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BACKGROUND: Non-nutritive sucking is used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants. The rationale for this intervention is that non-nutritive sucking facilitates the development of sucking behaviour and improves digestion of enteral feedings. Non-nutritive sucking has been considered to be a benign intervention, although it has the potential to have a negative effect on breastfeeding or on the incidence of later oral aversion. OBJECTIVES: To determine whether non-nutritive sucking (NNS) in preterm infants influences: a) weight gain, b) energy intake, c) heart rate, d) oxygen saturation, e) length of hospital stay, f) intestinal transit time, g) age at full oral feeds, or h) any other clinically relevant outcomes. SEARCH STRATEGY: MEDLINE and CINAHL databases back to 1976 and the Cochrane Controlled Trials register were searched. Reference lists/bibliographies of relevant articles and reviews were also searched. A comprehensive list of relevant articles was sent to two major authors in this area. They were asked if they knew of any other published or unpublished studies relevant to the area that had not been included in the original list. SELECTION CRITERIA: All trials utilizing experimental or quasi-experimental designs in which non-nutritive sucking in preterm infants was compared to no provision of non-nutritive sucking. Measured clinically relevant outcomes. Reports were in English or a language for which a translator was available. Computerized searches were conducted by both reviewers. All potentially relevant titles and abstracts identified by either reviewer were extracted. All retrieved articles were assessed for relevance independently by each reviewer, based on a pre-determined set of criteria. The reference lists/bibliographies of each article were reviewed independently for additional relevant titles and were also retrieved and assessed for relevance. Articles that met all relevance criteria were then assessed for methodologic quality based on a predetermined set of criteria. Those articles judged to have the appropriate quality by both reviewers were included in the analysis. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the two authors. No subgroup analyses were performed because of the small number of studies related to the relevant outcomes. MAIN RESULTS: This review consisted of 19 studies, 13 of which were randomized controlled trials. NNS was found to decrease significantly the length of hospital stay in preterm infants. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, and age at full oral feeds). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and behavior. No negative outcomes were reported in any of the studies. REVIEWER'S CONCLUSIONS: This review found a significant decrease in length of stay in preterm infants receiving a NNS intervention. The review did not reveal a consistent benefit of NNS with respect to other major clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, and age at full oral feeds). The review identified other positive clinical outcomes of NNS: transition from tube to bottle feeds and behavior. No negative outcomes were reported in any of the studies. There were also a number of limitations of the presently available evidence related to the design of the studies, outcome variability, and lack of long-term data. Based on the available evidence, NNS in preterm infants would appear to have some clinical benefit. It does not appear to have any short-term negative effects. In view of the fact that there are no long-term data, further investigations are recommended. In order to facilitate meta-analysis of these data, future research in this area should involve outcome measures
A population suffering from a serious form of malnutrition was examined. The effectiveness of nutritional rehabilitation is demonstrated by the statistically significant changes observed in clinical and laboratory indicators. Several anthropometric measurements related to nutritional status are also compared with total body potassium (TBK) in patients with a positive nitrogen balance during the process of nutritional rehabilitation. It is concluded that weight (W), arm circumference (AC), middle arm muscle circumference (MAMC) and skinfold thickness (ST) measures are useful, and sufficiently accurate and precise to follow the evolution of nutritional status and body compartments.
