[Incidence of catheter-related infection and associated risk factors in hospitalized patients with parenteral nutrition]. / Incidencia de infección asociada a catéter y factores de riesgo relacionados en pacientes hospitalizados con nutrición parenteral.

INTRODUCTION: The most severe complication of parenteral nutrition (PTN) is catheter-related infection (CRI). OBJECTIVES: To study the incidence rate and factors associated to CRI. MATERIAL AND METHODS: 271 patients followed at the Nutrition Unit for 6 months. The composition of the PTN was calculated according to the metabolic demands. 20.3% received a lipid solution enriched with omega-3 fatty acids (SMOF Fresenius Kabi®) and 79.7% with olive oil (Clinoleic Baxter®). RESULTS: The rate of CRI was 25 per 1,000 days of PTN (55 patients: 61.7±17.8 years, 60.3% males, 29.3±10.6 days of hospital stay and 10.4% mortality). Coagulase-negative Staphylococcus was the most frequently isolated microorganism. There were no differences by age, gender, mortality, or composition of the PTN between patients with or without infection. The patients treated with omega-3 received more calories with the PTN, at the expense of higher intake of glucose and lipids. However, the rate of infection was similar, although there was a not significant trend towards a lower infection rate when using the omega-3 composition (14.5% vs. 23.1%, respectively, p = 0.112). The duration of the nutritional support was higher in patients with CRI (13.0 ± 9.7 vs. 9.3 ± 8.1, p = 0.038). Total mortality (16.9%) was independent of the presence or absence of CRI (10.4% vs. 18.7%, p = 0.090) or of the use of omega-3 lipids or olive oil in the PTN (10.9% vs. 18.5%, p = 0.125). CONCLUSION: Patients submitted to PTN have a high rate of CRI. The presence of infection is related to the duration of the PTN, being independent of the age, gender, and composition of the solution. The use of omega-3 lipid solutions may be beneficial although further studies are needed to confirm this.

[Micronutrient supplementation in parenteral nutrition in Spanish hospitals]. / Utilización de micronutrientes en nutrición parenteral en los hospitales Españoles.

Several years ago, it was recommended not to add vitamins or oligoelements to parenteral nutrition (PN) solutions and to administer them immediately after the addition of the micronutrients to avoid their decay. Nowadays, it has been observed that with multilayer bags, ternary mixtures and sunlight protection vitamins degradation is minimal. Daily intake of micronutrients is necessary in the critically ill, malnourished or long-term PN patients. Aiming at knowing the schedules of use of micronutrients in PN in Spanish hospitals and the way PN bags are prepared regarding the factors conditioning their stability, we undertook a telephone survey to the pharmacists in charge of PN at the different hospitals. We compared the data obtained with those from other surveys performed in 2001 and 2003. Pharmacists from 97 hospitals answered the questionnaire (answer rate 88%). The hospital sizes ranged 104-1728 beds. As compared to the data form preceding years, we observed a better adequacy to the current recommendations, although there are still 30% of the hospitals that administer micronutrients on an every other day basis independent of the clinical situation of the patients. In most of the hospitals, multilayer bags are used and/or sunlight protection and ternary mixtures. According to these results showing the different criteria for administering vitamins and oligoelements in PN solutions, it seems necessary to elaborate consensus documents that adapt to the reality of the diverse practices besides promoting the performance of well-designed clinical studies establishing the requirements under special clinical situations.

Prebióticos en las fórmulas para lactantes. ¿Podemos modificar la respuesta inmune? / Prebiotics in infant formulae. Could we modify the immune response?

