Journal of Parenteral and Enteral Nutrition

Enteral nutrition is the practice of delivering nutrition to the gut either orally or through a tube or other device. Many children are reliant on enteral feedings to either supplement their nutrition or as a complete source of their nutrition. Managing children on tube feedings requires a team of providers to work through such dilemmas as feeding schedules, weaning from tube feeding, sensory implications of tube feeding, treatment of pain or nausea associated with eating, oral-motor issues, and behavioral issues in the child and family. The purpose of the current review is to summarize the multidisciplinary aspects of enteral feeding. The multidisciplinary team consists of a variable combination of an occupational therapist, speech-language pathologist, gastroenterologist, psychologist, nurse, pharmacist, and dietitian. Children who have minimal oral feeding experience and are fed via a nasogastric or gastrostomy tube often develop oral aversions. Limited data support that children with feeding disorders are more likely to have sensory impairment and that early life pain experiences contribute to feeding refusal. There are inpatient and outpatient programs for weaning patients from tube feeding to eating. The parent-child interaction is an important part of the assessment and treatment of the tube-fed child. This review also points out many information gaps, including data on feeding schedules, blenderized tube feedings, the best methods for weaning children off enteral feedings, the efficacy of chronic pain medications with tube-fed children, and, finally, the necessity of the assessment of parental stress among all parents of children who are tube fed.

Introduction: Malnutrition is common in hospitalized patients in the United States. In 2010, 80,710 of 6,280,710 hospitalized children <17 years old had a coded diagnosis of malnutrition (CDM). This report summarizes nationally representative, person-level characteristics of hospitalized children with a CDM. Methods: Data are from the 2010 Healthcare Cost and Utilization Project, which contains patient-level data on hospital inpatient stays. When weighted appropriately, estimates from the project represent all U.S. hospitalizations. The data set contains up to 25 ICD-9-CM diagnostic codes for each patient. Children with a CDM listed during hospitalization were identified. Results: In 2010, 1.3% of hospitalized patients <17 years had a CDM. Since the data include only those with a CDM, malnutrition’s true prevalence may be underrepresented. Length of stay among children with a CDM was almost 2.5 times longer than those without a CDM. Hospital costs for children with a CDM were >3 times higher than those without a CDM. Hospitalized children with a CDM were less likely to have routine discharge and almost 3.5 times more likely to require postdischarge home care. Children with a CDM were more likely to have multiple comorbidities. Conclusions: Hospitalized children with a CDM are associated with more comorbidities, longer hospital stay, and higher healthcare costs than those without this diagnosis. These undernourished children may utilize more healthcare resources in the hospital and community. Clinicians and policymakers should factor this into healthcare resource utilization planning. Recognizing and accurately coding malnutrition in hospitalized children may reveal the true prevalence of malnutrition.

Background: This investigation explores the feeding behaviors, comorbidities, and parenting stress in young children referred to an outpatient feeding clinic. Materials and Methods: Eligible participants (n =72) were primary caretakers of children ages 2–6 years referred to an interdisciplinary outpatient feeding disorder clinic, subcategorized according to the absence (n = 18) or presence (n = 54) of caretaker-reported medical or developmental comorbidities. This group was compared with an equivalent control sample of caretakers of age-matched children (n = 72). Measures included the Children’s Eating Behavior Inventory (CEBI) and the Parenting Stress Index–Short Form (PSI-SF). Results: The CEBI and PSI scores were higher in the feeding disorder group than in the control group. PSI total was incrementally increased for control vs feeding disorder without comorbidity vs feeding disorder with comorbidity. Conclusion: Increased maladaptive behaviors and parenting stress were evident in children with feeding disorder regardless of the presence of comorbidity. Parenting stress was exacerbated by the presence of comorbidity.

