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ISSN 1815-7262

Science supporting
better nutrition
2007 • Volume 3, Issue 2

In this issue

Enteral nutrition in
the critically ill child
Clinical nutrition abstracts
Highlights of Clinical Nutrition Week 2007

2
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CLINICAL
NUTRITION
HIGHLIGHTS
Science supporting
better nutrition
2007 • Volume 3, Issue 2

Feature article 2

Enteral nutrition in the critically ill child

Edward M. Barksdale, Jr

Clinical nutrition abstracts 11

Cancer 11
Critical care 11
General nutrition 13
Immunonutrition 14
Inflammatory bowel disease 15
Pancreatitis 16
Pediatrics 16
Trauma and burns 17

Highlights of Clinical Nutrition Week 18

28–31 January 2007

Conference calendar 24

Sponsored as a service to the medical profession by the Nestlé Nutrition Institute.

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Enteral nutrition in the
critically ill child
Feature article

Edward M. Barksdale, Jr, MD

Robert Izant Endowed Chair and Chief of Pediatric Surgery
Professor of Surgery
Rainbow Babies and Children’s Hospital/Case University
Cleveland, Ohio, USA

Introduction tion may reach 60% in the intensive care unit (ICU),
accruing greater metabolic debt and amplifying the
Over the last three decades, significant progress in the physiologic insult to these children. 4,5 The relationship
care of the critically ill child has heightened the aware- of malnutrition to impaired immunity, including reduc-
ness of the role of appropriate nutritional support in tions in T cell number and function, phagocytic cell
improving survival and long-term outcomes. Sepsis, activity, secretory immunoglobulin A (IgA) responses
shock, major trauma and severe inflammation initiate a and complement activation, and deficiencies in vitamins
profound sequence of hormonal, metabolic and and trace minerals, is well documented in the litera-
immunologic events that may increase resting energy ture. 6,7 These impairments translate into an increased
requirements by 30–100% (Figure). 1-3 This hypermet- risk of infection, poor wound healing and death. In
abolic response, combined with the limited energy contrast, overfeeding has been associated with diet-
reserves of children and the high incidence of malnutri- induced thermogenesis, increased CO 2 production
tion in pediatric critical care admissions, magnifies the leading to prolonged ventilation, and fatty deposition in
physiologic impact. Furthermore, in-hospital malnutri- the liver (steatosis). 8

Figure. Changes in metabolic rate and nitrogen excretion with various types of
physiologic stress

Starvation vs injury:
Nitrogen dynamics Resting metabolic expenditure

28 180
Major burns
Major burns
24 160
Peritonitis
Nitrogen excretion (g/day)

Resting metabolism (In %)

Skeletal trauma
20
140 Skeletal trauma
Severe sepsis
16
120
Infection
12
100 Normal range
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2

8 Normal range
Elective operation Elective operation
4 80

Partial starvation Partial starvation

0 60
Total starvation
Total

0
0 10 20 30 40 Days 0 10 20 30 40 50 Days
Reprinted from Long CL, Schaffel N, Geiger JW, Schiller WR, Blakemore WS. Metabolic Response to Adapted from Long CL, Schaffel N, Geiger JW, Schiller WR, Blakemore WS. Metabolic Response
Injury and Illness: Estimation of Energy and Protein Needs from Indirect Calorimetry and to Injury and Illness: Estimation of Energy and Protein Needs from Indirect Calorimetry and
Nitrogen Balance. JPEN J Parenter Enteral Nutr 1979:3:452-456 with permission from Nitrogen Balance. JPEN J Parenter Enteral Nutr 1979:3:452-456 with permission from
the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N. the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). A.S.P.E.N.
does not endorse the use of this material in any form other than its entirety. does not endorse the use of this material in any form other than its entirety.

2
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“ Several general principles have
emerged that are increasingly
guiding management in the ICU:
early nutritional intervention;
avoidance of overfeeding; and the
preferential utilization of enteral
relative to parenteral support.
”
Retrospective reviews indicate that primary
factors leading to poor nutritional outcome are an
inadequate initial nutritional assessment, inaccurate
prediction of energy and protein needs, and inconsistent
nutrient delivery during critical illness. 9 Despite these
observations, few carefully controlled studies exist to
offer evidenced-based guidelines for the nutritional
management of the critically ill child; therefore, much
of the practice currently employed in caring for the
pediatric patient is extrapolated from the adult litera-
ture. Nevertheless, several general principles have
emerged that are increasingly guiding management in
the ICU: early nutritional intervention; avoidance of
overfeeding; and the preferential utilization of enteral
relative to parenteral support.
The goals of nutrition interventions in the ICU
should be directed toward the maximal preservation of
major organ system function during the acute phase of
illness, minimization of the catabolic response and the
prompt restoration of the premorbid nutritional state
without producing treatment-related complications.
Increasing evidence supports early enteral feeding as the
most effective means of achieving these goals in the
majority of patients. 4,10,11
The purpose of this review is to discuss the role of
enteral nutrition in the pathophysiology and treatment
of critical illness in the pediatric population, with a
particular emphasis on patients with traumatic brain
injury, burns, cancer and bone marrow transplantation,
and pancreatitis. These conditions have been selected
because they are common and pose major nutritional
challenges in pediatric critical care.
10:33 AM Page 3
Metabolic response to injury
and stress
In the normal physiologic (non-stressed) state, there
exists a homeostatic balance between caloric intake,
Feature article
protein synthesis and the energy expenditure required
for maintenance, growth and development of the child.
Calories consumed via carbohydrates (60% of total
intake), fats (30–35%) and protein (5–10%) are prima-
rily utilized for baseline energy needs; excess
carbohydrate and fat are stored anabolically as fat in
the liver or the periphery, and excess protein is used to
build lean body mass. 12,13 Critical illness initiates a
cascade of events that induces a combined hypermeta-
bolic and hypercatabolic state, resulting in major
alterations in carbohydrate, fat and protein metabolism
and a significant increase in resting energy expenditure
(REE) (Figure). 4,6,14,15 This ‘stress’ response is mediated
by various hormones, growth factors and pro-inflam-
matory cytokines, such as tumor necrosis factor-α
(TNF-α) and interleukin-1β (IL-1β), that may last for a
few days or continue until the inciting condition is
brought under control. 12,14 Clinically, this may manifest
as fever, leukocytosis and hyperglycemia. During a
period in which nutrition intake is also diminished or
absent, these events lead to a ‘wasting syndrome’ most
characterized by loss of lean body mass and protein.
All organ systems are affected by this process, but
the liver and the gut appear to be the primary end-organ
targets. The pleiotropic role of the liver in orchestrating
the shift of metabolic events from the normal to hyper-
metabolic state is an important component of the stress
response. 15 Hepatic protein synthesis is redirected away
from negative acute-phase proteins (eg, albumin, trans-
ferrin, ceruloplasmin, prealbumin and retinol-binding
protein) to positive acute-phase proteins (eg, α-1 anti-
trypsin, α-1 acid glycoprotein, α-2-macroglobulin and
C-reactive protein [CRP]) that are considered to be
important in recovery. Proteolysis also supplies amino
acids that can provide substrate for the cells that will
enhance the protective immune response. 15
The gut is also affected by the stress response,
which may promote intestinal mucosal atrophy and
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
breakdown of mucosal barrier function. 16,17 These
changes are critical steps in the development of bacter-
ial translocation. Insights into the role of gut-origin
sepsis, its effects on the development of the systemic
inflammatory response syndrome (SIRS) and overall
outcome in the critically ill patient have led to the insti-
tution of early enteral nutrition support to ameliorate
these effects. Enteral nutrition improves gastric empty-
ing, enhances intestinal motility, positively alters gut
3
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07 10:33 AM
“
The goals of nutrition
Feature article
interventions in the ICU should be
directed toward the maximal
preservation of major organ
system function during the acute
phase of illness, minimization of
the catabolic response and the
prompt restoration of the
premorbid nutritional state
without producing treatment-
related complications.
”
flora, limits bacterial translocation, reduces aspiration
episodes and abrogates the stress response. 18
Multiple metabolic disturbances also occur as a
consequence of excess carbohydrate or caloric intake in
the critically ill child. The metabolic threshold for these
deleterious effects varies with patient age, premorbid
nutritional status and disease severity. Major individual
differences may also exist between patients relative to
their metabolic requirements during the acute stress
response. Excess carbohydrate intake or delivery results
in hyperinsulinemia, lipogenesis, hypertriglyceridemia,
decreased fatty acid oxidation, reduced ketogenesis, and
increased glucose oxidation. Elevated portal vein
insulin-to-glucagon ratios and serum levels of hepatic
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
enzymes secondary to hepatocellular injury are both
related to excess carbohydrate intake and result in
hepatic steatosis during acute metabolic stress and
sepsis. 8 Morphologic changes, including cholestasis and
steatosis, may occur as early as 5 days following the
initiation of total parenteral nutrition (TPN).
Significant ventilatory impairments occur as a conse-
quence of excess carbohydrate intake with or without
excessive caloric administration. Carbon dioxide (CO 2),
4
Page 4
one of the principal by-products of carbohydrate metab-
olism, is produced in excess during overfeeding.
Compensatory increases in the ventilatory rate to
remove excess CO 2 place significant physiologic
demands on an already debilitated patient population
and may precipitate respiratory insufficiency and fail-
ure. 8 Excess protein delivery has also been shown in
adults to exacerbate this condition and increases sensi-
tivity to CO 2. Furthermore, administration of excess
protein may lead to azotemia, hyperammonemia and
hypernatremia secondary to hypertonic dehydration
related to increased free water losses. 9 Replacing one
third of carbohydrate-based calories with lipid will
effectively reduce CO 2 production, lipogenesis and
ventilatory rate. 8 These observations indicate the need
for appropriate nutritional intervention in the care
of the critically ill child to avoid problems with
malnutrition or overfeeding. In addition, avoiding the
inappropriate use of TPN will also aid in preventing gut
compromise through maintenance of gastrointestinal
barrier function and stimulation of gut-associated
lymphoid tissue.
Nutrition assessment
The nutritional assessment of patients admitted to the
ICU is an important component of care and should be
comprehensive enough to not only identify those
patients at risk of adverse outcomes, but also to
establish a baseline evaluation to guide the ongoing
nutritional plan of care.19 Studies indicate that this is
frequently neglected in the evaluation of new admissions
to the pediatric ICU (PICU) due to factors such as time
constraints and more urgent acute medical concerns.20
This evaluation should document the baseline status (ie,
somatic and visceral protein levels, fat stores, vitamin,
mineral and trace element levels, REE), identify deficien-
cies (or excesses) and provide a monitoring tool to gauge
effectiveness of intervention. Specific focus in the critical
care setting should emphasize identification of patients
with or at risk of malnutrition. Acute and chronic
protein energy malnutrition (PEM) is present in 10–65%
of children admitted to the PICU.4,9-11 PEM, defined as
a weight for age, weight for height or height for age
less than the 3rd or 5th percentile, or a weight less than
90% of ideal (per Waterlow criteria), results from the
aggregate effects of inadequate protein intake, nutrient
loss, and increased nutrient and caloric needs.4 This
manifests as deficits in muscle and organ protein, and
lipid reserves. Similarly, obesity is increasingly recog-
nized as a premorbid risk factor that negatively impacts
outcomes in the PICU.21
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Table 1. Nutritional assessment of the critically ill child