Introducción: La microflora intestinal de los lactantes amamantados tiene un papel primordial en la función intestinal y en el desarrollo del sistema inmune. Los oligosacáridos presentes en la leche materna estimulan selectivamente el crecimiento de Bifidobacterias y Lactobacilos en el intestino. En los últimos años se han realizado varios intentos para obtener una flora similar en lactantes alimentados con fórmulas infantiles. Una de las posibilidades para obtener este efecto es proporcionar nutrientes selectivos para esta microflora beneficiosa (prebióticos). Objetivo: Realizar una revisión de la evidencia científica disponible sobre la incorporación de prebióticos a los alimentos para lactantes y su posible influencia en la respuesta inmune. Material y métodos: Se realizó un amplia búsqueda bibliográfica con los siguientes términos de búsqueda: "prebióticos OR oligosacáridos OR microflora intestinal AND fórmula infantil AND resultados". Se hizo especial análisis de los estudios clínicos con fórmulas infantiles que incorporaran prebióticos. Resultados: Un prebiótico es una sustancia no absorbible en el intestino delgado y susceptible de fermentación por la flora colónica. El empleo de una mezcla determinada de galactooligosacáridos y fructooligosacáridos en una fórmula infantil aumenta el número de bifidobacterias de una forma dependiente de la dosis (el efecto máximo obtenido a una concentración de 0,8 g/dl) y reduce el número de gérmenes patógenos tanto en lactantes pretérminos como a término cuando se comparaban con lactantes que recibían una fórmula no suplementada. El efecto de los oligosacáridos sobre el metabolismo bacteriano se estudió midiendo la producción de ácidos grasos de cadena corta y el pH fecal. Estudios más recientes han mostrado beneficios clínicos de la incorporación de una mezcla de prebióticos a una fórmula infantil. En primer lugar, se ha visto una disminución en el riesgo de aparición de dermatitis atópica en lactantes de riesgo; en segundo lugar, una reducción en el número de episodios infecciosos, fundamentalmente intestinales e infecciones de vías respiratorias superiores en el primer año de vida. Puede especularse que los prebióticos pueden tener un papel importante en la prevención de la alergia y de las infecciones leves en el lactante (AU)

Introduction: The intestinal microflora of breast-fed infants is an important physiological factor in gut function and the development of the immune system. Human milk oligosaccharides have been shown to selectively stimulate the growth of Bifidobacteria and Lactobacilli in the intestine. In the last few years several attempts have been made to establish the presence of similar microbiota in formula-fed infants. One of the approaches to modify the balance of intestinal microflora is to supply the potentially helpful microbiota with selective nutrients (prebiotics). Goal: To review the current scientific evidence related to the addition of prebiotics to infant feeds and their possible role in the immune function. Material and methods: A bibliographic search with Mesh terms: Prebiotics OR oligosaccharides OR intestinal microflora AND infant formula AND results was performed. Special analysis was done on clinical studies. Results: Prebiotics are substances that are not absorbed through the small intestine and are fermented by colonic bacteria. A prebiotic mixture from galacto-oligosaccharides and fructo-oligosaccharides has been used to mimic the effect of human milk oligosaccharides. It has been demonstrated that such a mixture significantly increases the number of bifidobacteria in a dose-related way (maximum effect at 0.8 g/dl) and reduces the number of pathogens in term as well as in preterm infants when compared with a group of infants fed a non-supplemented formula. The effect of oligosaccharides on bacterial metabolism was studied by measuring short chain fatty acid production and fecal pH. More recent studies have been able to show clinical benefits with the use of a prebiotic mixture in infant formulas. Firstly, it has been shown to decrease the risk of developing atopic dermatitis in high risk infants; secondly a reduced incidence of intestinal as well as upper airway infections in the first year of life. It can be hypothesized that prebiotics might play an important role as a new concept in allergy and infection prevention in infants (AU)

Uso de preparados a base de especies vegetales medicinales en niños / Herbal medicine in children

El uso de remedios a base de plantas medicinales se ha hecho muy popular en todo el mundo. Muchos pacientes pediátricos,en especial niños con enfermedades crónicas o recurrentes, usan este tipo de preparados. Sin embargo, algunos de estos productos pueden tener efectos secundarios o interactuar con los fármacos convencionales. Los niños son especialmente susceptibles a estas interacciones por sus características fisiológicas. Por tanto, es importante que el pediatra sepa hablar abiertamente con las familias de sus pacientes sobre el uso de plantas medicinales. Además, deben estar familiarizados con los fundamentos de su uso y conocer sobre todo los aspectos relacionados con su seguridad y eficacia. En este artículo se revisan los principios que deben regir estos conocimientos sobre plantas medicinales

The use of herbal medicine has become in creasing popular throughout the world. Many pediatric patients. especiallty hose with chronic or recurrent conditions, consum be o tanical remedies. Some of these agents may have side effects or may interact with drugs. Children are potentiall my are vulnerable to such interactions. Thus pediatricians must speak openly with their patients and their families abouth the use of dietary supplements specially herbal remedies.They should also become familiar with evidence-based resources concerning these remedies, especially with regard to their safety and efficacy.This article reviews principies that clinician should keep in mind when discussing the use of herbal remedies with parents

El desarrollo de los hábitos alimentarios en el lactante y el niño pequeño. Sentido y sensibilidad / Development of infant and toddler’s feeding habits. Sense and sensibility

