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
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...