Partial Parenteral Nutrition Research Articles

Feasibility and efficacy of early KMC in very low birth weight babies receiving noninvasive respiratory care in NICU: is it the way forward in resource limited setting?

Background: Objective of the study was t o assess the feasibility and efficacy of early KMC in VLBW babies receiving respiratory care in NICU. Methods: This is a prospective observational study conducted in a Multispecialty hospital with a level 3B NICU. Results: A total of 19 babies on non-invasive respiratory support and partial parenteral nutrition through PICC line were included in the study. Most of the babies (84%) had birth weight of less than 1250 gm. Forty eight percent of the babies were less than 30 weeks of gestation at the time of commencement of KMC. Average weight gain in our study was 11.27gm/kg/day which was comparable to others. KMC was initiated at an average of 7.91 days of age and the average duration was1.69 + 0.6 hour/day. 84.2% of the mothers did KMC for less than 3 hrs per day while 15.8% of them did KMC beyond 3 hrs per day. Of the 19 babies, 17 of them were on High flow nasal canula Oxygen and 13 of them on CPAP during KMC. Only one baby succumbed to NEC during the study. The most common reason for discontinuation of KMC in the study group was lack of confidence in the mother (31%) which was overcome by constant support from the nursing staff and the family members. Conclusions: Kangaroo mother care was found to be a feasible and effective method of care of VLBW babies even while on non-invasive respiratory support in NICU.

Assessment of the safety and efficacy of percutaneous laparoscopic endoscopic jejunostomy (PLEJ)

Introduction and AimsGastric feeding may not be possible in the neurologically impaired child with foregut dysmotility. Post-duodenal feeding can be crucial, thereby avoiding the need for parenteral nutrition. The aim of this study is to evaluate the technical success, complication and clinical outcome of our institution's technique in creating a jejunostomy using the percutaneous laparoscopic-endoscopic jejunostomy (PLEJ) technique. MethodsRetrospective review of all paediatric patients (<18) with PLEJ between January 2008 and April 2015 was conducted. Patients were identified using the electronic procedure code and clinic letters. Data were collected in regard to the procedure technical success, short and long-term complications and clinical outcomes. ResultsSixteen patients (age range, 2–17years) were identified. The procedure was successful in all cases. At a median follow up of 25months, eleven patients (68%) had significant improvement of their symptoms of feeding intolerance/aspirations and are permanently PLEJ fed and two (13%) were regraded to gastric feeds. Two patients moved from total parenteral nutrition to partial parenteral nutrition while on PLEJ feeds. All patients had experienced weight gain and either went up or maintained their weight centile. The only major complication was small bowel volvulus encountered in two patients with abnormal gastrointestinal anatomy requiring surgical intervention. ConclusionsIn our small case series, PLEJ placement was safe as it provides valuable visualization of the bowel loops intraabdominally. It is a technically feasible and successful approach for children requiring long-term jejunal feeding especially those with foregut dysmotility.

