Trophic Enteral Nutrition Research Articles

Comparison of human breast milk vs commercial formula-induced early trophic enteral nutrition during postoperative prolonged starvation in an animal model

The present study aimed to characterize the changes in macromolecular composition and structure in ileal tissue induced by postoperative prolonged starvation (PS), human breast milk feeding (HM) and commercial formula feeding (CF) for 48 and 72 h (h). Forty-two Wistar albino rats underwent an ileal transection and primary anastomosis and were then divided into six subgroups. Two groups of seven rats were food-deprived for 48 and 72 h with free access to water only in metabolic cages (48 h PS, 72 h PS). Then, two groups of seven rats received early enteral trophic nutrition (EEN) either using HM, and CF at 48 h post-operation (48 h HM, 48 h CF). The other two groups of seven rats received the same trophic enteral nutrition at 72 h post-operation (72 h HM, 72 h CF). An additional seven rats were fed normal rat chow (control), after which the ileal tissues were harvested and freeze-dried overnight. Then sample spectra were recorded by Fourier transform infrared (FTIR) spectroscopy. PS at 48 and 72 h resulted in an increase in the concentration of lipids and a decrease in the concentration of proteins. CF and HM trophic feeding induced a decrease in membrane fluidity and an increase in lipid order. Ileal tissues showed similar compositional and structural changes in lipids and proteins in the PS and CF groups after 48 and 72 h. A marked decrease in nucleic acid concentration was seen in CF at 48 h compared to HM. The human milk feeding groups did not induce any significant alterations and showed compositional and structural data similar to the controls. In conclusion, EEN application seems to be safer when introduced at 48 h rather than 72 h and time of this nutrition is crucial to maintain ileum structure and therefore immunity and well-being. HM-induced trophic nutrition is seen to protect the ileal tissue from significant alterations within lipid and protein compositions, whereas CF caused notable changes. HM is absolutely the best nutritional source for gut health in this animal model.

Trophic Nutrition in ICU Patients Undergoing High-Flow Oxygen Therapy and/or Noninvasive Mechanical Ventilation: The Nutri-Trophic Study.

Enteral nutrition (EN) therapy in ICU patients requiring oxygen therapy with high-flow nasal cannula (HFNC) and/or noninvasive mechanical ventilation (NIMV) is controversial. A prospective, cohort, observational, and multicenter study was conducted in 10 ICUs in Spain to analyze the 90-day mortality, tolerance, side effects, and infectious complications of trophic EN in patients requiring HFNC therapy and/or NIVM. A total of 149 patients were enrolled. The mean age, severity scores, tracheobronchitis, bacteremia, and antimicrobial therapy were significantly higher in deceased than in living patients (p < 0.05), and the mortality rate was 14.8%. A total of 110 patients received oral trophic feedings, 36 patients received nasogastric tube feedings (NGFs), and 3 received mixed feedings. Trophic EN was discontinued in only ten (14.9%) patients because of feeding-related complications. The variables selected for the multivariate logistic regression on feeding discontinuation were SOFA upon admission (OR per unit = 1.461) and urea (OR per mg/dL = 1.029). There were no significant differences in the development of new infections according to the route of EN administration. Early trophic feeding administered to patients with acute respiratory failure requiring noninvasive ventilation is safe and feasible, and is associated with few dietary and infectious complications in a mortality, setting comparable to similar studies.

Nutrition Therapy for Patients With Traumatic Brain Injury: A Narrative Review.

Traumatic brain injury (TBI) is a global health and socio-economic problem, resulting in significant disability and mortality. Malnutrition is common in TBI patients and is associated with increased vulnerability to infection, higher morbidity and mortality rates, as well as longer stays in the intensive care unit and hospital. Following TBI, various pathophysiological mechanisms, such as hypermetabolism and hypercatabolism, affect patient outcomes. It is crucial to provide adequate nutrition therapy to prevent secondary brain damage and promote optimal recovery. This review includes a literature review and discusses the challenges encountered in clinical practice regarding nutrition in TBI patients. The focus is on determining energy requirements, timing and methods of nutrition delivery, promoting enteral tolerance, providing enteral nutrition to patients receiving vasopressors, and implementing trophic enteral nutrition. Enhancing our understanding of the current evidence regarding appropriate nutrition practices will contribute to improving overall outcomes for TBI patients.

