Am J Clin Nutr-1997-Klein-683-706

Nutrition Support in Clinical Practice: Review of Published Data and
Recommendations for Future Research Directions
Summary of a Conference Sponsored by the National Institutes of Health, American Society for
Parenteral and Enteral Nutrition, and American Society for Clinical Nutrition
SAMUEL KLEIN, MD; JohN KINNEY, MD; KHURSHEED JEEJEEBHOY, MB, BS, PiiD; DA\ID ALPERS, MD; MARK HELLERSTEIN, MD, Th-ID;
MICHAEL MURRAY, MD, PiiD; PATRICK TWOIEY, MD; AND 0THERS*
ABSTRAC’fl In the last 30 years, marked advances in enteral further investigation. The panel was divided into five groups to
feeding techniques, venous access, and enteral and parenteral evaluate the following areas: nutrition assessment, nutrition sup-
nutrient formulations have made it possible to provide nutrition port in patients with gastrointestinal diseases, nutrition support
support to almost all patients. Despite the abundant medical lit- in wasting diseases, nutrition support in critically ill patients, and
erature and widespread use of nutritional therapy, many areas of perioperative nutrition support. The findings from each group
nutrition support remain controversial. Therefore, the leadership are summarized in this report.
at the National Institutes of Health, The American Society for This document is not meant to establish practice guidelines for
Parenteral and Enteral Nutrition, and The American Society for nutrition support. The use of nutritional therapy requires a care-
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Clinical Nutrition convened an advisory committee to perform a ful integration of data from pertinent clinical trials, clinical ex-
critical review of the current medical literature evaluating the pertise in the illness or injury being treated, clinical expertise in
clinical use of nutrition support; the goal was to assess our cur- nutritional therapy, and input from the patient and his/her family.
rent body of knowledge and to identify the issues that deserve (Journal ofParenteral and Enteral Nutrition 21:133-156, 1997)
In the past 30 years, marked advances in enteral feeding literature and make recommendations for future research
techniques, venous access, and enteral and parenteral nutri- directions.
ent formulations have made it possible to provide nutrition The panel was divided into five groups to evaluate the fol-
support to almost all patients. Information regarding the use lowing areas: (1) nutrition assessment, (2) nutrition support
of nutrition support has increased dramatically. In the past in patients with gastrointestinal diseases, (3) nutrition sup-
20 years, there has been a 10-fold increase in the annual rate port in wasting diseases, (4) nutrition support in critically ill
ofenteral and parenteral nutrition-related publications, from patients, and (5) penoperative nutrition support. The find-
50 per year in the early 1970s to 525 per year in the early ings from each group are summarized in this report. Each
1990s. The sophistication of nutrition technology has made section represents a critical review of the available literature
clinical nutrition agrowing medical subspecialty with its own and contains suggestions for future research. Whenever pos-
societies and journals. Despite the abundant medical litera- sible, prospective randomized clinical trials (PRCTh) were
ture and widespread use of nutritional therapy, many areas evaluated because this is the most reliable method for evalu-
ofnutrition support remain controversial. Therefore, the lead- ating clinical efficacy of a treatment. However, other pub-
ership at the National Institutes ofHealth, The American So- lished reports were also reviewed when appropriate PRCTs
ciety for Parenteral and Enteral Nutrition, and The Amen- were not available. Each conclusion was graded on the basis
can Society for Clinical Nutrition concurred that a critical of the strength of the supporting data, as follows: A = sup-
review of the current medical literature evaluating the cmi- ported by PRCTs or meta-analyses of PRCTh; B = supported
cal use ofnutrition support was warranted to assess our cur- by well-designed nonrandomized prospective, retrospective,
rent body of knowledge and to identify the issues that de- or case cohort controlled studies; and C = supported by un-
serve further investigation. To this end, an advisory committee controlled published experiences, case reports, or expert
representing the three organizations was formed, and a panel opinion.
of experts were recruited to review the current published This document is not meant to establish practice guide-
lines for nutrition support. The use of nutritional therapy re-
quires a careful integration of data from pertinent clinical
*See appendix. trials, clinical expertise in the illness or injury being treated,
clinical expertise in nutritional therapy, and sometimes in-
The opinions presented in this report are those of the authors and do not put from the patient and his/her family.
necessarily represent the opinions of the National Institutes of Health,
the American Society for Clinical Nutrition, or A.S.P.E.N.
NUTRITION ASSESSMENT
Received for publication, April 14, 1997
The field of nutrition support is based on two closely re-
Accepted for publication, April 17, 1997
Correspondence: Samuel Klein, MD, Washington tniversity School of Men- lated concepts: (1)nutrient depletion is associated with in-
cine, 660 South Euclid Avenue, Box 8127, St. Louis, MO 63110-1093. creased morbidity and mortality, and (2) ifthis association is
Am J Clin Nuir 1997:66:683-706. Printed in USA. 0 1997 American Society for Clinical Nutrition 683
684 NUTRITION SUPPORT IN CLINICAL PRACTICE
causative, the prevention or correction of nutrient deple- However, it can be difficult to determine true weight loss
tion can minimize or eliminate malnutrition-related mor- because of errors in recall. Morgan et al7 found that 33% of
bidity and mortality. This construct leads to three poten- patients with weight loss would be missed and 25% of
tial goals of nutrition assessment: weight-stable patients would be diagnosed as having lost
1. To identify patients who have, or are at risk of de- weight when weight loss is based on patient recall. Further-
veloping, protein-energy malnutrition or specific nu- more, small changes in body weight can be confounded by
trient deficiencies. changes in hydration status.
2. To quantify a patient’s risk of developing malnutri-
tion-related medical complications. Anthropometry
3. To monitor the adequacy of nutritional therapy.
Thceps and subscapular skinfold thicknesses provide an
This section concentrates on goal 2 because it was con-
index of body fat, and midarm muscle circumference pro-
sidered by the subcommittee to be the most important.
vides a measure of muscle mass. The most commonly used
At some point, the presence of protein-energy malnutri-
standards for triceps skinfold thickness and midarm muscle
tion or specific nutrient deficiencies increases morbid-
circumference are those reported by Jelliffe,8 which are based
ity and mortality. However, the ability to use nutrition
on measurements of European military men and low-income
assessment to predict clinical outcome can be problem-
American women, and those reported by Frisancho,9 which
atic because the interaction between malnutrition and
are based on measurements of white males and females par-
other factors that influence outcome makes it difficult
ticipating in the 1971-1974 US Health and Nutrition Survey.
to isolate any putative contribution from malnutrition
The use of these standards to identify malnutrition in many
alone. For example, illness and injury can affect tissue
patients is problematic because of the restricted database
metabolism and accelerate loss of tissue function and

and the potential confounding influence of age, hydration
mass. Inadequate protein and energy intake can also lead
status, and physical activity. Several studies have demon-
to alterations in intermediary metabolism, tissue func-
strated that 20% to 30% ofhealthy control subjects would be
tion, and body composition. Therefore, the presence of
considered malnourished on the basis ofthese standards’#{176}”
“malnutrition” can contribute to a poor clinical outcome
and that there is poor correlation between Jellife’s and
or may simply be associated with a poor outcome if the
Frisancho’s standards in classifying ts’ Furthermore,
disease itself affects markers of “nutritional status.”
interpretation of the data may be limited by inter-rater van-
The problem of malnutrition in hospitalized patients
ability’2 and the patient’s hydration status. Nevertheless,
was highlighted by several publications in the 1970s)
markedly abnormal values (below the 5th percentile) are
The high prevalence of malnutrition and the introduc-
often associated with poor clinical outcome.
tion of modern enteral and parenteral feeding techniques
in the 1970s and 1980s stimulated the development of
Creatinine-Height Index
several formal approaches for evaluating nutritional sta-
tus. All these approaches link nutrition assessment with The excretion of creatinine in urine provides an index of
clinical outcome. lean body ass’3 However, it is dependent upon an accurate
and complete urine collection while the patient is consum-
NUTRITIONAL ASSESSMENT TECHNIQUES
ing a meat-free diet, which can be difficult to achieve in some
patient care settings.
Body Composition Analyses
The body consists of35 components, which are organized Serum Protein Concentrations
into five levels of increasing complexity: atomic (eg, nitro- Albumin. Several studies have demonstrated that a low
gen, potassium); molecular (eg, water, protein); cellular (eg,
serum albumin concentration correlates with an increased
body cell mass, intracellular and extracellular fluid); tissue
incidence ofmedical complications.’4’6 Sick patients may
(eg, skeletal muscle, adipose tissue); and whole body (eg,
have low levels of serum albumin for several reasons.’7
weight, height). Although modern technology now allows
Inflammatory disorders cause a decrease in albumin syn-
measurement of all major body components in vivo, these
thesis, an increase in albumin degradation, and an increase
methodologies are not readily available for clinical use. Fur-
in albumin transcapifiary losses. Gastrointestinal and some
thermore, no body composition measurement has been
cardiac diseases increase albumin losses through the gut,
shown to consistently predict clinical outcome.
and renal diseases can cause albuminuria Wounds, burns,
and peritonitis cause major losses from the injured sur-
Body Weightand Weight Loss
face. Because the exchange between intravascular and ex-
Body weight is a practical measure and
of totalsimple travascular albumin is so large, even small variations in
body components. Weight with an “ideal”
can be compared the percentage of exchange can cause significant changes
or “desirable” weight, or assessment of body mass index in plasma albumin levels. The normal rate of albumin ex-
[weight (kg)/height(m)2 can be used to determine both un- change between intravascular and extravascular compart-
dernutrition and overnutrition. However, measurement of ments is more than 10 times the rate of albumin synthesis
body weight in sick patients is confounded by changes in or degradation. During serious illness, vascular permeabil-
body water because ofdehydration, edema, and ascites. Fur- ity increases dramatically. Albumin losses from plasma to
thermore, a person who starts at the upper end of the nor- the extravascular space were increased twofold in patients
mal range may be classified as “normal” despite consider- with cancer cachexia and threefold in patients with septic
able changes in the measured value. shock. Plasma albumin levels are usually not affected by
Unintentional weight loss greater than 10% within the pre- nutritional intake and will not increase in stressed patients
vious 6 months is a good prognosticator ofdllnical outcome.6 until the inflammatory stress ts’8
INTERSOCIETY COMMUNICATION 685
Serum albumin may not be a good measure of the ad- nutrient deficiencies and patients who are at high risk for
equacy of nutrient intake. Although protein-energy mal- future nutritional abnormalities. The ability of this ap-
nutrition causes a decrease in the rate of albumin synthe- proach to reliably identify patients at increased risk for
sis, this may have little impact on albumin levels because medical complications has not been evaluated in clinical
of albumin’s long half-life and large pool size. Indeed, studies.
plasma albumin concentration may actually increase dur-
ing short-term fasting because of contraction of intravas- Subjective Global Assessment
cular water.’9 Even during chronic malnutrition, plasma
Subjective global assessment (SGA) is a clinical method
albumin concentration is often nmintained because of a
for evaluating nutritional status that encompasses histori-
compensatory decrease in albumin degradation and a
cal, symptomatic, and physical parameters.#{176}3’ The SGA
transfer of extravascular albumin to the intravascular corn-
technique determines whether (1) nutrient assimilation has
partment. Prolonged protein-energy restriction induced
been restricted because of decreased food intake,
experimentally in human volunteers20 or observed clini-
maldigestion, or malabsorption, (2) any effects of malnu-
cally in patients with anorexia nervosa2’ causes marked
trition on organ function and body composition have oc-
reductions in body weight but little change in plasma
curred, and (3) the patient’s disease process influences
albumin concentration. A protein-deficient diet with
nutrient requirements. The findings of the history and
adequate calories in elderly persons decreases lean body
physical examination are subjectively weighted to rank
mass and muscle function without a change in plasma al-
patients as being well-nourished, moderately malnour-
bumin concentration.22
ished, or severely malnourished and is used to predict their
Prealbumin. Prealbumin is a transport protein for thy-
risk for medical complications. The use of SGA in evaluat-
roid hormones and exists in the circulation as a retinol-

