposure to Mn is toxic, particularly to the central nervous system (CNS) due to it causing the progressive destruction of nerve cells. Exposure to manganese is widespread and occurs by inhalation, ingestion, or dermal contact. Associations have been observed between Mn accumulation and neurodegenerative diseases such as manganism, Alzheimer's disease, Parkinson's disease, Huntington's disease, and amyotrophic lateral sclerosis. People with genetic diseases associated with a mutation in the gene associated with impaired Mn excretion, kidney disease, iron deficiency, or a vegetarian diet are at particular risk of excessive exposure to Mn. This review has collected data on the current knowledge of the source of Mn exposure, the experimental data supporting the dispersive accumulation of Mn in the brain, the controversies surrounding the reference values of biomarkers related to Mn status in different matrices, and the competitiveness of Mn with other metals, such as iron (Fe), magnesium (Mg), zinc (Zn), copper (Cu), lead (Pb), calcium (Ca). The disturbed homeostasis of Mn in the body has been connected with susceptibility to neurodegenerative diseases, fertility, and infectious diseases. The current evidence on the involvement of Mn in metabolic diseases, such as type 2 diabetes mellitus/insulin resistance, osteoporosis, obesity, atherosclerosis, and non-alcoholic fatty liver disease, was collected and discussed.

An Overview of Type B Lactic Acidosis Due to Thiamine (B1) Deficiency

Type B lactic acidosis can occur secondary to several factors, including thiamine deficiency, and is not as common as type A. Recognizing thiamine deficiency-associated lactic acidosis is challenging because serum thiamine concentrations are not routinely obtained, and a thorough and specific history is necessary for clinicians to suspect thiamine deficiency as a root cause. Furthermore, the appropriate dose and duration of thiamine treatment are not well defined. Untreated thiamine deficiency-associated lactic acidosis can lead to critical illness requiring lifesaving extracorporeal therapies. Additionally, if thiamine and glucose are not administered in an appropriate sequence, Wernicke encephalopathy or Korsakoff syndrome may occur. This review aims to summarize therapeutic treatment for thiamine deficiency-associated lactic acidosis, based on case reports/series and nutritional guidance. After a literature search of the PubMed database, 63 citations met inclusion criteria, of which 21 involved pediatric patients and are the focus of this review. -Citations describe dosing regimens ranging from 25 to 1000 mg of intravenous (IV) thiamine as a single dose, or multiple daily doses for several days. Specific guidance for critically ill adults recommends a thiamine range of 100 mg IV once daily to 400 mg IV twice daily. Although there are no specific recommendations for the pediatric population, given the relative safety of thiamine administration, its low cost, and our review of the literature, treatment with thiamine 100 to 200 mg IV at least once is supported, with ongoing daily doses based on clinical response of the patient, regardless of age.

ESPEN guideline on chronic intestinal failure in adults - Update 2023

BACKGROUND & AIMS

In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.

METHODS

The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.

RESULTS

The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%).

CONCLUSIONS

It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

A one size vial does not fit all: An evaluation of the micronutrient status of adult patients receiving home parenteral nutrition (HPN)

BACKGROUND & AIMS

Patients with chronic intestinal failure require HPN. Previous studies have reported a high prevalence of micronutrient deficiencies. We examined the micronutrient status of our patients receiving.

METHODS

We measured vitamins A, E, D, B12, Folate, Zinc, Selenium and Copper. Patients were excluded if they had undergone surgery or amendments in IV or oral micronutrient provision in the past six months. Blood samples were excluded if C-reactive protein was >15 mg/L. Univariate and multivariate analyses were performed on concentrations below normal to determine if clinical or demographic categories were significant.

RESULTS

93 samples were included (33 males:60 females). Samples were excluded due to surgery (n = 8) amendment in micronutrient provision (n = 42) or if C-reactive protein >15 mg/L (n = 18). Vitamins A, D and E were below normal in 26%, 33% and 13% of patients respectively. Lower vitamin A was more likely in patients >50 years (P = 0.02) and lower vitamin E was more likely in men (P = 0.02). No patients had low vitamin B12 or folate whereas 29% and 9% had concentrations above the normal range respectively. Zinc and selenium were below normal in 19% and 13% respectively. Patients with surgical complications were more likely to have lower zinc (P = 0.007) and selenium (P = 0.04). Lower zinc was more likely in patients with a BMI of >25 kg/m2 (P = 0.01) and those who received Additrace® ≤3 day/week (P = 0.06).

DISCUSSION

Low and high concentrations were observed in our patients but clinical and demographic factors did not impact consistently on micronutrient concentrations highlighting the importance of ongoing monitoring and adequate supplementation as per ESPEN guidelines. Current micronutrient preparations may be inadequate for some patients with dependent on HPN. Our results indicate a need for a preparation with higher amounts of vitamin D.

25 year experience of patterns of plasma vitamin C levels in patients requiring home parenteral support

OBJECTIVE

Vitamin C deficiency is common in patients with chronic intestinal failure. Risk factors are poorly understood and guidelines for monitoring largely based on expert opinion. The aim of this study was to describe patterns of vitamin C deficiency in patients on long-term home parenteral support (HPS).