COMPONENT GUIDELINES
I. History

Feature article
Medical history Should be detailed
Diagnosis Assess ± effects on metabolic rate
Medications Prescribed and over-the-counter
Supplements Nutritional, herbal
Allergies Environmental and food-related
Diet history Assess adequacy, risk for deficiencies, premorbid malnutrition (>10% weight loss)
II. Anthropometrics
Height Knee-height measurement, arm span, segmental measures
Weight Calculate weight-for-height ratio, % ideal body weight
Head circumference If <2 years of age
Triceps skinfold (TSF) To assess body fat stores
Mid arm circumference (MAC) Use to determine somatic protein stores (Mid arm muscle area [MAMA])
III. Body composition
Bioimpedance analysis (BIA)
Dual energy X-ray Use to measure lean body mass, fat mass, bone density
absorptiometry (DEXA)
IV. Biochemical profile
Basic metabolic panel (BMP) Use to assess hydration, renal function
Sodium (Na) 2–6 mEQ/kg/d; ↑ needs diuretic therapy, SIADH; ↓ needs fluid overload
Potassium (K) 2–3 mEQ/kg/d; ↑ needs refeeding syndrome, diuretics; ↓ needs renal failure
Chloride (Cl) 2–4 mEQ/kg/d; ↑ needs gastric losses (NG tube or vomiting)
Bicarbonate (HCO3) 2–5 mEQ/kg/d; ↑ needs small bowel drainage; ↑ needs diarrhea, renal wasting
Blood urea nitrogen (BUN) ↑ levels suggest renal dysfunction, excess protein load
Creatinine (Cr) ↑ levels suggest renal dysfunction
Glucose ↑ levels suggest diabetes or glucose intolerance
Liver function tests Assess hepatic function
Alkaline phosphatase ↑ in bone disease or biliary obstruction
Aspartate aminotransferase ↑ in hepatocellular injury, ie, trauma, drugs, toxins, TPN
Alanine aminotransferase ↑ in hepatocellular injury, ie, trauma, drugs, toxins, TPN
Lactate dehydrogenase Normal range varies with age of child; elevations imply hepatic injury
Total bilirubin ↑ intra- or extrahepatic ductal obstruction, ie, decreased secretion
Albumin ↓ levels may suggest liver synthetic dysfunction or malnutrition
Total protein ↓ levels present with loss of visceral and somatic protein stores
Triglyceride level
Complete blood count (CBC) To help identify micronutrient deficiencies
Hemoglobin/Hematocrit (Hgb/Hct) ↓ levels in anemia from chronic disease, iron deficiency, malnutrition
Platelet count Thrombocytopenia may indicate hepatic dysfunction or bone marrow failure
Mean corpuscle volume (MCV)
Prothrombin time (PT) Prolongation indicative of coagulopathy, possibly secondary to hepatic synthetic
dysfunction
Minerals and trace elements
Calcium 1–2.5 mEQ/kg/d; ↓ levels cause tetany
Phosphorus 0.5–1 mmoL/kg/d; ↓ levels cause weakness
Magnesium 0.3–0.5 mEQ/kg/d; ↓ levels cause seizures
Iron ↓ levels cause anemia
Zinc 2–5 mg/d (normal plasma level 90–110 µg/dL); ↓ levels acrodermatitis, diarrhea,
poor healing
Copper 200–500 µg/d (normal plasma level 80–163 µg/dL); ↓ levels leucopenia, anemia,
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2

poor healing
Selenium 30–40 µg/d (normal plasma level 50–150 µg/dL); ↓ levels cause muscle tenderness,
kwashiorkor
Vitamins
A ↓ (deficiency) scaly skin, night blindness
D ↓ rickets, craniotabes, tetany
E ↓ peripheral neuropathy, ataxia, nystagmus
B12 ↓ pernicious anemia, neuropathy
Folate ↓ macrocytic anemia

NG, nasogastric; SIADH, syndrome of inappropriate antidiuretic hormone; TPN, total parenteral nutrition

