Lisa Cheng, MD
- Staff Physician
- Berkeley Emergency Medicine Group
- Berkelely, California
- Formerly, Senior Resident
- Denver Health Residency in Emergency Medicine
- Denver, Colorado
Digestive capacity appears to develop rapidly in term infants  and dietary fat supplementation can enhance gastric lipase in preterm infants  7 medications that cause incontinence purchase discount pepcid on-line. However symptoms of appendicitis generic 40 mg pepcid with amex, there has been a low uptake of this strategy as it involves intramuscular injections and these could be considered unethical in small infants if the benefit derived is seen as relatively small [33 medications like zovirax and valtrex order pepcid 20mg with mastercard,34] medicine ads purchase pepcid 20mg on line. Carbohydrate Many preterm formulas contain a mixture of lactose and glucose polymer to overcome the low lactase levels observed in preterm infants medicine 7 day box buy discount pepcid 20 mg on-line. Some work has been carried out looking at the addition of lactase to feeds but a systematic review concluded that there is no evidence of benefit and that more studies are needed  medications epilepsy purchase pepcid online pills. Other data indicate that feeding a lactose containing milk will aid precocious development of lactase activity and hence feed tolerance . Vitamin D Very high enteral intakes were thought necessary to avoid development of bone disease of prematurity, but experimental trials of high vs. A recent study demonstrated that even a population from Preterm Infants 77 northerly latitudes, likely to have a lower range of vitamin D status at birth, did well on 10 g/day . The upper limit is not encouraged, but is included as the upper tolerable amount recommended for term infants. Vitamin E There has been debate concerning the need for routine supplementation of preterm infants as some maintain an adequate status on unfortified breast milk. Interest in prevention of diseases thought to be associated with insufficient antioxidant defences led to trials of pharmacological doses. Nevertheless, a recent systematic review concluded that this strategy was not to be recommended . However, when supplements are added, their solubility will affect the relative amounts given. It is worth remembering that while there are several restraints on calcium absorption, phosphorus economy is controlled largely at the renal level and, because of the high soft tissue requirements for phosphorus, it may be needed in large amounts . An important adjunct to appropriate nutrition for bone health may prove to be controlled physical activity  but this needs further careful evaluation. Iron Iron stores are low in preterm infants and without supplementation they will become depleted by 8 weeks . Although the early anaemia of prematurity is not affected by iron supplementation, there is some evidence that infants supplemented by 2 weeks have better iron status at discharge . Despite high ferritin levels after blood transfusions this stored iron may not be readily available for haemopoiesis, therefore (although not stipulated by Tsang et al. However, more may be needed for those who were smallest at birth and those who were sickest, because of lower iron stores and higher iron losses through multiple blood tests. As a result of the interactions of iron, copper and zinc during absorption, excessive amounts of each individual nutrient should be avoided. Calcium, phosphorus and magnesium the fetus acquires 80% of the normal term body levels of calcium during the last trimester  and preterm infants have very high requirements for calcium and other minerals needed for bone formation. It has been suggested it is desirable to supply these minerals at the same levels as those that cross the placenta, although intrauterine retention rates may be achieved with lower intakes . Contrary to earlier assumptions, inadequate mineral supply may be more important with respect to bone health in preterm infants than vitamin D . Low plasma phosphate levels in particular seem to indicate higher risk of bone disease in this group and the aim should be to keep levels >1. Excessive calcium supplementation should be avoided because of the risk of interaction with fatty acids leading to calcium soap formation in the gut, particularly in formula fed babies. Calcium soaps are a risk for both intestinal bolus obstruction and reduced fat absorption [42,43]. Although a specific calcium: phosphorus ratio is not recommended , the authors discuss factors Zinc Zinc is an important component of many enzyme 78 Clinical Paediatric Dietetics systems and is essential for subcellular metabolism. Skeletal muscle stores are low in preterm compared with term infants and skeletal muscle accounts for 40% of body zinc stores . Renal losses may be high because of repeated acute phase protein responses  and diuretic therapy . Intake should not be increased above that available from current formulas until evidence on outcome is available. Nucleotides Selenium Selenium is a component of the antioxidant enzyme glutathione peroxidase and is important in thyroid metabolism . Selenium status is low at birth in preterm infants  and in theory puts them at risk of diseases thought to be related to oxidative damage. However, a large trial found no differences in markers of oxidative stress between supplemented and unsupplemented groups . A systematic review concluded that supplementation was associated with a small reduction in sepsis rates, but no other benefit . Nevertheless, it is important to ensure that guidelines are followed to prevent deficiency . Nucleotides are a constant component of mammalian milks and may be conditionally essential for the gut and immune system during times of stress . This reflects the fact that the European Union has recognised nucleotides as semi-essential components of initial formula. However, in the preterm population supplemented formula requires further evaluation . Glutamine Glutamine is an important fuel for the small intestine and immune system and possibly becomes rate limiting during increased demand . A large series of controlled trials have now been conducted to allow a conclusive systematic review which recommends that supplemental glutamine is of no benefit to preterm infants . Iodine the only major role of iodine is in thyroid metabolism, but as hypothyroidism is associated with poor neurodevelopmental outcome it is essential to ensure a good status. There is risk of deficiency with unsupplemented preterm formulas , although the relative role of iodine supply compared with other factors related to preterm birth are not yet clear . Above a 12 mg/kg/minute glucose infusion Conditionally essential nutrients Beta-carotene No recommendations for the addition of betacarotene to preterm formula exist although its presence in human milk, its role as an antioxidant and its provitamin-A activity have prompted some infant formula manufacturers to add it. The unoxidised glucose would be used for lipogenesis which is an inefficient use of energy. However, raised blood glucose and triglyceride levels are common in sick preterm infants. Insulin is often given, but should not be used to aid tolerance of >12 mg/kg/minute glucose. Reduction of lipid infusion in response to lipaemia should be as brief as possible to minimise suboptimal energy, fat-soluble vitamin and essential fatty acid intake. There is a high risk of bone disease of prematurity when solutions containing