Journal of Parenteral and Enteral Nutrition current issue

A.S.P.E.N. Clinical Guidelines: Nutrition Support of Children With Human Immunodeficiency Virus Infection

Thu, 05 Nov 2009 10:07:44 PST

Butyrate Increases GLUT2 mRNA Abundance by Initiating Transcription in Caco2-BBe Cells

Mangian, H. F., Tappenden, K. A. — Thu, 05 Nov 2009 10:07:44 PST

Background: Glucose transporter 2 (GLUT2) is a high-capacity, facilitative intestinal monosaccharide transporter, known to be upregulated by short-chain fatty acids (SCFAs) derived from the intestinal microbiota during fermentation. Understanding the mechanisms regulating intestinal function is important to optimize therapies for patients with intestinal failure and ultimately reduce their dependence on parenteral nutrition. Objective: The objective was to examine the mechanism regulating the underlying response of GLUT2 to the SCFA butyrate. Methods: GLUT2 messenger RNA (mRNA) abundance was measured in differentiated Caco2-BBe monolayers treated for 0.5-24 hours with 0-20 mM butyrate using quantitative reverse transcription–polymerase chain reaction. Activation of the human GLUT2 promoter was measured using luciferase reporting in transiently transfected Caco2-BBe monolayers. Results: GLUT2 mRNA abundance was higher (P < .0001) with 1-4 hours of exposure to 2.5, 7.5, and 10 mM butyrate. Butyrate induced (P < .0001) promoter activity in a dose-dependent fashion. Analysis of the GLUT2 promoter indicated that regions –282/+522, –216/+522, and –145/+522 had a heightened (P < .05) response to butyrate compared with 1135/+522 and 564/+522. Conclusions: Butyrate upregulates GLUT2 mRNA abundance in Caco2-BBe monolayers by activating specific regions within the human GLUT2 promoter. These results identify a cellular mechanism wherein butyrate upregulates intestinal absorption that may be relevant to patients with reduced function. Additional work is necessary to understand cellular targets of butyrate therapy and define clinically appropriate means of providing such strategies, such as consuming prebiotics and probiotics.

Enteral Refeeding Rapidly Restores PN-Induced Reduction of Hepatic Mononuclear Cell Number Through Recovery of Small Intestine and Portal Vein Blood Flows

Thu, 05 Nov 2009 10:07:44 PST

Background: Absence of enteral nutrition (EN) reduces hepatic mononuclear cell (MNC) numbers and impairs their functions. However, enteral refeeding (ER) for as little as 12 hours following parenteral nutrition (PN) rapidly restores hepatic MNC numbers. We hypothesized that changes in small intestine and portal vein blood flows related to feeding route might be responsible for this phenomenon. Methods: In experiment 1, mice (n = 19) were randomized to Chow (n = 5), PN (n = 7) or ER (n = 7) groups. The Chow group was given chow ad libitum with intravenous (IV) saline for 5 days. The PN group was fed parenterally for 5 days, while the ER group was re-fed with chow for 12 hours following 5 days of PN. Then, small intestine and portal vein blood flows were monitored and hepatic MNCs were isolated and counted. In experiment 2, the effects of intravenous administration of prostaglandin E₁ (PGE₁) on hepatic MNC numbers were examined in fasted mice for 12 hours. Mice (n = 28) were randomized to Control (n = 8), PG0 (n = 10), or PG1 (n = 10) groups. The Control group was fed chow ad libitum with IV saline, while the PG0 and PG1 groups were fasted for 12 hours with infusions, respectively, of saline and PGE₁ at 1 µg/kg/minute. Blood flows and hepatic MNC numbers were examined. Results: Experiment 1: ER restored PN-induced reductions in small intestine and portal vein blood flows and hepatic MNC number to the levels in the Chow group. Small intestine and portal vein blood flows correlated positively with hepatic MNC number. Experiment 2: Fasting decreased small intestine and portal vein blood flows and hepatic MNC number. However, PGE₁ restored portal vein blood flow to the level of the Control group, and moderately increased hepatic MNC number. There was a positive correlation between portal blood flow and hepatic MNC number. Conclusions: Reduced small intestine and portal vein blood flows may contribute to impaired hepatic immunity in the absence of EN. ER quickly restores hepatic MNC number through recovery of blood flow in both the small intestine and the portal vein.

