/pdf/the-medical-management-of-paediatric-crohn-s-disease-an-ecco-1jwbh3x09p.pdf

The Medical Management of Paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update.

In the midst of a coronavirus disease 2019 (COVID-19) pandemic, a paucity of data precludes derivation of COVID-19-specific recommendations for nutrition therapy. Until more data are available, focus must be centered on principles of critical care nutrition modified for the constraints of this disease process, ie, COVID-19-relevant recommendations. Delivery of nutrition therapy must include strategies to reduce exposure and spread of disease by providing clustered care, adequate protection of healthcare providers, and preservation of personal protective equipment. Enteral nutrition (EN) should be initiated early after admission to the intensive care unit (ICU) using a standard isosmolar polymeric formula, starting at trophic doses and advancing as tolerated, while monitoring for gastrointestinal intolerance, hemodynamic instability, and metabolic derangements. Intragastric EN may be provided safely, even with use of prone-positioning and extracorporeal membrane oxygenation. Clinicians should have a lower threshold for switching to parenteral nutrition in cases of intolerance, high risk of aspiration, or escalating vasopressor support. Although data extrapolated from experience in acute respiratory distress syndrome warrants use of fiber additives and probiotic organisms, the lack of benefit precludes a recommendation for micronutrient supplementation. Practices that increase exposure or contamination of equipment, such as monitoring gastric residual volumes, indirect calorimetry to calculate requirements, endoscopy or fluoroscopy to achieve enteral access, or transport out of the ICU for additional imaging, should be avoided. At all times, strategies for nutrition therapy need to be assessed on a risk/benefit basis, paying attention to risk for both the patient and the healthcare provider.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/jpen.1930

Nutrition Therapy in Critically Ill Patients With Coronavirus Disease 2019.

https://nottingham-repository.worktribe.com/preview/6500816/AAM.pdf

Management of disease-related malnutrition for patients being treated in hospital.

BACKGROUND
To study the long-term prognosis of anorexia nervosa (AN), 484 adult AN patients were followed on a mean duration of 13 years.


RESULTS
The mortality rate was 1.2%. Eight factors were linked to the lack of recovery at 2 years: low BMI at discharge, low energy and fat intakes, high drive for excessive exercising, high score for perfectionism, for interpersonal distrust and for anxiety, use of tube-feeding and adhesion to treatment (P<0.02). Four factors explained the risk of the binge/purging form at 2 years: having had binge-eating disorder and overweight before AN, having had purging episodes within the first 2 years of AN; having had very high energy intakes through meals and being not treated by tube-feeding. During the 13-year follow-up, very few binge/purging patients turned out to have the restrictive form. Two main factors explained 67% of the variance of menses recovery: having a BMI>18.5 kg/m(2); and having no physical hyperactivity. The recovery rate increased with the elapsing of relapse-free time (P=0.02). After a 13.5-year follow-up, 292 out of the 484 patients were recovered (60.3%), 25.8% had a relatively good outcome, 6.4% a bad outcome and 6.4% a severe outcome. Very few factors were identified as predictors of a good outcome (binge-eating/purging subtype, personality disorder).

Iconography : Outcome in AN adult patients: A 13-year follow-up in 484 patients

Thiamine is an essential water-soluble vitamin that plays an important role in energy metabolism. Thiamine deficiency presents many challenges to clinicians, in part due to the broad clinical spectrum, referred to as thiamine deficiency disorders (TDDs), affecting the metabolic, neurologic, cardiovascular, respiratory, gastrointestinal, and musculoskeletal systems. Concurrent illnesses and overlapping signs and symptoms with other disorders can further complicate this. As such, TDDs are frequently misdiagnosed and treatment opportunities missed, with fatal consequences or permanent neurologic sequelae. In the absence of specific diagnostic tests, a low threshold of clinical suspicion and early therapeutic thiamine is currently the best approach. Even in severe cases, rapid clinical improvement can occur within hours or days, with neurological involvement possibly requiring higher doses and a longer recovery time. Active research aims to help better identify patients with thiamine-responsive disorders and future research is needed to determine effective dosing regimens for the various clinical presentations of TDDs. Understanding the clinical diagnosis and global burden of thiamine deficiency will help to implement national surveillance and population-level prevention programs, with education to sensitize clinicians to TDDs. With concerted effort, the morbidity and mortality related to thiamine deficiency can be reduced.

https://nyaspubs.onlinelibrary.wiley.com/doi/pdf/10.1111/nyas.14536

Thiamine deficiency disorders: a clinical perspective.

Introduction In the spring of 2017, the American Society for Parenteral and Enteral Nutrition (ASPEN) Parenteral Nutrition Safety Committee and the Clinical Practice Committee convened an interprofessional task force to develop consensus recommendations for identifying patients with or at risk for refeeding syndrome (RS) and for avoiding and managing the condition. This report provides narrative review and consensus recommendations in hospitalized adult and pediatric populations. Methods Because of the variation in definitions and methods reported in the literature, a consensus process was developed. Subgroups of authors investigated specific issues through literature review. Summaries were presented to the entire group for discussion via email and teleconferences. Each section was then compiled into a master document, several revisions of which were reviewed by the committee. Findings/recommendations This group proposes a new clinical definition, and criteria for stratifying risk with treatment and screening strategies. The authors propose that RS diagnostic criteria be stratified as follows: a decrease in any 1, 2, or 3 of serum phosphorus, potassium, and/or magnesium levels by 10%-20% (mild), 20%-30% (moderate), or >30% and/or organ dysfunction resulting from a decrease in any of these and/or due to thiamin deficiency (severe), occurring within 5 days of reintroduction of calories. Conclusions These consensus recommendations are intended to provide guidance regarding recognizing risk and identifying, stratifying, avoiding and managing RS. This consensus definition is additionally intended to be used as a basis for further research into the incidence, consequences, pathophysiology, avoidance, and treatment of RS.

