This document provides an update on drugs used to treat gastroesophageal reflux disease (GORD) in infants, children, and young people. It discusses non-pharmacological treatments like thickening feeds and positioning. For mild GORD, antacids like alginate formulations are often used. For moderate to severe GORD, treatment typically combines a prokinetic agent to increase motility (such as domperidone or erythromycin) with an acid suppressant like ranitidine or a proton pump inhibitor like lansoprazole or omeprazole. The withdrawal of cisapride in 2000 and limitations of other prokinetic drugs like metoclopramide are also reviewed.
Irritable bowel syndrome (IBS) is a common gut disorder affecting 1 in 7 adults. Researcher at Monash University have developed a diet therapy to treat IBS. This diet is based on restricting the dietary intake of certain short chain carbohydrates (named FODMAPs). ‘The Monash University Low FODMAP Diet app’ includes the largest FODMAP database and provides up-to-date information on the dietary management of gastrointestinal symptoms associated with IBS. Use this app in conjunction with advice from your health professional.
This document discusses enteral nutrition in infants and children. It covers nutritional assessment, indications for enteral nutrition such as inability to meet nutritional needs orally or increased metabolic demands, disease-specific considerations, formula selection, nutritional requirements, and administration methods. Enteral nutrition provides nutrients through the gastrointestinal tract and is preferable to parenteral nutrition when possible due to lower costs and health benefits from GI tract utilization.
The low FODMAP diet for irritable bowel syndrome: from evidence to practice Robin Allen
At the end of this session, participants will
be able to:
– Describe the mechanisms of action and
evidence for the use of the low FODMAP diet
in patients with irritable bowel syndrome
– Be familiar with the concepts of the 3 phases
for implementing the low FODMAP diet
– Discuss ways in which the diet could be
modified to suit the needs of the individual
This document provides information on nutrition for breast cancer patients. It discusses how nutrition needs may change due to cancer treatments causing side effects like sore mouth, taste changes, nausea, diarrhea or constipation. It provides tips for managing these side effects dietarily. The document also covers maintaining a healthy weight and diet through eating according to the food pyramid guidelines with a focus on whole grains, fruits and vegetables. Nutritional supplements are discussed as a potential option for getting adequate nutrition.
The document provides information on a brand plan for a curcumin nano particle supplement product. It discusses the growing market size for curcumin supplements, highlights clinical studies that show curcumin's benefits for reducing inflammation and managing IBD, and outlines the need for a nano-sized curcumin formulation to improve its bioavailability and targeting of inflamed tissues. The brand plan proposes a nano-sized curcumin supplement product called CurcuMed and references in vitro and in vivo studies confirming the anti-inflammatory effects of nano-sized curcumin particles.
The document outlines 6 statements that form an ASPEN bundle for providing nutrition to patients in intensive care units. The statements recommend: 1) assessing patients' nutrition risk and determining energy and protein goals, 2) initiating enteral nutrition within 24-48 hours and increasing to goals over a week, and 3) taking steps to reduce risks like aspiration and improve tolerance for enteral feeding.
The document discusses medical nutrition therapy (MNT) for diabetes. It provides guidelines on who should receive MNT, how counseling should be conducted, and what messages to emphasize for MNT in barangay health stations. These include choosing foods from the plate method and using hand sizes as guides for portion control. The document also outlines goals and approaches for MNT, including setting behavioral goals, assessing patients' views on food and willingness to change, and enhancing adherence through mobile phone interventions.
Irritable bowel syndrome (IBS) is a common gut disorder affecting 1 in 7 adults. Researcher at Monash University have developed a diet therapy to treat IBS. This diet is based on restricting the dietary intake of certain short chain carbohydrates (named FODMAPs). ‘The Monash University Low FODMAP Diet app’ includes the largest FODMAP database and provides up-to-date information on the dietary management of gastrointestinal symptoms associated with IBS. Use this app in conjunction with advice from your health professional.
This document discusses enteral nutrition in infants and children. It covers nutritional assessment, indications for enteral nutrition such as inability to meet nutritional needs orally or increased metabolic demands, disease-specific considerations, formula selection, nutritional requirements, and administration methods. Enteral nutrition provides nutrients through the gastrointestinal tract and is preferable to parenteral nutrition when possible due to lower costs and health benefits from GI tract utilization.
The low FODMAP diet for irritable bowel syndrome: from evidence to practice Robin Allen
At the end of this session, participants will
be able to:
– Describe the mechanisms of action and
evidence for the use of the low FODMAP diet
in patients with irritable bowel syndrome
– Be familiar with the concepts of the 3 phases
for implementing the low FODMAP diet
– Discuss ways in which the diet could be
modified to suit the needs of the individual
This document provides information on nutrition for breast cancer patients. It discusses how nutrition needs may change due to cancer treatments causing side effects like sore mouth, taste changes, nausea, diarrhea or constipation. It provides tips for managing these side effects dietarily. The document also covers maintaining a healthy weight and diet through eating according to the food pyramid guidelines with a focus on whole grains, fruits and vegetables. Nutritional supplements are discussed as a potential option for getting adequate nutrition.
The document provides information on a brand plan for a curcumin nano particle supplement product. It discusses the growing market size for curcumin supplements, highlights clinical studies that show curcumin's benefits for reducing inflammation and managing IBD, and outlines the need for a nano-sized curcumin formulation to improve its bioavailability and targeting of inflamed tissues. The brand plan proposes a nano-sized curcumin supplement product called CurcuMed and references in vitro and in vivo studies confirming the anti-inflammatory effects of nano-sized curcumin particles.
The document outlines 6 statements that form an ASPEN bundle for providing nutrition to patients in intensive care units. The statements recommend: 1) assessing patients' nutrition risk and determining energy and protein goals, 2) initiating enteral nutrition within 24-48 hours and increasing to goals over a week, and 3) taking steps to reduce risks like aspiration and improve tolerance for enteral feeding.
The document discusses medical nutrition therapy (MNT) for diabetes. It provides guidelines on who should receive MNT, how counseling should be conducted, and what messages to emphasize for MNT in barangay health stations. These include choosing foods from the plate method and using hand sizes as guides for portion control. The document also outlines goals and approaches for MNT, including setting behavioral goals, assessing patients' views on food and willingness to change, and enhancing adherence through mobile phone interventions.
