Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Indicators Recommended for the Identification and Documentation of Pediatric Malnutrition (Undernutrition)

Evaluating food security and nutritional pathways of rural farm families: Empirical evidence from northeast India

The study aimed to ascertain a relationship between agricultural status, socioeconomic factors, and nutrition of farm families. The study was conducted in selected villages in the West Garo Hills district of Meghalaya, using Stratified Random Sampling (St. RS). Using pretested interview schedules, we collected primary data from respondents in 2020 and 2021, focusing on socioeconomic variables, body mass index, and income from agriculture and related sectors. The data was analysed using correlation analyses and separate combined regression estimates for each year and month were obtained. Results from the study indicate that agricultural income significantly influenced nutritional status (p < 0.05) and household income growth was also found significant. The region's agricultural production of cereals, pulses, and vegetables was insufficient, as was the production of meat and meat products, milk, and milk products. Hence, expenditure towards purchasing the above food groups from the market was found to be significant (p < 0.05). Therefore, the markets near the mainland especially in the hilly region play a crucial role in the nutritional pathway of rural farm families.

The Validity of the Original and the Saudi-Modified Screening Tools for the Assessment of Malnutrition in Pediatrics: A Cross-Sectional Study

Background: Screening for malnutrition among hospitalized children is essential, and the Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) is a validated tool for this purpose. The study aimed to modify STAMP for a Saudi context and assess the sensitivity and specificity of both the original and modified tools. Method: A cross-sectional study was conducted among 307 hospitalized children, where both the original and Saudi-modified STAMP were applied. Anthropometric measurements were also recorded, and statistical analysis using SPSS and validity parameters was used to assess the tools' validity. Results: The Saudi-modified STAMP identified a higher percentage of children at high risk of malnutrition compared to the original STAMP (91.6% vs. 62.9%). The sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and agreement of the Saudi-modified STAMP compared to the original were 94.3%, 13.2%, 64.8%, 57.7%, 0.654, and 0.089, respectively. Conclusions: The Saudi-modified STAMP showed excellent sensitivity and varied negative predictive value, indicating its potential effectiveness in screening for the risk of malnutrition among hospitalized children compared to the original STAMP.

Role of the neonatal registered dietitian nutritionist in Canada: A description of staffing and a comparison to practices in the United States

BACKGROUND

Neonatal registered dietitian nutritionists (RDNs) are critical members of the neonatal intensive care unit (NICU) team. Ideal RDN staffing levels are unknown. Current staffing levels of neonatal RDNs in Canadian NICUs have not been recently reported. The objective of this study was to describe neonatal RDN staffing and responsibilities in Canada and contrast these findings with those of neonatal RDNs in the United States.

METHODS

An online cross-sectional neonatal RDN survey was performed in the Fall of 2021 to collect hospital-level and individual-RDN-level data. Descriptive statistics were performed to summarize Canadian neonatal RDN staffing levels and responsibilities and compared with US findings.

RESULTS

Canadian RDNs reported a median staffing ratio of 25.3 NICU beds per RDN full-time equivalent, with neonatal RDNs reporting a desired 31% increase in staffing. The majority of Canadian NICUs (n = 20/24) reported having a dedicated space to prepare infant feeds away from bedside. Canadian neonatal RDNs reported wanting to expand their responsibilities in research, administration, and education. Canadian neonatal RDNs reported a higher rate of order writing privileges as compared with that of US neonatal RDNs.

CONCLUSION

Canadian neonatal RDNs reported a desired increase in their staffing levels. Neonatal RDNs have the potential to expand their professional role but require additional staffing, dedicated time, and compensation to support this. Further research determining the optimal neonatal RDN staffing ratio to maximize patient outcomes is required.

Assessment of brain-derived neurotrophic factor and irisin concentration in children with chronic kidney disease: a pilot study

Patients suffering from chronic kidney disease (CKD) are particularly placed at risk of multiorgan complications. One of them is malnutrition, which adds up to a higher mortality factor among them. This study was designed to determine the usefulness of brain-derived neurotrophic factor (BDNF) and irisin assays in the assessment of CKD development. The study group included 28 children with CKD at stages 2-5 treated conservatively. The outcome of our study revealed decreased serum BDNF and irisin levels in CKD patients, whereas urine concentrations were increased for BDNF and decreased for irisin, comparing to healthy controls. There was a positive correlation between anthropometric measures and urine BDNF concentration, as well as anthropometric measures and both serum and urine irisin levels in the study group, however no dependence of the tested markers on the stage of CKD was observed. In recent years, a role of myokines was described as vital for maintaining metabolic homeostasis therefore we suspect a potential role of these multifaceted markers in detecting malnutrition in CKD children.

