Specialized nutrition support is required to provide either total or partial nutrient supplementation for patients with general undernutrition or other specific nutritional deficiencies. Nutrition support can be provided enterally, intravenously (parenteral nutrition), or by a combination of both routes.
The decision to provide specialized nutrition support starts with nutrition screening to identify patients who are malnourished, or those with risk factors that place the patient at risk for nutrition-related problems. The nutrition screen may determine the need for a more careful nutrition assessment. The assessment should consist of a detailed history, physical examination (including anthropometric measurements), and biochemical parameters in order to assess the presence of malnutrition as discussed in Chapter 21. Thus, the assessment should lead to nutrition risk stratification and specific nutrition therapy recommendations, including energy, protein, and micronutrient requirements; route of administration; and treatment goals and monitoring parameters.
The goal of appropriate nutrition therapy is to improve the outcome of a patient’s primary illness, although data supporting this goal are typically lacking. An individual’s requirements for nutrients are initially estimated and cannot be accurately predicted. Therefore, careful evaluation of nutritional status, including evaluation of growth and developmental parameters, diet history, physical examination, anthropometric measurements, and laboratory determinations, is required at regular intervals in all patients receiving specialized nutritional support. Teams that provide pediatric nutrition support services typically include physicians, nurse specialists, dietitians, pharmacologists, social workers, and feeding therapists. Such teams are now available at major medical centers to provide guidance and to monitor nutrition support for pediatric patients.
Enteral alimentation provides nutrition via a functioning gastrointestinal tract. It is preferable to intravenous feeding because it is significantly less costly and is associated with far fewer and less serious complications. Nevertheless, proper caution must be exercised to avoid deleterious effects from enteral feeding.
Nutrients can be introduced into the gastrointestinal tract orally or by orogastric, nasogastric, nasoduodenal, esophagostomy, gastrostomy, jejunostomy, or gastrojejunostomy feeding tubes. The route selected depends on patient tolerance and the underlying medical condition necessitating nutritional support. The orogastric route, most commonly employed in preterm infants with immature suck and swallow mechanisms, is useful to provide access for bolus feedings directly into the stomach. In older infants and children, nasogastric intubation permits more prolonged feedings because the tube can be secured and left in position for up to several weeks. Gastrostomy feedings are implemented when the oral and nasal routes cannot be used, when patients have severe neuromuscular problems with dysphagia, or if enteral tube feeding is warranted for more than 2 to 3 months. Nasoduodenal or jejunostomy tubes are used in patients who may have abnormal gastric emptying or gastroesophageal reflux and aspiration. Additionally, with specially designed tubes and the assistance of a gastroenterologist or radiologist, a gastrostomy tube can be converted into a gastrojejunostomy tube. Potential indications and contraindications for tube feedings are listed in Table ...