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- Volume 23, Issue sup-1, 2010
South African Journal of Clinical Nutrition - Supplement 1, February 2010
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Supplement 1, February 2010
Source: South African Journal of Clinical Nutrition 23, pp 03 –07 (2010)More Less
Intestinal failure (IF) requires the use of parenteral nutrition (PN) for as long as it persists and in case of irreversible IF may be an indication for intestinal transplantation (ITx). Biological evaluation of IF is becoming possible with the use of plasma citrulline as a marker of intestinal mass. Short bowel syndrome (SBS) is the leading cause of intestinal failure in infants while few epidemiological data are to date available. Data on morbidity and mortality in paediatric patients with SBS are very limited but long-term outcomes seem to be improving. Other causes of intestinal failure include neuro-muscular intestinal disease and congenital disease of enterocyte development. The management of IF should include therapies adapted to each type and stage of IF based on a multidisciplinary approach in centres involving paediatric surgery, paediatric gastroenterology, parenteral nutrition expertise, home-parenteral nutrition programme, liver-intestinal transplantation experience. Timing for referral of patients in specialised centres remains a crucial issue.
Source: South African Journal of Clinical Nutrition 23, pp 08 –10 (2010)More Less
Dietary lipids significantly contribute to preserve the efficiency of human metabolism and restore it during disease. Therefore, in the absence of absolute contraindications, it would not appear reasonable to exclude lipid emulsions when prescribing parenteral nutrition (PN). The metabolic role of lipids has been elucidated, and is far more complex than a mere energy-dense source. Indeed, it is now clear that fatty acids impact differently on the inflammatory and immune responses, either promoting or blunting them. Omega-6 fatty acids are the substrate for the production of potent mediators of inflammation, whereas omega-3 fatty acids promote the synthesis of less active factors. Omega-9 fatty acids exert a more neutral impact on immune and inflammatory responses. These specific metabolic activities should therefore be considered when prescribing lipid emulsions in PN. Ideally, the metabolic profile of patients should guide the prescription of lipid emulsions in order to promote the inflammatory response or blunt it according to the clinical needs. This new approach would wholly exploit the metabolic activities of lipid emulsions by providing patients not only with an energy-dense source, but also by priming and / or modulating the immune and inflammatory responses in order to favour healing.
Source: South African Journal of Clinical Nutrition 23, pp 11 –14 (2010)More Less
The provision of energy from a lipid source is an essential component of any parenteral nutrition (PN) therapeutic regimen in the appropriate clinical setting. All available sources of intravenous lipid emulsions have a low osmolarity but they strongly differ in their immunologic effects and their effects on oxidative stress, liver injury and mitochondrial function. The ω-9/ω-6 lipid emulsion with its relative immuneneutrality and also the newer fish oil admixtures are lipid emulsions that can be used in most critically ill and non-critically ill patients. Despite extensive research and encouraging progress in the availability of such lipid emulsions, there is still need for a lipid emulsions that could be advantageous in patients with real hyperinflammation.
Author E.D. NelSource: South African Journal of Clinical Nutrition 23, pp 15 –18 (2010)More Less
The relationship between diarrhoea and malnutrition is bidirectional: diarrhoea leads to malnutrition while malnutrition aggravates the course of diarrhoea. Many factors contribute to the detrimental effect of diarrhoea on nutrition. Reduced intake (due to anorexia, vomiting, and withholding of feeds), maldigestion, malabsorption, increased nutrient losses, and the effects of the inflammatory response are some of the factors involved. High volume stool losses (greater than 30 ml/kg/day) are associated with a negative balance for protein, fat, and sugar absorption. Enteric infections often cause increased loss of endogenous proteins, particularly after invasive bacterial infections. Initially, the major emphasis of treatment of acute diarrhoea in children is the prevention and treatment of dehydration, electrolyte abnormalities and comorbid conditions. The objectives of diarrhoeal disease management are to prevent weight loss, to encourage catch-up growth during recovery, to shorten the duration and to decrease the impact of the diarrhoea on the child's health. Addressing only diarrhoea or only food security is unlikely to be successful in decreasing the prevalence of malnutrition. Existing evidence provides some guidelines as to the optimal nutritional management of children with diarrhoea and novel treatments may prove to be valuable in future.