DESIGN

A retrospective review of a prospectively collated database for 236 HPS patients cared for in Glasgow, from 1998 to 2023, was interrogated for subjects with paired CRP and vitamin C measurements. Following analysis of the impact of CRP on vitamin C levels, further review of associated clinical, micronutrient and dietetic details in those with a paired CRP <5 mg L-1 were used to identify risk factors for hypoascorbataemia.

RESULTS

1527 recorded episodes with paired CRP and vitamin C measurements were analysed. Period prevalence of hypoascorbataemia was between 29.3 and 52.5%, depending on choice of the lower reference range for vitamin C as either 15 μmol L-1 or 26.1 μmol L-1. The influence of CRP appeared most significant early during HPS with other factors, including extensive mucosal disease, precedent surgery or presence of a colostomy identified as more significant on multivariate analysis for those on long-term HPS (OR 1.3261-1.5609, 1.0752-1.1008, and 0.6260-0.6663 for threshold vitamin C of 26.1 or 15 μmol L-1 respectively).

CONCLUSION

Vitamin C may present differently in long term HPS patients in comparison to those in the acute phase of illness. An evidence based approach to guideline development should be promoted to reduce morbidity.

Selenium intake and multiple health-related outcomes: an umbrella review of meta-analyses

Selenium is an essential trace metalloid element that is associated with fundamental importance to human health. Our umbrella review aimed to evaluate the quality of evidence, validity, and biases in the relationship between selenium intake and health-related outcomes according to published systematic reviews with pooled data and meta-analyses. Selenium intake is associated with a decreased risk of digestive system cancers, all-cause mortality, depression, and Keshan disease, when in children reduce the risk of Kashin-Beck disease. Additionally, selenium supplementation can improve sperm quality, polycystic ovary syndrome, autoimmune thyroid disease, cardiovascular disease, and infective outcomes. Selenium supplementation also has relationship with a decreased concentration of serum lipids including total cholesterol and very low-density lipoprotein cholesterol. However, no evidence has shown that selenium is associated with better outcomes among patients in intensive care units. Furthermore, selenium intake may be related with a higher risk of type 2 diabetes and non-melanoma skin cancers. Moreover, most of included studies are evaluated as low quality according to our evidence assessment. Based on our study findings and the limited advantages of selenium intake, it is not recommended to receive extra supplementary selenium for general populations, and selenium supplementation should not be continued in patients whose selenium-deficient status has been corrected.

Guidelines for parenteral nutrition in preterm infants: The American Society for Parenteral and Enteral Nutrition

BACKGROUND

Parenteral nutrition (PN) is prescribed for preterm infants until nutrition needs are met via the enteral route, but unanswered questions remain regarding PN best practices in this population.

METHODS

An interdisciplinary committee was assembled to answer 12 questions concerning the provision of PN to preterm infants. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process was used. Questions addressed parenteral macronutrient doses, lipid injectable emulsion (ILE) composition, and clinically relevant outcomes, including PNALD, early childhood growth, and neurodevelopment. Preterm infants with congenital gastrointestinal disorders or infants already diagnosed with necrotizing enterocolitis or PN-associated liver disease (PNALD) at study entry were excluded.

RESULTS

The committee reviewed 2460 citations published between 2001 and 2023 and evaluated 57 clinical trials. For most questions, quality of evidence was very low. Most analyses yielded no significant differences between comparison groups. A multicomponent oil ILE was associated with a reduction in stage 3 or higher retinopathy of prematurity (ROP) compared to an ILE containing 100% soybean oil. For all other questions, expert opinion was provided.

CONCLUSION

Most clinical outcomes were not significantly different between comparison groups when evaluating timing of PN initiation, amino acid dose, and ILE composition. Future clinical trials should standardize outcome definitions to permit statistical conflation of data, thereby permitting more evidence based recommendations in future guidelines. This guideline has been approved by the ASPEN 2022-2023 Board of Directors.

Carnitine supplementation increases serum concentrations of free carnitine and total acylcarnitine in preterm neonates: A retrospective cohort study

OBJECTIVE

Our goal was to determine the efficacy of the American Society for Parenteral and Enteral Nutrition's recommended carnitine dosage of 5 mg/kg/day in maintaining normal serum free carnitine and total acylcarnitine levels in preterm neonates receiving parenteral nutrition (PN).

STUDY DESIGN

A retrospective cohort study was conducted on neonates born <30 weeks gestation and weighing <1250 g, comparing those who received carnitine supplementation to those without supplementation. Free carnitine and total acylcarnitine data were collected from routine newborn screens in the first days of life and on full enetral feeds. Univariate analysis was performed, and those factors that were significantly different between the two groups were adjusted for using mixed effects analysis.

RESULTS

There were 108 supplemented and 45 unsupplemented neonates in the study. At baseline, free carnitine (19.8 ± 3.3 vs 18.9 ± 3.7 µmol/L, P = 0.53) and total acylcarnitine (26.6 ± 5.1 vs 22.5 ± 7.1 µmol/L, P = 0.11) were similar between the two groups. At full enteral feeds, compared with unsupplemented group, supplemented infants had significantly higher free carnitine (27.1 ± 16.4 vs 17.1 ± 8.5 µmol/L, P < 0.001) and total acylcarnitine (30.3 ± 11.5 vs 20.2 ± 10.1 µmol/L, P < 0.001). None of the supplemented neonates developed biochemical carnitine deficiency as compared with 18% in the unsupplemented group (P < 0.001). No difference was observed in time to reach full lipid provision, and there were no differences in the change in the triglyceride levels from baseline to the time on full PN lipid provision (P = 0.39).

