Category Archives: Nutrition

Will Vitamin D Prevent Osteoporosis –Probably Not

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A recent excerpt from the NY Times regarding a study published online in The Lancet.  nyti.ms/1gnT1vz 

In a large review of studies, researchers have found almost no evidence that taking vitamin D supplements has any effect in preventing osteoporosis in middle-aged adults.

The analysis…included 23 randomized trials that measured the effect of vitamin D on bone density at four sites — spine, neck, hip and forearm — and included more than 4,000 generally healthy participants whose average age was 59.

The studies used dosages that varied from 500 units a day to 800 or more, given on varying schedules. In some studies, the subjects were given calcium as well.

Neither the pooled data nor any single study showed a significant increase in bone density across all four sites….The authors write that the widely believed idea that vitamin D promotes bone mineralization is probably incorrect.

“We’re not talking about people who are really vitamin D deficient,” said the lead author, Dr. Ian R. Reid, a professor of medicine at the University of Auckland in New Zealand. “But for healthy people focused on osteoporosis prevention, vitamin D does not make a positive contribution.”

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Sweetened Beverages -A Big Problem for Little Kids

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Many times we may look at a study and think that the results could easily have been anticipated.  Yet, there are many examples when our assumptions are flat-out wrong.

A recent study (Pediatrics 2013; 132: 413-20 -thanks to Jeff Lewis for this reference) helps solidify what we think we already knew, namely that sugar-sweetened beverages (SSB) contribute to weight gain in young children.  This study showed that 2-5 year-olds, followed in the Early Childhood Longitudinal Survey–Birth Cohort (n=9600), who had more frequent SSB consumption had higher BMI z scores by age four (P < .05) than infrequent/nondrinkers of SSB.  This study, for the first time, shows this effect in this younger population.

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Rett Reference

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JPGN 2013; 57: 451-60.  “Assessment and Management of Nutrition and Growth in Rett Syndrome”

  • This references expert recommendations from an international multidisciplinary panel.  “The level of evidence for the statements was low.”
  • “A body mass index of approximately the 25% can be considered a reasonable target in clinical practice.  Gastrostomy is indicated for extremely poor growth, if there is risk of aspiratrion and if feeding times are prolonged.”
  • There was no consensus with regard to fundoplication.  It should be used with “caution in those with significant air swallowing.”

Related previous post:

GI & Nutrition Problems in Rett Syndrome | gutsandgrowth

Nutrition Module

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More notes from this year’s postgraduate course:

Clinical issues in parenteral nutrition, Praveen S. Goday, MBBS, CNSC (page 105)

  • Fish‐oil vs minimizing soybean oil‐based lipid emulsions
  • Catheter‐related bloodstream infections (CRBSI): Ethanol locks “Humans like ethanol and bacterial don’t.”  Meta‐analysis:  In comparison with heparin locks, ETOH locks (various regimens) reduced the following: a) CRBSI‐rate per 1000 catheter days by 7.67 events (81% ↓)  b) catheter replacements by 5.07 (72% ↓), c) 108‐150 catheter days of ETOH lock exposure were necessary to prevent 1 CRBSI, d) Adverse events – rare and included thrombotic events.  Reference: Oliveira et al. Pediatrics 2012;129:318–329

Parenteral Drug Shortages: All PN products except dextrose and water have been in short supply at some point since spring 2010

Imported components from Europe (higher cost)

• Peditrace™ – zinc, copper, manganese, selenium, fluoride, and iodine

• Addamel N™ – zinc, copper, manganese, selenium, fluoride, and iodine, molybdenum, iron, and chromium

Summary / Take‐home points

  • Reduction in soybean oil emulsion or provision of fish oil emulsion results in improvement in cholestasis
  • Ethanol lock therapy decreases CRBSI in children on home PN
  • Significant PN shortages have affected our ability to care for our PN patients; thus need vigilance and good communication between physician, dietitian and pharmacist

Severe Obesity in Your Clinic: The disconnect between the epidemic and the intervention Sarah E. Barlow, MD, MPH (page 125)

What to do for obesity?