inadequate levels of calcium and phosphate are given. For this reason, interest is growing in organic mineral salts such as glycerophosphate which allow larger amounts of mineral to be delivered because of their high solubility. Parenteral solutions should be protected from high light exposure and this should help to minimise photodegradation of susceptible nutrients and production of toxic hydroperoxides. Despite the theories that many of the diseases found in preterm infants may be linked to oxidative stress, there is much contradictory evidence and more work is needed , but it still seems advisable to reduce a large oxidative load. Mixing the intravenous vitamin preparations with the lipid helps reduce degradation  and increase delivery of some of the vitamins and may protect against lipid oxidation . However, there is now greater awareness of the high risk of zinc deficiency so it should always be included. In addition, zinc can be lost in large quantities via the renal route when given parenterally [6,76]. Human milk Human milk has been evaluated for the feeding of preterm infants in many studies, but in a systematic review most were excluded because of methodological flaws in both design and execution, leaving just one to review . There may be long term neurodevelopmental advantages in feeding human milk [86,87]. Human milk may be nutritionally adequate in many respects for infants >1500 g when fed in sufficient volumes. However, in infants <1500 g several nutrients may be limiting, particularly protein, and some minerals and vitamins. Individual requirements can vary considerably so the dose should be titrated according to serum biochemistry. Protein fortification can be considered once serum urea reaches 2 mmol/L after a consistent fall. Although not all fortifiers have undergone sufficiently large trials, one North American product supported growth and was well tolerated . A systematic review of available studies concluded that fortifiers promote short term growth, and that despite a lack of longer term outcome data it was unlikely that further trials would be carried out with an unfortified breast milk group . Choosing a fortifier that brings human milk nutritional composition to within the Tsang guidelines will negate the need for separate additions of most minerals, vitamins and protein. Fortification should occur as close to feeding time as possible to minimise interference with immunological factors . Routine supplementation of human milk with energy alone is not advised as there is a risk of reducing the protein: energy ratio to an unacceptably low level, particularly after the first 2 weeks of lactation. Occasionally, expressing technique may need improving to ensure all the hind milk is removed at each expression, thus avoiding a low fat and therefore low energy milk. When a mother is expressing milk of a lower fat content than average, a result can be that her infant has poor weight gain despite a serum urea level in the normal range. As yet there is not a bedside method for evaluating breast milk composition, although one group has shown improved weight gain when the latter half of each milk expression is fed preferentially . There are no firm guidelines on how long fortification should continue and criteria include until the infant is feeding fully from the breast and thriving, or around a weight of 2. Preterm formulas For those infants <2000 g birthweight who do not have access to human milk the feed of choice is a preterm formula. However, it is not advisable to mix and store human milk and formula for prolonged periods. There has been some work suggesting that hydrolysed protein formulas lead to shorter gastrointestinal transit times compared with whole protein  and might be preferable. This has resulted in reduced time taken to reach full feeds in one trial , although breast milk led to the largest cumulative feeding volume when compared with either milk formulas . Preterm formulas are highly specialised feeds designed to meet the increased nutritional needs of preterm infants without exceeding volume tolerance. Some formulas will need supplementing with iron in order to comply fully with the most recent guidelines, and although all contain sufficient folic acid many units appear to continue giving supplements. There is a wide variation between neonatal units as to the age and weight at which preterm formula is stopped. Using the upper weight limit may shorten time to achieve catch-up growth and allow infants to achieve the nutrient intake they need without having to take very large feed volumes . It is important to remember that at any age or weight each individual baby may need assessment to decide on the optimum formula. The composition of breast milk is variable and these figures should be used with caution when considering the individual infant. When looking at the data for long term outcome there is evidence that early very poor growth is detrimental to later development, but that breast milk can ameliorate these effects [86,87,104], hence reinforcing the recommendation that wherever possible breast milk should be used. In addition, recent data indicate that early rapid growth may 82 Clinical Paediatric Dietetics Table 6. Preterm Infants 83 lead to increased risk factors for cardiovascular disease later in life [105,106]. More evidence is needed before a truly aggressive nutritional approach is employed routinely. There are advantages and disadvantages to both bolus and continuous gastric tube feeding with a recent systematic review unable to give a firm recommendation of one method over the other . Boluses have been associated with less feed intolerance , but they may lead to a deterioration in respiratory function (resulting from gastric distension) in very compromised infants when compared with continuous feeds . Continuous feeding of human milk can lead to excessive fat loss  and risk of sedimentation of added minerals. An alternative method has been shown to work well; this involves 2-hour slow infusion every 3 hours and has led to improved feed tolerance . Transpyloric feeding is not recommended for routine use because of adverse outcomes in preterm infants . For some infants, particularly those who have been very unwell, the transition to nipple feeding, either breast or bottle, is very difficult. Liaison with an experienced speech and language therapist is invaluable in these circumstances. There has been much investigation into its aetiology because of its high mortality and morbidity rates. It appears to be triggered by a combination of one or all of the following factors: prematurity, hypoxia, gut ischaemia, gut bacterial overgrowth, disturbance of gut bacterial balance, sepsis, feeding of formula milk and over rapid advancement of enteral feeds. Chronic lung disease Chronic lung disease, previously known as bronchopulmonary dysplasia, is a disease first described following the survival of mechanically ventilated infants. It is now only the most immature and compromised at birth who sustain this disease. The result is a requirement for prolonged ventilatory support and possible discharge home on nasal prong oxygen. Elevated energy expenditure has been closely associated with respiratory status in one study , but not in another .
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- Pacemaker, a device that senses when your heart is beating irregularly, too slowly, or too fast. It sends a signal to your heart that makes your heart beat at the correct pace.
