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With the help of 55 nurses counseling young mothers in northern, central and eastern Switzerland the feeding habits of 371 infants born in March and April 1978 were studied during the first 6 months of life. Infants who were still breastfed at the end of the observation period were monitored for another 6 months. 92% of all infants were breastfed during the puerperium (62% receiving exclusively mother's milk). At the end of the second month some 60% of the infants were breast-fed (40% exclusively). At the end of the fourth month the numbers were 30% (15%) and after 6 months 18% (2%). The "mean corrected nursing period" was 10.25 weeks. The length of this period showed a direct correlation with the socioeconomic class of the family and especially with the educational status of the mother. A small difference in duration of the nursing period between male and female infants was not statistically significant, although during childbed there was a significant difference in favour of boys. There appeared to be a relationship between duration of nursing and age, parity and bodyweight of the mother. There were marked differences in frequency and duration of breast-feeding according to whether rooming-in was practiced during childbed or not. At the end of the first half year of life babies with a long nursing period had a significantly lower body weight than those with partial or no breastfeeding. A much smaller difference in body length resulted in a lower and probably more favourable weight/length ratio. There was no difference in head circumference. As compared with other industralized European countries, the authors regard current nursing habits in Switzerland as satisfactory.
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An audit was carried out over a 24 month period to assess the practice, safety and efficacy of nutritional support provided to surgical patients by a designated team. 135 patients received nutritional support: 51% were fed parenterally, 32% enterally and 17% via combined nutritional support. The duration of feeding ranged from 1-177 days with 23% being supported for < 7 days. The line infection rate for patients receiving intravenous nutrition was 6.5%. Nutritional outcome was assessed using weight, anthropometry and bioelectrical impedance analysis. Pre-and post-feeding results were available for 67% of patients. These patients were classified as either oedematous (n = 21), normally nourished (n = 23) or nutritionally depleted (n = 46). Overall, the oedematous patients lost water, the protein status of the normally nourished group deteriorated slightly and the nutritional status of the nutritionally depleted patients was maintained. Audit is a valuable means of defining the efficacy of a nutrition support service and has identified areas which require review.
Thirty patients with parenteral nutrition were studied in order to evaluate if they could be given enteral nutrition instead. Based upon absolute and relative contraindications for enteral nutrition, we calculated that 80% of the patients were possible candidates for enteral nutrition. Long-term use of parenteral nutrition may cause complications. Besides metabolic and other advantages when enteral nutrition is used, economical gains are also important. We have calculated an estimated annual net profit of US$ 357,000 in our hospital, if enteral instead of parenteral feeding is used in patients suitable for the former type of feeding. This implies that it is really cost-beneficial to consider enteral nutrition in hospitalized patients. Although parenteral nutrition will continue to have its place in the management of different occasions, increased use of enteral nutrition may result in improved patient outcomes and improved cost-effectiveness.
Benefits and risks of nutrition support were evaluated in 31 malnourished children with newly diagnosed Wilms' tumor managed according to the third National Wilms' Tumor Study protocol. Patients were classified at diagnosis as being at high nutritional risk (HNR, n = 19) or low nutritional risk (LNR, n = 12). Ten HNR patients were randomized to central parenteral nutrition (CPN) and nine HNR patients were randomized to peripheral parenteral nutrition (PPN) plus enteral nutrition (EN) for 4 weeks of initial intense treatment and EN (nutritional counseling, oral foods and supplements) thereafter. Thirteen HNR patients (seven CPN, six PPN) completed the protocol. Twelve LNR patients received EN; 11 Stage I malnourished patients were randomized to 10 or 26 weeks of chemotherapy. Dietary, anthropometric, and biochemical data were determined for HNR patients at weeks 0-4, 6, 13, 19, and 26 and for LNR patients at weeks 1, 2, 5, and 26. In HNR patients, adequate parenteral nutrition support reversed protein energy malnutrition (PEM), and prevented chemotherapy and radiotherapy delays due to granulocytopenia. CPN was superior to PPN in reversing PEM: energy intake, weight gain, and retinol binding protein were higher (P less than 0.05). LNR patients lost weight and fat reserves in the first 2 weeks of treatment; depletion persisted at week 5, and 25% had chemotherapy delays. Thereafter, EN reversed PEM in patients with both chemotherapy regimens. These data suggest that CPN is preferable during initial intense treatment for HNR patients, and that, although EN is ineffective in preventing depletion and treatment delays in the first 5 weeks of treatment for LNR patients, it is effective thereafter.
