Nutrition in Clinical Practice

Malnutrition in adult hospitalized patients has been a significant issue for almost 40 years. Changes in 2007 to the diagnosis related groups reimbursement methodology, as outlined by the Center for Medicare and Medicaid Services, provided an impetus to improve the diagnosis and documentation of malnutrition in adult patients. Being able to accurately assess, diagnose, and document malnutrition has been challenged by the lack of a standard malnutrition definition. In 2012 a workgroup of the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition published a consensus paper outlining characteristics for the diagnosis of adult hospital malnutrition. Using the etiology approach for defining malnutrition as outlined by Jensen and colleagues, 6 general characteristics are outlined with specific thresholds to delineate severe and nonsevere malnutrition. The purpose of this article is to provide practical strategies for criteria implementation and to describe one institution’s experience in implementing a broad-based “malnutrition program” within its healthcare system.

One of the most important aspects of a well-child examination is an assessment of a child’s growth. Children who are failing to grow are often labeled “failure to thrive.” However, close examination of the pattern of growth on standardized growth charts often allows the caregiver to characterize the growth failure as failure to grow, failure to gain weight, or failure to grow and gain weight. Such refinement of the pattern of growth failure allows for a more specific differential diagnosis and helps to focus laboratory and radiographic evaluation.

Premature infants are highly susceptible to extrauterine growth restriction. Without early and adequate nutrition support, nutrition deficits of energy and protein can quickly accrue. Growth failure has been implicated in poor neurodevelopmental outcomes and long-term morbidity, creating a major focus on neonatal nutrition alongside medical management. Optimal nutrition is paramount for optimal growth outcomes. The purpose of this article is to review the implications and long-term effects of growth failure in premature infants, specifically, those with very low birth weights. In addition, nutrition interventions and treatments will be presented to manage and improve growth outcomes of the neonate.

Background: Food allergies affect up to 8% of American children. The current recommended treatment for food allergies is strict elimination of the allergens from the diet. Dietary elimination of nutrient-dense foods may result in inadequate nutrient intake and impaired growth. The purpose of this review was to critically analyze available research on the effect of an elimination diet on nutrient intake and growth in children with multiple food allergies. Methods: A systematic review of the literature was conducted and a workgroup was established to critically analyze each relevant article. The findings were summarized and a conclusion was generated. Results: Six studies were analyzed. One study found that children with food allergies are more likely to be malnourished than children without food allergies. Three studies found that children with multiple food allergies were shorter than children with 1 food allergy. Four studies assessed nutrient intake of children with multiple food allergies, but the inclusion and comparison criteria were different in each of the studies and the findings were conflicting. One study found that children with food allergies who did not receive nutrition counseling were more likely to have inadequate intake of calcium and vitamin D. Conclusion: Children with multiple food allergies have a higher risk of impaired growth and may have a higher risk of inadequate nutrient intake than children without food allergies. Until more research is available, we recommend monitoring of nutrition and growth of children with multiple food allergies to prevent possible nutrient deficiencies and to optimize growth.

Malnutrition is one of the main burdens of disease in cystic fibrosis (CF) along with lung disease. Data from the most recent Cystic Fibrosis Foundation registry report show the prevalence of malnutrition is decreasing in the CF population primarily from interventions focusing on preventing malnutrition. Despite success of interventions and decreased prevalence of malnutrition in this population, prevention of malnutrition in CF patients remains a dilemma that must be managed throughout the life cycle. The pathogenesis of malnutrition in CF can be further categorized into 3 main areas: increased energy losses, increased energy needs, and inadequate calorie intake. The purpose of this review is to further explore the causes of malnutrition and explain current research to prevent malnutrition in the CF population.

Sarcopenia is defined as an age-related decrease in muscle mass and performance. Several consensus definitions of sarcopenia exist, each providing different cut points and methodologies for assessing muscle mass and muscle strength. Thus, wide variation in the prevalence of sarcopenia has been reported, generally ranging up to 45% for men and 26% for women. Risk factors for sarcopenia include age, malnutrition, and physical inactivity. Additional evidence suggests a protective role for protein supplementation in older adults to preserve lean body mass and prevent frailty, accepted intervention targets for reducing the risk of sarcopenia. Protein supplements vary widely in their composition, and small trials of heterogeneous study designs have made it difficult to extrapolate findings to develop data-driven, evidence-based recommendations for protein supplementation in sarcopenia prevention. Short-term randomized controlled trials of muscle protein synthesis have demonstrated that whey protein increases synthesis more so than casein or soy isolates. Studies also suggest that essential amino acids stimulate muscle protein synthesis to a greater extent than nonessential amino acids. This review summarizes the epidemiological and clinical trial evidence establishing the current definitions for sarcopenia and provides an overview of the state of the evidence for protein supplementation to prevent and/or mitigate sarcopenia.