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The effect of dietary fat medications starting with p generic 40mg pepcid mastercard, antioxidants medicine expiration dates cheap pepcid 40mg on line, and pro-oxidants on blood lipid symptoms 3 dpo buy pepcid 40mg otc, lipoproteins symptoms quotes purchase 20mg pepcid with visa, and atherosclerosis treatment xanax overdose best purchase pepcid. A randomized trial comparing the effect of casein with that of soy protein containing varying amounts of isoflavones on plasma concentrations of lipids and lipoproteins medications hydroxyzine order on line pepcid. A comparison of the effects of 2 doses of soy protein or casein on serum lipids, serum lipoproteins, and plasma total homocysteine in hypercholesterolemic subjects. Provitamin A carotenoid intake and carotid artery plaques: the Atherosclerosis Risk in Communities Study. Dietary antioxidant vitamins and death from coronary heart disease in postmenopausal women. Effect of Supplemental Antioxidants Vitamin C, Vitamin E, and Coenzyme Q10 for the Prevention and Treatment of Cardiovascular Disease. Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality. Effects of long-term vitamin E supplementation on cardiovascular events and cancer: a randomized controlled trial. Use of antioxidant vitamins for the prevention of cardiovascular disease: metaanalysis of randomized trials. Total plasma homocysteine level and risk of cardiovascular disease: a meta-analysis of prospective cohort studies. Effect of homocysteine-lowering therapy with folic acid, vitamin B12, and vitamin B6 on clinical outcome after percutaneous coronary intervention: the Swiss Heart study: a randomized control trial. Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. Beneficial effects of a diet high in monounsaturated fatty acids on risk factors for cardiovascular disease. Serum lipid response to the graduated enrichment of a Step I diet with almonds: a randomized feeding trial. Plant stanol esters affect serum cholesterol concentrations of hypercholesterolemic men and women in a dose-dependent manner. Decrease in plasma low-density lipoprotein cholesterol, apolipoprotein B, cholesteryl ester transfer protein, and oxidized low-density lipoprotein by plant stanol ester-containing spread: a randomized, placebo-controlled trial. Changes in myocardial perfusion abnormalities by positron emission tomography after long-term, intense risk factor modification. Estimated effects of reducing dietary saturated fat intake on the incidence and costs of coronary heart disease in the United States. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: the Evidence Report. Position of the American Dietetic Association and Dietitians Canada: Dietary fatty acids. Pork: center-cut ham*, loin chops and tenderloin Luncheon meats at least 95% fat-free Egg whites, cholesterol-free egg substitute Reduced cholesterol eggs or egg substitutes Fat-free or 1% fat milk and buttermilk, low-fat or nonfat yogurt, fruited or frozen (1% or less milk fat) Eggs Milk and Dairy Products (2 to 3 serving/day) Low-fat cheese: any cheese labeled 2 to 6 g of fat per oz, part-skim mozzarella cheese, cottage cheese (1% or 2%) or, part-skim ricotta cheese (1/4 cup) *High in salt. Cookies: graham crackers, gingersnaps, animal crackers, fig bars, vanilla wafers Pudding made with fat free milk Hard candy *High in salt. Indications A fat-controlled diet is indicated for individuals who are unable to properly digest, metabolize, and absorb fat. Common diseases of the hepatobiliary tract, pancreas, intestinal mucosa, and lymphatic system impair fat digestion, metabolism, and absorption (1-5). A low fat-diet may also be useful in the treatment of patients with gastroesophageal reflux (4,6). Contraindications In pancreatic insufficiency, enzyme preparations remain the primary treatment for steatorrhea. As normal a diet as possible is encouraged to increase the likelihood that a nutritionally adequate diet will be consumed (5,7,8). The treatment of choice for gallstones at the present time, where indicated, is surgery. There is no reason in the postoperative period to restrict or modify fat intake in any way. However, the requirement for vitamin E is proportional to the intake of polyunsaturated fatty acids, which will also be reduced in a Fat-Controlled Diet. Ordering the Diet Order as "Low-Fat Diet" or "50-Gram-Fat Diet" can be ordered (this is sufficiently restricted for many indications). Effectiveness of enteric coated pancreatic enzymes given before meals in reducing steatorrhea in children with cystic fibrosis. Bile salts or micelles are not required for dispersion in water and subsequent absorption (2). If patient is prescribed a ketogenic diet, use sugar-free beverages and follow fluid restrictions. Implementing a ketogenic diet based on medium-chain triglyceride oil in pediatric patients with cancer. Foods that have been defined in qualitative terms as having tough fibers are also eliminated. Animal products, refined grain products and cereals (providing < 2 g/serving), and selected fruits and vegetables are included. Due to no scientifically acceptable definition of residue and the lack of widespread availability of resources to provide this information, the term is no longer used by the Academy of Nutrition and Dietetics (1,2). Since fiber content of the diet can be estimated from food composition tables, "low fiber diet" is the preferred title of this diet and used throughout this manual (1,2). Indications To prevent the formation of an obstructing bolus when the intestinal lumen is narrowed. The goal of nutrition therapy is to establish tolerance to a wider variety of foods and to make a transition to a regular diet. Contraindications A fiber-restricted diet is contraindicated when a soft stool is desired, as in individuals with diverticulosis. If a soft texture is desired, as in the case of a patient with esophageal narrowing, a mechanical soft diet may be ordered. However, for individuals with inflammatory bowel disease who present with a primary or secondary lactose deficiency, a low-fiber, low-lactose dietary restriction may be appropriate. Select cereals, grains and bread products, and vegetables that are low in fiber (< 2 g fiber/serving) 2. For patients with a lactose intolerance, dairy products may need to be avoided or limited 3. Whole milk, half and half, cream, sour cream, regular ice cream Whole-wheat, rye, pumpernickel or bran breads, crackers, muffins Buckwheat pancakes Rye wafers Breads and crackers containing fruit, nuts, or seeds Brown rice; barley Wheatena, rolled wheat, and other wholegrain cooked cereals Ready-to-eat whole-grain, oat and bran cereals including bran flakes, granola, Grape-Nuts, oat bran, 100% bran, puffed wheat, shredded wheat, wheat bran, wheat flakes, wheat germ Prune juice. Juice with pulp Fruit Juices (0 gm fiber/serving per allowed foods) No limit of allowed foods Fruits (2. Banana, applesauce Canned and well cooked fruits All fresh fruits except banana Mushrooms (cooked) Tomato/vegetable juice Tomato sauce Canned and well cooked vegetables except those on the Foods to Exclude list Meat, Fish, Poultry, Cheese, Eggs (0 gm fiber/serving) No limit of allowed foods Tender, well-cooked meats, poultry, fish, eggs, and soy prepared without added fat. Smooth nut butter Raw or