Extremely large air distension of the bowel

A 14-year-old girl presented to our paediatric department in May, 2012, with massive abdominal distension that had developed over the previous 2 years. She reported chronic abdominal discomfort, alternating diarrhoea and constipation, and two previous subocclusive episodes that had resolved with laxative therapy. Plain abdominal radiographs showed substantial large bowel distension and several air–fluid levels. No air was evident in the rectum or anal canal (figure).She underwent surgery, and because no mechanical obstruction was observed a diverting ileostomy was done. Analysis of full-thickness large bowel and rectal biopsy samples obtained during surgery showed a decreased number of ganglion cells and acetylcholinesterase activity compatible with the diagnosis of hypoganglionosis. In November, 2012, she had large bowel resection, ileorectal anastomosis, and ileostomy repositioning. The postoperative course was characterised by progressive intestinal recanalisation, although she had persistent watery stools with faecal sodium loss. The resulting electrolyte imbalance was corrected with partial parenteral nutrition. The patient was discharged 2 months after the procedure and continued parenteral nutrition at home. She had a gradual reduction of watery diarrhoea so we tapered the partial parenteral nutrition and weaning was possible after 12 months. At last follow-up in July, 2014, the patient reported no more episodes of abdominal distension.Hypoganglionosis is classed as a hypogenetic type of intestinal innervation disorder characterised by very low or absent acetylcholinesterase mucosal activity and a decreased number of ganglion cells within the myenteric and submucosal plexus of a variable intestinal segment. The most common presenting symptoms of hypoganglionosis are acute constipation, intestinal obstruction, and enterocolitis. The disorder thus resembles Hirschsprung's disease, but clinical presentation might be subtle and misdiagnosed as chronic constipation. The median age at diagnosis is usually higher in patients with hypoganglionosis than Hirschsprung's disease. Definitive diagnosis requires the analysis of full-thickness biopsy sample of the affected intestinal segment. The treatment is surgical, involving resection of the hypoganglionotic tract of the intestine.ContributorsAll authors cared for the patient and contributed to writing of the report. Written consent to publication was obtained. A 14-year-old girl presented to our paediatric department in May, 2012, with massive abdominal distension that had developed over the previous 2 years. She reported chronic abdominal discomfort, alternating diarrhoea and constipation, and two previous subocclusive episodes that had resolved with laxative therapy. Plain abdominal radiographs showed substantial large bowel distension and several air–fluid levels. No air was evident in the rectum or anal canal (figure). She underwent surgery, and because no mechanical obstruction was observed a diverting ileostomy was done. Analysis of full-thickness large bowel and rectal biopsy samples obtained during surgery showed a decreased number of ganglion cells and acetylcholinesterase activity compatible with the diagnosis of hypoganglionosis. In November, 2012, she had large bowel resection, ileorectal anastomosis, and ileostomy repositioning. The postoperative course was characterised by progressive intestinal recanalisation, although she had persistent watery stools with faecal sodium loss. The resulting electrolyte imbalance was corrected with partial parenteral nutrition. The patient was discharged 2 months after the procedure and continued parenteral nutrition at home. She had a gradual reduction of watery diarrhoea so we tapered the partial parenteral nutrition and weaning was possible after 12 months. At last follow-up in July, 2014, the patient reported no more episodes of abdominal distension. Hypoganglionosis is classed as a hypogenetic type of intestinal innervation disorder characterised by very low or absent acetylcholinesterase mucosal activity and a decreased number of ganglion cells within the myenteric and submucosal plexus of a variable intestinal segment. The most common presenting symptoms of hypoganglionosis are acute constipation, intestinal obstruction, and enterocolitis. The disorder thus resembles Hirschsprung's disease, but clinical presentation might be subtle and misdiagnosed as chronic constipation. The median age at diagnosis is usually higher in patients with hypoganglionosis than Hirschsprung's disease. Definitive diagnosis requires the analysis of full-thickness biopsy sample of the affected intestinal segment. The treatment is surgical, involving resection of the hypoganglionotic tract of the intestine. Contributors All authors cared for the patient and contributed to writing of the report. Written consent to publication was obtained.

Data Mined Distinctive Features of Pediatric Chronic Idiopathic Intestinal Pseudo-obstruction in Japan

Background: A former nationwide survey in Japan on pediatric chronic intestinal pseudo-obstruction (CIPO) determined the most common etiology to be 'idiopathic'. However, currently no appropriate diagnostic criteria for pediatric chronic idiopathic intestinal pseudo-obstruction (CIIP) in children has been defined. The report utilized data mining to identify key clinical features that would qualify statistically CIIP diagnostic criteria. Methods: Sixty-nine cases were reviewed and subject to standard mining association rule. Cases were assigned to three groups: fully dependent on parenteral nutrition (PN) (group A, n = 15), on partial PN or independent from PN, but requiring permanent enterostomy for decompression (group B, n = 37), and all the other (group C, n = 17). Distinctive features related to each group assignment were then extracted from 87 reported clinical features of the CIPO. The statistical operation was performed by an expert in medical informatics using apriori algorithm. Results: Key features of patients in group A and B, thought to be severely intractable cases, were the presence of abdominal distension, intestinal dysmotility, ileus without mechanical obstruction, and the absence of histopathological abnormalities in the intramural ganglion cells. Conclusions: The presence of clinical features of a functional ileus, in the absence of proven histopathological abnormalities, can be used for diagnostic criteria for CIIP covering all the intractable cases in Japanese children. It is highly significant that a normal full-thickness histopathological finding was statistically extracted as one key feature for CIIP in our analysis.