BACKGROUND: Liver dysfunction in children dependent on parenteral nutrition (PN) is well established, and the extent of hyperbilirubinemia has been shown to correlate with morbidity and mortality. The aim of this study was to assess whether increasing provisions of enteral nutrition can improve PN-associated hyperbilirubinemia over time. METHODS: A retrospective review was conducted on infants in our institution's Short Bowel Syndrome Clinic from 1999 to 2004. Inclusion criteria included PN duration more than 1 month, serum direct bilirubin more than 3 mg/dL while on PN, and tolerance of full enteral nutrition with eventual discontinuation of PN. Paired t tests were used for statistical analyses. RESULTS: Twelve infants were identified with a PN duration of 5 +/- 1 months. Five patients underwent liver biopsy while on PN, and histological evidence of cholestasis was found on all specimens. Peak total and direct bilirubin levels were 10.5 +/- 1.9 and 7.0 +/- 1.6 mg/dL, respectively, and occurred at time of PN discontinuation. Only 2 patients had improvement in serum bilirubin levels before initiation of full enteral nutrition. After initiation of full enteral nutrition and discontinuation of PN, all patients achieved permanent normalization of bilirubin levels by 4 months (P < .05) after a 1-month plateau phase. Alkaline phosphatase levels approached reference range within this time but were not significant. CONCLUSION: These data demonstrate for the first time that although PN-dependent infants can achieve normalization of marked hyperbilirubinemia with enteral nutrition, the improvement in liver function usually begins only after full enteral nutrition is tolerated and PN is withdrawn. These findings support the aggressive weaning of PN to enteral nutrition in infants with short bowel syndrome.
Most of the counselling in health care targeted at child nutrition is delivered via the parents, but little is known about the effects of such counselling on the nutrition knowledge and dietary habits of the parents. In the Special Turku Coronary Risk Factor Intervention Project for Children (STRIP), we studied how 6.5 years of child-targeted nutrition counselling affected the knowledge, attitudes and dietary habits of the parent mainly responsible for food purchase and preparation. We used a questionnaire and a 24-h recall interview in a time-restricted cohort of 98 families belonging to the intervention group and 89 families belonging to the control group in the STRIP project. After controlling for background variables, the intervention parents had better knowledge than the control parents of causal relationships between food choices and coronary heart disease and of the nutritional composition of foods. Knowledge of nutrition concepts did not differ between the two groups. The quality of fat was better in the diet of the intervention parents, they consumed less salt and they also had more knowledge concerning these subjects compared to the control parents (higher behavioural capability scores). The behavioural capability scores of the total group correlated poorly with their nutrient intakes. Thus, child-targeted nutrition intervention delivered to the parents increased parental nutrition knowledge and improved the quality of the parents' diet. However, as nutrition knowledge of the parents correlated poorly with their nutrient intakes, other factors than knowledge appear to influence parental dietary decisions.
The Chair introduced "Pasteur's Quadrant" as a potentially useful paradigm for modern science. Developed by Princeton's Donald E Stokes, the quadrant is two-by-two matrix that classifies knowledge as fundamental and/or applied. The Chair also noted the effect of competitive pressures, and the necessity for cooperation among nutrition societies. The Presidents of The American Society for Nutritional Sciences (ASNS), The American Society for Clinical Nutrition (ASCN), The American Society for Parenteral and Enteral Nutrition (ASPEN), and the Chair of the Institute of Food Technologist's (IFT) Nutrition Division presented their views on how societies can prepare to meet their members' upcoming needs. The Director of the Center for Food and Nutrition Policy discussed the future role of nutrition societies and how they might interact with various interest groups. The Forum, which included an opportunity for audience participation, took place soon after the February 1996 release of "Meeting the Challenge: A Research Agenda for America's Health, Safety, and Food." Published by the Executive Office of the President's Office of Science and Technology Policy, the report highlights the importance of nutrition to our nation's health.