This document discusses intermittent fasting as a way to improve health and longevity. It notes that calorie restriction and fasting can delay disease onset, increase longevity, and reduce age-related diseases. There are different types of intermittent fasting discussed, including time-restricted feeding that limits eating to a 4-12 hour window each day and periodic or intermittent full or partial fasting. The document also covers some of the challenges of intermittent fasting, such as difficulty adhering to it and managing social aspects, and provides alternatives like low-carb, high-fat diets or bespoke personalized fasting patterns.
total parental nutrition in neonate guidlinemandar haval
This document discusses total parenteral nutrition (TPN) in neonates. It begins by describing the history and development of TPN, from early experiments in the 19th century to its modern use. It then discusses appropriate use of TPN in neonates, noting specific conditions where enteral feeding is not possible. The document provides details on components of TPN solutions, including fluids, energy and carbohydrate requirements, protein needs, and lipids. It stresses the importance of meticulous care, monitoring, and early transition to enteral feeding to minimize complications of TPN therapy in neonates.
Patient Education Health Issues PresentationSusanW2
This document summarizes information about type 2 diabetes, including frequently asked questions, diet and lifestyle recommendations, medication options, and resources for additional information. It recommends eating regular meals according to an exchange list, monitoring carbohydrate and fat intake, and being physically active. Insulin and other medications may be needed to manage blood sugar levels. Regular testing and working with a doctor is important for diabetes care and management.
carbohydrates and_health by the UK Scientific Advisory Committee on Nutrition New Food Innovation Ltd
Dietary carbohydrates and their role in health were last considered by the Committee on the Medical Aspects of Food Policy in reports published in the 1980s and 1990s. Since then, considerable evidence has emerged on the role of carbohydrates in cardio- metabolic, colo-rectal and oral health. The present report details the evidence SACN has considered and the approach SACN has taken to reviewing the relationships between dietary carbohydrates and health. The evidence was assessed using the SACN Framework for the Evaluation of Evidence and graded according to a system developed specifically for this review. SACN commissioned systematic reviews of the evidence on cardio- metabolic, colo-rectal and oral health to inform this report and this is the first time the committee has taken that approach. The findings of the systematic reviews have been used to inform the very detailed main body of the text which thereby provides a comprehensive and transparent account of the evidence and how SACN drew its conclusions.
As a result of its deliberations, SACN is now recommending that a new definition of dietary fibre be adopted in the UK and that a definition of ‘free sugars’ be used in nutrition advice in place of ‘non-milk extrinsic sugars’. Following careful consideration of the evidence, SACN is also recommending that the dietary reference value for carbohydrates be maintained at a population average of approximately 50% of total dietary energy intake and that the dietary reference value for dietary fibre for adults should be increased to 30g/day. Furthermore, SACN is recommending that population average intake of free sugars should not exceed 5% of total dietary energy. This advice, that people’s intake of ‘free sugars’ should be lower than that currently recommended for non-milk extrinsic sugars, is based on SACN’s assessment of evidence on the effect of free sugars on the risk of dental caries and on total energy intake. A higher sugars intake increases the risk of higher energy intakes - the higher the consumption of sugars, the more likely people are to exceed their estimated average requirement (EAR) for energy. Therefore, if intakes of free sugars are lowered, the more likely it is that the EAR for energy will not be exceeded, and this could go some way to addressing the significant public health problem of obesity.
FODMAPS, Put simply, FODMAPs are a collection of short-chain carbohydrates (sugars) that aren’t absorbed properly in the gut, which can trigger symptoms in people with IBS. FODMAPs are found naturally in many foods and food additives.
Consuming cruciferous vegetables even by people with thyroid problems could potentially provide certain health benefits, such as antioxidant and ant inflammatory effects to the gland, without a negative impact to its functioning.
Intermittent Fasting is the new kid on the block in terms of weight loss. But is it just a fad or are the proclaimed benefits backed by science?
http://blackbeltwhitehat.com/mma/nutrition/intermittent-fasting-diet-plan/
Type 2 DM in children & adolescents management overviewAbdulmoein AlAgha
The document discusses the management of type 2 diabetes in children and adolescents. It notes that obesity prevalence has increased type 2 diabetes in young people. Lifestyle modifications are the primary treatment, focusing on dietary changes, physical activity, and behavioral counseling. Pharmacological options include metformin, insulin, and GLP-1 receptor agonists. In rare cases, bariatric surgery may be considered for children with severe obesity if conservative measures fail. The goals of management are to achieve near-normal blood glucose control, improve insulin sensitivity, and prevent diabetes complications through lifestyle and medical treatment.
This document discusses bariatric surgery as a treatment for obesity, diabetes, and hypertension - known as the "dangerous triad". It outlines the obesity epidemic globally and in India. Bariatric surgery is presented as the most effective long-term treatment, as other options like diet, exercise, and medication often only achieve temporary weight loss. The document describes various bariatric surgical procedures and their mechanisms for weight loss and resolving comorbidities. Case studies are presented demonstrating successful weight loss and comorbidity resolution through bariatric surgery. Risks are low but include leaks, strictures, and potential for weight regain. A multidisciplinary team approach is emphasized for best outcomes.
Intermittent fasting is an Interventional strategy where in individuals are subjected to varying periods of fasting.
It doesn’t specify which foods you should eat but rather when you should eat them.
Intermittent fasting (IF) is an eating pattern that cycles between periods of fasting and eating.
It’s currently very popular in the health and fitness community.
Recently attracted attention because:
1- Its Evidence-Based Health Benefits
2- Its potential for correcting metabolic Abnormalities
3- Better adherence than other methods
The presentation provided an overview of the ketogenic diet, including:
- Defining the ketogenic diet and how it works to produce ketone bodies and treat epilepsy.
- Discussing various ketogenic diet protocols like the classic ketogenic diet, MCT oil diet, Modified Atkins Diet, and Low Glycemic Index Treatment Diet.
- Outlining the clinical pathway for initiating and monitoring the ketogenic diet therapy for epilepsy.
- Noting potential side effects, challenges, and nutritional inadequacies of maintaining the restrictive ketogenic diet long-term.
The presentation aimed to educate on the science and evidence behind using ketogenic diets to treat chronic diseases like obesity and type 2
Enteral nutrition involves delivering nutrients through the gastrointestinal tract, typically using a feeding tube. Tube feedings are preferred if adequate GI function is present. Parenteral nutrition delivers nutrients intravenously and is used when GI function is inadequate. Standard formulas are used for patients with normal digestion while hydrolyzed formulas contain pre-digested nutrients for impaired digestion. Formula selection considers nutritional needs, medical issues, and tolerance. Tube feeding complications include diarrhea, clogging and are addressed by modifying the formula or administration method.
Adam's presentation on Alternate Day and Intermittent Fasting ADF/IFBernie Williams
ADF/IF refers to nutrition protocols that extend the usual daily fasting period. ADF involves fasting whole days, while IF extends the ordinary fasting period by delaying the first meal. Both aim to reduce total caloric intake. Studies show calorie restriction can increase lifespan and reduce disease risk. IF methods include 16/8 fasting and alternate-day fasting. Purported benefits include improved blood glucose, reduced inflammation, and weight loss. The best protocol is one that can be consistently followed while still reducing weekly calorie intake.
