Enteral Nutrition Therapy: Historical Perspective, Utilization, and Complications.

PURPOSE OF REVIEW: Enteral nutrition (EN) therapy can provide vital nutrition support for patients with various medical conditions as long as it is indicated and supported by ethical reasoning. This review seeks to offer a detailed account of the history of EN development, highlighting key milestones and recent advances in the field. Additionally, it covers common complications associated with EN and their management. RECENT FINDINGS: After years of research and development, we have reached newer generations of enteral feeding formulations, more options for enteral tubes and connectors, and a better understanding of EN therapy challenges. Given the availability of many different formulas, selecting a feeding formula with the best evidence for specific indications for enteral feeding is recommended. Initiation of enteral feeding with standard polymeric formula remains the standard of care. Transition to small-bore connectors remains suboptimal. Evidence-based practices should be followed to recognize and reduce possible enteral feeding complications early.

Dietitian Involvement Improves Consumption of Oral Nutrition Supplements in Hospitalized Patients.

Hospitalized patients are at an increased risk of malnutrition due to multiple factors including, but not limited to, acute and chronic diseases especially those affecting gastrointestinal tract, surgery, appetite, and frequent nil per os while undergoing diagnostic workup. Because of this, guidelines suggest the use of oral nutritional supplements (ONS) in hospitalized patients to reduce the risk of malnutrition and its complications. The current report aims to highlights key findings from a cross-sectional survey of 99 hospitalized patients who were at risk for or diagnosed with malnutrition and prescribed ONS. Data regarding ONS prescriber information as well as number ordered and consumed were collected. Of the 2.4 ± 1.5 supplements ordered per person each day, only 1.3 ± 1.1 were consumed, and there was 48% wastage of prescribed ONS. However, dietitian involvement was associated with significant reduction in wastage. Given the need and benefit, it is imperative for the nutrition community to further explore best practices to improve ONS consumption.

Transition to peptide-based diet improved enteral nutrition tolerance and decreased healthcare utilization in pediatric home enteral nutrition.

BACKGROUND: Home enteral nutrition (HEN) use continues to increase in children unable to meet nutritional needs through oral intake. Some patients do not tolerate standard polymeric formula (SPF), which may lead to malnutrition. Use of peptide-based diet (PBD) has demonstrated benefits in adults, however there remains a paucity of data in pediatric population. METHODS: Retrospective review of medical records of children receiving HEN between October 2015 and October 2019 was conducted. Nutrition, tolerance, and healthcare utilization was tracked through May 2020. Children receiving PBD as initial formula or transitioned to PBD from SPF were included. Our objective was to assess gastrointestinal tolerance and impact on healthcare utilization in children receiving PBD. RESULTS: During study period, 30 children (mean age, 9 ± 5.44 years; 20 of 30 [66.7%] male) utilized PBDs. Twenty-one patients started PBD directly with malnutrition as primary indication. Nine patients transitioned from SPF to PBD, most often due to intolerance of SPF (66%). After transition to PBD, no symptoms were reported in 6 of 9 (66.7%) patients, and symptoms of SPF intolerance resolved in 4 of 9 (44.5%) patients. Healthcare utilization declined significantly after transition to PBD, including mean numbers of emergency room visits (0.78 ± 1.09 to 0.11 ± 0.33; P = .025), provider visits (1.67 ± 1.32 to 0.56 ± 0.73; P = .007), and phone calls (1.22 ± 1.39 to 0.33 ± 0.50; P = .026). CONCLUSIONS: PBD is well tolerated and can result in significant reduction in healthcare utilization in children intolerant to SPF.

Use of Home Enteral Nutrition in Malnourished Post-Bariatric Surgery Patients.

BACKGROUND: Bariatric surgery is by far the most effective treatment option available for successfully achieving and maintaining weight loss in the obese population, but it can also be associated with complications that lead to malnutrition. There is limited data on how enteral nutrition (EN) can be used to provide nutrition support in such cases. METHODS: Retrospective review of our Home Enteral Nutrition (HEN) database was conducted from February 2013 to April 2018 to identify patients who received HEN because of bariatric surgery-related complication. RESULTS: During the study period, 72 patients (86% female, mean age 50.3 ± 11.6 years) initiated HEN because of bariatric surgical complication. Most common bariatric surgery was Roux-en-Y (74%) and most common indication for HEN was malnutrition/failure to thrive (33%). HEN was most commonly provided through nasojejunal feeds and resulted in an average increase in body weight and body mass index from 74.8 kg and 26.5, respectively, before HEN to 76.9 kg and 27.2, respectively, at the end of the HEN period. Through HEN, patients received 22.2 ± 7.9 kcal/kg/d and 1.0 ± 0.3 g/kg/d protein, meeting 94% ± 17% of their energy goals and 95% ± 29% of their protein goals. Vitamin deficiencies were noted in 69% of patients at the time of HEN initiation, which improved to 10% after enteral feeds and appropriate vitamin supplementation. CONCLUSION: HEN is safe and effective in treating malnutrition and vitamin deficiencies that might occur as a complication of bariatric surgery, leading to avoidance of parenteral nutrition support in most cases.