Enteral Nutrition in the Management of Pediatric Intestinal Failure

Intestinal failure is an uncommon but devastating condition whose natural history has dramatically improved over the past two decades (1). Infants with intestinal failure due to severe short bowel syndrome or other diagnoses previously considered incompatible with life are now routinely being saved and cared for in cutting edge, multidisciplinary programs. Enteral nutrition plays a central role in the management of children with intestinal failure. This review provides an overview of enteral nutrition in pediatric intestinal failure, with specific emphasis on recent advances in clinical management, patient outcomes, and emerging therapies.

End-stage anorexia nervosa in a young man: multifaceted metabolic, endocrine and infectious derangements managed in an internal medicine setting

Anorexia nervosa (AN) in males is an overlooked disease which requires early diagnosis and proper treatment. Clinical presentation is often severe and the risk of death is not negligible. We report the case of a young man with a 1-year history of AN who was admitted to our internal medicine department for a dramatic malnutrition (BMI: 10.5 kg/m(2)). Several biochemical and hormonal alterations were ascertained. Partial parenteral nutrition and a balanced diet were started. Asymptomatic refeeding syndrome occurred and was managed by enhanced electrolyte parenteral supplementation. Many hematologic abnormalities (anaemia, leukopenia and thrombocytopenia) were present and worsened during the occurrence of sepsis which required hemotransfusions and targeted parenteral antibiotics with improvement of both clinical condition and hematologic parameters. Bone marrow aspiration and cytofluorimetric evaluation showed hyperplasia and dysplasia of erythroid lineage and reduction of myeloid lineage. Significant body weight gain (+17 % vs. admission) was obtained and the patient was discharged with stable cardiovascular parameters and referred to an eating disorders centre where is currently followed.

Higher versus lower protein intake in formula-fed low birth weight infants.

The ideal quantity of dietary protein for formula-fed low birth weight infants is still a matter of debate. Protein intake must be sufficient to achieve normal growth without negative effects such as acidosis, uremia, and elevated levels of circulating amino acids. To determine whether higher (≥ 3.0 g/kg/d) versus lower (< 3.0 g/kg/d) protein intake during the initial hospital stay of formula-fed preterm infants or low birth weight infants (< 2.5 kilograms) results in improved growth and neurodevelopmental outcomes without evidence of short- and long-term morbidity.To examine the following distinctions in protein intake. 1. Low protein intake if the amount was less than 3.0 g/kg/d. 2. High protein intake if the amount was equal to or greater than 3.0 g/kg/d but less than 4.0 g/kg/d. 3. Very high protein intake if the amount was equal to or greater than 4.0 g/kg/d.If the reviewed studies combined alterations of protein and energy, subgroup analyses were to be carried out for the planned categories of protein intake according to the following predefined energy intake categories. 1. Low energy intake: less than 105 kcal/kg/d. 2. Medium energy intake: greater than or equal to 105 kcal/kg/d and less than or equal to 135 kcal/kg/d. 3. High energy intake: greater than 135 kcal/kg/d.As the Ziegler-Fomon reference fetus estimates different protein requirements for infants based on birth weight, subgroup analyses were to be undertaken for the following birth weight categories. 1. < 800 grams. 2. 800 to 1199 grams. 3. 1200 to 1799 grams. 4. 1800 to 2499 grams. The standard search methods of the Cochrane Neonatal Review Group were used. MEDLINE, CINAHL, PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library) were searched. Randomized controlled trials contrasting levels of formula protein intake as low (< 3.0 g/kg/d), high (≥ 3.0 g/kg/d but < 4.0 g/kg/d), or very high (≥ 4.0 g/kg/d) in formula-fed hospitalized neonates weighing less than 2.5 kilograms were included. Studies were excluded if infants received partial parenteral nutrition during the study period or were fed formula as a supplement to human milk. Studies in which nutrients other than protein also varied were added in a post-facto analysis. The standard methods of the Cochrane Neonatal Review Group were used. Five studies compared low versus high protein intake. Improved weight gain and higher nitrogen accretion were demonstrated in infants receiving formula with higher protein content while other nutrients were kept constant. No significant differences were seen in rates of necrotizing enterocolitis, sepsis, or diarrhea.One study compared high versus very high protein intake during and after an initial hospital stay. Very high protein intake promoted improved gain in length at term, but differences did not remain significant at 12 weeks corrected age. Three of the 24 infants receiving very high protein intake developed uremia.A post-facto analysis revealed further improvement in all growth parameters in infants receiving formula with higher protein content. No significant difference in the concentration of plasma phenylalanine was noted between high and low protein intake groups. However, one study (Goldman 1969) documented a significantly increased incidence of low intelligence quotient (IQ) scores among infants of birth weight less than 1300 grams who received a very high protein intake (6 to 7.2 g/kg). Higher protein intake (≥ 3.0 g/kg/d but < 4.0 g/kg/d) from formula accelerates weight gain. However, limited information is available regarding the impact of higher formula protein intake on long-term outcomes such as neurodevelopmental abnormalities. Available evidence is not adequate to permit specific recommendations regarding the provision of very high protein intake (> 4.0 g/kg/d) from formula during the initial hospital stay or after discharge.

