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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 intravenously (total parenteral nutrition), enterally, or by a combination of both routes.


The decision to provide specialized nutrition support starts with nutrition screening to identify those patients that are malnourished, or those with risk factors that place the patient at risk for nutrition-related problems. The nutrition screen may determine that a more careful nutrition assessment is necessary.1 The assessment should consist of a detailed history, physical examination (including anthropometric measurements), and biochemical parameters to assess the presence of malnutrition as discussed in Chapter 28. It should lead to nutrition risk stratification and specific nutrition therapy recommendations (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 but cannot be accurately predicted. Therefore, careful monitoring of the 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 nutritional support services include physicians, nurse specialists, dietitians, pharmacologists, social workers, and feeding therapists. Such teams are now available at major centers to assist or impart guidance to provide and monitor nutritional support for pediatric patients.


Enteral alimentation provides nutrition via the functioning gastrointestinal tract. It is preferable to intravenous feeding because it is less costly and has 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 intestinal tract by oral intake 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 specialized 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; the tube usually is removed after each feeding. 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 when access for enteral tube feeding is necessary for more than 2 to 3 months.1 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 sometimes with the assistance of a gastroenterologist or radiologist, a gastrostomy tube can be converted into a gastrojejunostomy tube to treat these patients. Indications and contraindications for tube feedings are listed in Table 33-1...

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