CONCLUSION

Preterm neonates routinely supplemented with parenteral carnitine at 5 mg/kg/day demonstrated higher free carnitine and total acylcarnitine levels at full feeds, with none developing biochemical carnitine deficiency.

Metabolic and nutritional aspects in continuous renal replacement therapy

Nutrition is one of the foundations for supporting and treating critically ill patients. Nutritional support provides calories, protein, electrolytes, vitamins, and trace elements via the enteral or parenteral route. Acute kidney injury (AKI) is a common and devastating problem in critically ill patients and has significant metabolic and nutritional consequences. Moreover, renal replacement therapy (RRT), whatever the modality used, also profoundly impacts metabolism. RRT and of the extracorporeal circuit impede 'effect the evaluation of a patient's energy requirements by clinicians. Substrates added and removed within the extracorporeal treatment are not always taken into consideration, making treatment even more challenging. Furthermore, evidence on nutritional support during continuous renal replacement therapy (CRRT) is scarce, and there are no clinical guidelines for nutrition adaptations during CRRT in critically ill patients. Most recommendations are based on expert opinions. This review discusses the complex interaction between nutritional support and CRRT and presents some milestones for nutritional support in critically ill patients on CRRT.

Inflammation and micronutrient deficiency as major risk factors for anemia in children with intestinal failure: A longitudinal cohort study

BACKGROUND

Most data on anemia in children with intestinal failure (IF) have been obtained from studies in which the data were collected at a single point in time. We aimed to identify the frequency of anemia and factors associated with hemoglobin levels in children with IF during their course of home parenteral nutrition.

METHODS

We performed a longitudinal cohort study of patients with IF followed up at a pediatric intestinal rehabilitation center. Outcome variables were hemoglobin levels and prevalence of anemia during the follow-up period. The exposure variables were age, duration of parenteral nutrition, chronic disease, and serum concentrations of C-reactive protein, iron, copper, selenium, vitamins A, D, B₁₂ , and folic acid.

RESULTS

Twenty-five children with a median time of receiving parenteral nutrition of 40.7 months were included. A median (and interquartile range) of 40.7 (25.2-58) hemoglobin measurements were performed per patient. Mean (SD) hemoglobin was 10.7 (1.8) g/dL at baseline and 11.6 (0.9) g/dL in the last observation (paired t test, P = 0.07); 32% of patients had mean hemoglobin values below the lower limit for age. In a multivariable predictive model, having C-reactive protein >1 mg/dL was associated with a decrease of 0.57 g/dL in hemoglobin (95% CI, -0.90 to -0.24, P = 0.01), and an increase of 1 mg/L in vitamin A concentration was associated with the increase of 0.93 g/dL in Hb level (95% CI, 0.24-1.61; P = 0.008).

CONCLUSION

Anemia affects almost one-third of children with IF and its frequency decreases during the follow-up period. Hemoglobin levels are associated with inflammatory response and serum micronutrient concentrations.

The Role of Chosen Essential Elements (Zn, Cu, Se, Fe, Mn) in Food for Special Medical Purposes (FSMPs) Dedicated to Oncology Patients-Critical Review: State-of-the-Art

The scoping review aimed to characterise the role of selected essential elements (Zn, Cu, Se, Fe, Mn) in food for special medical purposes (FSMPs) aimed at oncology patients. The scope review was conducted using Scopus, Google Scholar, and Web of Science to find published references on this subject. Data from the reviewed literature were related to the physiological functions of the element in the body, and the effects of deficiencies and excesses, referring to the latest ESPEN and EFSA guidelines, among others. Important dietary indices/parameters based on the literature review are provided for each element. On the basis of the literature, data on the level of elements in patients with cancer were collected. The content of these elements in 100 mL of FSMPs was read from the manufacturers' declarations. The literature has been provided on the importance of each element in cancer. Our findings show that the essential elements (Zn, Cu, Se, Fe, and Mn) of FSMPs for cancer patients are not adequately treated. We suggest solutions to ensure the safe use of FSMPs in oncology patients.

Prevalence of thyroid dysfunction in neonates receiving parenteral nutrition in the intensive care unit

OBJECTIVE

The use of parenteral nutrition (PN) formulations that do not contain iodine can contribute to the deficiency of this mineral, potentially leading to hypothyroidism and, ultimately, neurocognitive impairments. This study aimed to evaluate TSH alterations in newborns receiving PN.

METHODS

Retrospective study of neonatal intensive care unit patients receiving PN for > 15 days. Nutritional, anthropometric, and biochemical variables (TSH, T4, CRP) were analyzed. Hypothyroidism was defined by TSH > 10 mU/L.