Colonic GLP-2 is not Sufficient to Promote Jejunal Adaptation in a PN-Dependent Rat Model of Human Short Bowel Syndrome

Thu, 05 Nov 2009 10:07:44 PST

Background: Bowel resection may lead to short bowel syndrome (SBS), which often requires parenteral nutrition (PN) due to inadequate intestinal adaptation. The objective of this study was to determine the time course of adaptation and proglucagon system responses after bowel resection in a PN-dependent rat model of SBS. Methods: Rats underwent jugular catheter placement and a 60% jejunoileal resection + cecectomy with jejunoileal anastomosis or transection control surgery. Rats were maintained exclusively with PN and killed at 4 hours to 12 days. A nonsurgical group served as baseline. Bowel growth and digestive capacity were assessed by mucosal mass, protein, DNA, histology, and sucrase activity. Plasma insulin-like growth factor I (IGF-I) and bioactive glucagon-like peptide 2 (GLP-2) were measured by radioimmunoassay. Results: Jejunum cellularity changed significantly over time with resection but not transection, peaking at days 3-4 and declining by day 12. Jejunum sucrase-specific activity decreased significantly with time after resection and transection. Colon crypt depth increased over time with resection but not transection, peaking at days 7-12. Plasma bioactive GLP-2 and colon proglucagon levels peaked from days 4-7 after resection and then approached baseline. Plasma IGF-I increased with resection through day 12. Jejunum and colon GLP-2 receptor RNAs peaked by day 1 and then declined below baseline. Conclusions: After bowel resection resulting in SBS in the rat, peak proglucagon, plasma GLP-2, and GLP-2 receptor levels are insufficient to promote jejunal adaptation. The colon adapts with resection, expresses proglucagon, and should be preserved when possible in massive intestinal resection.

Measurement of Resting Energy Expenditure in Healthy Children

Mellecker, R. R., McManus, A. M. — Thu, 05 Nov 2009 10:07:44 PST

Background: The role that the components of energy expenditure play in the etiology of childhood obesity has highlighted the need for greater accuracy and standardized protocols for the measurement of resting energy expenditure (REE). However, protocols used to assess REE in children are varied, and consensus on a suitable method for measuring REE in children has not been reached. This study was undertaken to determine the effect of measurement time and measurement device (mask or mouthpiece) on REE in healthy children. Design: Following a 12-hour fast and abstinence from exercise, 23 children (age, 7–12 years) completed two 35-minute protocols: one with a face mask and the other with a mouthpiece/noseclip. Energy expenditure was measured continuously via indirect calorimetry, while device acceptability was assessed using a 6-point comfort rating scale. Results: Repeated measures ANOVA indicated that there was no significant difference in REE when measured after 10, 15, 20, or 25 minutes of rest compared to 30 minutes for either the mask or mouthpiece/noseclip (REE range, 1371–1460 kcal/d). Examination of the percentage coefficient of varia tion (CV) in energy expenditure for each time period by device showed that the least variation existed after 20 minutes of measurement using the mask (CV 6%). Paired t test analysis indicated significantly less discomfort when wearing the mask compared to the mouthpiece/noseclip. Conclusion: It would appear that a 20-minute protocol using a mask may increase compliance and prove to be a more practical protocol for measuring REE in children.