Effects of enteral nutrition with different energy supplies on metabolic changes and organ damage in burned rats.

Enteral nutrition (EN) is an important treatment for burn patients. However, severe gastrointestinal damage caused by major burns often leads to EN intolerance. Trophic EN solves this problem basically, but how to transition from trophic EN to standard EN smoothly is still a challenge in burn clinical nutrition. The aim of this study is to investigate the effects of EN with different energy supplies on metabolic changes, organ damage and prognosis in burned rats. Different feeding regimens were designed based on the continuous monitoring of resting energy expenditure in rats. Thirty-two Sprague-Dawley rats were randomly divided into a normal control group, burn +50% REE group, burn +75% REE group and burn +100% REE group. At the end of a nutritional treatment cycle (14th day), nuclear magnetic resonance spectroscopy, blood biochemistry analysis and quantification of subscab bacteria were performed to explore the differences in metabolic changes, degrees of organ damage and prognoses between the groups. Sixteen metabolites involving seven metabolic pathways were identified from the different energy supply groups. After burn injury, resting energy consumption and body weight loss increased obviously. Meanwhile, weight loss was inversely related to energy supply. The greatest changes in the degree of organ damage, the level of plasma proteins, lipids and endotoxins, as well as the quantification of subscab bacteria were observed in the 50% REE group, followed by the 75 and 100% groups. Achieving an early balance between energy supply and expenditure is conducive to mitigating metabolic disorders and improving prognosis after burn injury.

Luzhou-Feier powder reduces inflammatory response and improves intestinal immune barrier in rats with severe acute pancreatitis.

As we know, nutritional support plays a key role in the treatment of severe acute pancreatitis (SAP). Since total parenteral nutrition (TPN) was discovered, the mortality of SAP had been greatly reduced. But researchers recently demonstrated that the prognosis of SAP could be improved by early enteral nutrition (EEN), which has been a priority for nutritional support in patients with SAP. However, implementation of total enteral nutrition is often challenging in the early stage of SAP. If the enteral nutrition is overused, the burden on the gastrointestinal tract will be aggravated. Under such circumstances, the combination of enteral and parenteral nutrition for nutritional support of SAP patients would be a better choice. Therefore, in this study, we compared the efficacy of two enteral nutrition agents: traditional nutritional supplement named Luzhou-Feier powder (LZ-FP) and enteral nutritional suspension (TPF) combined with parenteral nutrition to total parenteral nutrition (TPN) in the treatment of SAP rats. Our analysis revealed that the combination of enteral nutrition and parenteral nutrition was more effective than TPN in SAP. And LZ-FP met the requirements for enteral nutrition of SAP supporting its clinical application in SAP. PRACTICAL APPLICATIONS: Luzhou-Feier powder (LZ-FP) is a traditional Chinese nutritional supplement that was originally developed as a nutritional supplement for infants and is currently used for nutritional support in patients with chronic and consumptive diseases. Our research investigated the effect and its possible mechanisms of LZ-FP as early trophic enteral nutrition in SAP rats and compared it with TPF and TPN which have been used clinically. We found that LZ-FP helped to reduce inflammatory response and improve the intestinal immune barrier of SAP. The curative effect of LZ-FP was comparable to that of TPF. And this effect may be achieved by inducing the secretion of gut hormones. Our research indicates that LZ-FP should be considered as an enteral nutrition preparation for SAP.

Enteral Nutrition With High-Dose Vasopressors.

Enteral Nutrition With High-Dose Vasopressors.

Enteral and parenteral nutrition therapy for neonates at a neonatal unit: a longitudinal retrospective study

Background The goals of nutrition therapy include providing adequate growth and development, avoiding a negative energy and nitrogen balance, and preventing complications. Objective To evaluate the nutrition therapy received by newborns at the neonatal intensive care unit (NICU) of a public maternity hospital in Rio de Janeiro, Brazil. Methods Retrospective longitudinal observational study in which data were collected on newborns admitted to NICU, in Rio de Janeiro, in 2016. The time that elapsed before commencement of parenteral and trophic enteral nutritional, time to reach full enteral nutrition, type of diet at the beginning of trophic enteral nutrition and at discharge from the NICU, and the relationship between birth weight and nutritional therapy were evaluated. Results Trophic enteral nutrition began after 24.42 (SD +20.23) hours, on average, and the mean time to reach full enteral nutrition was 10.0 (SD +5.51) days. Newborns with a birth weight below 1500 g had a longer hospital stay (p = .002), longer oxygen therapy (p = .009), a longer time before commencement of enteral feeding (p = .005), and took longer to reach full enteral feeding (p = .010). Conclusions The institutional nutritional therapy practices were consistent with those proposed in the literature, but more support is needed for breastfeeding in this group.

