Partial Enteral Nutrition Research Articles

Minimal Enteral Glutamate Slows Gastric Emptying in Preterm Pigs

Glutamate (GLU) is the major excitatory neurotransmitter in the body. GLU receptors and transporters are present in the gut. Emerging evidence suggests that GLU may play a functional role in promoting gastric emptying and digestion. We hypothesized that dietary GLU stimulates gastric emptying in the developing gut. 10‐d preterm, parenterally‐fed pigs received partial enteral nutrition (25%) as milk‐based formula supplemented with monosodium glutamate (MSG) at 0, 2, 4 and 6 times the basal GLU intake (n=5–8 pigs/group) for 7 d. Calorimetry and 13C‐octanoic acid breath test were performed on d 3, 5, 7 and 9 of life. We found no differences in body weight gain, organ weight and arterial plasma GLU and glutamine concentrations between the treatment groups. However, portal GLU concentration was significantly higher in pigs fed the MSG 4 and 6 doses. There was no treatment effect on VO2 uptake, VCO2 production, respiratory exchange ratio and heat production. The average lag time (Tlag) and gastric half emptying time (T1/2) between all treatment groups were 121 and 188 min, respectively. Tlag and T1/2 tended to increase with MSG supplementation in a dose dependent manner. At d 9, the cumulative % recovery of 13C‐octanoic acid was lower in MSG‐4 and MSG‐6 groups. Our results suggest that enteral MSG supplementation slows gastric emptying in the developing gut. (Funded by Ajinomoto)

Enteral Arginine Does Not Increase Superior Mesenteric Arterial Blood Flow but Induces Mucosal Growth in Neonatal Pigs

Arginine is an essential amino acid in neonates synthesized by gut epithelial cells and a precursor for NO that regulates vasodilatation and blood flow. Arginine supplementation has been shown to improve intestinal integrity in ischemia-reperfusion models and low plasma levels are associated with necrotizing enterocolitis. We hypothesized that enteral arginine is a specific stimulus for neonatal intestinal blood flow and mucosal growth under conditions of total parenteral nutrition (TPN) or partial enteral nutrition (PEN). We first tested the dose dependence and specificity of acute (3 h) enteral arginine infusion on superior mesenteric artery (SMA) blood flow in pigs fed TPN or PEN. We then determined whether chronic (4 d) arginine supplementation of PEN increases mucosal growth and if this was affected by treatment with the NO synthase inhibitor, N(G)-nitro-l-arginine methyl ester (L-NAME). Acute enteral arginine infusion increased plasma arginine dose dependently in both TPN and PEN groups, but the plasma response was markedly higher (100-250%) in the PEN group than in the TPN group at the 2 highest arginine doses. Baseline SMA blood flow was 90% higher in the PEN (2.37 ± 0.32 L⋅kg(-1)⋅h(-1)) pigs than in the TPN pigs (1.23 ± 0.17 L⋅kg(-1)⋅h(-1)), but was not affected by acute infusion individually of arginine, citrulline, or other major gut fuels. Chronic dietary arginine supplementation in PEN pigs induced mucosal growth in the intestine, but this effect was not prevented by treatment with L-NAME. Intestinal crypt cell proliferation, protein synthesis, and phosphorylation of mammalian target of rapamycin and p70S6 kinase were not affected by dietary arginine. We conclude that partial enteral feeding, but not acute enteral arginine, increases SMA blood flow in the neonatal pig. Furthermore, supplementing arginine in partial enteral feeding modestly increases intestinal mucosal growth and was NO independent.

923 The Addition of Synbiotics to Partial Enteral Nutrition Enhances Intestinal Adaptation in a Piglet Model of Intestinal Failure

923 The Addition of Synbiotics to Partial Enteral Nutrition Enhances Intestinal Adaptation in a Piglet Model of Intestinal Failure

Intensive medicine - Guidelines on Parenteral Nutrition, Chapter 14.