ing hospitalized patients has been shown to give repro-
binding-prealbumin complex. The turnover rate of this
ducible results with more than 80% agreement when two
protein is rapid, with a half-life of 2 to 3 days. It is synthe-
blinded observers assessed the same patient.’#{176}” In pro-
sized by the liver and is catabolized partly in the kidneys.
spective studies, SGA was a good predictor of complica-
Protein-energy malnutrition reduces the levels of
tions in general surgical patients,’#{176} patients undergoing
prealbumin, and refeeding (particularly with carbohydrate)
liver transplantation,32 and patients on dialysis.#{176} In one
restores levels.23 However, prealbumin levels decrease
study, preoperative SGA was found to be a better predic-
without malnutrition in infections24 and in response to
tor of postoperative infectious complications than serum
cytokine25 and hormone infusion.2 Renal failure in-
albumin, serum transferrin, DCH, anthropometry, creati-
creases,27 while liver failure may decrease, plasma con-
nine-height index, and the prognostic nutritional index.14
centrations.
Combining SGA with some of the “traditional” markers of
nutritional status, such as serum albumin, DCH, and crea-
Immune Competence
tinine-height index, increased (from 82% to 90%) the abil-
Immune incompetence, as measured by delayed cuta- ity to identify patients who developed complications but
neous hypersensitivity (DCH), has been shown to be as- also increased (from 25% to 30%) the percentage of pa-
sociated with a poor clinical outcome. Although DCH is tients identified as “malnourished” but who did not de-
affected by severe malnutrition, several diseases and drugs velop a postoperative complication. Therefore, combin-
influence DCH, making it a poor measure of malnutrition ing nutrition assessment techniques increases sensitivity
in sick patients. The following factors alter DCH in the but may also increase the number of patients who might
absence ofmalnutrition: (1) infections (viral, bacterial, and receive unnecessary nutrition support.
granulomatous); (2) illnesses (uremia, cirrhosis, hepati-
tis, trauma, burns, and hemorrhage); (3) medications (cor-
Muscle Function
ticosteroids, immunosuppressants, cimetidine, warfarin,
and perhaps aspirin); and (4) general anesthesia and sun- Muscle function tests represent the newest approach
gery. Therefore, in the severely ill patient many factors for evaluating nutritional status and include measuring grip
can alter DCH independent of nutritional status; correct- strength, respiratory muscle strength, and the response
ing the underlying medical problem can reverse anergy. ofspecific muscles to electrical stimulation. Starvation and
refeeding causes specific alterations in adductor pollicis
Discriminant Function Analysis muscle response to electrical stimulation. Furthermore,
changes in muscle function induced by nutritional therapy
Mathematical equations, developed by use of stepwise
occur rapidly and before there are any changes in body
multiple regression analyses of selected “nutritional” pa-
nitrogen or protein content.’ In one study, the combina-
rameters, have been used as an objective measure to iden-
tion of an abnormal force-frequency curve and slow re-
tify patients at increased risk for medical complications.28#{176}
laxation rate was more specific and sensitive than other
However, only the Prognostic Nutritional Index-based
parameters of nutritional status, such as arm muscle cir-
on serum albumin, serum transfernin, triceps skinfold
cumference, serum albumin, and transfernin concentra-
thickness, and DCH-has been shown to predict clinical
tions, as a preoperative predictor of postoperative corn-
outcome in a prospective evaluation.28
plications. Hand grip, respiratory muscle strength, and
relaxation rate of the adductor pollicis have also been
Clinical Assessment
shown to be better than weight loss as a predictor of post-
The clinical assessment of nutritional status involves a operative complications.37 It is not known whether restor-
focused history and physical examination in conjunction ing muscle function with nutritional therapy improves clini-
with selected laboratory tests aimed at detecting specific cal outcome.
Special Considerations in Pediatric Patients
Nutrition concerns in infants and children differ from

those in adults primarily because children are growing.
Slowing of normal growth velocity, which equates to slow- 1. Malnutrition is a continuum that starts with mad-
ing of normal weight velocity, is an important and early equate nutrient intake, followed by a progressive se-
consequence of undernutrition. However, as in adults, nies ofmetabolic, functional, and body compositional
weight loss is a nonspecific marker that may be influenced changes. (B)
by stress and disease. Restoration of normal growth ye- 2. There is no “gold standard” for determining nutri-
locity and “catch-up” growth may also reflect improvement tional status because (a) there is no universally ac-
in disease status but do not occur in the absence of ad- cepted clinical definition of malnutrition, (b) all cur-
equate energy and nutrient intake. Day-to-day changes are rent assessment parameters are affected by illness
interpreted most usefully by comparison of rate of weight and injury, (c) it is difficult to isolate the effect of
gains with norms for age and sex and in accordance with malnutrition from the influence ofthe disease on clini-
goals for catch-up growth. Changes over longer periods, cal outcome, and (d) it is not clear which of the corn-
ie, weeks or months, are best evaluated by plotting data monly used nutrition assessment techniques is the
on weight-for-age and weight-for-length (height) percen- most reliable because of the paucity of comparative
tile charts.” data. (B)
Weight should also be assessed as percent of ideal body 3. Most current nutrition assessment techniques are
weight. The standards adopted recently by the Cystic Fl- based on their ability to predict clinical outcome.
brosis Foundation39 have wider applicability to all infants However, the validity of any of these techniques to

and children: truly measure “nutritional risk” has not been proved
and the effect of nutritional therapy to influence out-
90-100% IBW Normal range come in patmentsjudged to be “malnourished” has not
85-89% IBW Underweight been consistent in PRCTs. (C)
80-84% IBW Mild undernutrition 4. Muscle function testing represents a promising new
75-79% IBW Moderate undernutrition approach for evaluating the adequacy of nutrient in-
<75% IBW Severe malnutrition take and identifying patients who are at increased risk
for medical complications. However, additional data
Length (or height) is also evaluated in terms of age- and more widespread availability of the technology
dependent percentiles or Z scores. Low height-for-age are needed before this approach can be incorporated
percentiles may be the consequence of factors other than into clinical practice. (B)
malnutrition, such as chronic disease, endocrine disorders,
intrauterine growth retardation, or constitutional short
stature.
The importance of chronic malnutrition, as evidenced
by low and/or declining length-for-age and/or weight-for- 1. Establish clinical criteria using history and physical
age percentiles, in influencing clinical outcome has been examination and selected laboratory tests that can
well-documented in the developing world. This applies identify patients at risk for malnutrition-induced
especially to recovery from acute diarrhea and to the risk medical complications. This requires demonstrating
of persistent diarrhea.4 It may also apply to the risk of that a nutrition assessment technique can predict out-
acute respiratory tract infections. There is evidence, al- come and that nutritional therapy has a beneficial
beit not from PRCTs, that the provision of adequate nutri- clinical effect in “malnourished” patients. Ethical con-
tion to improve growth percentiles in children with cystic siderations prevent testing this hypothesis in “se-
fibrosis may improve or prevent deterioration in pulmo- verely malnourished” patients.
nary function.41” 2. Develop objective technologies for nutrition assess-
The younger the infant or child, the more vulnerable he ment that can identify patients at risk for malnutri-
or she may be to adverse effects of malnutrition. Of spe- tion-induced medical complications. This requires
cial note is the vulnerability of the growing brain. There- demonstrating that a nutrition assessment technique
fore, measurement of head circumference should also be can predict outcome and that nutritional therapy has
a routine component of initial assessment and subsequent a beneficial clinical effect in “malnourished” patients.
follow-up of the infant and toddler. An initially low or a Two potential areas for future focus are:
declining head circumference percentile together with a. Muscle function testing
other indices of malnutrition is an indication to use nutri- b. Body composition analysis.
tion support. 3. Develop criteria for measuring the nutritional
Monitoring nutrient intake and ability to absorb nutri- adequacy of enteral and parenteral nutrition therapy.
ents delivered orally or enterally may be of special impor-
tance in the sick child. The younger the infant or child, the GASTROINTESTINAL DISEASES
more rapid and severe may be the clinical consequences
of undernutrition and starvation. Therefore, the accept-
able period of complete starvation or of hypocaloric nu- SHORT BOWEL SYNDROME
trient intake may be more limited in the child, particularly Massive resection of the small intestine can cause con-
infants.’ siderable malabsorption, depending on the amount of
remaining small intestine, the site of resection, and the Crohn’s Disease-Enteral Nutrition
functional status of the remaining gastrointestinal tract.
Many PRCTs have evaluated the clinical efficacy of
Many patients who have had extensive intestinal resec-
defined-formula feeding in patients with Crohn’s disease.
tion require total parenteral nutrition (TPN) temporarily
Most compare one diet with standard pharmacotherapy,
until adequate adaptation occurs and allows them to be
such as corticosteroids, or one diet with another diet, such
transitioned to oral or enteral feedings. The use of TPN
as an elemental (all nitrogen as amino acids) with a
permits these patients to leave the hospital sooner and
nonelemental formula. Most of these trials suffer from
facilitates their rehabilitation. A subset of patients with
small sample size, heterogeneous patient populations, a
short bowel syndrome (SBS) cannot survive without long-
high percentage of withdrawals in the diet group, and di-
term TPN because they have such severe impairment in
ets with variable composition. Three studies,52’ using
nutrient absorption. Patients with ajejunostomy and <100
meta-analysis to examine the results of published PRCTs,
cm of jejunum and those who have an intact colon but
concluded that enteral nutrition was not as effective as
have <50 cm of jejunum or ileum usually require perma-
corticosteroids (pooled odds ratio, 0.35; 95% confidence
nent TPN.4546 Providing TPN at home has made a dramatic
interval, 0.23-0.53 in all studies); overall remission rates
clinical impact on this patient population. Most patients
for nutrition- and steroid-treated patients were approxi-
with SBS who receive home TPN restore normal body
mately 60% and 80%, respectively. In addition, the pooled
composition, and two-thirds return to school or employ-
data did not demonstrate an advantage of elemental over
ment.4748
nonelemental formulas (jooled odds ratio, 0.87, 95% con-
Aggressive oral or tube feeding can sometimes elimi-
fidence interval 0.41-1.83); overall remission rates for pa-
nate the need for TPN. This usually requires ingestion of
tients treated with elemental and nonelemental formulas

large amounts of fluid, calories, protein, vitamins, and
were 65% and 61%, respectively. Furthermore, dropout
minerals.49 Continuous nighttime tube feedings have been
rates were often high (up to 41%) in patients randomized
used successfully to supplement daytime oral intake to
to receive elemental formulas.
maximize nutrient absorption by the compromised gut.5#{176}
It is not known whether enteral nutrition has a thera-
Oral rehydration therapy can be used effectively for pa-
peutic effect in patients with Crohn’s disease because there
tients who cannot maintain fluid and electrolyte homeo-
are no PRCTs comparing enteral nutritional therapy with
stasis.5’ These patients often have ajejunostomy and <100
a placebo. However, the overall remission rate of approxi-
cm of small bowel, a negative sodium balance, and large
mately 60% reported after treatment with enteral nutni-
gastrointestinal fluid losses.45
tion52 is higher than the 20% to 40% remission rate re-
ported in other studies for placebo-treated patients with
mild to moderately active disease.5556
Crohn ‘S Disease-Parenteral Nutrition

