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Back to Basics: Estimating Protein Requirements for Adult Hospital Patients. A Systematic Review of Randomised Controlled Trials

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DOI: 10.4236/fns.2013.42028    6,671 Downloads   10,432 Views   Citations

ABSTRACT

Aim: To review the supporting evidence for protein requirements in hospitalised adults, and compare the findings with commonly-used guidelines and resources. Methods: a systematic review was conducted based on a computerised bibliographic search of MEDLINE, EMBASE and CINAHL from 1950 to October 2011, as well as a citation review of relevant articles and guidelines. Studies were included if they were randomised clinical trials in hospitalised or chronically ill adults, comparing two or more different levels of protein intake. Information about study quality, setting, and findings was extracted using standardised protocols. Due to the heterogeneity of study characteristics, no meta-analysis was undertaken. Results: 116 papers were obtained in the search and 33 of these met all inclusion criteria. Five studies could not be obtained. The remainder reported outcome measures such as nitrogen balance, anthropometric measurements (including body weight, BMI, and mid-arm circumference), blood electrolyte levels and serum urea, which provide support for recommended protein intakes in various clinical conditions. The results were summarized and compared with current recommendations. Conclusion: high-level evidence to support current recommendations is lacking. The studies reviewed generally agreed with current guidelines and resources.

Conflicts of Interest

The authors declare no conflicts of interest.

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S. Ferrie, S. Rand and S. Palmer, "Back to Basics: Estimating Protein Requirements for Adult Hospital Patients. A Systematic Review of Randomised Controlled Trials," Food and Nutrition Sciences, Vol. 4 No. 2, 2013, pp. 201-214. doi: 10.4236/fns.2013.42028.

References

[1] World Health Organization, Food and Agriculture Organization of the United Nations, and UN University, “Protein and Amino Acid Requirements in Human Nutrition: Report of a Joint WHO/FAO/UNU Expert Consultation,” WHO Technical Report Series 935, Geneva, 2007.
[2] A. Goldberg and D. Goldspink, “The Influence of Food Deprivation and Adrenal Steroids on DNA Synthesis in Various Mammalian Tissues,” American Journal of Physiology, Vol. 288, No. 1, 1975, pp. 310-317.
[3] I. Brodsky, P. Balagopal and K. Nair, “Effects of Testosterone Replacement on Muscle Mass and Muscle Protein Synthesis in Hypogonadal Men: A Clinical Research Center Study,” Journal of Clinical Endocrinology and Metabolism, Vol. 81, No. 10, 1996, pp. 3469-3475. doi:10.1210/jc.81.10.3469
[4] L. S. Chow, R. C. Albright, M. L. Bigelow, G. Toffolo, C. Cobelli and K. S. Nair, “Mechanism of Insulin’s Anabolic Effect on Muscle: Measurements of Muscle Protein Synthesis and Breakdown Using Aminoacyl tRNA and Other Surrogate Measures,” American Journal of Physiology—Endocrinology and Metabolism, Vol. 291, No. 4, 2006, pp. E729-E736. doi:10.1152/ajpendo.00003.2006
[5] V. Stefansson, “Arctic Manual,” Macmillan, New York, 1944.
[6] D. H. Calloway and H. Spector, “Nitrogen Balance Is Related to Caloric and Protein Intake in Active Young Men,” American Journal of Clinical Nutrition, Vol. 2, No. 6, 1954, pp. 405-412.
[7] D. A. D’Alessio, E. C. Kavle, M. A. Mozzoli, et al., “Thermic Effect of Food in Lean and Obese Men,” Journal of Clinical Investigation, Vol. 81, No. 6, 1988, pp. 1781-1789. doi:10.1172/JCI113520
[8] E. Jequier, “Thermogenesis Induced by Nutrient Administration in Man,” Infusionstherapie, Vol. 11, No. 4, 1984, pp. 184-188.