Author Goddard, E,ASource: South African Journal of Clinical Nutrition 23, pp 19 –21 (2010)More Less
Nutrition support is a vitally important issue in the pretransplantation period. Once a child has been assessed and placed on a list for transplantation the child must see a dietitian to optimise the child's nutritional status as this is vital to improve the outcome at surgery. Children with chronic liver disease who are candidates for transplantation have a better posttransplant outcome and growth potential if their nutrition is optimised pretransplantation. Well monitored nutritional support posttransplantation improves the long-term quality of life by minimising the complications associated with transplantation. An interdisciplinary approach to nutritional care of a transplant recipient involving the expertise of paediatricians, surgeons, dietitians and nursing staff is essential to optimise the outcome of these patients.
Author C. SchublSource: South African Journal of Clinical Nutrition 23, pp 22 –24 (2010)More Less
In summary, if the Millenium Development Goals (MDGs) are to be addressed effectively, it is imperative that severe malnutrition be addressed at the international and national level, using strategies that work, and that additional resources are committed to improving hospital treatment and establishing community-based rehabilitation programmes. Many gaps still exist in our knowledge regarding the management of severe malnutrition at all levels. Until such time when research can fill these gaps, we will have to continue to use what guidelines have shown to produce positive results.
Author Chetty, SSource: South African Journal of Clinical Nutrition 23, pp 25 –28 (2010)More Less
In the last three decades the nutritional and pharmacologic effects of arginine have been the subject of intense investigation. Taking into consideration the many benefits that have been demonstrated from arginine supplementation, the question remains: ''Can we afford not to supplement with this immuno-nutrient''. The potential life-saving cardiovascular effects of arginine in both acute and chronic arginine supplementation has the ability to revolutionise the management of vascular disease, yet much more research must be done in this area. In addition, the proposed benefits of such supplementation in the sepsis model, makes arginine a very attractive model for decreasing the mortality statistics of this worldwide disease process. However, owing to the fact that arginine is a precursor for nitric oxide synthesis, the effects of which are potentially detrimental in the septic patient, further research is warranted in this field to determine the suitability of this agent in patient management.
Source: South African Journal of Clinical Nutrition 23, pp 29 –32 (2010)More Less
During the last four years revised clinical practice guidelines on nutritional support have been published by the major nutritional societies worldwide. The aim of these guidelines is to promote the safe and effective care of patients who need nutritional support as part of their overall management. All guidelines are based on the available ''best evidence'' in order to assist nutrition professionals in making decisions on the appropriate and cost-effective nutritional practices. Although such guidelines are a useful tool to patient management, they are meant to support, not replace, the clinical judgment and experience of nutrition professionals.
Source: South African Journal of Clinical Nutrition 23, pp 33 –36 (2010)More Less
Inflammatory bowel disease (IBD) such as Crohn's disease (CD) results from the interaction between an individual's immune response and precipitant environmental factors, which generate an anomalous chronic inflammatory response in those who are genetically predisposed. Protein-energy malnutrition (PEM) is a frequent consequence of CD. Macrophage products such as Tumour Necrosis Factor-α (TNF-α) and interleukins 1 and 6 may be the central molecules that link the inflammatory process to derangements of homeostasis. CD is associated with frequent nutritional deficiencies, the pattern and severity of which depends on the extent, duration and activity of the inflammation. Nutritional support is especially important in childhood CD as an alternative to pharmacological treatment, especially steroids. Current treatment regimens limit the use of corticosteroids, by using immunomodulatory drugs, recommend the use of enteral nutrition, and, if necessary, consider surgery for intestinal complications of localised CD. Biologic agents with the potential for mucosal healing hold promise of growth enhancement even among children whose growth remained compromised with previously available therapies. For all treatment modalities, there is a window of opportunity to achieve normal growth before puberty is too advanced.
