Accuracy and costs of bedside methods for confirming nasoenteral feeding tube position: a diagnostic accuracy study.

AIM: To analyze the accuracy and costs of bedside methods for confirming the position of a nasoenteral feeding tube newly inserted blindly by nurses. DESIGN: Diagnostic accuracy study of three clinical methods (ultrasound, epigastric auscultation, and pH measurement) compared to radiography. The direct costs of each method used to confirm the positioning of the nasoenteral tube were also measured. METHODS: Seventy-six adult patients underwent a total of 87 nasoenteral tube insertion procedures in hospital units located within the Northeast region of the State of São Paulo, Brazil. The clinical methods were conducted on all study participants in the specified sequence: ultrasound (as index test), followed by epigastric auscultation and pH measurement (also index tests). RESULTS: The outcomes regarding the confirmation of the accurate positioning of the nasoenteral tube are as follows: ultrasonography demonstrated sensitivity and specific of 79.0% and 66.7%, respectively. Epigastric auscultation exhibited a sensitivity of 81.3% and specificity of 83.3%. The pH measurement method displayed sensitivity and specificity of 89.3% and 100% respectively. Additionally, in terms of estimated direct costs, the pH measurement method incurred a higher cost (USD $8.31) compared to the other methods, with a difference of USD $6.68. CONCLUSIONS: Based on these results, X-ray examination remains the primary method for confirming the placement of nasoenteral tubes recently inserted blindly at the bedside. However, when considering the costs of the evaluated methods, it is advisable to consider the variations in expenses between non-radiological methods and X-ray examinations.

Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy for enteral feeding: A systematic review and meta-analysis.

BACKGROUND: Percutaneous radiological gastrostomy (PRG) and percutaneous endoscopic gastrostomy (PEG) are minimally invasive gastrostomy techniques for individuals requiring prolonged enteral feeding. Recent meta-analyses concerning their efficacy and safety mainly included retrospective studies and yielded conflicting results. This meta-analysis of randomized controlled trials (RCTs) aimed to compare efficacy, safety, and procedure time between PRG and PEG for enteral feeding. METHODS: MEDLINE, Embase, and the Cochrane Library were searched for eligible RCTs comparing PRG and PEG for enteral feeding through February 23, 2024. The primary outcome was technical success. The secondary outcomes were (1) adverse events (AEs), (2) mortality, and (3) procedure time. We used the random-effects model to calculate pooled risk ratio (RR) and mean difference (MD) with corresponding 95% CIs for dichotomous and continuous outcomes, respectively. RESULTS: Five RCTs with 544 patients (268 PRG and 276 PEG) were included. There was similar technical success (RR = 1.02; 95% CI = 0.98-1.05; I² = 35%; moderate certainty of evidence because of inconsistency), overall mortality (RR = 1.25; 95% CI = 0.63-2.47; I² = 47%; very low certainty of evidence because of inconsistency, indirectness, and imprecision), and overall AEs risk (RR = 1.06; 95% CI = 0.63-1.76; I² = 81%; low certainty of evidence because of inconsistency and imprecision) between the two groups. However, compared with PEG, the procedure time was longer in the PRG group (MD = 19.35 min; 95% CI = 0.95-37.75 min; I² = 98%; very low certainty of evidence because of inconsistency and imprecision). CONCLUSION: PRG and PEG demonstrate similar efficacy and safety; however, the endoscopic technique may boast a shorter procedure time.

Effectiveness of Fistuloclysis in Nutritional Management of Enteroatmospheric Fistulas: A Retrospective Study at Santo Tomás Hospital, Panama.

Introduction Enteroatmospheric fistulas (EAF) present significant challenges in surgical management due to their complex nature and high mortality rate. Traditional approaches often rely on prolonged parenteral nutrition, but emerging evidence suggests the potential benefits of enteral nutrition via fistuloclysis, an underappreciated enteral nutrition route. This study aims to evaluate the effectiveness of nutritional therapy, specifically fistuloclysis, in patients with EAF managed at the Trauma Unit of Santo Tomás Hospital, Panama. Methods A retrospective analysis was conducted on nine male patients diagnosed with EAF between January 2016 and December 2020. Data on demographics, fistula characteristics, and nutritional management were collected through chart review. Descriptive statistics were used for analysis. Results We analyzed nine patients, all of whom received enteral nutrition (EN) via fistuloclysis in a median of 5.5 days from the diagnosis of EAF. Seven patients required parenteral nutrition (PN) at the beginning. The use of specialized enteral formulas, supplemented with hydrolyzed proteins and medium-chain triglycerides, facilitated discontinuation of PN once 80% of nutritional requirements were met via the enteral route, and EN was continued until definitive surgery. The median duration of PN was 34 days. No adverse effects related to EN were observed, whereas complications such as central venous catheter infections were reported in all cases requiring PN. Conclusion Fistuloclysis is a viable and effective alternative to traditional PN in patients with EAF. Specialized nutritional strategies, including the use of semi-elemental formulas, contribute to improved outcomes and reduced complications. Early initiation and gradual increase in enteral nutrition via fistuloclysis demonstrate safety and efficacy, underscoring the importance of tailored nutritional approaches in optimizing patient care for complex surgical conditions.

Experiencias alrededor de la indicación nutricional para prematuros en instituciones con Bancos de Leche Humana / Experiences around the nutritional indication for premature infants in institutions with Human Milk Banks

RESUMEN Objetivo Caracterizar, desde las experiencias propias, las dinámicas de la interacción entre los profesionales vinculados a la Unidad de Cuidados Intensivos Neonatales de Hospitales Públicos de Colombia y la estrategia de Bancos de Leche Humana en torno a la alimentación de los prematuros. Método Estudio cualitativo con enfoque fenomenológico interpretativo, en el que participaron 43 profesionales de la salud de 8 Instituciones Prestadoras de Salud que cuentan con Unidad de Cuidado Intensivo Neonatal y Banco de Leche Humana en Colombia. Resultados Las dinámicas de interacción entre los profesionales de la salud de las Unidades de Cuidados Intensivos Neonatales y los Bancos de Leche Humana relacionadas con la alimentación de los prematuros están mediadas por prácticas que vinculan competencias, materialidades y sentidos atravesados por la utilización o no de la leche humana en el tratamiento de los mismos. Discusión La disponibilidad de Bancos de Leche Humana en instituciones prestadoras de salud que brindan atención a recién nacidos prematuros posibilita la existencia y el despliegue de unas indicaciones nutricionales para esta población que van en línea con los protocolos diseñados para su tratamiento. Sin embargo, las decisiones tomadas en esta interacción están matizadas por debates que van surgiendo en el proceso, los cuales, lejos de ser una barrera para el uso de los Bancos de Leche Humana, se convierten en herramientas de vital importancia en la construcción de conocimiento en lo que respecta a la práctica de alimentación de los recién nacidos prematuros y la valoración de la estrategia.