[9] N. Tentolouris, S. Pavlatos, A. Kokkinos, D. Perrea, S. Pagoni and N. Katsilambros, “Diet-Induced Thermogenesis and Substrate Oxidation Are Not Different between Lean and Obese Women after Two Different Isocaloric Meals, One Rich in Protein and One Rich in Fat,” Metabolism—Clinical and Experimental, Vol. 57, No. 3, 2008, pp. 313-320. doi:10.1016/j.metabol.2007.10.004
[10] D. J. Millward, “An Adaptive Metabolic Demand Model for Protein and Amino Acid Requirements,” British Journal of Nutrition, Vol. 90, No. 2, 2003, pp. 249-260. doi:10.1079/BJN2003924
[11] Australian Government Department of Health and Ageing, National Health and Medical Research Council, and New Zealand Ministry of Health, “Nutrient Reference Values for Australia and New Zealand,” Commonwealth of Australia, Canberra, 2006.
[12] US Food and Nutrition Board, “Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals,” Institute of Medicine, US National Academies, Washington DC, 2004.
[13] S. Ferrie and M. Ward, “Back to Basics: Estimating Energy Requirements for Adult Hospital Patients,” Nutrition & Dietetics, Vol. 64, No. 3, 2007, pp. 192-199.
[14] F. Mariotti, D. Tomé and P. P. Mirand, “Converting Nitrogen into Protein—beyond 6.25 and Jones’ Factors,” Critical Reviews in Food Science and Nutrition, Vol. 48, No. 2, 2008, pp. 177-184. doi:10.1080/10408390701279749
[15] A. Trichopoulou, T. Psaltopoulou, P. Orfanos, C. Hsieh and D. Trichopoulos, “Low-Carbohydrate-High-Protein Diet and Long-Term Survival in a General Population Cohort,” European Journal of Clinical Nutrition, Vol. 61, No. 5, 2007, pp. 575-581.
[16] P. Lagiou, S. Sandin, E. Weiderpass, et al., “Low Carbohydrate—High Protein Diet and Mortality in a Cohort of Swedish Women,” Journal of Internal Medicine, Vol. 261, No. 4, 2007, pp. 366-374. doi:10.1111/j.1365-2796.2007.01774.x
[17] L. E. Kelemen, L. H. Kushi, D. R. Jacobs Jr. and J. R. Cerhan, “Associations of Dietary Protein with Disease and Mortality in a Prospective Study of Postmenopausal Women,” American Journal of Epidemiology, Vol. 161, No. 3, 2005, pp. 239-249. doi:10.1093/aje/kwi038
[18] T. L. Halton, W. C. Willett, S. Liu, et al., “Low-Carbohydrate Diet Score and the Risk of Coronary Heart Disease in Women,” New England Journal of Medicine, Vol. 355, No. 19, 2006, pp. 1991-2002. doi:10.1056/NEJMoa055317
[19] D. F. Goldspink, “The Influence of Activity on Muscle Size and Protein Turnover,” Journal of Physiology, Vol. 264, No. 1, 1977, pp. 283-296.
[20] A. L. Goldberg, “Protein Turnover in Skeletal Muscle: Effects of Denervation and Cortisone on Protein Catabolism in Skeletal Muscle,” Journal of Biological Chemistry, Vol. 244, No. 12, 1969, pp. 3223-3229.
[21] T. Kameyama and J. D. Etlinger, “Calcium-Dependent Regulation of Protein Synthesis and Degradation in Muscle,” Nature, Vol. 279, 1979, pp. 344-346. doi:10.1038/279344a0
[22] M. J. Rennie, “Muscle Protein Turnover and the Wasting Due to Injury and Disease,” British Medical Bulletin, Vol. 41, No. 3, 1985, pp. 257-264.
[23] P. O. Hasselgren, P. Pedersen, H. C. Sax, B. W. Warner and J. E. Fischer, “Current Concepts of Protein Turnover and Amino Acid Transport in Liver and Skeletal Muscle during Sepsis,” Archives of Surgery, Vol. 123, No. 8, 1988, pp. 992-999. doi:10.1001/archsurg.1988.01400320078016
[24] M. Shuran and R. Nelson, “Updated Nutritional Assessment of the Elderly,” Geriatrics, Vol. 41, No. 7, 1986, pp. 48-70.