Temporal Trends in the Use of Parenteral Nutrition in Critically Ill Patients

Clinical practice guidelines recommend enteral over parenteral nutrition in critical illness and do not recommend early initiation. Few data are available on parenteral nutrition use or timing of initiation in the ICU or how this use may have changed over time. We used the Project IMPACT database to evaluate temporal trends in parenteral nutrition use (total and partial parenteral nutrition and lipid supplementation) and timing of initiation in adult ICU admissions from 2001 to 2008. We used χ2 tests and analysis of variance to examine characteristics of patients receiving parenteral nutrition and multilevel multivariate logistic regression models to assess parenteral nutrition use over time, in all patients and in specific subgroups. Of 337,442 patients, 20,913 (6.2%) received parenteral nutrition. Adjusting for patient characteristics, the use of parenteral nutrition decreased modestly over time (adjusted probability, 7.2% in 2001-2002 vs 5.5% in 2007-2008, P<.001). Enteral nutrition use increased simultaneously (adjusted probability, 11.5% in 2001-2002 vs 15.3% in 2007-2008, P<.001). Use of parenteral nutrition declined most rapidly in emergent surgical patients, patients with moderate illness severity, patients in the surgical ICU, and patients admitted to an academic facility (P≤.01 for all interactions with year). When used, parenteral nutrition was initiated a median of 2 days (interquartile range, 1-3), after ICU admission and >90% of patients had parenteral nutrition initiated within 7 days; timing of initiation of parenteral nutrition did not change from 2001 to 2008. Use of parenteral nutrition in US ICUs declined from 2001 through 2008 in all patients and in all examined subgroups, with the majority of parenteral nutrition initiated within the first 7 days in ICU; enteral nutrition use coincidently increased over the same time period.

Contenants et contaminants en nutrition parentérale : l’aluminium, un revenant ?

Aluminium is a well-known potentially hazardous contaminant in parenteral preparation for dialysis or drug delivery. The main objective of the study is to assess aluminium exposure from chronic parenteral nutrition supply. The specific objectives of the study were (i) to assess aluminium concentration in parenteral nutrition compounds (n=26) and in hospital-made parenteral nutrition mixture (n=56), (ii) to compare aluminium concentration in nutrition products to the maximum allowable concentration (i.e. 25μg/L), and finally (iii) to compare the daily rate infused per kilogram of weight to the limit value recommended by American Society of Parenteral and Enteral Nutrition (i.e. 2μg.kg−1 per day). Aluminium content, assessed by atomic absorption spectrophotometry, was determined in parenteral nutrition compounds and in hospital-made parenteral nutrition admixtures to clinically stable patients undergoing total or partial parenteral nutrition. Aluminium concentration in fourteen parenteral nutrition compounds and all parenteral nutrition admixtures excessed 25μg/L. Furthermore, two thirds of patients were exposed to a rate of aluminium significantly upper than that recommended by the American Society of Parenteral and Enteral Nutrition (i.e. 2μg.kg-1 per day). This study shows that parenteral nutrition compounds and parenteral nutrition admixtures were overloaded in aluminium. A monograph specifying acceptable aluminium content of parenteral nutrition products seems necessary for further redaction of European pharmaceutical norm or guidance.