A significant obstacle to nutrition literacy among physicians is a paucity of Physician Nutrition Specialists (PNSs) on medical school faculties who can effectively advocate for change in medical school and residency curricula and who can serve as role models for incorporating nutrition into patient care. To address these issues, the Intersociety Professional Nutrition Education Consortium developed a paradigm for PNSs that is designed attract more physicians into the field; promulgated educational standards for fellowship training of PNSs; and established a unified mechanism for certifying PNSs, the American Board of Physician Nutrition Specialists (ABPNS). This article details the consensus paradigm and specific training standards and outlines the features and history of the ABPNS. The ABPNS certificate is intended to be the premier comprehensive credential for physicians who wish to identify nutrition as an area of expertise. Certification is equally accessible to physicians with backgrounds in any of the specialties relevant to clinical nutrition. It is hoped that more physicians will identify nutrition as a specialty interest if training opportunities are available in a variety of settings and are merged with their other professional interests. ABPNS invites input and feedback from colleagues around the world.
STUDY DESIGN: A prospective randomized study evaluating nutritional depletion in spine surgery patients. OBJECTIVE: To determine whether use of total parenteral nutrition (TPN) in patients undergoing staged spinal reconstructive procedures could affect their nutritional parameters or decrease their complication rates. SUMMARY OF BACKGROUND DATA: Several studies have shown that nutritional depletion occurs after major spinal surgery and that patients undergoing staged spinal surgery may be at particular risk of nutritional loss and its complications. METHODS: Forty adult patients undergoing staged spinal reconstructive surgery were randomized as to whether they received TPN postoperatively. Nutritional parameters, including skin fold measurement and albumin, pre-albumin, transferrin, and total lymphocyte counts, were obtained pre-operatively and at regular intervals. RESULTS: Five patients did not complete the study, leaving 35 patients for analysis. There was a significant decrease in incidence of albumin and pre-albumin depletion for the patients who did not receive TPN compared with those who did receive TPN (P < 0.025, P < 0.006, respectively). Patients with depleted albumin or pre-albumin counts were more likely to develop other postoperative infectious complications such as pneumonia or urinary tract infections (P < 0.035). There were no statistically significant differences in wound complications in this small patient study. There were no complications secondary to use of the TPN. CONCLUSIONS: For complex patients requiring staged anterior/posterior surgery, TPN appears to significantly lessen the decrease in nutritional parameters. Because depletion of nutritional parameters appears to correlate with an increased likelihood of perioperative infectious complications, use of TPN may result in a decrease of such complications in these patients.
PURPOSE OF REVIEW: Preoperative nutritional support in severely malnourished patients decreases complications after major surgery. This review summarizes previous studies on head and neck cancer patients undergoing surgery, and offers recommendations on preoperative nutritional support based on the literature and our experience. RECENT FINDINGS: Head and neck cancer has a large impact on the patient's quality of life and a high mortality rate. Aggressive surgical resection followed by soft-tissue and osseous reconstruction is the gold standard of treatment. The incidence of postoperative complications is high at 20-50%. Malnutrition and alcohol withdrawal syndrome are often present, and are considered risk factors for developing wound infection after head and neck cancer surgery. Proactive intervention by preoperative nutritional support may correct nutrient deficiencies, minimize malnutrition-related morbidity and mortality, reduce the length and cost of hospitalization, and may prevent alcohol withdrawal syndrome. Nutritional support given preoperatively for 7-10 days decreases postoperative complications by approximately 10% in malnourished patients with weight loss of 10% or more. Oral liquid supplements and enteral nutrition are useful to support head and neck cancer patients preoperatively. Enteral nutrition is safer, more physiological, less expensive and practicable at home compared with parenteral nutrition, which is not usually indicated in these patients. SUMMARY: Enteral nutrition is efficient in preoperative phase to prevent postoperative complications. However evidence is insufficient to conclude that preoperative immune-enhancing enteral feeding provides any supplementary benefit by comparison with a standard diet. Our experience with the preoperative approach in head and neck cancer patients is reported in this paper.