The document discusses the importance of nutrition in diabetes management. It states that diabetes treatment involves controlling factors like diet, drugs, and daily activity. Proper nutrition therapy is an integral part of diabetes management. The document then compares the effects of high-carbohydrate and high-fat diets on various health markers in diabetics. It proceeds to describe Balance-D diabetes medical nutrition therapy, highlighting its balanced macronutrient profile, glycemic control benefits, improved compliance, and other advantages.
Philippine Clinical Practice Guidelines for the Diagnosis and Management of T...Iris Thiele Isip-Tan
This document presents guidelines from a consensus panel of Philippine diabetes organizations for the screening, diagnosis, and management of type 2 diabetes in the Philippines. It includes:
1. Recommendations for annual screening of individuals over 40 or those with risk factors, using fasting plasma glucose as the preferred initial test.
2. Criteria for the diagnosis of diabetes based on fasting plasma glucose, random plasma glucose, and oral glucose tolerance tests.
3. Algorithms outlining testing and follow up procedures based on risk factors and initial test results.
4. Notes that complications are often already present at diagnosis in the Philippine context, emphasizing the need for prevention and control efforts.
This presentation deals with the various approaches of medical nutrition therapy in Diabetes, comparison of the ADA, RSSDI and ICMR guidelines. It also talks about the various calorie counting apps as well.
Sports Nutrition is a very crucial aspect in the training of athletes and many research papers are coming out everyday to support theories on the same. Therefore, here I present to you my slides on effect of fasting and fat ingestion in athletes.
1. Surgical nutrition is important for well-nourished and malnourished patients who cannot take oral food for over a week after surgery to avoid prolonged starvation.
2. There are two main types of nutritional support - enteral involving feeding through the gastrointestinal tract, and parenteral involving intravenous feeding.
3. Enteral feeding has advantages of being more physiological but also risks like tube dislodgement, while parenteral nutrition is used when enteral is not possible and improves outcomes but carries risks of infections. Monitoring is important for both.
This document discusses irritable bowel syndrome (IBS) and the role of diet. It begins by defining IBS and outlining the Rome III criteria used for diagnosis. It describes symptoms like diarrhea, constipation, abdominal pain that are relieved by defecation. It discusses triggers for IBS like certain foods, caffeine, food dyes, MSG that can cause diarrhea. The document presents a case study of a patient who found significant relief of IBS symptoms by eliminating trigger foods. It also summarizes that traditional drug therapies only treat symptoms, not underlying causes, and that food intolerance can be an important factor in IBS for some patients.
Nutrition support in critically ill patients prevents metabolic
deterioration and loss of lean body mass
• Decrease in length of hospital stay , morbidity rate and
improvement in patient outcomes have attracted an valued the use
of nutrition support in the critically ill patients
The document provides information about doing business with the U.S. Environmental Protection Agency (EPA) and its Office of Small Business Programs (OSBP). It outlines EPA's mission to protect human health and the environment. OSBP supports this mission by fostering partnerships and contracting opportunities for small businesses. The document discusses EPA's procurement goals for small businesses, common contracts and services purchased, certification requirements, and tips for small businesses to pursue EPA opportunities.
This short document promotes the creation of Haiku Deck presentations on SlideShare, suggesting the reader may feel inspired to do so. It provides a call to action to get started making Haiku Deck presentations by simply clicking a button labeled "GET STARTED".
This document discusses intermittent fasting as a way to improve health and longevity. It notes that calorie restriction and fasting can delay disease onset, increase longevity, and reduce age-related diseases. There are different types of intermittent fasting discussed, including time-restricted feeding that limits eating to a 4-12 hour window each day and periodic or intermittent full or partial fasting. The document also covers some of the challenges of intermittent fasting, such as difficulty adhering to it and managing social aspects, and provides alternatives like low-carb, high-fat diets or bespoke personalized fasting patterns.
total parental nutrition in neonate guidlinemandar haval
This document discusses total parenteral nutrition (TPN) in neonates. It begins by describing the history and development of TPN, from early experiments in the 19th century to its modern use. It then discusses appropriate use of TPN in neonates, noting specific conditions where enteral feeding is not possible. The document provides details on components of TPN solutions, including fluids, energy and carbohydrate requirements, protein needs, and lipids. It stresses the importance of meticulous care, monitoring, and early transition to enteral feeding to minimize complications of TPN therapy in neonates.
Patient Education Health Issues PresentationSusanW2
This document summarizes information about type 2 diabetes, including frequently asked questions, diet and lifestyle recommendations, medication options, and resources for additional information. It recommends eating regular meals according to an exchange list, monitoring carbohydrate and fat intake, and being physically active. Insulin and other medications may be needed to manage blood sugar levels. Regular testing and working with a doctor is important for diabetes care and management.
carbohydrates and_health by the UK Scientific Advisory Committee on Nutrition New Food Innovation Ltd
Dietary carbohydrates and their role in health were last considered by the Committee on the Medical Aspects of Food Policy in reports published in the 1980s and 1990s. Since then, considerable evidence has emerged on the role of carbohydrates in cardio- metabolic, colo-rectal and oral health. The present report details the evidence SACN has considered and the approach SACN has taken to reviewing the relationships between dietary carbohydrates and health. The evidence was assessed using the SACN Framework for the Evaluation of Evidence and graded according to a system developed specifically for this review. SACN commissioned systematic reviews of the evidence on cardio- metabolic, colo-rectal and oral health to inform this report and this is the first time the committee has taken that approach. The findings of the systematic reviews have been used to inform the very detailed main body of the text which thereby provides a comprehensive and transparent account of the evidence and how SACN drew its conclusions.
As a result of its deliberations, SACN is now recommending that a new definition of dietary fibre be adopted in the UK and that a definition of ‘free sugars’ be used in nutrition advice in place of ‘non-milk extrinsic sugars’. Following careful consideration of the evidence, SACN is also recommending that the dietary reference value for carbohydrates be maintained at a population average of approximately 50% of total dietary energy intake and that the dietary reference value for dietary fibre for adults should be increased to 30g/day. Furthermore, SACN is recommending that population average intake of free sugars should not exceed 5% of total dietary energy. This advice, that people’s intake of ‘free sugars’ should be lower than that currently recommended for non-milk extrinsic sugars, is based on SACN’s assessment of evidence on the effect of free sugars on the risk of dental caries and on total energy intake. A higher sugars intake increases the risk of higher energy intakes - the higher the consumption of sugars, the more likely people are to exceed their estimated average requirement (EAR) for energy. Therefore, if intakes of free sugars are lowered, the more likely it is that the EAR for energy will not be exceeded, and this could go some way to addressing the significant public health problem of obesity.
