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Nutrients May 2022Enteral nutrition (EN) provides critical macro and micronutrients to individuals who cannot maintain sufficient oral intake to meet their nutritional needs. EN is most... (Review)
Review
Enteral nutrition (EN) provides critical macro and micronutrients to individuals who cannot maintain sufficient oral intake to meet their nutritional needs. EN is most commonly required for neurological conditions that impair swallow function, such as stroke, amytrophic lateral sclerosis, and Parkinson's disease. An inability to swallow due to mechanical ventilation and altered mental status are also common conditions that necessitate the use of EN. EN can be short or long term and delivered gastrically or post-pylorically. The expected duration and site of feeding determine the type of feeding tube used. Many commercial EN formulas are available. In addition to standard formulations, disease specific, peptide-based, and blenderized formulas are also available. Several other factors should be considered when providing EN, including timing and rate of initiation, advancement regimen, feeding modality, and risk of complications. Careful and comprehensive assessment of the patient will help to ensure that nutritionally complete and clinically appropriate EN is delivered safely.
Topics: Clinical Protocols; Enteral Nutrition; Food, Formulated; Humans; Intubation, Gastrointestinal; Micronutrients
PubMed: 35683980
DOI: 10.3390/nu14112180 -
JPEN. Journal of Parenteral and Enteral... May 2023Drug administration through feeding tubes presents many challenges to the healthcare provider. There is little information available on medications than can be delivered... (Review)
Review
BACKGROUND
Drug administration through feeding tubes presents many challenges to the healthcare provider. There is little information available on medications than can be delivered safely when crushed and what efforts can be implemented to minimize clogging the feeding tube. Our institution requested a comprehensive examination of all oral medications for the feeding tube route.
METHODS
This report is a synopsis of the physical evaluation of 323 different oral medications for their appropriateness for feeding tube administration with distal site in either the stomach or jejunum. A worksheet was created for each medication. This document contained a review of the chemical and physical properties that would contribute to delivery of the medication. Each medication was then studied for the degree of disintegration, pH, osmolality, and potential to form clogs. For drugs that needed to be crushed, the volume of water needed to dissolve the drug, time for that process, and volume needed to rinse the tube after administration was also studied.
RESULTS
The results of this review are summarized in a table and based on a composite of the documents cited, tests conducted, and author's judgements based all the data collected. Thirty-six medications were identified as inappropriate for feeding tube administration, and an additional 46 medications were identified as inappropriate for direct jejunal administration.
CONCLUSION
The information produced by this study will enable clinicians to make informed choices in selecting, compounding, and rinsing medications through feeding tubes. Using the template provided, they will be able to evaluate a drug not studied here for potential issues in feeding tube administration.
Topics: Humans; Enteral Nutrition; Intubation, Gastrointestinal; Pharmaceutical Preparations; Osmolar Concentration; Health Personnel; Administration, Oral
PubMed: 36847617
DOI: 10.1002/jpen.2490 -
Internal Medicine (Tokyo, Japan) Jan 2020Various methods of rehabilitation for dysphagia have been suggested through the experience of treating stroke patients. Although most of these patients recover their... (Review)
Review
Various methods of rehabilitation for dysphagia have been suggested through the experience of treating stroke patients. Although most of these patients recover their swallowing function in a short period, dysphagia in Parkinson's disease (PD) and Parkinson-related disorder (PRD) degenerates with disease progression. Muscle rigidity and bradykinesia are recognized as causes of swallowing dysfunction, and it is difficult to easily apply the strategies for stroke to the rehabilitation of dysphagia in PD patients. Disease severity, weight loss, drooling, and dementia are important clinical predictors. Silent aspiration is a pathognomonic sign that may lead to aspiration pneumonia. Severe PD patients need routine video fluoroscopy or video endoscopy to adjust their food and liquid consistency. Patients with PRD experience rapid progression of swallowing dysfunction. Nutrition combined with nasogastric tube feeding or percutaneous endoscopic gastrostomy feeding should be considered owing to the increased risk of aspiration and difficulty administrating oral nutrition.
Topics: Deglutition; Deglutition Disorders; Disease Progression; Enteral Nutrition; Humans; Hypokinesia; Muscle Rigidity; Parkinson Disease; Pneumonia, Aspiration; Respiratory Aspiration; Stroke Rehabilitation
PubMed: 30996170
DOI: 10.2169/internalmedicine.2373-18 -
The Cochrane Database of Systematic... Aug 2021The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the... (Review)
Review
BACKGROUND
The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing.
OBJECTIVES
To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake.
SEARCH METHODS
We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021.