In intensive care patients parenteral nutrition (PN) should not be carried out when adequate oral or enteral nutrition is possible. Critically ill patients without symptoms of malnutrition, who probably cannot be adequately nourished enterally for a period of <5 days, do not require full PN but should be given at least a basal supply of glucose. Critically ill patients should be nourished parenterally from the beginning of intensive care if they are unlikely to be adequately nourished orally or enterally even after 5–7 days. Critically ill and malnourished patients should, in addition to a possible partial enteral nutrition, be nourished parenterally. Energy supply should not be constant, but should be adapted to the stage, the disease has reached. Hyperalimentation should be avoided at an acute stage of disease in any case. Critically ill patients should be given, as PN, a mixture consisting of amino acids (between 0.8 and 1.5 g/kg/day), carbohydrates (around 60% of the non-protein energy) and fat (around 40% of the non-protein energy) as well as electrolytes and micronutrients.

Parenteral nutrition in patients with renal failure - Guidelines on Parenteral Nutrition, Chapter 17.

Partial EN (enteral nutrition) should always be aimed for in patients with renal failure that require nutritional support. Nevertheless PN (parenteral nutrition) may be necessary in renal failure in patient groups with acute or chronic renal failure (ARF or CRF) and additional acute diseases but without extracorporeal renal replacement therapy, or in patients with ARF or CRF with additional acute diseases on extracorporeal renal replacement therapy, haemodialysis therapy (HD), peritoneal dialysis (PD) or continuous renal replacement therapy (CRRT), or in patients on HD therapy with intradialytic PN. Patients with renal failure who show marked metabolic derangements and changes in nutritional requirements require the use of specifically adapted nutrient solutions. The substrate requirements of acutely ill, non-hypercatabolic patients with CRF correspond to those of patients with ARF who are not receiving any renal replacement patients therapy (utilisation of the administered nutrients has to be monitored carefully). In ARF patients and acutely ill CRF patients on renal replacement therapy, substrate requirements depend on disease severity, type and extent/frequency of extracorporeal renal replacement therapy, nutritional status, underlying disease and complications occurring during the course of the disease. Patients under HD have a higher risk of developing malnutrition. Intradialytic PN (IDPN) should be used if causes of malnutrition cannot be eliminated and other interventions fail. IDPN should only be carried out when modifiable causes of malnutrition are excluded and enhanced oral (like i.e. additional energy drinks) or enteral supply is unsuccessful or cannot be carried out.

Mutations in SPINT2 Cause a Syndromic Form of Congenital Sodium Diarrhea

Autosomal-recessive congenital sodium diarrhea (CSD) is characterized by perinatal onset of a persistent watery diarrhea with nonproportionally high fecal sodium excretion. Defective jejunal brush-border Na(+)/H(+) exchange has been reported in three sporadic patients, but the molecular basis of the disease has not been elucidated. We reviewed data from a large cohort of CSD patients (n = 24) and distinguished CSD associated with choanal or anal atresia, hypertelorism, and corneal erosions--i.e., a syndromic form of CSD--occurring in ten families from an isolated form--i.e., classic CSD--presenting in seven families. Patients from both groups have a high risk of mortality due to immediate electrolyte imbalances and complications from long-term parenteral nutrition in the first years of life, but survivors can eventually adapt to partial or complete enteral nutrition. A genome-wide SNP scan was applied and identified a homozygous c.593-1G-->A splicing mutation in SPINT2, encoding a Kunitz-type serine-protease inhibitor, in one extended kindred with syndromic CSD. The same mutation and four distinct, homozygous or compound heterozygous mutations (p.Y163C, c.1A-->T, c.337+2T-->C, c.553+2T-->A) were identified in all syndromic patients. No SPINT2 mutations were found in classic-CSD patients. SPINT2 mutations were associated with loss of protein synthesis or failure to inhibit the serine protease trypsin in vitro. We delineate syndromic CSD as a distinct disease entity caused by SPINT2 loss-of-function mutations. SPINT2 mutations might lead to an excess of yet unknown serine protease activity in affected tissues.