1. Enteral and parenteral nutrition support can prevent
malnutrition and is essential for survival in selected Several PRCTs have evaluated the importance of bowel
patients with SBS. (B) rest and TPN as primary therapy for patients with Crohn’s
2. Appropriate manipulation of enteral feeding and the disease. These trials demonstrated that bowel rest itself
use of oral rehydration therapy can obviate the need is not necessary to achieve clinical remission; patients with
for TPN in selected patients with SBS. (B) Crohn’s disease who were randomized to bowel rest and
TPN fared no better than those who received oral or tube
feedings.5759
Colitis (Crohn ‘s and Ulcerative)

1 . Evaluate importance of growth factors in increasing
Two PRCTs, containing small numbers ofpatients, corn-
residual gut mass and absorptive function in patients
pared the use of TPN and bowel rest with a regular diet in
with SBS.
patients receiving steroid therapy for acute ulcerative or
2. Evaluate technologies to improve small-bowel trans-
Crohn’s colitis.#{176}6’ There was no difference in frequency
plantation.
of surgery or duration of required medical treatment be-
3. Evaluate motility patterns and investigate ways to
tween the control and TPN groups. A PRCT comparing
slow transit and increase intestinal-nutrient contact
total enteral nutrition with TPN (both used as an adjunct
time.
to steroids) was performed in patients with severe acute
INFLAMMATORY BOWEL DISEASE ulcerative colitis.2 Remission rate and need for colectorny
were similar in both groups. However, adverse effects re-
Protein-calorie malnutrition and specific nutrient defi-
lated to nutrition support were significantly less frequent
ciencies occur commonly in patients with inflammatory
and milder in the enteral nutrition-treated than in TPN-
bowel disease (IBD) because ofdecreased nutrient intake,
treated patients (9% vs 35%).
malabsorption, drug-nutrient interactions, and protein-los-
ing enteropathy. Therefore, nutritional therapy is an ac-
Specific Nutrient Therapy
cepted and important component of the overall manage-
ment of patients with IBD by preventing or correcting Increasing interest in the role of eicosanoids as modu-
nutrient deficiencies. Because the usefulness of nutrition lators of inflammation and the immune response has led
support as a primary therapy for IBD is more controver- to studies of co-3 fatty acids from fish oil in the treatment
sial, it was the focus of the review by the subcommittee. of IBD. Conflicting results from various PRCTs have been
reported showing success and failure in maintaining 3. Noncompliance limits the usefulness of monomeric
clinical remission in patients with Crohn’s disease. Fish and oligomeric diet therapy. (A)
oil supplementation in patients with ulcerative colitis has 4. Clinical outcome in response to monomeric, oligo-
resulted in a moderate decrease in disease activityt meric, and polymeric formulas is similar. (A)
and prevention of early but not late relapse.69 There is 5. Bowel rest is not necessary to achieve clinical remis-
evidence of a steroid-sparing effect in patients with ul- sion. (A)
cerative colitis given fish oil treatment, but it is not ef- 6. TPN has not been shown to be an effective primary
fective alone in maintaining remission of disease. therapy for patients with ulcerative or Crohn’s coli-
No conclusions can yet be made regarding the use of tis. (A)
glutamine in the treatment of IBD because the experi- 7. Enteral nutrition or TPN promotes growth in pediat-
mental evidence is inadequate. Short-chain fatty acid en- nc patients with growth retardation. (B)
ernas have not been effective in the treatment of chronic
pouchitis after colonic resection and ileo-anal anastomo-
sis. Recurrence of pouchitis symptoms was prevented in
only 3 of 9 patients with chronic pouchitis who were given
twice-daily butyrate enemas for 2 1 days.7#{176} 1 . Determine the clinical efficacy of nutritional therapy
in patients with steroid-resistant or steroid-dependent
Gastrointestinal Fistulas Crohn’s disease.
2. Determine the value of perioperative enteral nutri-
Although no PRCTs have evaluated the use of nutri-
tion or TPN therapy in decreasing the length of intes-
tion support in patients with gastrointestinal fistulas, it

tinal resection and postoperative complications.
is likely that the use of TPN in conjunction with bowel
3. Determine the clinical efficacy of specific nutrient
rest has improved clinical outcome. Before the use of
therapy on pouchitis.
TPN, mortality in patients with gastrointestinal fistulas
4. Evaluate the relationship between dietary factors (eg,
was caused by electrolyte and fluid losses, malnutrition,
potential protein antigens or long-chain triglycerides)
and generalized peritonitis.7’ A retrospective analysis of
and disease activity in patients with Crohn’s disease.
patients with small-bowel fistulas found lower mortality
rates (8% vs 33%), higher spontaneous fistula closures
ACUTE PANCREATITIS
(56% vs 27%), and higher surgical closure rates (92% vs
59%) in patients who received nutrition support than in
Effect ofTPN and Enteral Nutrition on Pancreatic
those who did not.72
Secretion
Anastomotic fistulas at sites of recent resection in pa-
tients with Crohn’s disease may permanently close with Ingestion of a regular diet during an episode of acute
TPN, bowel rest, and/or octreotide.71 However, fistulas pancreatitis often causes abdominal pain and increased
arising from bowel with active Crohn’s disease are less levels of plasma pancreatic enzymes. Therefore, nutrition
likely to heal. Combining data from many studies sug- support in patients with acute pancreatitis can be given
gests that fistula closure following TPN and bowel rest only if it does not exacerbate symptoms. This concept has
(35% of patients) is often not maintained after the pa- led to many studies evaluating the effect of various feed-
tient resumes an oral diet (only 17% of patients main- ing regimens on pancreatic exocrine secretion, with the
tamed fistula closure for more than 3 months).74 idea that it is the stimulation of pancreatic secretion that
causes increased pancreatic inflammation and pain.
Pediatric Patients With IBD and Growth Failure Most studies suggest that TPN does not stimulate, or
only minimally stimulates, pancreatic secretion.8’T Intra-
Growth failure and delayed pubertal maturation are
venous lipids are usually well-tolerated.89 However, sev-
common complications in pediatric patients with IBD.
eral cases have been reported in which lipid infusions
Growth faltering is more common in children with
caused pancreatitis, presumably because of hyper-
Crohn’s disease than in those with ulcerative colitis. TPN
triglyceridema.#{176}
or supplementation with liquid formula feeding, given
The effect ofenteral feeding on pancreatic secretion is not
orally or by intermittent nasogastric tube feedings at
clear because data are conflicting. hi some studies, jejunal
night, can cause marked improvement in both height and
feeding ofalow-fat elemental formula did not stimulate pan-
weight.7578 In addition, patients treated with elemental
creatic secretion,15 while others have found increased pan-
enteral nutrition 1 month out of every 4 months grew
creatic enzyme secretion duringjejunal feedingY98
better and had less-active
Mild or Moderate Pancreatitis
Approximately 80% to 90% of patients with acute pan-

creatitis have mild or moderate disease, as judged by
1. Enteral nutrition support is likely to have a therapeu- Ranson criteria’ or computed tomographic scanning. ‘#{176}#{176}
tic effect in patients with Crohn’s disease, but no These patients can be managed with standard supportive
PRCT has compared such nutritional therapy with pla- measures and do not need special treatment. There is no
cebo. (B) evidence that aggressive enteral nutrition or TPN therapy
2. Steroid therapy is more effective than enteral nutri- changes the natural course of the illness in patients with
tional therapy in inducing clinical remission in pa- mild or moderate disease. A PRCT evaluating the use of
tients with Crohn’s disease. (A) TPN in patients with mild to moderate disease found no
beneficial effects on morbidity or ty’#{176}’

In fact, pa- 2. Patients who have a protracted clinical course, such
tients given TPN had greater insulin requirements and a as those with severe disease or complications, often
higher incidence of catheter-related infections than the require nutrition support to prevent the adverse ef-
control group. Recently, McClave et al’#{176}2
demonstrated that fects of nutrient deprivation. The timing, route, and
jejunal tube feeding of a hydrolyzed oligomeric formula nutrient formulation for optimal nutritional therapy
was well-tolerated and was less expensive than TPN. How- are not clear because of the paucity of clinical trials.
ever, only 82% of patients who received enteral nutrition (C)
reached their caloric goal, compared with 96% of patients 3. Enteral feeding can be safely administered to patients
given TPN. Clinical outcome was the same in both groups. with pancreatitis. Jejunal tube feeding is often toler-
ated without an exacerbation ofsyrnptoms in patients
Severe Pancreatitis with mild or moderate disease and in patients who
have had surgery for complications of pancreatitis.
Approximately 10% to 20% of patients with pancreatitis
(A) However, the site of feeding (gastric vs duodenal
have severe disease and are at high risk for medical corn-
vsjejunal) and the nutrient formulation (elemental vs
plications. These patients may have increased nutrient
polymeric; low fat vs normal fat) that cause the least
requirements because of increased rates of energy expen-
risk for exacerbating disease symptoms are not
diture and protein 03, 104 Negative nitrogen bal-
known.
ance has been associated with adverse clinical outcome.
4. The use of intravenous lipid emulsions is safe in pa-
In one study, patients with pancreatitis who were in nega-
tients with acute pancreatitis, provided hyper-
tive nitrogen balance had a 10-fold increased mortality rate
triglyceridernia (>400 rng/dL) is avoided. (A)
than those in positive balance.’#{176}5 However, the relation-

ship between nitrogen balance and outcome may simply
reflect the relationship between nitrogen balance and se-
verity of disease.
No PRCTs have evaluated the clinical efficacy of nutri-
1. Controlled studies are needed to evaluate the clini-
tion support in patients with severe pancreatitis. The use
cal efficacy and cost-effectiveness of enteral nutri-
of TPN has been reported in studies that used historical
tion and TPN in patients with severe pancreatitis, as
controls,3”#{176}’#{176}7had no controls,’#{176}8 or contained only a sub-
set of patients with severe disease.’#{176}5”#{176}#{176}”#{176}
Furthermore,
defined by both clinical evaluation and modern im-
aging techniques.
severe pancreatitis was usually defined by Ranson crite-
2. The importance of feeding site (oral, gastric, duode-
ria rather than more recently used radiologic approaches,
which may be more sensitive in identifying patients with a nal, andjejunal) and formulation (elemental and low
poor prognosis.” The safety and clinical efficacy of tube fat) in determining tolerance to enteral feeding should
feedings in patients with severe pancreatitis is not known. be evaluated in patients with protracted severe or
Jejunal feedings of an elemental formula were tolerated complicated pancreatitis.
without an exacerbation of pancreatitis in patients who
were fed soon after surgery for complicated pancreatitis. 12
LIVER DISEASE
However, two patients died from complications related to Protein-energy malnutrition is common in patients with
the placement of the needle jejunostorny. advanced chronic liver disease. However, assessment of
nutritional status in this patient population can be difficult
Complicated Acute Pancreatitis because of the confounding influence of liver disease on
The most common serious complications of acute pan- the traditional markers of nutritional status. In a retrospec-
creatitis are pancreatic fistulas and ascites. Data on the use tive study, the severity of “protein-energy malnutrition” cor-
of enteral nutrition or TPN in these situations are hi the form related with the severity of liver disease and clinical out-
of case reports or uncontrolled retrospective series.81”4 1 16 Furthermore, improvement in nutritional status
Nutrition support was given after the initial bout of acute after 30 days ofhospitalization was associated with reduced
pancreatitis subsided and complications developed. Nearly mortality, although it is not clear whether improved nutri-
all patients with fistulas were treated with TPN, and over tional status affected survival or whether clinical improve-
90% ofthe fistulas closed. Pancreatic ascites resolved in 4 of ment affected the markers of nutritional status.
5 patients, and enteral nutrition was used in two patients.”5
Alcoholic Hepatitis
Pediatric Patients
The clinical efficacy of peripheral parenteral amino ac-
The incidence of pancreatitis in children is low corn- ids in alcoholic hepatitis has been evaluated by several
pared the incidence in adults, and no PRCTs have evalu- groups (cf, McCullough et al”7). Most studies found im-
ated the potential benefits of nutritional therapy for acute proved histology or liver biochemistries but no consistent
pancreatitis. decrease in morbidity or mortality in patients who received
parenteral amino acids. Some studies evaluated the use
of nutritional therapy in conjunction with steroids in pa-
tients with alcoholic hepatitis. One PRCT compared pa-
tients randomized to peripheral parenteral nutrition (PPN)
1. Neither enteral nutrition nor TPN has a beneficial (50 g of glucose and 35 g of amino acids daily),
effect on clinical outcome in patients with mild or oxandrolone, the combination, or no treatment for 2 1 days.
moderate pancreatitis. (A) Child’s Pugh score improved significantly in those who
received PPN plus oxandrolone, but mortality rates were ease; (2) the causes of acute and chronic liver diseases
similar all groups.”8”9
in Mendenhall et al’2#{176}studied the are more varied in children; (3) a larger proportion of pe-
effect of a combination of oxandrolone with a branched- diatric patients have inborn errors of metabolism, biliary
chain amino acid (BCAA)-enriched enteral supplement in tract disease, primary infections, and autoimmune disor-
patients with moderate or severe alcoholic hepatitis. On ders’27’28; and (4) the higher anabolic needs for growth
an intention-to-treat basis, mortality rates were similar in coupled with the catabolic effects of liver disease may
both treated and control groups of patients with severe result in more nutritional deficiencies. No PRCTs evaluat-
alcoholic hepatitis. In apost hoc subgroup analysis, involving the clinical efficacy of nutritional therapy in children
ing only those with markers suggesting either advanced have been performed.
liver disease or moderate malnutrition, liver function im-
proved and 1- and 6-month mortality rates in patients
treated with nutritional therapy.
Alcoholic Cirrhosis 1. Providing adequate enteral nutrition or TPN therapy