FODMAPS, Put simply, FODMAPs are a collection of short-chain carbohydrates (sugars) that aren’t absorbed properly in the gut, which can trigger symptoms in people with IBS. FODMAPs are found naturally in many foods and food additives.
Consuming cruciferous vegetables even by people with thyroid problems could potentially provide certain health benefits, such as antioxidant and ant inflammatory effects to the gland, without a negative impact to its functioning.
Intermittent Fasting is the new kid on the block in terms of weight loss. But is it just a fad or are the proclaimed benefits backed by science?
http://blackbeltwhitehat.com/mma/nutrition/intermittent-fasting-diet-plan/
Type 2 DM in children & adolescents management overviewAbdulmoein AlAgha
The document discusses the management of type 2 diabetes in children and adolescents. It notes that obesity prevalence has increased type 2 diabetes in young people. Lifestyle modifications are the primary treatment, focusing on dietary changes, physical activity, and behavioral counseling. Pharmacological options include metformin, insulin, and GLP-1 receptor agonists. In rare cases, bariatric surgery may be considered for children with severe obesity if conservative measures fail. The goals of management are to achieve near-normal blood glucose control, improve insulin sensitivity, and prevent diabetes complications through lifestyle and medical treatment.
This document discusses bariatric surgery as a treatment for obesity, diabetes, and hypertension - known as the "dangerous triad". It outlines the obesity epidemic globally and in India. Bariatric surgery is presented as the most effective long-term treatment, as other options like diet, exercise, and medication often only achieve temporary weight loss. The document describes various bariatric surgical procedures and their mechanisms for weight loss and resolving comorbidities. Case studies are presented demonstrating successful weight loss and comorbidity resolution through bariatric surgery. Risks are low but include leaks, strictures, and potential for weight regain. A multidisciplinary team approach is emphasized for best outcomes.
Intermittent fasting is an Interventional strategy where in individuals are subjected to varying periods of fasting.
It doesn’t specify which foods you should eat but rather when you should eat them.
Intermittent fasting (IF) is an eating pattern that cycles between periods of fasting and eating.
It’s currently very popular in the health and fitness community.
Recently attracted attention because:
1- Its Evidence-Based Health Benefits
2- Its potential for correcting metabolic Abnormalities
3- Better adherence than other methods
The presentation provided an overview of the ketogenic diet, including:
- Defining the ketogenic diet and how it works to produce ketone bodies and treat epilepsy.
- Discussing various ketogenic diet protocols like the classic ketogenic diet, MCT oil diet, Modified Atkins Diet, and Low Glycemic Index Treatment Diet.
- Outlining the clinical pathway for initiating and monitoring the ketogenic diet therapy for epilepsy.
- Noting potential side effects, challenges, and nutritional inadequacies of maintaining the restrictive ketogenic diet long-term.
The presentation aimed to educate on the science and evidence behind using ketogenic diets to treat chronic diseases like obesity and type 2
Enteral nutrition involves delivering nutrients through the gastrointestinal tract, typically using a feeding tube. Tube feedings are preferred if adequate GI function is present. Parenteral nutrition delivers nutrients intravenously and is used when GI function is inadequate. Standard formulas are used for patients with normal digestion while hydrolyzed formulas contain pre-digested nutrients for impaired digestion. Formula selection considers nutritional needs, medical issues, and tolerance. Tube feeding complications include diarrhea, clogging and are addressed by modifying the formula or administration method.
Adam's presentation on Alternate Day and Intermittent Fasting ADF/IFBernie Williams
ADF/IF refers to nutrition protocols that extend the usual daily fasting period. ADF involves fasting whole days, while IF extends the ordinary fasting period by delaying the first meal. Both aim to reduce total caloric intake. Studies show calorie restriction can increase lifespan and reduce disease risk. IF methods include 16/8 fasting and alternate-day fasting. Purported benefits include improved blood glucose, reduced inflammation, and weight loss. The best protocol is one that can be consistently followed while still reducing weekly calorie intake.
The document discusses the importance of nutrition in diabetes management. It states that diabetes treatment involves controlling factors like diet, drugs, and daily activity. Proper nutrition therapy is an integral part of diabetes management. The document then compares the effects of high-carbohydrate and high-fat diets on various health markers in diabetics. It proceeds to describe Balance-D diabetes medical nutrition therapy, highlighting its balanced macronutrient profile, glycemic control benefits, improved compliance, and other advantages.
Philippine Clinical Practice Guidelines for the Diagnosis and Management of T...Iris Thiele Isip-Tan
This document presents guidelines from a consensus panel of Philippine diabetes organizations for the screening, diagnosis, and management of type 2 diabetes in the Philippines. It includes:
1. Recommendations for annual screening of individuals over 40 or those with risk factors, using fasting plasma glucose as the preferred initial test.
2. Criteria for the diagnosis of diabetes based on fasting plasma glucose, random plasma glucose, and oral glucose tolerance tests.
3. Algorithms outlining testing and follow up procedures based on risk factors and initial test results.
4. Notes that complications are often already present at diagnosis in the Philippine context, emphasizing the need for prevention and control efforts.
This presentation deals with the various approaches of medical nutrition therapy in Diabetes, comparison of the ADA, RSSDI and ICMR guidelines. It also talks about the various calorie counting apps as well.
Sports Nutrition is a very crucial aspect in the training of athletes and many research papers are coming out everyday to support theories on the same. Therefore, here I present to you my slides on effect of fasting and fat ingestion in athletes.
1. Surgical nutrition is important for well-nourished and malnourished patients who cannot take oral food for over a week after surgery to avoid prolonged starvation.
2. There are two main types of nutritional support - enteral involving feeding through the gastrointestinal tract, and parenteral involving intravenous feeding.
3. Enteral feeding has advantages of being more physiological but also risks like tube dislodgement, while parenteral nutrition is used when enteral is not possible and improves outcomes but carries risks of infections. Monitoring is important for both.
This document discusses irritable bowel syndrome (IBS) and the role of diet. It begins by defining IBS and outlining the Rome III criteria used for diagnosis. It describes symptoms like diarrhea, constipation, abdominal pain that are relieved by defecation. It discusses triggers for IBS like certain foods, caffeine, food dyes, MSG that can cause diarrhea. The document presents a case study of a patient who found significant relief of IBS symptoms by eliminating trigger foods. It also summarizes that traditional drug therapies only treat symptoms, not underlying causes, and that food intolerance can be an important factor in IBS for some patients.
