Nutrition in the critically-illChild. Past and Future.

Dr. Rainer Paulino Basulto. MscDra.Mileidis Pupo Vera.

Dr. Willians Rios. IKatima Mulilo. Caprivi Health Directorate.

Abstract

Enteral feeding is a commonly used form of nutritional supplementation for patients with intestinal failure, both in hospitals and in the community. This article concentrates on the basic principles of enteral feeding, including the physiological effects of feeding into the intestinal tract. It covers the indications for enteral feeding, the different methods of supplying enteral feeds to the gastrointestinal tract, and the potential complications.

INTRODUCTION

Enteral nutrition consists of providing nutrients via the gastrointestinal tract. Although the term technically refers to nutrition given either by mouth or through a feeding tube, in common usage the term usually refers to tube feeding. In comparison to parenteral nutrition (the provision of nutrients via a venous catheter directly into the bloodstream), enteral nutrition offers several advantages, including lower costs, beneficial effects from utilization of the gastrointestinal tract, and avoidance of the many potential complications of parenteral nutrition.

Parental Nutrition Enteral nutrition

The mucosal associated lymphoid tissues (MALT) are the specific arm of the immune system which protects the intestinal and extraintestinal external mucosal surfaces through production and secretion of IgA. MALT contains 50% of the body's total immune cell mass and produces more IgA than all other antibodies combined.

•Short enteral fasting (3 days), causes gutmucosal atrophy, expressed as a decrease in

villus height and crypt depth

Normal Atrophy.

Intestinal Failure (stress).Bacterial

Translocation.Mixed

infection.

Provide humoral protection as a frontline defense against pathogen borne in aerosols, environment, and the diet.

CD4

Hypothesis

Critically ill children need enteral feeding for survival, so nutrition plays an important role on the health and development of a critically ill child.

Scientific problem

COST.

Although enteral nutrition therapy is more costly than standard feeds, compared to parenteral nutrition therapy, enteral nutrition is approximately two- to fourfold cheaper on an inpatient or out-patient basis. Based on US Medicare charges, the annual cost of providing enteral nutrition per patient is approximately US$9,605 US$9,327 compared with US$55,193. US$30,596 for parenteral solu-tions.4 In addition, the frequency and cost of hospitalization is higher for patients supported on parenteral nutrition therapy compared with enteral nutrition therapy

Cheap

Objective.

1.To evaluate those factors that impact on the delivery of enteral tube feeding.

Method

Prospective studies With transversal curt.

In 33 patient withSevere dehydration,Severe malnutrition,

Severe Sepsis.Severe Malaria.

prematurity

Bolus feeding(without pump)

Bolus feeding involves the delivery of 10mls to 30mls

over a period of 10-30minutes and can be given

4-6 times a day depending on patients individual feeding regime. Administration can be with a syringe using only

the barrel as a funnel to allow the feed to infuse using

gravity.

Result. Table 1Age distribution

Age Number Percent.

1m - 1y. 9 27.2

1y - 2y 11 33.3

2 - 5y 8 24.2> 5 Y 5 15.1

Result. Table 2.Distribution according to diagnosis

Diagnosis. Number Percent.

Severe malnutrition

11 47.8

Severe Sepsis 8 34.7

Acute gastroenteritis with severe dehydration.

7 17.3

Cerebral malaria

3 9

Prematurity New born

4 12.1

Table.3 Feeding Used.

Feeding used number percentMilk 16 69.5Pediasure and Milk

11 47.8

Resomal 12 52.1ORS 2 8.6Juice 18 78.2Hyper caloric food

24 72.7

Table. 4 Physiological effects of feeding into the intestinal tract

Physiological effects

Became down 72h

After 72 h

Fever behavior 28 / 84.8.% 5 / 15.1%

Category 1 Category 20

102030405060708090

Table. 5 Physiological effects of feeding into the intestinal tract. Hemodynamic Parameter.

Physiological effects

Getting normal 72h

After 72 h

HR 29 / 87.8% 4 / 12.1%BP 31 / 93.9% 2 / 6%Neurological condition

28/ 84.8% 5/ 15.1 %

Table 6.Physiological effects of feeding into the intestinal tract. General condition.

General condition

Improving 72h

After 72 h

Good external connection

29 / 87.8% 4 / 12.1%

Category 1

Category 2

0

20

40

60

80

100

Table 7. Physiological effects of feeding into the intestinal tract. Metabolic control.

Metabolic control

First 72h After 72 h

Hypo glycaemia 1 / 4.3% 0hyper glycaemia

5 / 21.7% 2 / 8.6%

Category 1

Category 2

05

10152025

Table 8. Physiological effects of feeding into the intestinal tract

Physiological effects

< 36 c > 36 c

Temperature management

2 / 6 % 31 / 93.9%

Table 9.Physiological effects of feeding into the intestinal tract. Weigh behavior

.

Physiological effects

Weigh gain first 72h

Weigh loss first 72h

Weigh behavior 19/57.5% 14/42.4%

Category 1 Category 205

101520

Table.10.Gastrointestinal complications in critically illchildren with enteral tube nutrition

Complication. Number percentAbdominaldistension

5 15.1%

Gastro intestinal bleeding.

0 0

Duodenalperforation

0 0

Tube occlusion. 2 3%Pulmonary aspiration

0 0

Accidental tube removal

3 9%

Table 11. Mortality rate.

Diagnosis. Number PercentSevere Malnutrition.

1 3.03%

Severe Sepsis. 2 6.06%Acute gastroenteritis with severe dehydration.

Cerebral malariaPrematurity 1 3.03%

Conclusions.

Early enteral feedings are feasible, well tolerated, and cost effective in critically ill pediatric patients.

WHEN THE ENTERALROUTE IS AVAILABLE

USE IT !

REFERENCES

1. Harkness L. The history of enteral nutrition therapy: From raw eggs and nasal tubes to purifi ed amino acids and early post-operative jejunal delivery. J Am Diet Assoc 2002;102:399–404.

2. Braga M, Gianotti L, Gentilini O, et al. Early postopera-tive enteral nutrition improves gut oxygenation and reduces costs compared with total parenteral nutrition. Crit Care Med 2001;29:242–8.

3. de Lucas C, Moreno M, Lopez-Herce J, et al. Transpyloric enteral nutrition reduces the complication rate and cost in the critically ill child. J Pediatr Gastroenterol Nutr 2000;30:175–80.

4. Reddy P, Malone M. Cost and outcome analysis of home par-enteral and enteral nutrition. JPEN J Parenter Enteral Nutr 1998;22:302–10. 5. North American Home Parenteral and Enteral Nutrition Patient Registry. Annual report with outcome profi les 1985–1992. Albany, NY: Oley Foundation; 1994.6. Howard L, Ament M, Fleming CR, et al. Current use and clinical outcome of home parenteral and enteral nutri-tion therapies in the United States. Gastroenterology 1995;109:355–65.7. Board of Directors and Clinical Guidelines Task Force, American Society for Parenteral and Enteral Nutrition. Guidelines for the use of parenteral and enteral nutrition in adults and pediatric patients. JPEN J Parenter Enteral Nutr 2002;26:18SA–9SA.8. Braunschweig CL, Levy P, Sheean PM, et al. Enteral com-pared with parenteral nutrition: A meta-analysis. Am J Clin Nutr 2001;74:534–42