fried vegetables Broccoli Corn Mixed vegetables Skin of potato Brussel Sprouts Cabbage Cauliflower Succotash (also see legumes) Collard, mustard, and turnip greens Avoid fried meat including sausage and bacon. Luncheon meats, such as bologna or salami, hot dogs, tough or chewy cuts of meat, fried eggs, all dried beans, peas, and nuts, Chunky nut butters. A high-fiber diet emphasizes the consumption of dietary fiber from foods of plant origin, particularly minimally processed fruits, vegetables, legumes, and whole-grain and high-fiber grain products. A plant-based diet may also provide other nonnutritive components such as antioxidants and phytoestrogens that have implications as health benefits (1). Dietary fiber intake in the United States continues to be at less than the recommended levels, with an average daily intake of only 15 g (1,2). The American Academy of Pediatrics recommends that children 2 years and older consume a daily amount of fiber equal to or greater than their age plus 5 g (1). Some definitions are based primarily on analytical methods used to isolate and quantify dietary fiber, whereas others are physiologically based (1). Crude fiber is the amount of plant material that remains after treatment with acid or alkali solvents. It is predominantly a measure of the cellulose content of a food and, as such, significantly underestimates the total dietary fiber found in plant food. For labeling purposes in the United States, dietary fiber is defined as the material isolated by analytical methods approved by the Association of Official Analytical Chemists. Although the Institute of Medicine recommends that the terms soluble and insoluble fiber not be used (2), food labels still may include soluble and insoluble fiber data (1). The Panel on the Definition of Dietary Fiber under the Food and Nutrition Board of the National Academy of Sciences has developed definitions for dietary fiber, functional fiber, and total fiber. Dietary fiber is the nondigestible component of carbohydrates and lignin naturally found in plant foods (2,5). Functional fiber refers to fiber sources that have similar health benefits as dietary fiber, but are isolated or extracted from natural sources or synthetic sources (2,5). The intent of these definitions is to recognize the physiologic actions of fiber and its demonstrable health effects and to reduce the emphasis on dietary fiber as a constituent of food requiring quantification (2,5). There has been a trend to assign specific physiologic effects either to soluble or insoluble fibers (5). This approach makes it difficult to evaluate the effects of fiber provided by mixed diets (5). In addition, soluble and insoluble fiber foods often have similar benefits vs independent benefits that affect health outcomes. For example, both psyllium seed husk, an insoluble fiber source, and oat bran, a soluble fiber source, increase stool weight, improve laxation, and lower blood cholesterol levels (1). Only the viscous soluble fibers (not all soluble fibers) are hypocholesterolemic agents (1). Indications and Nutrition Intervention Guidelines Constipation and normal laxation: Consumption of dietary fiber is a frequently prescribed nutrition intervention for the prevention or treatment of constipation. Many fiber sources; including cereal brans, psyllium seed husk, methylcellulose, and a mixed high-fiber diet increase stool weight, thereby promoting normal laxation (1,6). The increase in stool weight is caused by the presence of fiber, the water that the fiber holds, and the partial fermentation of the fiber, which increases the amount of bacteria in stool (7). The large intestine responds to the larger and softer mass of residue produced by a high-fiber diet by contracting, which moves the contents toward excretion (1). Fiber in mixed diets, legumes, and whole-grain and high-fiber grain products are particularly effective promoters of normal laxation (1). A fiber supplement may be needed when food intake is low, as in the case of inactive older adults (1). Many foods are natural laxatives because they contain indigestible carbohydrates and other compounds with natural laxative properties; these foods include cabbage, brown bread, oatmeal porridge, fruits with rough seeds, vegetable acids, aloe, rhubarb, cascara, senna, castor oil, honey (fructose), tamarinds, figs, prunes, raspberries, strawberries, and stewed apples (1). Fluid intake, exercise, stress, and relaxation also influence fecal elimination and should be considered when a dietitian is planning treatment. Diverticulosis: Diverticular disease of the colon is thought to occur secondary to increased intracolonic pressure caused by hard, dry fecal material and the increased effort necessary to eliminate this type of stool. Well-controlled, experimental studies confirming the benefits of a high-fiber diet in the prevention and management of diverticular disease are relatively few, with less than conclusive results. One study found that 90% of patients with diverticular disease remained symptom-free after 5 years on a high-fiber diet (1,8). This result may be explained by the fact that a high-fiber diet promotes the formation of soft, large stools that are defecated more easily, resulting in lower colonic pressure and less straining during elimination (1). Also, a high-fiber diet may reduce the chance that an existing diverticulum will burst or become inflamed (1). The National Institute of Diabetes and Digestive and Kidney Diseases recommends 20 to 35 g of fiber each day for the management of diverticular disease (1,9). Mild pain medications may help to relieve symptoms; however, many pain medications affect the emptying of the colon, an undesirable side effect for people with diverticulosis (9). To increase stool bulk, studies suggest increasing the consumption of whole-grain breads, cereals, and brans. In cases of diverticulosis, a common practice has been to provide a high-fiber intake that excludes the hulls of nuts, corn, and seeds because they may get trapped in the diverticula (1). However, a recent study found that the consumption of nuts, corn, and popcorn was not associated with an increased risk of complicated diverticular disease. Instead, the researchers observed inverse relationships between nut and popcorn consumption and the risk of diverticulitis (10). According to the National Institute of Diabetes and Digestive and Kidney Diseases, "foods such as nuts, popcorn hulls, and sunflower, pumpkin, caraway, and sesame seeds have been recommended to be avoided by physicians out of fear that food particles could enter, block, or irritate diverticula, however this is not validated by the research" (9). Poppy seeds and seeds in tomatoes, zucchini, cucumbers, strawberries, and raspberries are generally considered harmless (9). The recommendation to avoid nuts, seeds, corn, and popcorn in diverticular disease should be reconsidered (11). Patients who present with rectal bleeding, weight loss, iron deficiency anemia, nocturnal symptoms, and a family history of selected organic diseases (colon cancer, inflammatory bowel disease, or celiac disease) should undergo medical testing to exclude underlying causes (12). Certain antispasmodics (hyoscine, cimetropium, pinaverium, and peppermint oil) may provide short term relief of abdominal pain and discomfort (12).