Nutrition support in critically ill patients prevents metabolic
deterioration and loss of lean body mass
• Decrease in length of hospital stay , morbidity rate and
improvement in patient outcomes have attracted an valued the use
of nutrition support in the critically ill patients
The document provides information about doing business with the U.S. Environmental Protection Agency (EPA) and its Office of Small Business Programs (OSBP). It outlines EPA's mission to protect human health and the environment. OSBP supports this mission by fostering partnerships and contracting opportunities for small businesses. The document discusses EPA's procurement goals for small businesses, common contracts and services purchased, certification requirements, and tips for small businesses to pursue EPA opportunities.
This short document promotes the creation of Haiku Deck presentations on SlideShare, suggesting the reader may feel inspired to do so. It provides a call to action to get started making Haiku Deck presentations by simply clicking a button labeled "GET STARTED".
Chelsea Stenvig seeks a position with a nonprofit organization. She has a bachelor's degree in secondary education and English from Concordia University Wisconsin and a master's degree in leadership and innovation from Wisconsin Lutheran College. She has several years of experience teaching middle and high school English and serving in administrative roles at charter schools in Milwaukee.
Sonai Muthu is seeking a role applying technical knowledge in information security and risk management. He has a B.E. in computer science from Velammal College of Engineering and Technology. His experience includes over 2 years as an IDAM developer for Wipro Technologies working on the Lloyds Banking Group compliance team. In this role, he created and managed applications and reviews in Aveksa Compliance Manager, performed data analysis, and provided technical support and resolutions. He received an award as a best performer from the Head of Identity and Access Management at Lloyds Banking Group.
Adelvis González es un ingeniero que proporciona sus contactos de correo electrónico, Twitter y Facebook para que las personas puedan comunicarse con él.
Asturias Ecoturismo - Turismo ecológico en la Montaña Central de AsturiasASTURIAS ECOTURISMO
El documento presenta varias actividades turísticas relacionadas con la naturaleza y la cultura de Asturias, incluyendo visitas a cascadas, elaboración de dulces tradicionales, paisajes mineros, ríos, hórreos, minas prehistóricas y bosques. Se proporcionan detalles como la ubicación, fecha y horario de cada actividad, así como opciones y precios de alojamiento.
Tyler Taylor is seeking part-time employment in a customer-focused retail environment while pursuing an AA degree. He has 5 years of broad experience in boutique retail stores and supermarkets, performing roles such as sales, customer service, loss prevention, and janitorial duties. Tyler is an enthusiastic, hard-working self-starter with a focus on customer satisfaction and perfect attendance.
Este documento describe el proceso de creación de bases de datos documentales. Se divide en tres fases: análisis, diseño e implementación. En la fase de análisis se estudian el sistema de actividades humanas y el sistema de conocimiento que justifican la base de datos. En la fase de diseño se crea un modelo conceptual y un diccionario de datos. Finalmente, en la fase de implementación se selecciona el software y hardware, se realizan pruebas y se implementa y promueve la base de datos.
El documento describe el aprendizaje autónomo y el autoaprendizaje. El aprendizaje autónomo es la capacidad de una persona para orientar, controlar y evaluar su propio aprendizaje mediante el uso de estrategias para alcanzar metas. El autoaprendizaje se basa en la curiosidad y la autodisciplina y es un proceso individual. El documento también menciona tres formas de aprendizaje: visual, auditivo y kinestésico.
The document provides a strategic recommendations report for the event planning company hooRAE. It includes a market insights analysis of hooRAE's target customers, a competitive analysis of similar companies, and recommendations for hooRAE's social media strategy, PR and partnerships, and website. The report aims to help hooRAE increase its brand awareness and capitalize on opportunities for growth in the wedding and events industry.
Department of Revenue, Potential Fiscal and Revenue Options (6.4.2015)Brad Keithley
The document discusses potential fiscal and revenue options for the Walker-Mallott administration to address Alaska's budget deficit. It provides an overview of Alaska's current fiscal situation resulting from declining oil prices. It then summarizes and categorizes over 20 potential options, including continued budget restraint, measures related to the permanent fund and oil/gas taxes, and new statewide taxes. The document emphasizes that multiple substantial changes will be needed to address both short- and long-term budget imbalances.
Obesidad: nutrientes moduladores de neuropeptidos y neurotransmisoresNutriline SRL
This document discusses ketogenic enteral nutrition (KEN) as a treatment for obesity. It describes a study of over 19,000 obese patients who underwent 10-day cycles of receiving 50-65 grams of protein per day via continuous nasogastric tube infusion, without any carbohydrates. This protocol resulted in an average weight loss of 10.2 kg over 2.5 cycles, with 57% of the loss being fat mass. No significant adverse effects occurred. KEN is concluded to be a safe, fast, and inexpensive treatment that provides good long-term weight maintenance results.
This document discusses rumination disorder in a 16-year-old female patient. Rumination disorder involves repeatedly regurgitating and rechewing or reswallowing food after eating. It is considered a learned behavior rather than a medical condition. Treatment involves behavioral therapy like relaxation techniques and diaphragmatic breathing. For severe cases with weight loss, enteral nutrition may be needed. Multidisciplinary teams including nutrition, psychology, and gastroenterology have been shown to help patients learn to stop the rumination behavior through programs that focus on eating skills.
This document discusses nutrition in surgical patients. It begins by outlining the goals of nutritional support, which include identifying patients at risk of malnutrition, preventing or reversing catabolism, and meeting energy requirements. It then covers topics like malnutrition, nutritional assessment tools, estimating energy needs, and administration of enteral and parenteral nutrition. The key points are that nutritional support should begin preoperatively for high-risk patients or if oral intake won't resume within 7 days post-op, and the enteral route is preferred over parenteral nutrition when possible.
The document discusses various treatments for acute diarrhea in children. It begins by noting that diarrhea remains a significant cause of illness and death in children under 5 years old worldwide. It then reviews several treatment options including oral rehydration therapy (ORT), lactose-free formulas, the clay mineral diosmectite, the antisecretory drug racecadotril, zinc supplementation, and probiotics. For each treatment, it summarizes available evidence on effectiveness and safety from studies and reviews. The document emphasizes that ORT is the recommended first-line treatment for rehydration and that there is insufficient evidence to recommend routine use of other treatments, though some like zinc may provide benefit in specific cases.
The intense fetal growth and development during pregnancy requires maternal physiologic adaptation and a change in nutritional needs.
Adequate maternal intake of macronutrients and micronutrients promotes normal embryonic and fetal development.
Importantly, maternal nutritional status is a modifiable risk factor that can be evaluated, monitored, and, when appropriate, improved.