improves some parameters of liver function in pa-
Several PRCTs have found that enteral nutrition sup-
tients with chronic alcoholic liver diseases. (A)
port in patients hospitalized for complications of cirrho-
2. The aggregate of data are inconclusive to determine
sis was well-tolerated, and improved liver function, hepatic
whether enteral nutrition or TPN decreases morbid-
encephalopathy, and Child’s score.’21’24 In addition, one
ity and mortality in patients with alcoholic liver dis-
study found a trend toward decreased in-hospital mortal-
eases. (A)
ity in patients with cirrhosis and protein-calorie malnutri-

3. BCAA-enriched TPN increases recovery from acute
tion who were given enteral tube feeding with a formula
hepatic encephalopathy compared with high-dextrose
enriched with BCAAS (mean intake 2115 kcal/day; mor- =
solutions that do not contain amino acids; BCAA-en-
tality 12%) compared with an ad lib hospital diet (mean
riched solutions have not been shown to be superior
intake = 1320 kcal; mortality 47%).124 However, the differ-
to standard amino acid formulas. (A)
ence between groups may have been exaggerated by the
4. In patients who are protein-intolerant because of
unusually high mortality rate observed in the control group.
chronic or latent hepatic encephalopathy, BCAA-en-
riched formulas permit greater protein intake with-
Acute Hepatic Encephalopathy
out inducing encephalopathy than do standard pro-
The clinical
efficacy of BCAA-enriched TPN solutions in tein formulas. (A)
patients acute hepatic
with encephalopathy has been evalu-
ated in 9 PRCTs. These trials were reviewed by using meta-
analysis to pool data across studies. ‘ Patients who received
BCAA-enriched solutions demonstrated a statistically sig-
nificant improvement in recovery from encephalopathy 1. Determine if enteral nutrition support alters health
during short-term (7- to 14-day) nutritional therapy. Con- care costs and long-term clinical outcome in patients
siderable heterogeneity in mortality rates between studies with (a) alcoholic hepatitis and (b) cirrhosis.
precluded meaningful aggregation of mortality data. In ad-
dition, the design of most ofthe studies may have inadvert- WASTING DISORDERS: CANCER AND AIDS
ently favored the treatment group. The control groups usu-
ally received suboptimal, and possibly harmful, nutrition Wasting disorders are characterized by involuntary loss
support consisting ofhigh-dextrose solutions without amino of body weight and lean tissue in the setting of a chronic
acids. Only one study compared BCAA-enriched TPN with illness. Although wasting can occur in any ill patient, the
a standard amino acid TPN solution, and this study did not subcommittee focused its report on patients with cancer
demonstrate a beneficial effect ofBCAA-enriched solutions. and AIDS because of the prevalence and clinical impor-
None of the studies reported on complications associated tance of cachexia in these disorders.
with nutritional therapy and none evaluated whether short- Many studies have demonstrated a direct relationship
term benefits of nutritional therapy led to a long-term re- between mortality and loss of either body weight or lean
duction in complications. body mass (LBM). 129-132 Furthermore, starvation-induced
malnutrition can affect strength, ambulation, exercise
Chronic Hepatic Encephalopathy performance, and cognitive function,’33 which can im-
pair daily activities and quality of life. The association
Studies of the efficacy of enteral BCAA formulas vs con-
between wasting and death has led to the assumption
ventional protein sources for treatment of chronic hepatic
that prevention or reversal of wasting will delay or pre-
encephalopathy have produced conflicting results. How-
vent death from AIDS or cancer; however, there are no
ever, the studies with the largest number of patients and
published observations providing direct evidence that
least chance for a type II statistical error tend to demon-
wasting is a cause of death or that reversal of wasting
strate a beneficial effect of BCAAS on protein tolerance
improves outcome. Therefore, the association between
and symptoms of encephalopathy, particularly in protein-
wasting and adverse outcome may reflect an associa-
intolerant 7,126
tion between wasting and severity of illness, rather than
a cause-and-effect relationship. In nonmedical settings,
Pediatric Patients With Liver Disease
such as prison hunger-strikers and victims of famine,
Pediatric patients with liver disease differ from adults there is a causal relationship between weight loss and
in several ways: (1) fewer pediatric patients have liver dis- mortality.
The ability to replenish LBM with nutritional therapy during the course of chemotherapy. The use of TPN usu-
may depend on the etiology of wasting. Two factors can ally caused an increase in body weight, but the body
cause wasting in patients with cancer or AIDS: (1) inabil- compartment(s) responsible for the increase in weight was
ity to assimilate nutrients, caused by gastrointestinal ob- not determined. Overall, the use ofTPN did not affect sur-
struction, rnalabsorption, and anorexia; and (2) abnormali- vival and did not decrease hematologic or gastrointesti-
ties in rnacronutrient metabolism, caused by alterations nal toxicity from chemotherapy. Half of the studies re-
in regulatory hormones and cytokines. Patients with can- ported infectious complications; infection rates were
cer or AIDS may have metabolic derangements that in- higher in patients who received TPN, with a pooled odds
crease LBM loss or inhibit its repletion. Loss of LBM as a ratio four times that of the control group.”6”7 No study
percentage oftotal weight loss is often disproportionately included a sophisticated measure of the effect of nutri-
high compared with a pure semi-starvation model.’2t’ Fur- tion support on function, performance, or quality-of-life.
thermore, when nutrition support results in weight gain, Seven PRCTs examined the use of enteral nutrition
it is often the net result of increased fat deposition and therapy given either as oral supplements or as tube
increased body water, not an increase in LBM. ‘‘ Body cell feedings (cf, Klein and Koretz’35). These studies varied in
mass is more likely to be restored by nutritional therapy the composition, timing, and duration of enteral nutrition.
in patients with simple macronutrient deficiency than in No obvious therapeutic benefits in survival, tumor re-
those who have primary alterations in metabolism. sponse, or chemotherapy toxicity were observed in these
studies. No PRCTs comparing TPN to enteral nutrition
CANCER were found. The use of home TPN or enteral therapy has
At least 40 PRCTs have been reported evaluating the also not been evaluated by PRCTs.
in patients with can- One PRCT evaluated the effectiveness oforal glutanune

clinical efficacy of nutritional therapy
cer receiving chemotherapy or radiation therapy (cf, Klein supplementation in managing oral mucositis in patients
and Koretz’35). Two meta-analyses, which pooled the re- receiving chemotherapy for metastatic gastrointestinal
sults from many of these trials, concluded that the use of cancer.’38 though the supplement was well-tolerated, it
adjunctive nutrition support did not demonstrate benefi- did not increase plasma glutarnine concentrations and
cial effects.’36’37 Moreover, the pooled data suggested, on failed to affect mucositis.
the basis of higher infection rates, that TPN was harmful
in patients receiving chemotherapy. However, serious Radiation Therapy
shortcomings in the design of the published PRCTs may
Data were inconsistent as to the overall merits of TPN
limit the applicability of these conclusions to current pa-
or enteral nutrition support in patients receiving radiation
tient care. The most important criticisms of the PRCTs
therapy. Most studies contained a small sample size and
include the following: (1) patient populations were het-
failed to stratify by disease, pretreatment group differ-
erogeneous and included patients with different tumor
ences, nutritional status, or concomitant therapies. Four
types and stages of disease, which may have masked ben-
PRCTs studied the clinical efficacy of TPN in patients re-
eficial effects of therapy in certain subgroups; (2) many
ceiving radiation therapy for treatment of abdominal or
studies excluded patients with severe malnutrition, thus
pelvic cancers (cf, Klein and Koretz”). Overall, there were
excluding those who might have shown the greatest ben-
no definitive differences in survival or radiation therapy-
efit from nutrition support; patients with normal pretreat-
induced side effects between patients receiving nutrition
ment nutritional status-who may have been unlikely to
support and the control group.
show a beneficial effect of nutritional therapy-were in-
Seven PRCTs evaluated the use of enteral nutritional
cluded; (3) the specific type of cancer therapy varied be-
therapy (cf, Klein and Koretz”). Oral or enteral nutritional
tween studies and often was not consistent within a study;
therapy decreased the amount ofweight lost during radia-
(4) the composition, timing, and duration of nutrition sup-
tion treatment. There were fewer hernatologic or gas-
port may not have been optimal (for example, excess glu-
trointestinal side effects of radiation therapy in nutrition-
cose or lipid in many studies may have affected immune
ally treated patients who received radiation for abdominal
function and increased infection risk); (5) the use of corn-
and pelvic cancer, but there were more in one study of
plication and mortality rates alone as outcome measures
patients receiving radiation therapy for head and neck
is inadequate because these are less likely to be affected
cancer. Nutritional therapy did not affect survival, which
by nutritional therapy than are other important clinical
was reported in only two studies, and the effect of nutri-
endpoints, such as LBM accrual, growth in children, func-
tional therapy on functional ability was not evaluated.
tional status, and quality of life, which were rarely evalu-
Some studies reported greater weight gain or less weight
ated; (6) most studies involved the use of TPN, which is
loss in patients who received nutrition support, but reli-
more likely to have infectious complications than other
able analysis of body composition was not performed.
routes ofnutrition support; and (7) the sample size of even
the pooled analyses may have been inadequate to detect
Bone Marrow Transplantation
small, but clinically important, benefits of nutrition sup-
port. Bone marrow transplantation results in very negative
nitrogen balances and a disproportionately greater loss of
lean body mass than body weight or fat losses. A subset of
Cancer Chemotherapy
patients who have had bone marrow transplantation de-
Eighteen PRCTs evaluated the use of TPN in patients velop considerable gastrointestinal dysfunction and re-
receiving chemotherapy (cf, Klein and Koretz’). TPN was quire TPN for survival. Two PRCTs studied the use of stan-
usually given for a short period (3 to 6 weeks) before or dard nutrition support in patients treated with bone
marrow transplantation, which included patients with both formula supplemented with a-linolenic acid, arginine, and
allogenic and autologous transplants (cf, Klein and RNA compared with a control supplement in 10 patients
Koretz’35). There was no stratification by presence or ab- with symptomatic HIV infection.’52 Modest weight gain
sence of malnutrition. Myelosuppression, incidence of occurred when patients were given the specialty formula,
graft-vs-host disease, length of hospital stay, and bacter- but more important clinical parameters, such as morbid-
ernia were not decreased by providing TPN. Patients given ity, mortality, and quality-of-life, were not evaluated. Two
TPN maintained or increased body weight compared with studies that evaluated w-3 fatty acid (“fish oil”) supple-
control patients, but reliable measures of body composi- mentation did not demonstrate clinical benefits, although
tion were not performed and nitrogen balance remained the studies were not designed to measure clinical out-
negative. In one study”9 an impressive improvement in ‘3,’#{176}’
mean survival (21-month survival) was reported in patients