https://aspenjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/ncp.10474

ASPEN Consensus Recommendations for Refeeding Syndrome

BACKGROUND Nutrition management of pediatric intestinal failure (IF) requires interdisciplinary coordination of parenteral nutrition (PN) and enteral nutrition (EN) support. Nutrition strategies used by specialists in pediatric intestinal rehabilitation to promote gut adaptation and manage complications have not been previously summarized. METHODS A practice survey was distributed to members of the dietitian subgroup of the American Society for Parenteral and Enteral Nutrition Pediatric Intestinal Failure Section. The survey included 24 open-ended questions related to PN and enteral feeding strategies, nutrition management of PN-associated liver disease, and laboratory monitoring. RESULTS Dietitians from 14 centers completed the survey. Management components for patients at risk for cholestasis were consistent and included fat minimization, trace element modification, avoiding PN overfeeding, and providing EN. Parenteral amino acid solutions designed for infants/young children are used in patients <1 or 2 years of age. Trace minerals are dosed individually in 10 of 14 centers. Eleven centers prescribe a continuous infusion of breast milk or elemental formula 1-2 weeks after resection while 3 centers determine the formula type by the extent of resection. Most (86%) centers do not have a protocol for initiating oral/motor therapy. Laboratory panel composition varied widely by center. The selection and frequency of use depended on clinical variables, including cholestatic status, exclusive vs partial PN dependence, postrepletion verification vs routine monitoring, intestinal anatomy, and acuity of care. CONCLUSION EN and PN management strategies are relatively consistent among U.S. centers. Collaborative initiatives are necessary to define better practices and establish laboratory monitoring guidelines.

/pdf/survey-of-nutrition-management-practices-in-centers-for-3u9627ysmo.pdf

Survey of Nutrition Management Practices in Centers for Pediatric Intestinal Rehabilitation.

Although crucial in improving health outcomes in the preterm infants, parenteral nutrition (PN) is not without risk, especially if handled improperly. A growing body of evidence suggests that components of PN admixtures, including lipid injectable emulsions (ILEs), are susceptible to degradation, including oxidation when exposed to light (ie, photo-oxidation), resulting in the production of reactive oxygen species. Infants, especially those born preterm, are considered more susceptible to consequences of oxidative stress than children and adults. Oxidative stress is associated with bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, and intestinal failure-associated liver disease. The American Society for Parenteral and Enteral Nutrition (ASPEN) assembled a working group to provide recommendations on clinical practice surrounding photoprotection of PN.This Position Paper reviews the scientific literature on the formation of quantifiable peroxides and other degradation products when PN admixtures and ILEs are exposed to light and reports adverse clinical outcomes in premature infants exposed to PN. Recommendations for photoprotection of PN admixtures and ILEs are provided, as well as the challenges in achieving complete photoprotection with the equipment, supplies, and materials currently available in the US. ASPEN and the authors understand that the full implementation of complete photoprotection may not currently be feasible given current product availability; recommendations provided in this paper serve to represent the goal to which to strive as well as to highlight the importance of product availability to achieve these practices. This paper has been approved by the ASPEN Board of Directors.

Recommendations for photoprotection of parenteral nutrition for premature infants: An ASPEN position paper.

1. Nithin S. Ravi, MD, MPH*
2. Niyomi Gandhi, MD†
3. Stacey Noel, MD‡
4. Carolyn Commissaris, MD‡
5. Austin Michalski, RD§
6. Yiling Katharine Chang, MD†


 

1. *University of Michigan Medical School, Ann Arbor, MI;

2. †Department of Pediatrics,

3. ‡Department of Pediatric Emergency Medicine, and

4. §Patient Food and Nutrition Services, CS Mott Children’s Hospital, University of Michigan, Ann Arbor, MI

A developmentally normal 5-year-old boy presents to the emergency department with epistaxis, arthralgias, refusal to ambulate, and gingival hyperplasia. Six weeks before presentation, the patient developed bilateral lower-extremity arthralgias. One week later, he fell and subsequently refused to ambulate. At the initial evaluation by his pediatrician, he had normal lower-extremity radiographs with appropriate growth and development for age, so no further recommendations were provided to the parents.

During the following 2 weeks, the pain in his lower extremities progressed to his lower back, wrists, and hands. The patient presented to an outside hospital, where plain radiographs revealed a stress fracture of the left tibial plateau that was treated with casting. Two days before presentation, the cast was removed, and a petechial rash in the distribution of the cast was noted, with associated joint swelling. A rheumatology appointment was scheduled.

On the day before his scheduled rheumatology appointment the patient presents to the emergency department. The parents state a chief complaint of “vomiting bright red blood.” With additional history, this is determined to be more consistent with epistaxis than with hematemesis. Vital signs reveal mild tachycardia of 132 beats/min but are otherwise normal. Weight is normal for age at 38.4 …

Austin Michalski

Papers

ASPEN Consensus Recommendations for Refeeding Syndrome

Survey of Nutrition Management Practices in Centers for Pediatric Intestinal Rehabilitation.

Recommendations for photoprotection of parenteral nutrition for premature infants: An ASPEN position paper.

Visual Diagnosis: Petechiae, Gingival Hyperplasia, Metaphyseal Lucencies, and Refusal to Ambulate in a 5-year-old Boy