[25] M. J. Rennie, R. H. T. Edwards, P. W. Emery, D. Halliday, K. Lundholm and D. J. Millward, “Hypothesis: Depressed Protein Synthesis Is the Dominant Characteristic of Muscle Wasting and Cachexia,” Clinical Physiology, Vol. 3, No. 5, 1983, pp. 387-398. doi:10.1111/j.1475-097X.1983.tb00847.x
[26] N. Ishibashi, L. D. Plank, K. Sando and G. L. Hill, “Optimal Protein Requirements during the First 2 Weeks after the Onset of Critical Illness,” Critical Care Medicine, Vol. 26, No. 9, 1998, pp. 1529-1535. doi:10.1097/00003246-199809000-00020
[27] S. Ferrie and M. Allman-Farinelli, “Defining and Evaluating the Role of Dietitians in Intensive Care; State of Play,” The European E-Journal of Clinical Nutrition and Metabolism, Vol. 6, No. 3, 2011, pp. e121-e125.
[28] D. Voss, “The CARI Guidelines: Caring for Australians with Renal Impairment: Protein in Pre-Dialysis Patients,” 2012. http://www.cari.org.au/CKD_nutrition_list_published/Protein_in_pre_dialysis.pdf
[29] European Society for Clinical Nutrition and Metabolism, “ESPEN Guidelines on Enteral Nutrition,” Clinical Nutrition, Vol. 25, No. 2, 2006, pp. 180-360.
[30] European Society for Clinical Nutrition and Metabolism, “ESPEN Guidelines on Parenteral Nutrition,” Clinical Nutrition, Vol. 28, No. 4, 2009, pp. 359-479.
[31] S. A. McClave, R. G. Martindale, V. W. Vanek, et al., “ASPEN Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient,” Journal of Parenteral and Enteral Nutrition, Vol. 33, No. 3, 2009, pp. 277-316. doi:10.1177/0148607109335234
[32] Nutrition Education Materials Online (NEMO), “Estimating Energy and Protein Requirements for Adult Clinical Conditions,” 2012. http://www.health.qld.gov.au/nutrition
[33] National Institute for Health and Clinical Excellence, “Nutrition Support in Adults—Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition (Clinical Guideline 32),” Dietitians’ Association of Australia and Dietitians New Zealand, Canberra, 2006.
[34] R. Snell, “Dietitians’ Pocket Book,” Curtin University of Technology School of Public Health, Bentley, 2006.
[35] R. Stewart, “Griffith Handbook of Clinical Nutrition & Dietetics,” 3rd Edition, Griffith University School of Public Health, Southport, 2009.
[36] A. Liberati, D. G. Altman, J. Tetzlaff, et al., “The PRISMA Statement for Reporting Systematic Reviews and MetaAnalyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration,” Journal of Clinical Epidemiology, Vol. 62, No. 10, 2009, pp. e1-e34. doi:10.1016/j.jclinepi.2009.06.006
[37] American Dietetic Association, “ADA Quality Criteria Checklist: Primary Research,” 2012. http://www.adaevidencelibrary.com/topic.cfm?cat=1317
[38] Trans-Tasman Dietetic Wound Care Group, “Evidence Based Practice Guidelines for the Dietetic Management of Adults with Pressure Injuries,” DAA and DNZ, 2011.
[39] E. Cereda, A. Gini, C. Pedrolli and A. Vanotti, “DiseaseSpecific versus Standard Nutritional Support for the Treatment of Pressure Ulcers in Institutionalized Older Adults: A Randomized Controlled Trial,” Journal of the American Geriatrics Society, Vol. 57, No. 8, 2009, pp. 1395-1402. doi:10.1111/j.1532-5415.2009.02351.x
[40] K. Paridaens, A. M. de Cock, L. de Paepe and M. Vandewoude, “Optimal Amount of Protein in Tube Feeding in Hospitalized Geriatric Patients,” Tijdschrift Gerontologie en Geriatrie, Vol. 26, No. 3, 1995, pp. 122-129.
[41] R. C. Smith, L. Burkinshaw and G. L. Hill, “Optimal Energy and Nitrogen Intake for Gastroenterological Patients Requiring Intravenous Nutrition,” Gastroenterology, Vol. 82, No. 3, 1982, pp. 445-452.
