Nutrition support for bone marrow transplant patients.

BACKGROUND: Bone marrow transplantation involves the administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop a poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is the first choice but is associated with an increased risk of infection. Enteral nutrition (EN) is an alternative, as is the addition of substrates e.g. glutamine to enteral and parenteral solutions. However, the relative effectiveness of these treatments is not clear. OBJECTIVES: To determine the efficacy of EN or PN support for patients receiving a bone marrow transplant. SEARCH STRATEGY: Trials were identified by searching the Cochrane Library (Issue 4, 2000 ), MEDLINE (1966-2000), EMBASE (1988-2000) and CINAHL (1982-2000 ). Reference lists of identified trials and conference proceedings were searched for relevant reports. Date of the most recent search: 2000. SELECTION CRITERIA: RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients were included. DATA COLLECTION AND ANALYSIS: Thirty five reports were identified, 11 were excluded. Two reviewers extracted data from 24 studies; 16 were allocated to four interventions: oral glutamine versus placebo; PN and glutamine versus standard PN; PN versus IV hydration; PN versus EN. Eight studies were other interventions. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival. Trialists were contacted for unreported data. MAIN RESULTS: Two studies (82 subjects) found that glutamine mouthwash reduced days of neutropaenia (6.82 days, 95% CI (1.67-11.98) p=0.009) compared with placebo. Three studies (103 subjects) showed that patients receiving PN with glutamine had a reduced hospital stay, 6.62 d (95% CI 3.47, 9.77, P=0.00004) compared with patients receiving standard PN. Two studies (73 subjects) indicated that patients receiving PN plus glutamine had a reduced incidence of positive blood cultures (OR 0.23, 95% CI 0.08-0.65, p=0.006) compared to those receiving standard PN. One study, (25 subjects) showed patients receiving PN had a higher incidence of line infections (odds ratio 21.23, 95% CI 4.15,108.73, P=0.0002) compared to those receiving standard IV fluids. There were no evaluable data to compare PN with EN. REVIEWER'S CONCLUSIONS: Lack of evaluable data means that the relative effectiveness of EN versus PN cannot be evaluated. Further studies and missing data from completed trials need to be retrieved. Studies comparing PN with glutamine versus standard PN suggest that patients leave hospital earlier, and experience a reduced incidence of positive blood cultures, than those receiving standard PN. Patients with gastrointestinal failure should consider PN with the addition of glutamine if enteral feeding is not possible.

Support for breastfeeding mothers.

BACKGROUND: Both observational and recent experimental evidence support the promotion of breastfeeding as the optimal form of infant nutrition. There is, however, uncertainty as to the most effective way of providing support to women who choose to breastfeed their children. A systematic review was performed to describe studies undertaken in this area and to assess the effectiveness of supplementary support. OBJECTIVES: The objective of this review was to assess the effects of breastfeeding support. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register, MEDLINE and EMBASE. These were last searched in March 2001. Secondary references were searched and researchers in the field were contacted. SELECTION CRITERIA: Controlled trials of acceptable quality comparing extra support for breastfeeding mothers with usual maternity care. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer and checked by a second reviewer. MAIN RESULTS: Twenty eligible randomised or quasi-randomised controlled trials from 10 countries were identified involving 23,712 mother-infant pairs. There was a beneficial effect on the duration of any breastfeeding in the meta-analysis of all forms of extra support (relative risk (RR) for stopping any breastfeeding before six months 0.88 [95% confidence interval (CI) 0.81,0.95]; 15 trials, 21,910 women). The effect was greater for exclusive breastfeeding (RR 0.78 [95% CI 0.69,0.89]; 11 trials, 20,788 women). Extra professional support appeared beneficial for any breastfeeding (RR 0.89 [95% CI 0.81,0.97]; 10 trials, 19,696 women) and for exclusive breastfeeding (RR 0.90 [95% confidence interval 0.81,1.01]; six trials, 18,258 women) although the latter effect did not achieve full statistical significance. Lay support was effective in reducing the cessation of exclusive breastfeeding (RR 0.66 [95% CI 0.49,0.89]; five trials, 2530 women) but its effect on any breastfeeding did not reach statistical significance (RR 0.84 [95% CI 0.69,1.02]; five trials, 2224 women). Professional support in the largest trial to assess health outcomes produced a significant reduction in the risk of gastro-intestinal infections and atopic eczema. In two trials with children suffering from diarrhoeal illness extra support was highly effective in increasing short term exclusive breastfeeding rates and reducing recurrence of diarrhoea. REVIEWER'S CONCLUSIONS: Consideration should be given to providing supplementary breastfeeding support as part of routine health service provision. There is clear evidence for the effectiveness of professional support on the duration of any breastfeeding although the strength of its effect on the rate of exclusive breastfeeding is uncertain. Lay support is effective in promoting exclusive breastfeeding while the strength of its effect on the duration of any breastfeeding is also uncertain. Evidence supports the promotion of exclusive breastfeeding as central to the management of diarrhoeal illness in partially breastfed infants. Further trials are required to assess the effectiveness (including cost-effectiveness) of both lay and professional support in different settings - in particular in those communities with low rates of breastfeeding initiation. Research is also required into the most appropriate training for those, whether lay or professional, who support breastfeeding mothers.