Effect of two different doses of parenteral amino acid supplementation on postnatal growth of very low birth weight neonates — A randomized controlled trial

To evaluate the effects of two different doses of parenteral aminoacid supplementation on postnatal growth in Very Low Birth Weight (VLBW) infants receiving partial parenteral nutrition (PPN). Double blinded randomized controlled trial. Level 3 NICU between February 2008 to February 2010. 150 inborn babies with birthweight between 900-1250 g, irrespective of gestational age, were randomized to either of the two interventions of amino acid supplementation. Two different initial doses of parenteral amino acids (AA) in the PPN solutions--Low AA group: 1 g/kg/d versus High AA group: 3 g/kg/d from day 1 of life with increment by 1 g/kg every day till a maximum of 4 g/kg/d, until babies tolerated 75% enteral feeds. Average postnatal weight gain (in g/kg/d)) by 28 days of life. Both groups had similar baseline characteristics. The gain in weight, length and head circumference at 28 days were significantly lower in the High AA group. The average weight gain at 28 days was 8.67 g/kg/d in the High AA group and 13.15 g/kg/d in the Low AA group (mean difference 123.12, 95% CI 46.67 to 199.37, P<0.001). The incidences of neonatal morbidities associated with prematurity were similar in both groups. Higher initial parenteral aminoacid supple-mentation, in settings where partial parenteral nutrition is administered, results in poor growth in VLBW infants due to inadequate non-protein calorie intake.

Continuous regional arterial infusion effective for children with acute necrotizing pancreatitis even under neutropenia

Severe acute pancreatitis is one of the critical conditions that may develop in children with cancer. The leading cause of death due to acute pancreatitis is infectious pancreatitis or circulation collapse. Therefore, patients who develop acute pancreatitis while undergoing chemotherapy or after hematopoietic transplantation are at risk for a life-threatening and fatal course. We treated 140 patients with malignancy from April 2002 to March 2009 at our hospital and encountered 3 patients under neutropenia who developed severe acute pancreatitis. Two of them were successfully treated with continuous regional arterial infusion of a protease inhibitor and antibiotic even under agranulocytosis. Another patient was treated with conventional therapy with intravenous antibiotics plus a protease inhibitor and total or partial parenteral nutrition. Even though the two patients treated with continuous regional arterial infusion presented much more severe conditions, their symptoms resolved earlier. In conclusion, acute pancreatitis is one of the severe complications of childhood malignancy. Even under agranulocytosis, continuous regional arterial infusion of a protease inhibitor and antibiotic was well tolerated and effective among our cases and might reduce early death due to pancreatitis.

A Potent Amino Acid Mixture to Mitigate Radiation-induced Gastrointestinal Toxicity

In addition to cancer cells, radiation targets cells with rapid mitotic activity in close proximity to tumors. Rapid mitosis occurs in the lower third of the crypt, producing daughter cells that replace those of the villus. Radiation-induced damage to the villus results in reduced electrolyte and nutrient absorption, thereby leading to gastrointestinal (GI) toxicity. Previous studies showed that radiation induces a dose-dependent increase in anion secretion and diarrhea. Partial or total parenteral nutrition (TPN) complicated GI function, which delayed weaning the patients off TPN.

226 Nutrition in the Critically Ill: Enteral and Parenteral Nutrition in the Newborn

Initiating both parenteral nutrition with adequate protein:energy ratios and early enteral feedings strategies (within the first hours of life, whenever possible) seem to offer preventive advantage towards developing complicating illnesses...

Update on lipid and protein intakes in the critical newborn

The influence of critical illnesses on adverse outcomes in newborn infants seems to be mediated by nutritional intakes during the first week or few weeks of life. Changes in amounts and ratios of protein and energy, fat quality (medium chain triglycerides, and n-3 long-chain polyunsaturated fatty acids), maintaining normoglycemia during full or partial parenteral nutrition, rate of feeding advancements and avoidance of postnatal growth retardation represent the main items whose roles in critically ill preterm infants have been considered so far. In a condition such as extreme prematurity, feeding higher amounts of amino acids since the first day of life has been shown so far to be safe and effective in terms of metabolic balance, body growth and neurodevelopment outcome. In other clinical conditions and as far as other nutrients are concerned, available data are still limited and do not allow for firm conclusions in most cases.

