Analysis of the Spanish national registry for pediatric home enteral nutrition (NEPAD): implementation rates and observed trends during the past 8 years

A prospective observational study on microbiological isolation in low-profile gastrostomy's feeding extension sets in children on long-term home enteral nutrition

BACKGROUND

Although reuse of enteral feeding equipment has been linked to risk of microbial contamination and risk of infection, there is a paucity of research in this area. Per the manufacturer's instructions low-profile gastrostomy feeding extension sets (LPG-FES) may be reusable for the same patient, but there are no recommendations on replacement intervals.

METHODS

We conducted a prospective observational study to analyze and compare the contamination rate of LPG-FES after 15 (T1) and after 30 days (T2) of regular use. We included children 2-18 years of age exclusively receiving long-term home enteral nutrition (HEN) via LPG.

RESULTS

We included 17 patients with a median age of 5 years (interquartile range: 3-8 years). We did not find statistically significant differences in microbial overgrowth comparing LPG-FES obtained after 15 or 30 days of use, although overgrowth was slightly higher in LPG-FES used for 30 days (64.7% and 70.6% vs 52.9% and 58.8%). Every patient presented at least one positive culture, either in T1 or T2. Candida parapsilosis was globally the most frequent microbiological finding. We found no relation between duration of HEN and type of feeding and positive culture at T1 and T2. We found no symptoms of local nor systemic infection during the study period.

CONCLUSION

Despite the high rate of microbial overgrowth in the LPG-FES, no patient had clinical symptoms of infection secondary to this finding. Microbiological isolation in FES may represent only a form of contamination without clinical implications, which raises doubts on possible LPG-FES dwell times.

A Narrative Review of Home Enteral Nutrition in Australia with a Focus on Blended Tube Feeding

Enteral nutrition, commonly known as tube feeding, is a life-sustaining intervention for individuals who cannot meet their nutritional needs orally due to medical conditions affecting swallowing, digestion, or nutrient absorption. Since its introduction in the 1970s, home enteral nutrition (HEN) has enabled the safe delivery of complete or supplemental nutrition in community settings, enhancing both quality of life and healthcare outcomes. The HEN landscape in Australia is rapidly evolving, driven in part by the renewed interest in blended tube feeding (BTF). This narrative review explores the current state of HEN care and BTF support in Australia, focusing on prevalence, funding models, provider and client perspectives, clinical guidelines, and advocacy efforts.

[The registers of pediatric patients with home artificial nutrition. The Spanish experience]

Introduction

Background: the number of infants and children who receive artificial nutrition at home has been steadily increasing over the last decades, as better outcomes for children with chronic conditions have been achieved. In order to evaluate the need of resources to implement the technique it is necessary to know how many patients benefit from home artificial nutrition. This information can be estimated from the register of patients, when available. Methods: in this paper the characteristics of all registers were reviewed, especially those devoted to pediatric patients. Results: only two pediatric registers are active in 2023: the Canadian register and the Spanish one. NADYA register from the Spanish Society for Clinical Nutrition and Metabolism (SENPE) and the recent REPAFI, form the Spanish Society of Pediatric Gastroenterology, Hepatology and Nutrition. The most valuable register from the British Society, BANS, stopped providing information in 2018. Conclusion: despite the fact of acknowledging the importance of having gathered information on the prevalence and incidence of home artificial nutrition, to fit resources to necessities, the number of active registers is quite short.

Weaning children from prolonged enteral nutrition: A position paper

Enteral nutrition (EN) allows adequate nutritional intake in children for whom oral intake is impossible, insufficient or unsafe. With maturation and health improvements, most children ameliorate oral skills and become able to eat orally, therefore weaning from EN becomes a therapeutic goal. No recommendations currently exist on tube weaning, and practices vary widely between centres. With this report, the French Network of Rare Digestive Diseases (FIMATHO) and the French-Speaking Group of Paediatric Hepatology, Gastroenterology and Nutrition (GFHGNP) aim to develop uniform clinical practice recommendations for weaning children from EN. A multidisciplinary working group (WG) encompassing paediatricians, paediatric gastroenterologists, speech-language therapists, psychologists, dietitians and occupational therapists, was formed in June 2018. A systematic literature search was performed on those published from January 1, 1998, to April 30, 2020, using MEDLINE. After several rounds of e-discussions, relevant items for paediatric tube weaning were identified, and recommendations were developed, discussed and finalized. The WG members voted on each recommendation using a nominal voting technique. Expert opinion was applied to support the recommendations where no high-quality studies were available.

A benchmarking study of home enteral nutrition services

BACKGROUND & AIMS

Patients receiving home enteral nutrition (HEN) via an enteral feeding tube often have complex healthcare requirements. There is limited information regarding how HEN care is provided within Australia and New Zealand. This study aimed to investigate the characteristics of HEN services and the provision of nutrition care to individuals receiving HEN within Australia and New Zealand.