Aim: We hypothesized that the implementation of a feeding quality improvement (QI) program among premature neonates accelerates feeding milestones, safely lowering hospital length of stay (LOS) compared with the baseline period. Methods: Baseline data were collected for 15 months (N = 92) prior to initiating the program, which involved development and implementation of a standardized feeding strategy in eligible premature neonates. Process optimization, implementation of feeding strategy, monitoring compliance, multidisciplinary feeding rounds, and continuous education strategies were employed. The main outcomes included the ability and duration to reach enteral feeds–120 (mL/kg/d), oral feeds–120 (mL/kg/d), and ad lib oral feeding. Balancing measures included growth velocities, comorbidities, and LOS. Results: Comparing baseline versus feeding program (N = 92) groups, respectively, the feeding program improved the number of infants receiving trophic feeds (34% vs 80%, P < .002), trophic feeding duration (14.8 ± 10.3 days vs 7.6 ± 8.1 days, P < .0001), time to enteral feeds–120 (16.3 ± 15.4 days vs 11.4 ± 10.4 days, P < .04), time from oral feeding onset to oral feeds–120 (13.2 ± 16.7 days vs 19.5 ± 15.3 days, P < .0001), time from oral feeds–120 to ad lib feeds at discharge (22.4 ± 27.2 days vs 18.6 ± 21.3 days, P < .01), weight velocity (24 ± 6 g/d vs 27 ± 11 g/d, P < .03), and LOS (104.2 ± 51.8 vs 89.3 ± 46.0, P = .02). Mortality, readmissions within 30 days, and comorbidities were similar. Conclusions: Process optimization and the implementation of a standardized feeding strategy minimize practice variability, accelerating the attainment of enteral and oral feeding milestones and decreasing LOS without increasing adverse morbidities.

Introduction: Parenteral nutrition (PN) in preterm infants leads to PN-associated liver disease (PNALD). PNALD has been linked to serum accumulation of phytosterols that are abundant in plant oil but absent in fish oil emulsions. Hypothesis: Whether modifying the phytosterol and vitamin E composition of soy and fish oil lipid emulsions affects development of PNALD in preterm pigs. Methods: We measured markers of PNALD in preterm pigs that received 14 days of PN that included 1 of the following: (1) Intralipid (IL, 100% soybean oil), (2) Intralipid + vitamin E (ILE, d-α-tocopherol), (3) Omegaven (OV, 100% fish oil), or (4) Omegaven + phytosterols (PS, β-sitosterol, campesterol, and stigmasterol). Results: Serum levels of direct bilirubin, gamma glutamyl transferase, serum triglyceride, low-density lipoprotein, and hepatic triglyceride content were significantly lower (P < .05) in the ILE, OV, and PS compared to IL. Hepatic cholesterol 7-hydroxylase and organic solute transporter–α expression was lower (P < .05) and portal plasma FGF19 higher in the ILE, OV, and PS vs IL. Hepatic expression of mitochondrial carnitine palmitoyltransferase 1A and microsomal cytochrome P450 2E1 fatty acid oxidation genes was higher in ILE, OV, and PS vs IL. In vivo ¹³C-CDCA clearance and expression of pregnane X receptor target genes, cytochrome P450 3A29 and multidrug resistance-associated protein 2, were higher in ILE, OV, and PS vs IL. Conclusions: α-tocopherol in Omegaven and added to Intralipid prevented serum and liver increases in biliary and lipidemic markers of PNALD in preterm piglets. The addition of phytosterols to Omegaven did not produce evidence of PNALD.

Background: Tocopherols and tocotrienols possess vitamin E activity and function as the major lipid-soluble antioxidants in the human body. Commercial lipid emulsions are composed of different oils and supply different amounts of vitamin E. The objective of this study was to measure all 8 vitamin E homologs within 4 different commercial lipid emulsions and evaluate their distribution in guinea pig tissues. Materials and Methods: The distribution of vitamin E homologs within plasma and guinea pig tissues was determined using a high-performance liquid chromatography (HPLC) system. Lipid hydroperoxides in lipid emulsions were determined using a commercial kit (Cayman Chemical Company, Ann Arbor, MI), and malondialdehyde tissue levels were determined using an HPLC system. Results: The lipid emulsions contained variable amounts of tocopherols, which were significantly different between emulsions. Tocotrienols were present at very low concentrations (≤0.3%). We found no correlation between the amount of vitamin E present in the lipid emulsions and lipid peroxidation. Hydroperoxides were the lowest with an olive oil–based emulsion and highest with a fish oil emulsion. The predominant vitamin E homolog in guinea pig tissues was α-tocopherol. No tissues had detectable levels of tocotrienols. Vitamin E levels (primarily α-tocopherol and γ-tocopherol) were highly variable among organ tissues. Plasma levels were a poor reflection of most tissue levels. Conclusion: Vitamin E levels within different lipid emulsions and plasma/tissues are highly variable, and no one tissue or plasma sample serves as a good proxy for levels in other tissues. All study emulsions were well tolerated and did not significantly increase systemic lipid peroxidation.

