Israel Medical Association Journal

Only two approaches are currently accepted for patients with advanced dementia who are unable to eat independently or refuse to eat. One is feeding by either nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG). The other is to avoid artificially feeding the patient to spare the prolonged suffering associated with these procedures. The second approach is generally reserved for patients with terminal malignant diseases and is less common in patients with advanced dementia, especially when their life expectancy is unknown. PEG and NGT nutrition can lead to complications such as the likelihood of patients pulling out feeding tubes due to cognitive impairment. Various studies have shown that this feeding approach can be distressing to patients and does not extend life expectancy compared to spoon-feeding [1,2].

Background: Infants younger than 6 months of age are not eligible for coronavirus disease 2019 (COVID-19) vaccinations. Maternal variables during pregnancy and the postnatal period may affect the clinical and laboratory course of COVID-19 positive infants.

Objective: To assess the clinical manifestation and laboratory differences in infants with three maternal variables: breastfeeding, vaccinated, and co-illness.

Methods: We conducted a single-center retrospective cohort study of positive COVID-19 infants with three subgroups of maternal variables. The population included infants under 6 months of age hospitalized due to COVID-19. Data about clinical features, laboratory tests, and maternal information including vaccination status, breastfeeding status and maternal positive COVID-19 infection was gathered. All variables were compared among the three subgroups.

Results: Breastfed infants had shorter hospitalization period (mean 2.61 ± 1.378 days) compared to non-breastfed infants (mean 3.8 ± 1.549) (P = 0.051). COVID-19 infants of positive COVID-19 mothers had a higher absolute neutrophil count (mean 4.4 ± 3.8) compared to infants of COVID-19 negative mothers (mean 2.7 ± 2.4) (P = 0.042).

Conclusion: Breastfeeding was associated with shorter periods of hospitalization in COVID-19 positive infants. In addition, positive COVID-19 infants of mothers who were positive for COVID-19 are likely to have a higher absolute neutrophils count.

Background: Despite its wide use, evidence is inconclusive regarding the effect of percutaneous endoscopic gastrostomy (PEG) in patients with chronic diseases and dementia among hospitalized patients with malnutrition.

Objectives: To examine the effect of PEG insertion on prognosis after the procedure.

Methods: This retrospective analysis of medical records included all adult patients who underwent PEG insertion between 1 January 2009 and 31 December 2013 during their hospitalization. For each PEG patient, two controls similar in age, sex, referring department, and underlying condition were randomly selected from the entire dataset of patients admitted. The effect of PEG on mortality and repeated admissions was examined.

Results: The study comprised 154 patients, 49 referred for PEG insertion and 105 controls (mean age 74.8 ± 19.8 years; 72.7% females; 78.6% admitted to internal medicine units). Compared to controls, the PEG group had a higher 2-year mortality rate (59.2% vs. 17.1%, P < 0.001) but the 2-year readmission rate did not differ significantly (44.9% vs. 56.2% respectively, P = 0.191). Regression analysis showed PEG was  associated with increased risk of the composite endpoint of death or readmission (hazard ratio 1.514, 95% confidence interval 1.016–2.255, P = 0.041). No specific characteristic of admission was associated with increased likelihood of death or readmission. Among readmitted patients, reasons for admission and baseline laboratory data, including albumin and cholesterol, did not differ between the PEG patients and controls.

Conclusions: In-hospital PEG insertion was associated with increased mortality at 2 years but had no effect on readmissions.

Background: Adequate dietary habits and physical activity during childhood and adolescence may promote growth and cognitive development and contribute to the prevention of chronic disease in later life. School is considered an important social environment that can promote healthy eating habits and life-style changes.

Objectives: To evaluate the effects of a school-based intervention on nutritional knowledge, eating habits, and physical activity of adolescents.

Methods: We conducted a prospective questionnaire-based study. Anonymous questionnaires were administered at the beginning of the academic year (September 2014) in one high school. During the following year, vending machines containing milk products were installed within the school facility, and students were given two informative nutrition lectures regarding proper nutrition for age, calcium requirement and importance, and physical activity. One active sports day was initiated. At the beginning of the following academic year (September 2015), the students completed the same questionnaires.