ABSTRACT Objective To characterize from their own experiences the dynamics of the interaction between the professionals linked to the Neonatal Intensive Care Unit of Public Hospitals in Colombia and the Human Milk Bank strategy regarding the feeding of premature infants. Methods Qualitative study with an interpretative phenomenological approach, in which 43 health professionals from 8 health care institutions with Neonatal Intensive Care Unit and Human Milk Bank in Colombia participated. Results The dynamics of interaction between health professionals in Neonatal Intensive Care Units and Human Milk Banks related to the feeding of premature infants are mediated by practices that link competencies, materialities and meanings which are crossed by the use or not of human milk in the treatment of premature infants. Discussion The availability of Human Milk Banks in health care institutions that pro-vide care to premature newborns makes possible the existence and development of nutritional indications for this population that are in line with the protocols designed for their treatment. However, the decisions taken in this interaction are tinged by some debates that arise in the process, which far from being a barrier to the use of Human Milk Banks, become tools of vital importance in the construction of knowledge regarding the feeding practice of preterm newborns and the assessment of the strategy.

Impact of early-onset preeclampsia on feeding tolerance and growth of very low birth weight infants during hospitalization / Efeito da pré-eclâmpsia precoce na tolerância alimentar e no crescimento de recém-nascidos de muito baixo peso durante a hospitalização

ABSTRACT Objective: The provision of adequate enteral nutrition to preterm infants is a great challenge, and preeclampsia (PE) may have a detrimental effect on the safety of nutrition supply. This study aims to investigate the influence of early-onset PE on preterm infants' enteral feeding tolerance and growth during hospitalization. Methods: This is a prospective study with 55 preterm infants <34 weeks born to PE mothers matched by gestational age with 55 preterm infants born to normotensive mothers from 2013 to 2016. We evaluated maternal, gestational, and neonatal clinical data. The outcomes were feeding intolerance and growth during hospitalization. Comparison between groups was performed by Student's t-test or Mann-Whitney U test, chi-square test, or Fisher's exact test. Multiple logistic regression was used to investigate whether PE was an independent risk factor for feeding intolerance. Results: The mean gestational age was 30 weeks. Preterm infants of mothers with PE had lower birth weight and were smaller at discharge. Feeding intolerance was frequent, but necrotizing enterocolitis was rare in this sample (PE=4% vs. control=2%) with no difference between groups. Preterm infants of mothers with PE had worse growth outcomes; however, PE was not an independent risk factor for feeding intolerance. The increase in gestational age was a protective factor, and being born small for gestational age (SGA) increased the risk of feeding intolerance by six times. Conclusions: Preterm infants of mothers with early-onset PE were more likely to be born SGA and had a worse growth trajectory during hospitalization. In adjusted analyses, however, low gestational age and SGA were independent predictors of feeding intolerance.

RESUMO Objetivo: A nutrição enteral adequada para recém-nascidos prematuros é um grande desafio, e a pré-eclâmpsia (PE) pode comprometer a segurança da oferta alimentar. O objetivo deste estudo é investigar a influência da PE de início precoce na tolerância alimentar e no crescimento de prematuros durante a hospitalização. Métodos: Estudo prospectivo, com 55 prematuros <34 semanas de mães com PE pareados por idade gestacional e com 55 prematuros de mães normotensas, de 2013 a 2016. Foram avaliados dados clínicos maternos, gestacionais e neonatais. Os desfechos foram intolerância alimentar e crescimento durante a hospitalização. Na comparação entre grupos, utilizaram-se teste t de Student ou de Mann-Whitney e teste qui-quadrado ou exato de Fisher. Regressão logística múltipla foi usada para investigar se a PE é fator de risco para intolerância alimentar. Resultados: A idade gestacional média foi de 30 semanas. Prematuros de mães com PE tiveram menor peso ao nascer e eram menores na alta. A intolerância alimentar foi frequente, mas a enterocolite necrosante foi rara nesta amostra (PE=4% vs. controle=2%), sem diferença entre grupos. Prematuros de mães com PE tiveram pior crescimento, mas a PE não foi fator independente de risco para intolerância alimentar. O aumento da idade gestacional foi fator de proteção, e nascer pequeno para a idade gestacional (PIG) aumentou em seis vezes o risco de intolerância alimentar. Conclusões: Prematuros de mães com PE de início precoce tiveram maior probabilidade de nascer PIG e pior trajetória de crescimento na hospitalização. Em análises ajustadas, baixa idade gestacional e PIG foram preditores independentes de intolerância alimentar.

Neonatal Antibiotic Treatment Can Affect Stool Pattern and Oral Tolerance in Preterm Infants.

Preterm neonates are at high risk of infectious and inflammatory diseases which require antibiotic treatment. Antibiotics influence neonatal gut microbiome development, and intestinal dysbiosis has been associated with delayed gastrointestinal transit. Neonates who take less time to pass meconium have a better tolerance to enteral feeding. We analyzed the effect of neonatal antibiotic treatment on the stool pattern and oral tolerance in 106 preterm infants < 33 weeks gestational age. Neonates were classified in 3 groups according to neonatal antibiotic (ABT) treatment days: no antibiotics, 3−7 d ABT, and ≥8 d ABT. Preterm infants from the ≥8 d ABT group took longer to pass meconium and to start green and yellow stools, took longer to reach 100 and 150 mL/kg/day, and reached reduced volumes in enteral feeds at day of life 14 and 28 than infants from no ABT and 3−7 d ABT groups. Multiple linear regression models showed that neonatal antibiotic treatment, birth weight, invasive mechanical ventilation, surfactant, enteral feeding start day, neonatal parenteral nutrition, and neonatal fasting days are associated with the stool pattern and oral tolerance in preterm infants.