SELECTION CRITERIA
We included randomised controlled trials (RCTs), or controlled non-randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post-pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers.
DATA COLLECTION AND ANALYSIS
Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non-randomised Studies of Interventions' (ROBINS-I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre-agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta-analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study.
MAIN RESULTS
We found no eligible RCTs. We included fourteen controlled, non-randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low-certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate-certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very-low certainty evidence). Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low-certainty evidence. Five studies reported a variety of harm-related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia.
AUTHORS' CONCLUSIONS
We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here.
Topics: Adult; Caregivers; Dementia; Enteral Nutrition; Gastrostomy; Humans; Intubation, Gastrointestinal; Malnutrition; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 34387363
DOI: 10.1002/14651858.CD013503.pub2 -
Tumori Feb 2023In recent years, the influence of nutrition on the health and growth of children has become increasingly important. The relevance of nutrition is even greater for... (Review)
Review
In recent years, the influence of nutrition on the health and growth of children has become increasingly important. The relevance of nutrition is even greater for children who are facing cancer. Malnutrition, within the context of undernutrition and overnutrition, may impact not only the effectiveness of treatments and outcomes, but also the quality of life for patients and their families. In this article, we review nutritional assessment methods for children with cancer, focusing on the specific characteristics of this population and analyze the efficacy of nutritional interventions, which include enteral, parenteral, and nutritional education. From our analysis, two important conclusions emerged: i) there is a need to focus our attention on the nutritional status and the body composition of oncologic children, since these factors have a relevant impact on clinical outcomes during treatment as well as after their conclusion; ii) the support of skilled clinical nutrition personnel would be extremely helpful for the global management of these patients.
Topics: Humans; Child; Nutritional Status; Enteral Nutrition; Quality of Life; Malnutrition; Neoplasms
PubMed: 35722985
DOI: 10.1177/03008916221084740 -
Critical Care (London, England) Jul 2023Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent... (Review)
Review
Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent literature are presented. Low-dose enteral nutrition (EN) or parenteral nutrition (PN) can be started within 48 h of admission. While EN is preferred route of delivery, new data highlight PN can be given safely without increased risk; thus, when early EN is not feasible, provision of isocaloric PN is effective and results in similar outcomes. Indirect calorimetry (IC) measurement of energy expenditure (EE) is recommended by both European/American guidelines after stabilization post-ICU admission. Below-measured EE (~ 70%) targets should be used during early phase and increased to match EE later in stay. Low-dose protein delivery can be used early (~ D1-2) (< 0.8 g/kg/d) and progressed to ≥ 1.2 g/kg/d as patients stabilize, with consideration of avoiding higher protein in unstable patients and in acute kidney injury not on CRRT. Intermittent-feeding schedules hold promise for further research. Clinicians must be aware of delivered energy/protein and what percentage of targets delivered nutrition represents. Computerized nutrition monitoring systems/platforms have become widely available. In patients at risk of micronutrient/vitamin losses (i.e., CRRT), evaluation of micronutrient levels should be considered post-ICU days 5-7 with repletion of deficiencies where indicated. In future, we hope use of muscle monitors such as ultrasound, CT scan, and/or BIA will be utilized to assess nutrition risk and monitor response to nutrition. Use of specialized anabolic nutrients such as HMB, creatine, and leucine to improve strength/muscle mass is promising in other populations and deserves future study. In post-ICU setting, continued use of IC measurement and other muscle measures should be considered to guide nutrition. Research on using rehabilitation interventions such as cardiopulmonary exercise testing (CPET) to guide post-ICU exercise/rehabilitation prescription and using anabolic agents such as testosterone/oxandrolone to promote post-ICU recovery is needed.
Topics: Humans; Intensive Care Units; Nutritional Support; Critical Care; Nutritional Status; Enteral Nutrition; Critical Illness
PubMed: 37403125
DOI: 10.1186/s13054-023-04539-x -
Nutrients Apr 2022Congenital heart defects are known causes of malnutrition. Optimal nutritional management is paramount in improving short and long-term prognosis for neonates and... (Review)
Review
Congenital heart defects are known causes of malnutrition. Optimal nutritional management is paramount in improving short and long-term prognosis for neonates and infants with congenital heart malformations, as current strategies target preoperative and postoperative feeding requirements. Standardized enteral and/or parenteral feeding protocols, depending on the systemic implications of the cardiac defect, include the following common practices: diagnosing and managing feeding intolerance, choosing the right formula, and implementing a monitoring protocol. The latest guidelines from the American Society for Parenteral and Enteral Nutrition and the European Society of Paediatric and Neonatal Intensive Care, as well as a significant number of recent scientific studies, offer precious indications for establishing the best feeding parameters for neonates and infants with heart defects.