These grades 5 medications related to the lymphatic system proven pepcid 20 mg, which are based on the quality and extent of the research treatment 3 phases malnourished children discount 40mg pepcid free shipping, are a tool for practitioners to use when determining the certainty of information medicine 44-527 order pepcid online from canada. Uses large number of subjects; outcomes directly related to question; statistical difference is large and meaningful; can be generalized to population of interest symptoms by dpo order pepcid. Grade V Practitioner should exercise judgment and be alert to emerging Insufficient evidence publications that report evidence that clarifies the balance of benefit vs medications jock itch order genuine pepcid on line. Also treatment 8mm kidney stone buy pepcid line, the recommendations that are graded may be frequently updated as evidence emerges. The grading information is provided to assist practitioners in making decisions about clinical care and interventions. Grading information should complement clinical decision-making, not replace sound clinical judgment or expertise. This section also contains information (eg, medical diagnostic tests or laboratory indexes) that may not necessarily be mentioned in the nutrition assessment care plan. In conclusion, the approaches mentioned for each condition are suggestions that should not be interpreted as definitive nutrition therapy for the given condition. The evidence grades are provided to guide clinical decision-making and the selection of optimal nutrition approaches. Medical approaches are listed with medical nutrition therapy approaches to create an awareness of coordinated therapies. To form the basis for the development of disease- or condition-specific protocols and nutrition prescriptions as required by the organization. By inhibiting the action of vitamin K, there is a reduced risk of abnormal blood clotting. Indications Oral anticoagulants are typically prescribed for the primary and secondary prevention of the following conditions: venous thrombosis pulmonary embolism myocardial infarction Persons with prosthetic heart valves, atrial fibrillation with embolization, or heredity disorders that result in a hypercoagulant state may be treated with anticoagulants indefinitely (1,2). Nutrition Implications of Anticoagulant Therapy the goal of medical nutrition therapy for persons receiving anticoagulant therapy is to provide a consistent intake of vitamin K. The Daily Value can be used as an appropriate goal for persons on anticoagulant therapy (3,4). The average dietary intake of vitamin K for adults in the United States is estimated to be 90 to 118 mcg/day (5-7). Persons who receive anticoagulant therapy should limit their consumption of foods that have a high level of vitamin K. The list of drugs that interact with vitamin K antagonists is constantly expanding (7). Drug-drug interactions that increase or decrease the effect of anticoagulant therapy should be evaluated before concluding that dietary intake is responsible for a change in the anticoagulant response (2,5,7). Drugs that increase the anticoagulant effect are agents for gout treatment, anabolic steroids, antiarrhythmic agents, antibiotics, antifungal agents, antihyperlipidemic agents, cimetidine, disulfiram, isoniazid, omeprazole, sulfonylureas, and tamoxifen citrate. Drugs that decrease the anticoagulant effect are anticonvulsant agents, cholestyramine, griseofulvin, oral contraceptives, rifampin, sucralfate, and vitamin K (5,8). After the dose is established, a reasonable goal is to maintain the daily vitamin K intake within 250 mcg of baseline (1,9). If major changes in food intake occur, the anticoagulant level may need to be reestablished. Vitamin K intake may increase when a patient starts a weight-reduction diet and includes a greater number of vegetables that are high in vitamin K or begins a high-protein, low-carbohydrate diet (see discussion below). Other reasons for an increased vitamin K intake may include an adjustment in diet because of hospitalization or a change in seasonal eating patterns (1). Unlike other fat-soluble vitamins, stores of vitamin K are rapidly depleted if intake is deficient (1). This information should be considered when assessing the vitamin K level of a patient who has had a low intake of food for a week or longer, as may occur in the hospital setting. Nutrition Intervention and Monitoring Patients should be educated about the dietary changes that impact anticoagulant therapy. Patients should be encouraged to keep their diet consistent with their present pattern. Therefore, these foods and other foods and beverages not listed (including coffee and tea) may be consumed as desired (9). Consuming more than 3 servings of alcoholic beverages per day can increase the effect of warfarin (9). Limiting or avoiding alcohol may be advised, and persons who do consume alcohol should consult with their physician. This increase may result in more warfarin binding to serum albumin, thereby decreasing the anticoagulant effect of warfarin (12). Patients receiving warfarin therapy should be monitored and educated about the potential interaction that occurs with warfarin and high-protein, low-carbohydrate diets (12). In addition, persons who take vitamin and mineral supplements containing vitamin K should be monitored. Vitamin and mineral supplements that are taken consistently pose less of a problem than supplements that are taken sporadically (9). Persons taking or considering taking vitamin E supplements should consult with their physician. Enteral nutrition: Patients who are receiving enteral nutrition support while on anticoagulant therapy should be monitored closely. Significant vitamin K intake from enteral formulas can antagonize the effect of the anticoagulant drug warfarin and result in treatment failure (6). Most enteral formulations contain modest amounts of vitamin K and provide daily vitamin K intake similar to the average dietary intake from foods (6). Consistent intake of an enteral formulation containing less than 100 mcg of vitamin K per 1,000 kcal is not expected to cause warfarin resistance (6,8). However, warfarin resistance can occur in patients on enteral nutrition support whose intake of vitamin K is substantially low (13). This resistance may occur as a result of warfarin binding to protein contained in the enteral formula; however, this mechanism has not been substantiated by clinical data (13,14). A reasonable approach to treating warfarin resistance associated with a low vitamin K intake is to initiate a trial of holding the enteral nutrition regimen for at least 1 hour before and after the warfarin dose (13,14). Silver Spring, Md: American Society for Parenteral and Enteral Nutrition; 2012; page 309. Important Information To Know When You Are Taking: Warfarin (Coumadin) and Vitamin K. Committee on Safety of Medicine and the Medicines and Healthcare Products Regulatory Agency. Decreased warfarin effect after initiation of high-protein, low-carbohydrate diets. Reversal of osmolite-warfarin interaction by changing warfarin administration time. Warfarin resistance and