nutritional disorders
Protein Energy Undernutrition (PEU)
Treatment of Protein Energy Undernutrition
Usually oral feeding Possibly avoidance of lactose (eg, if persistent diarrhea suggests lactose intolerance) Supportive care (eg, environmental changes, assistance with feeding, orexigenic medications) For children, feeding delayed 24 to 48 hours Worldwide, the most important PEU preventive strategy is to reduce poverty and improve nutritional education and public health measures. Mild or moderate PEU, including brief starvation, can be treated by providing a balanced diet, preferably orally. Liquid oral food supplements (usually lactose-free) can be used when solid food cannot be adequately ingested. Diarrhea often complicates oral feeding because starvation makes the gastrointestinal tract more likely to move bacteria into Peyer patches, facilitating infectious diarrhea. If diarrhea persists (suggesting Carbohydrate Intolerance ), yogurt-based rather than milk-based formulas are given because people with lactose intolerance can tolerate yogurt. Patients should also be given a multivitamin supplement. Severe PEU or prolonged starvation requires treatment in a hospital with a controlled diet. The first priority is to correct Water and Sodium Balance and treat infections. A recent study suggested that children may benefit from antibiotic prophylaxis. The next priority is to supply macronutrients orally or, if necessary (eg, when swallowing is difficult), through a feeding tube, a nasogastric tube (usually), or a gastrostomy tube ( Other treatments may be needed to correct specific deficiencies, which may become evident as weight increases. To avoid deficiencies, patients should take micronutrients at about twice the recommended daily allowance until recovery is complete. Underlying disorders in children with PEU should be treated. For children with diarrhea, feeding may be delayed 24 to 48 hours to avoid making the diarrhea worse; during this interval, children require Oral Rehydration . Feedings are given often (6 to 12 times/day) but, to avoid overwhelming the limited intestinal absorptive capacity, are limited to small amounts ( Energy distribution among macronutrients should be about 16% protein, 50% fat, and 34% carbohydrate. An example is a combination of powdered cow’s skimmed milk (110 g), sucrose (100 g), vegetable oil (70 g), and water (900 mL). Many other formulas (eg, whole [full-fat] fresh milk plus corn oil and maltodextrin) can be used. Milk powders used in formulas are diluted with water. Usually, supplements should be given with the formulas: Magnesium 0.4 mEq/kg/day IM is given for 7 days. B-complex vitamins at twice the recommended daily allowance are given parenterally for the first 3 days, usually withvitamin A, phosphorus, zinc,manganese,copper, iodine, fluoride, molybdenum, andselenium. Because absorption of oral iron is poor in children with PEU, oral or IM iron supplementation may be necessary. Parents are taught about nutritional requirements. Underlying disorders should be treated. For example, if AIDS or cancer results in excess cytokine production,megestrolacetate ormedroxyprogesteronemay improve food intake. However, because these medications dramatically decreasetestosteronein men (possibly causing muscle loss),testosteroneshould be replaced. Because these medications can cause adrenal insufficiency, they should be used only short-term (<3 months). An orexigenic medication, such as the cannabis extractdronabinol, should be given to patients with anorexia when no cause is obvious or to patients at the end of life when anorexia impairs quality of life. An anabolic steroid (eg,testosteroneenanthate, nandrolone) or growth hormone can benefit patients with cachexia due to renal failure and possibly older patients (eg, by increasing lean body mass or possibly by improving function). Correction of PEU in adults generally resembles that in children; feedings are often limited to small amounts. However, for most adults, feeding does not need to be delayed. A commercial formula for oral feeding can be used. Daily nutrient supply should be given at a rate of 60 kcal/kg and 1.2 to 2 g of protein/kg. If liquid oral supplements are used with solid food, they should be given at least 1 hour before meals so that the amount of food eaten at the meal is not reduced. Treatment of institutionalized older patients with PEU requires multiple interventions: Environmental measures (eg, making the dining area more attractive) Feeding assistance Changes in diet (eg, use of food enhancers and caloric supplements between meals) Treatment of depression and other underlying disorders Use of orexigenic medications, anabolic steroids, or both The long-term use of gastrostomy tube feeding is essential for patients with severe Dysphagia ; its use in patients with dementia is controversial. Increasing evidence supports the avoidance of unpalatable therapeutic diets (eg, low salt, diabetic, low cholesterol) in institutionalized patients because these diets decrease food intake and may cause severe PEU. In patients with functional limitations, home delivery of meals and feeding assistance are key. Treatment of PEU can cause complications (refeeding syndrome), including fluid overload, electrolyte deficits, hyperglycemia, cardiac arrhythmias, and diarrhea. Diarrhea is usually mild and resolves; however, diarrhea in patients with severe PEU occasionally causes severe dehydration or death. Causes of diarrhea (eg,sorbitolused in elixir tube feedings,Clostridioides difficileif the patient has received an antibiotic) may be correctable. Osmotic diarrhea due to excess calories is rare in adults and should be considered only when other causes have been excluded. Because PEU can impair cardiac and renal function, Volume Overload can cause intravascular volume overload. Treatment decreases extracellular potassium and magnesium. Depletion of potassium or magnesium may cause During treatment, endogenousinsulinmay become ineffective, leading to hyperglycemia. Dehydration and hyperosmolarity can result. Fatal ventricular arrhythmias can develop, possibly caused by a prolonged QT interval. With parenteral feedings, infection is a risk because the catheter is left in place for a long time and the glucose in the solution promotes bacterial growth. For unknown reasons, Total Parenteral Nutrition (TPN) , when given for more than about 3 months, causes bone density to decrease in some people. The best treatment is to temporarily or permanently stop this type of feeding. Total parenteral nutrition can also cause liver malfunction, most commonly in premature infants. Blood tests are done to monitor liver function. Adjusting the solution may help. A feeding tube may irritate and erode nasopharyngeal and/or esophageal tissues. In such cases, using a different type of feeding tube may enable feedings to continue. In older patients fed by tube, aspiration is common. Food is less likely to be aspirated when the solution is given slowly and when the head of the bed is elevated for 1 to 2 hours after tube feeding. 