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Table 2. Resting energy expenditure equations
Age Gender WHO23
0–3 years Male 60.9 W – 54
Feature article
Female 61 W – 51
3–10 years Male 22.7 W + 495
Female 22.5 W + 499
10–18 years Male N/A
Female N/A
H, height; W, weight
The nutrition assessment should consist of a
complete history (medications, growth and development,
diet and activity), biophysical evaluation (height, weight,
height:weight ratio, anthropometrics) and biochemical
profile, and the establishment of a customized nutritional
plan of care. Consideration of the use of indirect
calorimetry in the PICU setting may allow for a more
tailored regimen. This assessment allows for stratification
of patients at greatest risk of adverse outcomes and facil-
itates targeting of timely therapeutic interventions.
Frequent and dynamic re-evaluation and assessment of
these interventions allows them to be customized to avoid
under- or overfeeding. A summary of the major compo-
nents of the nutritional assessment are listed in Table 1;
more detailed information on nutritional assessment can
be obtained from the references.
Nutrition support
Nutrition for the critically ill child involves the provi-
sion of nutrients, calories and fluids that meets the
patient’s dynamic requirements for the preservation of
tissue integrity (ie, prevention of muscle and visceral
protein degradation) and fulfillment of the energy
supply to meet organ needs and prevent major system
dysfunction (ie, cardiovascular, pulmonary and
immune). The establishment of a uniform approach in
children mandates a thorough understanding of disease
pathophysiology, the beneficial and adverse effects asso-
ciated with therapeutic interventions, the complications
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
of the disease and the options for the provision of nutri-
tion support. The goals of therapy are to rapidly replete
the protein deficits that occur as result of catabolism,
restore normal physiology and homeostasis, decrease
injury-related morbidity and mortality, and facilitate
physical growth in the recovery phase.
Lack of consensus exists on the appropriate equa-
tion to estimate REE in the critically ill child. Many of
the equations used to assess energy needs in the healthy
6
Page 6
Schofield24
0.17 W + 1.517 H – 617.6
16.25 W + 1.0232 H – 413.5
19.6 W + 0.1303 H + 414.9
16.97 W + 161.8 H + 371.2
16.3 W + 0.1372 H + 515.5
8.365 W + 4.65 H + 200.0
child have been empirically adjusted to account for the
theoretically increased caloric needs of the hypermeta-
bolic child in the PICU, but most overestimate true
calorie/energy needs. REE, as measured by indirect
calorimetry, reveals that the hypermetabolic response is
less than predicted by these equations. Many PICUs
may not have the resources to perform indirect
calorimetry, or it may be difficult to perform in the non-
intubated child. It is also not accurate in children who
weigh less than 5 kg, have a fraction of inspired O 2
>60%, or endotracheal tube leakage >10%. Several
equations exist that allow REE to be estimated at base-
line and in the stressed state; the Harris-Benedict,
Talbott, World Health Organization, Schofield and
Curreri equations provide a starting point for estimat-
ing energy needs (Table 2). 22-25 Most studies suggest that
dynamic clinical judgment and reassessment should be
the principal tools utilized to guide the ongoing
adequacy of nutritional support therapy.
Traumatic brain injury
Brain injury is the primary cause of traumatic death in
children in developed nations, with an annual incidence
of approximately 3,000 deaths in the United States
alone. The magnitude of the burden of traumatic brain
injury (TBI) in pediatrics is much greater considering
that in the United States each year approximately
400,000 children will suffer injury and, of these, nearly
30,000 will require hospitalization. 26,27 Many of these
children will develop cognitive impairments that require
rehabilitation or result in long-term disability. TBI is
associated with significant hypermetabolism, the degree
of which depends on the extent of injury and the
treatment (ie, neuromuscular paralysis, hypothermia,
etc). 27,28 Compelling evidence indicates that early enteral
support has both short- and long-term benefits, associ-
ated with a reduction in infectious complications in
patients with TBI. Although data regarding the
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optimal nutritional management of TBI in the PICU
are sparse and somewhat conflicting relative to
survival, emerging evidence regarding a reduction in
morbidity supports aggressive initiation of enteral
nutrition. Following initial stabilization, enteral nutri-
tion support is ideally commenced within 72 hours of
admission, with progression to full feeding over the next
48 hours. 26
Gastrointestinal disturbances – gastroesophageal
reflux and delayed gastric emptying – associated with
brain injury often challenge this approach.
Gastroesophageal reflux, a common occurrence in TBI,
predisposes patients to aspiration and pneumonia.
Following head trauma in adults, delayed gastric empty-
ing is observed in 50% during the first 2 weeks and
25% during the first 4 weeks. 29
The etiology of both
these conditions is most likely mediated centrally by the
effects of increased intracranial pressure on the
medullary centers that control vagal nerve function.
Metoclopramide has been demonstrated to be beneficial
in this population. The potential for gastrointestinal
disturbances in the patient with head injury makes the
small bowel a better site for feeding. Post-pyloric feed-
ing regimens are generally uniformly employed in most
high volume pediatric neurosurgical ICUs.
The central nervous system regulates fluid and
electrolyte balance through the hypothalamic-
neurohypophyseal axis. Fluid and electrolyte shifts,
common following severe brain injury, make the
routine monitoring of weight changes and serum
protein levels an unreliable parameter for dynamic
nutritional assessment and monitoring. 30
Sodium
dysregulation, either through iatrogenic or pathologic
processes, may exacerbate brain injury and worsen
prognosis. Excessive free water administration
via intravenous fluids or formula may lead to
cerebral edema and increased intracranial pressure.
Alternatively, excess sodium administration from
enteral or parenteral sources may lead to hyper-
natremic cerebral dehydration, which can
fatal. Patients with TBI are at risk of developing
the syndrome of inappropriate antidiuretic hormone
(SIADH) or cerebral salt-wasting syndrome.
Antidiuretic hormone (ADH) or vasopressin produced
by the posterior pituitary leads to renal sodium preser-
vation, decreased urine sodium levels and urinary
concentration. Lack of sufficient ADH causes excessive
salt and dilute urine loss. This may be treated with
fluid replacement and ADH administration with
desmopressin (DDAVP). Many of the enteral formulas
lack adequate sodium to meet these increased needs
and supplementation is necessary. Serum and urine
7/10/07 10:33 AM Page 7
electrolyte measurements should be monitored meticu-
lously and appropriate supplementation given with
caution in these patients to maintain optimum sodium
levels between 135 and 145 mEq/L. 30-32
During the acute phase of brain injury, the synthe-
Feature article
sis of visceral proteins (negative acute-phase reactants,
such as albumin, prealbumin and transferrin) are down-
regulated to shift toward the production of acute-phase
reactants, such as CRP and α-1–acid glycoproteins, that
are necessary for wound healing and immune response. 33
Monitoring of serum CRP and prealbumin levels may
herald trends in injury recovery versus overt malnutri-
tion. Serial measurements of serum CRP should
decrease and prealbumin should rise when catabolism
subsides and anabolism begins. Hence, advancement to
full caloric feeds may be targeted during this phase of
recovery. Elevated protein requirements up to twice the
recommended daily allowance may be indicated during
the anabolic phase of recovery from severe brain injury.
This is emerging as a tool to manage calorie delivery in
this population. 4
Burns
Burn injury is associated with the greatest hypermetab-
olism of all traumatic conditions and nutrition support
has formed the foundation of modern care. Large burns
(≥20% total body surface area) may induce a hyper-
metabolic phase lasting more than 4 weeks from the
initial injury. 34,35 Burns are associated with an exagger-
ated catabolic response relative to other critical
injuries, while loss of lean body mass, decreased host
defenses and abnormal immune responses are also
magnified. 35 The REE may increase by up to 100%
depending on the depth and extent of burn injury. 36 The
Curreri formula is the most commonly used formula to
estimate total calorie requirements in children with
burns. 25 The route of nutrient delivery is significantly
affected by the medical status of the patient. Extreme
be hemodynamic lability, use of pressors and the presence
of other medical conditions may preclude the safe initi-
ation of enteral feeding. Parenteral nutrition may be an
effective metabolic bridge until the gut may be utilized.
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
Even during these brief periods of TPN use, alteration
in intestinal flora, disruption of mucosal barrier func-
tion and impaired immunity may occur. If feasible,
dual-feeding with small amounts of enteral nutrition
may be advantageous, as gut-mediated sepsis plays a
major role in the morbidity and mortality of burn
patients in the PICU. Most centers aim to initiate
enteral feeding following the return of intestinal
peristalsis to assure ileus resolution, and decrease
7
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vomiting and aspiration risk. Slow increases to meet
the target calorie and nutrient goals by 5–7 days post-
injury are generally well tolerated using this overall
therapeutic strategy.
Glutamine-supplemented formulas have recently
Feature article
been shown to attenuate the effects on intestinal barrier
function. 37,38 Although data with regard to the duration
of therapy are limited, it appears clear that optimum
doses ranging from ~0.35–0.57 g/kg of body weight per
day for at least 5 days are of some benefit and without
apparent clinical toxicity in adults. The addition of
glutamine to pediatric formulas in a similar dose range
appears to be indicated. 39 Increased tissue and urinary
losses of zinc and copper are also associated with ther-
mal injury, and require meticulous monitoring and
supplementation. These micronutrients are critical for
bone matrix formation (osteogenesis), bone mineraliza-
tion, prevention of bone resorption and wound healing
(collagen cross-linking). 40
Cancer and bone marrow
transplantation
Considerable controversy exists within the literature as
to the incidence of malnutrition among children diag-
nosed with cancer. It appears that diagnosis (ie,
hematologic versus solid tumor), clinical stage and
socioeconomic factors, among several other variables,
may impact the presence and degree of malnutrition
at initial diagnosis and following therapy. 41-43
Chemotherapy, radiation and surgery have major
adverse effects on the nutritional status of pediatric
patients. Multiple determinants influence the etiology of
malnutrition in this population, and may be categorized
into three major groups:
1) Increased energy needs;
2) Impaired caloric consumption; and
3) Increased energy losses.
A hypermetabolic state analogous to that seen in
major trauma or sepsis, with the release of pro-inflam-
matory factors and tumor-associated cytokines as
detailed above, may increase the metabolic demands
and REE. However, some of these increased metabolic
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
demands may be offset by the associated decrement in
physical activity that occurs in these chronically ill
patients. 44-46
Changes in oral food intake may occur as
a result of treatment-related complications, such as
mucositis, dysphagia, emesis, food aversion and
anorexia. Direct radiation or chemotherapy effects on
the intestinal mucosa leading to diarrhea, protein-losing
enteropathy and malabsorption may contribute to
increased energy losses. 4
8
Page 8
During the last decade, bone marrow transplan-
tation (BMT) has emerged as an aggressive therapy in
the treatment of several malignant and non-malignant
conditions. BMT is frequently associated with a
reversible multisystem organ failure that results in
major nutritional sequelae, including protein-energy
malnutrition, and vitamin and trace element deficien-
cies. In many patients, transient intestinal failure may
be associated with impaired nutritional status that
lasts for up to 1 year after BMT. One component of
transient intestinal failure associated with BMT is
protein-losing enteropathy, in which protein is lost
through an inflamed and abnormal intestinal
mucosa. 47
The effects of radiation, chemotherapy,
graft-versus-host disease (GVHD) and viral infection
may contribute individually or in concert to this
process. 41 Impairments in vitamin, mineral and trace
element metabolism and absorption associated with
chemotherapy and BMT are also quite common. The
most commonly observed among these include
thiamine and vitamins K and B 12 . The levels of the
minerals and trace elements magnesium, copper, zinc
and selenium are frequently found to be low in this
population of patients. Attention to these potential
deficiencies should be addressed through routine
serologic monitoring and appropriate nutritional
supplementation (Table 1). 41 If feasible, the initiation
of enteral nutrition has been associated with
fewer biochemical zinc and selenium deficiencies
than TPN. 48
Pancreatitis
Acute pancreatitis is an inflammatory process that
involves the pancreas, peripancreatic tissues and occa-
sionally remote organs, and is increasing in frequency
in children. 49,50 Although the initiating event remains to
be identified, the pathophysiology of acinar cell injury
leading to activation of trypsin from its precursor
trypsinogen and subsequent pancreatic autodigestion
is well described. 51 In the vast majority of cases, this is
a local process that typically resolves within a few
days with minimal pancreatic or remote organ
dysfunction. However, in severe cases, this local
process may activate a cascade of pathophysiologic
events that leads to the development of SIRS with
extensive pancreatic necrosis, intestinal ischemia,
bacterial translocation, respiratory distress, multisys-
tem organ failure and, potentially, death. Fortunately,
the full SIRS response is seldom seen in children,
but an attenuated form of the systemic process
may occur. 51,52
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Enteral nutrition was long considered to have
adverse effects on the management of patients with
acute pancreatitis, secondary to the stimulation of
pancreatic enzymatic activity precipitating further
autodigestion. 53,54 In fact, ‘gut rest’ has long been
considered the standard of care for patients with
acute pancreatitis. Emerging evidence in adult litera-
ture challenges this old paradigm and supports the
premise that enteral nutrition via a nasojejunal feed-
ing tube with a semi-elemental diet (a high-protein,
low-fat formulation) is superior to parenteral nutri-
tion. 55
Furthermore, the early initiation of enteral
support may not only be tolerated but therapeutic in
acute pancreatitis. Studies show that enterally-fed
patients with severe pancreatitis had significantly
fewer septic episodes and total complications, and a
lower risk of multisystem organ failure and SIRS. 55,56
Furthermore, there were significant reductions in
length of hospitalization and cost of care. 55,56 The
provision of trophic enteral nutrition attenuates the
SIRS response by improving splanchnic blood flow,
inhibiting immune effector cell activation, decreasing
cytokine production, enhancing intestinal motility
and bile salt recirculation, and decreasing bacterial
overgrowth. 54
Although many studies suggest a superior role
for enteral versus parenteral nutrition support in
patients with pancreatitis, some caution must be
employed in the clinical setting. Enteral, even elemen-
tal, feeding may in some patients stimulate
pancreatitis, but this may be minimized by very distal
jejunal feeding tube placement and judicious clinical
“
Emerging evidence supports
the initiation of early enteral
feeding to enhance long-term
outcomes in most pediatric
critical illnesses.
”
10:33 AM Page 9
decision-making to stop feeding in the presence of
worsening clinical signs and symptoms. 52,53 There are
few reported controlled studies in children with acute
pancreatitis; however, many centers are adapting the
strategy of initiating early enteral nutrition. Meta-
Feature article
analyses of multiple reports in the adult literature
allow some general conclusions to be drawn that may
likely be applicable in pediatrics. Enteral nutrition
may be safely administered to patients with acute
pancreatitis within 48 hours of presentation using a
radiographically- or endoscopically-placed flexible
nasojejunal feeding tube. In the absence of pain or
clinical symptoms of worsening pancreatitis, enteral
support may be advanced to goal feeds as tolerated
over 2–4 days. 55,56
Summary
The increased recognition of the role that malnutrition
plays as an adverse prognostic factor in critically ill
children has led to greater focus on the importance of
premorbid nutritional status and post-morbid nutri-
tional support. Emerging evidence supports the
initiation of early enteral feeding to enhance long-term
outcomes in most pediatric critical illnesses. Trophic
feeds are ideally initiated within 48–72 hours, or as
soon as the disease process is stabilized or ileus
resolves. Typically, feeding is advanced to full support
over a 3–5-day period with dynamic attention to
changes in the metabolic requirements to avoid over-
or underfeeding. Estimates of the caloric/energy and
protein needs may be made using standard equations
adjusted for age, injury severity and associated medical
therapies (eg, neuromuscular paralysis). New insights
into the pathophysiology of the hypermetabolic
syndrome, protein energy malnutrition and gut
mucosal physiology are changing old paradigms of
withholding enteral nutrition support in the PICU that