Analysis of Amino Acid Patterns With Nutrition Regimens in Preterm Infants With Extrauterine Growth Retardation

Background: Amino acid (AA) metabolic patterns have emerged as an analytical technique to characterize biomarkers compromising normal growth and elucidate underlying nutritional exposure. This study aimed to identify AA metabolites most likely associated with poor growth and examine the association between AA metabolites and nutrition regimens in preterm infants during transition from parenteral nutrition (PN) to enteral nutrition (EN), using gas chromatography-mass spectrometry (GC-MS).Methods: This observational cohort study was conducted in infants born at <32 weeks' gestation with birth weight of <1,500 g. The outcome of extrauterine growth retardation (EUGR) based on whether the weight was <10th percentile for post-menstrual age, was evaluated when full EN reached. Samples were collected at four sampling points according to nutritional status. AA profiles in dried sampling point spots (DBS) were quantified using GC-MS; and were compared simultaneously. The correlation of AA concentration with growth and nutritional parameters was examined using multivariate analysis.Results: We identified 40 eligible infants: 20 in the EUGR group and 20 in the non-EUGR group. AA deficiency progressively emerged during the transition. Lower concentrations of four AAs, including citrulline (Cit), were associated with increased risk of EUGR when adjusted for gestational age, birth weight z-score, age when trophic EN was started, as well as average energy and protein intakes in synchronous nutritional period. Moreover, a lower Cit concentration was positively correlated with the compromised protein and energy deficits in EN during early transition.Conclusion: A low Cit concentration during transition from PN to full EN should be noticed by the clinician to more closely examine nutrition practices to prevent EUGR.

The Clinical Importance of 21-Day Combined Parenteral and Enteral Nutrition in Active Inflammatory Bowel Disease Patients.

The aim of the study was to show the clinical magnitude of short-term feeding: enteral nutrition (EN) combined with parenteral nutrition (PN) in active Crohn’s disease and ulcerative colitis patients. Among 122 eligible inflammatory bowel disease (IBD) patients, 65 met the inclusion criteria. Combined EN and PN was administered for 21 days, wherein over the first 3–5 days of treatment, trophic enteral nutrition (300 kcal/day) was used with an energy increase of up to 1500 kcal. An EN was administered using a nasogastric tube or, in case of intolerance, using a naso-jejunal tube. For PN, the “All in One” system was used according to individually prepared admixtures (ESPEN Guidelines). In addition to routine blood measurement (i.e., ALAT, ASPAT, GGTP, creatinine, lipid profile), the following parameters were assessed: adiponectin, leptin, (hs)TNF-α, hsIL-6 and hsIL-10, TSH, NT-proBNP, serum vitamin B12 concentration, and tHcy. The results showed a considerable improvement in all clinically significant parameters (p < 0.05), showing the benefits and importance of short-term well-balanced EN combined with PN for nutritional and clinical status in IBD patients with active disease. The daily work at hospitals with active IBD patients demonstrates the potential of continued administration of home-based nutrition by patients.

Update on Feeding the Open Abdomen in the Trauma Patient

Describe how and when nutrition for trauma patients should be provided after damage control laparotomy. Early enteral nutrition is a requisite component of open abdomen critical care support to achieve optimal outcomes. Providing trophic enteral nutrition is beneficial. Enteral nutrition with an open abdomen complicated by enteroatmospheric fistula is safe and feasible. Enteral nutrition is initiated with resolution of acidosis, coagulopathy, and hypothermia. Absent intestinal discontinuity, the only absolute contraindication, enteral nutrition is started as soon as possible via any standard route of enteral access. Post-pyloric access should be trialed in patients intolerant to gastric feeds. Parenteral nutrition is considered if an absolute contraindication to enteral nutrition is expected to persist beyond 5–7 days, the patient is intolerant to enteral nutrition, or caloric goal is not achieved with enteral nutrition after 5–7 days. Protein requirements for the OA patient are higher, 2 g/Kg/day.