Las influencias precoces en la alimentación del lactante y el niño pequeño condicionan las preferencias futuras por determinados alimentos. Existe una tendencia natural en el recién nacido a aceptar los sabores dulces y rechazar los amargos, lo que constituye una ventaja para la especie. Los niños que reciben lactancia materna tienen preferencia por los sabores que experimentan a través de la leche y que, en general, constituyen los hábitos tradicionales de su cultura. A medida que el niño crece, otros factores entran en juego que diluyen en parte esos factores condicionantes iniciales. Los sabores a los que el niño se ve expuesto en los primeros meses de la vida se aceptan mejor que si la exposición se produce más tardíamente en la niñez. Estas características llevan a señalar algunas recomendaciones prácticas en la introducción de la alimentación complementaria en el niño. Las estrategias de educación nutricional se han enfocado clásicamente a proporcionar información sobre las características de los alimentos. Sin embargo, no han sido eficaces en la prevención de trastornos relacionados con la comida, en especial los trastornos de la conducta alimentaria o la obesidad. El objetivo de esta revisión es proporcionar conocimientos que puedan servir de base para desarrollar hábitos de alimentación infantil que fomenten patrones sanos de aceptación de los alimentos, al tiempo que contribuyan a reducir la ansiedad de los padres en relación con la alimentación de sus hijos (AU)

Early influences on feeding practices in infants and toddlers have a relevant role on later food preferences. There is a natural preference for sweet tastes and dislike for strong bitter tastes, and this characteristic is an adaptative advantage. Infants present a preference for food flavours experienced in their mother’s milk. These flavours reflect her food choices and the food choices of her culture. As the infant grows up, other influences on food preference will come into play, so these early effects cannot be expected to lead to exclusive preferences. In the first few months of life, infants do accept unusual flavours more easily than when they are offered later on life. Following these early influences it seems advisable to suggest some practical recommendations for the introduction of complementary foods in the infant diet. Educational strategies involving attempts to impart basic nutritional information have not been successful in decreasing obesity or in achieving healthy eating habits. An alternative strategy would be to teach parents more about child development that may help both to promote start healthy feeding guidelines for infants and toddlers and to decrease parental anxiety related to infant feeding (AU)

Recientes avances en fórmulas infantiles / Recent advances in infant formulas

La alimentación durante los primeros meses de vida tiene una gran importancia tanto en las fases tempranas del desarrollo como en su salud a largo plazo. La Organización Mundial de la Salud señala que la lactancia materna exclusiva es el alimento ideal para el recién nacido a término sano desde el nacimiento hasta los 6 meses de edad. Cuando una madre no puede amamantar a su hijo, las fórmulas infantiles constituyen la mejor alternativa como fuente de alimentación. A medida que hemos ido conociendo mejor las necesidades nutricionales del lactante, se ha ido modificando la composición de las fórmulas. Se han añadido nuevos ingredientes funcionales en el intento de hacerlas más semejantes a la leche humana. En la presente revisión se comentará el interés nutricional y funcional de los avances más recientes en las fórmulas infantiles para lactantes sanos, como son la adición de alfalactoalbúmina, ácidos grasos poliinsaturados de cadena larga, palmítico en posición beta, nucleótidos, oligosacáridos con efecto prebiótico y los probióticos (AU)

Feeding during the first months of life has a decisive influence not only on early developmental phases in infants but also in their long-term health. The World Health Organization points out that exclusive breastfeeding is the ideal feeding from birth to sixth months of age in the healthy term newborn. When a mother cannot breastfeed her offspring, infant formulas stay as a good alternative for infant feeding. The deeper our knowledge on the nutritional needs of infants the more precise the composition of infant formulas. New functional ingredients have been incorporated to paediatric milk formulas with the goal of mimicking the functional properties of human milk. In the present article we review the most recent advances in infant formulas: alpha-lactalbumin, polyunsaturated fatty acids, beta-palmitate, nucleotides, prebiotic oligosaccharides and probiotics (AU)

[Therapeutic alternatives in intestinal failure]. / Alternativas terapéuticas en el fracaso intestinal.