Author H. SteinmanSource: South African Journal of Clinical Nutrition 23, pp 37 –41 (2010)More Less
Food allergy is becoming an increasing problem worldwide, with an estimated 6-8% of children affected at some point in their childhood. It is important to recognise that the nutritional implications encompass not only the elimination of essential food(s) from the diet (and the consequent attendant lack of energy, protein or other macro or micro constituents, including vitamins), but that undiagnosed or poorly managed conditions such as severe hayfever or asthma may result in decreased activity, and / or increased or decreased food intake, which in turn may cause either negative effects on growth, or obesity. Clinical awareness is required among health professionals as to the clinical characteristics, epidemiology, investigation, and management of food allergic disorders, as is the inclusion of a dietitian as part of the allergy team. Good dietary intervention in children (and adults) with single or multiple food allergies should be seen as an integral part of the allergy consultation. It remains an essential part of holistic care.
Author M.L. CookeSource: South African Journal of Clinical Nutrition 23, pp 42 –46 (2010)More Less
Diarrhoeal disease and its complications remain a major cause of morbidity and mortality in children, especially in developing countries. Diarrhoea is characterised by an increased frequency and volume, and decreased consistency of stool from the norm. Pathogens vary between developed and developing world settings. Rotavirus diarrhoea is the most important aetiological agent implicated in severe dehydrating diarrhoea. Although it is important to recognise the specific microbiological causation of diarrhoea in order to target appropriate treatment, the broader preventive aspects put forward by the World Health Organization (WHO) indicate the fundamental contributors to the massive burden of disease in developing countries. The management of a child presenting with acute diarrhoea must include a thorough history and examination with evaluation of hydration status, nutritional status and comprehensive clinical evaluation for any complications or associated illnesses. The most recent advances in the area of acute diarrhoeal disease include zinc supplementation, reduced osmolarity oral rehydration solution (ORS) and rotavirus vaccination.
Author A. TillSource: South African Journal of Clinical Nutrition 23, pp 47 –49 (2010)More Less
The identification of the metabolic syndrome (MS) has been under discussion and intense investigation since 1998. Only recently does it appear that consensus is being reached between different organisations regarding its identification. Nonetheless, the true value in identifying the MS remains under question, as does the debate around its existence. The real value in identifying the MS may simply be the ability to identify individuals at increased risk for developing cardiovascular disease (CVD) and diabetes. Further identification of abnormalities associated with the MS should encourage practitioners to investigate and search for other risk factors associated with CVD and diabetes. Part of the problem in identifying and treating the MS is that the cause of associated abnormalities remains unclear. However current research seems to indicate that oxidative stress and inflammation may play a pivotal role in the development of insulin resistance (IR) and the MS. Regardless of the usefulness of indentifying the MS and its contributing causes, certain take home messages for practitioners remain the same, including emphasis on the importance of weight loss in overweight patients, the role of regular exercise and diet quality, with a new emphasis on the role of an adequate micronutrient intake and specifically nutrients with antioxidant properties.
Author A. PrinsSource: South African Journal of Clinical Nutrition 23, pp 50 –54 (2010)More Less
The acute phase response is associated with metabolic derangements, including hyperglycaemia. Hyperglycaemia is associated with adverse clinical outcomes, including increased morbidity and mortality in various patient populations. The obvious question is: does tight blood glucose control improve morbidity and mortality in critically ill patients? Tight glycaemic control (TGC) or intensive insulin therapy (IIT) has become a major area of research, debate and controversies. The belief that hyperglycaemia is a physiological response and intervention is only warranted when the renal threshold is exceeded rapidly changed to aggressive control and, currently, clinical practice is moving to a mid-point between the two.
Author R. BlaauwSource: South African Journal of Clinical Nutrition 23, pp 55 –57 (2010)More Less
The majority of enteral nutrition products for diabetes mellitus have a carbohydrate content of 30-45% and fat between 40-49%, mainly monounsaturated fat, with a mix of soluble and insoluble fibre (total of 14-24 g/l). Does this have short- and long-term benefits and which component(s) is / are crucial for the outcome or is it the combination that counts? Both manipulations of DM specific enteral formulae, i.e. addition of fibre and altered carbohydrate to fat percentage seem to be effective for short-term glucose control, but do not show convincing evidence regarding lipid management. In terms of gastro-intestinal function, there seems to be adequate evidence that fibre plays an important role for the management of diarrhoea and constipation. The implications of high fat intake on the longer-term, especially in patients suffering from gastroparesis, are less clear.