enteral feedings: two case reports and a supporting in vitro study. Aggressive nutritional support is required to meet metabolic demands, prevent the depletion of body energy and nitrogen stores, support wound healing, enhance immunity, and improve survival (1-3). Energy requirements increase linearly in proportion to burn size to a maximum of approximately twice the normal levels (1). Factors such as agitation, pain, and heat loss during dressing changes are associated with a large increase in energy expenditure (1). Approaches Energy requirements in adults: Many formulas are available to determine energy requirements. Unfortunately, many of these formulas have not been validated for the burn population (1,3). This figure provides the total energy expenditure for which the clinician would base the nutrition prescription. If indirect calorimetry is not available, evidence based guidelines recommend using predictive equations considering age (< 60 years or age, or > 60 years of age) and whether the patient is obese or non-obese. The Academy currently suggests (listed in order of accuracy) Penn State (2003b), Brandi equation, Mifflin St Jeor Equation x 1. However, the Curreri equation has not been recently tested for measures of reliability and validity (6). Clinicians should recognize the values obtained from all predictive equations are approximate and should be used only as guidelines in predicting energy requirements in burn patients (1-3). Chemical neuromuscular paralysis decreases energy requirements of critically ill patients by as much as 30% (3). As previously mentioned, the Curreri formula is a tool for specifically deriving the energy needs of burn patients (7,8). The Curreri equation appears to be most accurate in assessing energy requirements during the early postburn phase (7-to-10 days postburn), when energy expenditure is at its maximum (7,8). Because the equation has not been validated in recent years, the clinician should consider using multiple equations known to be validated (eg, Brandi equation) and compare averages with Curreri if it is used. Energy requirements in children: Indirect calorimetry, if available, should be used on admission to the hospital and twice weekly thereafter until the patient is healed. The Curreri junior formula is designed for burns of less than 50% total body surface area. Age 0 to 1 year: Age 1 to 3 years: Age 3 to 15 years: Basal kcal + 15 kcal x % Burn Basal kcal + 25 kcal x % Burn Basal kcal + 40 kcal x % Burn Protein requirements: Protein needs of burn patients are directly related to the size and severity of the burn. The increased protein demand is necessary to promote adequate wound healing and to replace nitrogen losses through wound exudate and urine. Failure to meet heightened protein needs can yield suboptimal clinical results in terms of wound healing and resistance to infection. Infants and children further adapt to inadequate protein intake by curtailing growth of cells, conceivably sacrificing genetic growth potential. The clinician should realize daily variances that cause protein breakdown such as surgery, infections and sepsis. Most likely, aggressive nutrition support (eg, enteral nutrition feedings) will be necessary to achieve this goal. Over time as wound closure is achieved, protein needs can taper and a range of +2 to +4 is acceptable for a wound < 5% open (3). Children Initiate dextrose at 7 to 8 mg/kg per minute and advance as needed to maximum of 20% dextrose solution. Infants Initiate dextrose infusion at 5 mg/kg per minute and advance to 15 mg/kg per minute over a 2-day period. For all burn patients, carbohydrates should account for approximately 50% of total energy. Fat (3,16,17) Adults Children >1 year Children <1 year 10% to 30% of total energy in critical care with 2 % to 4% as essential fatty acids to prevent deficiency (3) 30% to 40% of total energy Up to 50% of total energy Feeding Approach High-energy, high-protein oral diet is generally sufficient. If feeding is to be given totally by nutrition support, the enteral route is preferred over total parenteral nutrition (3). Starting an intragastric feeding immediately after the burn injury (6 to 24 hours) has been shown to be safe and effective. Total parenteral nutrition should be reserved for only those patients with prolonged alimentary tract dysfunction. Dubuque, Iowa: American Society of Enteral and Parenteral Nutrition; 2001:338-341. The Curreri formula: a landmark process for estimating the caloric needs of burn patients. The usability of harris-benedict and curreri equations in nutritional management of thermal injuries. Intensive insulin therapy exerts anti-inflammatory effects in critically ill patients, as indicated by circulating mannose-binding lectin and C-reactive protein levels. To optimize clinical outcomes, patients who are diagnosed with cancer should receive early nutrition intervention with a complete nutritional assessment and a plan of care (1). Similar findings are seen in patients who are receiving chemotherapy for esophageal cancer, head and neck cancer, lung cancer, or acute leukemia (1). The clinician, however, can refer to this resource for guidance when determining if specific therapeutic nutrition interventions should be initiated or discontinued (1). Vitamin and mineral supplements, special foods, and alternative health products such as herbal products are commonly used by patients diagnosed with cancer. The following discussion is based on the Oncology Evidence-Based Nutrition Practice Guideline from the Academy of Nutrition and Dietetics (1). Doses of antioxidants (eg, vitamin C, vitamin E, beta-carotene, and selenium) that are greater than the tolerable upper intake level, which are used in an attempt to improve treatment outcomes, are not recommended for patients who are receiving chemotherapy for advanced non-small cell lung cancer. Evidence remains limited as to the best methods for calculating enery and protein needs in patients with cancer. In general, the Academy evidence anlaysis library suggests indirect calorimetry is the best method for assessing resting metabolic rate (1). Protein requirements vary depending on type of cancer and adjunctive treatment (1). Reprinted by permission from the Nutrition Screening Initiative, a project of the American Academy of Family Physicians, the Academy of Nutrition and Dietetics, and the National Council on Aging, and funded in part by a grant from Ross Products division, Abbott Laboratories. Dryness, soreness, or inflammation of oral mucosa (secondary to tumor, chemotherapy, radiation therapy) Evaluate effect of medications. For prevention of dental caries, between-meal candies and gum should be sugarless. Determine if other problems, such as pain, fear of vomiting, medication, or constipation, could be factors. Vigorous nutrition intervention may reverse some of the factors causing anorexia and taste abnormalities. Consider the use of pharmacotherapy (eg, progestational agents, cannabinoids, anabolic agents, prokinetic agents, antiserotonergic agents) (2). Patient should rinse mouth with tea, ginger ale, or salt water before and after eating.