METHODS

A cross-sectional study, surveying lead HEN dietitians for HEN services was conducted from the period 09 July 2019 to 20 September 2019 inclusive. An online survey was used to obtain data relating to the demographics, funding and clinical resources of respondents' HEN services. Services were benchmarked against a HEN service implementation checklist adapted from the Agency for Clinical Innovation (ACI).

RESULTS

Responses were received from 107 HEN services, with an estimated combined population of 7122 HEN patients. Services were predominantly government-funded (n = 102, 95.3%) and operated from acute hospitals (n = 57, 53.3%). The reported combined cost of all HEN equipment to the patient ranged from $0-$77 per week or $0-$341 per month. Fifty-two services were reported to have a dedicated HEN dietitian/coordinator, which was positively associated with the undertaking of quality improvement activities (p = 0.019). Mean compliance to the ACI HEN implementation checklist was 70.4% (±15.7%) with a range of 13.0-98.2%. Mean compliance was significantly higher in services with a HEN dietitian/coordinator than services without one (75.5% (±12.0%) vs 64.3% (±16.6%); p < 0.001).

CONCLUSIONS

This study provides detailed information regarding the characteristics of HEN services and nutrition care provided to enterally-fed patients across Australia and New Zealand. The majority of HEN services are not adhering to the ACI HEN service guidelines and there is considerable variation in cost burden for consumers indicating inequitable delivery of care to patients.

Home Artificial Nutrition in Polish Children: An Analysis of 9-Year National Healthcare Provider Data

Background: Home artificial nutrition (HAN) is a developing method of treatment that reduces the need for hospitalizations. The epidemiology of pediatric HAN in Poland has not yet been covered in detail. This study is a longitudinal nationwide analysis of incidence, prevalence, and patients’ profile for HAN in Polish children. Methods: Assessment of National Health Fund (NFZ) data covering all pediatric patients treated with HAN in Poland between 2010 and 2018. Results: HAN was received by 4426 children, 65 patients were on home enteral nutrition (HEN) or home parenteral nutrition (HPN) at different times (HEN n = 3865, HPN n = 626). HAN was most frequently started before the child was 3 years old and long-term HAN programs (5–9 years) were reported. The most common principal diagnosis in HEN was food-related symptoms and signs. In HPN, it was postoperative gastrointestinal disorders. A regionally differentiated prevalence of HAN patients and centers was demonstrated. Mortality among patients was 24.9% for HEN, and 9.6% for HPN, and the main in-hospital cause of death was cardiac arrest. Conclusions: HAN’s use is increasing and evolving in Poland. Uneven distribution of patients and centers results in difficult access to the nutritional procedure which, together with the increasing number of patients, highlights the need for data analysis and development of nutrition centers.

A Literature Review of Percutaneous Endoscopic Gastrostomy: Dealing With Complications

Sufficient energy and essential nutrients are vital for normal growth and development in childhood. Ideally, nutrition should be provided orally. However, if the gastrointestinal system is functional, enteral tube feeding can be used when nutritional requirements cannot be provided orally, thus providing nutritional benefits and enabling positive disease management in pediatric patients. Postoperative care in children allows monitoring of the position and functionality of the tube; performing nutrition intolerance, growth, hydration, and nutritional assessments; and performing metabolic and complication follow-ups. Tube feeding in pediatric patients is beneficial and has positive effects in controlling and managing diseases and providing appropriate nutrition in children. However, in postoperative patients, it is important to prevent potential complications, which can be classified into 5 groups: mechanical, gastrointestinal, metabolic, infectious, and pulmonary complications. Important points for managing complications include having enteral nutrition practices based on evidence-based guidelines, sharing outcomes with nurses working in clinical settings, creating enteral feeding guides in clinical settings, providing patients/patients' family with training in line with these guides, and maintaining follow-ups at home. This literature review discusses complications and practices regarding the management of complications after percutaneous endoscopic gastrostomy.

Health-Related Quality of Life and Home Enteral Nutrition in Children with Neurological Impairment: Report from a Multicenter Survey

We aimed to measure the health-related quality of life (HRQoL) of children with neurological impairment (NI) on home enteral nutrition (HEN). An original survey among the caregivers of NI children on HEN for ≥ 12 months followed in three Italian centers (Messina, Como and Varese) was carried out between January 2013 and September 2018. The questionnaire was made up of 12 issues focused on the frequency with which certain situations associated with HEN are perceived, and grouped into physical and psychological/social dimensions. The results were analyzed statistically according to the age of the children, underlying disease, and the HEN programs' duration. In total, 80 caregivers were approached, and 75 surveys were completed (an overall response rate of 93.7%). Nearly all the caregivers reported a satisfying HRQoL, ranging from acceptable (n = 6, 8%), to good (n = 22, 29.3%), to excellent (n = 47, 62.7%). A significant correlation was found between HRQoL and underlying NI-associated disease (p = 0.001). Our data showed that HEN positively affects the QoL of NI children and their caregivers. This should encourage healthcare providers to consider this nutritional intervention early in the approach to this group of patients, in order to prevent or reduce QoL impairment.

