Nutrition entérale à domicile en cas de troubles du comportement alimentaire

Weight restoration is crucial for successful treatment of anorexia nervosa (AN). Without it, patients may face serious or even fatal complications of severe starvation. Renutrition should take into account clinical characteristics unique to these patients, such as gastroparesis and fear of gaining body weight. The efficacy of tube feeding and home-tube feeding (Home-TF) has been suggested in AN and proven in bulimia nervosa (BN). TF and home-TF allow a better body weight gain (mainly fat-free mass) in AN patients and a strong decrease in the frequency and the intensity of binge-eating/purging episodes at relatively short-term (1 year) in BN patients. In AN, home-TF does not increase anxiety, depression, or worsen the eating behavior. In BN patients, home-TF decreases anxiety and depressive state and improves the quality of life. The goal of home-TF is not to cure the patients, but only to avoid serious malnutrition and its complications and to insure a better investment of the patients for their psychotherapy. Home-TF must be associated with psychotherapy, namely cognitive behavioural therapy and family therapy in adolescents. If the fear of gaining body weight is too high, the risk of failure of home-TF, because of poor compliance, is increasing. In any case, the aims and the goals of home-TF should be extensively explained.     

Nutrition entérale intermittente en réanimation

Intermittent enteral feeding is defined as the brief (20 to 60 minutes) and repeated (4 to 6 times daily) administration of enteral nutrition solution. This alternative, described as more physiological, seems to offer attractive benefits compared to the classic pattern of continuous administration, considered as a gold-standard in the ICU setting. Intermittent feeding seems to facilitate the achievement of daily energy targets and potentiate muscle anabolism in ICU patients, without increasing infectious complications or digestive side effects. No difference in terms of insulin consumption or glycemic variability has been reported in patients with intermittent enteral nutrition. Intermittent enteral nutrition may facilitate the accomplishment of mobilization sessions or physical exercise as part of an early functional rehabilitation strategy. Large randomized controlled trials are needed to incorporate this innovative technique into our daily clinical practice.     

Épidémiologie de la nutrition entérale à domicile chez l’adulte en France

French epidemiological data regarding home enteral nutrition (HEN) are not well known and give rise to imprecise estimates. In a first study, and using health insurance data based on NED specific packages (installation package, follow-up packages), we were able to determine the overall incidence and prevalence of the global population (children and adults). This second study targets the adult population to obtain more accurate data especially by trying to determine the pathologies associated with the NED.Patients and methodsA retrospective and observational study covering the year 2012 (from 01/01 to 31/12/2012) has been carried out, with the data of the adult population aged over 15 years, by defining three age groups: 15–39 years, 40–64 years, over 65 years. The databases of the health insurance allowed to obtain on the one hand, the number of patients who started a NED and on the other hand, the number of patients followed in NED. The target population (health insurance beneficiary population) being known, these data allowed to calculate incidence and prevalence, respectively. The data were also crossed with the thirty long-term diseases file of health national insurance (ALD 30), allowing patients to be classified into five categories: cancer, neurology, chronic intestinal inflammatory diseases, organ deficiency and others.ResultsData from 11 regions, totaling 21.8 million adults, were obtained. The average incidence and prevalence of NED was estimated at 29/100,000 hab/yr and 67/100,000 hab/yr, respectively. The main pathologies were cancer and neurology, but with variations depending on age groups. Inflammatory bowel diseases were the second cause of NED in the age range 15–39 years.ConclusionThis is the first reliable study on the epidemiology of NED in adults in France. The projection of these figures to the entire French adult population leads to an estimate of around 39,000 patients per year benefiting from national health insurance for HEN, mainly for cancer and neurological diseases.     

Épidémiologie de la nutrition entérale à domicile chez l’enfant en France

ObjectiveEpidemiologic data regarding home enteral nutrition (HEN) in children are scarce. The aim of this study was to determine the incidence and prevalence of HEN in children in France.MethodsThe total number of children < 15 years on HEN, and the number of new children who started HEN in 2012 were extracted from the French health insurance database. Data from ten French regions, totalling 4.96 millions children < 15 years (41% total French population < 15 years), were obtained.ResultsThe overall incidence and prevalence of HEN in children < 15 years were respectively 11.4 and 46.6 per 100,000 inhabitants per year. Main indications of HEN were neurological disorders (37%) and organ failure (20%).ConclusionThis is the first study reporting exhaustive epidemiologic data on HEN in children in France. The projection of this data to the total French population leads to an estimate of 6,000 children < 15 years on HEN per year in France.     