Permissive or Trophic Enteral Nutrition and Full Enteral Nutrition Had Similar Effects on Clinical Outcomes in Intensive Care: A Systematic Review of Randomized Clinical Trials.

The aim of this study was to systematically review the effect of permissive underfeeding/trophic feeding on the clinical outcomes of critically ill patients. A systematic review of randomized clinical trials to evaluate the mortality, length of stay, and mechanical ventilation duration in patients randomized to either hypocaloric or full-energy enteral nutrition was performed. Data sources included PubMed and Scopus and the reference lists of the articles retrieved. Two independent reviewers participated in all phases of this systematic review as proposed by the Cochrane Handbook, and the review was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 7 randomized clinical trials that included a total of 1,717 patients were reviewed. Intensive care unit length of stay and mechanical ventilation duration were not statistically different between the intervention and control groups in all randomized clinical trials, and mortality rate was also not different between the groups. In conclusion, hypocaloric enteral nutrition had no significantly different effects on morbidity and mortality in critically ill patients when compared with full-energy nutrition. It is still necessary to determine the safety of this intervention in this group of patients, the optimal amount of energy provided, and the duration of this therapy.

Effect of early use of different doses of enteral nutrition on prognosis of patients with acute respiratory failure

To observe the impact of initial low-dose (trophic type) enteral nutrition (EN) support on mechanical ventilation (MV) time, the incidence of complications and survival rate in patients with acute respiratory failure (ARF). A prospective study was conducted. Forty-four patients with ARF undergoing MV admitted to Department of Critical Care Medicine of Hangzhou Traditional Chinese Medical Hospital from September 2015 to February 2017 were enrolled, and they were divided into a trophic feeding group (n = 23, study group) and a standard-dose feeding group (n = 21, control group). In the two groups, the EN support feeding was given to the patients through a nasogastric tube within 24-hour MV for consecutive 7 days, the protein supply to each one of all of them was 1.2-1.6 g×kg-1×d-1. The study group received EN according to non-protein calories of 41.84-83.68 kJ×kg-1×d-1 to calculate, while the control group accepted EN according to non-protein calories of 104.60-125.50 kJ×kg-1×d-1 to calculate. The serum albumin (Alb) and fasting blood glucose (FBG) levels were measured in two groups 1 day before EN treatment and at 1, 2, 3, 7 days of treatment, and the energy levels in initial 3 days and 7 days of MV and the 24-hour urine creatinine (UCr) level on the 7th day after treatment were recorded. The creatinine-height index (CHI, CHI = actual UCr/standard UCr) was calculated. The incidence of intestinal intolerance (vomiting, gastric retention, diarrhea, gastrointestinal bleeding, etc.) in 7 days of treatment, MV time, the length of stay in ICU, the total length of stay in the hospital and the 28-day incidence of new infections (pulmonary, hematogenous, urinary, abdominal, and other infections) and 60-day survival rate were observed between the two groups. The EN supplies within 3 days and 7 days in the study group were significantly lower than those in the control group [within 3 days (kJ/d): 1 710.58±703.96 vs. 4 152.79±1 334.65, 7 days (kJ/d): 2 471.28±815.50 vs. 5 058.08±875.25, both P < 0.05]; there were no statistically significant differences in CHI after EN therapy for 7 days and serum Alb levels before and after EN between the two groups. FBG level of the study group was significantly lower than that of the control group since the 2nd day of treatment (mmol/L: 8.58±2.37 vs. 10.93±3.75), and continued to the 7th day (mmol/L: 8.96±1.76 vs. 10.97±4.11, both P < 0.05), the incidence of elevated blood glucose was also significantly lower than that of the control group [26.1% (6/23) vs. 66.7% (14/21), P < 0.05]. The incidence of feeding intolerance in the study group was significantly lower than that in the control group from 2 days of treatment till 7 days (26.1% vs. 47.6%, P < 0.05). There were no statistically significant differences in MV time (days: 15.04±6.75 vs. 16.14±8.51), the length of stay in ICU (days: 16.52±6.89 vs. 17.24±7.67), total length of stay in hospital (days: 26.35±9.69 vs. 25.33±7.73), 28-day new infection rate [26.1% (6/23) vs. 42.9% (9/21)] and 60-day survival rate [65.2% (15/23) vs. 66.7% (14/21)] between the study and control groups (all P > 0.05). Initial trophic EN feeding results in clinical outcomes similar to those of early standard-dose EN feeding in MV patients with ARF, but the former one has less incidence of high blood sugar and more satisfactory gastrointestinal tolerance situation.

