Macronutrient Delivery Research Articles

Nutrient delivery in mechanically ventilated surgical patients in the pediatric critical care unit

PurposeInadequate nutrient intake is associated with poor outcomes in critically ill children. We examined macronutrient delivery in surgical patients in the pediatric intensive care unit (PICU). MethodsIn a prospective international cohort study of mechanically ventilated children (1month to 18years), we recorded adequacy of cumulative nutrient delivery in the PICU. Surgical patients enrolled in this study were included in the current analysis. Protein intake <60% of the prescribed goal was deemed inadequate. ResultsFive hundred nineteen surgical patients, 45% female, median age 2years (IQR 0.5, 8), BMI z score −0.26, with 9-day median PICU stay and 60-day mortality 5.8% were enrolled. Three hundred forty-one (66%) patients received enteral nutrition (EN), and median time of initiation was PICU day 2. EN delivery was interrupted in 68% of these patients for a median duration of 9hours. Median enteral protein delivery was <15% of the prescribed goal and was <60% in two-thirds of the cohort. Patients with inadequate enteral protein delivery had longer time to EN initiation (p<0.001) and longer duration of EN interruptions (p<0.001) compared to those with adequate delivery. ConclusionEnteral protein delivery in critically ill pediatric surgical patients is inadequate. Early EN initiation and minimizing interruptions may increase protein delivery and potentially improve outcomes in this population. Level of evidenceI. Type of studyProspective study.

Nutritional status, metabolic state and nutrient intake in children with bronchiolitis

Nutrition has a coadjuvant role in the management of children with acute diseases. We aimed to examine nutritional status, macronutrient requirements and actual macronutrient delivery in bronchiolitis. The nutritional status was classified according to WHO criteria and resting energy expenditure (MREE) was measured using an indirect calorimeter. Bland–Altman analysis was used to examine the agreement between MREE and estimated energy expenditure (EEE) with standard equations. Based on the ratio MREE/EEE in relation to Schofield equation on admission, we defined the subjects’ metabolic status. A total of 35 patients were enrolled and 46% were malnourished on admission, and 25.8% were hypermetabolic, 37.1% hypometabolic and 37.1% normometabolic. We performed a 24-h recall in 10 children and 80% were overfed (AEI: MREE >120%). Mean bias (limits of agreement) with MREE was 8.9 (−73.9 to 91.8%) for Schofield; 61.0 (−41 to 163%) for Harris–Benedict; and 9.9 (−74.4 to 94.2%) for FAO-WHO equation. Metabolism of infants with bronchiolitis is not accurately estimated by equations.

Energy and Protein Delivery in Overweight and Obese Children in the Pediatric Intensive Care Unit.

Early and optimal energy and protein delivery have been associated with improved clinical outcomes in the pediatric intensive care unit (PICU). Overweight and obese children in the PICU may be at risk for suboptimal macronutrient delivery; we aimed to describe macronutrient delivery in this cohort. We performed a retrospective study of PICU patients ages 2-21 years, with body mass index (BMI) ≥85th percentile and >48 hours stay. Nutrition variables were extracted regarding nutrition screening and assessment, energy and protein prescription, and delivery. Data from 83 patient encounters for 52 eligible patients (52% male; median age 9.6 [5-15] years) were included. The study cohort had a longer median PICU length of stay (8 vs 5 days, P < .0001) and increased mortality rate (6/83 vs 182/5572, P = .045) than concurrent PICU patient encounters. Detailed nutrition assessment was documented for 60% (50/83) of patient encounters. Energy expenditure was estimated primarily by predictive equations. Stress factor >1.0 was applied in 44% (22/50). Median energy delivered as a percentage of estimated requirements by the Schofield equation was 34.6% on day 3. Median protein delivered as a percentage of recommended intake was 22.1% on day 3. The study cohort had suboptimal nutrition assessments and macronutrient delivery during their PICU course. Mortality and duration of PICU stay were greater when compared with the general PICU population. Nutrition assessment, indirect calorimetry-guided energy prescriptions, and optimizing the delivery of energy and protein must be emphasized in this cohort. The impact of these practices on clinical outcomes must be investigated.

