Enteral nutrition (pediatrics)

Enteral nutrition is the most effective and acceptable way to achieve and maintain adequate nutritional status in children who have a functioning GIT. The profile of enteral nutrition substrates is similar to the parenteral profile.

In addition to balanced products, supplementary products for the treatment of renal and liver disorders and nutrition of patients with stress, immunodeficiency and lung disease are also produced. There are products with a trace amount of lactose, residual products with a higher fiber content. There are also different types of defined products for children.

Enteral nutrition has fewer complications compared to parenteral nutrition, is easier to prepare and administer, and is cheaper. If not sufficiently tolerated, supplemental parenteral nutrition is indicated. The so-called Early enteral nutrition in the post-exercise period represents enteral nutrition started within 24 hours after the stroke or within 8 hours after the operation. The advantage of this approach is the reduction of the hypermetabolic response and the improvement of the integrity of the GIT. It prevents the formation of mucosal atrophy, improves wound healing, reduces the incidence of infectious complications and bacterial translocation. Shortening of hospitalizations was also confirmed in some studies.


 * Benefits of early enteral nutrition


 * satisfaction of nutritional requirements
 * reduction of complications related to total parenteral nutrition
 * lower price
 * GIT integrity support
 * improving tolerance to enteral nutrition
 * improving wound healing
 * shortening of hospitalization
 * reducing the incidence of infections, sepsis and bacterial translocation
 * reduction of the hypermetabolic response to exercise

For critically ill patients, we are leaving the so-called hospital dietary system. Therapeutic nutrition for this group of patients must have pharmaceutical parameters with a precise definition of the mineral content, the proportions of individual substrates, vitamins and trace elements determined by the recipe.

In the transition from parenteral nutritional care to critically ill patients to enteral care, we assume the use of products whose absorption is ensured even when altering GIT function. We consider the administration of oligopeptic preparations with fat -containing triglycerides with a medium chain fatty acids (MCT, medium chain triacylglycerol ) not requiring pancreatic lipase to be absorbed. The transport capacity for oligopeptides and amino acids is separate and the load on one transport system does not affect the function of the other. Only after the critical phase of the disorder has passed, we switch to a balanced high-molecular diet and dietary system.

Content

 * 1Indication
 * 2Contraindication
 * 3Method of administration of enteral nutrition products
 * 4Classification of enteral nutrition products
 * 4.1Elemental nutrition (low molecular weight I. generation; molecular)
 * 4.2Oligomeric nutrition (low molecular weight 2nd generation; oligopeptide)
 * 4.3High molecular weight (polymer) nutrition
 * 4.4Modular nutrition
 * 4.5Fiber
 * 4.6Fats
 * 5Practical recommendations for the application of enteral nutrition
 * 6Links
 * 6.1related articles
 * 6.2Source

Indication

 * disorders of digestion and absorption of nutrients
 * upper GIT passage disorders
 * CNS diseases and neuromuscular diseases
 * metabolic and other chronic diseases
 * prevention and treatment of hypercatabolism

Contraindication
Enteral nutrition is absolutely contraindicated in


 * NPB
 * ileal states
 * toxic megacolon
 * acute pancreatitis
 * liver failure
 * severe diarrhea
 * bleeding into the GIT

Method of administration of enteral nutrition products
PEG scheme. If you need short-term nutritional support (3 to 4 weeks), we choose a nasogastric or nasojejunal tube. Nasojejunal administration is indicated for gastric intolerance. A modern option in nasojejunal nutrition is the introduction of a trluminal enteral tube by the endoscopic method. The most proximal port is reserved for gastric bubble derivation, the middle port is used for aspiration of gastric contents and the distal jejunal port is intended for self-feeding. Metoclopramide and erythromycin are sometimes preferred for the administration of prokinetics.

In the case of long-term nutritional support, we then choose gastrostomy ( PEG ), jejunostomy ( PEJ ).

Enteral nutrition can be given continuously or in the form of boluses. In general, children tolerate tube feeding better when administered continuously, but bolus administration is "more physiological". Continuous administration of enteral nutrition products requires an enteral pump, especially in children who do not tolerate fluctuations in the volumes administered and in children in need of night feeding.

Classification of enteral nutrition products
In terms of the formulation of enteral preparations, it is necessary to monitor their energy density, osmolality, protein content and their main source, fat content and its main source, as well as carbohydrate content. Some products are specifically enriched with arginine, nucleotides, taurine , glutamine and fiber.

Therapeutic enteral nutrition can be divided into nutrition:


 * balanced or balanced,
 * organ - specific and
 * tissue or system specific.

Balanced nutrition contains all standard nutritional components and its composition usually meets the needs of the organism without serious organ damage.

Organ-specific nutrition is indicated for patients with organ involvement, especially the liver and kidneys. It usually serves as a supplement to a balanced diet (eg in patients with chronic renal failure ).

Tissue- or system-specific nutrition, eg immunomodulatory, is based on a balanced preparation with an increase in substances with an immunomodulatory effect (nucleotides, glutamine, arginine, taurine, omega-3 polyunsaturated fatty acids). It is usually used to feed severe stressful conditions and patients with secondary immunodeficiency.