The incidence of malnutrition in hospitalized patients is relatively high (up to 55%) despite breakthroughs in nutrition support therapies. These patients have increased morbidity and mortality, extended hospital stays, and care that is associated with higher costs. These patients are often poorly managed due to inadequate nutrition assessment and poor medical knowledge and practice in the field of nutrition. Nutrition support teams (NSTs) are interdisciplinary support teams with specialty training in nutrition that are often comprised of physicians, dietitians, nurses, and pharmacists. Their role includes nutrition assessment, determination of nutrition needs, recommendations for appropriate nutrition therapy, and management of nutrition support therapy. Studies have demonstrated significant improvements in patient nutrition status and improved clinical outcomes as well as reductions in costs when patients were appropriately managed by a multispecialty NST vs individual caregivers. Despite this, there has been steady decline in the number of formal NST in recent years (65% of hospitals in 1995 to 42% in 2008) as hospitals and other healthcare organizations look for ways to cut costs. Given the importance of nutrition status on clinical outcomes and overall healthcare costs, a number of institutions have introduced and sustained strong nutrition training and support programs and teams, demonstrating both clinical and economic benefit. The benefits of NST, training and implementation strategies, and tips for justifying these clinically and economically beneficial groups to healthcare organizations and governing bodies are discussed in this review.

Recent articles have addressed the characteristics associated with adult malnutrition as published by the Academy of Nutrition and Dietetics (the Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). This article describes a successful interdisciplinary program developed by the Department of Food and Nutrition at New York-Presbyterian Hospital to maintain and monitor clinical documentation, ensure accurate International Classification of Diseases 9th Edition (ICD-9) coding, and identify subsequent incremental revenue resulting from the early identification, documentation, and treatment of malnutrition in an adult inpatient population. The first step in the process requires registered dietitians to identify patients with malnutrition; then clear and specifically worded diagnostic statements that include the type and severity of malnutrition are documented in the medical record by the physician, nurse practitioner, or physician’s assistant. This protocol allows the Heath Information Management/Coding department to accurately assign ICD-9 codes associated with protein-energy malnutrition. Once clinical coding is complete, a final diagnosis related group (DRG) is generated to ensure appropriate hospital reimbursement. Successful interdisciplinary programs such as this can drive optimal care and ensure appropriate reimbursement.

Conducting nutrition-focused physical examinations and reporting the findings from the perspective of nutrition status strengthen the practitioner’s assessments, interventions, and monitoring. The nutrition-focused physical examination of the oral cavity is particularly useful to identify nutrient deficiencies early and with accuracy as the tissues in the oral mucosa have a turnover rate of <1 week. As biomarkers may not always be reliable for identifying micronutrient deficiencies, these physical examinations are important for providing comprehensive nutrition care. The purpose of this article is to discuss the methods of conducting a nutrition-focused oral screening examination and compile and document the evidence regarding the effects of micronutrient deficiencies on the oral mucosa. The information is formatted into a table that can be used as a tool when conducting an oral screening by identifying possible deficiencies based on the observations and other relevant findings. The tool will also guide the practitioner in confirming the physical findings, suggesting interventions to treat the deficiency and how to monitor the outcomes.

Parenteral nutrition (PN) is a life-sustaining therapy for hundreds of thousands of people who have severe impairment of gastrointestinal function. Trace elements are a small but very important part of PN that can be overlooked during busy practice. Serious complications can result from trace element deficiencies and toxicities, and this is especially problematic during times of product shortages. Practical information on parenteral trace element use can be gleaned from case reports, some retrospective studies, and very few randomized controlled trials. A general knowledge of trace element metabolism and excretion, deficiency and toxicity symptoms, products, optimal dosages, and strategies for supplementation, restriction, and monitoring will equip practitioners to provide optimal care for their patients who depend on PN.