A Longitudinal 1H NMR-Based Metabolic Profile Analysis of Urine from Hospitalized Premature Newborns Receiving Enteral and Parenteral Nutrition.

Preterm newborns are extremely vulnerable to morbidities, complications, and death. Preterm birth is a global public health problem due to its socioeconomic burden. Nurturing preterm newborns is a critical medical issue because they have limited nutrient stores and it is difficult to establish enteral feeding, which leads to inadequate growth frequently associated with poor neurodevelopmental outcomes. Parenteral nutrition (PN) provides nutrients to preterm newborns, but its biochemical effects are not completely known. To study the effect of PN treatment on preterm newborns, an untargeted metabolomic 1H nuclear magnetic resonance (NMR) assay was performed on 107 urine samples from 34 hospitalized patients. Multivariate data (Principal Component Analysis, PCA, Orthogonal partial least squares discriminant analysis OPLS-DA, parallel factor analysis PARAFAC-2) and univariate analyses were used to identify the association of specific spectral data with different nutritional types (NTs) and gestational ages. Our results revealed changes in the metabolic profile related to the NT, with the tricarboxylic acid cycle and galactose metabolic pathways being the most impacted pathways. Low citrate and succinate levels, despite higher glucose relative urinary concentrations, seem to constitute the metabolic profile found in the studied critically ill preterm newborns who received PN, indicating an energetic dysfunction that must be taken into account for better nutritional management.

Acurácia e custo de métodos utilizados por enfermeiros na confirmação do posicionamento de sondas nasoenterais recém inseridas às cegas à beira leito / Accuracy and cost of methods used by nurses in confirming the placement of recently inserted nasoenteral tubes at bedside

Os objetivos do estudo foram analisar a acurácia e os custos de métodos realizados à beira leito para confirmar a posição de sonda nasoenteral recém inserida às cegas à beira leito por enfermeiros. Tratou-se de estudo de acurácia diagnóstica de três métodos (ultrassonografia, ausculta epigástrica e medição do pH) utilizados na prática clínica por enfermeiros e compará-los com a radiografia, que é o padrão-ouro na confirmação do posicionamento de sondas nasoenterais. Os dados foram coletados nas enfermarias e unidades de cuidados críticos de um hospital universitário de grande porte do interior do estado de São Paulo. A amostra foi de conveniência e incluiu todos os pacientes que necessitaram de sonda nasoenteral durante a internação, no período de 19/11/2019 a 18/03/2020. Os métodos foram realizados na seguinte ordem: ultrassonografia, ausculta epigástrica e medição do pH (testes índice). Posteriormente, os resultados dos três métodos foram comparados com a radiografia (teste de referência). Também foram comparados os resultados provenientes da combinação entre ausculta epigástrica e medição do pH com a radiografia. Dados sociodemográficos, clínicos e terapêuticos foram obtidos do prontuário do paciente e registrados no formulário de coleta de dados eletrônico. Também foram mensurados os custos diretos de cada método utilizado para confirmar o posicionamento da sonda nasoenteral. Foram realizados 53 procedimentos de inserção de sonda nasoenteral em 41 pacientes adultos. Destes, 58,5% estavam posicionadas no estômago, 11,3% estavam posicionadas no esôfago ou pulmão, 11,3% no intestino, e em 18,9%, não foi possível definir se a ponta da sonda estava localizada no estômago ou no intestino na radiografia. Dentre os métodos utilizados neste estudo, a medição do pH foi o que apresentou maior sensibilidade (87,5%) e especificidade (100%). A sensibilidade do ultrassom foi de 76,6%. Ademais, quando combinados, a ausculta epigástrica e a mensuração do pH apresentaram sensibilidade, especificidade, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) iguais a 100%. A medição do pH e o ultrassom apresentaram concordância considerável com a radiografia e, quando avaliado o método combinado, a concordância foi quase perfeita. Em média, a ausculta abdominal apresentou o menor custo (R$ 6,62) quando comparado aos demais métodos avaliados no presente estudo. Considerando as probabilidades de observação da posição da sonda pela ultrassonografia, o custo esperado foi de R$ 35,76, enquanto pelo método da mensuração do pH, o custo mínimo foi de R$ 8,49. Contudo, não foi possível obter o aspirado gástrico em 35,2% dos procedimentos realizados, apesar das intervenções. Nesses casos, o custo da mensuração do pH foi maior (R$ 43,38) quando comparado aos demais métodos. A ultrassonografia pode ser uma alternativa para situações em que a radiografia não esteja disponível. Entretanto, estudos futuros são necessários para avaliar a acurácia desse método em amostra maior de pacientes. Ademais, na impossibilidade de implementação de métodos radiológicos para confirmar o posicionamento das sondas, o enfermeiro deve considerar a associação de dois métodos não radiológicos, sendo eles a mensuração do pH e a ausculta epigástrica.