who received TPN compared with control patients (7- Pediatric Patients
month survival). However, the survival advantage was not
Children with cancer have marked weight loss during
evident until 6 months after transplantation. In the sec-
induction therapies.’55 Although both survival and quality
ond ri’40 patients were randomized to receive either TPN
of life are associated with measures of nutritional sta-
or enteral nutrition. More than two-thirds of the patients
tus,’”57 few PRCTs have evaluated the efficacy of nutri-
randomized to enteral nutrition were given additional
tional therapy in children with cancer. In one PRCT, no
parenteral intravenous amino acids to meet their estimated
improvement in clinical outcome was observed when TPN
requirements. Survival was not different between the two
was given as routine adjuvant therapy, in the absence of
groups.
pretreatment malnutrition; weight gained was fat, not lean

Two PRCTs evaluated the potential benefit of glutamine-
tissue, and crude performance measures did not im-
enriched TPN compared with standard TPN. In one study’4’
In a small subset
58 of severely malnourished chil-
100-day survival rates were the same in both groups, but
dren (n=4), however, improvement in performance status
the patients who received glutamine had a lower rate of
was observed in patients who received TPN. In uncon-
infection, shorter duration ofhospitalization, and improved
trolled studies, children who are malnourished prior to
nitrogen balance. In contrast, in the second trial’42 the rate
therapy showed weight gain and increased muscle mass
of survival, rate of infections, and duration of hospitaliza-
when given TPN,’59 but clinical or functional outcome
tion was not significantly different between groups when
measures were not reported. In well-nourished children,
all randomized patients were included in the analysis.
weight gained during TPN is predominantly fat.’”#{176}
However, when outliers were excluded, the length of hos-
Children with AIDS frequently exhibit stunting and de-
pital stay was significantly shorter for patients receiving
creased weight for height. No PRCTs evaluating the use of
the glutamine-enriched formulation.
nutrition support in children with AIDS have been re-
ported. Uncontrolled trials of enteral nutrition support
AIDS
suggest that nutritional therapy increases body weight;
A reliable assessment of the clinical efficacy of TPN or
however, the increase in weight is mostly due to an in-
enteral nutrition support in patients with AIDS is difficult
crease in body fat without a change in LBM or 16,62
because so few studies have evaluated this issue. Further-
No PRCTs have evaluated clinical or functional outcomes,
more, most of the reported studies contained small num-
home TPN, or long-term oral/enteral nutrition support.
bers of subjects and few were designed as a PRCT.
Retrospective and prospective uncontrolled experiences
Long-Term Management ofChronic Wasting
have reported conflicting results regarding the effect of
TPN or oral/enteral feeding on body weight and body corn- The important issue of long-term management of wast-
position in patients with HIV infection.’4’’5#{176} The differ- ing patients who are unable to eat because of their under-
ences observed between studies may be related to the pres- lying disease or therapy has not been carefully addressed
ence of underlying illness. Home TPN did not cause an in clinical studies. It is possible that home nonvolitional
increase in LBM, despite increases in weight and fat in 12 feeding can improve quality of life and survival in appro-
AIDS patients; post hoc analyses suggested that LBM in- priately selected patients. However, there is a paucity of
creased in five patients who had anorexia-induced weight objective data that address this hypothesis or that help
loss but not in seven patients who had systemic infec- determine which patients with cancer or AIDS should be
48 Percutaneous gastrostomy tube feeding in eight considered for long-term nutritional therapy.
malnourished patients with anorexia increased LBM,’49 The use of home TPN in the United States more than
whereas enteral feeding did not prevent weight loss in pa- doubled between 1989 and 1992, in large part because of
tients who had concomitant secondary infections. ‘#{176} the increased use in patients with cancer, who accounted
Several studies have evaluated the use of oral formulas for 46% of new home TPN patients in 1989.’ In contrast
fortified with nutrient(s) designed to modify the physi- to patients with benign diseases, less than half of the pa-
ologic response to the disease. A 6-month PRCT compared tients receiving home TPN who had cancer or AIDS were
a peptide-based oral supplement containing additional alive at 6 months, and only 20% and 10%, respectively, were
medium-chain triglycerides, (3-carotene, and soluble fi- alive at 1 year. A recent PRCT provided 2 months of home
ber with a standard supplement and found better weight TPN to patients with AIDS who had lost > 10% oftheir body
maintenance and fewer hospital admissions (between weight had diarrhea but did not have a secondary infec-
months 3 and 6 only) in those who received the specialty tion; the results showed that this treatment caused an in-
formula.’5’ An 8-month controlled, double-blinded, ran- crease in body weight, body cell mass, Karnofsky index,
domized, crossover design was used to evaluate an oral and subjective feeling of health compared with a decline
in these parameters in patients randomized to receive di- on definitive, research-based evidence because of the
etary counselling only. ‘ However, the rate of rehospital- absence of clinically relevant PRCTs. (C)
ization and survival was the same in both groups.
Gastrostorny or jejunostomy tube feedings are associ-
ated with fewer complications and are less expensive than
feeding with home TPN. Prospective uncontrolled stud-
ies and retrospective data suggest that long-term gastros- 1 . Perform PRCTS to determine the effect of enteral and
tomy tube feedings are well-tolerated, are associated with parenteral nutritional therapy on body composition,
few complications, and may prolong survival in patients functional status, quality oflife, and clinical outcome
with cancer or MDS’6”’ However, no PRCTs have stud- in defined populations of malnourished patients with
ied this issue. cancer or AIDS.
2. Determine objective criteria that can identify wast-
ing patients who are likely to achieve long-term ben-
efits from adjunctive nutritional therapy.
3. Evaluate the potential benefits of specialized nutri-
1. The routine use of adjunctive short-term enteral nu- tional formulas supplemented with glutamine, argin-
trition or TPN does not decrease complications or me, ribonucleic acids, w-3 fatty acids, or other nutri-
mortality in patients who are receiving chemotherapy ents.
or radiation therapy for cancer. (A) However, many 4. Determine (1) the optimal means for measuring body
of the reported PRCTs have serious limitations in composition in patients with wasting diseases and (2)
study design that may limit their applicability to cur- the relationship between lean body mass and clinical

rent medical practice. (C) outcome (including muscle function, psychosocial
2. Long-term enteral nutrition or TPN may be benefi- function, quality of life, performance status, morbid-
cial by maintaining hydration, providing nutrients, ity, and mortality) in patients with cancer or AIDS.
increasing comfort, and improving survival in patients
unable to eat or absorb adequate nutrients for a pro-
CRITICAL ILLNESS
longed period. (B) However, no PRCTs have evalu-
ated this issue. Evaluating the clinical efficacy of nutrition support is
3. Use of TPN is associated with an increased rate of particularly difficult in patients requiring intensive care.
infection (including non-catheter-related infections) This is partly due to the difficulty ofassembling large nurn-
in patients treated with chemotherapy. (A) It is pos- bers of patients with the same diagnosis and severity of
sible that technical advances in line insertion, im- illness and comparable nutritional status, as well as con-
proved methods of catheter care, and the trend to- ducting a clinical trial in the face of multiple therapies that
ward lower calorie and/or fat administration may are altered according to a changing clinical condition. The
decrease the incidence ofTPN-induced infections but theoretical value of nutrition support in patients with criti-
this has not been proven in PRCTs. (C) cal illnesses is to provide exogenous substrates to meet
4. Standard TPN given after bone marrow transplanta- protein and energy requirements, thereby protecting vital
tion does not decrease treatment toxicity, graft-vs- visceral organs and attenuating breakdown of skeletal
host disease, or bacteremia; does not increase lean muscle. The potential benefits of nutrition support were
tissue accrual; and does not affect short-term (<6- examined in adult patients who had the following illnesses:
month) survival. However, one PRCT found short- trauma, sepsis/systemic inflammatory response syndrome
term TPN may increase long-term survival (>6-month) (SIRS), multiple organ dysfunction syndrome (MODS),
and decrease the rate of tumor relapse. (A) thermal injury, acute lung injury (ALl), or acute renal fail-
5. The impressive loss of tissue mass and function that ure. The effect of nutrition support in critically ill children
occurs in patients with wasting disorders makes res- was not reviewed because there are no PRCTs evaluating
toration of disordered body composition a reason- this issue. Given the differences between adults and chil-
able clinical goal, until definitive studies are per- dren in their tolerance to the adverse effects of malnutri-
formed to evaluate this hypothesis. (C) tion and the need for growth, results from studies in adults
6. TPN, enteral, and oral nutrition support may prevent should not be extrapolated to pediatric patients.
or reverse weight loss and replenish body cell mass
in patients with AIDS who have poor food intake or
TRAUMA (BLUNT TRAUMA/HEAD TRAUMA)
rnalabsorption and do not have an active opportunis-
tic infection. Nutritional therapy does not have ben- No studies have compared giving nutrition support with
eficial effects on body composition in patients with not giving nutrition support to traumatized patients. Two
AIDS who have systemic infection. (B) studies assessed whether early enteral nutrition would
7. Despite the striking weight loss or stunting that ofbenefit patients with trauma.’6”7#{176} In one study’#{176}the pa-
ten occurs in children with cancer or AIDS, routine tients in the control group who were not eating within 5
use of TPN in these children does not improve qual- days ofthe start ofthe trial were begun on TPN. The other
ity of life, growth, or survival. (B) Nutrition support study’7#{176}examined the use of a commercial enteral diet,
may increase muscle mass in children who are mal- which was provided after 72 hours; the early-fed group
nourished prior to therapy. (B) had a greater number of infections, without differences in
8. Many decisions relevant to nutrition practice for pa- other clinical outcomes (eg, days on mechanical ventila-
tients with wasting disorders cannot be based solely tion, length ofstay, etc). Four studies compared TPN with
enteral nutrition support in patients with non-head tious complications.’ One other trial, assessing another
trauma.’71’74 Three ofthese studies’72’74 demonstrated that formulation containing a-linoleic acid, 3-carotene, and
patients given enteral nutrition had fewer infections than arginine, is difficult to interpret because of a serious break-
those given TPN. It is not clear from these studies whether down in the randomization procedure.’97
enteral nutrition provides a specific benefit, or whether
TPN is associated with increased infections, which has SEPsIs/SIRS/MODS
been noted in other conditions.’’37’7’77 Patients who re-
One study compared enteral nutrition support consist-
ceived TPN were fed more calories then those random-
ing of a BCAA-based solution with a formulation contain-
ized to receive enteral nutrition, which may have contrib-
ing SAAs; no difference in mortality was seen between
uted to the increased infection rate. There is no good
groups.’99 Four trials compared BCAA- with SAA-based
evidence that solutions enriched with BCAAS decrease
TPN2#{176}#{176}2#{176}3;
only one demonstrated any difference in clini-
morbidity or mortality’713”#{176} or that the administration of
cal outcome, a decrease in mortality in the group receiv-
albumin has clinical benefits in patients receiving TPN.’’
ing the BCAA-enriched formula.2#{176}#{176}
However, the data from
Several studies have compared TPN with enteral nutri-
this trial are only available as an abstract. Finally, one trial
tion in patients with head trauma.’87’9’ In one, all 20 pa-
found no differences between groups given equivalent
tients who received TPN lived, whereas 8 of 18 patients who
nutrients by parenteral or enteral routes.2#{176}
received nasogastnc feeding di’87 However, the increased
mortality may have been secondary to pulmonary aspira-
THERMAL INJURY
tion of gastric contents related to gastroparesis associated
with head injury. When the same investigators repeated the Many PRCTs have examined nutrition support in patients