Enteral Supplementation Enriched With Glutamine, Fiber, and Oligosaccharide Prevents Gut Translocation in a Bacterial Overgrowth Model

Normal gut flora plays an important role in the intestinal mucosal barrier function under various critical conditions. The flora may alter after severe insults, such as trauma and shock. Enteral nutrition should preserve the gut environment; however, full support is usually difficult for severely ill patients because of impaired gastrointestinal motility. Currently, we have commercial enteral supplementation product enriched with glutamine, dietary fiber, and oligosaccharide (GFO) in Japan. This study examines the hypothesis that the enteral supplementation ameliorates gut injury induced by a bacterial overgrowth model, even in small volumes and quantities. Balb/c mice received antibiotics (4 mg/mL of streptomycin) in their drinking water for 4 days to kill the normal gut flora after which they were orally inoculated with a streptomycin-resistant strain of Escherichia coli, known as E. coli C-25. The mice that were administered bacterial monoassociation received 0.5 mL of GFO twice daily (GFO group) or 10% of glucose solution (GLU group). Unsupplemented drinking water was used for control animals (control) whose gut flora was normal. The mice were killed and their mesenteric lymph nodes complex was harvested and processed to test gut bacterial translocation. The cecal population levels of bacteria and ileum histology were also examined. The incidence and magnitude of gut translocation to the lymph nodes complex in the GLU group were significantly higher than those in the control (p < 0.01). Treatment with GFO prevented the gut translocation although animals in the GFO group had same level of the cecal bacterial population. Histologic findings in the ileum were not different between the GLU and GFO. GFOs supplement prevented gut translocation for bacterial overgrowth even in small volumes and quantities. The intestinal histologic findings could not explain the protective mechanisms of GFO. Further studies may be needed to elucidate the benefit of the partial enteral nutrition.

Meta‐analysis: enteral nutrition in active Crohn’s disease in children

Controversy exists surrounding the optimal treatment for inducing remission in active Crohn's disease. To review and update evidence on the effectiveness of enteral nutrition (EN) in treating active Crohn's disease in children. MEDLINE, EMBASE and The Cochrane Library (up to February 2007) were searched for randomized controlled trials (RCTs) relevant to Crohn's disease and EN in children. We included 11 RCTs (n = 394). Seven RCTs (n = 204) compared EN with corticosteroid therapy. On the basis of pooled results of four RCTs (n = 144), we found no significant difference in the remission rates between groups (relative risk, RR 0.97, 95% CI 0.7-1.4, random effect model). Four RCTs (n = 190) compared two EN regimens. One of the four RCTs (n = 50) revealed a significant increase in the percentage of patients achieving remission in the total EN group compared with the partial EN group (RR 2.7, 95% CI 1-7.4). Because of lack of data, formal pooling of results was not possible for many outcomes (e.g., time until remission, duration of remission, growth data). Limited data suggest similar efficacy for EN and corticosteroids. As the number of patients needed to provide a definite answer is too large, future studies should focus on detailed outcome measurements including growth and quality of life.

NO2/NO3 Plasma Profile under Different Parenteral Nutrition Regimens in Newborns

Objective: Free radical production is increased by the administration of total parenteral nutrition (TPN) and may be linked to its adverse effects. Some of the complications of TPN can be ameliorated by partial enteral feeding. In the present study, we investigated plasma nitrate/nitrite (NO₂/NO₃) levels in newborns under parenteral and enteral plus parenteral nutrition (PN). Study Design: Six categories of patients were studied: (1) 10 term infants receiving enteral feeding, (2) 10 term infants receiving PN plus enteral feeding, (3) 10 term infants receiving TPN, (4) 10 preterm infants receiving enteral feeding, (5) 10 preterm infants receiving PN plus enteral feeding, and (6) 10 preterm infants receiving TPN. Plasma nitrate/nitritelevels were measured in all infants initially and in infants receiving TPN and PN plus enteral feeding on the 1st and 5th days, 3 h after the lipid infusion. Results: There was a statistically significant difference in the weighs of infants between the term and preterm groups. There was no difference in NO₂/NO₃ levels between the term and preterm groups. When the groups of term (groups 1, 2, 3) and preterm (groups 4, 5, 6) infants were compared separately within the groups, no statistically significant difference was found in any parameters. We also made comparison among the six groups’ gestational ages, and we found a difference between all term groups and all preterm groups except between groups 1 and 2; groups 1 and 3; groups 2 and 3; groups 4 and 5, and groups 5 and 6 (p < 0.05). Furthermore, the baseline, 1st and 5th days NO₂/NO₃ levels were compared in the term and preterm groups receiving PN. Plasma NO₂/NO₃levels before TPN were significantly lower in the term infants receiving parenteral fluids compared with NO₂/NO₃levels of 1st day of TPN (p < 0.05). In preterm infants receiving TPN the NO₂/NO₃levels before TPN were significantly lower than the levels on the 5th day of PN (p < 0.05). There was no significant difference among other NO₂/NO₃levels of the patients at baseline, 1st and 5th days in the term and preterm groups. Partial enteral feeding did not change the levels of NO₂/NO₃in term and preterm infants on PN. Conclusion: This study shows that TPN has some impact on nitric oxide (NO) production in newborn and partial enteral nutrition does not reduce this effect. However, since the numbers are very small these findings need to be verified by larger groups of patients.