  • Behavior modification
  • Pharmacotherapy (and behavior modification)
  1. Orlistat (Xenical, Alli) -Enteric lipase inhibitor, FDA approved starting at age 12 years (OTC $200 per month)
  2. Approved for adults Lorcaserin (Belviq): 5-HT2C agonist
  3. Approved for adults: phentermine and topirimate (Qsymia)
  • Surgery (and behavior modification)
  • Meal replacement (and behavior modification)

Orlistat trial for adolescent obesity:

  • 54 week double-blind RCT
  • 539 subjects: 12 to 16 years of age, BMI 36 ±  4 kg/m2
  • BMI change kg/m2 (mean):  – .55  vs. + 0.31 for control
  • Fecal urgency (%) 20.7 (11.0 in controls)
  • Flatulence (%) 9.1 (4.4 in controls)
  • Fecal incontinence (%) 8.8 (0.6 in controls)
  • Reference: Chanoine et al. JAMA 2005;293:2873

Orlistat meta-analysis among adults :

  • -2.87 kg [95CI -3.21, -2.53] = placebo-subtracted change at 1 year
  • Reference  Rucker D. BMJ 2007;225:1194

Multiple potential medications are being studied

Selection criteria for adolescent bariatric surgery

  • Tanner stage IV or V
  • BMI ≥ 35 kg/m2 with severe
  • Comorbidity or BMI ≥ 40 kg/m2 with comorbidity
  • “Have failed” 6 month of organized attempts at weight loss
  • Committed to pre and post medical and psychological care
  • Supportive family
  • Able to give informed assent
  • Frequent barriers: Distance from center, Insurance, Age, Reluctance
  • Reference: Pratt Obesity 2009;17:901

Complications from Surgery

  • For all procedures: nutritional deficiencies, especially iron, vitamins B12, D, and thiamine
  • For gastric bypass: postprandial hypoglycemia in adults
  • For lap band: need for re-operation for slippage or erosion in adults and small adolescent study.
  • Also pouch dilatation
  • For sleeve gastrectomy: leak or bleeding along suture site

Summary

  1. 4% of children 6 to 19 are severely obese
  2. Severe obesity leads to high levels of cardiovascular disease risk factors, NAFLD, OSA, and pre-diabetes
  3. Behavior modification has modest efficacy, is a partner in all other intensive interventions, but is not readily available behavior modification is underutilized because it is time-intensive and resource-intensive.  It it is necessary even though it is not sufficient.
  4. Orlistat is the only medication currently available for adolescents.

 5 2 1 0

  • 5 servings of fruits and vegetables a day
  • 2 hours or less of screen time
  • 1 hour (60 minutes) or more of physical activity
  • 0 sugar-sweetened beverages

Postgraduate Course Syllabus (posted with permission): PG Syllabus

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.

TPN Drug Shortages -A Useful Reference

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A recent article in Today’s Dietician offers advice on drug shortages with TPN.

The following is a link (from a Kipp Ellsworth retweet) and an excerpt: http://t.co/CBKti0mNep

Lipids. Two US manufacturers produce three lipid concentrations  (10%, 20%, and 30%) of IV fat emulsions. The 30% concentration can be used only  in total nutrient admixtures. ICU patients receiving propofol can forgo IV fat  emulsions, since propofol is in a lipid-based emulsion that provides 1.1  kcal/mL, just like the 10% IV fat emulsion.

Since essential fatty acid deficiency doesn’t develop until  after two weeks of lipid-free PN, IV fat emulsions can be safely withheld for  the first two weeks if lipids are in short supply.1 After two weeks of  lipid-free PN, the minimum dose of IV fat emulsions, which is 100 g/week, can  be provided to prevent essential fatty acid deficiency.

IV fat emulsions should be discontinued in patients  tolerating EN and who don’t have malabsorption concerns.

IV Multiple Vitamins               When there’s a shortage of IV multiple vitamins, dietitians  should evaluate all patients for their ability to absorb enteral multiple  vitamin supplements in capsule, tablet, liquid, or chewable forms. For patients  who can’t absorb enteral vitamin supplements, the IV multiple vitamin dose  should be decreased from 10 mL to 5 mL/day to conserve supplies. If IV multiple  vitamins remain in short supply despite conservation efforts, the standard dose  of 10 mL should be given three times per week.2

If supplies have been exhausted, PN must be supplemented  intravenously with individual parenteral vitamins according to the following  ASPEN recommendations: thiamin: 6 mg; folate: 0.6 mg; ascorbic acid: 200 mg;  pyridoxine: 6 mg; and vitamin K: 0.5 to 1 mg/day or 5 to 10 mg/week.2 In  addition, cyanocobalamin (vitamin B12) must be given intramuscularly at least  once per month.2

Trace Elements               Combination trace elements and individual trace element  products offer alternatives to PN products in short supply.