Disparate Response to Metoclopramide Therapy for Gastric Feeding Intolerance in Trauma Patients With and Without Traumatic Brain Injury

Thu, 05 Nov 2009 10:07:44 PST

Patients with traumatic brain injury (TBI) have delayed gastric emptying and often require prokinetic drug therapy to improve enteral feeding tolerance. The authors hypothesized that metoclopramide was less efficacious for improving gastric feeding tolerance for trauma patients with TBI compared to trauma patients without TBI. A retrospective analysis was conducted of patients admitted to the trauma or neurosurgical intensive care unit who received gastric feeding from January 2006 to April 2008. Gastric feeding intolerance was defined by a gastric residual volume >200 mL or emesis with abdominal distension or discomfort. Patients with gastric feeding intolerance were given metoclopramide 10 mg intravenously every 6 hours, followed by a dose escalation to 20 mg, and then combination therapy with metoclopramide and erythromycin 250 mg intravenously every 6 hours if intolerance persisted. In total, 882 trauma patients (49% with TBI) were evaluated. TBI patients had a higher incidence of gastric feeding intolerance than those without TBI (18.6% vs 10.4%, P ≤ .001). Efficacy rates for metoclopramide 10 mg, metoclopramide 20 mg, and metoclopramide-erythromycin were 55%, 62%, and 79%, respectively (P ≤ .03). Metoclopramide failure occurred in 54% of patients with TBI compared to 35% of patients without TBI, respectively (P ≤ .02), due to a greater prevalence of tachyphylaxis. Single-drug therapy with metoclopramide was less effective for TBI trauma patients compared to trauma patients without TBI. Combination therapy with erythromycin as first-line therapy for TBI trauma patients with gastric feeding intolerance is indicated if there are no contraindications or significant drug interactions.

Riboflavin Status in Acutely Ill Patients and Response to Dietary Supplements

Gariballa, S., Forster, S., Powers, H. — Thu, 05 Nov 2009 10:07:44 PST

Background: Although a number of studies have reported riboflavin deficiency in free-living older people, no data are available on riboflavin intake and status in older people during acute illness. Methods: To determine the riboflavin response to dietary supplements during acute illness, 297 hospitalized, acutely ill older patients are randomly assigned to receive a daily oral nutritional supplement containing 1.3 mg of riboflavin or a placebo for 6 weeks. Outcome measures are riboflavin intake and riboflavin biochemical status at baseline, 6 weeks, and 6 months using the erythrocyte glutathione reductase activation coefficient (EGRAC), a measure of riboflavin tissue saturation. EGRAC values are inversely proportional to riboflavin status. Results: Fifty-six percent of patients (167/297) have suboptimal riboflavin status (EGRAC > 1.30). No significant correlation is found between EGRAC and either total energy or riboflavin intakes. Significant correlations are found between total energy intake and riboflavin intakes both in hospital and at home (r = 0.67, P < .0001 and r = 0.57, P < .0001, respectively). Smokers and patients with chronic obstructive pulmonary disease (COPD) have lower riboflavin status (high EGRAC values) compared with nonsmokers and those without COPD. Riboflavin status improves significantly in the supplement group at 6 weeks compared with the placebo group, but status declines between 6 weeks and 6 months, after patients stop taking the supplements. Conclusions: A high proportion of acutely ill patients have suboptimal riboflavin status. Supplementation with a physiological amount of riboflavin in a mixed-nutrient supplement significantly improves riboflavin status, but the effect is transient and status deteriorates again after patients stop taking the supplements.

Intestinal Redox Status of Major Intracellular Thiols in a Rat Model of Chronic Alcohol Consumption

