Transcript Enteral nutrition - PTNT Asian Hospital

Principles of Nutrition Support
in Sick Children:
Roles of Enteral and Parenteral Nutrition
Mercedita Magdaleno-Macalintal, MD, DPPS
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Objectives
Participants will be able to:
 Identify candidates for nutritional support
 Describe and compare methods of
nutrition intervention
 Select the appropriate method of
nutrition support
 Describe and select appropriate
nutrition support access
 Monitor nutrition support to prevent or
manage complications and achieve
nutrition support objectives
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Content
 Nutrition decision making –
paradigms
 Who needs nutritional support
 Enteral vs. parenteral nutrition
 Access and formulation
 Algorithm
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The Goal of Nutritional Support
 Provide appropriate amounts of energy
and nutrients for optimal growth and
development while:
• Preserving body composition
• Minimizing gastrointestinal
symptoms
• Promoting developmentally
appropriate feeding habits and skills
Axelrod D, et al. JPEN 2006;30(suppl1):S2-S26.
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Considerations in Nutritional Planning
 High prevalence of malnutrition
• 10% to 50% of patients are
nutritionally compromised
 Special nutritional requirements
• Growth and development
• Immature organs/systems
• Limited reserves
Merritt RJ, et al. Am J Clin Nutr 1979;32:1320-1325. Secker DJ, et al. Am J Clin Nutr 2007;85:1083-1089. Pawellek I, et al. Clin Nutr 2008;27:72-76.
Marino LV, et al. S Afr Med 2006;96:993-995. Hendricks KM, et al. Arch Pediatr Adolesc Med 1995;149:1118-1122.
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Considerations in Nutritional Planning
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Severe and possible permanent sequelae
• IQ
• School performance
• Cognition
Use of enteral or parenteral feeding may
adversely affect normal development of
feeding skills and behavior/attitudes
Specialized nutritional therapies are the
treatment of choice for different disorders
Liu J, et al. Am J Psychiatry 2004;161:2005-2013. Daniels MC, et al. J Nutr 2004;134:1439-1446. Liu J, et al. Arch Pediatr Adolesc Med 2003;156:593-600.
Mason SJ, et al. Dysphagia 2005;20:46-66. Damen RS. Adv Perit Dial 1990;6:276-9.
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Creating a Nutritional Plan
 Identify at-risk children
 Set caloric/protein goals
 Establish feeding method
 Choose formula type and
composition
 Monitor
Nutrition Decision-Making Paradigms
 Nutrition evaluation and support should
be
an essential part of clinical evaluation
and care in the pediatric (hospital) setting
and, therefore, should be performed
routinely
 Nutritional support should be implemented
in all children with or at risk of developing
malnutrition
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Indications for Nutrition Support
 Inadequate growth:
• Inadequate growth or weight gain
for >1 month in a child <2 years
• Weight loss or no weight gain for a
period >3 months over the age of 2 years
• Change in weight/age or weight/height
(length) over 2 growth channels on the
growth charts
• Triceps skin-fold consistently
<5th percentile for age
Axelrod D, et al. JPEN 2006;30(suppl1):S2-S26.
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Indications for Nutrition Support
 Inadequate intake:
• Inability to consume at least 80%
of energy needs orally
 Inadequate feeding skills:
• Total feeding time >4 hours/day
for a neurologically impaired child
Axelrod D, et al. JPEN 2006;30(suppl1):S2-S26.
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Conditions That May
Require Nutritional Intervention
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Disorders causing inadequate oral
intake
Disorders of digestion and absorption
Disorders of gastrointestinal motility
Increased nutritional requirements
and losses
Growth failure or chronic malnutrition
Crohn’s disease
Inborn errors of metabolism
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Methods of Nutrition Intervention
4. Parenteral Nutrition
3.
Enteral
Feeding
2. Oral
Nutritional Supplements
1. Nutritional Counseling
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Nutrition Interventions: Definitions
 Nutritional counseling: A nutrition professional works
with patient/caregiver to assess how to improve
dietary intake and provides information, education
materials, support and follow-up
 Oral nutrition supplementation: Providing
supplementary nutrition by mouth
 Enteral nutrition: Providing supplemental or total
nutrition via a feeding tube
• Includes all forms of nutritional support that involve
use of “dietary foods for special medical purposes”
 Parenteral nutrition: Providing supplemental or total
nutrition intravenously
Lochs H, et al. Clin Nutr 2006;25:180-186.
Koletzko B, et al. J Pediatr Gastroenterol Nutr 2005;41 (suppl2):S1-S87.
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Enteral Nutrition Indications
If the gut works, use it!