In order to assess the benefits of a Nutritional Team in our hospital, the Nutritional Committee made a prospective study concerning the Parenteral Nutrition application between June 8th and July 23rd 1992. We studied 94 patients, mean age 51.5 (0-88). They had 918 nutritional units (20 NU/day) for a mean time of 13.2 days. The main nutritional indication was intestinal pathology (47.9% onco-surgical patients). A Parenteral Nutrition standard type was usually given to patients through a Drum type catheter. Infectious complications reached a 38.5% (13.8% thrombophlebitis). We have performed analytical controls in 83.7% patients, 83.6% of them had pathologic results. The percentage was of deaths 7.5%. After these results, we conclude that there is a need for a specifically trained medical group taking care of the nutritional management of the patients. Thus, we could assure the quality of nutritional therapy.
We performed randomized controlled study to compare the short-term therapeutic effect of total parenteral nutrition (TPN), elemental diet (ED) and polymeric diet (PD) given as primary therapy in active phase of Crohn's disease. In hospital for Crohn's disease, twenty-eight patients were given nutritional therapy: 9 patients by TPN, 10 by ED, and 9 by PD. Nutritional state, inflammatory reactions, disease activity and clinical remission rate were assessed two weeks and four weeks after treatment, and morphological findings were assessed before and after each nutritional therapy by radiographic and colonoscopic findings. Inflammatory reactions were more effectively controlled by TPN and ED than by PD, and early improvement achieved by TPN and ED was especially note-worthy. Clinical remission rate after treatment by TPN was highest in three types of nutritional approach, but no significant difference was seen at any point. In nutritional state, disease activity and morphological findings, comparable changes were effected without preference. These results suggest that nutritional therapy by total parenteral nutrition and elemental diet is superior to polymeric diet for treating active phase of Crohn's disease with marked inflammatory reactions.
AIMS: The head and neck tumors are most often associated with a precarious nutritional status. Radiotherapy increases the risk of denutrition because of its secondary effects on the secretory and sensorial mucous membranes. The purpose of our retrospectively study was to evaluate the interest of a precocious and regular nutritional therapy on the ability to maintain the nutritional status of the patient during the radiotherapy. PATIENTS AND METHODS: The fifty-two patients included in the survey have been classified retrospectively in two different groups based on their observance to the nutritional therapy: group 1 "good observance", group 2 "bad observance". RESULTS: The 31 patients of group 1 have lost an average of 1.9 kg by the end of the irradiation, whereas the 21 patients of group 2 have lost an average of 6.1 kg (p<0.001). The almost stability in weight of patients in group 1 was linked to a lower frequency of breaks in the radiotherapy (6 vs 33% p=0.03) and in a decrease in grade of inflammatory mucous membranes (10% of grade 3 in group 1 vs 52% in group 2, p=0.006). The quantity of calories ingested in form of nutritional supplements was greater in group 1 and consequently enabled patients to stabilized their weight (1200 calories in group 1 versus 850 calories in group 2, p<0.005). CONCLUSIONS: The given nutritional advice and the prescription of adapted nutritional supplements consequently allowed limiting efficiently the weight lost during the irradiation and the grade of mucositis. The systematization of a precocious nutritional therapy for patients irradiated for head and neck tumors seems absolutely essential.
BACKGROUND & AIMS: Nutrition screening tools (NST) identify individuals who are malnourished or at risk of becoming malnourished and who may benefit from nutritional support. The aims of this study were to design, pilot and evaluate a NST based on four nutritional parameters (weight, height, recent unintentional weight loss and appetite) recommended by the British Association for Parenteral and Enteral Nutrition as the minimum required to identify patients with nutritional problems. METHODS: A dietitian assessed the nutritional status of 100 patients admitted to the general medical wards. Results from the study were used to design a NST. The concurrent validity of the screening tool was then assessed, by comparing it with a nutritional assessment by an experienced dietitian in 100 patients admitted to acute medical and elderly care wards. The inter-rater reliability of the screening tool was also assessed using three nurses and 26 acute medical patients. RESULTS: All four nutritional parameters were required to identify all at-risk patients. There was good agreement between the screening tool and the dietitian's assessment (kappa = 0.717) and inter-rater reliability was reasonable (mean kappa = 0.66). CONCLUSION: The screening tool was valid and reliable in identifying medical patients at risk of malnutrition and was quick and simple to use.