Intensive enteral nutrition is ineffective for individuals with severe alcoholic hepatitis treated with corticosteroids.

peer reviewedBACKGROUND & AIMS: Severe alcoholic hepatitis (AH) is a lifethreatening disease for which adequate oral nutritional support is recommended. We performed a randomized controlled trial to determine whether the combination of corticosteroid and intensive enteral nutrition therapy is more effective than corticosteroid therapy alone in patients with severe AH. METHODS: We enrolled 136 heavy consumers of alcohol (age, 18–75 y) with recent onset of jaundice and biopsy-proven severe AH in our study, performed at 18 hospitals in Belgium and 2 in France, from February 2010 through February 2013. Subjects were assigned randomly (1:1) to groups that received either intensive enteral nutrition plus methylprednisolone or conventional nutrition plus methylprednisolone (controls). In the intensive enteral nutrition group, enteral nutrition was given via feeding tube for 14 days. The primary end point was patient survival for 6 months. RESULTS: In an intention-to-treat analysis, we found no significant difference between groups in 6-month cumulative mortality: 44.4% of patients died in the intensive enteral nutrition group (95% confidence interval [CI], 32.2%–55.9%) and 52.1% of controls died (95% CI, 39.4%– 63.4%) (P ¼ .406). The enteral feeding tube was withdrawn prematurely from 48.5% of patients, and serious adverse events considered to be related to enteral nutrition occurred in 5 patients. Regardless of group, a greater proportion of patients with a daily calorie intake less than 21.5 kcal/kg/day died (65.8%; 95% CI, 48.8–78.4) than patients with a higher intake of calories (33.1%; 95% CI, 23.1%–43.4%) (P < .001). CONCLUSIONS: In a randomized trial of patients with severe AH treated with corticosteroids, we found that intensive enteral nutrition was difficult to implement and did not increase survival. However, low daily energy intake was associated with greater mortality, so adequate nutritional intake should be a main goal for treatment

Research priorities in pediatric parenteral nutrition: a consensus and perspective from ESPGHAN/ESPEN/ESPR/CSPEN

Parenteral nutrition is used to treat children that cannot be fully fed by the enteral route. While the revised ESPGHAN/ESPEN/ESPR/CSPEN pediatric parenteral nutrition guidelines provide clear guidance on the use of parenteral nutrition in neonates, infants, and children based on current available evidence, they have helped to crystallize areas where research is lacking or more studies are needed in order to refine recommendations. This paper collates and discusses the research gaps identified by the authors of each section of the guidelines and considers each nutrient or group of nutrients in turn, together with aspects around delivery and organization. The 99 research priorities identified were then ranked in order of importance by clinicians and researchers working in the field using a survey methodology. The highest ranked priority was the need to understand the relationship between total energy intake, rapid catch-up growth, later metabolic function, and neurocognitive outcomes. Research into the optimal intakes of macronutrients needed in order to achieve optimal outcomes also featured prominently. Identifying research priorities in PN should enable research to be focussed on addressing key issues. Multicentre trials, better definition of exposure and outcome variables, and long-term metabolic and developmental follow-up will be key to achieving this. Impact: The recent ESPGHAN/ESPEN/ESPR/CSPEN guidelines for pediatric parenteral nutrition provided updated guidance for providing parenteral nutrition to infants and children, including recommendations for practice.However, in several areas there was a lack of evidence to guide practice, or research questions that remained unanswered. This paper summarizes the key priorities for research in pediatric parenteral nutrition, and ranks them in order of importance according to expert opinion