Early Trophic Enteral Nutrition Is Associated With Improved Outcomes in Mechanically Ventilated Patients With Septic Shock: A Retrospective Review.

Current guidelines provide weak recommendations for starting enteral nutrition (EN) in patients with septic shock (on vasopressor support). Outcomes of patients receiving EN in septic shock on vasopressor support have not been well studied. We hypothesize that early trophic EN in mechanically ventilated patients with septic shock is associated with improved outcomes. Single-center retrospective study of mechanically ventilated patients admitted with septic shock to identify patients receiving (1) no EN, (2) <600 kcal/d within 48 hours, and (3) ≥600 kcal/d within 48 hours. Outcomes studied included in-hospital mortality, length of intensive care unit stay (LOS), duration of mechanical ventilation (DOMV), and complications of feeding intolerance. Sixty-six patients were identified. In all, 15 received no EN, 37 received <600 kcal/d, and 14 received ≥600 kcal/d EN daily. Median LOS was 12, 5, and 13 days, respectively. The LOS was lower in patients receiving <600 kcal/d when compared to either no EN (P < .001) or those receiving ≥600 kcal/d (P < .001). Median DOMV was lower in patients receiving <600 kcal/d (median 3, P < .001) as compared to no EN (median 7, P < .001) or those receiving ≥600 kcal/d (median 7.5, P < .001). Mortality was not different. There were no significant complications among groups. In patients with septic shock, those receiving <600 kcal/d EN within 48 hours had lower DOMV and LOS when compared to those who did not receive EN or those who received ≥600 kcal/d. These observations provide strong justification for prospective evaluation of the effect of early trophic EN in patients with septic shock.

PTH-193 Time to prescribe? an audit of the management of patients on parenteral nutrition

Introduction The Allied Health Professionals prescribing and medicines supply mechanisms scoping project report identified an evidence base for extending prescribing rights to dietitians based on improved patient safety and experience, effectiveness and value and clear clinical responsibility. 1 Currently at our Trust the dietitian completes the nutritional assessment and calculates requirements for patients requiring parenteral nutrition (PN) and then a doctor signs the prescription. This means that the doctor is taking legal responsibility for another healthcare professional’s assessment which has implications for patient safety. The aim of this audit was to identify who completed the nutritional assessment, calculated requirements and decided on the composition of the PN prescription and formulation and who signed the legal prescription. Method This was a point prevalence audit at a tertiary referral centre for intestinal failure. All patients receiving PN were included and a questionnaire regarding the healthcare professionals involved in the assessment and the decision regarding the prescription of the PN was completed. Results Twenty-seven patients were on PN on the day of the audit. Ten patients were on a surgical ward and 17 were on a medical ward. The initial nutritional assessment and calculation of requirements was completed by a dietitian in 100% of cases. Nine patients (33%) were considered at risk of refeeding syndrome but none developed refeeding. In 89% of cases (n = 24) the legal prescription was signed by a junior doctor. Of these 24 patients the doctor was directly involved in the patients nutritional care in only 7 cases (29%). Over the previous 7 days amendments to the PN were made by the dietitian alone (n = 14), the dietitian and doctor (n = 4), the dietitian and pharmacist (n = 2). Nineteen patients were also receiving oral diet, 2 were on trophic enteral nutrition and 6 were nil by mouth. Conclusion This audit has shown that at this tertiary referral centre the dietitian is responsible for completing the nutritional assessment and calculating requirements for patients requiring PN including the prevention of refeeding syndrome. Ongoing monitoring of the patient occurs in conjunction with other members of the nutrition team. Previous work showed a dietitian and pharmacist working together are safe to prescribe and manage PN. 2 Supplementary prescribing would enable dietitians to work in conjunction with pharmacists to take clinical and legal responsibility for the PN they are recommending instead of asking junior doctors to take on responsibility for their clinical decisions. This is likely to save doctors time and improve patient safety. Disclosure of interest None Declared. References Marks D. Allied Health Professionals prescribing and medicines supply mechanisms scoping project report. Department of Health, 2009 Farrer K et al . Pharm J 2008;280:626

How soon should we start interventional feeding in the ICU?