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Update on drugs for gastro-oesophageal reflux
disease
Simon Keady
Arch. Dis. Child. Ed. Pract. 2007;92;ep114-ep118
doi:10.1136/adc.2006.106328
Updated information and services can be found at:
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PHARMACY UPDATE
UPDATE ON DRUGS FOR GASTROOESOPHAGEAL REFLUX DISEASE
Simon Keady
ep114
Arch Dis Child Educ Pract Ed 2007; 92:ep114–ep118. doi: 10.1136/adc.2006.106328
G
astro-oesophageal reflux (GOR) is a common and usually self-limiting condition involving
the regurgitation of gastric contents into the oesophagus. It causes symptoms (table 1) such
as heartburn, oesophagitis, acute life-threatening events and respiratory disease,1–3 at which
point it is defined as gastro-oesophageal reflux disease (GORD).
The prevalence of GOR and GORD in infants is between 20–40%, higher than that in children and
adults. This high number is associated with the transient immaturity of the oesophagus and the stomach.
Features include a short abdominal oesophagus (,1 cm), increased oesophageal clearance, increased
number of transient lower oesophageal sphincter relaxations coupled with delayed gastric emptying.4–6
Methods of detection include oesophageal pH monitoring, especially with respiratory manifestations,1 3 7–9 or multiple intraluminal impedance.10–12 The latter allows detection of continued
postprandial reflux despite a neutralisation of gastric contents by milk formula.
However, there continues to be a wide variation in diagnostic and management strategies even
across major neonatal intensive care units in the UK, requiring further work to evaluate
appropriateness and effectiveness.13
TREATMENT OF GOR AND GORD IN INFANTS, CHILDREN AND YOUNG PEOPLE
The principal aims of treatment are to alleviate symptoms, allow healing of the oesophageal mucosa
if indicated, manage and prevent any complications and to maintain long-term remission.
Treatment strategies and options depend upon the severity of the GORD and may include lifestyle
changes or pharmacological and surgical interventions. Older children and young people should be
counselled on specific lifestyle changes such as weight reduction if obese and the avoidance of
smoking and drinking alcohol if necessary.
For the purpose of this article, the focus will primarily be on drug management of this condition
(table 2).
TREATMENT OF GOR OR MILD GORD
Normal steps in the management of mild conditions are usually non-pharmacological and may
involve reassurance of parents/carers, thickening of feeds and placing the infant in a supine position.
The latter, while often suggested, has few data to support its recommendation.14
FEED THICKENERS
Carob-based thickeners can be used in infants under one to thicken feeds. For those infants being
breast fed, the thickener can be given as a paste prior to feeds. Starch-based thickeners can be used in
feeds and liquids for children over the age of 1.
Caesin-based infant formula is a pre-thickened formula that contains small quantities of pregelatinised starch. It is primarily recommended for those infants with mild GOR. The formula is prepared
in the same way as a normal infant formula and is able to flow through a standard teat. The feed does not
thicken on standing but does so in the stomach when it is exposed to an acidic environment.
ANTACIDS (INCLUDING ALGINATE FORMULATIONS)
__________________________
Correspondence to:
Mr S Keady, University College
London Hospitals NHS
Foundation Trust, 235 Euston
Road, London NW1 2BU, UK;
simon.keady@uclh.nhs.uk
__________________________
www.archdischild.com
Initial pharmacological intervention is usually with antacid therapy which neutralises gastric acid
and reduces the symptoms of indigestion and oesophagitis. The major advantage of antacids is their
rapid onset of action in providing relief. An intragastric pH above 3.5 can be achieved within minutes.
Their limitation, however, is maintaining this pH in the presence of continued acid secretion and the
gastric emptying rate.
Alginate-containing antacids (for example, Gaviscon Infant) form a ‘‘raft’’ that floats on the
surface of the stomach contents which should reduce reflux and afford some protection to the
oesophageal mucosa. However, recent assessment of Gaviscon Infant on GOR by combined
intraluminal impedance/pH questions its efficacy at preventing reflux.15
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PHARMACY UPDATE
Table 1 Symptoms of gastro-oesophageal reflux disease
(GORD)
Usual manifestations
Specific manifestations
Nausea
Vomiting
Regurgitation
Symptoms related to GORD complications
Symptoms related to iron deficiency anaemia
Dysphagia (direct symptom of oesophagitis or from stricture formation)
Weight loss and/or failure to thrive
Epigastric or retrosternal pain
Non-cardiac angina-like chest pain
Belching, postprandial fullness
General irritability
Irritable oesophagus
Unusual presentations
GORD related to chronic respiratory disease (bronchitis, asthma,
laryngitis, etc)
Sandifer–Sutcliffe syndrome
Apnoeas, apparent life-threatening event and sudden infant death
syndrome
Congenital and/or central nervous system abnormalities
Intracranial tumours, cerebral palsy, psychomotor retardation
Those alginate preparations containing aluminium should be
avoided in chronic use wherever possible, especially in
neonates, infants and children with renal impairment, because
of accumulation leading to an increased plasma-aluminium
concentration.
Gaviscon Infant should not be used when excessive water
loss is likely—such as pyrexia, diarrhoea or vomiting or where
there is a risk of intestinal obstruction.
The prescribing and co-administration of alginates and
thickening agents should be undertaken with caution because
of the risk of agglutinated intragastric materials being formed
which can lead to possible intestinal obstruction.
To avoid confusion in the use of Gaviscon Infant, each half of
the dual sachet is identified as ‘‘one dose’’. The prescription
should be in terms of dual sachets when prescribing a dose—
that is, two doses (one dual sachet).
