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Biological Impact of Recent Guidelines on Parenteral Nutrition in Preterm Infants.
Guellec, I, Gascoin, G, Beuchee, A, Boubred, F, Tourneux, P, Ramful, D, Zana-Taieb, E, Baud, O
Journal of pediatric gastroenterology and nutrition. 2015;(6):605-9
Abstract
OBJECTIVES Recent guidelines for preterm neonates recommend early initiation of parenteral nutrition (PN) with high protein and relatively high caloric intake. This review considers whether these changes could influence homeostasis in very preterm infants during the first few postnatal weeks. METHODS This systematic review of relevant literature from searches of PubMed and recent guidelines was reviewed by investigators from several perinatal centers in France. RESULTS New recommendations for PN could be associated with metabolic acidosis via the increase in the amino acid ion gap, hyperchloremic acidosis, and ammonia acidosis. The introduction of high-intake amino acids soon after birth could induce hypophosphatemia and hypercalcemia, simulating a "repeat feeding-like syndrome" and could be prevented by the early intake of phosphorus, especially in preterm infants born after fetal growth restriction. Early high-dose amino acid infusions are relatively well tolerated in the preterm infant with regard to renal function. Additional studies, however, are warranted to determine markers of protein intolerance and to specify the optimal composition and amount of amino acid solutions. CONCLUSIONS Optimal PN following new guidelines in very preterm infants, despite their demonstrated benefits on growth, may induce adverse effects on ionic homeostasis. Clinicians should implement appropriate monitoring to prevent and/or correct them.
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2.
Electrolyte and Mineral Homeostasis After Optimizing Early Macronutrient Intakes in VLBW Infants on Parenteral Nutrition.
Senterre, T, Abu Zahirah, I, Pieltain, C, de Halleux, V, Rigo, J
Journal of pediatric gastroenterology and nutrition. 2015;(4):491-8
Abstract
OBJECTIVES The aim of the present study was to evaluate electrolyte and mineral homeostasis in very-low-birth-weight (VLBW) infants who received high protein and energy intakes with a unique standardized parenteral nutrition solution containing electrolytes and minerals from birth onward. METHODS Prospective cohort study in 102 infants with birth weight <1250 g. The evolution of plasma biochemical parameters was described during the first 2 weeks of life. RESULTS During the first 3 days of life, mean parenteral intakes were 51 ± 8 kcal · kg · day with 2.7 ± 0.4 g · kg · day of protein, 1.1 ± 0.2 mmol · kg · day of sodium and potassium, and 1.3 ± 0.2 mmol · kg · day of calcium and phosphorus. Afterwards, most nutritional intakes (parenteral and enteral) met growth requirements. No infant developed a hyperkalemia >7 mmol/L, and a hypernatremia >150 mmol/L occurred only in 15.7% of the infants. In contrast, hyponatremia <130 mmol/L and hypokalemia <3 mmol/L occurred in 30.4% and 8.8% of the infants, respectively. The initial neonatal metabolic acidosis rapidly resolved in most infants and only 2.0% developed a base deficit >10 mmol/L after day 3 of life. Early hypocalcemia <1.8 mmol/L occurred in 13.7% of the infants. In contrast, hypophosphatemia <1.6 mmol/L occurred in 37.3% and hypercalcemia >2.8 mmol/L occurred in 12.7% of the infants. CONCLUSIONS Increasing early protein and energy intakes in VLBW infants in the first week of life improves electrolyte homeostasis. It also increases the phosphorus requirements with a calcium-to-phosphorus ratio ≤1.0 (mmol/mmol) and the potassium and sodium requirements to avoid the development of a refeeding-like syndrome. These data suggest that the parenteral nutrition guidelines for VLBW infants for the first week of life need to be revised.
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3.
Metabolic and nutritional support of critically ill patients: consensus and controversies.
Preiser, JC, van Zanten, AR, Berger, MM, Biolo, G, Casaer, MP, Doig, GS, Griffiths, RD, Heyland, DK, Hiesmayr, M, Iapichino, G, et al
Critical care (London, England). 2015;(1):35
Abstract
The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients.
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4.
Nutritional Issues in the Short Bowel Syndrome - Total Parenteral Nutrition, Enteral Nutrition and the Role of Transplantation.
O'Keefe, SJ
Nestle Nutrition Institute workshop series. 2015;:75-90
Abstract
In this review, I focus on the extreme of the short bowel syndrome where the loss of intestine is so great that patients cannot survive without intravenous feeding. This condition is termed short bowel intestinal failure. The review outlines the principles behind diagnosis, assessing prognosis and management. The advent of intravenous feeding (parenteral nutrition) in the 1970s enabled patients with massive (>90%) bowel resection to survive for the first time and to be rehabilitated back into normal life. To achieve this, central venous catheters were inserted preferably into the superior vena cava and intravenous infusions were given overnight so that the catheter could be sealed by day in order to maximize ambulation and social integration. However, quality of life has suffered by the association of serious complications related to permanent catheterization - mostly in the form of septicemias, thrombosis, metabolic intolerance and liver failure - from the unphysiological route of nutrient delivery. This has led to intense research into restoring gut function. In addition to dietary modifications and therapeutic suppression of motility, novel approaches have been aimed at enhancing the natural adaptation process, first with recombinant growth hormone and more recently with gut-specific glucagon-like peptide-2 analogues, e.g. teduglutide. These approaches have met with some success, reducing the intravenous caloric needs by approximately 500 kcal/day. In controlled clinical trials, teduglutide has been shown to permit >20% reductions in intravenous requirements in over 60% of patients after 6 months of treatment. Some patients have been weaned, but more have been able to drop infusion days. The only approach that predictably can get patients with massive intestinal loss completely off parenteral nutrition is small bowel transplantation, which, if successful (1-year survival for graft and host >90%) is accompanied by dramatic improvements in quality of life.
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5.
A single-blinded randomised clinical trial of permissive underfeeding in patients requiring parenteral nutrition.
Owais, AE, Kabir, SI, Mcnaught, C, Gatt, M, MacFie, J
Clinical nutrition (Edinburgh, Scotland). 2014;(6):997-1001
Abstract
BACKGROUND & AIMS The importance of adequate nutritional support is well established, but characterising what 'adequate nutrition' represents remains contentious. In recent years there has been increasing interest in the concept of 'permissive underfeeding' where patients are intentionally prescribed less nutrition than their calculated requirements. The aim of this study was to evaluate the effect of permissive underfeeding on septic and nutrition related morbidity in patients requiring short term parenteral nutrition (PN). METHODS This was a single-blinded randomised clinical trial of 50 consecutive patients requiring parenteral nutritional support. Patients were randomized to receive either normocaloric or hypocaloric feeding (respectively 100% vs. 60% of estimated requirements). The primary end point was septic complications. Secondary end points included the metabolic, physiological and clinical outcomes to the two feeding protocols. RESULTS Permissive underfeeding was associated with fewer septic complications (3 vs. 12 patients; p = 0.003), and a lower incidence of the systemic inflammatory response syndrome (9 vs. 16 patients; p = 0.017). Permissively underfed patients had fewer feed related complications (2 vs. 9 patients; p = 0.016). CONCLUSION Permissive underfeeding in patients requiring short term PN appears to be safe and may results in reduced septic and feed-related complications. TRIAL REGISTRATION NCT01154179 TRIAL REGISTRY http://clinicaltrials.gov/ct2/show/NCT01154179.