Nutrition in the critically ill patient remains a controversial topic. Most clinicians have viewed nutrition as part of patient care but not as a therapeutic intervention. Recent studies have looked at type and timing of nutrition to determine whether they affect important clinical outcomes. Large-scale, multicentre randomized trials have found that supplemental parenteral nutrition has a deleterious effect in comparison to enteral nutrition alone. Use of early parenteral nutrition in critically ill patients in whom enteral nutrition was contraindicated did not significantly improve clinical outcomes. Also, low-dose or trophic enteral nutrition has similar benefits with less gastrointestinal complications compared with early full dose caloric feedings. The timing of early nutrition has been defined in most large-scale studies as beginning within 48 h of intubation, though some earlier studies used a 24-h cut-off point with some improved outcomes. Although not strong, the best available data suggest that critically ill patients should be started on enteral tube feeds within 48 h of intubation whenever possible. The use of parenteral nutrition should be limited within the first 6 days, and not used to augment caloric intake. Finally, similar benefits are seen in patients receiving minimal enteral feeds versus full caloric enteral nutrition.

Effect of Aggressive Early High-Dose Intravenous Amino Acid Infusion and Early Trophic Enteral Nutrition on Very Low Birth Weight Infants

Objective: Very-low-birth-weight (VLBW) preterm infants are at risk of growth delay if they do not receive adequate nutritional support. This study evaluated the effect of aggressive early high-dose amino acid infusion plus early enteral trophic feeding on growth in VLBW infants within the first day of life. Study Design: The effect of a high-dose 3 g amino acid (HAA)/kg/d regimen beginning on the first day of life was compared with that of low-dose amino acid (LAA) supplementation at a dose of 0.5 or 1.0 g/kg/d. The primary outcome measures were the days of regained birth weight and achieved full enteral feeding. Result: Compared with the 19 infants in the LAA group, the 17 infants in the HAA group achieved significantly earlier full enteral feeding (7.8 ± 3.6 vs. 15.2 ± 8.9, p = 0.003) and regained birth weight (13.3 ± 3.8 vs. 17.5 ± 7.9, p = 0.047). In addition, shorter parenteral nutrition time was achieved by HAA administration (p < 0.05). Total energy intake was greater during the first 7 days of life in the HAA group (85 ± 12 kcal/kg/d on day 7) than in the LAA group (60 ± 16 kcal/kg/d on day 7, p < 0.001). Other clinical parameters such as length of hospital stay and morbidity favored the use of HAA. Conclusion: Aggressive early simultaneous amino acid administration plus enteral feeding during the first few days of life for preterm infants was associated with improved weight gain and earlier full enteral feeding.

Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure

Enteral nutrition is provided to mechanically ventilated patients who cannot eat normally, yet the amount of support needed is unknown. We conducted this randomized, open-label study to test the hypothesis that initial low-volume (i.e., trophic) enteral nutrition would decrease episodes of gastrointestinal intolerance/complications and improve outcomes as compared to initial full-energy enteral nutrition in patients with acute respiratory failure. Randomized, open-label study. A total of 200 patients with acute respiratory failure expected to require mechanical ventilation for at least 72 hrs. Patients were randomized to receive either initial trophic (10 mL/hr) or full-energy enteral nutrition for the initial 6 days of ventilation. The primary outcome measure was ventilator-free days to day 28. Baseline characteristics were similar between the 98 patients randomized to trophic and the 102 patients randomized to full-energy nutrition. At enrollment, patients had a mean Acute Physiology and Chronic Health Evaluation II score of 26.9 and a PaO2/FiO2 ratio of 182 and 38% were in shock. Both groups received similar durations of enteral nutrition (5.5 vs. 5.1 days; p = .51). The trophic group received an average of 15.8% ± 11% of goal calories daily through day 6 compared to 74.8% ± 38.5% (p < .001) for the full-energy group. Both groups had a median of 23.0 ventilator-free days (p = .90) and a median of 21.0 intensive-care-unit-free days (p = .64). Mortality to hospital discharge was 22.4% for the trophic group vs. 19.6% for the full-energy group (p = .62). In the first 6 days, the trophic group had trends for less diarrhea (19% vs. 24% of feeding days; p = .08) and significantly fewer episodes of elevated gastric residual volumes (2% vs. 8% of feeding days; p < .001). Initial trophic enteral nutrition resulted in clinical outcomes in mechanically ventilated patients with acute respiratory failure similar to those of early full-energy enteral nutrition but with fewer episodes of gastrointestinal intolerance.

