| Parenteral nutrition refers to nutritional support | | | | should be considered to improve quality of life if the |
| provided by an intravenous route. Access may be a | | | | patient, caregivers and medical team agree to this |
| peripheral vein or central vein. Peripheral venous | | | | intervention. |
| access is usually used for short term support and | | | | Common Dietary Problems |
| limits the volume of fluids and nutrients that can be | | | | During the course of treatment and care, many |
| delivered. Whenever possible, enteral nutrition is | | | | dietary problems can arise. Strategies to help alleviate |
| preferred in order to provide nutrients to the gut and | | | | common problems are addressed in |
| maintain the intestinal barrier. | | | | Pregnancy, Lactation and HIV |
| Indications for Parenteral Nutrition | | | | Pregnancy, lactation, and HIV disease engender |
| Parenteral nutrition is used in cases of gut failure or | | | | physiologic stress, with increased nutritional needs for |
| severe gastrointestinal disease. Catheter-related | | | | energy, protein and micronutrients. It is well |
| sepsis is a significant risk in immunocompromised | | | | recognized that the nutritional health of a pregnant |
| patients. In HIV/AIDS, TPN will induce weight gain, | | | | woman influences pregnancy outcome. |
| the composition of which depends on the underlying | | | | Nutritionalstatus has even greater implications for the |
| etiology of the malnutrition. Septic patients tend to | | | | HIV-infected woman who is at higher risk of |
| gain primarily fat whereas those with malabsorption | | | | premature delivery and having a low birth weight |
| or inadequate dietary intake gain more body cell | | | | infant. |
| mass. It is possible that this modality may not be | | | | Low birth weight infants have an increased incidence |
| widely available throughout the Region. However, it is | | | | of infant mortality as well as medical and |
| an option that should be pursued when necessary. | | | | developmental complications. Other risk factors, such |
| Components of Parenteral Nutrition | | | | as pregnancy during adolescence, substance use, |
| The solution for parenteral nutrition consists of | | | | opportunistic infection, low pre-pregnancy weight and |
| nutrients in their simple form,namely dextrose, amino | | | | inadequate gestational weight gain impose further |
| acids, lipids and micronutrients. Dextrose is the | | | | risks of a poor pregnancy outcome. Moreover, |
| monosaccharide that provides the major source of | | | | vitamin A deficiency has been associated with poor |
| non-protein energy. Each gram of dextrose in | | | | pregnancy outcome and increased risk of perinatal |
| parenteral solution provides 3. 4 kilocalories or 14. 2 | | | | HIV transmission. Pregnant HIV-positive women |
| kilojoules. Carbohydrate should be provided in | | | | should be referred early in pregnancy to a dietitian or |
| adequate amounts to spare protein, but not in | | | | other suitable health care professional for counselling |
| excess as this may cause hyperglycemia, fatty liver | | | | to optimize nutritional status and improve pregnancy |
| or other complications. The recommended rate of | | | | outcome. It is essential to assess complementary |
| dextrose infusion should not exceed 4 to 5 mg/kg | | | | therapy use, as mega-doses of vitamins and some |
| minute. Amino acids provide protein to maintain | | | | herbal preparations are contraindicated in pregnancy. |
| nitrogen balance and prevent degradation of somatic | | | | Weight Gain in Pregnancy |
| proteins. Protein requirements are calculated based on | | | | Recommended weight gain based on pre-pregnancy |
| clinical condition and goals of treatment. Amino acid | | | | weight: |
| solutions provide 4 kilocalories per gram or 18. 1 | | | | Underweight (BMI 25): |
| kilojoules per gram. Parenteral lipid emulsions provide a | | | | Nutritional Requirements |
| concentrated source of energy and essential fatty | | | | 12. 5-18. 0 kg |
| acids. They may be used in conjunction with | | | | 11. 5-16. 0 kg |
| carbohydrate and amino acid solutions or alone for | | | | 7. 0-11. 5 kg |
| caloric enhancement. The energy content of lipid | | | | According to the Recommended Dietary Allowances |
| emulsions depends on the formulation. ten percent | | | | for use in the Caribbean, the following requirements |
| yields 1. 1 kilocalorie per mL; 20% yields 2. 0 | | | | for pregnancy/lactation are in addition to the |
| kilocalories per mL; 30% yields 3. 0 kilocalories per mL. | | | | requirements for HIV+ women: |
| There is some evidence that parenteral lipids may | | | | 4? Additional 285 kilocalories per day to support fetal |
| have a negative effect on immunity. In patients with | | | | growth and development |
| HIV infection lipids should not exceed 30% of total | | | | Additional 6 grams protein per day |
| energy intake or 1 g/kg/day. Hyperlipidemia may also | | | | Prenatal multivitamin-mineral daily (to include at least |
| develop if lipids are not cleared. Thus serum lipids | | | | 0. 4 mg folic acid) |
| should be monitored at baseline and regular intervals | | | | Other micronutrient supplements as needed (e. g. |
| thereafter. Micronutrients and electrolytes are | | | | iron, calcium) |
| provided as standardized components of parenteral | | | | Lactation: additional 500 kcal per day and 11 grams of |
| solutions. These may be modified according to the | | | | protein Vitamin A: |
| needs of the patient. | | | | Maternal vitamin A deficiency is associated with |
| Anabolic Therapy | | | | increased risk of vertical HIV transmission to the |
| Nutrition support will usually result in weight gain, but | | | | infant. However, there is little evidence that vitamin A |
| for some PLWHA, classified as non-responders, there | | | | supplementation of the pregnant woman reduces the |
| is evidence of an anabolic block, whereby the | | | | risk of HIV infection to the infant. Moreover, high |
| regained weight is composed of a disproportionately | | | | doses of vitamin A can be teratogenic. Should |
| high amount of body fat with limited accretion of lean | | | | supplementation be necessary, the following WHO |
| tissue. This phenomenon can be identified with body | | | | guidelines can be used. |
| composition analysis. Thus,although re-feeding is | | | | Iron deficiency anemia is highly prevalent in pregnant |
| always necessary, it is not always sufficient for some | | | | women throughout the world. Anemia is associated |
| individuals. In cases where lean tissue gains are | | | | with increased risk of maternal and fetal morbidity |
| insufficient, an anabolic agent may be required such | | | | and mortality, as well as intrauterine growth failure. |
| as testosterone replacement. Other anabolic | | | | Iron status should be assessed and deficiency should |
| therapies that have shown favorable results include | | | | be treated. WHO recommend that women receive |
| Oxandrin, Decadurabolan, and Recombinant Growth | | | | 60 mg iron during 6 months of pregnancy and 120 |
| Hormone. | | | | mg per day to treat severe anaemia. |
| Palliative Care | | | | Folate deficiency: |
| When AIDS patients become terminally ill and medical | | | | Folate deficiency causes megaloblastic anemia and is |
| care becomes mainly palliative,not curative, the | | | | associated with risk of neural tube defects in the |
| nutrition care plan should reflect the overall goals of | | | | infant (e. g. spina bifida). WHO recommends 0. 4 mg |
| care. Nutritional therapy is directed to alleviating | | | | folate supplement daily. |
| symptoms and providing comfort. Nutrition support | | | | |