Background: Clostridium difficile infection (CDI) is one of the leading causes of hospital-acquired infections, creating a financial burden for the U.S. healthcare system. Reports suggest that vitamin D–deficient CDI patients incur higher healthcare-associated expenses and longer lengths of stay compared to nondeficient counterparts. The objective here was to evaluate the relationship between vitamin D level and CDI recurrence. Materials and Methods: A retrospective chart review was conducted for 112 patients with vitamin D level drawn within 3 months of CDI diagnosis. Recurrence, severity of disease, 30-day mortality, and course of CDI were assessed. Results: The vitamin D–deficient group included 56 patients, and the normal group included 56 patients. The mean age of vitamin D–deficient and –sufficient groups was 68 ± 15.7 and 71 ± 14.4 years, respectively. The mean 25(OH) D level in the deficient group was 11.7 ± 4.6 ng/mL, and it was 36.2 ± 16.2 ng/mL in the normal group. A longer course of diarrhea was apparent in the vitamin D–deficient group compared to the normal group: 6.1 days (95% confidence interval [CI], 4.9–7.2) vs 4.2 days (95% CI, 3.5–4.9; P = .01). Sepsis rate was 24% in vitamin D–deficient group and 13% in normal group (P = .03). There were no differences in CDI recurrence, length of stay, severity of illness, and mortality with respect to vitamin D status. Conclusion: There may be an association between course of diarrhea and increased rate of sepsis in vitamin D–deficient CDI patients.

Background: Shortages of parenteral nutrition (PN) components have been common in recent years. Effects on patient management and outcomes have not been well documented. This study aimed to determine the effect of a parenteral magnesium shortage, and an institutional decision to omit magnesium from adult PN, on magnesium and potassium doses and serum concentrations. Materials and Methods: This was a retrospective cohort study of adult surgical patients during two 6-month periods: prior to the magnesium shortage (2011) and during the shortage (2012). The relation between study period and electrolyte doses was evaluated by unadjusted and adjusted mixed models, while the relation between study period and hypokalemia and hypomagnesemia exposure was evaluated by Student’s t tests and multiple linear regression. Results: During the shortage, patients received more supplemental magnesium (0.11–0.12 mEq/kg/d, P < .0001) but received less total daily magnesium (0.08–0.09 mEq/kg/d, P < .0001) and had greater exposure to hypomagnesemia (9.6–14.2 h·mcg/dL/h, P < .05 for all comparisons except multivariate analysis in a matched subpopulation). Patients received similar amounts of potassium in PN (0.06–0.08 mEq/kg/d less, P < .05 for full cohort but P > .05 for matched cohort), in supplemental doses (0.01–0.05 mEq/kg/d less, P > .05), and in total (0.07–0.14 mEq/kg/d less, P > .05), and they had similar exposure to hypokalemia. Conclusion: Daily magnesium doses were lower and hypomagnesemia exposure was greater during the shortage, but the differences were numerically small and their clinical significance was questionable. Potassium doses and hypokalemia exposure were not higher during the shortage. This supports the strategy of omitting magnesium from PN of select patients and supplementing as clinically necessary.

