title: Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis.
abstract: BACKGROUND
  There have been few systematic reviews and no meta-analyses of the clinical benefits of nutritional support in patients with, or at risk of developing, pressure ulcers. Therefore, this systematic review and meta-analysis was undertaken to address the impact of enteral nutritional support on pressure ulcer incidence and healing and a range of other clinically relevant outcome measures in this group.
  
  
  METHODS
  Fifteen studies (including eight randomised controlled trials (RCTs)) of oral nutritional supplements (ONS) or enteral tube feeding (ETF), identified using electronic databases (including Pub Med and Cochrane) and bibliography searches, were included in the systematic review. Outcomes including pressure ulcer incidence, pressure ulcer healing, quality of life, complications, mortality, anthropometry and dietary intake were recorded, with the aim of comparing nutritional support versus routine care (e.g. usual diet and pressure ulcer care) and nutritional formulas of different composition. Of these 15 studies, 5 RCTs comparing ONS (4 RCTs) and ETF (1 RCT) with routine care could be included in a meta-analysis of pressure ulcer incidence.
  
  
  RESULTS
  Meta-analysis showed that ONS (250-500 kcal, 2-26 weeks) were associated with a significantly lower incidence of pressure ulcer development in at-risk patients compared to routine care (odds ratio 0.75, 95% CI 0.62-0.89, 4 RCTs, n=1224, elderly, post-surgical, chronically hospitalised patients). Similar results were obtained when a combined meta-analysis of ONS (4 RCT) and ETF (1 RCT) trials was performed (OR 0.74, 95% CI 0.62-0.88, 5 RCTs, n=1325). Individual studies showed a trend towards improved healing of existing pressure ulcers with disease-specific (including high protein) versus standard formulas, although robust RCTs are required to confirm this. Although some studies indicate that total nutritional intake is improved, data on other outcome measures (quality of life) are lacking.
  
  
  CONCLUSIONS
  This systematic review shows enteral nutritional support, particularly high protein ONS, can significantly reduce the risk of developing pressure ulcers (by 25%). Although studies suggest ONS and ETF may improve healing of PU, further research to confirm this trend is required.
authors.affiliation: Institute of Human Nutrition, University of Southampton, MP 113 F Level, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK. R.J.Stratton@soton.ac.uk
authors.forename: Rebecca J
authors.initials: RJ
authors.lastname: Stratton
authors.forename: Anna-Christina
authors.initials: AC
authors.lastname: Ek
authors.forename: Meike
authors.initials: M
authors.lastname: Engfer
authors.forename: Zena
authors.initials: Z
authors.lastname: Moore
authors.forename: Paul
authors.initials: P
authors.lastname: Rigby
authors.forename: Robert
authors.initials: R
authors.lastname: Wolfe
authors.forename: Marinos
authors.initials: M
authors.lastname: Elia
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004044:Dietary Proteins / Q000008:administration & dosage; D004750:Enteral Nutrition; D005260:Female; D005526:Food, Formulated; D006801:Humans; D008297:Male; D009752:Nutritional Status; D017063:Outcome Assessment, Health Care; D003668:Pressure Ulcer / Q000517:prevention & control / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic
chemical_list: D004044:Dietary Proteins