OBJECTIVE: To compare documentation of two groups of clinical nutrition practitioners for evidence of the nutrition care process. DESIGN: This study used a comparative descriptive design. A retrospective chart review was conducted on all nutrition documentation in closed patient records. Documentation of two groups of nutrition practitioners (institution A=practitioners who received initial orientation and routine reinforcement in use of nutrition care process standards; institution B=practitioners who received orientation in use of a further assessment and medical nutrition therapy intervention procedure) was compared for evidence of a six-step nutrition care process. SAMPLE/SETTING: The sample consisted of randomly selected patient records (N=60). A total of 15 oncology and 15 chronic renal failure patient records from each of two Midwestern tertiary-care hospitals were reviewed. MAIN OUTCOME MEASURES: Outcome measures were number of nutrition care process steps documented, appropriate relationships among documented steps in the nutrition care process, and the number of complete, incomplete, and interrupted chains. STATISTICAL ANALYSES: Two-sample t tests and chi(2) analyses were used. RESULTS: Nutrition practitioners at institution A documented approximately three times as many nutrition care process steps per patient per chain that demonstrated appropriate relationships as did nutrition practitioners at institution B (2.69+/-1.15 and 0.80+/-0.62, respectively [mean+/-standard deviation]) (P<.001). There were no outcome judgments related to goals documented in chains at either institution and because of this there were no completed nutrition care process chains at either institution. CONCLUSIONS: Nutrition practitioners with orientation to nutrition care process standards documented more related nutrition care process steps than practitioners without this orientation. Providing nutrition practitioners with ongoing education and clinical experiences in use and documentation of the nutrition care process and a standardized language may be indicated to increase the number of completed nutrition care process chains and improve documentation of nutrition care and patient outcomes.
In the last 30 years, marked advances in enteral feeding techniques, venous access, and enteral and parenteral nutrient formulations have made it possible to provide nutrition support to almost all patients. Despite the abundant medical literature and widespread use of nutritional therapy, many areas of nutrition support remain controversial. Therefore, the leadership at the National Institutes of Health, The American Society for Parenteral and Enteral Nutrition, and The American Society for Clinical Nutrition convened an advisory committee to perform a critical review of the current medical literature evaluating the clinical use of nutrition support; the goal was to assess our current body of knowledge and to identify the issues that deserve further investigation. The panel was divided into five groups to evaluate the following areas: nutrition assessment, nutrition support in patients with gastrointestinal diseases, nutrition support in wasting diseases, nutrition support in critically ill patients, and perioperative nutrition support. The findings from each group are summarized in this report. This document is not meant to establish practice guidelines for nutrition support. The use of nutritional therapy requires a careful integration of data from pertinent clinical trials, clinical expertise in the illness or injury being treated, clinical expertise in nutritional therapy, and input from the patient and his/her family. (Journal of Parenteral and Enteral Nutrition 21:133-156, 1997).
In the last 30 years, marked advances in enteral feeding techniques, venous access, and enteral and parenteral nutrient formulations have made it possible to provide nutrition support to almost all patients. Despite the abundant medical literature and widespread use of nutritional therapy, many areas of nutrition support remain controversial. Therefore, the leadership at the National Institutes of Health, The American Society for Parenteral and Enteral Nutrition, and The American Society for Clinical Nutrition convened an advisory committee to perform a critical review of the current medical literature evaluating the clinical use of nutrition support; the goal was to assess our current body of knowledge and to identify the issues that deserve further investigation. The panel was divided into five groups to evaluate the following areas: nutrition assessment, nutrition support in patients with gastrointestinal diseases, nutrition support in wasting diseases, nutrition support in critically ill patients, and perioperative nutrition support. The findings from each group are summarized in this report. This document is not meant to establish practice guidelines for nutrition support. The use of nutritional therapy requires a careful integration of data from pertinent clinical trials, clinical expertise in the illness or injury being treated, clinical expertise in nutritional therapy, and input from the patient and his/her family.