The objectives of the study were to analyze the accuracy and the costs of methods performed at bedside to confirm the placement of the nasoenteral tube which were recently and blindly inserted at bedside by nurses. It was a diagnostic accuracy study of three diagnostic methods (ultrasonography, epigastric auscultation, and pH measurement) used in clinical practice by nurses and compare them to the radiography, which is the gold standard in confirming the placement of nasoenteral tubes. The data were collected in wards and critical care units of a large size university hospital in the countryside of São Paulo state. It was a convenience sample, and it comprised all the patients who needed nasoenteral feeding tube during their hospitalization, from 11/19/2019 to 03/18/2020. The methods were performed in the following order: ultrasonography, epigastric auscultation and pH measurement (index tests). Afterwards, the results of the three methods were compared to that of the radiography (reference test). The results from the combination of epigastric auscultation and pH measurement were also compared to the radiograph. Sociodemographic, clinical, and therapeutic data were obtained from the patient record and registered in an electronic data collection form. The direct costs of each method used to confirm the placement of nasoenteral feeding tube were also measured. Fifty-three (53) procedures for inserting the nasoenteral feeding tube were performed in 41 patients. Out of these, 58.5% were positioned in the stomach, 11.3% were positioned in the esophagus or lung, 11.3% in the intestine and, in 18.9% of them, it was not possible to define whether the tip of the tube was placed in the stomach or in the intestine in the radiograph. Among the methods used in this study, the pH measurement was the one which presented greater sensitivity (87.5%) and specificity (100%). The ultrasound sensitivity was 76.6%. Moreover, when combined, the epigastric auscultation and the pH measurement presented sensitivity, specificity, positive predictive value (PPV) and Negative Predictive Value (NPV) equal to 100%. The pH measurement and the ultrasound presented substantial match with the radiography and when the method was assessed in combination, the match was almost perfect. On average, the abdominal auscultation presented the lowest cost (R$ 6.62) if compared to the other methods assessed in this study. Considering the probability of the tube position observation by the ultrasonography, the expected cost was R$ 35.76, while the pH measurement method minimum cost was R$ 8.49. Nevertheless, it was not possible to obtain the gastric aspirator in 35.2% of the procedures carried out, despite the interventions. In these cases, the pH measurement cost was higher (R$ 43.38) when compared to other methods. The ultrasonography may be an alternative for situations where radiography is not available. Nevertheless, future studies are needed in order to assess the accuracy of this method in a greater sample of patients. Besides, in case of implementation impossibility of the radiologic methods to confirm the placement of the tubes, the nurse must consider the association of two non-radiologic methods, which are the pH measurement and epigastric auscultation.

Association of specialized enteral nutrition with glycemic control and clinical outcomes in critically ill patients: A meta-analysis of randomized controlled trials.

OBJECTIVE: To evaluate the association of glycemic-control formulae (GCF) with measurements of glycemic control and clinical outcomes compared to standard enteral formulae (SF) in critically ill patients. DATA SOURCES: MEDLINE, EMBASE, Scopus and the Cochrane Central Register of Controlled Trials were searched from inception up to January, 2021. STUDY SELECTION: RCTs that assessed the effects of GCF relative to SF in adult critically ill patients. DATA EXTRACTION: Measurements of glycemic control were the primary outcomes. Secondary outcomes included insulin requirements, mechanical ventilation (MV), length of intensive care unit (ICU) stay and mortality. Two authors independently extracted data and assessed risk of bias using the Cochrane's RoB 2 tool and the GRADE approach was used to assess the quality of evidence. DATA SYNTHESIS: Ten studies (12 reports, 685 patients) were included. The use of GCFs was associated with lower blood glucose (WMD, -16.06 mg/dL; 95% CI -23.48 to -8.63; I2 = 47%) and lower daily administered insulin (WMD, -7.20 IU; 95% CI -13.92 to -0.48; I2 = 53%). Glycemic variability, measured by the coefficient of variation, was also associated with the use of GCFs (WMD, -6.84%; 95% CI, -13.57 to -0.11; I2 = 95%). In contrast, analyses for length of ICU stay (WMD, -0.12, 95% CI -1.77 to 1.52; I2 = 0%), duration of MV (WMD, -0.34 days; 95% CI, -1.72 to 1.04; I2 = 0%) and mortality (RR, 1.13; 95% CI 0.82 to 1.56; I2 = 0%) were not statistically significant. Quality of evidence ranged from low to very low, and only one study was judged as at low risk of bias. CONCLUSIONS: In this meta-analysis, GCFs were significantly associated with lower insulin requirements and improved glycemic control. Although results for clinical outcomes were not statistically significant, there is insufficient evidence to confirm or exclude important differences due to serious imprecision in the effect estimates and overall low quality of evidence. The effects of GCFs on clinical outcomes require confirmation in larger randomized trials.

Is perioperative fasting associated with complications, length of hospital stay and mortality among gastric and colorectal cancer patients? A cohort study

ABSTRACT BACKGROUND: During a surgical procedure, patients are often subjected to fasting for times that are more prolonged than the ideal, which may lead to complications. OBJECTIVE: To evaluate the duration of perioperative fasting and its association with postoperative complications, length of hospital stay (LOS) and mortality among gastric and colorectal cancer patients. DESIGN AND SETTING: Cohort study developed in a surgical oncology hospital in the city of Natal (Rio Grande do Norte, Brazil). METHODS: Patients aged over 18 years were included. The Clavien-Dindo surgical complication scale was used to evaluate occurrences of postoperative complications. LOS was defined as the number of days for which patients stayed in the hospital after surgery, or until the day of death. RESULTS: Seventy-seven patients participated (59.8 ± 11.8 years; 54.5% females; 70.1% with bowel tumor). The incidences of postoperative complications and death were 59.7% and 3.9%, respectively. The duration of perioperative fasting was 59.0 ± 21.4 hours, and it was higher among non-survivors and among patients with prolonged hospital stay (≥ 6 days). For each one-hour increase in the durations of perioperative and postoperative fasting, the odds of prolonged hospitalization increased by 12% (odds ratio, OR = 1.12; 95% confidence interval, CI 1.04-1.20) and 5% (OR = 1.05; 95% CI 1.02-1.08), respectively. CONCLUSION: Prolonged perioperative fasting, especially in the postoperative period, was observed in a sample of patients with gastric and colorectal cancer, and this was an independent predictor of LOS.

Risk of Hospitalizations Following Gastrostomy in Children with Intellectual Disability.