RESULTS

Two hundred newborns were evaluated [156 (78%) preterm, 31±5 weeks of gestational age, 112 (56%) with very or extremely low birth weight]. The median (IQR) hospital stay was 68 (42-110) days, PN duration was 31 (21-47) days, and 188 (94%) patients also received enteral nutrition. Overall, 143 (71.5%) newborns underwent at least one TSH measurement. The prevalence of hypothyroidism was 10.5%. The Median PN duration in this group was 51 (34-109) days. Among those with hypothyroidism, 10 received Lugol's solution and six levothyroxine. Thirteen patients received prophylactic Lugol's solution with a median PN duration of 63 (48-197) days. TSH levels correlated positively with PN duration (r = 0.19, p = .02).

CONCLUSIONS

The present data suggest that changes in TSH and T4 levels are present in neonates receiving PN for > 15 days, suggesting this population may be at risk for developing hypothyroidism. Therefore, the authors suggest that TSH and T4 measurements should be included as routine in neonatal patients receiving PN for > 15 days if PN formulations are not supplemented with iodine, and that iodine supplementation be provided as necessary.

Parenteral Nutrition Overview

Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes and water. PN should be provided via a central line because of its hypertonicity. However, peripheral PN (with lower nutrient content and larger volume) can be administered via an appropriate non-central line. There are alternatives for the compounding process also, including hospital pharmacy compounded bags and commercial multichamber bags. PN is a costly therapy and has been associated with complications. Metabolic complications related to macro and micronutrient disturbances, such as hyperglycemia, hypertriglyceridemia, and electrolyte imbalance, may occur at any time during PN therapy, as well as infectious complications, mostly related to venous access. Long-term complications, such as hepatobiliary and bone disease are associated with longer PN therapy and home-PN. To prevent and mitigate potential complications, the optimal monitoring and early management of imbalances is required. PN should be prescribed for malnourished patients or high-risk patients with malnutrition where the feasibility of full EN is in question. Several factors should be considered when providing PN, including timing of initiation, clinical status, and risk of complications.

The Effects of Glutamine Supplementation on Reducing Mortality and Morbidity among Burn Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Glutamine (GLN) has been proven to improve the prognosis of severely burned patients. GLN supplementation in critical illness has gained extreme popularity among researchers over the years, and its safety and efficacy are still under question. Therefore, we aim to study the role of GLN supplements in decreasing mortality, length of hospitalization (LOH), and infection in severely burned patients. PRISMA guidelines were used to design and conduct this systematic review. MEDLINE, Cochrane, and EMBASE databases were used to search for randomized controlled trials (RCTs) in January 2022. In order to assist in the search, MeSH terms such as burn injury, GLN, and RCT were used. As a result of reviewing the literature, 1112 publications were found. We included only 7 RCTs after implanting our inclusion criteria. There were 328 patients enrolled in the study, with 166 patients (50.61%) were allocated to GLN supplementation and 162 patients in the control groups (49.39%). The risk of infection was significantly lower among patients who received GLN supplementation than those in the control groups (RR = 0.41, 95% CI, 0.18 to 0.92, p = 0.030). The risk of death was significantly lower among GLN-receiving patients compared to non-GLN-receiving patients (RR = 0.09, 95% CI, 0.01 to 0.63, p = 0.016). GLN supplementation has been linked to lower hospital mortality and infection-related morbidity in burn patients. Furthermore, larger-scale and higher-quality studies are needed to assess whether there are any statistically and clinically significant changes.

Prenatal exposure to multiple metallic and metalloid trace elements and the risk of bacterial sepsis in extremely low gestational age newborns: A prospective cohort study

BACKGROUND

Prenatal exposures to metallic and metalloid trace elements have been linked to altered immune function in animal studies, but few epidemiologic studies have investigated immunological effects in humans. We evaluated the risk of bacterial sepsis (an extreme immune response to bacterial infection) in relation to prenatal metal/metalloid exposures, individually and jointly, within a US-based cohort of infants born extremely preterm.

METHODS

We analyzed data from 269 participants in the US-based ELGAN cohort, which enrolled infants delivered at <28 weeks' gestation (2002-2004). Concentrations of 8 trace elements-including 4 non-essential and 4 essential-were measured using inductively coupled plasma tandem mass spectrometry in umbilical cord tissue, reflecting in utero fetal exposures. The infants were followed from birth to postnatal day 28 with bacterial blood culture results reported weekly to detect sepsis. Discrete-time hazard and quantile g-computation models were fit to estimate associations for individual trace elements and their mixtures with sepsis incidence.

RESULTS

Approximately 30% of the extremely preterm infants developed sepsis during the follow-up period (median follow-up: 2 weeks). After adjustment for potential confounders, no trace element was individually associated with sepsis risk. However, there was some evidence of a non-monotonic relationship for cadmium, with hazard ratios (HRs) for the second, third, and fourth (highest) quartiles being 1.13 (95% CI: 0.51-2.54), 1.94 (95% CI: 0.87-4.32), and 1.88 (95% CI: 0.90-3.93), respectively. The HRs for a quartile increase in concentrations of all 8 elements, all 4 non-essential elements, and all 4 essential elements were 0.92 (95% CI: 0.68-1.25), 1.19 (95% CI: 0.92-1.55), and 0.77 (95% CI: 0.57-1.06). Cadmium had the greatest positive contribution whereas arsenic, copper, and selenium had the greatest negative contributions to the mixture associations.

CONCLUSIONS

We found some evidence that greater prenatal exposure to cadmium was associated with an increased the risk of bacterial sepsis in extremely preterm infants. However, this risk was counteracted by a combination of arsenic, copper, and selenium. Future studies are needed to confirm these findings and to evaluate the potential for nutritional interventions to prevent sepsis in high-risk infants.

