Sanja Kolaček
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Table 2. Clinical indications for pediatric EN 1 Inadequate oral intake
Disorders of sucking and swallowing: prematurity, cleft lip and palate, neuromuscular impairment (e.g. cerebral palsy, myopathies)
Congenital abnormalities of the upper gastrointestinal tract: tracheoesophageal fistula Tumors of oral cavity, head and neck cancer
Trauma and extensive facial burns
Critical illness: coma, mechanical ventilation Severe gastroesophageal reflux
Psychiatric disorders: food aversion, anorexia, depression 2 Disorders of digestion and absorption
Cystic fibrosis Short bowel syndrome Inflammatory bowel disease
Malabsorption syndrome due to food intolerances and allergy Enteritis due to chronic infection (Giardia lamblia, protozoa, etc.) Protracted diarrhea in infancy
Pancreatic insufficiencies
Severe primary or acquired immunodeficiency Chronic liver disease
Graft-versus-host disease Intestinal fistulae
Disorders of gastrointestinal motility with pseudo-obstruction 3 Increased nutritional requirements and losses
Cystic fibrosis
Chronic solid organ diseases: renal, heart, liver, lungs Multiple trauma, extensive burns
4 Growth failure or chronic malnutrition (in addition to the above) Nonorganic failure
Food deprivation
5 Altered metabolism and metabolic inborn errors 6 Primary disease management (e.g. Crohn’s disease)
Table 1. Suggested criteria for EN support for children with sufficiently preserved gut function [1, 2]
Insufficient oral intake
Inability to meet 60–80% of individual requirements for >10 days Total time of feeding a disabled child of >4–6 h/day
Wasting and stunting
Inadequate growth or weight gain for >1 month below the age of 2 years Weight loss/no weight gain for >3 months above the age of 2 years Change in weight-for-age or weight-for-height over 2 growth channels Triceps skinfolds consistently at <5th percentile for age
Treatment of disease
Metabolic diseases (galactosemia, primary lactose intolerance, etc.) Food allergy in infants (cow’s milk protein allergy, multiple food allergy, etc.) Crohn’s disease
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gastric (NG) tube placement and maintenance, sterile feed preparation and administration, en- teral pump management, as well as prevention, recognition and management of the most com- mon complications.
Transition to normal oral feed needs to be gradual, and EN can be stopped when oral intake satisfies caloric and nutrient requirements while growth continues to be age appropriate.
Enteral Formula Properties and Selection Criteria
Enteral formulae should supply a balanced intake of energy and nutrients to support age-appropri- ate growth and development. The content of all essential nutrients should provide at least 100% of the reference intake for healthy individuals of the relevant age group. Standard (polymeric) pediat- ric enteral formulae are recommended as the ad- equate and cost-effective form of EN for the ma- jority of patients [1] ; this implies an energy den- sity of 1 kcal/ml (or 0.67 kcal/ml for infants), iso-osmolality (300–350 mOsm/kg), whole pro- teins as a nitrogen source, and a nutrient content adapted to the requirements of children under the age of 10 years. In addition, it is generally lactose and gluten free. More concentrated enteral for-
mulae are also available (1.3–2.0 kcal/ml) for pa- tients with increased energy requirements or lim- ited fluid intake. Since recently, standard formu- lations also contain nondigestible carbohydrates (fibers), which have benefits in reducing gastroin- testinal side effects such as diarrhea and constipa- tion [5] . If pediatric formulae are not available, an adult formulation can be used only after the age of 8–10 years [1] . In polymeric formulae, macro- nutrients are provided in an intact form. If pro- teins are hydrolyzed to an extent that can be toler- ated by at least 90% of patients with verified al- lergy to the nitrogen source, the formula is called
‘semi-elemental’ or ‘oligomeric’ [6] . Monomeric/
elemental formulae are nutritionally complete so- lutions containing amino acids, carbohydrates and fats, often as a mixture of long- and medium- chain triglycerides. A comparison of different formulae is presented in table 3 .