were predicated on concerns about risks of aspiration
and gut injury. Evidence demonstrating faster recovery,
shorter ventilatory courses, fewer septic complica-
tions, decreased length of stay and lower costs in
selected patients receiving early enteral feeds is being
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
reported for many diagnoses. The use of small, flexible
feeding tubes, a variety of available elemental or semi-
elemental formulas and the judicious use of
promotility agents are facilitating this new approach
to care. Further advances in our understanding of the
hypermetabolic syndrome coupled with new formula
developments may usher in a new paradigm of enteral
nutrition as therapy in critical illness.
9
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CLINICAL NUTRITION ABSTRACTS
CANCER
Modulation of lipid rafts by Ω-3 fatty acids in
inflammation and cancer: Implications for use
of lipids during nutrition support
Nutr Clin Pract 2007 Feb;22(1):74-88.
Siddiqui RA, Harvey KA, Zaloga GP, Stillwell W.
Methodist Research Institute, Cellular Biochemistry, Indianapolis, Indiana,
USA.
Current understanding of biologic membrane structure and
function is largely based on the concept of lipid rafts. Lipid
rafts are composed primarily of tightly packed, liquid-
ordered sphingolipids/cholesterol/saturated phospholipids
that float in a sea of more unsaturated and loosely packed,
liquid-disordered lipids. Lipid rafts have important clinical
implications because many important membrane-signaling
proteins are located within the raft regions of the
membrane, and alterations in raft structure can alter activ-
ity of these signaling proteins. Because rafts are lipid-based,
their composition, structure, and function are susceptible to
manipulation by dietary components such as ω-3 polyunsat-
urated fatty acids and by cholesterol depletion. We review
how alteration of raft lipids affects the raft/nonraft localiza-
tion and hence the function of several proteins involved in
cell signaling. We focus our discussion of raft-signaling
proteins on inflammation and cancer.
CRITICAL CARE
Feeding practices of severely ill intensive care
unit patients: An evaluation of energy sources and
clinical outcomes
J Am Diet Assoc 2007 Mar;107(3):458-465.
Hise ME, Halterman K, Gajewski BJ, Parkhurst M, Moncure M, Brown JC.
The University of Kansas Medical Center, Department of Dietetics and
Nutrition, Kansas City, Kansas, USA.
OBJECTIVE: The quantity of nutrition that is provided to
intensive care unit (ICU) patients has recently come under
more scrutiny in relation to clinical outcomes. The primary
objective of this study was to assess energy intake in severely
ill ICU patients and to evaluate the relationship of energy
intake with clinical outcomes. DESIGN: Prospective cohort
study. SUBJECTS/SETTINGS: Seventy-seven adult surgery
and medical ICU patients with length of ICU stay of at least
5 days. STATISTICAL ANALYSES PERFORMED:
Student's t test and χ2 tests were used to examine ICU popu-
lations. To determine the relationship of patient variables to
The abstracts included in this section were selected from a search on clinical nutrition and related topics of the PubMed database of the United States National
Library of Medicine. PubMed may be accessed via the National Library of Medicine Web site at www.nlm.nih.gov.
7/10/07 10:33 AM Page 11
hospital length of stay and ICU, length of stay regression
trees were calculated. RESULTS: Both groups were underfed
with 50% of goal met in surgical ICU and 56% of goal met
in medical ICU. Medical ICU patients received less propofol
and significantly less dextrose-containing intravenous fluids
when compared to surgical ICU patients (p = 0.013). From
regression analysis, approaching full nutrient requirements
during ICU stay was associated with greater hospital length
Clinical nutrition
of stay and ICU length of stay. For combined groups, if %
abstracts
goal was ≥82%, the estimated average value for ICU length
of stay was 24 days; whereas, if the % goal was <82%, the
average ICU length of stay was 12 days. This relationship
held true for hospital length of stay. CONCLUSIONS:
Medical and surgical ICU patients were insufficiently fed
during their ICU stay when compared with registered dieti-
tian recommendations. Medical ICU patients received
earlier nutrition support, on average more enteral nutrition,
with fewer kilocalories supplied from lipid-based sedatives
and intravenous fluid relative to surgical ICU patients.
Based upon length of stay, the data suggest that the most
severely ill patient may not benefit from delivery of full
nutrient needs in the ICU.
Effect of nutritional support on glucose control
Curr Opin Clin Nutr Metab Care 2007 Mar;10(2):210-214.
Seematter G, Tappy L.
Service of Anaesthesiology, University Hospital of Canton de Vaud (CHUV),
Lausanne, Switzerland.
PURPOSE OF REVIEW: There is evidence that maintaining
a normal glycemia level in critically ill patients has beneficial
effects on outcome. Strategies aimed at lowering glycemia
are based on the understanding of mechanisms regulating
glucose metabolism. RECENT FINDINGS: Activation of
AMP protein kinase in skeletal muscle and in the liver leads
to a reduction in glucose production, a stimulation of
glucose uptake, and a lowering of glycemia. These mecha-
nisms appear to be activated during exercise, or by the
endogenous adipokine adiponectin. Alterations in
adiponectin concentrations during critical illness may thus
play a role in the metabolic stress responses. In addition,
AMP-activated protein kinase is the target for drugs
(metformin, thiazolidinediones), which may be of interest in
the intensive care unit. Besides insulin, plasma glucose
concentrations may be lowered by hypocaloric feeding, or
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
by feeding 'diabetic' formula with low glucose content and
supplemented with fructose. Whether such approaches lead
to beneficial effects comparable to those observed with
insulin remains to be established. SUMMARY: Recent find-
ings regarding the molecular mechanisms underlying glucose
transport and metabolism are summarized, and potential
strategies other than insulin are outlined which may
contribute to lowering glycemia in critically ill patients.
11
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Effect of an enteral diet supplemented with a
specific blend of amino acid on plasma and
muscle protein synthesis in ICU patients
Clin Nutr 2007 Feb;26(1):30-40.
Mansoor O, Breuillé D, Béchereau F, Buffiére C, Pouyet C, Beaufrére B,
Vuichoud J, Van't-Of M, Obled C.
RCO Département d'anesthésie-réanimation, CHU, 63000 Clermont-Ferrand,
France.
BACKGROUND & AIM: Polytrauma patients are charac-
terized by a negative nitrogen balance and muscle wasting.
Standard nutrition is relatively inefficient to improve muscle
protein turnover. The aim of this study was to investigate the
effect of enteral nutrition (EN) supplemented with specific
amino acids on protein metabolism in polytrauma patients.
Clinical nutrition
METHODS: In a double-blind study, 12 polytrauma
abstracts
patients were randomized to receive EN supplemented with
either a mixture of cysteine, threonine, serine and aspartate
(AA patients) or alanine at isonitrogenous levels (Ala
patients). An intravenous infusion of Ŀ-[1-13C]-leucine was
performed in the fed state between day 9 and 12 post-injury
(Df) in patients and in a group of healthy volunteers (n = 8)
(EN+Ala) to measure whole body leucine kinetics, plasma
and muscle protein synthesis rates. Nitrogen balance,
3-methyl histidine excretion were measured from day 3 to
Df. RESULTS: The contribution of total plasma proteins to
whole body protein synthesis was greatly increased, from
11% in healthy volunteers to about 25% in polytrauma
patients. AA supplementation had no effect on nitrogen
balance, leucine kinetics or plasma protein synthesis in
patients. In contrast, the urinary excretion of 3-methyl histi-
dine tended to decrease along the study in the AA
supplemented group compared to an increase in the Ala
group. Muscle protein synthesis tended to be higher in the
AA group than in the Ala group (46%, p = 0.065).
CONCLUSION: During injury, an increased supply of
cysteine, threonine, serine and aspartate could be able to
better cover the specific amino acid requirements, thus
resulting in improved muscle protein synthesis without
impairment of acute-phase protein synthesis.
Erythromycin is more effective than
metoclopramide in the treatment of feed
intolerance in critical illness
Crit Care Med 2007 Feb;35(2):483-489.
Nguyen NQ, Chapman MJ, Fraser RJ, Bryant LK, Holloway RH.
Department of Gastroenterology, Hepatology and General Medicine, Royal
Adelaide Hospital, and University Department of Medicine, University of
Adelaide, South Australia, Australia.
OBJECTIVE: This study aimed to a) compare the efficacy
of metoclopramide and erythromycin in the treatment of
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
feed intolerance in critical illness; and b) determine the
effectiveness of "rescue" combination therapy in patients
who fail monotherapy. DESIGN: Randomized controlled
trial. SETTING: Level III mixed medical and surgical
intensive care unit. PATIENTS: Ninety mechanically venti-
lated, medical patients with feed-intolerance (gastric
residual volume ≥250 mL). INTERVENTIONS: Patients
received either metoclopramide 10 mg intravenously four
times daily (n = 45) or erythromycin 200 mg intravenously
twice a day (n = 45) in a double-blind, randomized fash-
ion. After the first dose, nasogastric feeding was
12
Page 12
commenced and 6-hourly nasogastric aspirates were
performed. If a gastric residual volume ≥250 mL recurred
on treatment, open-label, combination therapy was given.
Patients were studied for 7 days. Successful feeding was
defined as 6-hourly gastric residual volume <250 mL with
a feeding rate ≥40 mL/h. MEASUREMENTS AND MAIN
RESULTS: Demographic data, blood glucose levels, and
use of inotropes, opioids, and benzodiazepines were simi-
lar between the two groups. After 24 hours of treatment,
both monotherapies reduced the mean gastric residual
volume (metoclopramide, 830 ± 32 mL to 435 ± 30 mL,
p < 0.0001; erythromycin, 798 ± 33 mL to 201 ± 19 mL,
p < 0.0001) and improved the proportion of patients
with successful feeding (metoclopramide = 62% and
erythromycin = 87%). Treatment with erythromycin was
more effective than metoclopramide, but the effectiveness
of both treatments declined rapidly over time. In patients
who failed monotherapy, rescue combination therapy
was highly effective (day 1 = 92%) and maintained its
effectiveness for the study duration (day 6 = 67%).
High pretreatment gastric residual volume was associated
with poor response to prokinetic therapy. CONCLU-
SIONS: In critical illness, erythromycin is more effective
than metoclopramide in treating feed intolerance, but the
rapid decline in effectiveness renders both treatments
suboptimal. Rescue combination therapy is highly effec-
tive, and further study is required to examine its role as the
first-line therapy.
Hypocaloric feeding of the critically ill
Nutr Clin Pract 2006 Dec;21(6):617-622.
Boitano M.
Clinical Nutrition, Scripps Memorial Hospital–Encinitas, Encinitas,
California, USA.
During critical illness, the stress response causes acceler-
ated gluconeogenesis and lipolysis, leading to
hyperglycemia and elevated serum triglyceride levels. The
traditional nutrition support strategy of meeting or exceed-
ing calorie requirements may compound the metabolic
alterations of the stress response. Hypocaloric nutrition
support has the potential to provide nutrition support
without exacerbating the stress response. Studies have
shown hypocaloric nutrition support to be safe and to
achieve nitrogen balance comparable with traditional regi-
mens. Benefits shown include improved glycemic control,
decreased intensive care unit (ICU) length of stay (LOS),
and decreased ventilator days and infection rate; however,
not all studies have produced identical results. Providing
adequate dietary protein has emerged as an important
factor in efficacy of the hypocaloric regimen. Although it
is inconclusive, currently available research suggests that a
nutrition support goal of 10–20 kcal/kg of ideal or
adjusted weight and 1.5–2 g/kg ideal weight of protein
may be beneficial during the acute stress response. Well-
designed, randomized, controlled studies with adequate
sample size that evaluate relevant clinical outcomes such as
mortality, ICU LOS, and infection while controlling for
factors such as glycemic control, severity of illness, incor-
poration of calories from all sources, in addition to feeding
regimens, are needed to definitively determine the effects
of hypocaloric nutrition support.
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd
Feeding the critically ill obese patient: The role of
hypocaloric nutrition support
Respir Care Clin N Am 2006 Dec;12(4):593-601.
Miller JP, Choban PS.
Mount Carmel Health System, Columbus, Ohio, USA.
Obesity and its many metabolic and physiologic comorbidi-
ties are becoming more common. Thus, a strategy to
approach the nutritional needs of obese critically ill patients
is warranted. The adverse effect of obesity on the respiratory
system is well established. The obesity may be an inciting
event or merely an additional burden in the obese critically
ill patient. A strategy of hypocaloric nutrition support
avoids the many detrimental effects of overfeeding and has
been considered for all critically ill patients. In the obese
patient, the strategy addresses the additional problem of the
excessive fat store and has the additional benefit of fat
reduction while sparing lean body mass. In the patient with
normal renal and hepatic function, hypocaloric nutrition
support simplifies care and may improve outcome.
Nutrition support for the long-term ventilator-
dependent patient
Respir Care Clin N Am 2006 Dec;12(4):567-591, vi.
Cresci G, Cue JI.
Surgical Nutrition Service, Department of Surgery, Medical College of Georgia,
Augusta, Georgia, USA.
This article discusses issues related to nutrition support for
the critically ill (CCI), especially those who are dependent
on ventilators for long periods. A large and growing popu-
lation of patients survives acute critical illness only to
become CCI with profound debilitation, weeks to months of
hospitalization, and often permanent dependence on
mechanical ventilation and other life-sustaining modalities.
Despite resource-intensive treatment, outcomes for the CCI
remain poor. Topics addressed in this article include
neuroendocrine profiles in CCI patients, allostatic overload,
causes of prolonged mechanical ventilation, and the metab-
olism of chronic ventilator dependence. The article also
describes issues related to assessing the nutrition, determin-
ing nutrition requirements, and deciding the route of
nutrient delivery for CCI patients.
GENERAL NUTRITION
Nutritional therapies in Parkinson's disease
Curr Treat Options Neurol 2007 May;9(3):198-204.
Evatt ML.
Department of Neurology, Movement Disorders Section, Emory University
School of Medicine, Atlanta, Georgia, USA.
Advise patients with Parkinson's disease (PD) to consume
a balanced diet, with special attention to adequate intake
of dietary fiber, fluids, and macro- and micronutrients.
Regularly reassess patients' nutritional history and anthro-
pomorphic measures (height and weight), particularly in
patients with advanced disease. PD-related psychosocial,
as well as physical and cognitive, limitations increase
susceptibility to subacute and chronic malnutrition.
7/10/07 10:33 AM Page 13
Nutritional requirements may change with PD progression
or after surgical therapy for PD. Patients and caregivers
may benefit from counseling by a dietician who is knowl-
edgeable about the nutritional risks and needs of PD.
Regularly inquire about dysphagia symptoms, and
consider speech therapy consultation for clinical and modi-
fied barium-swallowing evaluations and management
recommendations. Although non-oral delivery options of
dopaminergic therapy are increasing, severe dysphagia
may warrant percutaneous endoscopic gastrostomy tube
placement for nutritional support and more reliable PD
medication dosing. Analyze vitamin B12 and D concentra-
tions at regular intervals. Both vitamins are frequently
deficient in elderly persons but may not be routinely
Clinical nutrition
checked by primary care physicians. Record over-the-
abstracts
counter and nutritional supplement medications at each
visit, and assist patients in periodically re-evaluating their
potential benefits, side effects, drug interactions, and costs.
To date, clinical trials of antioxidant vitamins and nutri-
tional supplements have provided insufficient evidence to
support routine use for PD in the clinic. Data from several
clinical trials of antioxidant vitamins/nutritional supple-
ments are expected in the near future. Consider altering
medication dosing in relation to meals to help with mild to
moderate motor fluctuations. Patients with severe motor
fluctuations may benefit from adapting the 5:1 carbohy-
drate-to-protein ratio in their daily meals and snacks.
Following a "protein redistribution" diet is logistically
more difficult and less palatable, and therefore less
frequently recommended. To ensure adequate protein
intake, a registered dietician should supervise patients who
follow either of these diets.
Successful new method of extracorporeal
percutaneous endoscopic gastrostomy (E-PEG)
Surg Endosc 2007 Apr 3; [Epub ahead of print].
Toyama Y, Usuba T, Son K, Yoshida S, Miyake R, Ito R, Tsuboi K, Kashiwagi H,
Tajiri H, Yanaga K.
Department of Surgery, Jikei University School of Medicine, Kashiwa, Chiba,
Japan.
BACKGROUND: Although percutaneous endoscopic
gastrostomy (PEG) has become popular for patients with
swallowing disorders as a nutrition support or a decom-
pressant of gastrointestine, perioperative complications
associated with PEG have not decreased, especially peris-
tomal infections. To reduce peristomal infections, we
designed a new method of gastrostomy by extracorporeal
approach under endoscopic observation, named as extra-
corporeal PEG (E-PEG). METHODS: Experimental studies
for E-PEG were performed repeatedly using pigs under
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
general anesthesia to confirm the safety of this procedure