Sleep patterns of patients receiving home parenteral nutrition: A home-based observational study

BACKGROUND

Patients supported with home parenteral nutrition (HPN) often report poor sleep; however, limited research has been conducted to objectively measure sleep patterns of HPN-dependent patients.

METHODS

We aimed to characterize the sleep patterns of patients receiving HPN through 7-day actigraphy in a home-based observational study. Sleep measures of clinical importance were derived from actigraphy, including sleep duration, sleep efficiency, sleep onset latency, and wake after sleep onset. Participants also completed validated sleep surveys.

RESULTS

Twenty participants completed all study procedures (mean [SD]: age = 51.6 [13.9] years, body mass index = 21.4  [4.6], and 80% female). The population median (IQR) for sleep duration, sleep efficiency, sleep onset latency, and wake after sleep onset was 6.9 (1.1) h, 83.3% (7.8%), 11.8 (7.1) min, and 57.2 (39.9) min, respectively, and 55%, 60%, 35%, and 100% of participants did not meet the recommendations for these measures from the National Sleep Foundation. Sixty-five percent of participants reported napping at least once during the 7-day period. Based on the Insomnia Severity Index, 70% of participants were classified as having subthreshold or more severe insomnia. Based on the Pittsburgh Sleep Quality Index, 85% were classified as having significant sleep disturbance.

CONCLUSION

Most HPN-dependent patients likely have disrupted sleep largely driven by difficulty maintaining sleep. The extent to which HPN contributed to poor sleep cannot be elucidated from this observational study. Addressing known factors that contribute to sleep disruption and considering sleep interventions may improve the overall quality of life of patients receiving HPN.

The Role of Nutrition in Primary and Secondary Prevention of Cardiovascular Damage in Childhood Cancer Survivors

Innovative therapeutic strategies in childhood cancer led to a significant reduction in cancer-related mortality. Cancer survivors are a growing fragile population, at risk of long-term side effects of cancer treatments, thus requiring customized clinical attention. Antineoplastic drugs have a wide toxicity profile that can limit their clinical usage and spoil patients' life, even years after the end of treatment. The cardiovascular system is a well-known target of antineoplastic treatments, including anthracyclines, chest radiotherapy and new molecules, such as tyrosine kinase inhibitors. We investigated nutritional changes in children with cancer from the diagnosis to the end of treatment and dietary habits in cancer survivors. At diagnosis, children with cancer may present variable degrees of malnutrition, potentially affecting drug tolerability and prognosis. During cancer treatment, the usage of corticosteroids can lead to rapid weight gain, exposing children to overweight and obesity. Moreover, dietary habits and lifestyle often dramatically change in cancer survivors, who acquire sedentary behavior and weak adherence to dietary guidelines. Furthermore, we speculated on the role of nutrition in the primary prevention of cardiac damage, investigating the potential cardioprotective role of diet-derived compounds with antioxidative properties. Finally, we summarized practical advice to improve the dietary habits of cancer survivors and their families.

ESPEN micronutrient guideline

BACKGROUND

Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. Recent research has shown the importance of MNs in common pathologies, with significant deficiencies impacting the outcome.

OBJECTIVE

This guideline aims to provide information for daily clinical nutrition practice regarding assessment of MN status, monitoring, and prescription. It proposes a consensus terminology, since many words are used imprecisely, resulting in confusion. This is particularly true for the words "deficiency", "repletion", "complement", and "supplement".

METHODS

The expert group attempted to apply the 2015 standard operating procedures (SOP) for ESPEN which focuses on disease. However, this approach could not be applied due to the multiple diseases requiring clinical nutrition resulting in one text for each MN, rather than for diseases. An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL. The search focused on physiological data, historical evidence (published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations.

RESULTS

There was a limited number of interventional trials, preventing meta-analysis and leading to a low level of evidence. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90% of votes. Altogether the guideline proposes sets of recommendations for 26 MNs, resulting in 170 single recommendations. Critical MNs were identified with deficiencies being present in numerous acute and chronic diseases. Monitoring and management strategies are proposed.

CONCLUSION

This guideline should enable addressing suboptimal and deficient status of a bundle of MNs in at-risk diseases. In particular, it offers practical advice on MN provision and monitoring during nutritional support.

Antioxidants: Role the in prevention and treatment of bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is one of the major causes of chronic respiratory diseases among infants. Both pharmacological and nonpharmacological approaches have been proposed for its management. Since oxidative stress is known to play a pivotal role in the pathogenesis of BPD, it is reasonable to consider the potential of antioxidant strategies in the prevention and treatment of this condition. Indeed, antioxidants can prevent or inhibit substrate oxidation. Some studies have evaluated the efficacy of the exogenous administration of vitamins and micronutrients in reducing the propagation of free radicals through their scavenging capacity. Nonetheless, encouraging preclinical results did not translate into effective preventive and/or therapeutic interventions. This narrative review evaluates the current evidence about the antioxidants that are potentially useful for preventing and treating BPD and explores the most relevant issues affecting their implementation in clinical practice, as well as their associated evidence gaps and research limitations.