Hepatic ultrastructure in a neonatal piglet model of intestinal failure-associated liver disease (IFALD)

This study was designed to evaluate liver disease in neonatal piglets with surgical short bowel syndrome causing intestinal failure with partial parenteral nutrition dependence. The short bowel piglets had 75% surgical resection of distal small intestine, including all ileum and cecum, and were compared with sham controls, without resection, and to healthy sow-reared controls. After 18 days of combined parenteral and enteral nutrition in short bowel and sham piglets, liver tissue was collected for quantitative and semi-quantitative histological and ultrastructural evaluation. The short bowel piglets developed biochemical and histological cholestasis, not observed in sham and control piglets. Ultrastructural examination revealed bile canaliculus dilation with bile plugging, microvillus flattening and disappearance, but without abnormalities of the pericanalicular zone. Interestingly, these data are similar to bile canaliculus changes seen in human neonates with IFALD supporting an initial consideration of this model to elucidate the pathogenesis of IFALD.

Surgical Management of Extremely Low Birth Weight Infants with Neonatal Bowel Perforation: A Single-Center Experience and a Review of the Literature

Background: Necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) are major causes of morbidity in infants with extremely low birth weight (ELBW). Objective: To evaluate the surgical procedures applied, and the survival and long-term outcome of ELBW infants with NEC and FIP in a single-center study. Methods: Inborn and outborn ELBW infants (<1000 g) with NEC and FIP were analyzed retrospectively from 2002 to 2007. Data collected include surgical procedures, survival as well as complications, length of partial parenteral nutrition and hospital stay. The short-term and long-term outcomes after 2–7 years were assessed and compared with a matched control group. Results: Out of 280 ELBW infants, 28 underwent surgery, 19 because of FIP and 9 for NEC. Fourteen infants in the FIP group were treated with primary laparotomy and 5 with peritoneal drainage (PD). In the NEC group, only 1 infant was treated with PD. PD was used for unstable patients and was always followed by secondary laparotomy after stabilization. Five of 28 (18%) surgically treated ELBW infants and 4 (14%) matched controls died. The following complications occurred in the surgical group: complete (n = 1) or minor wound dehiscence (n = 4), stoma prolapse (n = 5), parastomal hernia (n = 2), stoma fistula (n = 1), and wound infection (n = 2). Dependency on parenteral nutrition was significantly shorter in infants with FIP, while there were no differences in time to stoma closure and length of hospital stay between those with FIP and those with NEC. Eleven of 23 (47.8%) surviving patients with FIP or NEC showed developmental delay, compared with 9 of 24 (37.5%) in the controls. Conclusions: The management of EBLW infants with NEC and FIP remains challenging. Our treatment approach was associated with low mortality. Developmental delay seems to be caused by extreme prematurity rather than NEC- or FIP-related bowel perforation.

A Multi-Center International Survey Related to the Nutritional Support after Hematopoietic Stem Cell Transplantation Endorsed by the ASIA Pacific Blood and Marrow Transplantation (APBMT)

Background: The nutritional support after hematopoietic stem cell transplantation (HSCT) has not been well established due to the scarcity of clinical trials. To conduct international clinical trials in Asia, we performed the questionnaire survey to investigate the current standard of nutritional support after HSCT. Method: We sent the questionnaire to the physicians nominated by the Asia Pacific Blood and Marrow Transplantation (APBMT) members of each country/ region. Result: We received 15 responses from 7 different countries/regions. The target calorie amount is 1.0 - 1.3 × basal energy expenditure (BEE) in 11 institutes when partial parenteral nutrition is used. When total parenteral nutrition (TPN) is used, the target calorie amount is 1.0 - 1.3 × BEE in 9 institutes and 1.3 - 1.5 × BEE in 4 institutes. Lipid emulsion is routinely used in 12 institutes. Multivitamins and trace elements are routinely added to TPN used in most institutes. It is still uncommon to use the immunonutrition. Blood glucose levels are routinely monitored in all institutes, but the target range varies (<110 in 2 institutes, <150 in 4 institutes, and <200 in 8 institutes). Conclusions: Basic nutritional support is similar in participating institutes. However, the target glucose level varies and the use of immunonutrition is rather rare. These points can be the theme of future clinical trials.

Mangel- und Fehlernährung bei HNO-Tumoren

Tumours of the upper aerodigestive tract cause malnutrition in the majority of ENT cancer patients. This situation is complicated by multimodal treatment regimens (including surgery and/or irradiation). The resulting malnutrition is a disease entity in its own right and requires special treatment concepts. Effective screening tools (NRS2002) need to be introduced and data such as body mass index and bioimpedance analysis need to be gathered. The nutrition plan for individual ENT patients differs according to the grade of malnutrition and dysphagia. Oral nutrition should always form the basis of any nutrition programme, such that logopedic therapy is required in all cases of dysphagia. Artifical, oral high-energy nutrition is a pharmacological procedure as well as enteral feeding via PEG or PEJ. Partial or total parenteral nutrition (central venous access) should be restricted to crisis interventions or fast-track regimens.