study, this time using postpyloric feeding, no differences with thermal j2a52I2 One study, containing a total of only
were observed between enterally and parenterally fed 16 patients, found no statistically significant differences in
groups.” An alternative explanation is that the original survival between patients given parenteral fat and glucose
study actually assessed the effect of adequate (TPN) vs in- with amino acids compared with those given fat and glucose
adequate (enteral nutrition) feeding, because of the time it without amino acids.207 One study examined TPN with solu-
normally takes a critically ill patient to meet caloric needs tions containing either 45% or 19% of amino acids as BCAAS
with enteral gs’87 The failure to see a difference in and failed to demonstrate any differences in survival between
the second study could be because the investigators were the two study groups.2#{176}” Chiarelli et al2#{176}’
found no significant
now able to successfully meet caloric needs earlier with differences in infections or mortality in patients fed by
enteral feeding and thus both groups received adequate nu- nasogastric tube immediately after admission compared with
trition support. Other studies have failed to demonstrate those fed at least 48 hours later. A study examining standard
differences in morbidity or mortality in comparisons of TPN enteral nutrition support with and without additional whey
with postpyloric enteral nuthtion’ or even with nasogasthc protein demonstrated that patients who received the higher
dings89#{176}” Grahm et al’11 in a quasi-randomized prospec- proteinlevels had less morbidity and greatersurvival.21#{176} How-
tive trial, observed fewer infections in 16 patients who re- ever, the interpretation of these results is complicated be-
ceivedjejunal tube feedings within 72 hours oftheir admis- cause more patients in the low-protein group than in the high-
sion compared with another 16 who received gastric tube protein group received supplemental parenteral nutrition.
feedings after 72 hours. Jenkins et al21’ demonstrated that patients who received en-
tera.l nutrition throughout an operative procedure tolerated
Immunonutrition the feedings and had fewer postoperative wound infections.
Herndon et al205’2#{176}t’
have reported two trials in patients with
Several PRCTs have evaluated the effects of various
50% surface area bums who were randomized to receive en-
enteral formulas supplemented with selected nutrients
teral nutrition as tolerated with or without additional
(co-3 fatty acids, arginine, nucleic acids, glutamine) on clini-
parenteral nutrition. The mortality rates in patients who re-
cal outcome.”#{176}’98 Two studies’’3’94 compared an enteral
ceived additional parenteral nutrition were numerically
diet containing increased amounts ofw-3 fatty acids, argi-
higher than in those fed only enterally, and in one study2#{176} the
nine, and ribonucleic acids to a standard enteral formula
differences achieved statistical significance. However, the
diet. The authors from both studies concluded that infec-
patients who received parenteral nutrition in addition to en-
tious complications and hospital lengths-of-stay were de-
teral feedings may have received excessive amounts of en-
creased in patients who received the modified formula,
ergy. Garrell et al212 compared three enteral nutrition feedings
but these claims were based on post hoc subgroup data
containing 15% (with or without w-3 fatty acids) or 35% fat;
analyses. In one study’94 the recipients of the modified for-
the patients who received the lower fat formulations had a
mula showed a trend toward a higher mortality rate. A
lower frequency ofpneurnonia. Finally, one trial compared a
recent abstract compared the use of diet with a different
specially prepared enteral formulation containing whey,
“control” diet; the data suggested that the recipients of
glutamine, arginine, and w-3 fatty acids with two different
the experimental diet had fewer complications and when
stamiard enteral diets.213 Patients who received the specially
complications occurred, they were less expensive to man-
prepared formula had a shorter duration of hospitalization
198 Another PRCT found that patients given a modified
and fewer infections.
formula diet containing additional glutamine, arginine,
nucleic acids, and w-3 fatty acids had less multiorgan fail-
ACUTE LUNG INJURY
ure than those given a standard amino acid (SAA)-based
elemental diet.’95 A recent trial comparing this prepara- High-fat, low-carbohydrate intake has been recom-
tion with a protein-supplemented standard enteral formula mended for patients with pulmonary diseases to decrease
found that patients who received it had fewer major infec- carbon dioxide production. Only one PRCT has shown a
beneficial effect of a diet high in fat and low in carbohy- ing essential and nonessential amino acids. However, the
drate; Al-Saady et al214 found that patients given a high-fat, clinical benefits of providing such nutrients have not yet
low-carbohydrate diet had a 16% decrease in PaCO9 and been demonstrated in PRCTs.
spent 62 hours less time on mechanical ventilation than
patients who received standard feeding. Van den Berg et
al215 were not able to find a decrease in ventilator time in
patients receiving a high-fat, low-carbohydrate diet, even
though their patients did exhibit a significant reduction in 1. Critically ill patients are hypermetabolic and have in-
CO2 production. In fact, Battistella et a1216 found that creased nutrient requirements. Although it has been
trauma patients randomized to receive a lipid-free formula assumed that nutrition support is clinically beneficial
for the first 10 days of their hospitalization spent less time in this patient population, this hypothesis has not been
on the respirator, in the ICU, and in the hospital than pa- tested by well-designed clinical trials. (C)
tients randomized to receive TPN containing lipids. How- 2. In the absence of carefully designed clinical trials, the
ever, the patients given lipids received more total cab- rationale for nutrition support is based mostly on clini-
ries. In 40 neonates with respiratory distress syndrome, cal judgment, and nutrition support is considered in
Gunn et al2’7 were not able to demonstrate a statistically patients who are unlikely to consume adequate nutri-
significant clinical benefit of TPN; however, the mortality ent intake for a “prolonged” period. Although it is not
rate in the group receiving TPN (15%) was half that of the known howlong a critically ill patient can tolerate lack
control group (30%), raising the possibility of a type II sta- of nutrient intake without adverse consequences, the
tistical error. loss of lean tissue that occurs in severely catabolic

patients (20 to 40 g ofnitrogenlday) suggests that criti-
ACUTE RENAL FAILURE cal depletion of lean tissue may occur after 14 days of
starvation. Therefore, nutrition support should be mi-
No PRCTs have assessed the clinical efficacy of enteral
tiated in patients who are not expected to resume oral
nutrition support, but several have evaluated the use of
feeding for 7 to 10 days. (C)
TPN in patients with acute renal failure.21222 All studies
3. Trauma patients fed by enteral nutrition have fewer
contained limitations in design that make it difficult to
complications than those given TPN. (B) However, it
assess the effect of nutritional therapy on morbidity and
is not clear whether enteral nutrition support provides
mortality. The numbers of patients studied in these trials
a specific benefit or whether TPN itself or overfeed-
were small, and most studies were primarily designed to
ing by TPN is associated with increased infections.
evaluate the metabolic effects of feeding rather than mor-
4. No definitive conclusions can be made regarding the
bidity and mortality. Moreover, some ofthe control groups
clinical efficacy of specialized nutrient formulations
were not “true” controls (ie, a group not receiving any form
(containing to-3 fatty acids, arginine, nucleic acids,
of TPN) and received isocaloric quantities of TPN with-
glutamine, and/or BCAAS) because of conflicting re-
out amino acids.2122#{176}Only one study218 showed a statisti-
sults from various studies.
cally significant difference in a clinical outcome between
groups-a greater recovery rate from acute renal failure
in patients given TPN containing nitrogen in the form of
essential amino acids only compared with a control group
who received TPN without any amino acids. In addition,
1. Perform PRCTs to determine whether enteral nutrition
two studies2’8’22#{176}showed arithmetically, but not statistically
support affects clinical outcome in uniform groups of
significant, increased survival rates in patients who re-
critically ill patients. These trials should be designed so
ceived TPN containing nitrogen in the form of essential
that the control group does not receive nutrition sup-
amino acids only compared with a control group given
port. Furthermore, these trials may need a “fall-safe”
equicaloric amounts of dextrose. Three trials22#{176}222corn-
process for the control group that does not allow a “pro-
pared TPN containing nitrogen as essential amino acids
longed” period ofstarvation (possibly 7 to 14 days). The
alone with TPN containing both essential and nonessen-
endpoints should include morbidity, mortality, organ
tial amino acids. Although the numbers of patients stud-
function, length ofintensive care unit and hospital stay,
ied were small, the recovery and survival rates were all
and long-term rehabilitation and quality of life.
arithmetically greater (but not statistically significant) in
2. Ifenteral feeding is shown to be ofbenefit, further stud-
the group who received only essential amino acids.
ies should be performed to determine the optimal tim-
The use of continuous filtration techniques (eg, continu-
ing and amount of enteral nutrients needed to improve
ous venovenous hemofiltration or continuous arterio-
outcome.
venous hemofiltration with or without hemodialysis or
3. Perform PRCTS to determine the clinical efficacy of in-
hemodiafiltration) usually leads to increased tolerance of
dividuai specific nutrient supplements. The appropri-
amino acid and protein intake.2 Moreover, the catabolic
ate control group (standard enteral formula feeding vs
state engendered by the severe comorbid conditions of
no feeding) will depend on results generated from the
many of these patients, the losses of nutrients through
studies comparing feeding with no feeding.
dialysis or ultrafiltration,224225 and the possible catabolic
stress of the hernodialysis or continuous filtration proce-
dure itself may increase the nutritional demands of these PERIOPERATIVE NUTRITION SUPPORT
patients. Thus it is anticipated that patients with acute
renal failure who are undergoing dialysis or ultrafiltration A total of 33 PRCTs,’7’77’22254 involving over 2500 sur-
therapy may need increased quantities of nutrients, includ- gical patients, were evaluated in this review. Only trials
that met the following criteria were included: full-length postoperative complications tended to be bower in patients
publication in an English language, peer-reviewed journal; who received preoperative enterab tube feedings (overall
presentation of an a priori hypothesis; nutritional therapy incidence = 12%) than in the control group (overall mci-
was given for at least 5 days and provided sufficient cab- dence =30%); the difference between groups was statisti-
ries and nitrogen to meet daily requirements; and data on cabby significant in one study.245 One PRCT, containing only
clinical outcome were reported. When multiple endpoints 20 patients with esophageal cancer, compared preopera-
were presented, the most “clinically significant” outcome tive enteral nutrition with TPN and found no significant
was selected (eg, “septic episodes” in preference to “wound differences in postoperative complications or mortality be-
infections”). If the original experimental design included tween groups.246
stratification, important results from stratified subgroups
were evaluated, but retrospectively identified patient sub- Postoperative Enteral Tube Feeding
groups or endpoints were not. When a significant number
Four PRCTs compared early postoperative jejunal tube
of similar studies were available, data were pooled to cab-
feeding with the usual advancement of an oral diet as tob-
culate a pooled estimate of the risk difference between
erated (Table III).247250 Most patients had gastrointestinal
patients given nutrition support and the control group (rate
cancer. The aggregate data show no obvious differences
of complication in nutritionally supported group minus
in postoperative morbidity or mortality. The effect of post-
rate in control group).25
operative jejunostomy tube feeding with a formula en-
riched with arginine, ribonucleic acids, and w-3 fatty ac-
PARENTERAL NUTRITION
ids was compared with a standard formula in a PRCT
involving patients with cancers of the upper gastrointesti-