Nutrition entérale en réanimation : le point de vue du pédiatre

Malnutrition at admission is frequent in critically ill children and associated with impaired outcomes. Profound metabolic and hormonal shifts occur during critical illness; they are responsible for faltering growth, leading to pediatric intensive care acquired weakness with long-term consequences. Nutritional support is essential in this setting; enteral nutrition should be favored, with rare contra-indications and good tolerance in most children. Nutritional goals should be set using indirect calorimetry or Schofield equations. Early enteral nutrition is recommended, through a gastric tube. Enteral nutrition should be increased over a few days to meet the predefined goals, following local written guidelines. Polymeric products should be first choice, and iso- versus hyper-caloric solutions should be chosen depending on fluid restriction requirements. Tolerance should be closely monitored, but the use of gastric residual volume needs to be further studied.     

Prise en charge de la nutrition parentérale à domicile par une structure d’hospitalisation à domicile en région Rhône-Alpes

Hospital home care services are developed throughout the entire country. Despite minor variations in accesses and runnings, it shares the properties and duties of a classical structure of hospitalization. It has to be certified by the French Health Authority (« Haute Autorité de santé »), and has to organize the training of the stakeholders as well as the coordination of the activities shared with hospital departments. Due to the complexity of treatment programs and the high risk of specific adverse events, hospital home care services are required for the follow-up of patients receiving parenteral nutrition. Such a multidisciplinary approach (including the guaranty of 24 hours a day availability, the coordination of the stakeholders from both outside and inside the hospital, as well as the continuity of the caring process) is a useful alternative towards hospital admission. Medical treatments are delivered according to the good clinical practice rules. Medical practices are optimized thanks to the use of recommendations and standardized protocols shared by all the health professionals involved. The risk/benefit ratio of parenteral nutrition should be regularly discussed, recorded and evaluated.     

Conduite pratique devant une diarrhée en nutrition entérale

Diarrhea occurs in up to 70% of patients receiving enteral nutrition. Among numerous causes, a feeding tube in jejunal site, an irregular output and concurrent therapeutics are the most relevant. They can be corrected and need to be looked for. In all patients on enteral tube feeding changes in the intestinal flora occurs resulting in a short chain fatty acid deficiency that can participate in diarrhea. Interventions on flora with probiotics or prebiotics have proved to be of interest in the prevention of enteral nutrition-induced diarrhea, and represent a major therapeutic approach for the future.     

Nutrition parentérale et grossesse

Chronic intestinal failure is a rare disease and short bowel syndrome is its main etiology. Chronic intestinal pseudo obstruction (CIPO) is also a cause of IIC. Home parenteral nutrition (HPN) has improved survival and quality of life of patients with IIC. Some pregnancy during HPN have been reported. The aim of this review was to summarize the state of knowledge on pregnancy during HPN, and to resume the needed adaptations of treatments and PN. During long term HPN, pregnancy are possible but the complication rate, due to PN and to underlying disease, is high. A close follow-up end pregnancy preparation are necessary, in order to prevent and treat some deficiencies and their deleterious effects.     

Intérêt du régime méditerranéen : extrapolation à la nutrition entérale au long cours

The Mediterranean diet, defined by an abundant consumption of fruits, vegetables and fish, has a beneficial impact on health. Many observational studies show a decrease in overall mortality and a reduction in cardiovascular disease. Although the absence of interventional studies makes it difficult to evaluate its effectiveness, all results reveal a positive impact in terms of cardiovascular prevention. Thus, the idea of transposing the Mediterranean diet concept for enteral nutrition seems to be a relevant option.     

Nutrition parentérale et sclérose latérale amyotrophique (SLA)

IntroductionAmyotrophic lateral sclerosis (ALS) is a neuromuscular disease with a severe prognosis, leading to disorders that promote the occurrence of undernutrition. This is an independent factor of survival in this disease. However, the digestive tract is most often functional. For reasons of difficulty in setting up enteral nutrition, or refusal of patients, parenteral nutrition (PN) has been proposed in some cases. The objective of the study was to review literature data regarding PN during ALS.MethodThe various articles in the literature were analyzed in the framework of an interprofessional thematic workshop and a detailed review.ResultsThere were only three articles on this subject, all of French origin, mono or multicentric, and representing 161 patients. Only one article was in part prospective. Patients were selected on the usual indications of PN or the presence of a vital capacity < 50%, or the combination of frontotemporal dementia. Infusions were performed using injection sites or peripherally inserted central catheters (PICC lines). The supervision was medico-dietary. These were patients whose evolution had been long, and their life under PN was very short. The prevalence of PN-related infections was in the range of usual values, and that of thromboses was higher. The quality of life of patients was not specified.ConclusionsPN in ALS is possible in late-stage patients. The technique should be reserved for contraindications of enteral nutrition, but a case-by-case discussion is needed. The present study made proposals for practical recommendations.