Author J. VisserSource: South African Journal of Clinical Nutrition 23, pp 58 –61 (2010)More Less
Despite the major developments on the importance of micronutrient status in health and disease, understanding of the exact role of the latter in critical illness remains elusive and ill defined, complicating decision-making on the part of the nutrition support practitioner. Micronutrient deficiencies in critically ill patients may occur as pre-existing conditions in patients with poor nutritional status prior to hospitalisation or as a result of severe illness or the injury itself. In practical terms it is clear that micronutrients should be provided at, at least, the current available recommended doses to prevent overt clinical deficiencies.
Author R. SmalbergerSource: South African Journal of Clinical Nutrition 23, pp 62 –64 (2010)More Less
The evidence connecting food and gastrointestinal cancers from epidemiological studies, case-control studies, and prospective observational studies, indicates that determining the independent effects of specific nutrients is extremely difficult, given the many potential environmental factors to consider. The nutritional management of a patient with gastrointestinal cancer first begins with an appropriate nutritional assessment, seeing that several factors could affect the patient's nutritional status. The most significant dietary advice for cancer patients in general, is to consume a significant amount of energy daily to maintain current body weight, as well as a liberal amount of protein. In cancer patients requiring gastrointestinal surgery, the benefit of delaying surgery to attain improved nutritional status needs to be determined for improved outcomes. Postoperatively, severely malnourished cancer patients, and patients with an anticipated inadequate nutritional intake for seven days or longer, will benefit from postoperative TEN, given within 48 hours after surgery. Regular monitoring and adjustments to nutritional prescriptions is imperative in order to improve the cancer patien's nutritional status within the context of the prognosis.
Author J.H. DownsSource: South African Journal of Clinical Nutrition 23, pp 65 –68 (2010)More Less
Gastrointestinal dysfunction has been recognised as a major manifestation of the human immunodeficiency virus (HIV) infection usually presenting as diarrhoea which may or may not be due to the presence of an opportunistic infection of the GIT. Contrary to earlier assumptions, there is now substantial evidence to demonstrate that there are significant changes in the gut in the acute phase of HIV infection; the most significant of these being the substantial loss of the CD4+ T-cells in the GIT. Delays in the initiation of HAART (that is, once the CD4+ T-cell count drops below 200 cells/uL), is associated with a greater severity of HIV-associated GIT enteropathy, and poor clinical outcome.
Author M. KrugerSource: South African Journal of Clinical Nutrition 23, pp 69 –70 (2010)More Less
Agreement between NRS-2002 and MUST nutrition risk scores - a retrospective study : short communicationSource: South African Journal of Clinical Nutrition 23, pp 71 –72 (2010)More Less
The nutritional status of hospitalised patients has been a growing concern during the past four decades. Worldwide studies indicate that 30% to 60% of hospitalised patients are malnourished. The complications of undernutrition, which include prolonged healing, increased length of hospital stay and increased hospital cost are well known. Early identification of undernutrition and / or risk to develop undernutrition while in hospital has been recommended. Various nutrition risk screening tools have been developed and are frequently used in the nutritional management of hospitalised patients. Based on sensitivity and specificity, the following four screening tools seemed to be valid and therefore recommended for nutrition risk screening: the Nutrition Risk Screening tool (NRS-2002), the quick and easy Malnutrition Universal Screening Tool (MUST), the Malnutrition Screening Tool (MST) as well as the Short Nutritional Assessment Questionnaire (SNAQ).
Agreement between estimated and measured heights and weights in hospitalised patients - a restrospective study : short communicationSource: South African Journal of Clinical Nutrition 23, pp 73 –74 (2010)More Less
The European Society for Clinical Nutrition and Metabolism (ESPEN) estimates that about 30% of all hospital patients are undernourished and need special nutritional care. ESPEN advises that all patients be screened for nutritional risk on admission. An ideal nutritional risk screening tool should be simple and quick to use by nursing staff when admitting patients to hospital. Tools recommended by ESPEN are the NRS 2002, MUST and MNA - all of which utilise body mass index (BMI = kg/m2) and require accurate recording of a patient's height and weight.