Preoperative TPN
nal tract.25’ In an intent-to-treat analysis, no significant dif-
Thirteen PRCTs, involving over 1250 patients, were iden- ferences were found between groups. However, when only
tified (Table I). Most patients in these studies had gas- patients who were successfully fed were evaluated, those
trointestinal cancer and were considered by the authors who received the enriched formula had fewer infections
to be at least “moderately malnourished” on the basis of and wound complications and a shorter duration of hos-
weight loss, plasma proteins, or prognostic indices. Pa- pitalization than those who received the standard formula.
tients randomized to nutrition support usually received However, in this subgroup analysis, more patients with
TPN for at least 7 to 10 days before surgery (Table I). Nine longer lengths of stay were eliminated from the treatment
of the 13 studies found that patients who received preop- group than from the control group.252
erative TPN had fewer postoperative complications than The effect of supplementary tube feeding was evaluated
the control group; in five studies these differences reached in elderly women after surgical repair of a femoral neck
conventionally accepted statistical significance. The fracture.2 Of 744 patients, 122 were “thin,” defined as 1
pooled results indicate that TPN therapy decreased the to 2 standard deviations below the mean weight, or “very
overall risk of postoperative complications by approxi- thin,” defined as >2 standard deviations below the mean
mately 10% (ie, a reduction in rate of complications from weight. These 122 women were randomized to receive ei-
approximately 40% to 30%) (Table I and Fig 1). Although ther a normal ward diet plus 1000 kcal each night by
one study found a statistically significant reduction in post- nasogastric tube or a normal ward diet alone. Women ran-
operative mortality in patients who received preoperative domized to receive additional enterab nutrition had a
TPN,23#{176}no difference between groups was demonstrated shorter time until weight-bearing and independent mobil-
in the pooled analysis (Table I). ity and were discharged from the hospital earlier than those
randomized to a normal diet. Furthermore, mortality rates
Postoperative TPN in the supplemented very thin patients were numerically,
although not statistically significantly, bower than in the
Routine administration of TPN to general surgical pa-
very thin control group (8% and 22%, respectively). Simi-
tients in the immediate postoperative period was studied
barly, Delrni et al2 found that the duration of hospitaliza-
in nine PRCTs involving over 700 patients (Table II and
tion and the rates of both short-term and long-term (6
Figure 2). These studies mostly contained patients with
months) complications were lower in elderly women given
gastrointestinal cancer who were considered by the au-
oral nutritional supplementation after surgical repair of a
thors to be at least “moderately malnourished” on the ba-
fractured femoral neck than in women who were random-
sis of weight loss, plasma proteins, or prognostic indices.
ized to receive regular meals.
The pooled analysis suggests that TPN therapy increased
the overall risk ofpostoperative complications by approxi-
mately 10% (ie, an increase in rate of complications from
approximately 30% to 40%). No statistically significant dif-
ferences in mortality between groups were found.
1. TPN given to “malnourished” (defined by weight boss,
plasma proteins, or prognostic indices) patients with
ENTERAL NUTRITION
gastrointestinal cancer for 7 to 10 days before sur-
gery decreases postoperative complications by ap-
Preoperative Enteral Tube Feeding
proximately 10%. (A)
Two PRCTs compared the use of preoperative enteral 2. Routine use of early postoperative TPN in “malnour-
tube feedings with an ad libitum oral diet (Table 111)244 24 ished” (defined by weight loss, plasma proteins, or
Most of the patients studied had cancer. The incidence of prognostic indices) general surgical patients who do
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Randomized, Controlled Trials
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Figure 1. Prospective randomized controlled trialS evaluating the effect of preoperative TPN on postoperative complications. The mean mcrease or
decrease in postoperative complications with 95% confidence intervals are shown for each study. Values above 0 indicate a decrease in complications
associated with the use ofTPN while those below 0 indicate an increase in complications. When the 95% confidence intervals are above or below 0 the
differences in postoperative complications between the group receiving TPN and the control group are statistically significant. The pooled analysis
ofthese trials found a 10% decrease (an overall decrease from 40% to 30%) in postoperative complications in patients who received preoperative TPN.
not receive preoperative TPN increases postopera- patient groups. (C)

tive complications by approximately 10%. (A) 5. Postoperative enteral feeding given to underweight
3. Postoperative nutrition support is necessary for pa- elderly women after surgery for hip fracture speeds
tients unable to eat for long periods after surgery to recovery of mobility, decreases postoperative corn-
prevent adverse effects of starvation. The exact du- plications, and decreases the length of hospital stay.
ration of starvation that can be tolerated without in- (A)
creased morbidity is unknown. The opinion of this
subcommittee is that wound healing and recovery
from surgery may be impaired if TPN is not started
within 5 to 10 days after the operation in patients who
are unable to eat or tolerate enteral feedings. (C) 1. Further studies are needed to help identify specific
4. In the majority of currently published PRCTs evalu- subsets of patients who may benefit from preopera-
ating the use of perioperative TPN, the quantity and tive TPN. These studies should also consider long-
type of substrates given were not optimal by current term outcomes and include a cost-benefit analysis of
standards. For example, calories were often given in nutritional therapy.
amounts substantially greater than metabolic needs. 2. PRCTs are needed to evaluate the clinical efficacy of
Therefore, it is possible that outcomes in many of preoperative enteral feeding in patients considered
these trials would be different if the trials were re- to be at high risk for postoperative complications.
peated using our present-day understanding of caloric 3. Evaluate the potential clinical benefits of specific nu-
needs and other metabolic requirements in specific trients, such as arginine, glutamine, nucleotides and
nucleosides, w-3 fatty acids, and antioxidants, in en-

. CC hancing immune function, ameliorating the inflamma-
tory response, and enhancing recovery from surgery.
C) C)
0
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n. CONCLUDING REMARKS
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il The development of modern nutrition support has been
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E- I- I- c’ C3
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century. To continue to improve the nutritional manage-
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al \j D © 0 ment ofpatients, it is important to have a clear understand-
ing of the published data evaluating the use of nutrition
C -
C)
C s-.
C
L’ t- C © support and to target areas that deserve future investiga-
- C C’ t’
tion. This document represents a careful review ofthe iden-
4 tified published literature evaluating nutritional assess-
©
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ment and the clinical efficacy of enterab and parenteral
\j V
nutrition. The interpretation of data presented here does
D Cl C c not always reflect uniformity of opinion among all mern-
C) - c
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bers of each subcommittee but does represent a consen-
©
sus of the entire group.
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- z The applicability of data obtained from published clini-

C)
cal trials to current practice is limited because of short-
a. C
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,
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© comings in study design and the absence of studies ad-
) 4 - - -
0 ,
dressing some important clinical issues. In addition,
.C)
changes that have occurred in both medical and nutritional
d. d.
S cC CC E E therapy may limit the application ofdata from earlier clini-
C 0 . .5 0 0 cC
cal trials to current practice. Therefore, practice guide-
C . . I .
C-
0I . 0. C -‘ lines for nutrition support cannot be based solely on this
report. Indeed, more than half of the A.S.P.E.N. Guide-
a z C lines2 and the Georgetown University School of Medicine
C)
C) C
C Conference practice guidelines for TPN257 are based on
C N 7 C CC © CC C’ N
CC
2 Al ‘‘ Al ‘ expert opinion rather than research-based evidence. Nev-
C)
C. C-
.C
ertheless, this document should serve to inform the prac-
.C
CC
titioner of the existing literature within the five areas re-
. CC C
viewed by this conference. This document also serves as
a C
C C a challenge to obtain the objective evidence needed to
.
determine the most clinically effective and cost-effective
.
C.-.
use of nutritional therapy.
a - LC CO N ©
- - ‘3 C C C4 C)
C)
C)
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CC ACKNOWLEDGMENT
C 1-
S C)
C) c C) This conference received educational grants from the
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a
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- ,
C
C’1
&t
CC
©
c
N
C’:
Lt7 C following: Clintec Nutrition, McGaw Inc, Mead Johnson
C
Nutritional Groups, Ross Laboratories, and The American
Dietetic Association.
.C
.c
? 2 ©
- - z z _ z z
.
C REFERENCES
1. Butterworth CE: Skeleton in the hospital closet. Nutrition Today
9:4, 1976
V a a a 2. Bistrian BR, Blackburn GL, Vitale J, et al: Prevalence of malnutri-
a a a
.
.2 .9 - .C tion in general medical patients. JAMA 235: 1567, 1976
. .9 3. Bistrian BR, Blackburn GL, Hallowell E, et al: Protein status of gen-
eral surgical patients. JAMA 230:858, 1974
<.9
c 4. Hill GL, Blackett RL, Pickford I, et al: Malnutrition in surgical pa-
cl
tients; an unrecognized problem. Lancet 1:689, 1977
z
N © Cl
e3 C)C
CC
C1
©
C)
©
1
5. Weinsier RL, Humber EM, Krumdieck CL, et al: Hospital malnutri-
CC
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II
0 o prior to chemotherapy in cancer patients. Am J Med 69:491, 1980
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. i -. d H from a single
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measurement
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8. Jelliffe DB: The assessment of the nutritional status of the commu-
- N CC N C © 4
C) CC N C N CC CC
-‘
CC CC nity: With special reference to field surveys in developing regions of
C) - ) - C4 C4 C4 C4
the world. Geneva World Health Organization, 1966
TABLE III
Results ofprospective randomized controlled trials evaluating perioperative enteral nutritional therapy
Major Postoperative
Ref First Author Patient Nutritional Number of Corn phcat,ons Mortality
. . (% (% C omments
(reference) Population Therapy Patients
EN Control EN Control
Preoperative Enteral Nutrition:

244 von Meyenfeldt Gastric, 10 d oratiNG feeding 101 12 14 8 4 Another group received
Colorectal CA preop TPN
245 Shukia GI, breast, and 10 d NG feeding 1 10 10 37* 6 12 40-50% of EN group
oropharynx had tube feeding
CA and complications
benign disease
Postoperative Enteral Nutrition:
247 Sagar GI CA 5 d NJ feeding 30 20 33 NR NR Signif. shorter length
ofstay in EN group
248 Ryan Colorectal CA 10 d NCJ feeding 14 0 43 NR NR
249 Smith GI CA 10 d NCJ feeding 50 44 36 17 4 Signif. longer length
of stay in EN group
250 lovinelli Oropharynx CA >5 d NJ feeding 48 15 22 NR NR
CA = cancer; EN = enteral nutrition; NJ = nasojejunal tube; NJ = needle catheterjejunostomy tube; NG = nasogastric tube; ND nasoduodenal
tube; NH = not reported. * Value significantly different from EN group, p < .05.