Thu, 05 Nov 2009 10:07:44 PST

Background: Alcohol consumption is associated with oxidative stress in multiple tissues in vivo, yet the effect of chronic alcohol intake on intestinal redox state has received little attention. In this study, we investigated the redox status of 2 major intracellular redox regulating couples: glutathione (GSH)/glutathione disulfide (GSSG) and cysteine (Cys)/cystine (CySS) in a rat model of chronic alcohol ingestion. Methods: Sprague-Dawley rats were fed the liquid Lieber-DeCarli diet consisting of 36% ethanol of total calories for 6 weeks. Control rats were pair-fed with an isocaloric, ethanol-free liquid diet. Defined mucosal samples from the jejunum, ileum, and colon were obtained and analyzed by high-performance liquid chromatography (HPLC) for GSH and Cys pool redox status. Mucosal free malondialdehyde (MDA) was measured as an indicator of lipid peroxidation. Results: In the ethanol-fed rats, Cys and mixed disulfide (GSH-Cys) were significantly decreased in all 3 segments of intestinal mucosa. Free MDA was increased in jejunal but not in ileal or colonic mucosa. Chronic ethanol ingestion significantly increased mucosal GSH concentration in association with a more reducing GSH/GSSG redox potential in the jejunum, but these indices were unchanged in the ileum. In the colon, chronic ethanol ingestion increased oxidant stress as suggested by decreased GSH and oxidized GSH/GSSG redox potential. Conclusions: Chronic alcohol intake differentially alters the mucosal redox status in proximal to distal intestinal segments in rats. Such changes may reflect different adaptability of these intestinal segments to the oxidative stress challenge induced by chronic ethanol ingestion.

Clinical Application of Magnetic Resonance Spectroscopy of the Liver in Patients Receiving Long-Term Parenteral Nutrition

Woodward, J. M., Priest, A. N., Hollingsworth, K. G., Lomas, D. J. — Thu, 05 Nov 2009 10:07:44 PST

Background: Intestinal failure–associated liver disease (IFALD) may have progressed to an advanced stage by the time it becomes evident via laboratory or physical signs. A safe, noninvasive technique for assessing the liver could significantly aid in monitoring the effects of therapeutic intervention, improve the timing of liver and small intestinal transplantation, and increase our understanding of the causes of IFALD. Methods: Six female patients fed intravenously for >1 year and 6 controls matched for body mass index (BMI) underwent liver magnetic resonance scanning with acquisition of ¹H and ³¹P resonance spectra. Areas under the curve for lipid (the sum of CH, CH₂, and CH₃), water, and choline peaks were calculated and expressed semi-quantitatively as ratios of lipid:water and choline:lipid. Phosphomonoester (PME) and phosphodiester (PDE) peak areas were similarly expressed as a ratio. Controls and cases were compared using Mann-Whitney U test; least squares regression analysis was used to compare the effect of measured variables on the lipid:water peak area ratio. Results: Patients and controls were well matched for BMI. Parenteral feeding was associated with a highly significant increase in lipid:water peak ratio (P < .005). Choline:lipid (P < .05) and choline:water (not significant) ratios were reduced in patients compared with controls. The increase in lipid:water ratios in patients was independent of BMI and choline:water ratios. A ratio of PME:PDE of >0.3 (and >3 SD from the control mean) predicted the 2 patients at most risk of advanced liver disease. Conclusions: This pilot study confirms the potential of magnetic resonance spectroscopic techniques in evaluating IFALD and could contribute significantly to our understanding and management of this condition.

Intravascular Embolization of Venous Catheter--Causes, Clinical Signs, and Management: A Systematic Review

Thu, 05 Nov 2009 10:07:44 PST

Background: Intravascular embolization of device fragments is a rare but potentially serious complication. Method: A systematic search of the PubMed and MEDLINE databases for all articles pertaining to central catheter related embolization published in English between 1985 and 2007 was made. Results: A total of 215 cases of intravenous catheter embolization were identified. There were 143 totally implanted venous devices (TIVD) or port catheters and 72 percutaneous venous catheters (PVC). Sites of catheter fragments following embolization were the superior vena cava or peripheral veins (15.4%), the right atrium (27.6%), right ventricle (22%), and pulmonary arteries (35%). Clinical signs of catheter embolization included catheter malfunction (56.3%), arrhythmia (13%), pulmonary symptoms (4.7%), and septic syndromes (1.8%), but 24.2% of cases were asymptomatic. The causes of intravascular catheter embolization were pinch-off syndrome (40.9%), catheter injury during explantation (17.7%), catheter disconnection (10.7%), and catheter rupture (11.6%). In 19.1% of cases, the cause of catheter embolization could not be identified. Most embolized catheter fragments (93.5%) were removed percutaneously. In 4.2% of cases, fragments were retained in the vascular bed; in 2.3%, embolized fragments were removed surgically via thoracotomy. Conclusion: Intravascular catheter embolization can go undiagnosed for prolonged periods. Patients might be asymptomatic or may develop severe systemic clinical signs. The mortality rate is 1.8%. There were no significant differences in clinical features of embolization between TIVD and PVC groups.