OBJECTIVE: To examine the frequency of hospital admissions before and after gastrostomy insertion in children with severe intellectual disability. STUDY DESIGN: We conducted a retrospective cohort study using linked health administrative and disability data from Western Australia (WA) and New South Wales (NSW). Children born between 1983 and 2009 in WA and 2002 and 2010 in NSW who had a gastrostomy insertion performed (n = 673 [WA, n = 325; NSW, n = 348]) by the end of 2014 (WA) and 2015 (NSW) were included. Conditional Poisson regression models were used to evaluate the age-adjusted effect of gastrostomy insertion on acute hospitalizations for all-cause, acute lower respiratory tract infections (LRTI), and epilepsy admissions. RESULTS: The incidence of all-cause hospitalizations declined at 5 years after procedure (WA cohort 1983-2009: incidence rate ratio, 0.70 [95% CI, 0.60-0.80]; WA and NSW cohort 2002-2010: incidence rate ratio, 0.63 [95% CI, 0.45-0.86]). Admissions for acute LRTI increased in the WA cohort and remained similar in the combined cohort. Admissions for epilepsy decreased 4 years after gastrostomy in the WA cohort and were generally lower in the combined cohort. Fundoplication seemed to decrease the relative incidence of acute LRTI admissions in the combined cohort. CONCLUSIONS: Gastrostomy was associated with health benefits including reduced all-cause and epilepsy hospitalizations, but was not protective against acute LRTI. These decreases in hospitalizations may reflect improved delivery of nutrition and medications.

Adult avoidant/restrictive food intake disorder: a case report / Transtorno alimentar evitativo/restritivo em uma adulta: um relato de caso

ABSTRACT The aim this report is to present an adult case of avoidant/restrictive food intake disorder (ARFID) in a patient with atypical development. To emphasize the diagnostic and behavioral characteristics of this new nosological category included in the Feeding and Eating Disorders (FED) section of DSM-5. A woman with Down Syndrome in early adulthood who developed restriction and avoidance symptoms of food until the total eating refusal with weight loss, malnutrition and dependence exclusively on enteral feeding by gastrostomy tube. This case exemplified how ARFID may remain a hidden diagnosis and even be misdiagnosed as other eating disorders, such as anorexia nervosa. The increase in diagnostic suspicion for this nosological entity with neurobiological/behavioral mechanisms involved in its clinical presentations in mind, might increase knowledge about this serious eating disorder, aiming the development of evidence-based interventions.

RESUMO O objetivo deste relato é apresentar um caso de transtorno alimentar evitativo/restritivo (TARE) em uma paciente adulta com desenvolvimento atípico e salientar as características diagnósticas e comportamentais dessa nova categoria nosológica incluída na seção de Transtornos Alimentares da DSM-5. Mulher com síndrome de Down que, no início da vida adulta, evoluiu com sintomas de restrição e evitação alimentar até a recusa total da alimentação, com perda de peso, desnutrição e dependência total de alimentação enteral por gastrostomia. Este caso elucida como o diagnóstico de TARE pode permanecer oculto e ser confundindo com outras condições patológicas alimentares, como a anorexia nervosa. O aumento da suspeição diagnóstica para essa entidade nosológica, tendo em mente os mecanismos neurobiológicos/comportamentais envolvidos em suas apresentações clínicas, possibilitará o aumento do conhecimento sobre esse grave transtorno alimentar, visando ao desenvolvimento de intervenções eficazes baseadas em evidências.

La alimentación enteral como cuidado paliativo (en el contexto de una enfermedad terminal). Una reflexión desde la biopolítica / Enteral feeding as palliative care (in the context of a terminal disease). A reflection from biopolitics / Alimentação enteral como cuidados paliativos (no contexto de uma doença terminal). Uma reflexão da biopolítica

En este trabajo se ofrece una problematización del dilema ético que representa el procedimiento médico de la alimentación enteral aplicado como un cuidado paliativo en el contexto de una enfermedad terminal. La hipótesis interpretativa es que este procedimiento puede ser visto desde una perspectiva biopolítica. Para sostener la tesis se hace una reflexión sobre los fundamentos que el Estado Moderno esgrime para la defensa de la vida desde las prácticas médicas con una perspectiva hipocrática, conformando así mecanismos de control de la vida. Acorde con la tesis, la alimentación enteral como cuidado paliativo se presentaría como una de las prácticas médicas que ejemplifican de manera más patente la intención del control político de la vida humana, tanto biológica como cultural.

This paper offers a problematization of the ethical dilemma that represents the medical procedure of enteral feeding as palliative care in the context of a Terminal disease. The interpretative hypothesis is that this procedure can be viewed from a biopolitical perspective.To support the thesis, I refer the basis that the Modern State uses to defend life from medical practices with a Hippocratic perspective, thus conforming mechanism for the control of life. According to the thesis enteral nutrition as palliative care would be presented as one of the medical practices that more clearly exemplify the intention of political control of human life.

Neste trabalho oferece-se uma problematização do dilema ético que representa o procedimento médico da alimentação enteral aplicado como um cuidado paliativo no contexto de uma doença terminal. A hipótese interpretativa é que este procedimento pode ser visto de uma perspectiva biopolítica. Para sustentar a tese se faz uma reflexão sobre os fundamentos que o Estado Moderno esgrime para a defesa da vida desde as práticas médicas com uma perspectiva hipocrática, conformando assim mecanismos de controle da vida. De acordo com a tese, a alimentação enteral como cuidado paliativo se apresentaria como uma das práticas médicas que exemplificam de maneira mais evidente a intenção do controle político da vida humana, tanto biológica como cultural.