In contrast to standard EN formulae there are disease-specific formulations which were first de- veloped for infants and children with intolerances such as food allergy or inborn errors of metabo- lism and who required elimination of one or more food components. The next step entailed different modifications aiming to be beneficial against spe- cific disorders. Examples are formulae with a high fat content, which may be of value to patients with insulin resistance and to hypercapnic patients
Table 3. Comparison of different enteral formulae for children and adults
Polymeric formulae Oligomeric formulae Monomeric formulae
Protein content, g/l 30–80 20–50 19.5–25
Nitrogen source polypeptides small peptides amino acids
Carbohydrate content, g/l 90–200 100–200 81–146
Fat content, g/l 20–90 5–20 35
Caloric density, kcal/ml 1–2 0.67–1.7 0.67–1
Osmolarity, mOsm/l 300 300–500 300–600
Advantages palatable, cheap hypoallergenic,
easily absorbed
nonallergenic Disadvantages requires intact gut,
allergenic
bitter taste, expensive hyperosmolar, expensive
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 152–157 DOI: 10.1159/000360330
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with pulmonary disease due to lower CO 2 pro- duction, formulae with reduced protein content for patients with renal disease, or formulae with a specific amino acid profile that may benefit pa- tients with hepatic encephalopathy. The most re- cent research topics in enteral formula design are contents of anti-inflammatory cytokines (trans- forming growth factor-β) or nutrients (e.g. gluta- mine, arginine and n–3 fatty acids), which, if pro- vided in high doses, may exert immune-regulat- ing effects. However, for all of these there are very few controlled studies of sufficient quality on pe- diatric patients and, therefore, claims of benefi- cial effects should be evaluated critically [7] .
In formula selection, the following should be considered: (a) nutrients and energy require- ments adjusted for age and clinical condition of the patient; (b) history of food intolerances or al- lergy; (c) level of intestinal function; (d) site and route of formula delivery; (e) formula character- istics such as osmolality, viscosity and nutrient density; (f) taste preference; and (g) cost.
Administration of EN
Sites of Delivery
EN can be administered either into the stomach or into the proximal small intestine. Among the two sites, intragastric feeding is associated with a more flexible feeding schedule, antimicrobial properties, larger volume and higher osmotic tol- erance, and lower frequency of diarrhea and of dumping syndrome because (a) of stimulation of normal digestive and hormonal responses, (b) of a preserved acid barrier, (c) tubes are more easily placed, and (d) the stomach serves as a reservoir gradually releasing nutrients. Postpyloric access is reserved for clinical conditions in which tra- cheal aspiration, gastroparesis and gastric outlet obstruction preclude gastric feeding. However, results of studies comparing both sites are con- flicting, often not showing benefits either in adults or in children [8, 9] .
Routes of Delivery
If the expected duration of EN is short (<6–12 weeks), it is preferentially delivered by NG or na- soenteric tube, but if the expected duration is lon- ger, a feeding gastrojejunostomy is recommend- ed, placed by endoscopy, which is the quickest and cheapest procedure with only a low rate of complications [10, 11] .
Among different tubes, those made of PVC are the least desirable, because of the potential re- lease of toxic phthalate esters into the lipid-con- taining feeds – and if left in place for >4 to 6 days, they may become rigid and cause lesions of the upper gastrointestinal tract. Silicon and polyure- thane tubes are more convenient and can be safe- ly kept in place for several weeks. Considering the required length of the tube, it equals the distance from the nose over the ear lobe to the xiphoid in children, and from the nose over the ear lobe to the mid-umbilicus in neonates. Placement into the stomach is confirmed by measuring the pH of the aspirate, which should be <4 in children and
≤ 5 in neonates. Radiologic confirmation must be obtained if (a) the pH is >5, (b) an aspirate cannot be obtained, or (c) the patient’s condition changes during NG tube insertion, with prolonged cough- ing, restlessness and discomfort or hoarseness [8, 12, 13] .
Modes to Deliver EN
EN delivery modes are intermittent, continuous or combined. Intermittent/bolus delivery is phys- iological, provides a cyclical hormone surge and regular gallbladder emptying, and, if delivered orally, supports the development of age-appro- priate feeding habits and oromotor skills. Con- tinuous formula infusion is often recommended for malnourished children with severe chronic di- arrhea and intestinal failure because reduced sur- face and transport proteins can be more efficient- ly used and the osmotic load is better tolerated [1, 14] . An appropriate and constant flow is ensured by the use of a peristaltic enteral pump. When the child can eat, both methods of feed delivery can
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be combined, with tube feeding overnight for 10–
12 h and oral intake during the day.
Initiation of EN
Initiation of EN should be gradual, depending on: (a) age; (b) clinical condition and gut status;
(c) formula choice (polymeric vs. elemental);
and (d) route of delivery (stomach vs. jejunum).
