Continuous Glucose Monitoring in Enterally Fed Children with Severe Central Nervous System Impairment.

Children with severe central nervous system (CNS) impairment are at risk of developing various degrees of nutritional deficit that require long-term nutritional intervention. Interventions are most often implemented through enteral nutrition (EN) using commercially manufactured feeds administered via gastro/jejunostomy or nasogastric or nasojejunal tubes. The modality of feeding-continuous feeding or bolus feeding-is dependent on the function of the gastrointestinal tract, particularly the efficiency of gastric emptying. In the literature, the relationship between this type of nutrition and the occurrence of hyperglycaemia is often discussed. In addition, children with chronic neurological diseases are vulnerable to disorders of many mechanisms of neurohormonal counter-regulation related to carbohydrate management, and due to limited verbal and logical contact, it is difficult to recognise the symptoms of hypoglycaemia in such patients. We aimed to assess the carbohydrate metabolism in children with severe CNS impairment, with enteral nutrition delivered via nasogastric, nasoenteral, or percutaneous tubes, based on continuous glycaemic monitoring (CGM) and the measurement of glycated haemoglobin (HbA1c) levels. MATERIALS AND METHODS: This prospective, observational study included nineteen patients (median (25-75 pc) age: 12.75 (6.17-15.55) years) with permanent CNS damage (Gross Motor Function Classification System V) receiving long-term tube enteral feeding, recruited from two paediatric university nutritional treatment centres. Patients with acute conditions and diagnosed diabetes were excluded. The nutritional status and nutritional support were analysed in all the inpatients in accordance with a uniform protocol. Using the CGM system (Medtronic iPro2), glycaemic curves were analysed, and in addition, HbA1C levels were determined in fourteen patients. CGM results were analysed using GlyCulator2.0. Statistical analysis was performed using the Statistica version 11 software (StatSoft Inc. Tulsa, OK, USA). RESULTS: More than half (11/19; 58%) of the patients were undernourished (BMI < 3 pc for age and gender), with the stature age being significantly lower than calendar age (5 (4.5-9) vs. 12.75 (6.17-15.55) years; p = 0.0010). The actual caloric intake was 50 (37.7-68.8) kcal/kg (median; 25-75 pc). In patients fed using the bolus method, the number of calories consumed per day was statistically significantly higher than in children subjected to a continuous feeding supply (56.00 (41.00-75.00) vs. 33.40 (26.70-50.00) kcal/kg BW (body weight; p = 0.0159). Decreases in blood glucose levels below the alarm level (<70 mg/dL) were recorded in fifteen patients (78.9%), including two patients with episodes of clinically significant hypoglycaemia (<54 mg/dL). The minimum and maximum glycaemic values recorded in any individual CGM records were 67 mg/dL (median) (minimum: 41 mg/dL; maximum: 77 mg/dL) and 146 (minimum: 114 mg/dL; maximum: 180 g/dL), respectively, for the entire recording. The maximum percentage of glycaemic concentrations > 140 mg/dL (TAR 140) recorded overnight in children with BMI ≥ 3 amounted to 1.6% vs. 0% in undernourished patients (TAR 140: 0.0 (0.00-1.6%) vs. 0% (0.00-0.0%; p = 0.0375); the percentage of glycaemic concentrations <70 mg/dL in the entire recording was comparable (0.77% (0.13-2.2%) vs. 1.8% (0.5-14.4%) vs. p = 0.2629). There was a positive correlation between the mean daily glucose recorded using the CGM method and patients' BMI z-scores (R = 0.48, p = 0.0397). No statistically significant relationship was demonstrated between the occurrence of alarm hypoglycaemia events in the CGM records and undernutrition expressed by BMI z-scores (OR = 1.50 (95%CI: 0.16-13.75), the type of diet (for commercially manufactured OR = 0.36 (95%CI: 0.04-3.52), and the modality of diet delivery (for bolus feeding OR = 2.75 (95%CI: 0.28-26.61). CONCLUSIONS: In children with chronic OU damage, enteral feeding is associated with a risk of hypoglycaemia, but further studies involving a larger number of patients are needed, and CGM might be a useful tool to estimate the metabolic adequacy of enteral nutritional support in terms of glucose control.

[Tolerance of enteral nutrition in children with acute pancreatitis]. / Tolerancja zywienia enteralnego u dzieci z ostrym zapaleniem trzustki.

AIM: evaluation of tolerance and efficacy of enteral nutrition inpatients with acute pancreatitis hospitalised in 2005-2006 in Department of Paediatric Allergology, Gastroenterology and Nutrition, Medical University of Lodz. MATERIAL AND METHODS: analysis involved the course of enteral nutrition in 15 children hospitalised in 2005-2006 (aged 11.24+/-3.31 year), in whom 19 episodes of acute pancreatitis were observed caused by: trauma (n=4), SPINK1 mutation (n=1, in analysing period 5 episodes was observed in patient) -mutation of serine protease inhibitor Kazal type 1, pancreas divisum (n=1), cholelithiasis (n=1), parasitic AP (n=2), drug-induced (n=3), idiopathic (n=3). 16 episodes were mild and 3 severe (2 pseudocysts and 1 rapture of pancreas). Half-elementary / low-fat diet (Peptisorb / NUTRICIA) was applied by nasojejunal cathether, using pomp (Flocare). Duration, clinical tolerance of enteral nutrition, amount of calories, change of body weight were estimated. RESULTS: the length of enteral nutrition varied from 3 to 46 days (average 16.15+/-10.71). The shortest course involved a patient with hereditary acute pancreatitis (average 7.4+/-2.6) the longest one -posttraumatic pancreatitis (average 28.5+/-12.28). By enteral nutrition we ensured the supply of 40.46+/-13.21 kcal/kg per day on average, reaching increase of body weight 733+/-714.23 g in 6 children; maintenance of initial weight in 3 and decrease in 10 patients (average 600+/-534.52 g). Undesirable effects (nausea, diarrhoea, vomitus), observed in 9 episodes of acute pancreatitis (47.4%) were short term in 6 (31%), needed modification of nutritional therapy in 3 (15.7%) (lowering dose of EN in 2, TPN in 1). CONCLUSIONS: 1. Enteral nutrition in children with mild acute pancreatitis is a useful method of therapy and undesirable effects appearing in some patients have transient character. 2. Developing complications in patients with posttraumatic pancreatitis may decrease tolerance to enteral nutrition.