Nutritional/growth status in a large cohort of medically fragile children receiving long-term enteral nutrition support
Enteral nutritional support (ENS) is well recognised therapeutic intervention oftenly used to sustain life of extremely premature and medically fragile infants with severe underlying medical conditions. The hypothesis that sufficient enteral nutritional support (ENS) automatically leads to optimal weight gain unfortunately does not prove true for all children. Reduced efficiency of ENS is mainly caused by an imbalance of beneficial variables and undesired side effects, which may even result in growth retardation. Unfortunately, there is very limited published literature on long-term outcomes of enteral nutrition in medically fragile patients, if so these data often appear arbitrary, non-scientific and incomparable.
Optimization of nutritional support is therefore an important potential avenue for further improvement of long-term clinical outcomes in critically ill children. The prognosis of any health condition also correlates with over or underfeeding and prolonged malnutrition might worsen a child’s development and even the underlying medical condition. This condition can result in failure to thrive age-appropriately although receiving sufficient amounts of carefully selected nutrients. Long-term tube feeding plans may not be able to provide the required amount of nutritional support, which surely compromise the efficacy of enteral nutritional support. Therefore, standardized tube management plans based on parents’ feedback are necessary to ensure the best possible developmental benefit and growth outcomes.
We aimed to assess the nutritional/growth status of a large cohort of children receiving long-term enteral nutritional support. For this purpose we conducted a survey by which we analyzed the nutritional/growth parameters of all children, aged 1-36 months (n = 287) over the last five years (2009-2013). When compared with World Health Organisation (WHO) standards, our results showed that (25%) children were malnourished/ underweight whereas (18%) were acutely malnourished i.e. wasted and (31%) were found to be chronically malnourished i.e. stunted. According to WHO “stunting is a result of long-term nutritional deprivation and often results in delayed mental development, poor school performance and reduced intellectual capacity” whereas “wasting in children is a symptom of acute under-nutrition usually as a consequence of insufficient food intake or a high incidence of infections, especially diarrhea. Wasting in turn impairs the functioning of the immune system and can lead to increased severity and susceptibility to diseases and increased risk of death.” So the high prevalence of malnutrition in these children is keeping them at continuous risk of developing secondary diseases which can compromise their quality of life and may lead to detrimental outcomes.
Majority of children on long-term ENS either do not receive or tolerate adequate amounts of energy for their needs. This may demonstrate ENS as being unable to provide optimum amounts of nutrients required for normal growth and development. To achieve catch up growth in medically fragile children dietary composition and especially maintenance of an ideal protein-energy ratio appears to be very important. Decreased enteral intake is often associated with deficiencies of specific nutrients like protein, vitamins and minerals. The clinical staff together with the parents should try to estimate the amount of actually administered feeds.
In medically fragile children ENS does not ensure adequate growth per se. The main reasons for this mismatch were limited tolerance, nausea, recurrent vomiting, gagging and retching. Therefore, ENS for medically fragile children requires highly specialized and individually tailored tube management and aftercare programs. These should include regular evaluation of growth parameters and caloric intake as well as re-evaluation and if necessary, the courage to make a change. The findings of this study also suggest that any child on enteral feeding should be monitored to recognize the point where adverse side effects might outsize the intended nutritional benefits.