Two hundred and fourteen hospitalized nonsurgical, nonacutely stressed adult patients, who were receiving, either prolonged (greater than 21 days) cyclic total parenteral nutrition (n = 106) or enteral nutrition (n = 108), including lipids, for gastrointestinal disorders, and who were free of prenutrition liver function test abnormalities were prospectively investigated for hepatic dysfunction: 41 p. 100 and 17 p. 100 of parenteral and enteral nutrition patients, respectively, developed abnormalities of liver function tests after 25 +/- 5 and 21 +/- 4 days (p less than 0.01). This prevalence was unrelated to catheter sepsis, blood transfusion, caloric load, site of digestive disease or initial nutritional status, and decreased by 50 and 40 p. 100 before the end of total parenteral nutrition and enteral nutrition respectively. In the parenteral nutrition group, separate infusion of lipids, as compared with mixed infusion, was associated with a lower rate of hepatic dysfunction (29 vs 54 p. 100; p less than 0.02). Nine (8.5 p. 100) parenteral nutrition but no enteral nutrition patients developed severe cholestatic jaundice, 47 +/- 39 days after the onset of liver function test abnormalities; no identifiable cause excepting parenteral nutrition per se was found in 3 patients with diffuse obstructive small intestinal disease; jaundice led to death from noncirrhotic hepatic failure in the 2 patients who remained totally parenteral nutrition-dependent.(ABSTRACT TRUNCATED AT 250 WORDS)
Two studies, one using a questionnaire completed by 40 medical school curriculum administrators and 178 nutrition educators, the other using a workshop for 100 medical-nutrition educators, were conducted in 1988 by the American Society for Clinical Nutrition. The goal of these investigations was to formulate recommendations for the number of hours that should be devoted to teaching nutrition in a medical school and to obtain a consensus on the relative importance of specific nutrition topics to be included in the medical curriculum. The results indicate close agreement between curriculum administrators and nutrition educators on the time that should be devoted to nutrition coursework and the relative importance of nutrition topic areas. The value of these findings is that specific nutrition topic areas that deserve relatively high (and low) priorities in the curriculum have now been identified. This is particularly valuable information for medical educators in institutions that have few curriculum hours available for teaching nutrition.
Objective of the study is to present an intervention model to evaluate nutritional risk of institutionalised elderly, suitably with the aims and resources of the Hygiene of Nutrition Services, and to individuate predictive variables of nutritional vulnerability. 237 subjects from the residential homes of ASL RMB were involved in the study; to each subject was administered: a) the Mini Nutritional Assessment (MNA); b) a questionnaire for the analysis of the risk factors. Multivariate logistic regression analysis was performed to evaluate the influence of the risk factors on nutritional status. On the basis of BMI the prevalence of malnutrition is 6.5% and the prevalence of overweight and obesity is respectively 41.6% and 22.9%; on the basis of MNA, 5.1% of the subjects is malnourished and 60.3% at risk for malnutrition. The absence of chewing difficulties (OR 2.94; I.C. 1.46-5.91) and the habit to eat all foods served at meals (OR 2.83; I.C. 1.46-5.91) are associated with a good nutritional status. The age > or = 90 years is a risk factor for malnutrition at the limit of statistical significance (OR 0.44; I.C. 0.14-1.00). Carrying out the MNA resulted easy and quick, confirming the hypothesis for feasibility of this protocol in the Hygiene of Nutrition Services. The results highlight an high nutritional risk of the elderly nursing home residents and the importance of planning programs of nutritional surveillance with particular attention on masticatory function impairments, meal intake and on the oldest subjects among the elderly as a group greatly vulnerable. We believe that these areas are very important in defining public health intervention programs.
Different nutritional outcome studies on the same subject can have vast differences in composition of the chosen food without justification, suggesting that the composition of "optimal" nutrition in patients is not known or that optimal nutrition does not exist. The result will be negative studies which reinforces the existing impression that nutritional intervention is of limited value in every day's patient care. This perspective will put arguments forward that optimal nutrition exists and that the definition of optimal nutrition should be the base of future nutrition intervention studies. This perspective aims at providing a definition of optimal nutrition and consequently a basis to critically appraise the literature upon nutritional interventions in disease states.
The prevalence of mild and serious nutritional disorders in patients with cystic fibrosis is high. One of the possible ways how to supplement the necessary nutrients is the administration of defined supplementary enteral nutrition. The objective of the presented work is to evaluate the effect of supplementary domiciliary enteral nutrition in adult patients with cystic fibrosis. To eight patients with cystic fibrosis, mean body weight 51.77 +/- 10.63 kg, mean age 24.7 +/- 1.9 years for a period of 6 +/- 1 months enteral nutrition was administered (containing 40 and 55.1% energy as fat) with a caloric density of 10 kcal/kg as supplementary domiciliary nutrition. The mean body weight increased from 51.77 +/- 10.63 to 53.13 +/- 10.59 kg (p < 0.02), the mean skinfold thickness increased from 7.98 +/- 6.04 to 8.65 +/- 6.30 mm (p < 0.05) and the mean serum albumin concentration increased from 33.66 +/- 0.97 to 37.29 +/- 3.33 g/l (p < 0.05). No undesirable side-effect associated with the administration of enteral nutrition were observed. The nutritional intervention by domiciliary enteral nutrition produced no undesirable side-effects and led to a statistically significant improvement of parameters of the nutritional status.