Which milk for the sick preterm infant?

Summary Understanding the nutritional needs of the sick preterm infant will ensure that nutritionally adequate milks are used, but to minimise complications an understanding of the interaction between milk composition and neonatal gastrointestinal physiology is required. Unmodified preterm breast milk is probably the safest milk, but might require supplementation with fortifiers to meet nutritional needs. Fortification affects the osmolarity, protein and mineral content of breast milk in ways that can have adverse effects on intestinal function. Although preterm formulas meet the nutritional requirements of sick preterm infants, formula milk is associated with an increased risk of necrotising enterocolitis. Hydrolysate and elemental formulas have a role in treating established malabsorption, dysmotility or obstruction, but they are nutritionally inadequate for the sick preterm baby and have features which make them unsuitable for the prevention of gastrointestinal disease. In some circumstances, the use of minimal or partial enteral nutrition can help to maintain nutrition in the particularly sick infant, in which case the nutritional content of the milk will be less critical.

Reflux in esophageal atresia, tracheoesophageal cleft, and esophagocoloplasty: Bianchi's procedure as an alternative approach

Purpose Fundoplication has been used successfully to treat gastroesophageal reflux (GER) in the pediatric population. Although successful in many patients, there is a significant risk of complications and failure, especially in high-risk patients such as those with certain types of associated anomalies, diffuse motility disorders, chronic pulmonary disease, neurological impairment, and young infants. However, the results are poorer with children with severe pathologic lesion associated to reflux: tracheoesophageal cleft, esophagocoloplasty, and esophageal atresia (EA) with severe dysmotricity. In neurologically impaired children with neuromuscular incoordination and GER, Bianchi has proposed total esophagogastric dissociation (TED). The authors report the use of esophagogastric or esocologastric dissociation to control reflux in children with severe GER in other situations, such as EA, burn esophageal lesions having led to coloplasty and severe esotracheal cleft. Methods The authors reviewed the patients operated on for an esogastric or cologastric disconnection between 1997 and 2002. It is a single center retrospective study. The initial diagnosis, previous surgical procedure, postoperative course, and follow-up results were studied. Results Between September 1999 and June 2003, 13 TEDs were performed in 6 boys and 7 girls. The mean age for TED procedure was 35 months (range 14 days to 218 months). Indication for TED was severe persistent reflux in, respectively, 9 cases of EA (7 with coloplasty and 2 with preservation of the native esophagus after atresia repair, associated in 1 case with an esotracheal cleft), 2 cases of esotracheal cleft type III, and 2 cases of esophagocoloplasty for caustic burns. Six patients had undergone previous fundoplications (1-4 procedures) that failed, whereas the remaining patients underwent TED as the primary antireflux procedure. The average follow-up was 26 months (range 1 month to 4 years). There were no complication during the immediate postoperative course. Three children died at 3, 4, and 12 months after the procedure from acute respiratory failure. Respiratory status was improved in 8 children, and recurrent bronchitis was noted in 1 child. Regarding the digestive status, gastrostomy was closed at 18 and 24 months in 2 children, and partial nocturnal enteral nutrition (200 to 900 mL/d) through the gastrostomy remains necessary in the other children. Conclusion Total esophagogastric dissociation procedure improves the respiratory consequences of severe GER, particularly in children for whom other surgical treatments have failed. The long-term safety of this operation remains to be determined especially regarding the consequences of a gastrointestinal Roux-en-Y loop procedure.