MANAGEMENT OF MODERATE TO SEVERE GORD
Drug treatment in this group of patients usually combines a
prokinetic agent with an appropriate acid suppressant. With the
withdrawal of cisapride and the adverse effects associated with
Table 2 Summary of drugs used to treat GOR and GORD
Drug
Available
formulations
Aluminium hydroxide
Maalox
Mucogel
Gaviscon Infant
Liquid
Liquid
Sachets
Suspension
Tablets
Domperidone
Liquid, tablets
Erythromycin
Metoclopramide
Liquid, tablets
Liquid, tablets
Ranitidine
Liquid, tablets
Lansoprazole
Capsules, FastTabs
(disp tabs),
suspension
Capsules, tablets
Omeprazole
Frequency
Licensed (Y/N)
14–18 years: 10–20 ml
12–18 years: 10–20 ml
Neonate under 4.5 kg: 1 dose with feeds/water when
required
Neonate over 4.5 kg: 2 doses with feeds/water when
required
1 mo–12 years: 2 doses with feeds/water when required
2–12 years: 2.5–5 ml
12–18 years: 5–10 ml
6–12 years: 1 tablet
12–18 years: 1–2 tablets
Neonate: 100–300 mg/kg
1 mo–12 years: 200–400 mg/kg (max 20 mg)
12–18 years: 10–20 mg
Neonate – 18 years: 3 mg/kg
Neonate: 100 mg/kg
1 mo–1 year and body-weight up to 10 kg: 100 mg/kg
1–3 year and body-weight 10–14 kg: 1 mg
3–5 year and body-weight 15–19 kg: 2 mg
5–9year and body-weight 20–29 kg: 2.5 mg
9–18 year and body-weight 30–60 kg: 5 mg
15–18 year and body-weight over 60 kg: 10 mg
Neonate: 2 mg/kg (up to max 3 mg/kg)
1 mo–6 mo: 1 mg/kg (up to max 3 mg/kg)
6 mo–12 year: 2–4 mg/kg (max 150 mg)
12–18 year: 150 mg
Child under 30 kg: 0.5–1 mg/kg (max 15 mg)
Child over 30 kg: 15 mg–30 mg
After meals and at bedtime
After meals and at bedtime
Max 6 times in 24 h
N (not ,14 years)
N (not ,12 years)
Y
Max 6 times in 24 h
Y
Max 6 times in 24 h
After meals and at bedtime
After meals and at bedtime
After meals and at bedtime
After meals and at bedtime
4–6 times daily before feeds
3–4 times daily before feeds
3–4 times daily before food
Four times a day
Every 6–8 h
Twice daily
2–3 times daily
2–3 times daily
Three times daily
Three times daily
Three times daily
Three times daily
Three times daily
Twice daily
Twice daily
Once daily in the morning
Once daily in the morning
Y
N
Y
N
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Neonate: 700 mg/kg increasing to 1.4 mg/kg after
7–14 days. Some neonates may require 2.8 mg/kg
Once daily
Y (for children >1 year
with severe ulcerating
reflux oesophagitis)
1 mo–2 year: 700 mg/kg increased to 3 mg/kg if
necessary (max 20 mg)
Body weight 10–20 kg: 10 mg initially increasing to
20 mg if necessary
Body weight over 20 kg: 20 mg once daily
increasing to 40 mg if necessary
Gaviscon Advance
Dose
Once daily
(not ,12 years)
(not ,12 years)
(not
(not
(not
(not
(not
(not
(not
(not
(not
(not
(not
(not
(not
(not
(not
for
for
for
for
for
for
for
for
for
for
for
for
for
for
for
GORD)
GORD)
GORD)
GORD)
GORD)
GORD)
GORD)
GORD)
GORD)
GORD)
GORD)
GORD)
GORD)
GORD)
GORD)
Once daily
Once daily
Doses based on recommendations from the British National Formulary for Children 2006.
www.archdischild.com
ep115
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KEADY
metoclopramide, the common prokinetic agents include domperidone and erythromycin.
PROKINETIC DRUGS
ep116
Domperidone
Domperidone is a peripheral D2 receptor antagonist that
increases motility and gastric emptying and decreases the
postprandial reflux time. Since the suspension of the marketing
authorisation of cisapride in 2000 and the company’s subsequent withdrawal of the product in 2005, domperidone has
become increasingly used.
Clinical trials assessing domperidone use in infants or
children with GORD are limited. Four randomised clinical
trials identified showed very little efficacy in the reduction of
symptoms in both GOR and GORD.16–19 The immaturity of the
nervous system and the blood/brain barrier in premature
infants, infants and children may make these patients more
susceptible to neurological symptoms (extrapyramidal and
oculo-gyric crisis)20 21 associated with domperidone. However,
in all four trials, no adverse events were documented.
Erythromycin
Erythromycin is a macrolide antibiotic which has demonstrated
an increase in GI motility by acting directly upon motilin
receptors in the GI tract. Motilin is a hormone secreted into the
GI tract during times of fasting and has a function on smooth
muscle contractions. Trials involving erythromycin have mainly
focused on its use in neonates and infants and although there is
some evidence of its efficacy in older children, none is
supported by prospective clinical trials.22–30
Both the oral and intravenous routes have been used while
doses have ranged from 1.5–12.5 mg/kg every 6 h. However,
erythromycin’s effects appear to be dose dependent and side
effects can be minimised without diminishing motility at doses
of 1–3 mg/kg.31
Adverse effects at these doses, although rare, can be severe.
They include GI upset, hepatotoxicity, anaphylaxis, arrhythmias and infantile hypertrophic pyloric stenosis.
As with all antibiotics, especially for non-infectious conditions, the potential for resistance should be considered prior to
initiating therapy.
Metoclopramide
Metoclopramide is a dopamine antagonist which increases
motility and accelerates gastric emptying by enhancing the GI
tract’s response to acetylcholine. It also increases the lower
oesophageal sphincter tone. Although it may appear to have the
ideal combination of properties to treat GORD, studies have
shown it to be little better than placebo.32
It is also associated with a number of serious adverse effects
including drowsiness, restlessness, galactorrhoea as well as
extrapyramidal reactions such as dystonia and tardive dysknesia.33 34
Other prokinetic agents available now limit its use.
Withdrawal of cisapride
In 2000 when the Committee on the Safety of Medicines (CSM)
withdrew the product license for cisapride, it had been used in 140
million patient treatments with 37.8 million of these in patients
up to 20 years of age. Of these, 25.2 million were in the under 1s.35
www.archdischild.com
The CSM cited concerns over cisapride’s potential to prolong
the QT interval, which could lead to adverse events such as
torsades des pointes or a clinically significant degree of
heartblock.36
With no agreed method for quantifying a normal QTc
interval, it makes a definitive description of a QTc prolongation
difficult. All the reported cases of torsades des pointes involved
the concomitant administration of cisapride with a macrolide
antibiotic, an overdose of cisapride or both.36 37
Post-marketing experience showed that doses up to 800 mg/kg/
day could be used safely. Recommendations were made in an
attempt to ensure the continued availability of cisapride.38 These
included a strict maximum dose limit, ECG monitoring, correction
of relevant electrolyte discrepancies prior to initiation of therapy
and awareness of drugs to avoid while on cisapride therapy.
Despite this, in 2005 the company terminated its product
license and ceased production of cisapride.
GASTRIC ACID SUPPRESSANTS
Histamine-2-receptor antagonists
Rantidine is the drug of choice in this group of drugs. It works
by inhibiting the H2 receptors of the gastric parietal cells. Side
effects, although rare, can include fatigue, dizziness, diarrhoea
and other gastrointestinal disturbances.39–41
Unsurprisingly, efficacy is greater in cases of mild oesophagitis than in severe ones where a proton pump inhibitor maybe
of more benefit.
Oral ranitidine given 2–3 times a day provides symptomatic
and endoscopic symptom improvement in erosive oesophagitis.