Caracterización general de Lactarios de Hospitales de Referencia de Asunción y Departamento Central

Introducción: Los lactarios iniciaron sus actividades en los hospitales de nuestro medio, con el objetivo de contribuir al mantenimiento del estado nutricional y a la recuperación de la salud de los pacientes hospitalizados, a través de una intervención nutricional de excelencia técnica. Objetivo: Caracterizar los Lactarios de Hospitales de Referencia de Asunción y Central, durante el periodo 2014, para establecer un diagnóstico de la situación de adecuación de los mismos a las normas internacionales. Materiales y Métodos: Diseño descriptivo, observacional. Se utilizó una encuesta a partir del documento "Orientaciones técnicas para Servicios Dietéticos de Leche (SEDILE) y Central de Fórmula Enteral (CEFE) del Ministerio de Salud de Chile. Se realizó observación directa de los lactarios y encuesta a los profesionales encargados. Estadística: A cada variable de las dimensiones evaluadas en los lactarios se le asignó una puntuación de acuerdo a la presencia (1) o ausencia (0) de la característica estudiada y estos resultados se compararon al 100% de los datos del instrumento de recolección. Las variables obtenidas fueron cualitativas, dicotómicas (presencia o ausencia) y para su descripción se utilizó la distribución de frecuencia en porcentajes. Para las variables cuantitativas se utilizaron las medidas de tendencia central y dispersión. Resultados: Ingresaron al estudio siete lactarios de hospitales públicos, dos de los cuales fueron para extracción de leche materna. En relación a la disponibilidad de: 1) Recursos físicos: el porcentaje (%) global fue del 55% (rango 38-80%). 2) Equipamiento: el % global fue del 42% (rango 27-62%). 3) Manual de funciones y organigrama: el % global fue del 55% (rango 25-75%). 4) Normas y procedimientos: el % global fue del 59% (rango 27-80%). Conclusiones: La dimensión más afectada en los lactarios evaluados fue el equipamiento, seguida de recursos físicos y la disponibilidad de manual de funciones y organigrama.

Introduction: The lactary became active in Paraguayan hospitals to contribute to maintain or restore the nutritional health of hospitalized patients through nutritional intervention. Objetive: To characterize the lactary operating at reference hospitals in Asuncion and the Central Department, in 2014, to determine their adequacy to international standards. Materials and Methods: We conducted a descriptive and observational study by direct observation of the lactary and a survey, based on the guidelines of SEDILE (technical guidelines for dietary milk services) and CEFE (enteric formula center). Statistics: Each variable assessed by SEDILE criteria was assigned a point value according to the presence (1) or absence (0) of the particular criterion and compared to the total data collected in the survey. Variables determined were qualitative and binary (presence or absence), and described with percentage frequency distribution. Central tendency and dispersion measures were used for quantitative variables. Results: Seven lactary from public hospitals were included, of which two were dedicated to extraction of breast milk. Overall availability of physical resources was 55% (range 38-80%), of equipment, 42% (range, 27-62%), of organization charts and job description manuals, 55% (range, 25-75%), and standard and procedures manuals 59% (range, 27-80%). Conclusions: The greatest shortfall in the lactary studied was of equipment, followed by physical resources and organization and job function manuals.

The Impact of Routine Evaluation of Gastric Residual Volumes on the Time to Achieve Full Enteral Feeding in Preterm Infants.

OBJECTIVE: To evaluate the time to full enteral feedings in preterm infants after a practice change from routine evaluation of gastric residual volume before each feeding to selective evaluation of gastric residual volume , and to evaluate the impact of this change on the incidence of necrotizing enterocolitis (NEC). STUDY DESIGN: Data were collected on all gavage-fed infants born at ≤34 weeks gestational age (GA) for 2 years before (n = 239) and 2 years after the change (n = 233). RESULTS: The median GA was 32.0 (IQR: 29.7-33.0) weeks before and 32.4 (30.4-33.4) weeks after the change (P = .02). Compared with historic controls, infants with selective evaluations of gastric residual volumes weaned from parenteral nutrition 1 day earlier (P < .001) and achieved full enteral feedings (150 cc/kg/day) 1 day earlier (P = .002). The time to full oral feedings and lengths of stay were similar. The rate of NEC (stage ≥ 2) was 1.7% in the selective gastric residual volume evaluation group compared with 3.3% in the historic control group (P = .4). Multiple regression analyses showed that the strongest predictor of time to full enteral feedings was GA. Routine evaluation of gastric residual volume and increasing time on noninvasive ventilation both prolonged the attainment of full enteral feedings. Findings were consistent in the subgroup with birth weights of <1500 g. Increased weight at discharge was most strongly associated with advancing postmenstrual, age but avoidance of routine evaluations of gastric residual volume also was a significant factor. CONCLUSIONS: Avoiding routine evaluation of gastric residual volume before every feeding was associated with earlier attainment of full enteral feedings without increasing risk for NEC.

Avaliação das condições higienicossanitárias de um lactário do sul de Minas Gerais / Evaluation of hygienic and sanitary conditions of a lactary from southern Minas Gerais

No ambiente hospitalar, a alimentação faz parte dos cuidados de recuperação e tratamento. É imprescindível que os alimentos ofertados nesse ambiente sejam adequados às necessidades do usuário e que sejam de qualidade. Foram realizadas análises microbiológicas das formulações em pó e reconstituídas utilizadas para alimentação infantil e enteral, além do ambiente de manipulação das mesmas. Foram realizadas contagens de bactérias aeróbias mesófilas, bolores e leveduras, identificação de Staphylococcus coagulase positiva, determinação do Número Mais Provável (NMP) de bactérias Coliformes a 35ºC e 45ºC, de Escherichia coli e pesquisa de Salmonella sp. A contagem de bactérias aeróbias mesófilas variou de 2,0x102 a 1,0x105 UFC/mL nas amostras. Bolores e leveduras tiveram variação entre <1x101 e 1x105. Para coliformes totais, o NMP não passou de < 0,3 mL, enquanto para os coliformes a 45ºC, o NMP mínimo foi de <0,3 e o máximo de 2,4x102, onde a análise para Escherichia coli foi ausente. Quanto à presença de Staphylococcus coagulase positiva obteve-se resultado negativo em todas as amostras. Em nenhuma amostra foi detectada a presença de Salmonella sp. Concluiu-se que as amostras analisadas não atendem em 100% o preconizado na resolução RDC 12/2001.