From the point of view of the chemical structure of the used substrates, we distinguish the preparations as follows:


 * elemental nutrition
 * oligomeric nutrition
 * polymer nutrition
 * modular nutrition

Elemental nutrition (low molecular weight I. generation; molecular)
It contains most of the components in molecular form ( glucose, amino acids , fatty acids ). It has a high osmolality. It does not need intestinal enzymatic equipment for absorption. It is administered by nasogastric or nasojejunal tube, or by PEG / PEJ.

Oligomeric nutrition (low molecular weight 2nd generation; oligopeptide)
It contains oligopeptides and amino acids, sugars are provided mainly by maltodextrin and fats with soybean oil. It has an osmolality of about 350 mosmol / l. It is administered mainly by gavage or PEG / PEJ. If it is well-corrected, its oral administration can be tolerated for a shorter period. It is the standard nutrition profile of critically ill patients.

High molecular weight (polymer) nutrition
It contains valuable protein, maltodextrin and fats with a high content of essential fatty acids and MCT. It is also administered orally. The osmolality is usually 300 mosmol / l. The possibility of good taste correction of the products ensures their long-term application by the oral route.

Modular nutrition
Modular nutrition offers individual nutrients in substrate modules. It is then possible for the patient to create the composition of the nutrition according to the current situation (nutrition prepared according to the patient's needs, so-called tailored nutrition ).

The profile of electrolytes, vitamins and trace elements in all products corresponds to the daily needs of the body while maintaining the recommended daily dose.

Pediatric products are intended for children from 1 to 6 years. They are complete balanced polymer diets with a lower content of protein, sodium and a higher concentration of calcium and vitamin D 3. For newborns and infants, it is possible to use infant formulas for enteral nutrition, including dietetics (low-lactose formulas, extensive hydrolysates). The choice of product and the method of enteral nutrition depends on the age, underlying disease and clinical condition of the child. From the point of view of nutritional tolerance, the actual way of introducing enteral nutrition is very important. Initiation of the application is most suitable continuously, undiluted nutritional preparation.

Fiber
Fiber is part of enteral nutrition products. In the past, it was not given nutritional importance. However, the current state of knowledge ranks fiber among substances with specific nutritional significance. Fiber has a major impact on maintaining the function of the gastrointestinal tract. These are residues of plant skeletons that are resistant to the action of digestive enzymes.

The main components of fiber are cellulose, hemicellulose, gums, lignin, pectins and mucilages. Fiber increases the growth of bacteria in the large intestine, increases stool weight, lowers cholesterol levels , regulates blood glucose levels and speeds up the passage of food through the intestine.

Fiber is digested in the large intestine by the effect of bacterial anaerobic fermentation. This process releases short chain fatty acids, acetic acid, butyric acid and propionic acid (SCFA). These are the main source of energy for the cells of the colon, stimulating the proliferation of mucosal cells and increasing blood flow in the wall of the colon. They are needed to maintain its integrity. The use of fiber-containing products reduces the incidence of some complications, such as diarrhea, in critically ill patients.

Fats
The source of fats in enteral nutrition is usually oil with a high content of polyunsaturated fatty acids, ie soybean oil, sunflower oil or rapeseed oil, fish oil in combination with vegetable, triglycerides with a medium chain fatty acids. Omega-3 and omega-6 polyunsaturated fatty acids are part of Omegaven® for enteral nutrition. Enteral administration shows that EPA and DHA located in the 2nd position of the triglyceride have a positive effect on their absorption, as well as faster absorption of medium chain triglycerides in the 1st and 3rd position and long chain fatty acid in the 2nd position. .

Practical recommendations for the application of enteral nutrition
At the beginning of enteral nutrition, we start continuously with 1 to 2 ml / kg / hour or frequent bolus feeding, when the bolus must be given slowly for about 15 to 30 minutes. Initially, we prefer maximum isotonic concentrations with an energy content of 0.5 kcal / ml. We increase the volume and concentration separately. First we increase the volume and only after reaching half the required volume we start to increase the concentration.

As a standard, we use formulas where 1 ml = 1 kcal and in 500 ml the content of nutrients: protein 20 g, carbohydrates 65 g, fats (MCT) 20 g. Especially then we use formulas with increased energy content, 1 ml = 1.5 kcal, they contain predominantly branched-chain amino acids. In exported products suitable for patients without organ involvement, almost 50% of energy is supplied in sugars, 30% in fats and about 20% is represented in proteins. In enteral nutrition, sugars are most often supplied in the form of maltodextrin or hydrolyzed corn starch. In the event of intolerance ( vomiting, diarrhea, excessive residual volume), we return to the still tolerated volume and concentration.

If the child does not receive full enteral nutrition, supplemental parenteral nutrition is inevitable. The addition of parenteral nutrition is indicated if at least 80% of the target energy value cannot be administered to the patient within 72 hours. In terms of protein quality assessment, it is necessary to mention some parameters and terms that are used in this regard. High nutritional quality protein should be used in all enteral nutrition products. This is evaluated by the so-called biological value given by the ratio between retained nitrogen and absorbed nitrogen. The chemical score compares the composition of amino acids in food with the composition of egg white protein. High quality proteins include egg protein, milk protein, meat and fish protein. Breast milk is the choice of nutrition for infantsor preparations containing egg white protein and casein.

related articles

 * Parenteral nutrition (pediatrics)
 * Child nutrition

Source

 * HAVRÁNEK, Jiří: Enteral nutrition