for human use. After approval of institutional ethics
review board in our university, thirty patients with prior
consent participated in this study. The operation time, the
incidence rate of complications and the hospital stay were
compared between E-PEG and ordinary pull-method PEG
groups. RESULTS: Two patients (6.7%) in E-PEG group
had postoperative complications, ie, aspiration pneumonia
and surgical site infection. The operation time of E-PEG
group was 5–16 (mean ± SD: 10.3 ± 2.96) min as
compared to 14–37 (mean ± SD: 26.9 ± 8.39) min with
13
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07 10:33 AM
pull-method PEG. The postoperative hospital day of
E-PEG was within 2 days except for the two complicated
cases. Significant differences in operation time, complica-
tion rate and postoperative hospital stay between those
groups were observed statistically. CONCLUSIONS: These
results indicate that E-PEG was safe, tolerable and speedy
when compared ordinary pull-method PEG.
Update on enteral nutrition support for cystic
fibrosis
Nutr Clin Pract 2007 Apr;22(2):223-232.
Erskine JM, Lingard C, Sontag M.
Dietetics Program, University of Northern Colorado, School of Natural and
Health Sciences, Greeley, Colorado, USA.
Clinical nutrition
Cystic fibrosis (CF) is an inherited disease affecting the
abstracts
respiratory, gastrointestinal, hepatobiliary, and reproduc-
tive systems. Nutrition status in persons with CF is often
compromised due to increased energy needs, frequent
infections, pancreatic insufficiency, lung disease, or
CF-related diabetes. Maintaining good nutrition status has
been associated with better pulmonary function, reduced
hospitalizations, and increased longevity. Nutrition
support as oral supplementation (used in >37% of the
CF population) or tube feeding (used in >13% of the CF
population) is often required for children and adults with
CF. The purpose of this update is to describe current
consensus and evidence for enteral nutrition support
guidelines, reported complications of enteral feeding in the
CF population, evidence of expected outcomes, and
to discuss related areas requiring further research.
A case report is provided to illustrate potential outcomes
of aggressive enteral support.
A local nutritional screening tool compared to
malnutrition universal screening tool
Eur J Clin Nutr 2007 Jan 31; [Epub ahead of print].
Gerasimidis K, Drongitis P, Murray L, Young D, McKee RF.
Human Nutrition Section, Division of Developmental Medicine, University of
Glasgow, Yorkhill Hospitals, Glasgow, United Kingdom.
OBJECTIVE: The aim of the study was to compare the
Glasgow Nutritional Screening Tool with the Malnutrition
Universal Screening Tool (MUST) recently recommended for
use by the British Association for Parenteral and Enteral
Nutrition. DESIGN: Comparison-validation study.
SETTING: Four adult acute hospitals in Glasgow, UK.
SUBJECTS: All 242 inpatients from a variety of specialties.
METHODS: Two investigators independently interviewed
202 in-patients for the comparison-validation study. Each
used a single tool with each patient, using each tool in turn.
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
Investigators were not aware of each other's assessments.
Forty other patients were interviewed by both raters sepa-
rately using the local tool to evaluate inter-rater reliability.
RESULTS: When compared with MUST as a 'gold stan-
dard', the local tool had a sensitivity of 95.3% and a
specificity of 64.9%, with moderate agreement between the
two tools using kappa test (κ = 0.57). Agreement between
the raters was substantial (κ = 0.69) with 85% of patients
classified the same by both raters. CONCLUSION: The
Glasgow Nutritional Screening Tool is a valid and reliable
tool that can be used on admission for nutritional screening.
14
Page 14
Usefulness of the MNA in the long-term and acute-
care settings within the United States
J Nutr Health Aging 2006 Nov-Dec;10(6):502-506.
Langkamp-Henken B.
Food Science and Human Nutrition Department, University of Florida,
Gainesville, Florida, USA.
The Mini Nutritional Assessment (MNA®) is a tool that
was developed for use with elders to provide rapid assess-
ment of nutritional risk. Although this screening tool has
been validated and frequently used in long-term and acute-
care settings in Europe, the MNA® has not been used
extensively within the United States. The MNA® may need
to be validated for use within US nursing and acute-care
facilities because validity may be affected by the acuity of
illness, the use of aggressive nutrition support, which
makes the scoring of the MNA® difficult, and the age of
patients admitted for care (acute care). Additionally, in
most long-term care settings, a specific screening tool
(Minimum Data Set) is already required to assess resident
function including nutritional risk. The MNA® may be
more useful in an assisted living facility, where nutrition
screening and assessment tools are not currently in
place, yet maintenance of functional status is important to
prevent transfer to a nursing facility.
IMMUNONUTRITION
Prospective randomized study on perioperative
enteral immunonutrition in laparoscopic colorectal
surgery
Surg Endosc 2007 Jul;21(7):1175-1179.
Finco C, Magnanini P, Sarzo G, Vecchiato M, Luongo B, Savastano S,
Bortoliero M, Barison P, Merigliano S.
Department of Medical and Surgical Sciences, 3rd General Surgery Clinic,
Coloproctological Unit, S. Antonio Hospital, University of Padova, Padova,
Italy.
BACKGROUND: Perioperative nutrition for patients
undergoing colon surgery seems to be effective in reducing
catabolism and improving immunologic parameters. A
relatively low-fiber and highly absorbable diet may facili-
tate the intestinal cleansing and loop relaxation
fundamental for laparoscopic surgery with a lower dose of
iso-osmotic laxative. METHODS: From 1 February 2004
to 30 July 2005, 28 patients referred to our unit with colon
disease (neoplasms and diverticular disease) amenable to
laparoscopic surgery were prospectively randomized into
two groups of 14 patients each. For 6 days preoperatively,
the patients in group 1 were given 750 mL/d of a diet
enriched with arginine, omega-3 fatty acids, and ribonu-
cleic acid (RNA) associated with low-fiber foods. They had
1 day of intestinal preparation with 3 L of iso-osmotic
laxative. On postoperative day 2, they were fed orally with
the same diet. The patients in group 2 preoperatively
received a low-fiber diet. They had 2 days of preparation
with iso-osmotic laxative (3 L/d). On postoperative day 3,
oral nutrition was restored. Intraoperatively, we evaluated
loop relaxation and intestinal cleanliness. Clinical trends
were monitored in both groups, as well as adverse reac-
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07
tions to early nutrition. The nutritional (albumin, prealbu-
min) and immunologic (lymphocyte subpopulations,
immunoglobulins) biohumoral parameters were evaluated
at the first visit, on the day before surgery, on postopera-
tive day 7, and 1 month after surgery. RESULTS: The two
groups did not differ in terms of age, gender, distribution
of disease, or baseline anthropometric, biohumoral, or
immunologic parameters. There was a significant increase
in CD4 lymphocytes on the day before surgery as
compared with baseline parameters (p < 0.05) in group 1,
but not in group 2. There was no statistically significant
difference between the two groups in intestinal
loop relaxation or cleanliness or in postoperative
infectious complications. CONCLUSIONS: Perioperative
immunonutrition proved to be safe and useful in increas-
ing the perioperative immunologic cell response. It may
contribute toward improving the preparation and relax-
ation of the intestinal loops despite the shorter intestinal
preparation.
Application of perioperative immunonutrition for
gastrointestinal surgery: A meta-analysis of
randomized controlled trials
Asia Pac J Clin Nutr 2007;16(suppl):253-257.
Zheng Y, Li F, Qi B, Luo B, Sun H, Liu S, Wu X.
Department of General Surgery, Xuanwu Hospital, Capital Medical University,
Beijing, China.
The aim of this study was to evaluate clinical and
economic validity of perioperative immunonutrition and
effect on postoperative immunity in patients with gastro-
intestinal cancers. Immunonutrition diet supplemented
two or more of nutrients including glutamine, arginine,
ω-3 polyunsaturated fatty acids and ribonucleic acids.
A meta-analysis of all relevant clinical randomized
controlled trials (RCTs) was performed. The trials
compared perioperative immunonutrition diet with stan-
dard diet. We extracted RCTs from electronic databases:
Cochrane Library, MEDLINE, EMBASE, SCI and assessed
methodological quality of them according to the handbook
for Cochrane reviewer in June 2006. Statistical analysis
was performed by RevMan4.2 software. Thirteen RCTs
involving 1,269 patients were included. The combined
results showed that immunonutrition had no significant
effect on postoperative mortality (OR = 0.91, p = 0.84).
But it had positive effect on postoperative infection rate
(OR = 0.41, p < 0.00001), length of hospital stay (WMD
= -3.48, p < 0.00001). Furthermore, it improved immune
function by increasing total lymphocytes (WMD = 0.40,
p < 0.00001), CD4 levels (WMD = 11.39, p < 0.00001),
IgG levels (WMD = 1.07, p = 0.0005) and decreasing
IL6 levels (WMD = -201.83, p < 0.00001). At the same
time, we did not find significant difference in CD8, IL2
and CRP levels. There were no serious side effects and two
trials found low hospital cost. In conclusion, perioperative
diet adding immunonutrition is effective and safe to
decrease postoperative infection and reduce length of
hospital stay through improving immunity of postopera-
tive patients as compared with the control group. Further
prospective study is required in children or critical patients
with gastrointestinal surgery.
10:33 AM Page 15
INFLAMMATORY BOWEL DISEASE
Nutritional modulation of the inflammatory
response in inflammatory bowel disease –
From the molecular to the integrative to
the clinical
World J Gastroenterol 2007 Jan;13(1):1-7.
Wild GE, Drozdowski L, Tartaglia C, Clandinin MT, Thomson AB.
Department of Medicine, Division of Gastroenterology, McGill University,
Montreal, Quebec, Canada.
Nutrient deficiencies are common in patients with
inflammatory bowel disease (IBD). Both total
Clinical nutrition
parenteral and enteral nutrition provide important
abstracts
supportive therapy for IBD patients, but in adults
these are not useful for primary therapy. Dietary inter-
vention with omega-3 polyunsaturated fatty acids
contained in fish oil may be useful for the care of IBD
patients, and recent studies have stressed the role of
PPAR on NFκB activity on the potential beneficial
effect of dietary lipids on intestinal function.
Impact of long-term enteral nutrition
on clinical and endoscopic recurrence
after resection for Crohn's disease: A
prospective, non-randomized, parallel,
controlled study
Aliment Pharmacol Ther 2007 Jan;25(1):67-72.
Yamamoto T, Nakahigashi M, Umegae S, Kitagawa T, Matsumoto K.
Inflammatory Bowel Disease Centre & Department of Surgery, Yokkaichi
Social Insurance Hospital, Yokkaichi, Mie, Japan.
BACKGROUND: The impact of enteral nutrition on
postoperative recurrence has not been properly exam-
ined. AIM: To investigate the impact of enteral
nutrition using an elemental diet on clinical and endo-
scopic recurrence after resection for Crohn's disease.
METHODS: Forty consecutive patients who under-
went resection for ileal or ileocolonic Crohn's disease
were studied. After operation, 20 patients continu-
ously received enteral nutritional therapy (EN group),
and 20 had neither nutritional therapy nor food
restriction (non-EN group). In the EN group, enteral
formula (Elental) was infused through a nasogastric
tube in the night-time, and low-fat foods were taken in
the daytime. All patients were followed up regularly
for 1 year after operation. Ileocolonoscopy was
performed at 6 and 12 months after operation.
RESULTS: One patient (5%) in the EN group and
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
seven (35%) in the non-EN group developed clinical
recurrence during 1-year follow-up (p = 0.048). Six
months after operation, five patients (25%) in the EN
group and eight (40%) in the non-EN group developed
endoscopic recurrence (p = 0.50). Twelve months after
operation, endoscopic recurrence was observed in six
patients (30%) in the EN group and 14 (70%) in the
non-EN group (p = 0.027). CONCLUSIONS: Our
long-term enteral nutritional therapy significantly
reduced clinical and endoscopic recurrence after resec-
tion for Crohn's disease.
15
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07
PANCREATITIS
Artificial nutrition and acute pancreatitis: A review
and update [article in Spanish]
Nutr Hosp 2007 Jan-Feb;22(1):25-37.
Gento Peña E, Martín de la Torre E, Miján de la Torre A.
Servicio de Aparato Digestivo Complejo Asistencial de Burgos, Facultad de
Medicina, Universidad de Valladolid, Spain.
Most of acute pancreatitis cases present as mild cases for
which nutritional support is not recommended provided the
patient is able to restart normal oral intake within 5–7 days.
By contrast, severe pancreatitis associates metabolic stress
Clinical nutrition
and requires early nutritional support. In these cases, enteral
abstracts
nutrition is recommended, which should be supplemented
with parenteral nutrition if needed. Recent studies indicate
that enteral nutrition may improve the course of severe
acute pancreatitis, reduce its complications and promote a
quicker improvement from the disease. Most of the patients
tolerate oligomeric nutrition administered as continuous
infusion distally to the Treitz's angle. Recent studies show,
however, that intragastric perfusion is safe and may be an
adequate therapeutic option in particular patients with acute
severe pancreatitis. Besides, specific agents added to the
nutrition (immunomodulators and probiotics) seem to
reduce hospital stay and infectious and non-infectious
complications of acute pancreatitis.
PEDIATRICS
Enteral nutrition in critically ill children: Are
prescription and delivery according to their energy
requirements?
Nutr Clin Pract 2007 Apr;22(2):233-239.
de Oliveira Iglesias SB, Leite HP, Santana e Meneses JF, de Carvalho WB.
Pediatric Intensive Care Unit, Department of Pediatrics, Federal University of
São Paulo, São Paulo, Brazil.
BACKGROUND: The purpose of this study was to compare
the differences between prescribed and delivered energy
among critically ill children and to identify the factors that
impede the optimal delivery of enteral nutrition in the first
5 days of nutrition support. METHODS: In a prospective
cohort study, we evaluated 55 critically ill children aged 8.2
± 11.4 months (0–162.3 months), who were fed for ≥2 days
through a gastric or postpyloric tube. The patients were
followed from admission until day 10 of enteral nutrition.
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
Prescribed and delivered energy were recorded daily and
compared with each other and with the estimated basal
metabolic rate (BMR). The Paediatric Index of Mortality 2
(PIM 2) was used to estimate illness severity. RESULTS: The
ratio of delivered:required energy was <90% in 55.7% of
the enteral nutrition days. Low prescription was the main
reason for not achieving the energy goal in the first 5 days
of enteral nutrition. Discrepancies between prescribed and
delivered: energy were attributable to interruptions in feed-
ing caused by clinical instability, airway management,
radiologic and surgical procedures, and accidental feeding
16
10:33 AM Page 16
tube removal. The other factors associated with the delivery
of less than required energy were PIM 2 ≥15%, gastro-
intestinal complications, dialysis, and use of α-adrenergic
vasoactive drugs. The latter was the only variable in multi-
variate analysis that was associated with not ultimately
achieving energy goal. CONCLUSIONS: The prescription
and delivery of energy were not adequate in >50% of enteral
nutrition days. The gap between the effective administration
and energy requirements can be explained by both under-
prescription and underdelivery. Administration of
vasoactive drugs was the only variable independently asso-
ciated with a low energy supply.
Risk factors for gastrointestinal complications in
critically ill children with transpyloric enteral
nutrition
Eur J Clin Nutr 2007 Feb 28; [Epub ahead of print].
López-Herce J, Santiago MJ, Sánchez C, Mencía S, Carrillo A, Vigil D.
Pediatric Intensive Care Unit, Preventive and Quality Control Service (DV),
Gregorio Marañón General University Hospital, Madrid, Spain.
OBJECTIVE: To study the risk factors for gastrointestinal
complications related to enteral nutrition in critically ill chil-
dren. DESIGN: A prospective, observational study.
SETTING: Pediatric intensive care unit. SUBJECTS: Five
hundred and twenty-six critically ill children who received
transpyloric enteral nutrition (TEN). METHODS:
Univariate and multivariate logistic regression analysis were
used to identify risk factors for gastrointestinal complica-
tions. RESULTS: Sixty-six patients (11.5%) presented
gastrointestinal complications, 33 (6.2%) abdominal disten-
sion and/or excessive gastric residue, 34 (6.4%) diarrhea,
one gastrointestinal bleeding, three necrotizing enterocolitis
and one duodenal perforation. Enteral nutrition was defini-
tively suspended because of gastrointestinal complications in
11 (2.1%) patients. Fifty patients (9.5%) died.
Gastrointestinal complications were more frequent in the
patients who died. Death was related to complications of the
nutrition in only one patient. The frequency of gastro-
intestinal complications was significantly higher in children
with shock, acute renal failure, hypokalemia, hypophos-
phatemia and in those receiving dopamine, epinephrine and
vecuronium. The stepwise multivariate logistic regression
analysis showed that the most important factors associated
with gastrointestinal complications were shock, epinephrine
at a rate higher than 0.3 µg/kg/min and hypophosphatemia.
CONCLUSIONS: The tolerance of TEN in critically ill chil-
dren is good, although the incidence of gastrointestinal
complications is higher in patients with shock, acute renal
failure, hypokalemia, hypophosphatemia, and those receiv-