[42] E. Isenring, “Evidence Based Practice Guidelines for the Nutritional Management of Patients Receiving Radiation Therapy,” Nutrition & Dietetics, Vol. 65, No. S1, 2008, pp. 1-20. doi:10.1111/j.1747-0080.2008.00252.x
[43] M. Findlay, J. Bauer, T. Brown, et al., “Evidence Based Practice Guidelines for the Nutritional Management of Adult Patients with Head and Neck Cancer,” Clinical Oncological Society of Australia, Sydney, 2011.
[44] E. A. Isenring, J. D. Bauer and S. Capra, “Nutrition Support Using the American Dietetic Association Medical Nutrition Therapy Protocol for Radiation Oncology Patients Improves Dietary Intake Compared with Standard Practice,” Journal of the American Dietetic Association, Vol. 107, No. 3, 2007, pp. 404-412. doi:10.1016/j.jada.2006.12.007
[45] J. D. Bauer, S. Ash, W. L. Davidson, et al., “Evidence Based Practice Guidelines for the Nutritional Management of Cancer Cachexia,” Nutrition & Dietetics, Vol. 63, No. Suppl S2, 2006, pp. S3-S32. doi:10.1111/j.1747-0080.2006.00099.x
[46] V. Charlin, F. Carrasco, C. Sepúlveda, M. Torres and J. Kehr, “Nutritional Supplementation According to Energy and Protein Requirements in Malnourished HIV-Infected Patients,” Archivos Latinoamericanos de Nutrición, Vol. 52, No. 3, 2002, pp. 267-273.
[47] F. R. Sattler, N. Rajicic, K. Mulligan, et al., “Evaluation of High-Protein Supplementation in Weight-Stable HIVPositive Subjects with a History of Weight Loss: A Randomized Double-Blind Multicenter Trial,” American Journal of Clinical Nutrition, Vol. 88, No. 5, 2008, pp. 1313-1321.
[48] D. Harris, M. Thomas, D. Johnson, K. Nicholls and A. Gillin, “The Caring for Australasians with Renal Impairment (CARI) Guidelines: Prevention of Progression of Kidney Disease,” Nephrology, Vol. 11, No. Suppl 1, 2006, pp. S2-S197. doi:10.1111/j.1440-1797.2006.00505.x
[49] D. Harris, M. Thomas, D. Johnson, K. Nicholls and A. Gillin, “The Caring for Australasians with Renal Impairment (CARI) Guidelines: Prevention of Progression of Kidney Disease,” 2012. http://www.cari.org.au/guidelines.php
[50] W. D. Kloppenburg, C. A. Stegeman, T. K. K. Hovinga, et al., “Effect of Prescribing a High Protein Diet and Increasing the Dose of Dialysis on Nutrition in Stable Chronic Haemodialysis Patients: A Randomized Controlled Trial,” Nephrology Dialysis Transplantation, Vol. 19, No. 5, 2004, pp. 1212-1223. doi:10.1093/ndt/gfh044
[51] National Kidney Foundation Kidney Disease Outcome Quality Initiative (K/DOQI) Advisory Board, “K/DOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure,” American Journal of Kidney Diseases, Vol. 35, No. Suppl 2, 2000, pp. S1-S140.
[52] European Dialysis and Transplantation Nurses Association (EDTNA)/European Renal Care Association (ERCA), “European Guidelines for the Nutritional Care of Adult Renal Patients,” EDTNA/ERCA Journal, Vol. 29, No. 1, 2003, pp. s1-s23.
[53] K. L. Wiggins, “Guidelines for Nutritional Care of Renal Patients,” 3rd Edition, Renal Dietitians Dietetic Practice Group, American Dietetic Association, Chicago, 2002.
[54] B. U. Ihle, G. J. Becker, J. A. Whitworth, R. A. Charlwood and P. S. Kincaid-Smith, “The Effect of Protein Restriction on the Progression of Renal Insufficiency,” New England Journal of Medicine, Vol. 321, No. 26, 1989, pp. 1773-1777. doi:10.1056/NEJM198912283212601
[55] P. Jungers, P. Chauveau, F. Ployard, B. Lebkiri, C. Ciancioni and N. K. Man, “Comparison of Ketoacids and Low Protein Diet on Advanced Chronic Renal Failure Progression,” Kidney International, Vol. 32, No. Suppl 22, 1987, pp. S67-S71.