Background: Recent clinical studies have shown that nasogastric tube feeding is safe in the majority of patients with acute pancreatitis. Patient-reported outcomes are important, but the impact of nasogastric tube feeding on the quality of life has not been investigated. This study aims to compare quality of life between nasogastric tube feeding and nil-by-mouth groups during and after hospitalization. Methods: Patient-reported outcomes were recorded daily in a patient diary during hospitalization. The Abdominal Surgery Impact Scale questionnaire was used to determine patients’ quality of life. The patients were then followed up at 1 week and 1, 3, and 6 months after discharge. Results: While 17 patients were randomized to nasogastric tube feeding, 18 were put on nil-by-mouth. The overall quality of life and individual domains did not differ significantly between the groups during hospitalization (P = .500) or follow-up. For the entire cohort, individual quality-of-life domains during hospitalization improved significantly, including functional impairment (P < .001), pain (P < .001), sleep (P = .035), and psychological function (P < .001). Quality of life further improved for all patients from time of hospital discharge to 3 (P = .002) and 6 months follow-up (P < .001) but not to 1 week and 1 month. Conclusions: The use of nasogastric tube feeding, in comparison with nil-by-mouth, does not impair patients’ quality of life. Given the clinical benefits of nasogastric tube feeding, nasogastric feeding should be considered the first-line approach in all acute pancreatitis patients requiring enteral nutrition.

Background: Catheter-related bloodstream infections (CRBSIs) are a serious complication in the provision of home parenteral nutrition (HPN). Antibiotic salvage of central venous catheters (CVCs) in CRBSI is recommended; however, this is based on limited reports. We assessed the efficacy of antibiotic salvage of CRBSIs in HPN patients. Materials and Methods: All confirmed CRBSIs occurring in patients receiving HPN in a national intestinal failure unit (IFU), between 1993 and 2011, were analyzed. A standardized protocol involving antibiotic and urokinase CVC locks and systemic antibiotics was used. Results: In total, 588 patients were identified with a total of 2134 HPN years, and 297 CRBSIs occurred in 137 patients (65 single and 72 multiple CRBSIs). The overall rate of CRBSI in all patients was 0.38 per 1000 catheter days. Most (87.9%) infections were attributable to a single microorganism. In total, 72.5% (180/248) of CRBSIs were salvaged when attempted (coagulase-negative staphylococcus, 79.8% [103/129], Staphylococcus aureus, 56.7% [17/30]; polymicrobial infections, 67.7% [21/30]; and miscellaneous, 66.1% [39/59]). CVC salvage was not attempted in 49 episodes because of life-threatening sepsis (n = 18), fungal infection (n = 7), catheter problems (n = 20), and CVC tunnel infection (n = 4). Overall, the CVC was removed in 33.7% (100/297) of cases. There were 5 deaths in patients admitted to the IFU for management of the CRBSI (2 severe sepsis at presentation, 3 metastatic infection). Conclusions: This is the largest reported series of catheter salvage in CRBSIs and demonstrates successful catheter salvage in most cases when using a standardized protocol.

Background: Hypertriglyceridemia is a frequent metabolic complication associated with fat administration in parenteral nutrition (PN). No clear guidelines have been published on how to proceed once hypertriglyceridemia has been detected. A new strategy could be to substitute the initial fat emulsion with another emulsion with faster clearance. Our objective was to determine the effectiveness in reducing triglyceridemia values, maintaining the caloric intake, and improving nutrition parameters in patients who had moderate hypertriglyceridemia during PN when an olive oil–based fat emulsion (OOFE) was substituted with a multiple-source oil fat emulsion (MOFE). We also assessed the safety of this substitution in hepatic and glycemic profiles. Materials and Methods: We performed a retrospective, observational study that included 38 adult patients to whom OOFE in PN was substituted with MOFE when moderate hypertriglyceridemia (≥250–400 mg/dL) was detected. Results: Triglyceridemia values decreased in 36 (94.7%) patients. The mean reduction was 71 (88–22) mg/dL. Fat load was slightly reduced after substitution (–0.14 [–0.23 to 0] g/kg/d; P < .001), but total caloric intake increased from 22.5 (19.7–25.1) to 23.1 (19.8–26.8) kcal/kg/d (P = .053). After substitution, nutrition parameters improved, liver parameters remained unchanged, and insulin requirements increased. Conclusion: The substitution of OOFE with MOFE in patients with moderate hypertriglyceridemia during PN resulted in a reduction in triglyceridemia values of about 70 mg/dL. That allowed maintaining the caloric intake and improved nutrition parameters without affecting the hepatic profile. For some patients, insulin requirements increased moderately.