The Comparison of Segmental Multifrequency Bioelectrical Impedance Analysis and Dual-Energy X-ray Absorptiometry for Estimating Fat Free Mass and Percentage Body Fat in an Ambulatory Population.

BACKGROUND: Despite malnutrition being associated with increased mortality and morbidity, there continues to be great difficulty in defining criteria and implementing widespread screening. Tools used to diagnose decreased fat-free mass (FFM [sarcopenia]) should be easy to use, relatively inexpensive, and safe. Bioelectrical impedance analysis (BIA) has the potential to meet these criteria, but reliability across body mass index (BMI) classes is a concern. METHODS: A total of 176 healthy ambulatory participants (aged 18-65 years) were recruited equally (n = 44) in 4 BMI categories: (1) 18.5-24.9, (2) 25.0-29.9, (3) 30-34.9, and (4) ≥35.0. Participants were fasting overnight and had S-MFBIA (InBody 770) measurements the next morning, with DXA being performed subsequently within 30 minutes. RESULTS: The measurement (mean ± SD) for FFM with DXA was 52.8 ± 11.0, and BIA was 53.6 ± 11.0. Delta (S-MFBIA vs DXA) was 0.8 ± 2.2 (5% limits of agreement -3.5 to +5.2), and concordance correlation coefficient (CCC) was 0.98 (95% CI, 0.97-0.98). The measurements (mean ± SD) for PBF with DXA was 37.5 ± 10.6% and S-MFBIA was 36.6 ± 11.3%. Delta (S-MFBIA vs DXA) was -0.9 ± 2.6 (5% limits of agreement 6.0 to +4.2), and CCC was 0.97 (95% CI, 0.96-0.98). The CCC according to the 4 BMI groups for FFM and PBF was between 0.96-0.98 and 0.90-0.94, respectively. CONCLUSIONS: FFM and PBF measured by S-MFBIA had good agreement with DXA across all BMI categories measured in the current study of ambulatory participants.

Repair of Central Venous Catheter in a Single-Center Adult Home Parenteral Nutrition Cohort.

BACKGROUND: Patients with chronic intestinal failure who require long-term parenteral nutrition rely on central venous catheters (CVCs) for access to nutrition and hydration. With prolonged use, complications such as central line-associated bloodstream infection (CLABSI), damage to CVC, and central venous thrombosis (CVT) can threaten the availability of life-preserving access. Because of this, all efforts should be made to preserve CVCs with techniques such as catheter salvage in case of CLABSI and catheter repair when damaged. The present study was conducted to evaluate the effectiveness and safety of catheter repair in our patient population. METHODS: Retrospective review in 1253 adult patients who received home parenteral nutrition at the Mayo Clinic between September 1, 1997, and April 30, 2018, was conducted to determine the incidence of CLABSI and CVT in patients who underwent CVC repair. RESULTS: Fifty-five CVC repairs were performed in 36 patients (n = 23 female) with mean age of 57.05 ± 16.96 years. A total of 14 catheters (25.45%) were complicated with 24 episodes of CLABSI. CLABSI rate before and after repair was 0.23/1000 catheter days and 0.21/1000 catheter days, respectively. Most common indications for eventual catheter replacement were mechanical damage (32%), infection (32%), and switching to alternate mode of nutrition (24%). We had a 100% success rate of catheter repair procedure, and no post-procedural complications were present. CONCLUSION: Catheter repair can increase the catheter survival without increasing the risk of CLABSI, providing not only socioeconomic benefit but also decreasing risk of compromising future vascular access.

Weight Regain After Bariatric Surgery: Prevalence, Etiology, and Treatment.

PURPOSE OF REVIEW: Obesity is a life-limiting disease that is associated with a number of co-morbidities. Bariatric surgery remains the most efficacious and durable weight loss method available to patients. However, a significant percentage of patients can regain weight resulting in frustration, depression, and return of obesity-related co-morbidities. The present review provides an overview of the most common therapeutic modalities available to combat weigh regain after weight loss surgery. RECENT FINDINGS: Given the high percentage of patients with weight regain after surgery, significant effort has been placed on developing treatment options in the last few years. Tremendous work has taken place in the realm of cognitive behavior therapy, appetite suppressants, and endoscopic procedures with the hope of reducing the need for revision surgery which can be associated with significant complications. Weight regain is unfortunately a common phenomenon associated with all weight loss modalities including bariatric surgery. We now have a number of treatment options that can reverse the weight loss trend.