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An examination previously developed and used for assessment of nutrition knowledge of medical students in the Southeastern Regional Medical-Nutrition Education Network was used to compare the effectiveness of a basic medical biochemistry course and a 58-hour required nutrition course. The examination was administered to a cohort of freshman students upon entry to medical school, after biochemistry, and then after nutrition. Two other student groups took the examination at the end of the sophomore and senior years, respectively. In the freshman cohort, mean nutrition knowledge scores increased slightly after biochemistry, (52% to 56%), which contained 37 nutrition-related lectures. The mean score of the cohort was 75% after the nutrition course. The sophomores scored 75% and the seniors 73%. These findings suggest 1) basic science courses such as biochemistry cannot be relied upon to add significantly to nutrition knowledge, and 2) a required freshman course can be an effective way to introduce basic and clinical nutrition with good retention of knowledge in subsequent years.
GOAL: To identify the current status of out-patient enteral nutrition among elderly patients in Galicia: indications, access routes, forms of administration, types of diet, complications, disability status. Assessment of nutritional status and concomitant pharmacological treatment. METHODS: Prospective, observational, multi-centric study lasting for one month. Data capture by means of a questionnaire regarding: age, sex, diagnosed pathology leading to nutritional analysis, disability status, current nutritional status, type of diet, months under treatment with NEA (out-patient enteral nutrition in its Spanish acronym), form of administration, complications, concomitant medication. The statistical methodology included a descriptive analysis and a study of the correlations between the different variables. For the comparison of both groups, Student's t test or Mann-Whitney's U test was used for quantitative variables and chi-squared, Yate's correction or Fisher's exact test was used for qualitative variables. RESULTS: 469 patients were studied, corresponding to 13 publicly-funded centres. Age: 81.15 years (95% CI 80.8-82.3), women (70.6%). DIAGNOSIS: neurological disorders (46.1%), cerebrovascular accidents (27.5%), neoplasia (12.4%) and others (14.1%). 45.2% presented a bedbound disability status and 53.5% presented communication difficulties. Standard diet was the most common (39.4%). DURATION OF THE NUTRITION: > 1 year in 36.7% of cases, between 6 months and 1 year for 21.3%, between 3 and 6 months for 10.9% and < 3 months in 13.7% of cases. Nasogastric tube was the route for administration in 55.2%. Patients with nutrition treatment lasting over 1 year presented a significantly lower rate of malnutrition (p < 0.0001). Neurological patients and those with communication difficulties had a lower prevalence of malnutrition (p < 0.0001), as did those with a greater degree of disability (p < 0.01). Undernourished patients presented a greater prevalence of bedsores (49.1% versus 25.8%, p < 0.0001). The mean number of prescribed medicines was 3.27 +/- 2.41, with 64% of them being administered through the nasogastric tube. The most frequent interaction was digoxin-fibre (29.6%) and incorrect administration was observed with omeprazol and medication to combat Parkinson's disease.
OBJECTIVE: To evaluate two short questionnaires for assessing the nutritional situation of elderly people, the DETERMINE Your Nutritional Health Checklist of the Nutrition Screening Initiative (NSI checklist) and the Mini Nutritional Assessment (MNA), by comparing equivalent cumulative scores with data on dietary intake, anthropometrics and blood biochemistries. DESIGN: Information similar to the questions of the NSI and MNA lists was collected by SENECA: the Survey in Europe on Nutrition and the Elderly, a Concerted Action. SUBJECTS: Records collected in 1993, could be used from 1161 European elderly men and women born between 1913 and 1918, mostly community dwelling, whose diet, lifestyle and health were studied twice, in 1989 and 1993. RESULTS: The MNA classified 55% of the examinees as well-nourished, 44% as at risk of malnutrition and 1% as malnourished. The NSI categorised the elderly people differently: 11% as good, 41% at moderate nutritional risk, 48% at high nutritional risk. Biochemical, dietary and anthropometric indices did not differ either between NSI categories or between MNA categories. Using serum albumin values (< 30 g/l) and lymphocyte counts (< 1500/ml) as standards, specificity and sensitivity of both instruments for identifying at-risk groups were below 0.6. Only with body weight loss (> or = 10%) as criterion variable were higher sensitivities (0.75 (NSI), 0.96 (MNA)) and specificities (0.54 (NSI), 0.60 (MNA)) found. CONCLUSION: It is concluded that in an apparently healthy elderly population both assessment tools are of limited value.