The lesion size should be noted as should its apparent infiltration and spread to adjacent pharyngeal or oral cavity subsites such as oral tongue medicine and science in sports and exercise pepcid 40 mg low cost, hypopharynx medicine education buy pepcid 40 mg visa, nasopharynx symptoms dizziness nausea purchase pepcid with a mastercard, and vallecula symptoms 9 days past iui order pepcid mastercard. In advanced cases medicine zofran buy generic pepcid 20 mg line, discerning the primary origin of the lesion medicine xarelto purchase 40mg pepcid overnight delivery, such as the tongue base or tonsil, is not always possible. Imaging Clinical staging may understage oropharynx tumors, especially the tongue base extension. Neck metastasis from oropharynx cancer may be cystic in morphology; this finding by itself should raise suspicion of a cancer in the tonsil or tongue base. Other Tests Patients with suspected cancer of oropharynx must undergo a biopsy and a sample of the lesion taken for pathologic examination. This may be done in an office setting in cases of tonsil cancer and soft palate cancer, but is not usually possible in cases of tongue base lesions. This is particularly important in patients who smoke or in patients with large, bulky tumors to establish the true extent of these lesions. Other cancers of the oropharynx include minor salivary gland carcinomas, lymphomas, and "lymphoepithelial-like" carcinomas. N Treatment Options For stage I oropharynx cancer, surgery or radiotherapy may be used depending on the expected functional deficit. Radiation clinical trials evaluating hyperfractionation schedules should be considered. Radiotherapy may be the preferred modality where the functional deficit is expected to be great. A combination of surgery with postoperative radiotherapy and/or chemotherapy is most often used. In advanced unresectable oropharyngeal cancer, radiotherapy or chemoradiation is used. Treatments currently under investigation include chemotherapy with radiation clinical trials as well as with radiosensitizers, radiation clinical trials evaluating hyperfractionation schedules and/or brachytherapy, particlebeam radiotherapy, and hyperthermia combined with radiotherapy. N Outcome and Follow-Up the overall 5-year disease-specific survival for patients with all stages of disease is 50%. Patients with cancer of the oropharynx should have a careful head and neck examination to examine for recurrence monthly for the first posttreatment year, every 2 months for the second year, every 3 months for the third year, and every 6 months to a year thereafter. Tumor invades the larynx, the deep/extrinsic muscle of tongue, the medial pterygoid muscles, hard palate, or the mandible. Tumor invades the lateral pterygoid muscle, pterygoid plates, the lateral nasopharynx or skull base, or encases the carotid artery. Evidence for a causal association between human papillomavirus and a subset of head and neck cancers. Malignant tumors of the oral cavity and oropharynx: clinical, pathologic, and radiologic evaluation. Diagnostic and prognostic value of [(18)F]fluorodeoxyglucose positron emission tomography for recurrent head and neck squamous cell carcinoma. Patients present with dysphagia, globus sensation, hoarseness, and referred otalgia. The hypopharynx is the part of the pharynx, which lies behind the larynx and connects the oropharynx and the esophagus. It is subdivided into three subsites: the paired pyriform sinuses, the posterior hypopharyngeal wall, and the postcricoid region. Sixty-five to 85% of cancers of the hypopharynx involve the pyriform sinuses, 10 to 20% involve the posterior pharyngeal wall, and 5 to 15% involve the postcricoid area. N Epidemiology Cancer of the hypopharynx is uncommon, with 2500 new cases diagnosed in the United States each year. Cancer of the hypopharynx typically presents in advanced stages, and the incidence of regional metastases and distant metastases are also among the highest of all head and neck cancers. Cancer of the hypopharynx is typically seen in men over 55 years old with a history of tobacco product use and/or alcohol ingestion. An exception is an increased incidence of postcricoid cancer in women aged 30 to 50 years with Plummer-Vinson syndrome. Asbestos may pose an independent risk for the development of cancer of the hypopharynx. Symptoms include dysphagia, chronic sore throat, hoarseness, globus sensation, and referred otalgia. Differential Diagnosis Differential diagnosis may include pharyngeal infections such as pharyngitis or candidal infection, benign hypopharynx or upper esophageal lesions, and pharyngeal manifestations of systemic diseases. N Evaluation History A detailed history should include questions about smoking and alcohol usage, prolonged hoarseness, dysphagia, odynophagia, hemoptysis, otalgia, and unintentional weight loss. The lesion size should be noted as should its infiltration and spread to adjacent laryngeal and hypopharynx subsites. During this examination, the patient should be taken through maneuvers such as protrusion of the tongue, puffing out the cheeks, lightly coughing, and speaking to better visualize and access the pharynx and larynx. It is important that laryngeal motility be assessed, as this is critical in tumor staging. On neck examination, loss of the grating sensation (laryngeal crepitus) of the laryngeal cartilages over the prevertebral tissues may indicate deep pharyngeal wall involvement. Superficial mucosal lesions in the pyriform sinus may be seen on barium swallow studies, although this is not the imaging modality of choice. Negative findings on swallow study despite progressive or continuous symptoms should not preclude an endoscopic examination. They provide information about the location and extent of tumor involvement and demonstrate the interface of tumor with cartilage, muscles, soft tissues, and blood vessels. Head and Neck 385 Labs Blood count, electrolyte, and liver function tests should be performed to assess nutritional status. Other Tests Patients with suspected cancer of the hypopharynx must undergo a biopsy and a sample of the lesion taken for pathologic examination. This biopsy may be coupled with a triple endoscopy to evaluate the patient for the presence of synchronous second primary tumors. The direct laryngoscopic exam under anesthesia is a critical part of staging and treatment planning. N Treatment Options the treatment of cancer of the hypopharynx is controversial, in part because of its low incidence and the inherent difficulty in conducting adequately powered, prospective, randomized clinical studies. In general, both surgery and radiotherapy are the mainstays of most curative efforts aimed at this cancer. Stage I Tumors Laryngopharyngectomy and neck dissection has been the most frequently used therapy for surgical hypopharyngeal cancers. Radiotherapy may be used as a primary treatment modality and