 Enteral nutrition should be implemented in
children who:
• Have some level of GI function but are
unable to meet their full nutritional
requirements orally
• Are malnourished
• Are at risk of malnutrition
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Contraindications to Enteral Nutrition :
 Absolute contraindications:
• Intestinal perforation, ischemia, peritonitis,
necrotizing enterocolitis
• GI obstruction, paralytic ileus
• Inability to access the GI tract
(severe burns, trauma)
 Relative contraindications:
• Vomiting and diarrhea
• Severe acute pancreatitis (pain, vomiting)
• High output enteric fistula
• GI bleeding
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Indications to Parenteral Nutrition
 Transient or permanent GI
failure
 GI tract failure is often
partial
• Some enteral nutrition
may be possible
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Parenteral Nutrition
Contraindications/Ethical Issues
 When enteral feeding is
possible
 Terminal illness
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Enteral & Parenteral
Nutrition Disadvantages
Enteral Nutrition
Parenteral Nutrition
Failure to meet
nutritional needs
Less acceptable to
patients
Frequent tube
replacement
Specialized
centers/teams
Expensive
Complications
Complications
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Decision Making for
Nutrition Support Method
Nutritional Assessment
Specialized Nutritional Support
Functional Gastrointestinal Tract
YES
NO
No contraindications to
enteral nutrition
Contraindications to
enteral nutrition
Enteral nutrition
Parenteral nutrition
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Enteral Formula Selection
Consider
 Site of delivery
 Route of delivery
 Mode of delivery
 Monitoring
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Enteral Formula Selection
 Nutrients and energy needs adjusted for the age and
clinical condition of the child:
• History of food intolerance or allergy
• Intestinal function
• Site and route of delivery
• Taste preference (oral supplementation)
 Formula characteristics:
• Nutritional composition
• Osmolarity and solute load
• Caloric density
• Cost
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Enteral Nutrition
Types of formulas according to degree of
hydrolyzation
 Polymeric
• Intact nutrients, require digestion
 Semi-elemental/partially hydrolyzed
• Partially “digested” for easy absorption
 Elemental
• Composed of free amino acids,
monosaccharides and little fat
Shaw V, Lawson M, eds. Clinical Paediatric Dietetics. 2nd ed. London: Blackwell; 2001.
Sobotka L. Basics in Clinical Nutrition, 3rd ed. Prague: Galen; 2004.
Lochs H, et al. Clin Nutr 2006;25:260–274.
A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. JPEN 2002;26:S97-S137.
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Enteral Nutrition
Modular formulas
 Made of modular components to produce an
individualized formula to meet special needs
Immunomodulating formulas
 Supplemented with functional ingredients
• Eg, glutamine, arginine, nucleotides, omega-3
fatty acids, antioxidants
Disease-specific formulas
 Modified in nutrient content, amount and ratio
Shaw V, Lawson M, eds. Clinical Paediatric Dietetics. 2nd ed. London: Blackwell; 2001.
Sobotka L. Basics in Clinical Nutrition, 3rd ed. Prague: Galen; 2004.
Lochs H, et al. Clin Nutr 2006;25:260–274.
A.S.P.E.N. Board of Directors and The Clinical Guidelines Task Force. JPEN 2002;26:S97-S137.
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Enteral and Parenteral
Nutrition Advantages
Enteral Nutrition
Parenteral Nutrition
Preserves
- GI structure & function
- Gut hormonal response
- Normal gut flora
- Normal blood supply to the
gut
- GALT integrity
No risk of tube feeding aspiration
May help prevent
bacterial translocation
Better patient acceptance
Decreased risk of infection
More reliable delivery
Less expensive
Supports survival in intestinal failure
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Enteral Nutrition
Sites of delivery:
 Gastric
 Post-pyloric
Choice of the delivery site is based on:
 Functional status of the gut
 Risk of aspiration
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Enteral Nutrition
 Gastric feeding
• Flexible feeding schedules
• Reservoir capacity
 Tolerance of volume and hyperosmolar feedings
• Less diarrhea, dumping syndrome
• Gastric acidity has antibacterial function
• Gastric tubes are relatively easy to place
 Post-pyloric feeding
• Allows delivery of EN in case of gastroparesis,
severe GERD, or gastric outlet obstruction
• Not recommended for preterm infants
McGuire W, McEwan P. Cochrane Database Syst Rev. 2007;3:CD003487.
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Enteral Nutrition
Nasogastric (NG) and nasoenteric feeding tubes
 Feeding duration 6-8 weeks
 PVC, polyurethane, silicone NG tubes
common
 PVC can release phthalate ester
 PVC can become rigid
 Change PVC NG tubes q 3-4 d,
transpyloric tubes q 8 d
 Smallest tube diameter desirable
 Tube length
 Tube placement confirmation
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Enteral Nutrition
 Gastrostomy/jejunostomy tubes
 For feeding duration >8 weeks
 Placement techniques
• Endoscopy
• Surgery
• Radiology
Loser C, et al. Clin Nutr 2005;24:848-61.
