Nutrition in Clinical Practice最新文献

Malnutrition is estimated to affect roughly 30%-80% of patients with inflammatory bowel disease (IBD). In those patients who cannot tolerate sufficient oral nutrition or there is no possibility for placing an enteral nutrition tube, parenteral nutrition offers a lifesaving alternative. However, this is not without risk. For patients with IBD, understanding the indications, contraindications, and complications associated with parenteral nutrition is crucial. In this review, we will discuss the indications and contraindications for parenteral nutrition in patients with IBD, the common complications associated with intravenous nutrition, the use of parenteral nutrition in special populations, such as in pediatric and perioperative patients, and the impact of parenteral nutrition on IBD-related outcomes.

In pediatric patients with intestinal failure, parenteral nutrition is lifesaving but also has several associated risks. The goals of intestinal rehabilitation include promoting growth, minimizing complications associated with intestinal failure, and reaching enteral autonomy, if possible. Pediatric intestinal rehabilitation programs are interdisciplinary teams that strive to provide optimal care for children dependent on parenteral nutrition. The provision of parenteral nutrition requires close monitoring of patients' growth, nutrition concerns, clinical status, and laboratory parameters. Recent advances in the field of intestinal rehabilitation include new lipid emulsions, considerations regarding enteral feeding, advances in micronutrient provision, and central venous catheter preservation techniques. Challenges in the field remain, including improving overall quality of life with home parenteral nutrition administration and preventing recently recognized complications such as chronic intestinal inflammation.

Intestinal failure-associated liver disease (IFALD) is a serious life-limiting complication that can occur throughout the clinical course of intestinal failure and its management by parenteral nutrition (PN). Despite this, there is a lack of a standardized definition for IFALD, which makes this insidious condition increasingly difficult to screen and diagnose in clinical practice. Attenuating the progression of liver disease before the onset of liver failure is key to improving morbidity and mortality in these patients. This requires timely detection and promptly addressing reversible factors. Although there are various noninvasive tools available to the clinician to detect early fibrosis or cirrhosis in various chronic liver disease states, these have not been validated in the patient population with IFALD. Such tools include biochemical composite scoring systems for fibrosis, transient elastography, and dynamic liver function tests. This review article aims to highlight the existing real need for an accurate, reproducible method to detect IFALD in its early stages. In addition, we also explore the role PN plays in the pathogenesis of this complex multifactorial condition. Various aspects of PN administration have been implicated in the etiology of IFALD, including the composition of the lipid component, nutrient excess and deficiency, and infusion timing. We aim to highlight the clinical relevance of these PN-associated factors in the development of IFALD and how these can be managed to mitigate the progression of IFALD.

Background: Focus on preterm nutrition strategies is imperative. Extrauterine growth restriction (EUGR) is a clinically relevant, but seemingly elusive consequence, often used to benchmark and compare outcomes.

Methods: This before-after observational study was designed to study the effect of a multipronged updated "nutrition care bundle" in very preterm infants on rate of EUGR compared with a cohort from a previous period. Eligible participants were neonates born at <32 weeks' gestation who completed care in the unit; a retrospective group from a previous period and a prospective cohort after implementation of the bundle were included. The bundle constituted of three key areas: (1) aggressive parenteral nutrition with high-dose amino acids and lipids from day 1, (2) "rapid-escalation" enteral feed regimens including earlier introduction of human milk fortifier (at 40-ml/kg/day feeds), and (3) colostrum mouth paint and structured oromotor stimulation to promote oral feeding. EUGR was defined as a z score difference of >-1 in weight for postmenstrual age (PMA) at discharge and at birth.

Results: Data of 116 infants were retrieved for the retrospective group; 103 infants were included in the prospective group. EUGR was reduced from 71% to 58% (P = 0.039) after implementation of the bundle. Infants in the prospective group achieved full oral feeds at earlier PMA (P < 0.001) and were discharged at earlier PMA (P = 0.002).

Conclusions: The proportion of neonates with EUGR was reduced significantly after implementation of the revised nutrition care bundle. Achievement of full oral feeds and discharge readiness were earlier in the prospective group.

Depending on the remaining bowel anatomy and the degree of bowel adaptation, patients with short bowel syndrome (SBS) may require parenteral nutrition (PN) and/or intravenous fluid support, sometimes temporarily and sometimes permanently. Although the use of parenteral support in SBS is often lifesaving, it is not without its limitations. Herein, we undertake a focused review of several issues related to use of parenteral support in patients with SBS, including initiation of parenteral support, considerations when formulating PN, select complications, short-term and long-term nutrition monitoring, and weaning strategies.

Background: Body mass index (BMI) is criticized for being unjust and biased in relatively healthy racial and ethnic groups. Therefore, the current analysis examines if BMI predicts body composition, specifically adiposity, in a racially and ethnically diverse acutely ill patient population.

Methods: Patients admitted with SARS-CoV-2 having an evaluable diagnostic chest, abdomen, and/or pelvic computed tomography (CT) study (within 5 days of admission) were included in this retrospective cohort. Cross-sectional areas (centimeters squared) of the subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and intramuscular adipose tissue (IMAT) were quantified. Total adipose tissue (TAT) was calculated as sum of these areas. Admission height and weight were applied to calculate BMI, and self-reported race and ethnicity were used for classification. General linear regression models were conducted to estimate correlations and assess differences between groups.

Results: On average, patients (n = 134) were aged 58.2 (SD = 19.1) years, 60% male, and racially and ethnically diverse (33% non-Hispanic White [NHW], 33% non-Hispanic Black [NHB], 34% Hispanic). Correlations between BMI and SAT and BMI and TAT were strongest revealing estimates of 0.707 (0.585, 0.829) and 0.633 (0.534, 0.792), respectively. When examining the various adiposity compartments across race and ethnicity, correlations were similar and significant differences were not detected for TAT with SAT, VAT, or IMAT (all P ≥ 0.05).

Conclusions: These findings support the routine use of applying BMI as a proxy measure of total adiposity for acutely ill patients identifying as NHW, NHB, and Hispanic. Our results inform the validity and utility of this tool in clinical nutrition practice.

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

There have been rapidly expanding uses of technology to enhance and improve nutrition in our smallest patients. Optimized nutrition in the neonatal patient is linked to improved outcomes, specifically neurodevelopmental outcomes and decreased length of stay. Despite advances in neonatal care that have improved survival, many patients being discharged from the neonatal intensive care unit are doing so with poor postnatal growth. Because the neonatal brain doubles in size from 20 weeks gestation to term, it is essential to focus care efforts on nutrition to optimize brain growth and development. This review focuses on three exciting areas of neonatal research, including the analysis of macronutrients in breast milk, measurement of body composition, and use of telemedicine.

In 2011, "Tubing Misconnections: Normalization of Deviance" reported >100 cases of enteral tubing misconnections leading to patient harm. Despite development of safer enteral device connectors, 96 new cases of enteral misconnections have been published since 2011. Publication and safety databases were searched for reports from 2011 to 2023. Reported misconnections lead to death in 4% of the cases and survival with harm were reported in 69% of cases. Reported misconnections occurred more often in infants and children than in adults. This article outlines why these misconnections happen, the history of the issue and development of safer connector standards, the safety threats and recommendations associated with the new cases, current conversion rates, and process steps, education, and resources for the conversion to safer connectors for enteral nutrition devices.