[56] F. Locatelli, D. Alberti, G. Graziani, G. Buccianti, B. Redaelli and A. Giangrande, “Prospective Randomised Multicentre Trial of Effect of Protein Restriction on Progression of Chronic Renal Insufficiency,” Lancet, Vol. 337, No. 8753, 1991, pp. 1299-1304. doi:10.1016/0140-6736(91)92977-A
[57] G. Mircescu, L. Garnea??, S. H. Stancu and C. C?pu??, “Effects of a Supplemented Hypoproteic Diet in Chronic Kidney Disease,” Journal of Renal Nutrition, Vol. 17, No. 3, 2007, pp. 179-188. doi:10.1053/j.jrn.2006.12.012
[58] P. S. Williams, M. E. Stevens, G. Fass, L. Irons and J. M. Bone, “Failure of Dietary Protein and Phosphate Restriction to Retard the Rate of Progression of Chronic Renal Failure: A Prospective Randomized Controlled Trial,” Quarterly Journal of Medicine, Vol. 81, No. 294, 1991, pp. 837-855.
[59] V. Teplan, O. Schück, O. Mengerová and J. R??i?ková, “Individually Supplemented Low-Protein Diet in Patients with Chronic Kidney Failure,” Vnitrní Lékarství, Vol. 40, No. 10, 1994, pp. 623-627.
[60] S. Chadban, M. Chan, K. Fry, et al., “The Caring for Australasians with Renal Impairment (CARI) Guidelines: Protein Requirement in Adult Kidney Transplant Recipients,” Nephrology, Vol. 15, No. Suppl 1, 2010, pp. S68-S71. doi:10.1111/j.1440-1797.2010.01238.x
[61] J. Córdoba, J. López-Hellín, M. Planas, et al., “Normal Protein Diet for Episodic Hepatic Encephalopathy: Results of a Randomized Study,” Journal of Hepatology, Vol. 41, No. 1, 2004, pp. 38-43. doi:10.1016/j.jhep.2004.03.023
[62] D. Twyman, A. B. Young, L. Ott, J. A. Norton and B. A. Bivins, “High Protein Enteral Feedings: A Means of Achieving Positive Nitrogen Balance in Head Injured Patients,” Journal of Parenteral and Enteral Nutrition, Vol. 9, No. 6, 1985, pp. 679-684. doi:10.1177/0148607185009006679
[63] Institute of Medicine (IOM), “Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel,” National Academies Press, Washington DC, 2011.
[64] J. Larsson, C. Lennmarken, J. M?rtensson, S. Sandstedt and E. Vinnars, “Nitrogen Requirements in Severely Injured Patients,” British Journal of Surgery, Vol. 77, No. 4, 1990, pp. 413-416. doi:10.1002/bjs.1800770418
[65] K. A’Beckett, L. Baytieh, A. Carr-Thompson, et al., “NSW Statewide Burn Injury Service Clinical Practice Guidelines for Burn Patient Nutrition Management,” NSW Agency for Clinical Innovation, Sydney, 2011.
[66] P. Serog, F. Baigts and M. Apfelbaum, “Energy and Nitrogen Balances in 24 Severely Burned Patients Receiving Four Isocaloric Diets of about 10 MJ/m2/Day (2392 Kcalories/m2/Day),” Burns, Vol. 9, No. 6, 1982, pp. 422-427. doi:10.1016/0305-4179(83)90106-7
[67] R. H. Demling and L. De Santi, “Increased Protein Intake during the Recovery Phase after Severe Burns Increases Body Weight Gain and Muscle Function,” Journal of Burn Care and Rehabilitation, Vol. 19, No. 2, 1998, pp. 161-168. doi:10.1097/00004630-199803000-00015
[68] A. Mesejo, J. A. Acosta, Y. C. Ortega, et al., “Comparison of a High-Protein Disease-Specific Enteral Formula with a High-Protein Enteral Formula in Hyperglycemic Critically Ill Patients,” Clinical Nutrition, Vol. 22, No. 1, 2003, pp. 295-305. doi:10.1016/S0261-5614(02)00234-0
[69] C. D. Scheinkestel, L. Kar, K. Marshall, et al., “Prospective Randomized Trial to Assess Caloric and Protein Needs of Critically Ill, Anuric, Ventilated Patients Requiring Continuous Renal Replacement Therapy,” Nutrition, Vol. 19, No. 6, 2003, pp. 909-916. doi:10.1016/S0899-9007(03)00175-8
[70] P. D. Greig, D. H. Elwyn, J. Askanazi and J. M. Kinney, “Parenteral Nutrition in Septic Patients: Effect of Increasing Nitrogen Intake,” American Journal of Clinical Nutrition, Vol. 46, No. 6, 1987, pp. 1040-1047.