The need to screen patients earlier than within the first 24 hours of hospital admission has resulted in the development of preadmission nutrition screening. At Providence Saint Joseph Medical Center (PSJMC), a 455-bed acute-care facility, this procedure has been used since 1994. The preadmission screening method was developed because of the use of critical pathways for patients in specific diagnosis-related groups. Critical pathways specified that registered dietitians must assess these patients within 24 hours of admission at PSJMC. However, at that time there was minimal data in the chart from which to assess the patient's nutritional status and the ability to interview the patient was often limited as a result of intubation or postoperative pain. Family members were not always available at the hospital to discuss a patient's preadmission nutritional status. To address this problem, we developed a system to call people at home before their admission to the hospital to obtain specific nutrition information. To analyze the effectiveness of the procedure, the Food and Nutrition Services Department developed a process to assess this method of screening and to improve the system. Patients were enrolled in a study over a 1-month period, demographics were identified for this sample population, and patient satisfaction was determined via an interview conducted by a dietetic technician after the patient was admitted. Most patients found this to be a very helpful process and an example is presented here on the role of preadmission nutrition screening in improving patient outcome. To better define the population of the case study presented, additional information was gathered on a second study group of patients screened before admission who were admitted for hip and knee surgery, one of the specific diagnosis-related groups with a critical pathway. Our findings indicate that preadmission nutrition screening has the potential to improve patient outcomes by increasing nutrient intake before their hospital admission, reducing hospitalization length, and enhancing patient satisfaction during their hospital stay.
Nutritional support is often necessary in chronic liver disease in childhood, and when enteral nutrition is insufficient, parenteral nutrition (PN) can be envisaged as a last resort. Pediatric experience is still limited in this indication. Seven children with severe liver disease received PN for a mean duration of 105 d, with additional enteral nutrition. Clinical tolerance was assessed and anthropometric and biological data were compared at the beginning and at the end of the study by the paired non-parametric test of Wilcoxon. Weight change, expressed as weight-for-age or weight-for-height Z-scores, increased. Conjugated bilirubin increased significantly. This retrospective study suggests that PN is a well-tolerated method for maintaining nutritional status in pediatric chronic liver disease when enteral nutrition has failed.
The effectiveness of central parenteral nutrition (CPN) versus peripheral parenteral nutrition (PPN) plus enteral nutrition in reversing protein-energy malnutrition was evaluated in 19 children (nine CPN, 10 PPN) with advanced neuroblastoma or Wilms' tumor. Weekly dietary, anthropometric, and biochemical measurements were compared for 15 patients (eight CPN, seven PPN) who completed more than 25 days of nutrition support. The groups had similar mean energy and protein intakes (CPN: 95 +/- 5% of healthy children, 2.5 +/- 0.3 g/kg; PPN: 102 +/- 5% of healthy children, 2.9 +/- 0.3 g/kg). Increases in weight (p less than 0.001), subscapular skinfold thickness (p less than 0.001), albumin (p less than 0.05), and transferrin (p less than 0.05) for the first 28 days were significant and did not differ between groups. Fever, sepsis, elevated SGOT, and severe anemia occurred with both CPN and PPN. PPN resulted in subcutaneous infiltrations and more psychological trauma. PPN with enteral nutrition seems most appropriate for short term intravenous nutrition support or as a temporary substitute for CPN; CPN is preferred for long-term support.