Laparoscopic Surgery Improves Blood Glucose Homeostasis and Insulin Resistance Following Distal Gastrectomy for Cancer

Kanno, H., Kiyama, T., Fujita, I., Tani, A., Kato, S., Tajiri, T., Barbul, A. — Thu, 05 Nov 2009 10:07:44 PST

Background: Prevention of blood glucose elevation and insulin resistance could be more pronounced in patients undergoing laparoscopic rather than open gastrectomy. Methods: Fifty-seven patients underwent distal gastrectomy by either laparoscopy (n = 36) or an open approach (n = 21). Blood glucose, serum insulin, and the daily insulin secretion rate (urinary C-peptide) were measured. Insulin resistance was evaluated using an adapted homeostasis model assessment of insulin resistance (HOMA-R). Results: Blood glucose levels were lower in the laparoscopy group than in the open group on the operative day and on postoperative days (POD) 1 and 3 (P < .001, P = .001, and P = .024, respectively). Serum insulin levels were lower in the laparoscopy group than in the open group on POD 1 and 3 (P = .045 and P = .027, respectively). HOMA-R was lower in the laparoscopy group than in the open group on POD 1 and 3 (P = .024 and P = .009, respectively). Daily insulin secretion rates were lower in the laparoscopy group than in the open group on POD 1 (P = .023). Conclusions: Laparoscopic surgery prevents blood glucose elevation and improves insulin resistance compared with open surgery.

Neonatal Parenteral Nutrition Hypersensitivity: A Case Report Implicating Bisulfite Sensitivity in a Newborn Infant

Huston, R. K., Baxter, L. M., Larrabee, P. B. — Thu, 05 Nov 2009 10:07:44 PST

This report describes a case of parenteral nutrition hypersensitivity in a 37 weeks' gestation infant with congenital diaphragmatic hernia complicated by bowel necrosis and functional short bowel syndrome. The patient developed a rash with subsequent urticaria beginning on the 50th day of life. The reactions were confirmed with a positive rechallenge. After the amino acid solution was replaced with a non–bisulfite-containing product, the infant was able to continue to receive nutrition support through parenteral nutrition without recurrence of symptoms. It is speculated that the bisulfite additive in the amino acid solution may have interacted with the lipid emulsion to sensitize the patient.

Low Availability of Aluminum in Formulations for Parenteral Nutrition Containing Silicate

Thu, 05 Nov 2009 10:07:44 PST

Background: Silicate (Si) and aluminum (Al) may be concomitant impurities in solutions for parenteral nutrition (PN). Silicate can bind to Al to form stable hydroxyaluminosilicates (HAS), thus reducing Al availability. This possibility is investigated by heating solutions containing constituents of PN in glass containers to promote the release of Si and Al. Methods: The total amount of Si and Al in solution is measured by atomic absorption spectrometry, and the Al not bound to Si is evaluated by reaction with morin. Results: When the Si:Al molar ratio is >5, no free Al is found in solution. For ratios <5, it is found that the lower the ratio, the higher the free Al fraction. However, in solutions of some amino acids, even with a low Si:Al ratio (<2), the amount of free Al is lower than that found in other solutions. The same tendency is observed among commercial formulations. Although in salt solutions the free fraction of Al reaches almost 100% when the Si concentration is low, in amino acid formulations the free fraction of Al does not surpass 50%. Moreover, even for Si:Al ratios >5, there is a "residual" fraction of free Al in amino acid formulations. Conclusions: The concomitant presence of Al and Si in solutions for PN reduces the amount of Al available attributable to the formation of HAS. In amino acid formulations this effect may be slightly reduced given the affinity of certain amino acids for Al. Therefore, amino acids may behave in the same fashion as silicate.