Nutritional Management of Short Bowel Syndrome

Short bowel syndrome (SBS) of infancy is a cause of prolonged morbidity with intolerance to enteral feeding, specialized nutritional needs, and partial/total dependence on parenteral nutrition. These infants can benefit from individualized nutritional strategies to support and enhance the process of intestinal adaptation. Early introduction of enteral feeds during the period of intestinal adaptation is crucial, even though the enteral feedings may need to be supplemented with an effective, safe, and nutritionally adequate parenteral nutritional regimen. Newer generation intravenous lipid emulsions can be effective in preventing and treating intestinal failure-associated liver disease. Prevention of infection(s), pharmaceutical interventions to enhance bowel motility and prevent/mitigate bacteria overgrowth, and specialized multidisciplinary care to minimize the injury to other organs such as the liver, kidneys, and the brain can assist in nutritional rehabilitation and lower the morbidity in SBS.

Advances in Trace Element Supplementation for Parenteral Nutrition

Parenteral nutrition (PN) provides support for patients lacking sufficient intestinal absorption of nutrients. Historically, the need for trace element (TE) supplementation was poorly appreciated, and multi-TE products were not initially subjected to rigorous oversight by the United States Food and Drug Administration (FDA). Subsequently, the American Society for Parenteral and Enteral Nutrition (ASPEN) issued dosage recommendations for PN, which are updated periodically. The FDA has implemented review and approval processes to ensure access to safer and more effective TE products. The development of a multi-TE product meeting ASPEN recommendations and FDA requirements is the result of a partnership between the FDA, industry, and clinicians with expertise in PN. This article examines the rationale for the development of TRALEMENT^® (Trace Elements Injection 4*) and the FDA’s rigorous requirements leading to its review and approval. This combination product contains copper, manganese, selenium, and zinc and is indicated for use in adults and pediatric patients weighing ≥10 kg. Comprehensive management of PN therapy requires consideration of many factors when prescribing, reviewing, preparing, and administering PN, as well as monitoring the nutritional status of patients receiving PN. Understanding patients’ TE requirements and incorporating them into PN is an important part of contemporary PN therapy.

Macronutrients and Micronutrients in Parenteral Nutrition for Preterm Newborns: A Narrative Review

Preterm neonates display a high risk of postnatal malnutrition, especially at very low gestational ages, because nutritional stores are less in younger preterm infants. For this reason nutrition and growth in early life play a pivotal role in the establishment of the long-term health of premature infants. Nutritional care for preterm neonates remains a challenge in clinical practice. According to the recent and latest recommendations from ESPGHAN, at birth, water intake of 70-80 mL/kg/day is suggested, progressively increasing to 150 mL/kg/day by the end of the first week of life, along with a calorie intake of 120 kcal/kg/day and a minimum protein intake of 2.5-3 g/kg/day. Regarding glucose intake, an infusion rate of 3-5 mg/kg/min is recommended, but VLBW and ELBW preterm neonates may require up to 12 mg/kg/min. In preterm infants, lipid emulsions can be started immediately after birth at a dosage of 0.5-1 g/kg/day. However, some authors have recently shown that it is not always possible to achieve optimal and recommended nutrition, due to the complexity of the daily management of premature infants, especially if extremely preterm. It would be desirable if multicenter randomized controlled trials were designed to explore the effect of early nutrition and growth on long-term health.

Micronutrient Improvement of Epithelial Barrier Function in Various Disease States: A Case for Adjuvant Therapy

The published literature makes a very strong case that a wide range of disease morbidity associates with and may in part be due to epithelial barrier leak. An equally large body of published literature substantiates that a diverse group of micronutrients can reduce barrier leak across a wide array of epithelial tissue types, stemming from both cell culture as well as animal and human tissue models. Conversely, micronutrient deficiencies can exacerbate both barrier leak and morbidity. Focusing on zinc, Vitamin A and Vitamin D, this review shows that at concentrations above RDA levels but well below toxicity limits, these micronutrients can induce cell- and tissue-specific molecular-level changes in tight junctional complexes (and by other mechanisms) that reduce barrier leak. An opportunity now exists in critical care—but also medical prophylactic and therapeutic care in general—to consider implementation of select micronutrients at elevated dosages as adjuvant therapeutics in a variety of disease management. This consideration is particularly pointed amidst the COVID-19 pandemic.

Sources of unintentional manganese delivery in neonatal parenteral nutrition

BACKGROUND

Manganese (Mn) neurotoxicity is a concern in neonates receiving parenteral nutrition (PN). Prior studies have identified Mn contamination of PN ingredients as a source of daily Mn exposure from PN. This study was conducted to determine which neonatal PN ingredients are sources of this unintentional Mn delivery.

METHODS

Mn concentration was measured in different lot numbers of individual PN ingredients using inductively coupled plasma mass spectrometry (ICP-MS). PN admixtures were then prepared using standard doses of the tested individual ingredients and admixture Mn concentration was measured.

RESULTS

Magnesium sulfate and calcium gluconate are the major contributors to hidden unintentional Mn exposure in neonatal PN. Maximum measured Mn concentrations in these two ingredients were 443 and 46.8 mcg/L, respectively. Sodium and potassium phosphate were the next highest at 40 and 24 mcg/L, respectively. Other ingredients contained a trivial or no measurable quantity of Mn. PN admixture Mn content was 16-30% higher than predicted values based on individual ingredient Mn content. If infused at 150 mL/kg/day, a standard neonatal PN admixture with no added Mn is capable of unintentionally delivering up to 0.9 mcg/kg/day of Mn.