Macronutrient Delivery in Critically Ill Patients Remains Challenging and Varies by Type of Intensive Care Unit

Macronutrient Delivery in Critically Ill Patients Remains Challenging and Varies by Type of Intensive Care Unit

Building High-fidelity Enteral Nutrition Protocol to Promote Macronutrient Delivery in the Neurosciences Intensive Care Unit

Building High-fidelity Enteral Nutrition Protocol to Promote Macronutrient Delivery in the Neurosciences Intensive Care Unit

The science and art of pediatric critical care nutrition.

Nutritional status and nutrient delivery during critical illness impact clinical outcomes. We have reviewed recent studies that may guide best practices regarding nutrition therapy in critically ill children. Malnutrition is prevalent in the pediatric ICU population, and is associated with worse outcomes. Nutrition support teams, dedicated dietitians, and educational programs facilitate surveillance for existing malnutrition and nutrition risk, but specific tools for the pediatric ICU population are lacking. Estimation of macronutrient requirements is often inaccurate; novel strategies to accurately determine energy expenditure are being explored. Indirect calorimetry remains the reference method for measuring energy expenditure. Enteral nutrition is the preferred route for nutrition in patients with a functioning gut. Early enteral nutrition and delivery of adequate macronutrients, particularly protein, have been associated with improved clinical outcomes. Delivery of enteral nutrition is often interrupted because of fasting around procedures and perceived intolerance. Objective measures for detection and management of intolerance to nutrient intake are required. In low-risk patients who are able to tolerate enteral nutrition, supplemental parenteral nutrition may be delayed during the first week of critical illness. Systematic research and consensus-based practices are expected to promote optimal nutritional practices in critically ill children with the potential to improve clinical outcomes.

Two new plant nutrient nanocomposites based on urea coated hydroxyapatite: Efficacy and plant uptake

Macronutrient delivery to plants, particularly nitrogen, is problematic because of losses occurring during fertilization. Currently, nanotechnology is being considered as a solution to improving nutrient use efficiency. In this study, we report the synthesis and plant uptake of two plant nutrient nanocomposites based on urea coated hydroxyapatite (UHA) and potassium encapsulated into (i) a nanoclay, montmorillonite (MMT) or (ii) cavities present in Gliricidia sepium stem resulting in a wood chip containing macronutrients. Soil leaching behaviour, efficacy and plant uptake of the nutrients were tested in a pot experiment using Festuca arundinacea during a period of 60 weeks. Two nanocomposites displayed slow release behaviour particularly for nitrogen, in soil leaching tests compared to the conventional formulations. Both nanoformulations displayed efficient plant nutrient uptake highlighting the improved nutrient use efficiency. These data clearly revealed that urea fabricated into its nanoscale provide platform for development of efficient fertilizer formulations.

Improved Delivery of Fat From Human Breast Milk via Continuous Tube Feeding.

Human breast milk is used sparingly in infants with intestinal failure due to observations from studies using syringe pumps that show loss of macronutrients with continuous feeding. Because of the potential benefits of using human milk, we sought to assess macronutrient losses using human milk as continuous tube feeds as done in the inpatient and home setting using a feeding bag and pump. Using in vitro simulations of human milk to assess macronutrient losses with continuous tube feeds, hourly samples were analyzed using the SpectraStar Near-Infrared Analyzer (Unity Scientific, Columbia, MD). Effects of agitation and positional changes of the feeding bag on macronutrient delivery were investigated in 249 total samples. Pairwise comparisons were performed using repeated-measures analysis of variance. Significant fat losses were observed at all rates at hours 1-4, averaging to 73% at 5 mL/h. Caloric losses correlated strongly with fat losses. Significant gains in the fat content (+116% at hour 4 at 5 mL/h) were seen in the preinfusion aliquots (feeding bags). Horizontal positioning and continuous agitation of the feeding bag only partially limited fat losses. Fat delivery at 5 mL/h was significantly enhanced to 87% when the feeding bag was placed in an inverted position and improved further up to 98% with higher infusion rates. No carbohydrates and proteins losses were seen. Enabling the delivery of the human milk from the top of the feeding bag optimizes fat delivery and limits losses. Such top infusing feeding bags should be developed and could decrease healthcare costs for intestinal rehabilitation programs.

Preventing bioenergetic failure in the preterm infant

The failure to match postnatal nutritional requirements to support growth and well-being in the extremely preterm infant has been a long-standing challenge with slow progress. Several large prospective cohorts over...