ing epinephrine, dopamine, and vecuronium.
Effect of exclusive enteral nutritional treatment on
plasma antioxidant concentrations in childhood
Crohn's disease
Clin Nutr 2007 Feb;26(1):51-56.
Akobeng AK, Richmond K, Miller V, Thomas AG.
Department of Paediatric Gastroenterology, Booth Hall Children's Hospital,
Manchester, United Kingdom.
BACKGROUND & AIMS: Oxidative stress and depletion
of antioxidants may play a role in the pathogenesis of
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07
Crohn's disease (CD). The aim of this study was to deter-
mine the effect of exclusive enteral nutrition, which is
increasingly being used as primary therapy for CD, on
plasma antioxidant concentrations in children with active
CD. METHODS: In a double-blind randomized controlled
trial, 15 children with active CD (mean age, 11.3 years,
range 6.8–15.7) attending a pediatric gastroenterology
referral center, were assigned to receive either a standard
polymeric diet (Group S, n=8) or a glutamine-enriched
polymeric diet (Group G, n=7) as primary therapy for
active CD. Plasma concentrations of selenium, urates, vita-
min A, vitamin E, vitamin C, glutathione, and also
malondialdehyde (MDA) were measured at baseline and
after 4 weeks of exclusive enteral nutritional treatment.
RESULTS: Mean (95% CI) selenium concentration of the
cohort increased significantly from 0.82 µmol/L (0.72,
0.91) to 1.14 µmol/L (0.98, 1.3), p < 0.001. There were,
however, significant reductions in mean concentrations of
vitamin C (11.8 mg/L [7.7, 15.8] to 6.5 mg/L [4.5, 8.7],
p = 0.01) and vitamin E (11.3 mg/L [10.3, 12.4] to 9.4
mg/L [8.7, 10.1], p = 0.03). The concentrations of vitamin
A, urates, glutathione and MDA did not change signifi-
cantly over the study period. Glutamine supplementation
did not have any significant effect on plasma antioxidant
concentrations. CONCLUSIONS: Significant changes in
circulating antioxidant concentrations occurred in children
with active CD receiving exclusive enteral nutritional treat-
ment. Glutamine supplementation was not beneficial in
improving plasma antioxidant status.
Nutritional status after intestinal transplantation
in children
Eur J Pediatr Surg 2006 Dec;16(6):403-406.
Encinas JL, Luis A, Avila LF, Hernandez F, Sarria J, Gamez M, Murcia J, Leal L,
Lopez-Santamaria M, Tovar JA.
Department of Pediatric Surgery Service, Hospital Universitario La Paz,
Madrid, Spain.
INTRODUCTION: The management of children receiving
small bowel grafts involves potentially life-threatening
complications that affect their nutritional status. The aim
of this paper was to define these factors and their influence
on nutritional outcome. PATIENTS AND METHODS:
Patients with intestinal failure (IF) who received an
isolated small bowel transplantation (SBT) or small
bowel/liver transplantation (SBLT) at our hospital during
the last 6 years were reviewed for weight Z-score,
biochemical nutritional parameters, total parenteral nutri-
tion (TPN) weaning, catheter-related sepsis, rejection and
steroid treatment. RESULTS: Twenty patients, 11 females
and 9 males, received an SBT or an SBLT and survived the
postoperative period; in the present study we only included
11 children with follow-up periods longer than 1 year.
Seven males and 4 females with a mean age of 4.5 years
(range, 1 to 20 years) received 6 SBLT and 5 SBT. Nine
(82%) were weaned from TPN to an amino-acid or
peptide enteral formula during the first 6 months after
surgery. During the first year there was a significant
increase in total protein from 5.11 ± 1.8 mg/dL to 6.1 ±
1.5 mg/dL (p < 0.05) and an increase in albumin from 3.8
± 0.9 mg/dL to 4.5 ± 1.1 mg/dL (p < 0.05). There was an
increase in weight Z-score in 9 patients (82%) during the
10:33 AM Page 17
first year. Mean Z-score improved from - 2.6 ± 1 at trans-
plant to - 1.0 ± 0.6 (p < 0.05) after 1 year. Three patients
(27.2%) had at least one rejection period, which was
treated with steroids alone or in combination. Mean weight
Z-score 1 year after surgery was - 0.9 ± 0.6 for patients
without rejection and - 1.24 ± 0.8 for those with at least
one rejection episode treated with steroids (p > 0.1). Four
patients (36%) had at least one catheter-related sepsis
episode. Mean weight Z-score 1 year after surgery was
- 1.01 ± 0.6 for patients without catheter-related sepsis and
- 1.24 ± 0.8 for those with at least one catheter-related
sepsis episode (p > 0.1). CONCLUSIONS: There was a
significant improvement in weight Z-score and biochemical
nutritional parameters 1 year after receiving a small bowel
Clinical nutrition
graft. No influence of steroids or catheter-related sepsis on
abstracts
children's nutritional status was noted 1 year after surgery,
although this point will need further evaluation.
TRAUMA AND BURNS
Synbiotics, prebiotics, glutamine, or peptide in
early enteral nutrition: A randomized study in
trauma patients
JPEN J Parenter Enteral Nutr 2007 Mar-Apr;31(2):119-126.
Spindler-Vesel A, Bengmark S, Vovk I, Cerovic O, Kompan L.
University Medical Centre, Ljubljana, Slovenia.
BACKGROUND: Since the hepatosplanchnic region plays
a central role in development of multiple-organ failure and
infections in critically ill trauma patients, this study
focuses on the influence of glutamine, peptide, and syn-
biotics on intestinal permeability and clinical outcome.
METHODS: One hundred thirteen multiple injured
patients were prospectively randomized into four groups:
group A, glutamine; B, fermentable fiber; C, peptide diet;
and D, standard enteral formula with fibers combined with
Synbiotic 2000 (Synbiotic 2000 Forte; Medifarm, Sweden),
a formula containing live lactobacilli and specific bioactive
fibers. Intestinal permeability was evaluated by measuring
lactulose-mannitol excretion ratio on days 2, 4, and 7.
RESULTS: No differences in days of mechanical ventila-
tion, intensive care unit stay, or multiple-organ failure
scores were found between the patient groups. A total of
51 infections, including 38 pneumonia, were observed,
with only 5 infections and 4 pneumonias in group D,
which was significantly less than combined infections (p =
0.003) and pneumonias (p = 0.03) in groups A, B, and C.
Intestinal permeability decreased only in group D, from
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
0.148 (0.056–0.240) on day 4 to 0.061 (0.040–0.099) on
day 7; (p < 0.05). In group A, the lactulose-mannitol excre-
tion ratio increased significantly (p < 0.02) from 0.050
(0.013–0.116) on day 2 to 0.159 (0.088-0.311) on day 7.
The total gastric retention volume in 7 days was 1,150
(785–2,395) mL in group D, which was significantly more
than the 410 (382–1,062) mL in group A (p < 0.02), and
620 (337–1,190) mL in group C (p < 0.03). CONCLU-
SIONS: Patients supplemented with synbiotics did better
than the others, with lower intestinal permeability and
fewer infections.
17
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07 10:33 AM
Highlights of
Clinical Nutrition Week
28–31 January 2007 • Phoenix, Arizona, USA
Keynote Address –
Translating research to the
bedside: Doing the right thing
and making a difference
MM Levy
Providence, RI, USA
Despite the extraordinary hard work and best intentions of
caregivers, the quality of health care delivered is unreliable
and has the potential to harm thousands of patients every
day (McGlynn EA, et al. N Engl J Med 2003;348:2635-
Highlights of Clinical
2645). A large gap exists between clinicians’ perceptions of
Nutrition Week
their use of evidence-based medicine and actual practice.
Data from clinical trials are not consistently applied to prac-
tice and evidence-based protocols are underused, resulting in
adverse outcomes (Soumerai SB, et al. JAMA 1997;277:115-
121. ARDS Network. N Engl J Med 2000;342:1301-1308.
Pronovost PJ, et al. J Crit Care 2004;19:158-164).
Studies show that guideline-based processes can
assess care and improve outcomes. Care bundles are power-
ful tools used to standardize care. A care bundle is a group
of interventions related to a disease process that when
executed together result in better outcomes than when
implemented individually. Providing each element of care
within a bundle leads to more reliable care for patients
(www.ihi.org/IHI/topics/reliability). Hospitals that have
implemented central line care bundles have nearly elimi-
nated catheter-related bloodstream infections, providing
compelling evidence that such protocols are effective
(Pronovost P, et al. N Engl J Med 2006;355:2725-2732.
Berenholtz SM, et al. Crit Care Med 2004;32:2014-2020).
The 100,000 Lives Campaign, a well-publicized
Institute for Healthcare Improvement (IHI) initiative involv-
ing more than 3,100 hospitals across the United States,
resulted in 122,000 lives saved and demonstrated that
hospitals could significantly improve care by implementing
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
six changes proven to save lives. The campaign has been
expanded with the goal of saving 5 million lives over the
next 2 years.
The Surviving Sepsis Campaign is a worldwide
campaign to reduce mortality rates in patients with sepsis by
25% in 5 years. The campaign utilizes sepsis management
bundles developed on evidence-based guidelines and involves
a multifaceted approach to bring the guidelines to the
bedside. Powerful data are emerging showing that identifying
18
Page 18
sepsis and implementing the bundles can reduce mortality
rates from 43% to 26% (Gao F, et al. Crit Care 2005;9:
R764-R770).
Dr Levy challenged ASPEN to rise above academic
debate and develop consensus recommendations for nutri-
tion interventions, identify interventions that are not being
performed, and develop methods for changing bedside nutri-
tion practice.
Surviving sepsis: Effective clinical
weapons
R Fields, P Posa, J Wooley
Ann Arbor, MI, USA
The Surviving Sepsis Campaign promotes a four-tier
approach to achieve a 25% reduction in mortality from
sepsis within 5 years:
1) Gain commitment throughout the organization from
administration to clinicians that severe sepsis must be
managed early and aggressively;
2) Implement early screening tools and identify triggers for
treatment;
3) Implement evidence-based sepsis care bundles; and
4) Measure process and outcomes changes.
Built-in screening tools and triggers throughout the
care continuum facilitate early and rapid identification of
patients by recognizing that “time is tissue” (Levy MM, et
al. Crit Care Med 2005;33:2194-2201).
Two sepsis care bundles, based on evidence-based
guidelines, provide specific recommendations that hospitals
can take to initiate rapid changes in the way sepsis is
managed. The Sepsis Resuscitation Bundle recommends
early antibiotic therapy and aggressive therapy to maintain
adequate blood pressure. The Sepsis Management Bundle
includes administering low-dose steroids for septic shock,
administering recombinant human activated protein C
(rhAPC), and maintaining tight glucose control and low
tidal volume ventilation. Protocols, guidelines and standard-
ized sets of standing physician orders drive care.
Enteral nutrition helps maintain tight glucose control
during sepsis and should start as soon as the patient is
hemodynamically stable. Pressor support does not preclude
enteral feedings in hemodynamically stable patients. Indirect
calorimetry is the gold standard to determine calorie
requirements. Goals are ≤100% of measured resting energy
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07
expenditure (MREE) during the shock and catabolic phases
of sepsis and 100–130% MREE during the anabolic phase
of critical illness (McClave SA, et al. JPEN J Parenter
Enteral Nutr 2003;27:16-20).
President’s Address –
Food for thought: It’s more
than nutrition
MF Winkler
Providence, RI, USA
Food and the rituals that surround eating serve many impor-
tant social purposes that extend far beyond merely meeting
nutritional needs. They enhance quality of life by giving
people physical comfort, a sense of security and the feeling
that they belong (Walker A. Food, Culture, and Society
2005;8:161-180).
Conversely, a diminished ability to enjoy food, stress-
ful eating problems, unpleasant experiences and decreased
autonomy can negatively impact quality of life.
Dietary restrictions and changes in dietary behavior,
especially those caused by disease and its treatment, are
highly stressful to both patients and their families (McGrath
P. Cancer Pract 2002;10:94-101). During the course of
disease, food develops different meanings. Psychosocial
meaning may be associated with positive feelings of well-
being or negative feelings of sorrow. Physiological meaning
may be associated with positive feelings of comfort or nega-
tive feelings of burden. Fatigue and lack of appetite give rise
to feelings of deprivation because of missing both eating and
the related social environment, and may lead to a loss of
personal identity. Family members are also affected by the
loss of social interaction at meals and changes in their loved
ones (Jacobsson A, et al. J Adv Nurs 2004;46:514-522).
Similarly, patients who are dependent on long-term
parenteral and enteral nutrition (PEN) experience decreased
quality of life. They express conflicting emotions about
nutrition support; viewing it, on one hand, as their lifeline
and, on the other hand, they experience psychosocial
distress with decreased physical, psychological and social
function. They report infusion-related complications,
lifestyle adaptations, feelings of low self-worth and isola-
tion, drug dependency, and sleep disturbance. Many also
experience hunger, and anger over food restrictions.
(Brotherton A, et al. J Hum Nutr Diet 2006;19:355-367.
Winkler MF, et al. JPEN J Parenter Enteral Nutr 2005;29:
162-170).
Strategies to reduce stress for patients on PEN and
their families include offering choices whenever possible,
tailoring the feeding system to the patient, and mimicking
the usual home mealtime. Comfort foods, which trigger past
associations and evoke feelings of caring and healing, and
‘happy hour’ beverages, presented in a social milieu, are
10:33 AM Page 19
options for anorectic patients who are still able to eat (Wood
P, Vogen BD. Geriatr Nurs 1998;19:192-194).
A better understanding by healthcare professionals of
the role food and eating play in quality of life will improve
care for patients on long-term PEN. More research that
addresses food and nutrition issues is needed to assess and
improve quality of life (Baxter JP, et al. Br J Nutr 2005;94:
633-638).
Use of immune-modulating
formulas to treat critically
ill children
P Goday
Milwaukee, WI, USA
Recent studies in Greece and Chile compared immuno-
enhancing formulas (IEF) with conventional early enteral
nutrition in critically ill children. One study in a pediatric
intensive care unit (ICU) in Greece randomized 50 children
Highlights of Clinical
to receive IEF or a control formula (Briassoulis G, et al.
Nutrition Week
Nutrition 2005;21:799-807). The study found IEF were not
as well tolerated as conventional early enteral nutrition, but
their use was feasible in children. Mortality and length of
stay did not differ between the two groups, though the IEF
group showed trends toward increased nutritional indices
and antioxidant catalysts and fewer nosocomial infections.
Appropriate modifications for specific age populations might
improve formula tolerability and benefits among children.
The same group compared nutritional and metabolic
measures along with various other outcomes (survival,
length of stay, and ventilator days) in 40 mechanically venti-
lated children with severe head injury receiving an IEF vs a
regular formula (Briassoulis G, et al. Pediatr Crit Care Med
2006;7:56-62). Interleukin-8 levels were lower in the IEF
group than in the regular formula group (p < 0.04), and
the IEF group had fewer positive gastric cultures
(p < 0.02). However, there was no difference in nosocomial
infections, length of stay, length of mechanical ventilation,
or survival, and, thus, no additional advantage of IEF over
regular early enteral nutrition.
Supplemental enteral arginine had no effect on meta-
bolic response in children admitted to a pediatric burn center
in Chile (Marin VB, et al. Nutrition 2006;22:705-712). There
were no differences in levels of interleukin-1 or -6, tumor-
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
necrosis factor (TNF)-α, C-reactive protein, prealbumin,
albumin or glucose; however, nitrogen-stimulated lymphocyte
proliferation did improve. Researchers concluded that the
benefits of arginine supplementation for the immune system
do not appear to be related to a metabolic response.
Based on work with immune-enhancing diets in adults
and the few available pediatric studies, glutamine and
antioxidants show the most promise for immune-modulat-
ing formulas for children.
19
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07 10:33 AM
Pancreatitis in critically ill children
MA Corkins
Indianapolis, IN, USA
Pancreatitis in children has multiple etiologies, including
trauma, structural anomalies, drug use, viral illnesses,
hereditary disorders, complications of multisystem
disorders, and idiopathic triggers (Benifla M, Weizman
Z. J Clin Gastroenterol 2003;37:169-172). The mortal-
ity rate of severe pancreatitis is 2–10% in children. A
pediatric-specific scoring system has been developed
to predict severity of pancreatitis in children and guide
clinical therapy (DeBanto JR, et al. Am J Gastroenterol
2002;97:1726-1731).
In mild pancreatitis, oral feedings can be started
with caution when symptoms begin to improve and
amylase and lipase levels begin to decrease. Enzyme
levels do not have to be normal to begin feedings.
In the pediatric patient who has more severe
Highlights of Clinical
pancreatitis but not an ileus, controversy exists on
Nutrition Week
whether to begin enteral feedings within 24 hours or to
wait 3–4 days. Patients with severe acute pancreatitis
and the presence of an ileus require parenteral nutrition
support until they begin to improve.
As ileus resolves, patients should receive jejunal feed-
ings to minimize pancreatic stimulation, though it
is difficult to obtain nasojejunal tube placement in
children. A meta-analysis of six studies of adult patients
with pancreatitis who received enteral feedings showed
better results compared with patients who received
parenteral nutritional (lower incidence of infection, reduced
need for surgical intervention and fewer hospital days)
