F.S. Ezgu, L. Tumer, G. Cinasal, A. Hasanoglu, M.
Gunduz
Gazi University Faculty of Medicine, Department of
Pediatrics, Ankara, Turkey.
Correspondence to: Faith Suheyl Ezgu, Gazi
University Faculty of Medicine,
Department of Pediatrics, Besevler 06540, Ankara, Turkey.
E-mail:
[email protected]
Manuscript received: August 20, 2004, Initial review
completed: September 28, 2004;
Revision accepted: November 29, 2004.
Abstract:
This study was conducted to investigate
growth and the complications in the hospitalized pediatric
patients receiving either enteral (n = 26) or parenteral (n =
15) nutrition. Anthropometric measures as well as the results of
biochemical analyses and complete blood counts were recorded.
Weight, height and weight for height were expressed in z scores.
The improvement in z scores for the 26 children receiving
enteral nutrition in weight for age (P = 0.001), height for age
( P = 0.002) and weight for height (P = 0.008) were all
statistically significant. There were also significant
correlations between the changes in weight for age (r2 = 0.15, P
= 0.0049) and height for age (r2 = 0.64 and P = 0.0001) z scores
and the time for follow up. Corresponding z scores in the
parenteral nutrition group were not statistically significant.
This study indicated that enteral nutrition provides significant
improvement not only in weight but also height of sick
hospitalized pediatric patients.
Key words: Enteral, Growth, Nutrition, Parenteral.
With the recognition of the untoward effects of
malnutrition in hospitalized pediatric patients, enteral and
parenteral nutrition have gained attention especially for the
critical and chronically ill patients(1,2). The number of patients
receiving enteral and parenteral nutrition in the hospital or even
at home is increasing everyday(3-5). The accelerated progression
in pediatric enteral and parenteral nutrition has led to the
development of new nutrition techniques such as percutaneous
endoscopic gastrostomy(6).
For about two years, severely, moderately or
chronically ill patients in the pediatric ward of Gazi University
Hospital, have been nutritionally supported by the nutrition team
of Department of Pediatric Metabolism and Nutrition. In this
retrospective study, the nutritional parameters, clinical outcomes
as well as the complications of the pediatric patients receiving
either enteral or parenteral nutrition were investigated during a
period of two years.
Subjects and Methods
Enteral Nutrition Group
A total of 36 pediatric patients received
enteral nutrition between January 2000 and January 2002. Among
these, 26 cases (10 females, 16 males) with median age 11.5 months
(range: 1-137) who solely received enteral nutrition were included
in the study. The median duration of follow-up was 21.5 days
(Range: 2-547). Patients whose clinical conditions prevented oral
feeding but also having an intact gastrointestinal system were
chosen as candidates for enteral nutrition. The main indications
for enteral feeding were loss of consciousness, lack of appetite
especially during chemotherapy and neutropenia, inability in
chewing or swallowing the foods, and inadequate daily oral caloric
intake. The most common diseases in this group were malnutrition
(26.9%), malignancy (19.2%) and inborn errors of metabolism
(15.3%).
Enteral nutrition was provided by either
continuous or intermittent infusions via pumps or gravity infusion
sets. Silicon nasogastric feeding tubes with 6, 8 or 10 French
size were used during the infusions. Standard commer-cial enteral
feeding products having either 1 or 1.5 kcal/1 mL was used for all
patients over one year of age depending on the allowed total daily
fluid intake whereas human milk and elemental or semi elemental
formulas were preferred for the patients under one year of age.
Parenteral Nutrition Group
This group consisted of 15 cases (5 females and
10 males) with median age 96 months (range: 4-136). The median
duration of follow-up was 10 days (range: 2-22). Patients who had
disability for the use of gastrointestinal tract for feeding were
given parenteral nutrition. The main indications for total
parenteral nutrition were loss of consciousness, intractable
vomiting, severe esophagitis and an inadequate daily caloric
intake and unavailable gastrointestinal tract. The most common
diseases in this group were malignancy (53.3%), gastrointestinal
disease (20%) and pulmonary disease (13.3%).
Total parenteral nutrition mixtures were
prepared by a compounder in a single bag with complete sterility
in a computer-controlled manner. Adequate vitamins, minerals and
trace elements were also supplied. All the solutions were given to
the patients through an antibacterial and particle preventing
filters.
The daily caloric requirement of each patient
was calculated according to the formula: Recommended Nutritient
intake for age Χ Ideal weight for height/actual weight(3).
The diagnosis of each patient along with age,
sex, weight, height, route and type of feeding were recorded.
Serum electrolytes, total protein, albumin, alanine and aspartate
aminotransferase, hemoglobin, mean corpuscular volume, white blood
cells, platelets as well as complications and infections during
the nutrition were also noted. Weight, height and weight for
height were expressed in z scores using the Centers for Disease
Control and Prevention anthropometric software package derived
from National Center for Health Statistics growth curves.