Combination Multiple Trace Element Products               Dietitians have a choice of two different multiple trace  element combination products: MTE4 and MTE5. MTE4 products contain zinc,  copper, chromium, and manganese and come in a standard 3 mL dose or a 1 mL  concentrated dose. MTE5 products contain the same four trace elements with the  addition of selenium in either the standard 3 mL dose or the 1 mL concentrated  dose.

If there’s a shortage of the concentrated products, RDs can  use the standard 3 mL dose of MTE4 and MTE5. When MTE4 products aren’t  available, RDs can substitute the MTE5 products. If MTE5 products aren’t  available, RDs should substitute MTE4 products and add 60 mcg of selenium  individually to achieve the equivalent composition of MTE5.

…If no MTE products are available, individual trace elements  should be added to PN solutions.

Individual Trace Elements               Individual trace elements are used when combination trace  element products are unavailable…

There’s no need to supplement manganese when there are  shortages of multiple trace element products. Whole blood manganese levels  frequently are elevated in long-term PN patients, and manganese contamination  often occurs in other PN products. No alternative IV forms of chromium are  available but, like manganese, there may be some chromium despite the fact it  isn’t intentionally added because of its contamination potential in other PN  products. RDs can evaluate a patient’s ability to absorb chromium as part of  multivitamin and mineral supplementation through the enteral route and monitor  for signs of deficiencies.

Other than the selenium content of MTE5 products, selenium  is available as a single IV trace element product. When MTE5 products and individual  IV selenium products aren’t available, RDs can consider using oral selenium  supplementation.

Copper is available as a single PN trace element in two  forms: IV copper chloride or IV cupric sulfate. If all supplies of IV copper  have been exhausted, a patient should be evaluated for oral copper supplements.

Zinc is available in either IV zinc sulfate or IV zinc  chloride. It’s important to note that if zinc is given enterally in high doses,  RDs should monitor for a copper deficiency, as zinc and copper both compete for  absorption with the same carrier protein when EN is used….

— Mandy L. Corrigan,  MPH, RD, LD, CNSC, is a nutrition support dietitian with Coram Specialty  Infusion Pharmacy.

 Professional  Resources • American Society of Health-System Pharmacists Drug  Shortages Resource Center: www.ashp.org/menu/DrugShortages

• American Society for Parenteral and Enteral Nutrition Drug  Shortages Update: www.nutritioncare.org/Professional_Resources/Drug_Shortages_Update

• FDA Current Drug Shortages Index: www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm

• FDA Fact Sheet: Drug Products in Shortage in the United  States: www.fda.gov/RegulatoryInformation/Legislation/FederalFoodDrugandCosmeticActFDCAct/ SignificantAmendmentstotheFDCAct/FDASIA/ucm313121.htm

• FDA Frequently Asked Questions About Drug Shortages: www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050796.htm

• Fresenius Kabi Adult Multitrace Element Availability  (product information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM355392.pdf

• Fresenius Kabi Pediatric Multitrace Element Availability  (product information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM354265.pdf

• Fresenius Kabi Phosphate Injection Availability (product  information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM354277.pdf

• National Medication Errors Reporting Program (patients and  clinicians): www.ismp.org/orderforms/reporterrortoISMP.asp

 

For More Information               The following references can serve as viable resources for  dietitians to learn more about parenteral nutrition drug shortages and their  impact on patient safety and patient care:

• Buchman AL, Howard LJ, Guenter P, Nishikawa RA, Compher  CW, Tappenden KA. Micronutrients in parenteral nutrition: too little or too  much? The past, present, and recommendations for the future. Gastroenterology.  2009;137(5 Suppl):S1-S6.

• Corrigan ML, Kirby DF. Impact of a national shortage of  sterile ethanol on a home parenteral nutrition practice: a case series. JPEN  J Parenter Enteral Nutr. 2012;36(4):476-480.

• Holcombe B. Parenteral nutrition product shortages: impact  on safety. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):44S-47S.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical management interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.

NASPGHAN Preview

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I had a few free minutes so I decided to take a look at a bunch of upcoming lectures from the 2013 NASPGHAN upcoming meeting.  With electronic media, it is easy to take a quick glance.  Here’s the master link to all of the following talks:

Annual Meeting page.