BACKGROUND: Long-term parenteral nutrition is effective in the treatment of intestinal failure. Equally, the results of intestinal transplantation (IT) are promising. The choice of one or other form of treatment depends on the balance between the advantages and disadvantages of each. Based on these premises, we analyzed the outcome of home parenteral nutrition (HPN) for intestinal failure in our patients. METHODS: Intestinal failure was considered when parenteral nutrition was required for more than 5 months. In the 14 patients included in the HPN program since 1993, we reviewed the indication of HPN as well as their suitability for IT. RESULTS: Five of the 14 patients received HPN for causes other than intestinal failure. Of the remaining nine patients, four had severe motility disorder, three had short bowel syndrome, and two had protracted diarrhea of infancy. All these patients would be potential candidates for IT. Five patients were weaned off HPN because of intestinal adaptation between 2.5 and 13 months after starting HPN. One patient died because of lack of venous access. Three patients currently continue on HPN. CONCLUSION: Intestinal rehabilitation constitutes the best option for patients with intestinal failure. HPN offers the best interim treatment while waiting for adaptation. IT should be reserved for those patients with severe complications due to HPN. Nevertheless, it may become a real option for those with indefinite HPN. HPN and IT should be considered as complementary treatments.

Alternativas terapéuticas en el fracaso intestinal / Therapeutic alternatives in intestinal failure

Antecedentes: La nutrición parenteral prolongada es eficaz en el tratamiento del fracaso intestinal. Paralelamente asistimos al desarrollo de programas de trasplante intestinal con resultados esperanzadores. El reto de elegir una u otra forma de tratamiento dependerá del balance entre ventajas e inconvenientes de ambas posibilidades. Bajo estas premisas se analiza la evolución de nuestros pacientes con nutrición parenteral domiciliaria (NPD) por fracaso intestinal. Métodos: Consideramos fracaso intestinal cuando se precisó nutrición parenteral más de 5 meses. Se revisó la indicación, la evolución y la idoneidad como candidato a trasplante en los 14 niños incluidos en el programa de NPD desde 1993.Resultados: Cinco de los 14 pacientes recibieron NPD por causas distintas del fracaso intestinal. De los otros nueve, cuatro padecían una grave alteración de la motilidad; tres un síndrome de intestino corto y dos una diarrea intratable del lactante. Todos serían potenciales candidatos para trasplante intestinal. En cinco niños fue posible suspender la nutrición parenteral por conseguir adaptación intestinal entre 2 meses y medio y 13 meses desde el inicio de la NPD. Una paciente falleció por falta de accesos venosos. Tres pacientes continúan actualmente con NPD. Conclusión: La rehabilitación intestinal constituye la mejor opción para pacientes con fracaso intestinal. La NPD constituye el mejor tratamiento provisional en espera de la adaptación intestinal. El trasplante intestinal debería reservarse para aquellos pacientes que presenten complicaciones graves asociadas a la NPD. Sin embargo, podría considerarse como alternativa para quienes dependen indefinidamente de NPD. Ambas técnicas, NPD y trasplante deben considerarse tratamientos complementarios (AU)

[Should the therapeutic effort in artificial nutrition be limited?]. / Se debe limitar el esfuerzo terapéutico en nutrición artificial?

BASIS: There exists general agreement among the experts in Bioethics in order not to maintain a treatment if it is considered that it is useless. However, there is no unanimity about if serotherapy, enteral nutrition (EN), and parenteral nutrition (PN) are really therapeutic measures or else they are measures that they are part of the concept of palliative care. OBJECTIVE: Know the opinion of users and health workers of National Health System (NHS) in these issues. DESIGN: Cross-sectional descriptive study. AREA: Primary and specialized care. METHODS: A survey was distributed to 219 individuals (84 users of the NHS, 135 health workers), that it included sociodemographic parameters, the opinion on different aspects of ethics and nutritional support, and the measures regarded as palliative care. RESULTS: The majority of the respondents think that the EN (70.8%; 95% IC: 64.2-76.8) and PN (54.8%; 95% IC: 47.9-61.6) are part of the basic care, with differences between the health personnel and the users of the NHS. 50.2% considers that there are no differences between applying or removing nutritional support. 71.3% of the health professionals answer that this decision depends on the medical, 60.5% of the users of the NHS thinks that it depends on the patient himself and/or its family members. All the evaluated measures are regarded as basic care, regardless of the characteristics of the respondent. CONCLUSIONS: Artificial nutrition is understood as a basic care, regardless of the situation and quality of life of the patient. While the health professionals think that the decision to initiate/to retire artificial nutrition depends on the physician, the users of the NHS consider that it depends on the patient/family in case of disability of this.

[Survey on parenteral nutrition preparation variability in pediatrics]. / Encuesta sobre la variabilidad en la elaboración de la nutrición parenteral en pediatría.