In the hospital environment, alimentation is part of recovery care and treatment. It is necessary that the food offered in this environment are suitable to user needs and that are of quality. Microbiological analyses were performed on the powder and reconstituted formulations used in infant and enteral formulations, in addition to handling the same environment. Were carried out scores of mesophilic aerobic bacteria, molds and yeasts, Staphylococcus coagulase positive identification, determination of the Most Probable Number (MPN) of coliform bacteria at 35ºC and 45ºC, Escherichia coli and Salmonella sp. The Mesophilic aerobic bacteria count ranged from 2.0 x 102 to 1.0 x 105 CFU / ml of the sample. Molds and yeasts had variation between <1x101 to 1x105. For bacteria total coliform MPN was nothing but <0.3 mL, while for 45°C coliforms the minimum NMP was <0.3 and maximum 2,4X102 where the analysis for Escherichia coli was absent. As for the presence of Staphylococcus coagulase positive, negative results was obtained for all samples. In none of sample was detected the presence of Salmonella sp. It is concluded that the samples do not meet 100% the recommended in Resolution RDC 12/2001.

Validation of Test Weighing Protocol to Estimate Enteral Feeding Volumes in Preterm Infants.

OBJECTIVE: To evaluate the accuracy of pre- and postfeeding weights to estimate enteral feeding volumes in preterm infants. STUDY DESIGN: Single-center prospective cohort study of infants 28-36 weeks' corrected age receiving gavage feedings. For each test weight, 3 pre- and 3 postgavage feeding weights were obtained by study personnel, blinded to feeding volume, via a specific protocol. The correlation between test weight difference and actual volume ingested was assessed by the use of summary statistics, Spearman rho, and graphical analyses. The relationship between categorical predictive variables and a predefined acceptable difference (±5 mL) was assessed with the χ2 or Fisher exact test. RESULTS: A total of 101 test weights were performed in 68 infants. Estimated and actual feeding volumes were highly correlated (r = 0.94, P < .001), with a mean absolute difference of 2.95 mL (SD: 2.70; range: 0, 12.3 mL; 5th, 95th percentile: 0, 9.3); 85% of test weights were within ±5 mL of actual feeding volume and did not vary significantly by corrected age, feeding tube or respiratory support type, feeding duration or volume, formula vs breast milk, or caloric density. With adherence to study protocol, 89% of test weights (66/74) were within ±5 mL of actual volume, compared with 71% (19/27, P = .04) when concerns about protocol adherence were noted (eg, difficulty securing oxygen tubing). CONCLUSIONS: Via the use of a standard protocol, feeding volumes can be estimated accurately by pre- and postfeeding weights. Test weighing could be a valuable tool to support direct breastfeeding in the neonatal intensive care unit.

Evacuación del meconio intestinal para mejorar tolerancia alimentaria en prematuro de muy bajo peso (protocolo Emita) / Meconium evacuation to improve feeding tolerance in very low birth weight preterm infants (Emita Protocol)

Introducción: Se ha descrito que la tolerancia alimentaria en el extremo prematuro se asocia a una precoz eliminación de meconio. Estudios prospectivos, randomizados o con controles históricos de estimulación de evacuación de meconio reportan diferentes resultados. El objetivo de este estudio fue evaluar el uso sistemático de enemas que aceleren la evacuación de meconio, y por ende la tolerancia alimentaria. Pacientes y Método: Estudio controlado, aleatorizado y multicéntrico que evaluó el uso de enemas de solución fisiológica con glicerina (0,8 ml de glicerina + 3 ml de solución fisiológica o 1 ml de glicerina + 5 ml de solución fisiológica según peso al nacer menor o mayor de 800 g, respectivamente) versus simulación, iniciado en las primeras 96 h de vida, en prematuros con peso al nacimiento entre 500 y 1.250 g. Se registraron antecedentes maternos (parto prematuro, infección ovular, síndrome hipertensivo del embarazo, administración de sulfato de magnesio, y corticoides prenatales, doppler fetal alterado, tipo de parto, sexo, peso y edad gestacional, evaluación de apgar y necesidad de ventilación asistida y oxígenoterapia) y nutricionales (edad al alcanzar volúmenes de alimentación de 100 ml//kg/día y alimentación enteral completa, edad para eliminar meconio, número de días en nutrición parenteral, peso a los 28 días, volúmenes semanales de leche materna y fórmula de prematuros). Resultados: En 101 sujetos incluidos en el estudio, no se obtienen diferencias significativas en la variable principal de edad para alcanzar el aporte enteral total o los 100 ml por kg por día. Tampoco se observan diferencias en las variables secundarias: número de episodios de sepsis tardías con o sin hemocultivo positivo, hiperbilirrubinemia, enterocolitis necrotizante o hemorragia intracraneana. Conclusiones: El uso sistemático de enemas de solución fisiológica y glicerina, en la forma utilizada en este estudio, no modifica la tolerancia alimentaria enteral de prematuros de muy bajo peso al nacer.

Introduction: it has been reported that feeding tolerance in preterm infants is associated with an early passage of meconium. prospective, randomized or historical control studies that stimulate meconium evacuation have reported varied results. this study was intented to evaluate the use of enemas to speed up meconium evacuation, facilitating feeding tolerance. Patients and Method: a controlled multicenter randomized trial that evaluated the use of physiological saline enemas with glycerol (0.8 ml glycerol + 3 ml saline or 1 ml glycerol + 5 ml saline depending on babies weighing less or more than 800 g at birth, respectively) versus simulation. This procedure was performed in the first 96 hours of life in infants with birth weight between 500 and 1,250 g. Maternal (preterm delivery, clinical chorioamnionitis, gestational hypertension, administration of magnesium sulfate and prenatal corticosteroids, fetal doppler altered, type of delivery, gender, weight and gestational age, assessment of apgar and need for assisted ventilation and oxygenotherapy) and nutritional history (age when feeding volumes of 100 ml/kg/day and full enteral feeding were reached, age to remove meconium, number of days on parenteral nutrition, weight at 28 days, weekly volumes of breast milk and preterm formula) were described. Results: No significant differences were obtained regarding the age to reach full enteral intake or 100 ml/kg/day were found among the 101 patients in the study. also, no differences in the following secondary variables are observed: number of episodes of late sepsis with or without positive blood culture, hyperbilirubine mia, necrotizing enterocolitis and intraventricular hemorrhage. Conclusions: the routine use of saline enemas and glycerin in this study does not alter the enteral feeding tolerance in very low birth weight preterm infants.