Adequate Nutrition May Get You Home: Effect of Caloric/Protein Deficits on the Discharge Destination of Critically Ill Surgical Patients.

Macronutrient deficit in the surgical intensive care unit (ICU) is associated with worse in-hospital outcomes. We hypothesized that increased caloric and protein deficit is also associated with a lower likelihood of discharge to home vs transfer to a rehabilitation or skilled nursing facility. Adult surgical ICU patients receiving >72 hours of enteral nutrition (EN) between March 2012 and May 2014 were included. Patients with absolute contraindications to EN, <72-hour ICU stay, moribund state, EN prior to surgical ICU admission, or previous ICU admission within the same hospital stay were excluded. Subjects were dichotomized by cumulative caloric (<6000 vs ≥ 6000 kcal) and protein deficit (<300 vs ≥ 300 g). Baseline characteristics and outcomes were compared using Wilcoxon rank and χ(2) tests. To test the association of macronutrient deficit with discharge destination (home vs other), we performed a logistic regression analysis, controlling for plausible confounders. In total, 213 individuals were included. Nineteen percent in the low-caloric deficit group were discharged home compared with 6% in the high-caloric deficit group (P = .02). Age, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II), and initiation of EN were not significantly different between groups. On logistic regression, adjusting for BMI and APACHE II score, the high-caloric and protein-deficit groups were less likely to be discharged home (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.08-0.96; P = .04 and OR, 0.29; 95% CI, 0.0-0.89, P = .03, respectively). In surgical ICU patients, inadequate macronutrient delivery is associated with lower rates of discharge to home. Improved nutrition delivery may lead to better clinical outcomes after critical illness.

CLINICAL NUTRITION WEEK 2015: Long Beach, CA February 14–17, 2015

CLINICAL NUTRITION WEEK 2015: Long Beach, CA February 14–17, 2015

Role of peptide YY(3–36) in the satiety produced by gastric delivery of macronutrients in rats

Peptide YY(3-36) [PYY(3-36)] is postulated to act as a hormonal signal from gut to brain to inhibit food intake. PYY(3-36) potently reduces food intake when administered systemically or into the brain. If action of endogenous PYY(3-36) is necessary for normal satiation to occur, then pharmacological blockade of its receptors should increase food intake. Here, we determined the effects of iv infusion of Y1, Y2, and Y5 receptor antagonists (BIBP 3226, BIIE 0246, CGP 71683) during the first 3 h of the dark period on food intake in non-food-deprived rats. Our results showed that 1) Y2 receptor blockade reversed the anorexic response to iv infusion of PYY(3-36) but did not increase food intake when administered alone; 2) Y1 and Y5 receptor antagonists neither attenuated PYY(3-36)-induced anorexia nor altered food intake when given alone; and 3) Y2 receptor blockade attenuated anorexic responses to gastric infusions of casein hydrolysate and long-chain triglycerides, but not maltodextrin. Previous work showed that Y2 antagonist BIIE 0246 does not penetrate the blood-brain barrier. Together, these results support the hypothesis that gut PYY(3-36) action at Y2 receptors peripheral to the blood brain barrier plays an essential role in mediating satiety responses to gastric delivery of protein and long-chain triglycerides, but not polysaccharide.

The Goldilocks Conundrum for Optimal Macronutrient Delivery in the PICU—Too Much, Too Little, or Just Right?

The Goldilocks Conundrum for Optimal Macronutrient Delivery in the PICU—Too Much, Too Little, or Just Right?

SCAMP: standardised, concentrated, additional macronutrients, parenteral nutrition in very preterm infants: a phase IV randomised, controlled exploratory study of macronutrient intake, growth and other aspects of neonatal care