Some of the power point lectures that I’ve seen so far:

  • Is my PPI dangerous for me? Eric Hassall MBChB, University of British Columbia One point in his slides that I had not seen much about was a hypothesis that PPI use may predispose to the development of eosinophilic esophagitis by allowing food proteins to be more intact ( attributed to Merwat, Spechler. Am J Gastro ’09).  He explains that “acid reflux” is a clever marketing term and has a slide with Madmen actors.  If there is “acid,” one must need acid suppression.
  • My child doesn’t go to school Lynne Walker MD, Vanderbilt University.  Lynne shows an interesting fax from a parent that asks if the problem is physical, how will she help? And, if it is psychological, how can this be remedied?  She outlines a lot of pain theory and indicates that parents need to become health coaches, avoid catastrophizing (?spelling), and encourages mental health evaluation.  Use the parents words ‘I’m going to refer xxx for relaxation and stress management.’
  • My child’s H. pylori will not go away – (the resistant bug) Benjamin Gold MD, Children’s Center for Digestive Healthcare. Ben manages to stuff so much information into his talk.  His talk is like one of those clown cars where more and more people keep coming out.  He has slides with worldwide resistance maps, slides with treatment regimens and algorithms, and the reasons for treatment failure. Perhaps I can convince him to give a live preview.
  • Administrative/executive functioning Richard Colletti MD, Fletcher Allen Healthcare. Offers personal and pragmatic advice for career advancement.  His slides indicate that he started his GI fellowship at age 40.  One of his quotes, “80% of success is showing up” (Woody Allen) is definitely true.  It’s pretty much akin to what I learned about success in medical school.  You need the three As: availability, affability, and ability.  My mentor said the first was what people needed most.
  • The changing face of intestinal transplantation
    Simon Horslen MD, Seattle Children’s Hospital.  Lecture notes that number of intestinal transplants have decreased dramatically, particularly in children. In 2012, only about 100 intestinal transplants were performed whereas it had peaked at nearly 200.  Much of the credit is due to intestinal rehabilitation work and adjustments in parenteral nutrition (eg. lipid minimization, line care).  Two most common reasons for intestinal transplantation at this time are gastroschisis and volvulus.
  •  Gluten sensitivity: Fact or fiction Alessio Fasano MD, MassGeneral Hospital for Children. This blog has covered a lot of the same material, but Alessio’s slides are pretty impressive.  Also, I was not aware that Lady Gaga consumes a gluten-free diet
  • Controversies in parenteral nutrition Christopher Duggan MD, Boston Children’s Hospital.  This lecture provides a timely update on nutrient deficiencies due to component shortages and discusses lipid minimization compared with fish oil-based lipid emulsions.
  • Vitamin D and immunity James Heubi MD, Cincinnati Children’s Hospital and Medical Center.  In the beginning of the slides, Jim provides a very user-friendly definition of an expert and a suitable picture.  He indicates that in 2011 there were 3746 vitamin D publications but inexplicably only chooses to review a tiny fraction.

At the time of this posting, I haven’t had a chance to look through these talks:

 

 

Growth after Liver Transplantation

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A retrospective chart review of patients from Australia and Japan who underwent liver transplantation between 1985-2004 provides some insight into the growth potential after liver transplantation (J Pediatr 2013; 163: 537-42).  The study included height data from 98 patients and weight data from 104 patients.

Study characteristics:

  • 58% were Australian and 42% were Japanese
  • 76 of 98 patients were transplanted for biliary atresia
  • 47% were younger than 2 years at the time of transplantation
  • Measurements were recorded pre-transplant, 1, 5, 10 and 15 years later

Findings:

  • Height recovery continued for at least 10 years to reach the 26th percentile (Z-score -0.67) 15 years after transplant.  Australian patients had better height recovery, reaching the 47th percentile (Z-score -0.06).
  • Weight recovery was most pronounced in 1st year after transplantation but also continued for 15 years.
  • The median height, weight, and BMI Z-scores are listed in Table II for all time periods
  • Those most malnourished and growth impaired at transplant exhibited the most catchup but remained significantly shorter and smaller 15 years later.

While the Australian patients had better growth in this study, this may be attributable to the fact that nearly all the Japanese in this study were transplanted before 1996 whereas Australian patients were transplanted over the entire period of the study.  Improvements in post-operative management with improved immunosuppressive treatment regimens (eg. reduced steroids) may have played a role.

Take-home message:  Most pediatric liver transplantation patients can expect to be normal-sized adults.  Those who are very malnourished at the time of transplantation, though, are likely to have some reduction in growth potential.