Enteral Nutrition and Cardiovascular Failure: From Myths to Clinical Practice

Berger, M. M., Chiolero, R. L. — Thu, 05 Nov 2009 10:07:44 PST

Cardiovascular failure and low flow states may arise in very different conditions from both cardiac and noncardiac causes. Systemic hemodynamic failure inevitably alters splanchnic blood flow but in an unpredictable way. Prolonged low splanchnic blood flow causes intestinal ischemia, increased mucosal permeability, endotoxemia, and distant organ failure. Mortality associated with intestinal ischemia is high. Why would enteral nutrition (EN) be desirable in these complex patients when parenteral nutrition could easily cover energy and substrate requirements? Metabolic, immune, and practical reasons justify the use of EN. In addition, continuous enteral feeding minimizes systemic and myocardial oxygen consumption in patients with congestive heart failure. Further, early feeding in critically ill mechanically ventilated patients has been shown to reduce mortality, particularly in the sickest patients. In a series of cardiac surgery patients with compromised hemodynamics, absorption has been maintained, and 1000-1200 kcal/d could be delivered by enteral feeding. Therefore, early EN in stabilized patients should be attempted, and can be carried out safely under close clinical monitoring, looking for signs of incipient intestinal ischemia. Energy delivery and balance should be monitored, and combined feeding considered when enteral feeds cannot be advanced to target within 4-6 days.

Malnutrition Syndromes: A Conundrum vs Continuum

Jensen, G. L., Bistrian, B., Roubenoff, R., Heimburger, D. C. — Thu, 05 Nov 2009 10:07:44 PST

This provocative commentary critically examines historic definitions for adult malnutrition syndromes as they apply to developed countries with modern healthcare. To stimulate further discussion, the authors propose an updated approach that incorporates current understanding of the systemic inflammatory response to help guide assessment, diagnosis, and treatment. An appreciation of a continuum of inflammatory response in relation to malnutrition syndromes is described. This discussion serves to highlight a research agenda to address deficiencies in diagnostics, biomarkers, and therapeutics of inflammation in relation to malnutrition.

How Immunocompromised Are Short Bowel Patients Receiving Home Parenteral Nutrition? Apropos a Case of Disseminated Fusarium Oxysporum Sepsis

Muller, C., Schumacher, U., Gregor, M., Lamprecht, G. — Thu, 05 Nov 2009 10:07:44 PST

Background: Catheter-related sepsis is the most frequent complication in patients receiving home parenteral nutrition (HPN) for short bowel syndrome (SBS). A low-grade systemic inflammatory state and an altered mucosal immune response, as well as diminished intestinal barrier function have been characterized in these patients. The possibility of systemic immunocompromise has only recently been suggested. Case Description: A 45-year-old female with traumatic SBS was admitted for possible catheter-related sepsis. She was asplenic and had insulin-dependent diabetes mellitus as a result of a pancreatic resection. A large skin ulceration was present on her left calf, which appeared unusual for a disseminated bacterial infection. Chest x-ray and computed tomography scan revealed multiple subpleural pulmonary infiltrates consistent with bacterial or fungal dissemination. Blood cultures from the port system and from the peripheral blood grew Staphylococcus haemolyticus and Fusarium oxysporum. The port system was removed, and flucloxacillin and voriconazole were given for 33 and 35 days, respectively. Clinical signs of disseminated sepsis resolved slowly. Bone marrow biopsy ruled out primary hematologic disease. Conclusions: (1) Catheter-related sepsis in patients on HPN is usually caused by Gram-positive or Gram-negative bacteria or by Candida species. Identification of molds in blood cultures strongly suggests Fusarium species, which should be treated appropriately with voriconazole or amphotericin B. (2) HPN and SBS aggravated by asplenism and diabetes mellitus can cause severe immunocompromise. (3) Fusaria have a strong tendency to persist or reappear after bone marrow transplantation, which is therefore relatively contraindicated in these patients.