The impact of enteral and parenteral feedings
on z scores was calculated by comparing the z score at the
beginning and end of the nutrition with paired t tests. The
progression of z score with time was assessed using linear
regression between differences in z scores and time of follow-up.
SPSS 9.0 Software for Windows was used for statistical analysis.
Results
The changes in z scores of the 26 children who
received enteral feeding are shown in Table I. The changes in z
scores of the 15 children who received parenteral feeding are
shown in Table II.
TABLE I
Changes in z Scores [Mean + (SD)] of
the 26 Children who Received Enteral Feeding
|
At the beginning |
At the end |
P value* |
Weight for age ( n = 26)
|
2.23 (1.13)
|
1.34 (1.63)
|
0.001
|
Height for age ( n = 26)
|
2.06 (1.04)
|
1.44 (1.36)
|
0.002
|
Weight for height ( n = 26)
|
1.38 (1.68)
|
0.84 (1.82)
|
0.008
|
* Paired t test.
TABLE II
Changes in z Scores [Mean
+ (SD)]
of the 15 Children who Received Parenteral Feeding.
|
At the beginning |
At the end |
P value* |
Weight for age ( n = 15)
|
1.44 (1.35)
|
1.26 (1.29)
|
0.06
|
Height for age ( n = 15)
|
0.97 (1.79)
|
0.94 (1.77)
|
0.33
|
Weight for height ( n = 15)
|
1.03 (1.45)
|
0.84 (1.47)
|
0.11
|
* Paired t test.
The improvements in z scores for the 26
children receiving enteral nutrition in weight for age, height for
age as well as weight for height were all statistically
significant. In contrast, neither of the improvements in 15
children receiving parenteral nutrition was significant. There
were also significant correlations between the changes in weight
for age (r 2 = 0.15, P = 0.049,
change in weight for age = 0.62 + 0.02. time) and also height for
age (r2 = 0.64 and P = 0.000l, change in height
for age = 0.22 + 0.01.time) z scores and the time for follow-up in
children receiving enteral nutrition.
The most common complications in the enterally
fed patients with 1kcal/l mL formula were tube occlusion (26.92%),
difficulty in transition to oral feeding (11.53%) and vomiting
(7.69%) whereas tube occlusion (50%), difficulty in transition to
oral/enteral feeding (15.38%) and diarrhea (3.84%) were most
commonly encountered in patient fed with 1.5 kcal/1 mL containing
formula. The most common complications noticed in the patients
receiving total parenteral nutrition were hypophosphatemia (60%),
hyper-glycemia (13.3%) and cholestasis ( 13.3%).
Discussion
The results of our analysis revealed that
adequate enteral feeding causes significant increase not only in
weight but also in height in sick children. This could be
attributed to providing nearly all the required daily calories per
kilograms of weight, especially by the help of high calorie (1.5
kcal/1 mL) enteral nutrition solutions without any serious
complications. There were no improvements in z scores for weight
for age of 9 patients with enteral nutrition but there were no
loss of weight also. Enteral nutrition has been preferred as the
initial route of nutritional support as it has been shown that it
improves nitrogen balance, prevents gastrointestinal mucosal
atrophy, decreases the frequency of bacterial trans-location and
septic complications, improves immune function, and reduces
cost(7).
Although there were not any significant
improvements in each of the z scores of the patients receiving
parenteral nutrition, weight loss in 14 out of 15 patients was
prevented without any significant complications. The hyperglycemia
in 2 patients was treated by continuous intravenous rapid acting
insulin infusions. Cholestasis in 2 patients was overcome by
applying low and normal amounts of aminoacide solution alternate
day. The very low rate of serious complications and prevention of
infection in every patient could be due to the preparation of the
solutions by using a sophisticated full-computer controlled
filling system and by strictly obeying the anti-infective
measures. Taylor, et al.(8) has also made a retrospective study on
95 children who received enteral or parenteral nutrition in
intensive care unit. In the follow-up of two years, the main
complication in the children who received enteral nutrition was
constipation (75%), which we have never seen in our study. The
reason for this finding could be that we have generally preferred
an enteral solution with a higher calorie per milliliter, which
also has a higher osmolarity and also could be attributed to our
preference of generally continuous enteral feeding rather than
intermittent. The most common complications in Taylors study was
electrolyte disturbances just as in ours.
Contributors: All authors were involved in
concept, design, data collection, analysis and drafting the study.
Funding: None.
Competing interests: None stated.
Key Messages |
Adequate enteral nutrition provides
significant improvement not only in weight but also height
of sick hospitalized pediatric patients especially by the
use of high calorie solutions with negligible complications.
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