CONCLUSION

Neonatal PN without any added Mn provides close to the ASPEN recommended 1 mcg/kg/day dosage of Mn. This supports the potential utility of a Mn-omission approach to trace element provision in neonatal PN. Further studies are needed to test such an approach, and to evaluate the clinical significance of unintended Mn delivery in neonates receiving PN. This article is protected by copyright. All rights reserved.

Evidence-based recommendations of the Andalusian Group for Nutrition Reflection and Investigation (GARIN) for the management of adult patients with short bowel syndrome

Introduction

In order to develop evidence-based recommendations and expert consensus for the nutritional management of patients with short bowel syndrome (SBS), we conducted a systematic literature search using the PRISMA methodology plus a critical appraisal following the GRADE scale procedures. Pharmacological treatment with antisecretory drugs, antidiarrheal drugs, and somatostatin contributes to reducing intestinal losses. Nutritional support is based on parenteral nutrition; however, oral intake and/or enteral nutrition should be introduced as soon as possible. In the chronic phase, the diet should have as few restrictions as possible, and be adapted to the SBS type. Home parenteral nutrition (HPN) should be individualized. Single-lumen catheters are recommended and taurolidine should be used for locking the catheter. The HPN's lipid content must be greater than 1 g/kg per week but not exceed 1 g/kg per day, and omega-6 fatty acids (ω6 FAs) should be reduced. Trace element vials with low doses of manganese should be used. Patients with chronic SBS who require long-term HPN/fluid therapy despite optimized treatment should be considered for teduglutide treatment. All patients require a multidisciplinary approach and specialized follow-up. These recommendations and suggestions regarding nutritional management in SBS patients have direct clinical applicability.

Parenteral nutrition compatibility and stability: A comprehensive review

Several guidance documents support best practices across the stages of the parenteral nutrition (PN)-use process to optimize patient safety. The critical step of PN order verification and review by the pharmacist requires a contextual assessment of the compatibility and stability implications of the ordered PN prescription. This article will provide working definitions, describe PN component characteristics, and present a wide-ranging representation of compatibility and stability concerns that need to be considered prior to preparing a PN admixture. This paper has been approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.

Effect of selenium-free parenteral nutrition on serum selenium of neonates and infants maintained on long-term parenteral nutrition

BACKGROUND

The risk of selenium deficiency increases for infants receiving long-term parenteral nutrition (PN). This study analyzed selenium deficiency in neonates and infants requiring long-term PN and evaluated the effect of intravenous (IV) selenium provision.

METHODS

This study was a retrospective study of neonates and infants who were admitted to a neonatal intensive care unit from January 2010 to December 2019, received PN for ≥2 weeks, and had their serum selenium concentration measured. Patients were divided into two groups, depending on their serum selenium concentration, a deficient group (n = 55) and a nondeficient group (n = 47).

RESULTS

Of the study participants, 53.9% (55 of 102) were deficient in selenium. No difference in demographic and clinical characteristics existed except bronchopulmonary dysplasia. A subgroup analysis was performed for patients (n = 29). The average dose of IV selenium administered to patients was 2.7 ± 1.0 mcg/kg/day. The average initial serum selenium concentration was 36.5 ± 18.0 mcg/L, and the serum concentration significantly increased to 52.5 ± 19.1 mcg/L after IV selenium administration (P < .001). The correlation between the average IV selenium dose and the change in serum selenium concentrations was statistically significant (r = .423; P = .022).

CONCLUSION

Selenium deficiency is common in neonates and infants receiving long-term PN. Serum selenium concentration increased proportionally as the IV selenium dose increased. Therefore, it is recommended to supply a proper dose of IV selenium depending on the degree of selenium deficiency.

Manganese Toxicity Associated With Total Parenteral Nutrition: A Review

Objective: To review hypermanganesemia-induced toxicities in adult patients receiving parenteral nutrition (PN) therapy. Data Sources: A comprehensive literature review was conducted from June 2020 to May 2021 on PubMED, MEDLINE, Scopus, ProQuest, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Web of Science. Study Selection and Data Extraction: Keyword and Boolean phrase searches were conducted using the following terminology: "manganese" OR "manganesemia" OR "manganism" or "hypermanganesemia" AND "total parenteral nutrition" OR "PN" or "parenteral nutrition" AND "toxicity" OR "accumulation." Appropriate filters, including "humans" and "English" and NOT "reviews," were utilized on all databases to improve search outcomes. Data Synthesis: A total of 4 reports detailing hypermanganesemia in 57 patient encounters were included in this review. Significant heterogeneity exists with regard to the duration of manganese supplementation and the dose of manganese. Toxicity associated with manganese was observed in as few as 15 days. The dose of manganese, though likely governed by content in commercially available products, may regularly exceed the recommendations of clinical guidelines and should be limited to 55 µg/day. Select patients with underlying malignancy, those with significant and prolonged Vitamin D deficiency, or those who have acquired a SLC30A10 genetic mutation may be at an increased risk of developing manganese toxicity. Conclusions: Clinicians must be cognizant of the concentration of trace elements added to PN, as manganese, and perhaps other biometals, may accumulate when dosed above the recommended daily allowances.