BackgroundInfants born <29 weeks gestation are at high risk of neurocognitive disability. Early postnatal growth failure, particularly head growth, is an important and potentially reversible risk factor for impaired neurodevelopmental outcome. Inadequate nutrition is a major factor in this postnatal growth failure, optimal protein and calorie (macronutrient) intakes are rarely achieved, especially in the first week. Infants <29 weeks are dependent on parenteral nutrition for the bulk of their nutrient needs for the first 2-3 weeks of life to allow gut adaptation to milk digestion. The prescription, formulation and administration of neonatal parenteral nutrition is critical to achieving optimal protein and calorie intake but has received little scientific evaluation. Current neonatal parenteral nutrition regimens often rely on individualised prescription to manage the labile, unpredictable biochemical and metabolic control characteristic of the early neonatal period. Individualised prescription frequently fails to translate into optimal macronutrient delivery. We have previously shown that a standardised, concentrated neonatal parenteral nutrition regimen can optimise macronutrient intake.MethodsWe propose a single centre, randomised controlled exploratory trial of two standardised, concentrated neonatal parenteral nutrition regimens comparing a standard macronutrient content (maximum protein 2.8 g/kg/day; lipid 2.8 g/kg/day, dextrose 10%) with a higher macronutrient content (maximum protein 3.8 g/kg/day; lipid 3.8 g/kg/day, dextrose 12%) over the first 28 days of life. 150 infants 24-28 completed weeks gestation and birthweight <1200 g will be recruited. The primary outcome will be head growth velocity in the first 28 days of life. Secondary outcomes will include a) auxological data between birth and 36 weeks corrected gestational age b) actual macronutrient intake in first 28 days c) biomarkers of biochemical and metabolic tolerance d) infection biomarkers and other intravascular line complications e) incidence of major complications of prematurity including mortality f) neurodevelopmental outcome at 2 years corrected gestational ageTrial registrationCurrent controlled trials: ISRCTN76597892; EudraCT Number: 2008-008899-14

Improving early protein intake for very preterm infants using a standardised concentrated parenteral nutrition formulation

summary Background & aims: Neonatal parenteral nutrition (NPN) does not prevent early postnatal growth failure and negative nitrogen balance in very preterm infants. Individualised NPN (iNPN) prescribing remains standard practice. Macronutrient delivery is often suboptimal with iNPN. Aim: to establish whether a new standardised concentrated NPN (scNPN) regimen can improve protein intake while maintaining metabolic stability. Methods: Demographic and biochemical data was collected from the NICU electronic/paper data management system. In the infant subset ( 12 days) detailed fluid/drug infusion data was collected. Actual calorie and protein intake were calculated and compared to the previous RCT control group receiving a nutritionally identical iNPN. Cost analysis of scNPN was performed. Results: ScNPN usage was: scNPN1 (18%); scNPN (65%); scPN3 (17%) in 118 infants receiving scNPN in June–December 2006 (1483 scNPN days). In the patient subset (n ¼ 38; 526scNPN days) median (range) of 98 (80–102)% prescribed scNPN target volume was delivered. Mean (SD) protein intake (g/kg/14 days) was 34.5 (4.1) for scNPN and 28.1 (2.5) for iNPN (p < 0.001). Rates of electrolyte derangement, treated hyperglycaemia or metabolic acidosis were within an acceptable range. Annual cost savings were £39 510 (38% reduction). Conclusions: Using scNPN improves the efficiency of PN delivery and early protein intake while maintaining biochemical and metabolic stability and at less cost.

Bioprocess engineering of cell and tissue cultures for marine seaweeds

Seaweeds are a rich source of valuable compounds including food additives and biomedicinals. The bioprocess engineering of marine macroalgae or “seaweeds” for the production of these compounds is an emerging area of marine biotechnology. Bioprocess technology for marine macroalgae has three elements: cell and tissue culture development, photobioreactor design, and identification of strategies for eliciting secondary metabolite biosynthesis. In this paper, the first two elements are presented. Firstly, the development of phototrophic cell and tissue culture systems for representative species within brown, green, and red macroalgae is described. In vitro culture platforms include microscopic gametophytes, undifferentiated callus filaments, and “microplantlets” regenerated from callus. Secondly, the controlled cultivation of these phototrophic culture systems in stirred tank, bubble-column, airlift, and tubular photobioreactors is described. Limiting factors on biomass production in photobioreactors including light delivery, CO2 transfer, and macronutrient delivery are compared. Finally, a mathematical model that integrates light delivery, CO2 delivery, and macronutrient delivery into the material balance equations for biomass production in a perfusion bubble-column photobioreactor is presented, and model predictions are compared to biomass production data for microplantlet suspension cultures of the model red alga Agardhiella subulata.