Topics: Child; Enteral Nutrition; Heart Defects, Congenital; Humans; Infant; Infant, Newborn; Malnutrition; Nutritional Status; Parenteral Nutrition
PubMed: 35458233
DOI: 10.3390/nu14081671 -
BMJ Open Gastroenterology Jul 2022Percutaneous endoscopic gastrostomy (PEG) was developed by Ponsky-Gauderer in the early 1980s. These tubes are placed through the abdominal wall mainly to administer... (Review)
Review
BACKGROUND
Percutaneous endoscopic gastrostomy (PEG) was developed by Ponsky-Gauderer in the early 1980s. These tubes are placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition but can also be used for drainage or decompression. The tubes consist of an internal and external retention device. It is a generally safe technique but major or minor complications may arise during and after tube placement.
METHOD
A narrative review of the literature investigating minor complications after PEG placement.
RESULTS
This review was written from a clinical viewpoint focusing on prevention and management of minor complications and documented with real cases from more than 21 years of clinical practice.
CONCLUSIONS
Depending on the literature the incidence of minor complications after gastrostomy placement can be high. To decrease associated morbidity, prevention, early recognition and popper management of these complications are important.
Topics: Enteral Nutrition; Gastrostomy
PubMed: 35851280
DOI: 10.1136/bmjgast-2022-000975 -
Nutrition (Burbank, Los Angeles County,... Oct 2022With increasing life expectancy of patients with cystic fibrosis (CF), gastrointestinal manifestations of the disease have been increasingly brought into focus. This was... (Review)
Review
With increasing life expectancy of patients with cystic fibrosis (CF), gastrointestinal manifestations of the disease have been increasingly brought into focus. This was a systematic review of the PubMed database and ongoing phase III clinical trials that aimed to summarize recent (published after June 1 2016) studies reporting the effects of nutritional interventions on anthropometric measures (weight, height, and body mass index) in patients with CF. Two ongoing trials and 40 published studies (18 interventional and 22 observational) were identified. Key results supported the benefits of comprehensive, individualized nutritional plans, high-fat, high-calorie diet including high-quality carbohydrates, and enteric tube feeding (albeit the latter was derived from observational studies only). In contrast, the supplementation of probiotics, lipids, docosahexaenoic, glutathione, or antioxidant-enriched multivitamin appeared to have little effect on anthropometric measures.
Topics: Body Height; Body Mass Index; Cystic Fibrosis; Enteral Nutrition; Humans; Nutritional Status
PubMed: 35816813
DOI: 10.1016/j.nut.2022.111725 -
Nutrients Dec 2022The most common cause of intestinal failure (IF) in childhood remains short bowel syndrome (SBS), where bowel mass is significantly reduced due to a congenital atresia... (Review)
Review
BACKGROUND
The most common cause of intestinal failure (IF) in childhood remains short bowel syndrome (SBS), where bowel mass is significantly reduced due to a congenital atresia or resection and parenteral nutrition (PN) needed. Home PN has improved outcome and quality of life, but the long-term therapeutic goal is to achieve enteral autonomy whilst avoiding long term complications. This paper is aimed at discussing nutritional strategies available to clinicians caring for these patients.
METHODS
A literature search was performed from 1992 to 2022 using Pubmed, MEDLINE and Cochrane Database of Systematic Reviews, and recent guidelines were reviewed. In the absence of evidence, recommendations reflect the authors' expert opinion.
RESULTS
Consensus on the best possible way of feeding children with IF-SBS is lacking and practice varies widely between centres. Feeding should commence as soon as possible following surgery. Oral feeding is the preferred route and breast milk (BM) the first milk of choice in infants. Donor BM, standard preterm or term formula are alternatives in the absence of maternal BM. Extensively hydrolysed or amino acid-based feeds are used when these are not tolerated. Solids should be introduced as soon as clinically appropriate. Children are encouraged to eat by mouth and experience different tastes and textures to avoid oral aversion. Aggressive weaning of PN and tube (over-) feeding are now discouraged.
CONCLUSIONS
To date, uniform agreement on the optimal type of feed, timing of food introduction and feeding regime used is lacking and great difference in practice remains. There is need for more research to establish common treatment protocols.
Topics: Infant, Newborn; Infant; Female; Humans; Child; Short Bowel Syndrome; Intestinal Failure; Quality of Life; Enteral Nutrition; Systematic Reviews as Topic; Parenteral Nutrition, Home
PubMed: 36615720
DOI: 10.3390/nu15010062