ESPEN practical guideline: Clinical nutrition in chronic intestinal failure

BACKGROUND

This practical guideline is based on the ESPEN Guidelines on Chronic Intestinal Failure in Adults.

METHODOLOGY

ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists, and nurses working with patients with chronic intestinal failure.

RESULTS

This practical guideline consists of 112 recommendations with short commentaries for the management and treatment of benign chronic intestinal failure, including home parenteral nutrition and its complications, intestinal rehabilitation, and intestinal transplantation.

CONCLUSION

This practical guideline gives guidance to health care providers involved in the management of patients with chronic intestinal failure.

Factors Affecting Selenium Status in Infants on Parenteral Nutrition Therapy

INTRODUCTION

Selenium is an essential micronutrient that must be supplemented in infants and young children on exclusive parenteral nutrition (PN). We examined selenium status and clinical factors associated with a deficiency in infants on PN.

METHODS

This was a retrospective cohort study of pediatric patients receiving PN with routine monitoring of selenium status. Deficiency was diagnosed using age-based norms of plasma selenium status. Associations between selenium deficiency and the following clinical factors were examined: birthweight status: extremely low birthweight (ELBW) versus very low birthweight (VLBW) versus low birthweight (LBW) versus normal birthweight (NBW), serum albumin status, presence of cholestasis, and co-administration of enteral feeds.

RESULTS

A total of 42 infants were included with gestational age [median (interquartile range)] 28 weeks (25,34). The prevalence of selenium deficiency was 80% and the prevalence of albumin deficiency was 87.5%. The odds of selenium deficiency were higher in ELBW infants (odds ratio = 17.84, 95% confidence interval [4.04-78.72], P < 0.001) and VLBW infants (odds ratio = 16.26, 95% confidence interval [1.96-135.04], P < 0.001) compared to NBW infants. The odds of selenium deficiency were 5-fold higher in patients with low serum albumin (odds ratio = 5.33, 95% confidence interval [1.39-20.42], P = 0.015). There were no associations seen between selenium status and presence of cholestasis or co-administration of enteral feeds.

CONCLUSION

In this cohort of infants on PN therapy, the main clinical factors associated with selenium deficiency were presence of hypoalbuminemia and history of ELBW or VLBW. These findings support dual measurement of serum albumin and serum selenium to improve interpretation of selenium status.

Effects of Total Enteral Nutrition on Early Growth, Immunity, and Neuronal Development of Preterm Infants

The feeding of colostrum and mother's transitional milk improves immune protection and neurodevelopmental outcomes. It also helps with gut maturation and decreases the risks of infection. The supply of nutrients from human milk (HM) is not adequate for preterm infants, even though preterm mother's milk contains higher concentrations of protein, sodium, zinc, and calcium than mature HM. The human milk fortifiers, particularly those with protein, calcium, and phosphate, should be used to supplement HM to meet the necessities of preterm infants. The management of fluid and electrolytes is a challenging aspect of neonatal care of preterm infants. Trace minerals such as iron, zinc, copper, iodine, manganese, molybdenum, selenium, chromium, and fluoride are considered essential for preterm infants. Vitamins such as A, D, E, and K play an important role in the prevention of morbidities, such as bronchopulmonary dysplasia, retinopathy of prematurity, and intraventricular hemorrhage. Therefore, supplementation of HM with required nutrients is recommended for all preterm infants.

Impact of nationwide essential trace element shortages: A before-after, single-center analysis of hospitalized adults receiving home parenteral nutrition therapy

BACKGROUND

Recent data on the prevalence of essential trace element (ETE) deficiencies in home parenteral nutrition (HPN) patients are scarce. We investigated whether ETE deficiencies are still an important issue for HPN patients and whether the prevalence of such deficiencies may be influenced by nationwide drug shortages.

METHODS

We conducted a single-institution, retrospective analysis from 2006 to 2015 of hospitalized HPN patients who continued PN during and in between hospitalizations. In subgroup analysis, patients were dichotomized as those with HPN duration <1 vs ≥1 year. Zinc (Zn), copper (Cu), and selenium (Se) levels were abstracted for patients over the study period. Prevalence of ETE deficiency was compared using chi-squared test for patients hospitalized during nonshortage vs shortage (2011-2014) periods.

RESULTS

Ninety-six patients were included in the analysis. Prevalence of ETE deficiency during nonshortage vs shortage periods was 48% vs 54% (Zn), 15% vs 21% (Cu), and 24% vs 48% (Se; P = .01), respectively. When comparing patients who received HPN <1 year vs ≥1 year, the prevalence of Se deficiency doubled during shortage in both subgroups (24% to 42% vs 26% to 49%); and Cu deficiency tripled during shortage period in the group receiving HPN ≥1 year (5% to 16%).

CONCLUSION

ETE deficiency is prevalent in hospitalized HPN patients and was exacerbated during nationwide shortages of parenteral supplements. Statistical significance may be limited by small sample size. Future studies are needed to determine optimal ETE supplementation strategies for minimizing the impacts of nationwide drug shortages on HPN patients.