80 Post-Op TPN and Morbidity
Randomized Controlled Trials
60
0
b 40
0
20
1
= 0
(I,
I
-20
.4
-60
N= 44 117 47 300 122 56 20 20 726
- C C - C V
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Author
Figure 2. Prospective randomized controlled trials evaluating the effect of early postoperative TPN (without preoperative TPN) on postoperative
complications. The mean increase or decrease in postoperative complications with 95% confidence intervals are shown for each study. Values above
0 indicate a decrease in complications associated with the use of TPN while those below 0 indicate an increase in complications. When the 95%
confidence intervals are above or below 0 the differences in postoperative complications between the group receiving TPN and the control group are
statistically significant. The pooled analysis of these trials found a 10% increase (an overall increase from 30% to 40%) in postoperative complications
in patients who received postoperative TPN.
9. Frisancho AR: New norms of upper limb fat and muscle areas for Washington, DC: (Publication No. IPHSI 78-1650) National Center
assessment of nutritional status. Am J Clin Nutr 34:2540, 1981 for Health Statistics, US Department of Health, Education, and Wel-
10. Harries AD, Jones LA, Heatley RV, et al: Malnutrition in inflamma- fare, 1977
tory bowel disease: An anthropometric study. Human Nutrition Clini- 39. Ramsey B, Farrell P, Pencharz P, et al: Nutritional assessment and
cal Nutrition 36C:307, 1982 management in cystic fibrosis: A consensus report. Am J Clin Nutr
1 1. Thuluvath PJ, Thger DR: How valid are our reference standards of 55:108-116, 1992
nutrition? Nutrition 11:731, 1995 40. Sazawal S, Black R, Bhan MN, et al: Zinc supplementation in young
12. Hall JCH, O’Quigley J, Giles GR, et al: Upper limb anthropometry: children with acute diarrhea in India. N Engl J Med 333:839-844,
The value of measurement variance studies. Am J Clin Nutr 33:1846, 1995
1980 41. Shepherd RW, Holt TL, Thomas RI, et al: Controlled studies of ef-
13. Forbes GF, Bruinmg GJ: Urinary creatinine excretion and lean body fects on nutritional growth retardation, body protein turnover, and
mass. Am J Clin Nutr 29: 1359, 1976 course of pulmonary disease. J Pediatr 109:788-794, 1986
14. Reinhardt GE Myscofski JW, Wilkens DB, et al: Incidence and mor- 42. Dalzell AM, Shepherd RW, Dean B, et al: Nutritional rehabilitation
tality of hypoalbuminemic patients in hospitalized veterans. JPEN of cystic fibrosis: A 5-year follow-up study. J Pediatr Gastroenterol
4:357, 1980 Nutr 15:141-145, 1992
15. Anderson CF, Wochos DN: The utility of serum albumin values in 43. Steinkamp G, von der Hardt H: Improvement of nutritional status
the nutritional assessment of hospitalized patients. Mayo Clin Proc and lung function after long-term nocturnal ga.strostomy feedings in
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patients with subtotal or total gastrectomy in 16 Japanese institu- sis. Surgery 104:727-733, 1988
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180. Jaing Z, Zhang F, Zhu Y, et al: Evaluation of parenteral nutrition in tation to improve liver function, immunity, and mortality in ther-
the postoperative patient. Surg Gynecol Obstet 166:1 15-120, 1988 mally injured patients. J Trauma 27:195-204, 1987
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184. Foley EF, Borlase BC, Dzik WH, et al: Albumin supplementation in port ofthermally injured patients. Crit Care Med 18:1096-1 101, 1990
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468, 1994 215. van den Berg B, Bogaard JM, Hop WCJ: High fat, low carbohydrate,
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735, 1989 217. Gunn T, Reaman G, Outerbridge EW, et al: Peripheral tots1 parenteral
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with arginine, RNA, and menhaden oil is independent of nitrogen 218. Abel RM, Beck CH Jr, Abott WM, et al: Improved survival and acute
balance. Nutrition 7:193-199, 1991 renal failure after treatment with intravenous essential L-amino ac-
194. Bower RH, Cerra FB, Bershadsky B, et al: Early enteral administra- ids and glucose. Results ofaprospective, double-blind study. N Engl
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221. Feinstein El, Kopple JD, Silberman H, et al: Total parenteral nutri- tomy feeding following major abdominal surgery: A controlled ran-
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patients with oesophageal cancer: A prospective, randomised clini- 1016, 1990
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trition in patients with gastrointestinal cancer. J Surg Res 30:497- 256. Wolfe BM, Mathiesen KA Clinical practice guidelines in nutrition sup-
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erative parenteral nutrition. World J Surg 10:53-63, 1986 and core statement of the Technology Assessnient and Practice
229. Bellantone R, Doglietto G, Bossola M, et al: Preoperative parenteral Guidelines Forum, Program on Technology and Health Care, De-
nutrition in the high risk surgical patients. JPEN 12: 195-197, 1988 partment of Community and Family Medicine, Georgetown Univer-
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in patients with gastrointestinal carcinoma Lancet 1:68-71, 1982

231. Smith R, Hartemink R: Improvement of nutritional measures during
preoperative parenteral nutrition in patients selected by the prog-
nostic nutritional index: A randomized controlled trial. JPEN 12:587-
APPENDIX
91, 1988
232. Heatley RV, Williams RHF Lewis MH: Pre-operative intravenous feed- Planning Committee: Bruce Bistrian, MD, PhD, Beth Is-
ing: A controlled trial. Postgrad Med J 55:541-545, 1979 rael Deaconess Medical Center, Harvard Medical Center,
233. Fan 5, Lo C, Lai E, et al: Perioperative nutritional support in pa- Boston, MA; Albert Bothe Jr, MD, University of Chicago
tients undergoing hepatectomy for hepatocellular carcinoma N Engl Medical Center, Chicago, IL; Margaret Heitkemper, RN,
J Med 331:1547-1552, 1994
PhD, University of Washington, Seattle, WA; Van Hubbard,
234. Meguid M, Curtas M, Meguid V, et al: Effects of pre-operative TPN
on surgical risk-preliminary status report. Br J Clin Prac MD, PhD, National Institute of Diabetes, and Digestive and
42(Suppl):53-58, 1988 Kidney Diseases, Bethesda, MD; David Schnackenberg,
235. Bellantone R, Doglietto G, Bossola M, et al: Preoperative parenteral PhD, ASCN, Bethesda, MD.
nutrition of malnourished patients. Acta Chir Scand 1988;22:249-
Conference Coordinator: Edward Bernstein, MPH,
251, 1988
236. Moghissi K, Hornshaw J, Teasdale P, et al: Parenteral nutrition in
A.S.P.E.N., Silver Spring, MD.
carcinoma of the oesophagus treated by surgery: Nitrogen balance Invited Participants: John Kinney, MD, Rockefeller Uni-
and clinical studies. Br J Surg 64:125-128, 1977 versity, New York, NY (Conference Chairman); Samuel
237. Abel R, Fischer J, Buckley M, et al: Malnutrition in cardiac surgical Klein, MD, Washington University School of Medicine, St.
patients: Results of a prospective randomized evaluation of early
Louis, MO (Conference Co-Chairman).
postoperative parenteral nutrition. Arch Surg 111:45-50, 1976
238. Preshaw R, Attisha R, Hollingworth W: Randomized sequential trial Nutrition Assessment Group: Khursheed Jeejeebhoy, MB,
of parenteral nutrition in healing of colonic anastomoses in man. BS, PhD, St. Michael’s Hospital, Toronto, Ontario, Canada
Can J Surg 22:437-439, 1979 (group leader); Michael Hambidge, MD, ScD, University
239. Woolfson A, Smith J: Elective nutritional support after major sur-
of Colorado Medical Center, Denver, CO; Steven
gery: A prospective randomized trial. Clin Nutr 8:15, 1989
240. Holter A, Fischer JE: The effects ofperioperative hyperalimentation
Heymsfield, MD, St. Luke’s Roosevelt Hospital, New York,
on complications in patients with carcinoma and weight loss. J Surg NY; Carol Ireton-Jones, PhD, RD, CORAM Healthcare,
Res23:31-37, 1977 Carrollton, TX; Marsha Wolfson, MD, Baxter Healthcare
241. Jensen 5: Clinical effects of enteral and parenteral nutrition Corp, McGaw Park, IL.
preceeding cancer surgery. Med Oncol Tumor Pharmacother 2:225-
Perioperative Patients Group: Patrick Twomey, MD, San
229, 1985
242. Collins J, Oxby C, Hill G: Intravenous amino acids and intravenous Francisco Veterans Administration Medical Center, San
hyperalimentation as protein-sparing therapy after major surgery: Francisco, CA (group leader); Danny Jacobs, MD, Brigham
A controlled clinical trial. Lancet 1:778-791, 1978 and Women’s Hospital, Boston, MA; Joyce Keithley, DNSc,
243. Reilly J, Mehta R, Teperman L, et al: Nutritional support after liver
RN, Rush Medical Center, Chicago, IL; Michael Meguid,
transplantation: A randomized prospective study. JPEN 14:386-391,
1990
MD, SUNY Health Sciences Center, Syracuse, NY; Susan
244. von Meyenfeldt M, Meijerink W, Rouflart M, et al: Perioperative flu- Pingleton, MD, tJniversity of Kansas Medical Center, Kan-
tritional support: a randomised clinical trial. Clin Nuti 11:180-186, sas City, KS.
1992 Critical Illness Group: Michael Murray, MD, Phi), Mayo
245. Shukla HS, Rao RR, Banu N, et al: Enteral hyperalinientation in mal- Clinic, Rochester, MN (group leader); Joel Kopple, MD,
nourished surgical patients. Indian J Med Res 80:339-346, 1984
246. 1Am S, Choa R, Lam K, et al: Total parenteral nutrition versus gas- Harbor-UCLA Medical Center, Torrance, CA; Ronald
trostomy in the preoperative preparation of patients with carcinoma Koretz, MD, olive View Medical Center, Sylmar, CA; Rob-
of the esopagus. Br J Surg 68:69-72, 1981 ert Shulnian, MD, Baylor College of Medicine, Houston,
247. Sagar S, 1-larland P, Shields R: Early postoperative feeding with el- TX; Douglas Wilmore, MD, Brigham and Women’s Hospi-
ernental diet. Br Med J 1:293-295, 1979
tal, Boston, MA.
248. Ryan JA, Page CP, Babcock L: Early postoperativejejunal feeding of
elemental diet in gastrointestinal surgery. Am Surgeon 47:393-403, Gastrointestinal Disease Group: David Alpers, MD,
1981 Washington University School of Medicine, St. Louis,
249. Smith RC, Hartemink RJ, Hollinshead JW, et al: Fine bore jejunos- MO (group leader); David Driscoll, PhD, RPh, Beth
Israel Deaconess Medical Center, Boston, MA; C. Rich- School of Medicine, St. Louis, MO; Timothy Lipman, MD,
ard Fleming, MD, Mayo Clinic, Jacksonville, FL; Harry Department of Veterans Affairs Medical Center, Wash-
Greene, MD, Slim-Fast Food Co, West Palm Beach, FL; ington, DC; Donald Mock, MD, PhD, University of Arkan-
Michael Sitrin, MD, University of Chicago, Chicago, IL. sas for Medical Sciences, Little Rock, AR.
Wasting Disease Group: Marc Hellerstein, MD, PhD, Uni- Other Contributors: Peggy Borum, PhD, University of
versity of California, Berkeley, Berkeley, CA (group Florida, Gainesville, FL; Eva Shronts, MMSc, RD, Uni-
leader); Virginia Herrmann, MD, St. Louis University versity of Minnesota, Minneapolis, MN.

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Nutrition Support in Clinical Practice: Review of Published Data and

Recommendations for Future Research Directions

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Special Considerations in Pediatric Patients

Nutrition concerns in infants and children differ from

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Crohn ‘S Disease-Parenteral Nutrition

Colitis (Crohn ‘s and Ulcerative)

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Approximately 80% to 90% of patients with acute pan-

beneficial effects on morbidity or ty’#{176}’

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Alcoholic Cirrhosis 1. Providing adequate enteral nutrition or TPN therapy

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mean survival (21-month survival) was reported in patients

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< C.) #{149}. -z 0 _C)

60 Pre-op TPN and Morbidity -

Randomized, Controlled Trials

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N= 40 21 105 395 101 125 113 34 19 124 66 100 15 1258

not receive preoperative TPN increases postopera- patient groups. (C)

nucleosides, w-3 fatty acids, and antioxidants, in en-

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Preoperative Enteral Nutrition:

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holic hepatitis: Results of a Department

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