Caulfield M. Gastrointest Endosc Clin N Am 1994;4:179-93.
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Enteral Nutrition
 Methods of enteral feeding administration
• Continuous feeding
 Continual delivery over 12 - 24 hours
 Feeding pump regulates delivery
• Intermittent bolus feeding
 Discrete volumes of formula delivered
several times daily
• Combined continuous and intermittent
feeding
Aynsley-Green A, et al. Acta Paediatr Scand 1982;71:379-83.
Jawaheer G, et al. J Pediatr 2001;138:822-5.
Shulman RJ, et al. J Pediatr Gastroenterol Nutr 1994;18:350-4.
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Enteral Nutrition
 Required monitoring
• Biochemical monitoring
 To prevent electrolyte and fluid abnormalities
and hypo- and hyperglycemia
• GI tolerance
 To prevent vomiting, abdominal distention,
pain, constipation
• Tube/stoma placement and maintenance
 To prevent tube displacement, tube clogging,
aspiration
• Growth and development
• Psychological aspects
(feeding aversion, loss of feeding skills)
Jeejeebhoy KJ. Curr Opin Gastroenterol 2005;21:187-91.
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Parenteral Nutrition
Decision to institute
parenteral nutrition
depends on:
•Nutritional status
•GI tract function
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Parenteral Nutrition
 Rapid initiation for young, small
children
• Preterm infants cannot tolerate
starvation
Institute parenteral nutrition
immediately after birth
• Older children can tolerate up to 7
days
 Combine with oral or enteral nutrition
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Parenteral Nutrition
 Access
• Peripheral access should be temporary
• Trained personnel insert and care
for central venous catheters
 Aseptic conditions are paramount
 Methods of insertion
• PICC
• Tunneled central venous catheters
 Insertion sites
• Femoral
• Jugular
• Subclavian
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Parenteral Nutrition
 Parenteral solutions
• Amino acids
• Glucose
• Lipids
• Electrolytes, vitamins, trace elements
 Tailored vs. standard solutions
 Computer prescription programs
encouraged
Guidelines on Paediatric Parenteral Nutrition of ESPGHAN and ESPEN, Supported by ESPR. J Pediatr Gastroenterol Nutr 2005:41(suppl2):S1-S87.
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Parenteral Nutrition
Monitoring
 Monitor Blood chem 2-3 times weekly
• Electrolytes, renal & liver function, blood lipids
 Routine nutrition assessment
 Parenteral nutrition >3 months
• Trace elements / Ferritin
• Folate / Vitamin B12
• Thyroid function
• Coagulation status
• Fat-soluble vitamins
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Parenteral Nutrition
Complications
 Catheter-related
• Infection, thrombosis, occlusion,
accidental removal, catheter damage
 Metabolic/nutritional
• Fluid-electrolyte abnormalities,
hypo-/hyperglycemia, failure to achieve
optimal nutritional status and growth
 Long-term parenteral nutrition
• Cholestasis, renal and bone disease,
growth impairment
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Parenteral Nutrition
Prevent complications
 Multi-disciplinary nutrition support
team
 Meticulous technique
 Avoid unbalanced/excessive
substrates
 Strict hygiene
 Emphasize enteral feeding
 Structured pathways
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Enteral Nutrition Possible
Normal Gastrointestinal Absorption Function
YES
NO
Standard Formula
Specialized Formula
Expected Period of Nutritional Support
Less than 4-6 weeks
More than 4-6 weeks
Risk of Aspiration
Nasogastric Tube
NO
Gastrostomy
Post-pyloric Tube
YES
Jejunostomy
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Enteral Nutrition not Possible
Intestinal Immaturity/Failure
Contraindications to Enteral Nutrition
Expected Period of PN Support
Temporary need for PN
Less than 7-10 days
Prolonged need for PN
More than 7-10 days
Peripheral venous access
Central venous access
Establish/provide energy and nutrient
requirements
Periodic evaluation of nutritional status
and GI function
Periodic monitoring/prevention and
treatment of complications
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Prolonged PN Support
Permanent or Severe Intestinal Failure
Prolonged period of parenteral nutrition is expected. Patient condition,
fluid/electrolytes status stable. Cyclic administration initiated
Arrange for home parenteral nutrition support
1. Teach family members aseptic technique for catheter
dressing, tube connection and disconnection
2. Teach solution and pump handling
3. Supply 24/7 assistance in case of emergency
Periodic evaluation of nutritional
status and GI function
Periodic monitoring/prevention and
treatment of complications
Evaluate the possibility of weaning from home parenteral nutrition
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Summary
 Nutrition decision making –
paradigms
 Who needs nutritional support
 Enteral vs. parenteral nutrition
 Access and formulation
 Algorithm
41