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Gastrostomy Tubes for Children with Cystic Fibrosis

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A recent report indicates that gastrostomy tubes (Gtubes) can be safe and useful for supplemental nutrition in children with cystic fibrosis (CF) and portal hypertension (JPGN 2013; 57: 245-47).

This small study from Australia was a retrospective study of their CF database from 1991-2011.  During this timeframe, 60 CF patients had gastrostomy tubes.  7 children had CF and portal hypertension.  The mean age of insertion was 10.6 years and all of these patients were pancreatic insufficient. Six of these 7 patients had percutaneous endoscopic gastrostomy (PEG); one had open surgical placement due to preexisting varices.  The median length of followup was 4 years.

Results:

  • No patients developed stomal varices
  • One patient had minimal cellulitis in the perioperative period, otherwise no complications were noted.
  • Two patients died related to advanced pulmonary disease
  • Three patients developed varices during the course of their care
  • Overall, there was improvement in BMI z-score at 2 years from -1.07 ± 0.87 to -0.58 ± 0.81 (p=0.05) and also at w years there was improvement in pulmonary function in 6 patients with mean FEV-1 going from 49.5 ± 12.6 to 62.3 ± 20.3 (P=0.04)

Take-home message: in a select group of 7 patients with Cystic Fibrosis and portal hypertension, gtube placement was safe and associated with better nutrition and lung function.

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More breastmilk, better development

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A recent study further explored breastmilk’s effect on infant cognitive and motor development in the French EDEN Mother-Child Cohort Study (J Pediatr 2013; 163: 36-42).

The authors acknowledge that previous studies have shown that breastfed children have  higher scores at tests on cognitive abilities; “however, some authors suggested that these results were due to the difference between the socio-demographic and occupational characteristics of mothers who breastfed and those who did not.”  Though, a large randomized trial (Arch Gen Psychiatry 2008; 65: 578-84) showed convincing data that a  longer duration of exclusive-breastfeeding duration improved children’s cognitive development.

So why did the authors bother with this study? The authors note that few studies have been performed in France where breastfeeding is less common than other European countries and their object of showing a dose-response relationship would further the arguments for causality.

Design: 1387 two-year-olds and 1199 three-year-old children were assessed from the EDEN cohort (2002 pregnancies) which prospectively collected data at birth, 4 months, 8 months,   1 year, and 2 years.

Results:

  • After adjusting for many confounding factors, infants who had breastfed scored 3.7 points higher on the Communicative Development Inventory (CDI) than infants who had never breastfed.
  • Longer breastfeeding duration was associated with better cognitive and motor development in 2- and 3-year-old children.  Each additional month of breastfeeding was associated with an increase of 0.75 CDI points and 1.00 in the Ages and Stages Questionnaire (ASQ).

Take-home message: Most studies, including the present, have shown benefits of breastfeeding on infant development.  In addition, there is likely a dose-response relationship.

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Elevated Celiac Serology Associated with Reduced Infant Birth Weights

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Using a population-based study of 7046 singleton pregnancies (from the Netherlands), the authors of a recent study have shown an inverse relationship between levels of anti-tissue transglutaminase IgA (TTG) antibodies and fetal growth (Gastroenterol 2013; 144: 726-35).

Results:

  • Newborns of positive TTG (>6 U/mL) weighed 159 g less at birth than newborns of mothers who tested negative for TTG.  In addition, newborns with mothers who had intermediate TTG levels ( 0.8 U/mL to 6 U/mL) had growth restriction of 53 g.
  • Among the intermediate TTG group, the results were more pronounced (2-fold greater) in those carrying the HLA risk molecules for celiac disease.
  • These birth weight changes were not associated with maternal nutritional status or deficiencies related to hemoglobin, iron, folate, or vitamin B12 deficiency.
  • Gestational age was not affected by TTG titers.

In the discussion, the authors note that other studies have shown that undiagnosed celiac disease increases the risk for intrauterine growth retardation; this risk can be eliminated by treating celiac disease.  The latter is a risk factor for lower neuropsychological performance.  This study was the first that took into effect the different TTG titers and correlated with additional nutritional parameters.

The authors speculate that celiac disease could have direct effects on the placenta.  In addition, other nutritional parameters could play a role such as vitamin D and calcium which were not included in this study.  Another important consideration is that celiac disease can result in increased miscarriages.  As a result, the “true” effect on newborn growth may be underestimated due to a “survivor bias.”

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