Background: Nutrition screening is usually administered by nurses. However, most studies on nutrition screening tools have not used nurses to validate the tools. The 3-Minute Nutrition Screening (3-MinNS) assesses weight loss, dietary intake, and muscle wastage, with the composite score of each used to determine risk of malnutrition. The aim of the study was to determine the validity and reliability of 3-MinNS administered by nurses, who are the intended assessors. Methods: In this cross-sectional study, 3 ward-based nurses screened 121 patients aged 21 years and over using 3-MinNS in 3 wards within 24 hours of admission. A dietitian then assessed patients’ nutrition status using Subjective Global Assessment within 48 hours of admission, while blinded to the results of the screening. To assess the reliability of 3-MinNS, 37 patients screened by the first nurse were rescreened by a second nurse within 24 hours, who was blinded to the results of the first nurse. The sensitivity, specificity, and best cutoff score for 3-MinNS were determined using the receiver operator characteristics curve. Results: The best cutoff score to identify all patients at risk of malnutrition using 3-MinNS was 3, with sensitivity of 89% and specificity of 88%. This cutoff point also identified all (100%) severely malnourished patients. There was strong correlation between 3-MinNS and SGA (r = .78, P < .001). The agreement between 2 nurses conducting the 3-MinNS tool was 78.3%. Conclusion: The 3-MinNS is a valid and reliable tool for nurses to identify patients at risk of malnutrition.

Background: Increased risk for infection has been associated with the administration of intravenous fat emulsion (IVFE). Typically, IVFE is infused daily as part of the parenteral nutrition (PN) regimen. However, a national IVFE shortage in 2010 compelled institutions to restrict administration to nondaily. This retrospective study evaluated the rate of infections associated with the nondaily as compared to daily IVFE infusion in hospitalized adult patients. Methods: Patients in the study group received nondaily IVFE during the shortage period, and patients in the control group received daily IVFE. The primary outcomes were the development of catheter-related bloodstream infections (CR-BSIs) or any bloodstream infection (BSI). Secondary outcomes were the development of respiratory, urinary, wound, or other infections. Results: Included in the study were 52 patients, 33 patients in the study group and 19 patients in the control group. There were no CR-BSIs reported. BSIs occurred in 1 patient in the study group. The total number of infections and urinary tract infections (UTIs) per 1000 catheter days were not different between the 2 groups (45.28 vs 21.24, P = .203) and (24.39 vs 5.525, P = .099), respectively. Survival analyses showed no difference between the 2 groups for the time to first infection (11.24 vs 6.59 days, P = .30) and time to first UTI (11.97 vs 7 days, P = .093), respectively. Conclusions: Nondaily vs daily IVFE infusion did not have a significant effect on the risk of infection or time to development of infection; however, results are limited due to the small sample size. Large prospective randomized clinical trials are needed to further evaluate the effect of daily as compared to nondaily IVFE infusion on infectious complications.

Background: Cyclic parenteral nutrition (PN) is used for both the treatment and prevention of parenteral nutrition–associated liver disease (PNALD). Early initiation of prophylactic cyclic PN may not be well tolerated in young neonates. Our objective was to test the hypothesis that prophylactic cyclic PN initiated prior to the onset of hyperbilirubinemia is associated with younger age at initiation, lower bilirubin levels, and similar rates of adverse events compared to therapeutic cyclic PN initiated after established cholestasis in surgical neonates. Methods: A retrospective review of infants with gastrointestinal disorders requiring surgical intervention who received cyclic PN 2006-2011 was performed. Results: Of the 43 infants eligible for analysis, 23 received prophylactic and 20 received therapeutic cyclic PN. Infants in both groups were comparable in demographics, surgical diagnoses, and illness severity. At initiation of cyclic PN, infants with prophylactic cyclic PN were significantly younger in chronologic (P = .003) and postmenstrual age (P = .029). Prophylactic cyclic PN was associated with a significantly lower incidence of hyperbilirubinemia (P = .001), lower maximum conjugated bilirubin (P < .0001), and lower last checked conjugated bilirubin (P = .032) compared to the therapeutic cyclic PN. The incidence of hypoglycemia, hyperglycemia, and hypertriglyceridemia was similar for the 2 groups. Conclusions: There may be a potential benefit to initiating cyclic PN prior to the development of hyperbilirubinemia in surgical neonates. Early initiation of prophylactic cyclic PN does not appear to increase the risk for adverse events.