[71] K. C. McCowen, C. Friel, J. Sternberg, et al., “Hypocaloric Total Parenteral Nutrition: Effectiveness in Prevention of Hyperglycemia and Infectious Complications—A Randomized Clinical Trial,” Critical Care Medicine, Vol. 28, No. 11, 2000, pp. 3606-3611. doi:10.1097/00003246-200011000-00007
[72] G. L. Clifton, C. S. Robertson and C. F. Contant, “Enteral Hyperalimentation in Head Injury,” Journal of Neurosurgery, Vol. 62, No. 2, 1985, pp. 186-193. doi:10.3171/jns.1985.62.2.0186
[73] S. L. Huang and S. T. Lee, “Nutritional Care of Severe Acute Head Injury Patients: Formulas for Early Enteral Alimentation,” Journal of the Formosan Medical Association, Vol. 89, No. 6, 1990, pp. 498-503.
[74] R. R. Wolfe, R. D. Goodenough, J. F. Burke and M. H. Wolfe, “Response of Protein and Urea Kinetics in Burn Patients to Different Levels of Protein Intake,” Annals of Surgery, Vol. 197, No. 2, 1982, pp. 163-171. doi:10.1097/00000658-198302000-00007
[75] J. Askanazi, C. Weissman, P. A. LaSala, J. Milic-Emili and J. M. Kinney, “Effect of Protein Intake on Ventilatory Drive,” Anesthesiology, Vol. 60, No. 2, 1984, pp. 106-110. doi:10.1097/00000542-198402000-00005
[76] M. J. Blumenkratz, J. D. Kopple, J. K. Moran and J. W. Coburn, “Metabolic Balance Studies and Dietary Protein Requirements in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis,” Kidney International, Vol. 21, 1982, pp. 849-861. doi:10.1038/ki.1982.109
[77] S. Klahr, A. S. Levey, G. J. Beck, et al., “The Effects of Dietary Protein Restriction and Blood-Pressure Control on the Progression of Chronic Renal Disease,” New England Journal of Medicine, Vol. 330, 1994, pp. 877-884. doi:10.1056/NEJM199403313301301
[78] J. D. Kopple, J. H. Shinaberger, J. W. Coburn, M. K. Sorensen and M. E. Rubini, “Evaluating Modified Protein Diets for Uremia,” Journal of the American Dietetic Association, Vol. 54, No. 6, 1969, pp. 481-485.
[79] J. D. Kopple and J. W. Coburn, “Metabolic Studies of Low Protein Diets in Uremia: Nitrogen and Potassium,” Medicine, Vol. 52, No. 6, 1973, pp. 583-595. doi:10.1097/00005792-197311000-00004
[80] J. B. Rosman, P. M. Ter Wee, S. Meijer, T. P. M. PiersBecht, W. J. Sluiter and A. J. M. Donker, “Prospective Randomised Trial of Early Dietary Protein Restriction in Chronic Renal Failure,” Lancet, Vol. 324, No. 8415, 1984, pp. 1291-1296. doi:10.1016/S0140-6736(84)90818-3
[81] J. Kondrup, K. Nielsen and A. Juul, “Effect of LongTerm Refeeding on Protein Metabolism in Patients with Cirrhosis of the Liver,” British Journal of Nutrition, Vol. 77, No. 2, 1997, pp. 197-212. doi:10.1079/BJN19970024
[82] C. Viall, K. Porcelli, J. C. Teran, R. N. Varma and W. P. Steffee, “A Double-Blind Clinical Trial Comparing the Gastrointestinal Side Effects of Two Enteral Feeding Formulas,” Journal of Parenteral and Enteral Nutrition, Vol. 14, No. 3, 1990, pp. 265-269. doi:10.1177/0148607190014003265

  
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