Percutaneous Gastrojejunostomy Placement in a Heart Failure Patient With Biventricular Assist Devices

Page, S., Cecere, R., Valenti, D. — Thu, 05 Nov 2009 10:07:44 PST

Heart failure patients who require a ventricular assist device often present a nutrition challenge. A 39-year-old woman suffering from an acute ST elevated myocardial infarction and severe cardiogenic shock underwent implant of left and right ventricular assist devices (BiVAD). Neurologic deficits prevented her from safely resuming oral intake, and long-term feeding access was required. The decision was made to insert a percutaneous gastrojejunostomy under fluoroscopic guidance. Patients implanted with ventricular assist devices may require enteral nutrition support. Placement of feeding access other than through the nasoenteric route can be rendered more challenging because of anatomical constraints related to BiVAD positioning; however, whenever enteral nutrition support is required for extended periods, percutaneous or ostomy access offers easier delivery of nutrition. Although technically difficult, successful placement of the enteral feeding tube allowed for continuous 24-hour feeds to optimize nutrition intake. This is the first time that a percutaneous enteral feeding access was obtained for a ventricular assist device patient at the authors' institution, and it has proven valuable in providing long-term nutrition in a safe and efficient manner.

Unanswered Questions of "ProCon"etic Therapy

MacLaren, R. — Thu, 05 Nov 2009 10:07:44 PST

Imaging Biochemistry Noninvasively: Magnetic Resonance Spectroscopy in Liver Disease

Serkova, N. J. — Thu, 05 Nov 2009 10:07:44 PST

Comment on: Measurement of Resting Energy Expenditure in Healthy Children

Bogucki, E. L. — Thu, 05 Nov 2009 10:07:44 PST

Background: The role that the components of energy expenditure play in the etiology of childhood obesity has highlighted the need for greater accuracy and standardized protocols for the measurement of resting energy expenditure (REE). However, protocols used to assess REE in children are varied, and consensus on a suitable method for measuring REE in children has not been reached. This study was undertaken to determine the effect of measurement time and measurement device (mask or mouthpiece) on REE in healthy children. Design: Following a 12-hour fast and abstinence from exercise, 23 children (age, 7–12 years) completed two 35-minute protocols: one with a face mask and the other with a mouthpiece/noseclip. Energy expenditure was measured continuously via indirect calorimetry, while device acceptability was assessed using a 6-point comfort rating scale. Results: Repeated measures ANOVA indicated that there was no significant difference in REE when measured after 10, 15, 20, or 25 minutes of rest compared to 30 minutes for either the mask or mouthpiece/noseclip (REE range, 1371–1460 kcal/d). Examination of the percentage coefficient of variation (CV) in energy expenditure for each time period by device showed that the least variation existed after 20 minutes of measurement using the mask (CV 6%). Paired t test analysis indicated significantly less discomfort when wearing the mask compared to the mouthpiece/noseclip. Conclusion: It would appear that a 20-minute protocol using a mask may increase compliance and prove to be a more practical protocol for measuring REE in children.(JPEN J Parenter Enteral Nutr. 2009;33:640-645)

Prebiotics and Enteral Feeding-Associated Diarrhea

Hegazi, R., Strausbaugh, K., Merritt, R. — Thu, 05 Nov 2009 10:07:44 PST

Author Response

Barrett, J. S, Shepherd, S. J., Gibson, P. R. — Thu, 05 Nov 2009 10:07:44 PST

Letter to the Editor

Williams-Dolan, J. M., Boullata, J. I. — Thu, 05 Nov 2009 10:07:44 PST