Background: Soy-based intravenous fat emulsion (IVFE) is known to cause a rise in pulmonary artery pressure in the preterm infant, thought to be mediated through eicosanoid metabolites of linoleic acid. We compared the effect of soy-based IVFE and an olive-oil-based IVFE containing less than half the content of linoleic acid on pulmonary artery pressure and eicosanoid metabolites in preterm infants receiving parenteral nutrition. Methods: In this pilot study at a regional neonatal intensive care unit (ICU), infants received either a soy-based or olive-oil-based IVFE as part of an otherwise identical feeding protocol. Pulmonary artery pressure and urinary thromboxane B2 and prostaglandin F1 alpha were measured at baseline and maximum lipid infusion. Results: There was a greater fall in pulmonary artery pressure in the olive-oil-based IVFE group compared with the soy-based IVFE group. A decrease in urine thromboxane/prostaglandin F1 alpha ratio was seen only in the olive-oil-based IVFE group. Conclusions: In the parenterally fed preterm infant, an olive-oil-based IVFE may have a beneficial effect on pulmonary artery pressure when compared with soy-based IVFE. Effects on pulmonary vascular tone are likely to be mediated through alterations in eicosanoid metabolism. A randomized trial is warranted to compare the effects of different lipid emulsions.

Background: Adequate energy intake is a component of successful recovery after injury, yet little is known about the energy requirements in the acute period following traumatic amputation. The purpose of this study was to compare the clinical applicability of resting energy expenditure (REE) measured by a handheld calorimeter and estimated by 3 different predictive equations to that measured by the gold standard, indirect calorimetry using a metabolic cart, during the acute postamputation period of inpatient hospitalization. Materials and Methods: Indirect calorimetry measured using both a metabolic cart and handheld calorimeter and predicted by 3 equations were used to assess energy needs of eligible subjects admitted to Brooke Army Medical Center with traumatic amputation(s). REE measured by the handheld calorimeter and estimated using 3 predictive equations (Mifflin St. Jeor, Ireton-Jones 1992, and the American College of Chest Physicians [ACCP]) were compared to the gold standard metabolic cart. Each measure was assessed for significant differences and level of clinical acceptability defined as ± 10% REE by metabolic cart. Results: Thirteen male service members with traumatic amputation(s) were included. The majority of subject’s measurements using the handheld calorimeter (n = 9, 69%) and 3 predictive equations (Mifflin St. Jeor [n = 7, 54%], Ireton-Jones 1992 [n = 8, 62%], ACCP [n = 7, 54%]) fell outside of the ± 10% range of clinical acceptability. Conclusion: Use of the metabolic cart for measuring energy needs remains optimal in this population.

We report a case of an inadvertent increase in the international normalized ratio (INR) after the addition of bismuth subsalicylate for the treatment of diarrhea in an enterally fed patient receiving warfarin therapy. A 56-year-old Caucasian female presented to the trauma intensive care unit (ICU) with multiple lower extremity fractures. Warfarin was initiated for deep vein thrombosis prophylaxis due to the patient’s inability to ambulate. The target INR was 2-3. Continuous intragastric enteral feeding was withheld 1 hour before and 1 hour after intragastric administration of warfarin. Bismuth subsalicylate 30 mL every 4 hours was prescribed for diarrhea. Within 3 days after starting bismuth subsalicylate therapy, the patient’s INR increased from 2.56 to 3.54 and minor bleeding was noted from the patient’s tracheostomy site. No significant change in warfarin dosage, variability in vitamin K intake, or medications that potentially alter warfarin metabolism were present during the unexpected rise in INR. When the bismuth subsalicylate was discontinued, the patient’s INR stabilized into the target range on the same warfarin dose given at the time of the supratherapeutic INR. Salicylate displaces warfarin from plasma protein binding sites and may result in a significant increase in INR secondary to redistribution of warfarin to the free active form. Evaluation of this case report using the Drug Interaction Probability Scale and Naranjo Adverse Drug Reaction Probability Scale yielded scores consistent with a probable adverse drug interaction. Bismuth subsalicylate exaggerates warfarin’s anticoagulant response and its concurrent use during warfarin therapy should be avoided.