Background:The Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN) recommend that obese, critically ill patients receive 11–14 kcal/kg/d using actual body weight (ABW) or 22–25 kcal/kg/d using ideal body weight (IBW), because feeding these patients 50%-70% maintenance needs while administering high protein may improve outcomes. It is unknown whether these equations achieve this target when validated against indirect calorimetry, perform equally across all degrees of obesity, or compare well with other equations. Methods: Measured resting energy expenditure (MREE) was determined in obese (body mass index [BMI] ≥30 kg/m²), critically ill patients. Resting energy expenditure was predicted (PREE) using several equations: 12.5 kcal/kg ABW (ASPEN-Actual BW), 23.5 kcal/kg IBW (ASPEN-Ideal BW), Harris-Benedict (adjusted-weight and 1.5 stress-factor), and Ireton-Jones for obesity. Correlation of PREE to 65% MREE, predictive accuracy, precision, bias, and large error incidence were calculated. Results: All equations were significantly correlated with 65% MREE but had poor predictive accuracy, had excessive large error incidence, were imprecise, and were biased in the entire cohort (N = 31). In the obesity cohort (n = 20, BMI 30–50 kg/m²), ASPEN-Actual BW had acceptable predictive accuracy and large error incidence, was unbiased, and was nearly precise. In super obesity (n = 11, BMI >50 kg/m²), ASPEN-Ideal BW had acceptable predictive accuracy and large error incidence and was precise and unbiased. Conclusions: SCCM/ASPEN-recommended body weight equations are reasonable predictors of 65% MREE depending on the equation and degree of obesity. Assuming that feeding 65% MREE is appropriate, this study suggests that patients with a BMI 30–50 kg/m² should receive 11–14 kcal/kg/d using ABW and those with a BMI >50 kg/m² should receive 22–25 kcal/kg/d using IBW.

Malnutrition increases the risk of infections in patients receiving medical and surgical procedures, but it is not clear whether it may facilitate also the development of opportunistic infections in human immunodeficiency virus (HIV)–negative patients not receiving immunosuppressive therapies. Here we report the first case of a non-HIV, severely malnourished woman who developed Pneumocystis jirovecii pneumonia. This report highlights the clinical relevance of malnutrition as a determinant of immune suppression, which in turn may also favor opportunistic infections. Therefore, routine nutrition screening and assessment, as well as timely start of nutrition therapy, should be prioritized in daily clinical practice to reduce complications and improve outcome.

Clinical trials of the glucagon-like peptide 2 analogue teduglutide resulted in approval of the drug by the Food and Drug Administration in 2012 as a treatment for parenteral nutrition–dependent short bowel syndrome in adults. This report presents the case study of a man with short bowel syndrome caused by portal vein thrombosis who had 4 years exposure to the drug at the time of his death due to cardiovascular disease.

Routine supplementation of iodine in parenteral nutrition (PN) solutions is not current practice in the United States. In this case study, we describe an incidental finding of goiter in a long-term PN-dependent adolescent. With increased iodine screening, we then identified additional patients with undetectable urinary iodine concentrations in our population of children with short bowel receiving long-term PN. We hypothesize that 2 practice changes are possibly reducing iodine provision to long-term PN-dependent patients: transition to alcohol-based skin preparations and lipid minimization.

Prado CMM, Heymsfield SB. Lean tissue imaging: a new era for nutritional assessment and intervention. JPEN J Parenter Enteral Nutr. 2014;38:940-953. (Original DOI: 10.1177/0148607114550189)

Gomez-Perez SL, Haus JM, Sheean P, et al. Measuring abdominal circumference and skeletal muscle from a single cross-sectional computed tomography image: A step-by-step guide for clinicians using National Institutes of Health ImageJ. JPEN J Parenter Enteral Nutr. 2016;40:308-318. (Original DOI: 10.1177/0148607115604149)