Avaliação e suporte nutricional na criança com colestase / Nutrition assessment and support of children with cholestasis

A colestase acomete 65% dos pacientes pediátricos com hepatopatia, sendo responsável por várias consequências clínicas, como: retenção hepática de substâncias excretadas pela bile, lesão hepática progressiva, má-absorção intestinal de gorduras e vitaminas lipossolúveis, anorexia e esteatorreia. Há risco subestimado de desnutrição nesses pacientes, que está associada a grande morbidade. Para classificar os pacientes quanto ao estado nutricional, usam-se os índices de avaliação do crescimento. Porém, considerando a condição clínica do paciente, que pode incluir visceromegalias e ascite, os índices que utilizam o peso na análise podem ser imprecisos. Nesses casos, o uso das medidas de pregas cutâneas e da circunferência braquial leva a avaliações mais fidedignas. O paciente com colestase exige suporte nutricional para compensar a má-absorção e possível desnutrição. Esse suporte inclui: aporte calórico elevado,ingestão proteica em níveis que não se induza hiperamonemia, oferta de ácidos graxos majoritariamente de cadeia média, suplementação de vitaminas lipossolúveis (A,D, E e K) e alguns minerais. Adequado suporte nutricional pode evitar a progressão rápida da doença hepática, facilitar o processo de cicatrização, aumentar a função imunológica, além de prevenir várias consequências da deficiência de uma variedade de micro ou macronutrientes que pode ocorrer na colestase...

Cholestasis affects 65% of pediatric patients with liver disease and it is responsible for several clinical consequences such as liver retention of substances excreted in bile, progressive liver damage, intestinal malabsorption of fats and fat-soluble vitamins, anorexia, and steatorrhea. There is an underestimated risk of malnutrition in these patients, whichis associated with high morbidity. Indexes of growth evaluation are used to classify patients according to their nutritional status. However, considering the clinical condition of the patient, which may include increase of some organs?s size and ascites, the indices that use weight in the analysis may be inaccurate. In these cases, the use of measures of skinfold thickness and arm circumference leads to more reliable evaluations. The patient with cholestasis requires nutritional support to compensate the malabsorption and possible malnutrition. This support includes: caloric intake higher than usual, protein intake at levels which do not induce hyperammonemia, an offer of fatty acids predominantly mediumchain (absorbed independently from the action of micellar bile acids), supplementation of fat-soluble vitamins (A, D, E and K) and some minerals. An adequate nutritional support can avoid the fast progression of liver disease, facilitate the healing process, and enhance immune function, besides of preventing many consequences from the deficiency of a variety of micro or macronutrients which may happens in cholestasis...

Nutrition management in chronic liver disease.

Liver has a central role in nutritional homeostasis and any liver disease leads to abnormalities in nutrient metabolism and subsequent malnutrition. All children with chronic liver disease (CLD) must undergo a periodic nutritional assessment--medical history, anthropometry esp. skinfold thickness and mid-arm circumference, and biochemical estimation of body nutrients. Nutritional rehabilitation is catered to the individual child but generally the caloric intake is increased to 130% of RDA by adding glucose polymers and/or MCT oil (coconut oil) with essential fatty acid supplementation (sunflower oil). The enteral route is preferred and occasionally nasogastric and/or nocturnal feeding are required to ensure an adequate intake. Proteins rich in branched chain amino acids are given in moderation (2-3 gm/kg/day) in compensated cirrhotics unless encephalopathy occurs when protein restriction may be necessary (1 gm/kg/day). Fat-soluble vitamins are supplemented in large quantities esp. in cholestasis along with other vitamins and minerals. Dietary therapy is the mainstay of management of some metabolic liver diseases and may be curative in disorders like galactosemia, fructosemia and glycogen storage disorders. Pre and postoperative nutritional support is an important factor in improving survival after liver transplantation.

Nutrición parenteral total ciclada en niños

El soporte nutricional con nutrición parenteral total (NPT) ha permitido que la sobrevida de muchos niños con disfunción intestinal sea mayor. la gama de disfunción y enfermedad hepática grave relacionada con el uso de la NPT ha emergido como consecuencia del uso de NPT por tiempo prolongado. La colestasis intrahepática, es uno de los problemas más frecuentes y ocacionalmente graves asociados con NPT prolongada. La NPT ciclada (NPT) referida también como intermitente o discontínua, disminuye la incidencia de complicaciones provocadas por NPT prolongada. Muchas ventajas teóricas y prácticas sicológicas por el uso de la NPTC han sido descritas. Este artículo describe las indicaciones, las deferencias maneras de ciclar, la monitori-zación y las complicaciones por la adminis-tración de NPTC en niños.