In infants, a three times a day regime is often required as
intragastric pH returns to its baseline level within 5 h.
Rises in gastric pH have been associated with bacterial
overgrowth in infants.42
Tolerance to the antisecretory effect of histamine-2-receptor
antagonists develops quickly and the possible occurrence of
rebound hypersecretion must be taken into account upon
discontinuation of the drug and a reduction in a stepwise
manner is recommended.43
The long-term effects of gastric acid blockade have yet to be
determined especially in infants. It is therefore still unclear as
to whether total acid suppression is an appropriate target or
whether small periods of gastric acid secretion through the day
are warranted.
However, with the introduction of proton pump inhibitors
and their demonstrated superiority over histamine-2-receptor
antagonists, this question may never be answered.
Proton pump inhibitors
Lansoprazole and omeprazole are proton pump inhibitors
(PPIs) that inactivate the H(+)/K(+) –ATPase pump in parietal
cells inhibiting gastric acid secretion and increasing the
intragastric pH. This series of events involves the protonation
of the drug molecule and through a variety of reactions, turns it
into an active form. Gastric acid secretion only returns once the
parietal cells synthesise new H+/K+ ATPase supplies.
PPIs are often well tolerated by patients with the commonest
side effects including mild to moderate headaches, abdominal
pain, vomiting and diarrhoea. Occasional electrolyte disturbances and minor reversible elevation of transaminase levels
have also been reported.
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PHARMACY UPDATE
Prolonged periods of hypochlorhydria have been identified in
neonates as well as adults, resulting in bacterial overgrowth. The
effects of this overgrowth still remain unclear but increases in
respiratory infections in critically ill patients have been reported.44
Approximately 40% of children prescribed omeprazole will
respond to a dosage of 0.73 mg/kg/day, a further 26% to an
increase to 1.44 mg/kg/day while approximately 35% will fail at
this dose.45
Pharmacokinetic studies of omeprazole in children have shown
a significant difference in the half life of the drug in children less
than 7 years of age and those over 7. The younger cohort of
patients appears to metabolise the drug quicker and this higher
metabolic rate suggests that these patients may benefit from a
twice daily regime instead of a single morning dose.
PPIs are metabolised by the hepatocyte cytochrome P450
isoforms CYP2C19 and CYP3A4 to inactive metabolites. The
CYP2C19 is the predominant enzyme with an affinity to the PPI
10 times that of the CYP3A4. CYP2C19 displays a known
genetic polymorphism which can lead to large variations in the
kinetic disposition of the PPI. The phenotype is present in
approximately 3–5% of the Caucasian and African-American
population but rises to 15–20% in the Asian population. This
variation of genetic polymorphism related to these enzymes will
further lead to differences in the kinetic disposition of PPIs. The
‘‘poor metabolisers’’, that is, reduced enzymatic activity, can
have plasma concentrations and area under the concentration
curve up to 5 times greater than ordinary metabolisers.
It would therefore be prudent to consider the impact of the
CYP2C19 genotype when researchers evaluate the pharmacokinetic and pharmacodynamic data of PPIs in the paediatric
population.
Current treatment options involving PPIs can be limited due
to a lack of suitable ‘‘child friendly’’ formulations. There is no
licensed liquid PPI available in the UK and granules and tablets
are not able to be crushed because of their gastro-protective
coat. Inadvertent crushing will lead to a significant change in
the drugs pharmacokinetic and pharmacodynamic properties
due to altered absorption and metabolism. This requires
manipulation of the solid dosage forms into a more suitable
version. Extemporaneous liquid formulations therefore have
limited information with regards to stability and bioavailability.
An extemporaneous liquid formulation of omeprazole in
sodium bicarbonate 8.4% can be made46 but there can still be
variations in absorption etc when compared to the administration of a tablet or capsule.
The lansoprazole FasTab is able to be administered down
enteral feeding tubes if necessary, which makes it a viable
choice in those infants requiring feed through nasogastric
tubes. The lansoprazole suspension should be avoided in this
group of patients because of its tendency to block the tube.
Future treatment options
In order to achieve a more rapid, potent and sustained degree of
remission, several other drugs have been tried.
Baclofen, a GABAB receptor agonist has been used as an add-on
therapy with PPIs, particularly in cases where there is persisting
reflux symptoms. It has been shown to inhibit transient lower
oesophageal sphincter pressure relaxations as well as possibly
increasing the basal lower oesophageal sphincter pressure.
Further work is required to determine optimum doses required
because of the variability in the volume of distribution of the drug
due to evolving body composition.47
Histamine receptor agonists continue to be viewed with
interest despite the withdrawal of cisapride. Prucalopride (a
highly specific 5-HT4 receptor agonist) demonstrated a stimulation of the peristaltic reflex and a decrease in colonic transit
time. However, its association with possible carcinogenicity48
led to its development being reduced and interest turning to
Tegaserod instead. Tegaserod is a partial 5-HT4 agonist but with
a high potency and specificity licensed in the USA by the Food
and Drug Administration (FDA) for the treatment of chronic
constipation in patients under 65 years of age. Advantages in
using this drug included increasing the peristaltic reflex,
decreasing visceral sensitivity and providing a reliable prokinetic activity in the colon. This was seen in the UK as a possible
option where current conventional therapy had failed or had
not fully resolved symptoms.
In March 2007, the FDA withdrew Tegaserod from the US
market due to concerns relating to increased incidences of
cardiac chest pain and stroke.49
Side-effect profiles of other groups of drugs which may be of
benefit—that is, anticholinergics, opioid mu receptor agonists
and nitric oxide synthase inhibitors—have so far prevented indepth study.50
Surgical management
Surgery can play an important role in GORD but for the purpose
of this article will only be covered briefly.
Surgical interventions such as Nissens fundoplication have
usually been reserved for those patients who are resistant to drug
therapy or who may require long-term medical management.
However, recent advances in surgical techniques, such as
endoscopic fundoplication which can be performed on a day case
basis, may well allow a surgical intervention to be considered at a
much earlier stage of the disease process. To date, no studies have
compared medical to surgical treatments and all information
reported is retrospective. Current results looking at a surgical
intervention suggest that any surgery of this type should be
delayed if possible until the child is 2 years of age.
CONCLUSION
GORD is a condition which undoubtedly benefits from
pharmaceutical intervention. However, the majority of drugs
used have limited robust data supporting their use. Further
work is needed in this field to identify optimal treatment
regimes through large, well designed, multicentre studies and
to assess pharmacokinetic and bioavailability of formulations to
ensure that not only can the best care be delivered but also that
the treatments become licensed for this specific indication.
Until this is achieved, clinicians and pharmacists will continue
to work with limited choices.
Competing interests: None.
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