Interventions for prevention of neonatal hyperglycemia in very low birth weight infants

Among very low birth weight (VLBW) infants, early neonatal hyperglycemia is common and is associated with increased risks for death and major morbidities. It is uncertain whether hyperglycemia per se is a cause of adverse clinical outcomes or whether outcomes can be improved by preventing hyperglycemia. To assess effects on clinical outcomes of interventions for preventing hyperglycemia in VLBW neonates receiving full or partial parenteral nutrition. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, issue 4 of 12, 2011; MEDLINE (1966 to April 2011); EMBASE (1980 to April 2011); CINAHL (1982 to Nov 2008); abstracts of Pediatric Academic Societies 2000 to 2011 and European Society for Pediatric Research 2005 to 2010. Randomized or quasi-randomized controlled trials of interventions for prevention of hyperglycemia in neonates with birth weight < 1500 g or gestational age < 32 wk. Two review authors independently selected studies for eligibility and extracted data on study design, methods, clinical features, and treatment outcomes. Included trials were assessed for blinding of randomization, intervention and outcome measurement, and completeness of follow-up. Treatment effect measures for categorical outcomes were relative risk and risk difference, and for continuous outcomes, mean difference, each with their 95% confidence intervals. We detected four eligible trials. Two trials compared lower versus higher rates of glucose infusion in the early postnatal period. These trials were too small to assess effects on mortality or major morbidities. Two trials, one a moderately large multicentre trial (NIRTURE, Beardsall 2008), compared insulin infusion with standard care. Insulin infusion reduced hyperglycemia but increased death before 28 days and hypoglycemia. Reduction in hyperglycemia was not accompanied by significant effects on major morbidities; effects on neurodevelopment are awaited. Glucose infusion rate: There is insufficient evidence from trials comparing lower with higher glucose infusion rates to inform clinical practice. Large randomized trials are needed, powered on clinical outcomes including death, major morbidities and adverse neurodevelopment.Insulin infusion: The evidence reviewed does not support the routine use of insulin infusions to prevent hyperglycemia in VLBW neonates. Further randomized trials of insulin infusion may be justified. They should enrol extremely low birth weight neonates at very high risk for hyperglycemia and neonatal death. They might use real time glucose monitors if these are validated for clinical use. Refinement of algorithms to guide insulin infusion is needed to enable tight control of glucose concentrations within the target range.

Megacystis microcolon intestinal hypoperistalsis syndrome: systematic review of outcome

Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a rare and the most severe form of functional intestinal obstruction in the newborn. This congenital condition is associated with non-obstructed urinary bladder, microcolon and decreased or absent intestinal peristalsis. This study was designed to determine the incidence and outcome of MMIHS. A systematic review of the literature (1976-2011) was performed for key words "megacystis microcolon intestinal hypoperistalsis". Resulting publications were reviewed for epidemiology and outcome. Reference lists were screened for additional cases. A total number of 227 MMIHS cases were reported from 1976 to 2011. A clear preponderance for female infants was found (female 70.6 vs. male 29.4%). One or more surgical interventions were reported in 115 patients (including gastrostomy, ileostomy, jejunostomy, segmental resections of small bowel, adhesiolysis and internal sphincter myectomy). For decompression of the megacystis, vesicostomy was performed in 41 patients. Outcome was reported in a total of 218 patients. Survival rate was 19.7% (survivors: n=43, non-survivors: n=175), the oldest survivor being 24years old. The vast majority of the surviving patients had to be maintained by total or partial parenteral nutrition (TPN). Main causes of death were sepsis, malnutrition and multiple organ failure. Twelve multivisceral transplantations have been reported to date in patients with MMIHS. The majority of the survivors are reported to be free of parenteral nutrition and show improving gastric emptying. However, intermittent catheterisation remains obligatory due to persistent bladder dysfunction. The survival in MMIHS in recent years has improved. The majority of survivors are either maintained by TPN or have undergone multiorgan transplantations.