小儿肠衰竭喂养困难的流行情况及潜在危险因素：是否考虑提倡经口喂养？
The prevalence of feeding difficulties and potential risk factors in pediatric intestinal failure: Time to consider promoting oral feeds?
机构信息
Department of Pediatrics, Cumming School of Medicine, University of Calgary, Alberta Children's Hospital Calgary, 28 Oki Drive NW, Calgary, AB, T3B-6A8, Canada.
Department of Pediatric Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Digestive Diseases, Pediatric Intestinal Failure Rehabilitation Center, Hôpital Necker-Enfants Malades, University of Paris Medical School, 149 Rue de Sèvres, 75015 Paris, France.
出版信息
Clin Nutr. 2021 Oct;40(10):5399-5406. doi: 10.1016/j.clnu.2021.08.018. Epub 2021 Sep 6.
BACKGROUND & AIMS: Although nutritional care is a cornerstone in the management of pediatric intestinal failure (IF), little is known about feeding difficulty (FD) prevalence. The aim of this study was to determine the frequency of FD and associated factors and to characterize eating behaviours in two pediatric IF rehabilitation centres (Hôpital-Necker Enfants Malades (NEM), France and Alberta Children's Hospital (ACH), Canada).
METHODS
Parents of children (aged 1-18 years) on home parenteral nutrition (PN) for >3 months followed at NEM and ACH completed two validated tools: Montreal Children's Feeding scale for severity of FD, Child Eating Behaviour Questionnaire and a pediatric IF-specific questionnaire for FD associated risk factors.
RESULTS
In the entire cohort (n = 59, median 5.2 years), 15% had mild, 19% had moderate and 25% had severe FD. No FD was seen in 53% vs 11% and severe FD was seen in 20% vs. 39% of the NEM and ACH cohorts respectively (p = 0.003). Current ETF was less common at NEM vs. ACH (3% vs. 50%, p < 0.001). The FD score was associated with current enteral tube feed (ETF) use (p = 0.04). Compared to healthy reference children, the NEM cohort did not differ for the enjoyment of food, whereas the ACH cohort's enjoyment was lower (p < 0.0001). The ACH cohort scored higher for food avoidance behaviours: food fussiness (p < 0.02), satiety responsiveness (p < 0.0001), and slowness in eating (p < 0.0001) while the NEM cohort was not different from healthy reference children. In the entire cohort, according to parental recall, 60% were reported to be NPO for >12 weeks in the first 6 months of life, and late introduction of purees (>9 months) and lumpy textures (>1 year) were found in 40% and 58%, respectively. Parent-recalled ETF differed between NEM and ACH in the first 6 months of life (45% vs 76%, p = 0.03).
CONCLUSIONS
Feeding difficulty and associated risk factors, including early ETF, prolonged NPO and delays in achieving feeding milestones were frequently reported in pediatric IF. Feeding medicalization with the use of ETF may inadvertently contribute to FD and eating disorder behavioural characteristics. This study highlights the need for FD prevention and an increased focus on establishing healthy eating. Future prospective study of FD, associated risk factors and clinical outcomes are merited.
背景与目的
尽管营养支持是儿科肠衰竭（IF）管理的基石，但关于喂养困难（FD）的患病率知之甚少。本研究的目的是确定 FD 的频率及其相关因素，并描述两个儿科 IF 康复中心（法国 Necker 儿童医院[NEM]和加拿大艾伯塔省儿童医院[ACH]）的进食行为。
方法
在 NEM 和 ACH 接受>3 个月家庭肠外营养（PN）治疗的 1-18 岁儿童的父母完成了两个经过验证的工具：蒙特利尔儿童喂养量表（用于评估 FD 的严重程度）、儿童饮食行为问卷和儿童 IF 特定的 FD 相关危险因素问卷。
结果
在整个队列中（n=59，中位数为 5.2 岁），15%的患儿有轻度 FD，19%的患儿有中度 FD，25%的患儿有重度 FD。NEM 组中无 FD 的患儿占 53%，ACH 组中无 FD 的患儿占 11%（p=0.003）；NEM 组中重度 FD 的患儿占 20%，ACH 组中重度 FD 的患儿占 39%（p=0.003）。NEM 组中目前使用肠内喂养管（ETF）的患儿比例较 ACH 组低（3% vs. 50%，p<0.001）。FD 评分与目前使用肠内喂养管（ETF）呈正相关（p=0.04）。与健康对照组儿童相比，NEM 组儿童在享受食物方面没有差异，而 ACH 组儿童的享受程度较低（p<0.0001）。ACH 组儿童在回避食物方面的行为评分较高：挑食（p<0.02）、饱腹感反应（p<0.0001）和进食缓慢（p<0.0001），而 NEM 组儿童与健康对照组儿童无差异。在整个队列中，根据父母的回忆，60%的患儿在生命的前 6 个月中有>12 周的禁食期，40%的患儿在 9 个月时才开始食用泥状食物，58%的患儿在 1 岁时才开始食用块状食物。在生命的前 6 个月，NEM 组和 ACH 组父母回忆的 ETF 使用率分别为 45%和 76%（p=0.03）。
结论
儿科 IF 中经常报告喂养困难和相关危险因素，包括早期使用 ETF、长时间禁食和喂养里程碑的延迟。使用 ETF 进行喂养医学化可能会无意中导致 FD 和饮食障碍行为特征。本研究强调了预防 FD 和更加关注建立健康饮食的必要性。未来对 FD、相关危险因素和临床结局的前瞻性研究是值得的。
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