Nutritional Outcome in Home Gastrostomy-Fed Children with Chronic Diseases

The aim of the study was to assess the anthropometric outcomes after gastrostomy tube (GT) placement in children with chronic diseases and the influence of primary diagnosis, age, and nutritional support. A longitudinal, multicenter, and prospective study was performed evaluating 65 children with GT feeding and chronic diseases (61.5% with neurological disease). Each child was evaluated three times (at baseline and at 6 and 12 months after GT placement) and the following data was collected: primary diagnosis, age at GT placement, anthropometry, and feeding regime. Repeated measures ANOVA were used to analyze the main effects (intra and intergroup) and the interactions effects on weight gain and linear growth at 6 and 12 months after GT placement. All patients significantly improved their body mass index (BMI)-for-age z-score (p < 0.001) and height-for-age z-score (p < 0.05) after 6 and 12-month of follow-up. BMI gain increased significantly the first 6 months, followed by a plateau, while height followed a linear trend. Children with GT placement before 18 months old experienced an accelerated growth rate during the first 6 months post-GT. This technique showed the effectiveness of GT placement improving nutritional status and growth catch up regardless of their primary diagnosis and the type of nutritional support.

Paediatric Home Artificial Nutrition in Italy: Report from 2016 Survey on Behalf of Artificial Nutrition Network of Italian Society for Gastroenterology, Hepatology and Nutrition (SIGENP)

Home Artificial Nutrition (HAN) is a safe and efficacious technique that insures children's reintegration into the family, society and school. Epidemiological data on paediatric HAN in Italy are not available.

AIM

to detect the prevalence and incidence of Home Parenteral Nutrition (HPN) and Home Enteral Nutrition (HEN), either via tube or mouth, in Italy in 2016.

MATERIALS AND METHODS

a specific form was sent to all registered SIGENP members and investigators of local HAN centres, inviting them to provide the requested centre's data and demographics, underlying diseases and HAN characteristics of the patients.

RESULTS

we recorded 3403 Italian patients on HAN aged 0 to 19 years from 22 centres: 2277 HEN, 950 Oral Nutritional Supplements (ONS) and 179 HPN programs. The prevalence of HEN (205 pts/million inhabitants) and HPN (16 pts/million inhabitants) has dramatically increased in Italy in the last 9 years. Neurodisabling conditions were the first indication for HEN by tube or mouth while HPN is mainly requested in digestive disorders.

CONCLUSIONS

HAN is a widespread and rapidly growing treatment in Italy, as well as in other European countries. Awareness of its extent and characteristics helps improving HAN service and patients' quality of life.

Outpatient services and primary care: scoping review, substudies and international comparisons

Aim

This study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.

Findings from the scoping review

Evidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.

Findings from the substudies

Because of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.

Conclusions

For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.

Funding

The NIHR Health Services and Delivery Research programme.

Unintended Adverse Effects of Enteral Nutrition Support: Parental Perspective

OBJECTIVES

The present study highlights the occurrence of unintended adverse effects of enteral nutrition in infancy and childhood, as viewed and reported from a parental perspective.

METHODS

Quantitative analysis of a standardized questionnaire, filled out online by parents of enterally fed children. The questions focused on the nutritive and nonnutritive adverse effects, and other medical and biometric data. Data were collected from January 1, 2009 to December 31, 2013.

RESULTS

The study cohort consisted of 425 infants and children with different underlying medical conditions and an average age of 2.17 (median = 1.63) years. Nasogastric tubes were used in 44.2% of all the patients, and 55.8% of the children were fed by percutaneous endoscopic gastrostomy tube. Nearly all of the children have been tube-fed since birth. A total of 56.0% of all tube-fed children showed regular gagging and retching episodes, 50.0% vomited frequently, 14.8% experienced nausea, 7.5% experienced extreme nervous perspiration during the feeding, 45.2% showed loss of appetite, 5.2% experienced local granulation tissue, and 1.9% had other skin irritations. No significant correlations could be found between age, sex, medical diagnoses, type of feeding tube, feeding schedules (bolus or continuous), and parental and child's behavior regarding the feeding situation and duration of tube feeding.

CONCLUSIONS

Enteral nutrition affects the child and the whole family system on more than just nutritional level. It is suggested that children and their families should be followed-up by health professionals periodically for nutritional optimization, growth documentation, and other aspects of tube management.