A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants

BACKGROUND: The aim of this study was to revise the 2003 Fenton Preterm Growth Chart, specifically to: a) harmonize the preterm growth chart with the new World Health Organization (WHO) Growth Standard, b) smooth the data between the preterm and WHO estimates, informed by the Preterm Multicentre Growth (PreM Growth) study while maintaining data integrity from 22 to 36 and at 50 weeks, and to c) re-scale the chart x-axis to actual age (rather than completed weeks) to support growth monitoring. METHODS: Systematic review, meta-analysis, and growth chart development. We systematically searched published and unpublished literature to find population-based preterm size at birth measurement (weight, length, and/or head circumference) references, from developed countries with: Corrected gestational ages through infant assessment and/or statistical correction; Data percentiles as low as 24 weeks gestational age or lower; Sample with greater than 500 infants less than 30 weeks. Growth curves for males and females were produced using cubic splines to 50 weeks post menstrual age. LMS parameters (skew, median, and standard deviation) were calculated. RESULTS: Six large population-based surveys of size at preterm birth representing 3,986,456 births (34,639 births < 30 weeks) from countries Germany, United States, Italy, Australia, Scotland, and Canada were combined in meta-analyses. Smooth growth chart curves were developed, while ensuring close agreement with the data between 24 and 36 weeks and at 50 weeks. CONCLUSIONS: The revised sex-specific actual-age growth charts are based on the recommended growth goal for preterm infants, the fetus, followed by the term infant. These preterm growth charts, with the disjunction between these datasets smoothing informed by the international PreM Growth study, may support an improved transition of preterm infant growth monitoring to the WHO growth charts

Time interval for preterm infant weight gain velocity calculation precision

Calculation of weight gain velocity is used to guide nutrition and fluid management practices in neonatal intensive care units. Calculations over short time periods may be more responsive to management changes, but less precise. Weight gain velocity calculated over 5 to 7+ days have lower variability and less noise than shorter periods. © Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ

Parenteral nutrition in premature infants

Optimizing postnatal nutritional supply is a major challenge in premature infants despite recent studies evaluating how to improve early nutritional support. Severe cumulative nutritional deficits may occur with adverse consequences on both short- and long-term outcomes. Complete enteral feeding is frequently delayed in premature infants and parenteral nutrition represents essential therapeutic option for these infants. Available recommendations suggest starting parenteral nutrition as soon as possible after birth and rapidly attaining adequate intakes with a well-balanced solution in order to promote anabolism, to improve clinical outcomes, and to avoid biological disorders. A minimum intake of 40-60 kcal/kg*d with 2-3 g/kg*d of amino acids, 1-2 g/kg*d of lipids and sufficient minerals is now recommended from the first hours of life in all premature infants. After immediate postnatal adaptation, intakes should rapidly increase during the first week of life, up to 90-120 kcal/kg*d with about 3-4 g/kg*d amino acids, 3-4 g/kg*d of lipids and adequate amounts of electrolytes, minerals, trace elements and vitamins. There is a wide range of variation in parenteral nutrition practices among the neonatal units. This chapter discusses the principal theoretical aspects of parenteral nutrition in premature infants, the recommendations and the opportunity to routinely optimize nutritional support, especially in very premature infant

Enteral nutrition in preterm neonates

Infants with birth body weight less than 1500 g develop a postnatal growth failure in the vast majority of the cases. To limit this risk, enteral nutrition should be introduced appropriately, with the respect to actual requirements of preterm neonates. Administration of enteral nutrition depends on postnatal age and clinical conditions. During the early adaptive period of life (from birth to approximately day 7), hemodynamic instability associated with immaturity of the gastrointestinal tract limit the use of enteral nutrition. Parenteral nutrition represents the main route of administration of nutrients in this period. However, enteral nutrition should be started since the first 1-2 days of life as minimal enteral feeding (10-30 ml/kg/d) and progressively increased (by 20-30 ml/kg/d) until full enteral feeding is reached (120 kcal/kg/d) and, contemporarily, parenteral nutrition could be stopped. In the stable growing period (from approximately day 7 to near term/discharge) all nutritional requirements, including macronutrients and micronutrients, should be reached only by enteral nutrition. Human milk is the preferred form of enteral nutrition for preterm babies, however fortification with adequate amount of protein, carbohydrates, lipids, electrolytes and micronutrients should be adopted to respect nutritional needs of these subjects. In this Chapter we focused on modalities to reach nutritional requirements by enteral nutrition