UNLABELLED: The prescription and preparation of paediatric parenteral nutrition in Spain are subject to great variability. AIM: To identify how paediatric parenteral nutrition is prescribed and prepared in Spain. MATERIAL AND METHODS: During the first quarter of 2001, a telephone survey was carried out among most of the hospitals in which parenteral nutrition is habitually prepared. The survey included questions on who was in charge of the prescription, the use of different solutions, addition of supplements (carnitine, heparin and glutamine), as well as information on the shelf-life of the mixtures. Subsequently, the results of the survey were compared with the following guidance documents: "Enteral and parenteral nutrition in paediatrics", drafted under the auspices of the Spanish Association for Paediatric Gastroenterology, Hepatology and Nutrition (2000) and the "Guidelines for the use of parenteral and enteral nutrition in adult and paediatric patients"/"Nutrition support practice manual" from the American Society for Parenteral and Enteral Nutrition (1998). RESULTS: Of the 48 hospitals surveyed, paediatric parenteral nutrition was not prepared in 12 of them. the number of food bags prepared daily correlated directly with the size of the hospital. In all cases, the paediatricians were responsible for prescription. In 87% of the centres, this prescription was customized (i.e. solutions adapted to each individual patient). All of the hospitals used dextrose as the source of carbohydrates and specific amino acid solutions for paediatric medicine. Basically, lipid emulsions with long chain triglycerides were used in 65% of cases and another 19% used physical mixtures of MCT and LCT. Only half of the hospitals routinely used all-in-one mixtures. Inorganic phosphate continued to be used in most cases (78%) versus sodium glycerol phosphate. Vitamins and trace elements were added daily in 65% of the hospitals, with alternate administration in the remainder. In half of the centres, heparin was added to the mixture and carnitine in 27%. For 40% of the centres responding to the survey, the solution had to be used within 24 hours of its preparation; 11% did not indicate the shelf-life. CONCLUSIONS: Although parenteral nutrition is prescribed by the paediatricians on all occasions, the preparation protocols differ significantly between hospitals. Standardization is exceptional. It is noteworthy that all-in-one mixtures are only used in half of the hospitals surveyed. We suggest the creation of a multidisciplinary working party (pharmacists, paediatricians, neonatologists) in order to draw up protocols for the preparation of paediatric parenteral nutrition.

[Corn starch in the treatment of patients with glycogenosis type I and III]. / Almidón de maíz crudo en el tratamiento de pacientes con glucogenosis tipo I y III.

RATIONALE: Administering raw corn starch can maintain normoglycemia for long periods after being ingested, thus facilitating control in patients with type I and III glycogenosis. METHODS: The metabolic effects and the effects on the nutritional status of a treatment with fractionated administrations of raw starch are assessed in two patients with type I glycogenosis (ages 18 and 12 years) and one patient with type III glycogenosis (aged 13 years). In the first two cases the response was previously studied after administering a load of raw corn starch in a water suspension, in an amount similar to the estimated rate of endogenous glucose production during the fasting period (5 mg/kg/minute). RESULTS: The results of the overload of starch showed a normoglycemia and an absence of lactoacidosis between 4 and 6 hours after its ingestion. The three patients were given two doses of raw corn starch (2 g/kg/dose) at 1.00 and 5.00 hours during the night. After one year of treatment, all patients showed glycemia levels at 9.00 AM that were greater than 90 mg/dl and lactic acid levels that were lower than 2.4 mmol/l. Moreover, in two of the cases there was an increase in the growth rate. In all cases the amount of the hepatomegaly decreased as did the size of the hepatic adenomas that were present in two of the cases. CONCLUSIONS: In patients with type I and III glycogenosis, raw corn starch can balance the results of the nightly gastric glucose infusion, both with regard to the metabolic control and with regard to the growth.

[Captopril treatment of neonatal arterial hypertension]. / Tratamiento con captopril de la hipertensión arterial neonatal.

Captopril, an orally active angiotensin I-converting inhibitor, is an effective drug in the treatment of hypertension in adults and children. The use in newborn infants has been, nevertheless, short. We report five cases of hypertension in newborn infants poorly responsive to large doses of other potent antihypertensive agents: furosemide, propanolol and hydralazine. We have got a reduction in mean blood pressure in three cases, with doses of 0.1-0.2 mg/kg/day for a time lesser than a month. Another patient had a reduction with high doses (5 mg/kg), showing increase in mean serum urea, creatinin, potassium and phosphorus levels. This effect disappeared after captopril was discontinued. We suggest the use of captopril in hypertension non-responsive to other antihypertensive agents, mainly in those of renovascular cause.