should include the neck. Neoadjuvant chemotherapy has been used to reduce tumors and render them more definitively treatable with either surgery or radiation. N Outcome and Follow-Up the prognosis of cancer of the hypopharynx is poor, with most series reporting a 25% 5-year survival rate. Presentation at a late stage, multisite involvement within the hypopharynx, unrestricted soft tissue tumor growth, an extensive regional lymphatic network allowing development of metastases, and restricted surgical options for complete resection contribute to an overall poor prognosis. The risk of a second primary carcinoma is highest in those who continue to smoke and patients should be strongly urged to quit. Tumor invades the thyroid/ cricoid cartilage, hyoid bone, the thyroid gland, the esophagus, or the central compartment soft tissue. Tumor invades the prevertebral fascia, encases the carotid artery, or involves the mediastinal structures. New York: Springer-Verlag; 2010 Bernier J, Domenge C, Ozsahin M, et al, for the European Organization for Research and Treatment of Cancer Trial 22931. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. Hypopharyngeal cancer: results of treatment based on radiation therapy and salvage surgery. Cancer arising from the squamous epithelium of the larynx is a common head and neck cancer, with well-known risk factors. The complex anatomy of the larynx explains the unique patterns of spread of laryngeal cancer: G G the preepiglottic fat is located in the anterior and lateral aspects of the larynx and is often invaded by advanced cancers. Invasion of this nerve causes hoarseness clinically and fixation of the vocal folds. G the larynx is divided into three anatomic regions: the supraglottic larynx, the glottis, and the subglottic region. Head and Neck 389 epiglottis, the preepiglottic space, the laryngeal aspects of the aryepiglottic folds, the false vocal folds, the arytenoids, and the ventricles. The inferior boundary is a horizontal plane drawn through the apex of the ventricle. This corresponds to the area of transition from squamous to respiratory epithelium. The glottis consists of the true vocal folds extending to roughly 1 cm below the true folds, the paraglottic space, and the anterior and posterior commissures extending inferiorly 1 cm. The subglottic larynx has its superior border at the inferior border of the glottis, 1 cm below the true vocal folds and extending inferiorly to the trachea. Laryngeal cancer can also be classified by anatomic location-signs, symptoms, and tumor behavior vary depending on the site and the extent of disease. N Epidemiology In 2008, 12,250 men and women were diagnosed with cancer of the larynx in the United States; of those, 3670 patients died. Risk factors include smoking and drinking alcohol, which act synergistically; laryngeal papillomatosis; radiation exposure; immunosuppression; and occupational exposure to metals, plastics, and asbestos. N Clinical Signs and Symptoms the common symptoms of supraglottic cancers include mild odynophagia, mild dysphagia, and mass sensation. Glottic cancers account for over half of all laryngeal cancers and present typically with hoarseness. Voice change often happens early and can help diagnose early stage cancer, improving prognosis. Advancing glottic cancer can spread posteriorly to the arytenoid complex causing vocal fold fixation, or anteriorly to the commissure, where it can invade the thyroid cartilage. Patients may be asymptomatic until advanced stages of disease and thus the prognosis is worse. Lymphatics drain through the cricothyroid and cricotracheal membranes to the pretracheal, paratracheal, and inferior jugular nodes, and occasionally to mediastinal nodes. Other prognostic factors may include sex, age, performance status, and a variety of pathologic features of the tumor, including grade and depth of invasion. History History should focus on timing and duration of symptoms and assessment of risk factors. Physical Examination A thorough physical examination of the head and neck should be performed, including inspection of the oral mucosa, laryngoscopy, bimanual palpation of floor of mouth and base of tongue, and a careful assessment of the cervical lymph nodes and thyroid cartilage contour. Other Tests Suspension direct laryngoscopy provides an opportunity for examination under general anesthesia, palpation, and biopsy. Extent of the tumor and the overall condition of the airway mucosa can be evaluated. Other less common types of laryngeal malignancies include adenoid cystic carcinoma, with 5. Head and Neck 391 a characteristic indolent course of growth and perineural invasion. Glottis Standard treatment options include: G G Radiotherapy Partial or hemilaryngectomy or total laryngectomy, depending on anatomic considerations. Glottis Standard treatment options include: G G G Surgery with or without postoperative radiotherapy Definitive radiotherapy with surgery for the salvage of radiation failures Chemotherapy administered concomitantly with radiotherapy can be considered for patients who would require total laryngectomy for control of disease. Subglottis Standard treatment options include: G G Laryngectomy plus isolated thyroidectomy and tracheoesophageal node dissection usually followed by postoperative radiotherapy Treatment by radiotherapy alone is indicated for patients who are not candidates for surgery. Head and Neck 393 Glottis Standard treatment options include: G G G Total laryngectomy with postoperative radiotherapy Definitive radiotherapy with surgery for salvage of radiation failures Chemotherapy administered concomitantly with radiotherapy can be considered for patients who would require total laryngectomy for control of disease. Subglottis Standard treatment options for: G G Laryngectomy plus total thyroidectomy and bilateral tracheoesophageal node dissection usually followed by postoperative radiotherapy. Treatment by radiotherapy alone is indicated for patients who are not candidates for surgery. Treatment Types Radiation Radiation is sometimes preferred because of the good oncologic results, preservation of the voice, and the possibility of surgical salvage in patients whose disease recurs locally. Surgery Surgical treatment options should be reviewed carefully to ensure adequate pulmonary and swallowing function postoperatively. Transoral laser microsurgery is ideal for the treatment of early to intermediate glottic and supraglottic cancer. This treatment has the same indications and contraindications as open partial laryngectomies. Survival and laryngeal preservation is comparable to other conventional treatments. Transoral robotic-assisted supraglottic laryngectomy may be ap- propriate for certain supraglottic cancers. When disease is small and involves only one vocal fold and arytenoid, a vertical hemilaryngectomy can be performed.
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