A slow, stepwise increase in volume and con- centration is particularly important for patients with grossly impaired intestinal function and when the feed is delivered postpylorically.
Monitoring and Complications
Patients receiving EN should be monitored regu- larly for growth, fluid, energy and nutrient intake, therapeutic efficacy, and hematologic and bio- chemical changes.
Possible complications and preventive mea- sures are listed in table 4 [1] . Their occurrence can be minimized by: (a) avoidance of drip feed-
ing and of blenderized feeds; (b) using silicon and polyurethane NG tubes; (c) gradual initiation and stepwise increase in volume and concentra- tion; (d) regular monitoring of residual gastric volumes; (e) strict adherence to management pro- tocols, particularly with respect to bacteriologi- cal safety; and (f) close supervision by a dedicated multidisciplinary team [1, 4, 15] .
Despite the broad range of potential complica- tions, EN is a well-established, safe and effective method of improving a patient’s clinical condi- tion, nutritional status and growth, particularly if procedural protocols are followed and regular quality control is applied [1] .
Areas for Future Developments and Research • Defining the criteria for initiation of EN sup-
port more precisely
• The suitability and benefits of disease-specific formulations should be evaluated in pediatric patients by controlled clinical studies
Table 4. Enteral feeding complications as well as preventive and therapeutic measures [1]
Complications Prevention and treatment
Gastrointestinal
Diarrhea, nausea, vomiting, bloating, abdominal distension
Technical
Occlusion, migration Metabolic
Fluid, glucose and electrolyte imbalance Infective
Gastroenteritis, septicemia Psychological
Oral aversion, altered body self-image
Formula selection
Polymeric vs. predigested Disease specific
Feeding techniques Bolus vs. continuous Gradual initiation of EN EN administration
Delivery site (stomach vs. jejunum) Delivery route (tube vs. stoma) Monitoring
Growth (weight, height/length, skinfolds) Hematology, biochemistry
Multidisciplinary team approach Protocol application and quality control Others
Tube selection (PVC vs. silicon), maintenance
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 152–157 DOI: 10.1159/000360330
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• Determination of the role of transpyloric feed- ing, and establishment of a practical and safe bedside method of checking the position of the feeding tube tip
• Identifying risk factors for complications, and developing protocols that minimize them, particularly with respect to bacterial contami- nation
Conclusions
• EN is a safe and effective method of nutrition- al therapy
• EN should be provided when oral feeds cannot sustain normal growth in a child with reason- ably preserved gastrointestinal function • Selection of an enteral formula depends on the
patient’s age and clinical condition, but for the majority of patients, a standard age-adapted polymeric formula is the appropriate choice, with the best cost-benefit ratio
• Technical, metabolic, gastrointestinal, infec- tive and psychological complications may oc- cur; close monitoring by a multidisciplinary team, application of procedural protocols and regular quality control are therefore re- quired
11 SENPE’s Standardization Group, Pedrón Giner C, Martínez-Costa C, Navas-López VM, et al: Consensus on paediatric en- teral nutrition access: a document ap- proved by SENPE/SEGHNP/ANECIPN/
SECP (in English/Spanish). Nutr Hosp 2011; 26: 1–15.
12 Koletzko B, Goulet O: Nutritional sup- port to infants, children and adoles- cents; in Sobotka L (ed): Basics in Clini- cal Nutrition, ed 4. Prague, Galen, 2011, pp 625–653.
13 Gilbertson HR, Rogers EJ, Ukoumunne OC: Determination of practical pH cut- off level for reliable confirmation of nasogastric tube placement. JPEN J Par- enter Enteral Nutr 2011; 35: 540–544.
14 Olieman JF, Penning C, Ijsselstijn H, et al: Enteral nutrition in children with short-bowel syndrome: current evidence and recommendations for the clinician.
J Am Diet Assoc 2010; 110: 420–426.
15 Bankhead R, Boullata J, Brantley C, Cor- kins M, et al; ASPEN Board of Directors:
Enteral nutrition practice recommenda- tions. JPEN J Parenter Enteral Nutr 2009; 33: 122–167.
References
1 Braegger C, Decsi T, Dias JA, Hartmann C, Kolaček S, et al: Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN Committee on Nutri- tion. J Pediatr Gastroenterol Nutr 2010;
51: 110–122.