(Marik PE, Zaloga GP. BMJ 2004;328:1407-1410);
however, pediatric data remain sparse.
One randomized trial showed better outcomes
with semi-elemental feedings in severe pancreatitis than
with polymeric feedings (Tiengou LE, et al. JPEN J
Parenter Enteral Nutr 2006;30:1-5). There are no stud-
ies on IEF in children with acute pancreatitis.
Acute injury response and
nutritional support in critically
ill infants
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
WJ Chwals
Cleveland, OH, USA
Hyperglycemia in the pediatric patient with sepsis is
associated with increased morbidity and mortality, and
longer length of hospital stay (Hall NJ, et al. J Pediatr
Surg 2004;39:898-901). The acute metabolic stress
response to injury contributes to hyperglycemia by
inducing a cascade of metabolic events, which increase
blood sugar levels, enhance gluconeogenesis, suppress
insulin production, and promote insulin resistance.
20
Page 20
Excess calories are another significant cause of
hyperglycemia and, during stress, can further increase
the metabolic demands of acute injury and increase
mortality (Alaedeen DI, et al. J Pediatr Surg 2006;
41:239-244). Therefore, calorie intake should not
exceed demand during acute metabolic response in criti-
cally ill pediatric patients.
During the catabolic response to injury, a child’s
caloric requirements drop markedly as somatic growth
stops. The younger the child is, the more significant
is this effect due to the relatively greater rate of
growth. Critically ill children frequently require
mechanical ventilation, and are sedated and main-
tained in temperature-controlled environments.
Together, these factors substantially reduce energy
needs. In one study of critically ill children, actual
measured energy expenditure averaged 50% of
predicted requirement (Chwals WJ, et al. J Surg Res
1988;44:467-472).
Using indirect calorimetry to measure energy
expenditure and providing only basal caloric support
can avoid overfeeding children during acute metabolic
stress. In the absence of indirect calorimetry, published
basal energy requirements based on age, weight and
gender offer reasonable guidelines for basal energy
requirements. Equations that incorporate metabolic
stress variables (such as body temperature) provide a
more accurate alternative to current predictive methods
in assessing energy requirements of ventilated, critically
ill children (White MS, et al. Crit Care Med 2000;28:
2307-2312).
Bowel sounds: Are they worth
waiting for?
RG Martindale
Portland, OR, USA
Bowel sounds traditionally have been used as evidence
that the bowel is functional and it is ‘safe’ to start
enteral feeding. Interestingly, this long-held belief is not
supported by evidence. In critically ill or postoperative
patients, no firm evidence is available to support with-
holding enteral feedings until bowel sounds are heard.
Bowel function and bowel sounds usually return
quickly after abdominal surgery (Shibata Y, et al.
World J Surg 1997;21:806-809).
Ileus, or postoperative bowel dysfunction, results
from a sequence of events that activate proinflamma-
tory cytokines and mediators in the muscularis of the
bowel, which alter normal peristalsis and motility
(Kalff JC, et al. Ann Surg 2003;237:301-315).
The occurrence and duration of ileus vary widely
in the ICU setting due to heterogeneity in the popula-
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07
tion, ie, variation in stressors, medications and co-
morbidities. Patients with pancreatitis, ongoing
peritonitis, and increased intracranial pressure develop
ileus more frequently, and dysmotility commonly
persists longer in these disease states.
Ileus is optimally managed by correcting elec-
trolyte abnormalities, maintaining meticulous glycemic
control, and minimizing the use of agents known to
decrease gut motility.
Many studies support the benefits of early enteral
feedings (<48 hours). Artinian and colleagues recently
reported a decrease in mortality when patients are fed
within 48 hours (Chest 2006;129:960-967). It is impor-
tant to evaluate the entire clinical situation, but, in
general, feedings should be held only in patients with
high-pitched tingling bowel sounds and nausea, as this
may indicate ileus and an obstructive pattern.
Otherwise, bowel sounds are not useful as the only
indicator of bowel dysfunction. In the majority of
patients, feedings should be started after adequate
resuscitation and not be delayed due to the absence of
bowel sounds or flatus. Prokinetics are not recom-
mended or required to initiate early enteral feedings.
Evaluate patient tolerance to feedings by monitoring
nasogastric tube output, distention, pain, glycemic
control, diarrhea and pneumatosis (Kozar RA, et al. J
Surg Res 2002;104:70-75). Advance feedings based on
the patient’s clinical condition, not on evidence from
bowel sounds.
Observations over 20 years on
the effects of TPN on the
gastrointestinal mucosal barrier:
Have we been barking up the
wrong tree?
WS Helton
New Haven, CT, USA
Parenteral nutrition is associated with increased
susceptibility to infection, caused by changes in
gastrointestinal (GI) mucosal defense and bacterial
translocation. Early work in understanding the mecha-
nism of action focused on changes in the anatomy and
physiology of the GI system, including villus morphol-
ogy, pancreatic exocrine function, gut hormones and
gut permeability. Studies showed total parenteral
nutrition (TPN) was associated with increases in endo-
toxin transport across the small bowel (Gonnella PA,
et al. Eur J Cell Biol 1992;59:224-247), increased gut
counter-regulatory hormones and cytokine response
(Fong YM, et al. Ann Surg 1989;210:449-456), and
gut atrophy. However, none of the changes seen
explained why bacterial translocation occurs.
10:33 AM Page 21
This led investigators to focus on changes in gut,
peritoneal and systemic immunity. While glutamine and
various peptides and hormones were shown to prevent
TPN-induced gut atrophy, they did not affect bacterial
translocation. This indicated that intestinal barrier
dysfunction and bacterial translocation during intra-
venous feeding are related to factors other than gut
atrophy (Helton WS, Garcia R. Arch Surg 1993;128:
178-183).
Later observations showed TPN impairs a variety
of macrophage functions and increases TNF release,
endotoxin transport across the gut wall, and death in
rodents injected with endotoxin. TPN is associated with
increased activation of the sympathetic nervous system
and increased incidence of fatty liver (Helton WS, et al.
Arch Surg 1995;130:209-214. Johnson KM, et al. Arch
Surg 1995;130:1294-1299).
Studies have identified changes in gut luminal
Highlights of Clinical
bacterial ecology and changes in the pathogenecity of
Nutrition Week
Enterobacteriaceae during periods of stress and
parenteral feeding (Lyte M, et al. Biochem Biophys Res
Commun 1997;232:682-686). These offer greater insight
into the pathophysiology associated with increased inci-
dence of infection in patients dependent on parenteral
nutrition.
Mechanisms by which intestinal
bacteria sense host stress and
nutritional status and respond
accordingly
JC Alverdy
Chicago, IL, USA
New studies show intestinal bacteria have the ability to
detect when a host is under extreme physiologic stress
and respond to changes in their microenvironment by
enhancing their virulence genes (Wu L, et al. Science
2005;309:774-777). These changes in bacterial gene
expression may be responsible for the high incidence of
fatality from Pseudomonas aeruginosa, a hospital-
acquired pathogen.
Patients with systemic inflammatory response
syndrome (SIRS) have changes in the normal gut
microflora and much higher levels of pathogenic
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
Staphylococcus and Pseudomonas spp than healthy
volunteers (Shimizu K, et al. J Trauma 2006;60:126-
133). During stress, inflammation, or nutrient depletion,
the P aeruginosa outer membrane protein, OprF, binds
specifically to cytokine interferon-gamma (IFN-γ) and
upregulates production of lethal virulence factor PA-1
(Wagner VE, et al. Trends Microbiol 2006;14:55-58).
Once activated, PA-1 acts as a pathogen in the gut, erod-
ing the protective barrier of the intestinal tract. Potent
21
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07 10:33 AM
endotoxins of the pathogen can then cross the gut wall
to the bloodstream where they are transported to the
lung and adhere to lung tissue, resulting in lethal
systemic sepsis. Thus, the endotoxin alone is not respon-
sible for death in critically ill and immunocompromised
patients; rather mortality is related to the degree of
stress which triggers upregulation of the endotoxin’s
virulence genes (Laughlin RS, et al. Ann Surg 2000;232:
133-142).
New research is focused on developing mechanisms
that interfere with the host-to-bacterial signaling path-
way, thereby rendering the bacteria insensitive to host
stress. By using substances that act as an intestinal mucin
and prevent bacteria from adhering to the intestinal
epithelium, it may be possible to protect against
Pseudomonas. Such a mechanism would contain rather
than eliminate potential pathogens, and may decrease
antibiotic usage and the incidence of virulent nosocomial
Highlights of Clinical
infections.
Nutrition Week
Nutrition and mucosal immunity
KA Kudsk
Madison, WI, USA
In trauma patients, enteral feeding significantly reduces
the complications of pneumonia compared with intra-
venous feedings. Both route of administration and type of
nutrition influence antibacterial respiratory tract immu-
nity (King BK, et al. Ann Surg 1999;229:272-278).
Dr Kudsk suggests that there is an immunologic
link between the GI and respiratory tracts – the common
mucosal immune hypothesis (Kudsk KA. Am J Surg
2003;185:16-21). Secretory immunoglobulin A (IgA) is
the principal specific immunologic defense at mucosal
surfaces. It produces antibodies that bind to bacteria in
the intestine and other sites, such as the respiratory tract,
preventing bacteria from attaching and, hence, causing
infection. The principal anatomic site for immunologic
sensitization is within the small intestine.
The route and type of nutrition affects the size and
function of most of the molecules involved in the produc-
tion of IgA. These include T and B cells, which are
sensitized to produce IgA, and gut-associated lymphoid
tissue (GALT), which is the site of T and B cell activation
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
(Janu P, et al. Ann Surg 1997;225:707-715). Nutrition
also affects adhesion molecules that direct unsensitized
T and B cells to the activation site, as well as most of the
molecules in the GALT, especially the cytokines IL-4 and
IL-10. Each is critical to intact mucosal immunity.
Parenteral nutrition reduces the mass and function
of most molecules in the GALT. These changes reduce the
production of IgA, which, in turn, negatively impacts both
the gut and respiratory tract. On the other hand, enteral
22
Page 22
nutrition induces recovery of immunologic function
(Ikeda S, et al. Ann Surg 2003;237:677-685. Genton L, et
al. JPEN J Parenter Enteral Nutr 2005;29:44-47).
Initiation and management of
nutrition support in the patient
with cancer
C Anastasio
Valley Stream, NY, USA
Perioperative nutrition support that is adequate in quality,
quantity and duration has a positive effect on patients
with GI cancer who are moderately to severely malnour-
ished. These findings are consistent with ASPEN’s
guidelines for nutrition support in adults with cancer.
Intensive nutrition counseling by a dietitian using a
standard protocol and oral supplements, if required,
resulted in statistically less weight loss and improved
quality of life in patients with head and neck and GI
cancer compared with the usual practice of giving general
advice and a nutrition booklet (Isenring EA, et al. Br J
Cancer 2004;91:447-452).
In the most comprehensive study to date, periopera-
tive nutrition support that provided 25 non-protein
calories/day reduced surgical complications and mortality
in moderately or severely malnourished GI cancer patients
(Wu GH, et al. World J Gastroenterol 2006;21:2441-
2444). This study was the first to look at patients who
achieved and maintained full feedings.
A nutrition pathway that includes early and regular
nutrition assessment, enteral nutrition intervention and
multidisciplinary nutrition care results in improved treat-
ment tolerance for patients with esophageal cancer
receiving chemoradiation (Odelli C, et al. Clin Oncol [R
Coll Radiol] 2005;17:639-645).
Nutritional supplements containing eicosapentaenoic
acid (EPA) have been shown to be beneficial in malnour-
ished patients. EPA interferes with mechanisms implicated
in the pathogenesis of cancer cachexia, and has been asso-
ciated with reversal of cachexia and improved survival
(Argiles JM. Eur J Oncol Nurs 2005;9[suppl 2]: S39-S50).
The challenge of nutritional
intervention for the dialysis patient
E Moore
Parma, OH, USA
Malnutrition affects up to half of all chronic dialysis
patients and is an important predictor of mortality, but
the efficacy of nutrition support interventions in dialysis
patients has been poorly studied (Mehrotra R, Kopple
JD. Annu Rev Nutr 2001;21:343-379).
Oral supplements and enteral nutrition have been
shown to be safe and efficacious in patients with chronic
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07
kidney disease receiving maintenance dialysis. In a small
retrospective analysis of chronic hemodialysis (HD)
patients, enteral tube feeding resulted in improved
biochemical data and/or weight gain (Holley JL, Kirk J.
J Ren Nutr 2002;12:177-182). Hypophosphatemia was
common and suggests that a non-renal enteral formula
may be useful to prevent hypophosphatemia in some
patients.
A recent meta-analysis of 18 studies suggests that
enteral support significantly increases serum albumin
concentrations and improves total dietary intake with
little effect on serum phosphate and potassium (Stratton
RJ, et al. Am J Kidney Dis 2005;46:387-405). Few stud-
ies reported clinical outcome, and there was insufficient
information to compare disease-specific versus standard
formulas, or enteral versus parenteral nutrition.
Results of studies on enteral nutrition in peritoneal
dialysis (PD) patients are less conclusive. One case study
showed long-term tube feeding of a high-calorie, high-
protein, low electrolyte formula was well tolerated and
resulted in improved albumin levels and weight gain
(Patel MG, Raftery MJ. J Renal Nutr 1997;7:208-211).
In contrast, a retrospective analysis of 10 PD patients
who required placement of percutaneous endoscopic
gastrostomy (PEG ) feeding tubes suggested PEG feeding
is associated with frequent complications (Fein PA, et al.
Adv Perit Dial 2001;17:148-152) PEG placement prior
to PD initiation appears to be safe. However, patients
who require PEG placement after PD has begun are at
higher risk of peritonitis and should be given antifungal
prophylaxis and maintained on HD for longer than
6 weeks after PEG placement.
Permissive underfeeding in the
critically ill patient
N Huff, L Tritt
Indianapolis, IN, USA
Permissive underfeedings, or the use of hypocaloric, high-
protein enteral or parenteral nutrition, may significantly
improve outcomes in critically ill patients (Dickerson RN.
Curr Opin Clin Nutr Metab Care 2005;8:189-196).
Underfeeding may reduce cytokine and inflammatory
responses, attenuate impact of exposure to toxins, and
reduce hyperglycemia, seen when patients receive 100% of
estimated needs during the initial phase of inflammation.
Reduced nutrient intake can also maintain GI tract integrity.
Recent studies in critically ill patients show short-term
permissive underfeeding of 9–18 kcal/kg/d, or 33–66% of
estimated needs, is associated with fewer infections and
ventilator days, and shorter lengths of stay than with
higher levels of calorie intake (Krishnan JA, et al. Chest
2003;124:297-305. Ash JL, et al. JPEN J Parenter Enteral
10:33 AM Page 23
Nutr 2005;29:S10-S11. Dickerson RN, et al. Nutrition
2002;18:241-246).
Rubinson et al found feeding less than 25% of recom-
mended energy intake increases risk for nosocomial
bloodstream infection (Rubinson L, et al. Crit Care Med
2004;32:350-357). Thus, there appears to be a minimum
level of feeding to minimize risk.
Current guidelines for underfeeding call for feeding
early, within 24 hours of admission; providing 33–66% of
calculated needs for 3–5 days; and increasing feeding to
100% of calculated needs over the next 3–5 days.
Scientific Paper Session –
Abstract of Distinction
Early enteral feeding of the open
abdomen – nutritional provision,
fistulae preventer, and abdomen
Highlights of Clinical
closer?
Nutrition Week
BR Collier
Nashville, TN, USA
This study evaluated the effect of early enteral feedings,
initiated within 4 days of admission, in patients with open
abdomens after celiotomy. The study included 57 patients
who underwent celiotomy and subsequently required an
open abdomen for at least 3 days, survived to discharge and
had available nutrition data. Seventy-nine percent of
patients had suffered blunt trauma; 21% had suffered gun
shot wounds.
In the study group, 53% (30 of 57) had early enteral
nutrition initiated and met 53% of calorie goal by day 4.
Two of the 30 patients (6.7%) with early enteral feeding
developed fistulae, compared with 5 of 27 (18.5%) of the
group with later feedings who formed fistulae. There were
no differences in mean injury severity scores, abdominal
abbreviated injury scores, initial base deficits, and initial
transfusion requirements. Seventy-seven percent (23 of 30)
of patients with early enteral feedings had the abdominal
cavity closed early, defined as within 8 days of initial
surgery; while 10 of 17 (59%) patients with later feedings
were closed early (p = 0.002).
This study showed that early initiation of enteral
nutrition with open abdomen care trends toward a lower
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2
fistulae rate and is associated with earlier closure of the
abdominal cavity.
The views expressed in this newsletter are of the
presenters and participants, not Nestlé Nutrition.
The next Clinical Nutrition Week will be held on
10–13 February 2008 in Chicago, Illinois, USA.
Further information may be found at www.nutritionweek.org.
23
CH-NES-008a(Ver7).qxd:CH-NES-008a_InsidePages.qxd 7/10/07 10:33 AM Page 24