Avaliação das condições higienicossanitárias de um lactário do sul de Minas Gerais

No ambiente hospitalar, a alimentação faz parte dos cuidados de recuperação e tratamento. É imprescindível que os alimentos ofertados nesse ambiente sejam adequados às necessidades do usuário e que sejam de qualidade. Foram realizadas análises microbiológicas das formulações em pó e reconstituídas utilizadas para alimentação infantil e enteral, além do ambiente de manipulação das mesmas. Foram realizadas contagens de bactérias aeróbias mesófilas, bolores e leveduras, identificação de Staphylococcus coagulase positiva, determinação do Número Mais Provável (NMP) de bactérias Coliformes a 35°C e 45°C, de Escherichia coli e pesquisa de Salmonella sp. A contagem de bactérias aeróbias mesófilas variou de 2,0x 102 a 1.0x105 UFC/mL nas amostras. Bolores e leveduras tiveram variação entre <1x101 e 1x105. Para coliformes totais, o NMP não passou de < 0,3 mL, enquanto para os coliformes a 45°C, o NMP mínimo foi de <0,3 e o máximo de 2,4x102, onde a análise para Escherichia coli foi ausente. Quanto à presença de Staphylococcus coagulase positiva obteve-se resultado negativo em todas as amostras. Em nenhuma amostra foi detectada a presença de Salmonella sp. Concluiu-se que as amostras analisadas não atendem em 100% o preconizado na resolução RDC 12/2001.(AU)

In the hospital environment, alimentation is part of recovery care and treatment. It is necessary that the food offered in this environment are suitable to user needs and that are of quality. Microbiological analyses were performed on the powder and reconstituted formulations used in infant and enteral formulations, in addition to handling the same environment. Were carried out scores of mesophilic aerobic bacteria, molds and yeasts, Staphylococcus coagulase positive identification, determination of the Most Probable Number (MPN) of coliform bacteria at 35ºC and 45ºC, Escherichia coli and Salmonella sp. The Mesophilic aerobic bacteria count ranged from 2.0 x 102 to 1.0 x 105 CFU / mL of the sample. Molds and yeasts had variation between <1X101 to 1x105. For bacteria total coliform MPN was nothing but <0.3 mL, while for 45°C coliforms the minimum NMP was <0.3 and maximum 2,4X102 where the analysis for Escherichia coli was absent. As for the presence of Staphylococcus coagulase positive, negative results was obtained for all samples. In none of sample was detected the presence of Salmonella sp. It is concluded that the samples do not meet 100% the recommended in Resolution RDC 12/2001.(AU)

Evacuación del meconiointestinal para mejorar tolerancia alimentaria en prematuro de muy bajo peso (protocolo Emita) / Meconium evacuation to improve feeding tolerance in very low birth weight preterm infants (Emita protocol)

Se ha descrito que la tolerancia alimentaria en el extremo prematuro se asocia a una precoz eliminación de meconio. Estudios prospectivos, randomizados o con controles históricos de estimulación de evacuación de meconio reportan diferentes resultados. El objetivo de este estudio fue evaluar el uso sistemático de enemas que aceleren la evacuación de meconio, y por ende la tolerancia alimentaria. Pacientes y Método: Estudio controlado, aleatorizado y multicéntrico que evaluó el uso de enemas de solución fisiológica con glicerina (0,8 ml de glicerina + 3 ml de solución fisiológica o 1 ml de glicerina + 5 ml de solución fisiológica según peso al nacer menor o mayor de 800 g, respectivamente) versus simulación, iniciado en los primeras 96 h de vida, en prematuros con peso al nacimiento entre 500 y 1.250 g. Se registraron antecedentes maternos (parto prematuro, infección ovular, síndrome hipertensivo del embarazo, administración de sulfato de magnesio, y corticoides prenatales, doppler fetal alterado, tipo de parto, sexo, peso y edad gestacional, evaluación de apgar y necesidad de ventilación asistida y oxígenoterapia) y nutricionales (edad al alcanzar volúmenes de alimentación de 100 ml//kg/día y alimentación enteral completa, edad para eliminar meconio, número de días en nutrición parenteral, peso a los 28 días, volúmenes semanales de leche materna y fórmula de prematuros). Resultados: En 101 sujetos incluidos en el estudio, no se obtienen diferencias significativas en la variable principal de edad para alcanzar el aporte enteral total o los 100 ml por kg por día. Tampoco se observan diferencias en las variables secundarias: número de episodios de sepsis tardías con o sin hemocultivo positivo, hiperbilirrubinemia, enterocolitis necrotizante o hemorragia intracraneana...

Introduction: It has been reported that feeding tolerance in preterm infants is associated with an early passage of meconium. Prospective, randomized or historical control studies that stimulate meconium evacuation have reported varied results. This study was intented to evaluate the use of enemas to speed up meconium evacuation, facilitating feeding tolerance. Patients and Method: A controlled multicenter randomized trial that evaluated the use of physiological saline enemas with glycerol (0.8 ml glycerol + 3 ml saline or 1 ml glycerol + 5 ml saline depending on babies weighing less or more than 800 g at birth, respectively) versus simulation. This procedure was performed in the first 96 hours of life in infants with birth weight between 500 and 1,250 g. Maternal (preterm delivery, clinical chorioamnionitis, gestational hypertension, administration of magnesium sulfate and prenatal corticosteroids, fetal Doppler altered, type of delivery, gender, weight and gestational age, assessment of Apgar and need for assisted ventilation and oxygenotherapy) and nutritional history (age when feeding volumes of 100 ml/kg/day and full enteral feeding were reached, age to remove meconium, number of days on parenteral nutrition, weight at 28 days, weekly volumes of breast milk and preterm formula) were described. Results: No significant differences were obtained regarding the age to reach full enteral intake or 100 ml/kg/day were found among the 101 patients in the study. Also, no differences in the following secondary variables are observed: number of episodes of late sepsis with or without positive blood culture, hyperbilirubinemia, necrotizing enterocolitis and intraventricular hemorrhage...