2 Axelrod D, Kazmerski K, Iyer K: Pediat- ric enteral nutrition. JPEN J Parenter Enteral Nutr 2006; 30(suppl):S21–S26.
3 Mehta NM, Bechard LJ, Cahill N, et al:
Nutritional practices and their relation- ship to clinical outcomes in critically ill children: an international cohort study.
Crit Care Med 2012; 40: 2204–2011.
4 Agostoni C, Axelson I, Colomb V, Gou- let O, Koletzko B, Michaelsen KF, Puntis J, Rigo J, Shamir R, Szajewska H, Turck D: The need for nutrition support teams in pediatric units: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2005; 41:
8–11.
5 Elia M, Engfer MB, Green CJ, Silk DB:
Systematic review and meta-analysis:
the clinical and physiological effects of fibre-containing enteral formulae. Ali- ment Pharmacol Ther 2008; 27: 120–145.
6 American Academy of Pediatrics Com- mittee on Nutrition: Hypoallergenic infant formulas. Pediatrics 2000; 106:
346–349.
7 Koletzko S: Progress of enteral feeding practice over time: moving from energy supply to patient and disease-adapted formulations; in Koletzko B, Koletzko S, Ruemmele F (eds): Drivers in Innova- tion in Pediatric Nutrition. Nestle Nutr Inst Workshop Ser Pediatr Program.
Basel, Karger, 2010, vol 66, pp 41–54.
8 Kolaček S: Enteral nutrition; in Szajew- ska H, Shamir R (eds): Evidence-Based Approaches in Human Nutrition. World Rev Nutr Diet. Basel, Karger, 2013, vol 108, pp 86–90.
9 Rosen R, Hart K, Warlaumont M: Inci- dence of gastroesophageal reflux during transpyloric feeds. J Pediatr Gastroen- terol Nutr 2011; 52: 532–535.
10 ASGE Standards of Practice Committee, Jain R, Maple JT, Anderson MA, Appa- laneni V, Ben-Menachem T, Decker GA, Fanelli RD, Fisher L, Fukami N, Iken- berry SO, Jue T, Khan K, Krinsky ML, Malpas P, Sharaf RN, Dominitz JA: The role of endoscopy in enteral feeding.
Gastrointest Endosc 2011; 74: 7–12.
3 Nutritional Challenges in Special Conditions and Diseases
Key Words
Parenteral feeding ã Intravenous alimentation ã Substrate requirements, parenteral ã Infant ã Child
Key Messages
• Parenteral nutrition (PN) is indicated when ade- quate nutrition cannot be provided orally or enter- ally
• PN is not indicated in patients with adequate small intestinal function who can be enterally (tube) fed • Ordering and monitoring of PN should follow
agreed algorithms to improve the quality of care • Patients receiving PN should be evaluated 2–3
times/week (e.g. clinical examination, weight, an- thropometry, laboratory values and dietary intake as appropriate)
• The available evidence-based guidelines on paedi- atric PN should guide practice, including the dos- age of substrate supply © 2015 S. Karger AG, Basel
Introduction
Parenteral nutrition (PN) is generally indicated when adequate nutrition cannot be provided orally or enterally, to prevent or correct malnutri- tion, and to sustain appropriate growth. It should be avoided whenever possible by use of adequate care, specialized enteral nutrition (EN) and artifi-
cial feeding devices as appropriate, because PN is more costly and carries higher risks than oral nu- trition or EN. PN is not indicated in patients with adequate small intestinal function in whom oral tube or gastrostomy feeding can be used. The time when PN should be initiated depends both on individual circumstances and the patient’s age and size. In small preterm infants, starvation for just 1 day may be detrimental, and PN must be instituted shortly after birth if it is obvious that adequate amounts of EN will not be tolerated soon. In older children and in adolescence, longer periods of inadequate nutrition (up to 7 days) may be tolerated, depending on the age, nutri- tional status and disease of the patient as well as on the type of intervention (surgery or medical).
Whenever possible, PN should be combined with some (at least minimal) EN. Establishing a multi- disciplinary paediatric nutrition support team for the supervision of PN can improve the quality of care and save costs; hence, it is highly recom- mended [1] . Ordering and monitoring PN should follow agreed algorithms to improve the quality of care. Patients receiving PN should be evaluated 2–3 times/week (e.g. clinical examination, weight, anthropometry, laboratory values and dietary in- take as appropriate). The recommendations pro- vided here are based on the recent evidence-based guidelines for paediatric PN [2, 3] .
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 158–162 DOI: 10.1159/000375190