Intestinal Protein and LPH Synthesis in Parenterally Fed Piglets Receiving Partial Enteral Nutrition and Enteral Insulinlike Growth Factor 1

ABSTRACTBackgroundProviding partial enteral nutrition (PEN) supplemented with insulinlike growth factor‐1 (IGF‐1) to parenterally fed piglets increases lactase–phlorizin hydrolase (LPH) activity, but not LPH mRNA. The current aim was to investigate potential mechanisms by which IGF‐1 up‐regulates LPH activity.MethodsNewborn piglets (n = 15) received 100% parenteral nutrition (TPN), 80% parenteral nutrition + 20% parenteral nutrition (PEN), or PEN + IGF‐1 (1.0 mg · kg−1 · d−1) for 7 days. On day 7, [2H3]‐leucine was intravenously administered to measure mucosal protein and brush border LPH (BB LPH) synthesis.ResultsWeight gain, nutrient intake, and jejunal weight and length were similar among the treatment groups. Partial enteral nutrition alone increased mucosal weight, villus width and cross‐sectional area, LPH activity, mRNA expression, and high mannose LPH precursor (proLPHh) abundance compared with TPN (P &lt;0.05). Insulinlike growth factor‐1 further increased mucosal weight, LPH activity, and LPH activity per unit BB LPH approximately twofold over PEN alone (P &lt; 0.05) but did not affect LPH mRNA or the abundance of proLPHh (one of the LPH isoforms) or mature LPH. Isotopic enrichment of [2H3]‐leucine in plasma, mucosal protein, and LPH precursors, and the fractional and absolute synthesis rates of mucosal protein and LPH were similar among the treatment groups. Insulinlike growth factor‐1 treatment increased total mucosal protein synthesis (60%, P &lt; 0.05) but not LPH synthesis compared with the other two groups.ConclusionsBecause IGF‐1 did not affect the fractional synthesis rate of either mucosal protein or LPH, the authors suggest that enteral IGF‐1 increases mucosal protein mass and LPH activity by suppressing mucosal proteolytic degradation.

Intestinal protein and LPH synthesis in parenterally fed piglets receiving partial enteral nutrition and enteral insulinlike growth factor 1.

Providing partial enteral nutrition (PEN) supplemented with insulinlike growth factor-1 (IGF-1) to parenterally fed piglets increases lactase-phlorizin hydrolase (LPH) activity, but not LPH mRNA. The current aim was to investigate potential mechanisms by which IGF-1 up-regulates LPH activity. Newborn piglets (n = 15) received 100% parenteral nutrition (TPN), 80% parenteral nutrition + 20% parenteral nutrition (PEN), or PEN + IGF-1 (1.0 mg. kg-1. d-1) for 7 days. On day 7, [2H3]-leucine was intravenously administered to measure mucosal protein and brush border LPH (BB LPH) synthesis. Weight gain, nutrient intake, and jejunal weight and length were similar among the treatment groups. Partial enteral nutrition alone increased mucosal weight, villus width and cross-sectional area, LPH activity, mRNA expression, and high mannose LPH precursor (proLPHh) abundance compared with TPN (P<0.05). Insulinlike growth factor-1 further increased mucosal weight, LPH activity, and LPH activity per unit BB LPH approximately twofold over PEN alone (P < 0.05) but did not affect LPH mRNA or the abundance of proLPHh (one of the LPH isoforms) or mature LPH. Isotopic enrichment of [2H3]-leucine in plasma, mucosal protein, and LPH precursors, and the fractional and absolute synthesis rates of mucosal protein and LPH were similar among the treatment groups. Insulinlike growth factor-1 treatment increased total mucosal protein synthesis (60%, P < 0.05) but not LPH synthesis compared with the other two groups. Because IGF-1 did not affect the fractional synthesis rate of either mucosal protein or LPH, the authors suggest that enteral IGF-1 increases mucosal protein mass and LPH activity by suppressing mucosal proteolytic degradation.