Results: The study was comprised of 330 teenagers, mean age 15.1 ± 1.39 years, 53% males. Response rate was 83.6% ± 0.4% to multiple choice questions, 60.7% ± 0.5% to multiple section tables, and 80.3% ± 0.9% to open questions. Post-intervention, respondents reported an increase in eating breakfast (57% vs. 47.5%, P = 0.02) and a decrease in purchasing food at school (61.6% vs. 54.3%, P = 0.03). No changes were observed in consumption of milk products, knowledge regarding calcium and vegetable consumption, or sports activities.

Conclusions: Short-term high school-based interventions may lead to improvements in eating habits but are not sufficient for changing nutritional knowledge and physical activity

Background: Infants born very prematurely have functionally and structurally immature gastrointestinal tracts.

Objectives: To assess the safety and tolerability of administration of enteral recombinant human (rh) insulin on formula fed preterm infants and to assess whether enteral administration of rh-insulin enhances gastrointestinal tract maturation by reducing the time to reach full enteral feeding.

Methods: A phase 2, multicenter, double-blind, placebo-controlled, randomized study was conducted. Premature infants (26–33 weeks gestation) were randomized 1:1 to receive insulin 400 μU/ml mixed with enteral feeding or placebo added to their formula. The primary efficacy outcome measure was the number of days required to achieve full enteral feeding. Safety outcomes included adverse events and blood glucose levels.

Results: The study consisted of 33 infants randomized for the safety population and 31 for efficacy analysis. The mean time to full enteral feeding was 6.37 days (95% confidence interval [95%CI] 4.59–8.15) in the enteral rh-insulin treatment group (n=16) and 8.00 days (95%CI 6.20–9.80) in the placebo group (n=15), which represents a statistically significant reduction of 1.63 days (95%CI 0.29–2.97; P = 0.023). There was no difference in blood glucose levels between the groups and none of the participants experienced hypoglycemia. Adverse events occurred in 9/17 (53%) infants in the enteral rh-insulin group and 12/16 (75%) in the placebo group.

Conclusions: Our trial demonstrated that administration of enteral rh-insulin as supplement to enteral nutrition significantly reduced time to achieve full enteral feeding in preterm infants with a gestational age of 26–33 weeks.

Background: The treatment of advanced dementia patients is very complex and presents a difficult dilemma for physicians, and especially for the patient's family. In many cases, when the advanced dementia patient has no decisional capacity, the family needs to decide about force-feeding and resuscitation for their relative.

Objectives: To examine public opinion regarding force-feeding and resuscitation of patients with advanced dementia.

Methods: Data from 1002 people who accompanied a patient to a hospital emergency department in Israel were collected and analyzed.

Results: We noted the following results: the more religious the orientation of the respondents, the more likely they were to agree to forcefully feed and resuscitate advanced dementia patients and advanced dementia patients older than 80 years; those accompanying younger patients were more likely to think that the medical staff should resuscitate advanced dementia patients and advanced dementia patients older than 80 years compared to those accompanying elderly patients; younger people were more likely than older people to agree to force-feed and resuscitate patients.

Conclusions: This paper attempts to provide decision-makers and medical staff with some knowledge about public opinion regarding a sensitive and complex issue. This awareness may guide physicians in making critical medical decisions about those with dementia.

Background: Hypernatremic dehydration is a common and potentially life-threatening condition in children. There is currently no consensus as to the optimal strategy for fluid management. Objectives: To describe the relationship between the type, route and rate of fluids administered and the rate of decline in serum sodium (Na+) concentration. 

Methods: We reviewed the medical records of all children under the age of 2 years who were hospitalized with hypernatremic dehydration (serum Na+ ≥ 155 mEq/L) in Shaare Zedek Medical Center during the period 2001–2010. Collected data of 62 subjects included initial and subsequent serum Na+ levels, and rate and Na+ concentration of all intravenous and oral fluids administered until the serum Na+ reached ≤ 150 mEq/L.

Results: Median initial serum Na+ was 159.5 mEq/L (IQR 157–163, maximal value 170). The median rate of decline in serum Na+ until serum Na+ reached 150 mEq/L was 0.65 mEq/L/hr (IQR 0.45–0.95). Forty-two children received hypotonic oral fluids which accounted for approximately one-quarter of all fluids they received. There was no significant difference in the rate of decline in serum Na+ between those who consumed oral fluids and those who did not. Neither was there a correlation between the rate of IV fluids, receipt of oral fluids or the degree of dehydration, with the rate of decline in serum Na+. No child experienced an apparent short-term adverse outcome. 