Current practice regarding the enteral feeding of high-risk newborns with umbilical catheters in situ.

Textbooks recognize the controversy of concomitant enteral nutrition (EN) during umbilical catheter usage in high-risk newborns, but support for the practice varies. There is only one clinical trial examining these practices in a small but randomized, controlled trial of enterally fed newborns with umbilical arterial catheters (UACs) in situ, and that trial did not demonstrate any adverse consequences. We speculate that concomitant EN with umbilical catheter usage is more common than some textbooks suggest-practiced by at least 20% of all US neonatal intensive care units (NICUs). The objective of this study is to determine the prevalence of NICUs where high-risk newborns with UAC or umbilical venous catheter (UVC) placement receive concomitant EN. Medical Directors listed in the American Academy of Pediatrics United States Neonatologist and Perinatologist Directory were surveyed by mail. On return of surveys, responses to multiple choice questions were recorded by electronic scanning and validated by manually conducted quality control checks. NICU identities were recorded by code to maintain anonymity. Following 2 requests for survey participation, 70% (549/785) of surveys were returned. Respectively, 82% and 62% of NICUs with and without training programs were represented. On average, surveyed medical directors had practiced neonatal medicine 18.1 +/- 0.3 years. Of surveyed NICUs, 99% reported placement of UVCs and UACs. Of the 92% believing that it is safe to provide trophic EN to newborns with UVCs in place, 51% practiced this some of the time, and 37% practiced it most of the time. By comparison, it was reported that newborns with UACs in place receive trophic EN most of the time (30%), some of the time (49%), or none of the time (22%). Of the 80% believing that it is safe to provide more complete EN to newborns with UVCs in place, 44% practiced this some of the time, and 24% practiced it most of the time. For newborns with UACs in place, more complete EN was provided most of the time (15%), some of the time (36%), or none of the time (49%). Concurrent UVC and UAC usage with EN is more commonly practiced than suggested in textbooks or published articles. The relative risk-benefit profiles of these practices remain uncertain secondary to the limited number of controlled clinical observations and to the infrequent occurrence of adverse events. A prospective, multicenter, controlled trial would address the continued advisability of these unexpectedly common practices.

Trophic enteral nutrition increases hepatic glutathione and protects against peroxidative damage after exposure to endotoxin

Background During total parenteral nutrition (TPN), hepatic concentration of the important intracellular antioxidant glutathione (GSH) is decreased. This study sought to determine whether enteral trophic (small quantity) feeding of GSH precursors would increase hepatic GSH levels during TPN and result in decreased peroxidative injury after endotoxin exposure. Methods Sprague-Dawley rats received full TPN for 7 days with postpyloric infusions of either (1) amino acid GSH precursors (cysteine, 60 mg/d; glycine, 86 mg/d; glutamate, 31 mg/d; F1); (2) iso-nitrogenous alanine (132 mg/d; F2); or (3) normal saline (SA). Hepatic GSH concentration was measured by gas chromatography/mass spectrometry. In a parallel study, animals were given TPN and either F1 or SA for 7 days, and endotoxin was administered intravenously before death. Hepatic lipid peroxidation and histology were assessed. Results Hepatic GSH concentration measured 11.7 ± 0.6 μmol/g in F1. This was significantly higher ( P < .001) than in F2 (7.0 ± 0.8 μmol/g) or SA (5.0 ± 0.4 μmol/g). F2 and SA were not significantly different. Hepatic malondialdehyde concentration after exposure to endotoxin was significantly higher in SA (10.36 μmol/g ± 0.65) than in F1 (7.38 μmol/g ± 0.77; P < .01). All SA animals had histologic evidence of hepatic necrosis, whereas none of the F1 group showed these changes. Conclusions Targeted trophic feeding of GSH amino acid precursors during parenteral nutrition markedly increased hepatic GSH concentration. This was associated with decreased lipid peroxidation and enhanced hepatocellular protection after endotoxin challenge. Thus, targeted trophic feedings may aid in the prevention of TPN-related liver disease.