Enteral Insulin‐like Growth Factor‐I Augments Intestinal Disaccharidase Activity in Piglets Receiving Total Parenteral Nutrition

ABSTRACTBackground:Partial enteral nutrition is administered to infants on parenteral nutrition to stimulate intestinal function. Herein, the hypothesis that supplementation of partial enteral nutrition with insulin‐like growth factor‐I would augment intestinal development was investigated.Methods:One‐day‐old piglets (n = 29) were randomly assigned to five dietary treatment groups: 100% of energy as enteral formula, 100% of energy as total parenteral nutrition, or 80% parenteral nutrition/20% enteral formula supplemented with either 0, 0.2, or 1 mg/kg insulin‐like growth factor‐I for 7 days. Weight gain, intestinal weight, morphology, protein, and DNA content and disaccharidase activity and mRNA expression were assessed.Results:Parenterally fed piglets had similar whole body weight gain and serum hormone concentrations but reduced intestinal mucosal weight, villus height, and sucrase and lactase activity compared with 100% enterally fed pigs. Partial enteral nutrition alone increased mucosal weight and protein content, villus height, and disaccharidase activity compared with 100% parenterally fed piglets. No effect of the lower dose of insulin‐like growth factor‐I (0.2 mg/kg per day) was observed, but supplementing partial enteral nutrition with 1 mg insulin‐like growth factor‐I/kg further increased villus width and cross‐sectional area and disaccharidase activity compared with partial enteral nutrition alone. Lactase mRNA expression was not affected by insulin‐like growth factor‐I, suggesting that the primary site of regulation of lactase by insulin‐like growth factor‐I occurs after transcription.Conclusions:Enteral insulin‐like growth factor‐I augmented intestinal morphology and disaccharidase activity in parenterally fed piglets over that observed with partial enteral nutrition alone. Thus enteral insulin‐like growth factor‐I may represent an efficacious clinical adjunct to promote intestinal development of parenterally fed neonates.

Low-dose enteral feeding is beneficial during total parenteral nutrition

Enteral support is the preferred feeding route for stressed patients due in part to the provision of gut-specific fuels. In those patients who must be maintained parenterally, small amounts of enteral stimulation might blunt gut atrophy and lead to improvement in host defense mechanisms decreasing macromolecular and/or bacterial translocation (BT). Forty-eight rats were infused with TPN for 9 days, and were randomized to receive 0%, 6%, 12%, or 25% of their calories as partial enteral nutrition (PEN) in an isocaloric, isonitrogenous fashion. Twenty-four hours before harvest animals were gavaged with lactulose and urinary excretion quantified. At harvest, mesenteric lymph nodes were cultured to assess BT and intestinal histology determined. Provision of as little as 25% of total calories PEN improved nitrogen balance and reduced BT, in a dose dependent fashion. It did not alter TPN-associated increased macromolecular lactulose permeability (4.4% +/- 1.0%). Concurrent small amounts of PEN, aimed to support the gut's metabolic needs, are beneficial during periods of prolonged TPN.

Hyperalimentation in autologous bone marrow transplantation for solid tumors. Comparison of total parenteralVersus partial parenteral plus enteral nutrition

Recipients of autologous bone marrow transplantation (ABMT) for solid tumors need nutritional support to maintain their body weight (BW). Severe BW-reduction (9.9%) was noticed retrospectively in ten ABMT patients fed orally, despite intensive counseling or occasional tube feeding. A prospective, randomized study of hyperalimentation (25 g nitrogen (N) and 3400 nonprotein kilocalories) with total parenteral nutrition (TPN) or partial parenteral plus enteral nutrition by tube feeding (PPN/EN) was done in 22 patients. Nutritional assessment included balance measurements of N, Na, K, Cl, P, Ca, Mg, Cu, and Zn, and serial measurements of BW, serum albumin, prealbumin, and transferrin. Both regimens were effective in maintaining BW (maximum percent of change, 2.5) and N-balance. Blood products accounted for an additional N-intake of 13% in both groups. The TPN group had a higher dietary N-intake versus PPN/EN, a positive K balance but negative Ca, Mg, Cu, and Zn balances. More mineral supplementation was given in the PPN/EN group where positive K, Mg, and Zn balances were seen. Visceral proteins and IgG, IgA, and IgM levels were decreased on days 7, 14, and 21. Creatinine clearance increased significantly in both groups. Compared with TPN, the PPN/EN group showed a twofold number of patients with a positive blood culture, although this observation did not reach statistical significance and patients had fewer days of diarrhea (31.1% versus 54.3%, P less than 0.01). Hyperalimentation with PPN/EN is an acceptable alternative to TPN in the nutritional support of ABMT recipients.