Conclusions: A cumulative rate of 5.9 ml/kg/hr of IV fluid administration may reduce the serum Na+ to an acceptable rate (0.65 mEq/L/hr). Fluid therapy comprising up to 25% hypotonic oral fluids and 75% IV fluids high in Na+ concentration was not associated with any short-term adverse outcome in our patient population. 

 

Objective: To determine whether there are such ethnic differences and what, if anything, is their clinical relevance.

Methods: Of the 3663 enrolled infants born at the Hillel Yaffe Medical Center during the 12 month study period, 55 were of Ethiopian origin and their medical records were retrospectively surveyed. The retrieved data were compared with those of 167 randomly selected non-Ethiopian newborns (controls). Exclusion criteria were preterm delivery, admission to the neonatal intensive care unit, and congenital birth defects.

Results: Newborn infants of Ethiopian origin spit up 57% more than control infants. The difference in the number of spit ups was more obvious when only the infants who spit up were compared (2.3 ± 1.7 Ethiopian newborns vs. 1.5 ± 0.9 controls, P = 0.002), although the percentage of infants who spit up was the same in the two groups. There was no difference in weight gain, days of hospitalization, bilirubin levels or nutrition type between the groups.

Conclusions: Infants of Ethiopian origin spit up more than the control newborn infants of non-Ethiopian origin, while other clinical parameters were similar. In the absence of other pathological signs, spitting up is a non-relevant clinical condition.

Background: Human milk produced during prolonged lactation (> 1 year) is extraordinarily rich in fat and has a higher energy content than human milk produced during short lactation.

Objectives: To estimate the fatty acid (FA) profile of human milk and to test the hypothesis that the proportion of C12 and C14 (two dietary saturated FA known to most promote hypercholesterolemia) in human milk during prolonged lactation is similar to that in short lactation.

Methods: We conducted a cross-sectional study of 30 mothers of term infants lactating for more than 1 year as compared with 25 mothers of full-term infants who lactated for 2–6 months. Milk was collected by manual expression in mid-breastfeeding.

Results: The two groups did not differ in maternal height, weight, body mass index, diet, infant birth weight and gestational age, but mothers in the prolonged lactation group were significantly older. There was a significant correlation between lactation duration and C12 or C14. The percentage of all FA combined (except for C12 and C14) decreased significantly over time. In contrast, C12:0 and C14:0 combined increased significantly during lactation (R2 = 10.0%, P < 0.03).

Conclusions: Women who lactated for more than 1 year had higher C12 and C14 FA percentages in their milk than women who lactated for 2–6 months.

Background: The rate and duration of breastfeeding in Ethiopia is very high. Factors that could affect breastfeeding among women emigrating to Israel include the desire to adopt "modern" behaviors, the availability of infant formulas, and the greater awareness of AIDS and fear of transmission via breast milk.

Objectives: To examine the rate and duration of breastfeeding among recent Ethiopian immigrants to Israel.

Methods Using a structured questionnaire we interviewed 93 Ethiopian born mothers of children aged 2 months to 5 years living in northern Israel.

Results: Ninety-two percent of the children born in Ethiopia were exclusively breastfed as compared to 76.3% of the Israeli born children, in whom the rate of mixed feeding was 18.3%. Although the duration of breastfeeding of the youngest child was significantly shorter than of the firstborn (20.1 vs. 24.8 months), it remains much longer than the average duration for native Israeli mothers. No association was seen between breastfeeding rate or duration and the years since immigration, work outside the home or exposure to formula. The women’s attitude towards breastfeeding was positive despite the lack of specific knowledge concerning breast milk and infant formulas.

Conclusions: Breastfeeding patterns among Ethiopian women have changed since their immigration to Israel. These changes probably reflect the cultural and societal pressures to acculturate to the mores of the adopted society. Reinforcing traditional family and peer support for these women is important to preserve breastfeeding in this population. This should be done within the context of changes in the support for breastfeeding in the general Israeli society.