Conference Calendar 2007

September 12th Congress of the Parenteral and

Enteral Nutrition Society of Asia
29th European Society for Clinical
(PENSA)
Nutrition and Metabolism (ESPEN)
Congress 17–20 October 2007
Manila, Philippines
8–11 September 2007
Organizer:
Prague, Czech Republic
PHILSPEN Secretariat
Organizer: Tel: +632 723 0101 local 5714
MCI Suisse SA Fax: +632 725 6868
Tel: +41 22 339 9580 E-mail: philspen_sec@yahoo.com
Fax: +41 22 339 9601 Web site: www.pensa2007.org
E-mail: espen2007@mci-group.com
Web site: www.espen.org
20th North American Society for
Pediatric Gastroenterology,
43rd Annual Meeting of the European
Hepatology, and Nutrition (NASPGHAN)
Association for the Study of Diabetes
Annual Meeting
(EASD)
25–27 October 2007
17–21 September 2007
Salt Lake City, Utah, USA
Amsterdam, The Netherlands
Organizer:
Organizer:
NASPGHAN
Eurocongres Conference Management
Tel: +1 215 233 0808
Tel: +31 20 679 3411
Fax: +1 215 233 3918
Fax: +31 20 673 7306
E-mail naspghan@naspghan.org
E-mail: easd@eurocongres.com
Web site: www.naspghan.org
Web site: www.easd.org
Conference Calendar

39th Annual Congress of the

ADA Food & Nutrition Conference &
International Society of Paediatric
Expo (FNCE) 2007
Oncology (SIOP)
29 September – 2 October 2007
Philadelphia, Pennsylvania, USA 29 October – 3 November 2007
Mumbai, India
Organizer:
American Dietetic Association Organizer:
Tel: +1 312 899 0040 Varriance Conferences and Events
E-mail: fnce2007@eatright.org Tel: +91 22 2438 1068
Web site: www.eatright.org/FNCE2007 Fax: +91 22 2438 5021
E-mail: siop2007@varriance.com
Web site: www.varriance.com/siop2007
October
20th European Society of Intensive November
Care Medicine (ESICM) Annual
2007 Annual Conference of the British
Congress
Association for Parenteral and Enteral
7–10 October 2007 Nutrition (BAPEN)
Berlin, Germany
27–28 November 2007
Organizer:
Harrogate, United Kingdom
ESICM Congress Manager
Tel: +32 2 559 0355 Organizer:
CLINICAL NUTRITION HIGHLIGHTS • 2007 • Volume 3, Issue 2

Fax: +32 2 527 0062 Sovereign Conference

E-mail: public@esicm.org Tel: +44 (0) 1527 518 777
Web site: www.esicm.org Fax: +44 (0) 1527 518 718
E-mail: enquiries@sovereignconference.co.uk
Web site: www.bapen.org.uk

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