Period Of Nutritional Support Research Articles

Insulin-like growth factor-1 as a nutritional monitoring factor in patients with chronic intestinal failure

Nutritional monitoring plays an important role in optimizing nutritional support inpatients with chronic intestinal failure (CIF) receiving long-term supplementation. Unlike initial nutritional assessment, however, there are no recommended guidelines for establishing a nutritional monitoring index. This study is to evaluate the suitability of insulin-like growth factor-1 (IGF-1) as a nutritional monitoring factor in CIF patients. We retrospectively analyzed the correlation between serum nutritional indicators, including IGF-1 levels, and nutritional assessment, nutritional monitoring, and lean body mass in 197 patients with CIF. The mean age of the 197 enrolled patients was 47.22±18.87 years old and; the mean BMI was 16.83±3.31. The mean NRS-2002 score was 3.49±0.83; and moreover, 76.3% of the patients were malnourished. The median length of hospital stay in hospital (LOS) was 18.5 days. IGF-1 was positively correlated with body mass index, hemoglobin, albumin, pre-albumin, retinol-binding protein (RBP), transferrin, serum creatinine (Scr) and cholesterol (p<0.05 for all). Testing performed over 3 weeks post-admission showed that significantly different weekly changes were observed only in IGF-1, RBP, and Scr during the period of nutritional support (p<0.05 for each). Multivariate linear regression analysis showed that IGF-1 and body mass index were independent factors influencing fat-free mass, skeletal muscle mass, and body protein mass (p<0.05 for each). IGF-1 is suitable for monitoring short-term changes in the nutritional status in CIF patients. This may be attributed to its shorter half-life, greater sensitivity, and better correlation with lean body mass. ClinicalTrials.gov number, NCT03277014.

Clinical features of selenium deficiency in infants receiving long-term nutritional support

Objective Selenium deficiency is a known complication in patients requiring long-term nutritional support; however, the clinical features of selenium deficiency in infants have not been completely described. We describe the clinical features of selenium deficiency in infants. Methods Six infants with selenium deficiency were studied retrospectively, with a focus on the period of nutritional support, the clinical symptoms, and the chronologic changes in serum selenium concentrations before and after the administration of selenite. Results The onset of selenium deficiency in five patients occurred at <6 mo of age; selenium deficiency occurred in one patient 14 mo after birth. One patient received parenteral nutrition for 15 mo after birth; the other five patients primarily received an elemental diet for 2–6 mo. In all patients, growth retardation and alopecia with pseudoalbinism were the characteristic symptoms of selenium deficiency. At the time of diagnosis, the serum selenium level in four patients was <2.0 μg/dL and serum selenium levels in two patients were 3.2 and 3.3 μg/dL, respectively. The resolution of hair symptoms corresponded to the level of serum selenium after 1–2 mo and a rapid improvement in growth occurred in all patients after the administration of selenite. Conclusion The early clinical symptoms of selenium deficiency in infants include growth retardation and alopecia with pseudoalbinism, which are reversible if the patients are treated with adequate amounts of selenite. Clinicians who manage infants receiving long-term nutritional support, including an elemental diet, should be aware of the symptoms associated with selenium deficiency.

Impaired pancreatic secretion in severely malnourished patients is a consequence of primary pancreatic dysfunction

Severe undernutrition has been associated with reduced secretions of gastric acid and pancreatic enzymes. This may be the result of an impaired gut mucosal response to food and primary gastric parietal and pancreatic acinar cell secretory dysfunction as a consequence of the poor nutritional state. To investigate the relative contributions of these factors, severely undernourished patients underwent enteral-meal–stimulated (ES; n = 7) or intravenous hormone (pentagastrin and cholecystokinin-8)–stimulated (HS; n = 12) gastric acid and pancreatic enzyme secretion before and after a period of nutritional support. Results were evaluated in comparison with normal healthy control subjects (ES = 7, HS = 10). In the control subjects, enteral-meal and cholecystokinin-8 stimulation resulted in similar outputs of the pancreatic enzymes amylase (2213 versus 2305 U/h), lipase (84.93 versus 118.6 U/h), and trypsin (498.9 versus 341.4 U/h), whereas acid output was significantly lower in the ES group (10.90 versus 25.53 mEq/h; P < 0.01). Compared with controls, malnourished groups had significantly reduced secretions of amylase (ES = 870.1 U/h, HS = 686.5 U/h; P < 0.02), lipase (ES = 30.68 U/h, HS = 25.96 U/h; P < 0.02), and trypsin (ES = 175.6 U/h, HS = 109.3 U/h; P < 0.01). The response to enteral-meal or CCK-8 stimulation was comparable. Gastric acid was similarly reduced in the undernourished patients (ES = 4.39 mEq/h, HS = 5.04 mEq/h; P < 0.01). After refeeding, secretion of amylase (ES = 2351 U/h, HS = 2228 U/h) and lipase (ES = 58.83 U/h, HS = 84.91 U/h) improved to levels not significantly different from controls, whereas trypsin (ES = 226.4 U/h, HS = 213.1 U/h; P < 0.03) and acid secretion (ES = 3.52 mEq/h, HS = 11.85 mEq/h; P < 0.01) remained significantly impaired. Severe undernutrition was associated with primary gastric parietal and pancreatic acinar cell dysfunction, which, at least in the case of pancreatic enzymes, appeared to be the determining factor controlling secretion in these patients.

The effect of severe undernutrition, and subsequent refeeding on digestive function in human patients.

Severe undernutrition may adversely affect gut function. To investigate the effects of severe undernutrition and subsequent refeeding on human digestive function. Severely undernourished patients (body mass index (BMI) < 17 kg/m2) were studied before, and after a period of intensive nutritional support. Standard intestinal absorption tests (faecal fat and urinary xylose excretion), pentagastrin-stimulated acid secretion, and cholecystokinin octapeptide (CCK-8)-stimulated pancreatic enzyme secretion tests were performed. In addition, duodenal biopies were taken to assess gut mucosal morphology. Findings were evaluated in comparison to a group of normal healthy volunteers. Mean BMI of the patients prior to nutritional support was 13.41 kg/m2, with improvement to 16.12 kg/m2 after. Duodenal histology showed evidence of villous atrophy in six of 14 (43%) undernourished patients. Mean xylose excretion following a 5 g oral dose was 0.62 g/5 h in the group of undernourished patients prior to nutritional support (normal > 1 g/5 h), with improvement to 1.40 g/5 h (P < 0.01) after feeding. Maximal gastric acid output was significantly impaired in the undernourished group, as compared to the controls (6.94 mEq/l vs 25.53 mEq/l, P < 0.02), with a significant improvement to 12.30 mEq/l (P < 0.05) following nutritional support. Pancreatic enzyme output was significantly reduced (amylase 830.9 U/h vs 2304 U/h, P < 0.01; lipase 38.0 U/h vs 118.6 U/h, P < 0.01; trypsin 119.7 U/h vs 341.4 U/h, P < 0.01). Following a period of nutritional support there was a significant improvement in amylase and lipase outputs to 1819 U/h and 85.5 U/h, respectively (P < 0.01). These levels were not significantly different from the normal controls. Trypsin output, however, remained significantly impaired at 174.3 U/h (P < 0.01). Severe undernutrition is associated with significant impairment of digestive function, with improvement occurring following nutritional support. These changes may affect initial tolerance to enteral feeding, particularly in those patients with co-existent gut disease.

GROWTH AFTER NEONATAL SMALL BOWEL RESECTION

5 Few data on long-term growth and final adult height are available in children who have undergone extensive small bowel resection in the neonatal period. Patients and methods: 87 neonates, born between 1975 and 1991 who underwent extensive neonatal small bowel resection, were followed up for a period of 13±4 years. 9 infants died before being weaned from parenteral nutrition (PN). The 78 survivors were divided in 3 groups: group A (n=9), still receive PN; group B (n=12) initially discontinued PN but, thereafter required once again PN or enteral feeding; group C (n=57), achieved permanent digestive autonomy. Anatomical data including small bowel length (SBL) and preservation of the ileocecal valve (ICV) were recorded and multivariate analysis was performed. Data on height and weight were collected from medical files or letters sent to the parents or to the physicians and expressed in standard deviation (SD). Results: The overall survival was 89,7%, depending on the year of birth. The duration of PN depended on SBL and ICV preservation. All Group A patients had SBL <40 cm and/or absence of ICV; they were dependent on PN for 9 to 19 years and grew normally. Group B patients had a 35,4±19,3 cm SBL, a resection of the ICV in 50% of cases and a duration of initial PN of 47±24 months. All presented a significant decrease of height and weight velocity within the 4 years following PN weaning, requiring that enteral or parenteral feeding be resumed. In group C children had a 57,2±18,7 cm SBL, the presence of the ICV in 81 % of cases and a duration of PN of 16±11 months. Although they showed a delay in growth at the cessation of PN, they had a slow catch up growth up between -2SD and +2SD. Their puberty occurred normally and their final height is at 99,7±3,4% of the expected parental height. A catch-up growth was observed in all children born small-for-gestational-age. Conclusion: About 10% of the patients remain permanently dependent on PN. For the others, in spite of extensive intestinal resection, anatomic factors and a short duration of initial PN are predictive of normal long-term growth and final height. On the opposite, growth failure following weaning of a long-term initial parenteral nutrition requires a new period of nutritional support in order to preserve final adult height.

Nutritional support and growth in thalassaemia major

Twelve thalassaemic children under 3 years of age received intensive nutritional support for one month and were discharged on a prescribed diet of locally available foods. Anthropometry, bioelectrical impedance analysis...

Pancreatic ascites in children

We report on three children with pancreatic ascites confirmed by endoscopic retrograde cholangiopancreaticography (ERCP) and treated with surgery. The children presented with ascites, malnutrition and severe weight loss. Pancreatic ascites was diagnosed by elevated ascitic fluid and serum amylase levels. ERCP demonstrated a pseudocyst and the site of disruption of the pancreatic duct, but not the etiology of the pancreatitis. Following a period of nutritional support, surgery was carried out. Two of the children underwent a stented transgastric drainage of the pseudocyst; a recurrent pseudocyst in one of the children required a revision cystojejunostomy. The third child was treated with a Roux-en-Y cystojejunostomy. All the children are pain-free and without ascites and are doing well on long-term follow-up. We conclude that pancreatic ascites must be considered in the differential diagnosis of intractable ascites in children. An ERCP is essential in planning management and cystoenterostomy is the definitive treatment.