Measurement of mid-upper arm circumference to screen for childhood malnutrition: General applicability and use in special populations

Since the development of consensus-recommended indicators for pediatric malnutrition in 2014, screening and diagnosis of pediatric malnutrition have improved, but the indicators are not always used; malnutrition continues to be underdiagnosed in some community and healthcare settings. In particular, mid-upper arm circumference (MUAC) is underused as a screening indicator for pediatric malnutrition, despite its unique advantages and usefulness in several clinical situations. In December 2022, a scientific roundtable was held to bring together several experts in pediatric malnutrition. One of the goals of the scientific roundtable was to discuss the clinical use of anthropometric measures as screening tools for pediatric malnutrition status, with a focus on the use of MUAC. This article arose from that event and is intended as an educational tool to aid clinicians in implementing MUAC measurements. In addition to describing the use of MUAC as a screening tool, the article discusses several clinical situations in which MUAC is especially useful. Additionally, the article reviews practical aspects of measuring and interpreting MUAC values, provides links to additional educational resources, and briefly reviews areas in which further research is needed regarding the use of MUAC for screening of nutrition status in children.

Predictive Validity of the Academy of Nutrition and Dietetics/American Society for Parental Nutrition Indicators to Diagnose Malnutrition and the Screening Tool for Risk on Nutritional Status and Growth among Hospitalized Children Relative to Medical Outcomes

OBJECTIVE

To evaluate predictive validity of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Indicators to diagnose pediatric malnutrition (AAIMp) and the Screening Tool for Risk on Nutritional Status and Growth (STRONGkids) in regard to pediatric patient outcomes in US hospitals.

STUDY DESIGN

A prospective cohort study (Clinical Trial Registry: NCT03928548) was completed from August 2019 through January 2023 with 27 pediatric hospitals or units from 18 US states and Washington DC.

RESULTS

Three hundred and forty-five children were enrolled in the cohort (n = 188 in the AAIMp validation subgroup). There were no significant differences in the incidence of emergency department visits and hospital readmissions, hospital length of stay (LOS), or health care resource utilization for children diagnosed with mild, moderate, or severe malnutrition using the AAIMp tool compared with children with no malnutrition diagnosis. The STRONGkids tool significantly predicted more emergency department visits and hospital readmissions for children at moderate and high malnutrition risk (moderate risk - incidence rate ratio 1.65, 95% CI: 1.09, 2.49, P = .018; high risk - incidence rate ratio 1.64, 95% CI: 1.05, 2.56, P = .028) and longer LOS (43.8% longer LOS, 95% CI: 5.2%, 96.6%, P = .023) for children at high risk compared with children at low risk after adjusting for patient characteristics.

CONCLUSIONS

Malnutrition risk based on the STRONGkids tool predicted poor medical outcomes in hospitalized US children; the same relationship was not observed for a malnutrition diagnosis based on the AAIMp tool.

Nutritional status and neurodevelopmental levels in infants at high risk of cerebral palsy

Importance

Nutrition is associated with neurodevelopment. Infants at high risk of cerebral palsy (CP) usually suffer from undernutrition, yet the relationship between nutritional status and neurodevelopmental levels is unclear.

Objective

To describe the nutritional status characteristics of infants at high risk of CP, and to explore the relationship between neurodevelopmental levels and nutritional status.

Methods

This single-center cross-sectional study enrolled infants at high risk of CP, with corrected age from 0 days to 12 months. Weight and height were measured and calculated into z-scores, which were used to classify the nutritional status based on the World Health Organization growth charts and American Society for Parenteral and Enteral Nutrition standards. The Bayley Scales of Infant and Toddler Development were used to evaluate the developmental levels of gross motor, fine motor, cognition, receptive communication, and expressive communication.

Results

A total of 479 infants at high risk of CP were recruited, with 43.4% classified as undernutrition. Compared to those with normal neurodevelopment, the odds of moderate and severe undernutrition were about 1.8 and 3.9 times higher in gross motor delay, 2.2 and 3.1 times higher in fine motor delay, 2.5 and 9.4 times higher in cognition delay, 2.2 and 3.9 times higher in receptive communication delay, and 3.0 and 5.6 times higher in expressive communication delay. There were significant positive correlations between nutritional status and neurodevelopmental levels (P < 0.001).

Interpretation

Undernutrition and neurodevelopmental delays are prevalent among infants at high risk of CP. Worse nutritional status was correlated with lower neurodevelopmental levels.

Growth at 2 years corrected age in preterm infants discharged on two different breast milk enhancements: An observational study

OBJECTIVE

Breast milk (BM) enhancement is often used to meet the nutritional needs of preterm infants after hospital discharge to achieve optimal growth. This study compared growth at 18-28 months corrected age (CA) among very preterm (VP) and very low birth weight (VLBW) infants discharged from the neonatal intensive care units (NICUs) on two BM enhancements.

METHODS

We conducted a retrospective chart review study of infants born between January 1, 2013 and December 31, 2017, with gestational age < 32 weeks or birthweight < 1500 g, discharged from the NICU on BM enhancements; fortification of BM with infant formula additives (BM-F) or unfortified BM supplemented with bottle feeds of infant formula (BM-S). BM enhancements were nonrandomized and determined by the medical team. A linear mixed model regression analysis with propensity score matching was used to estimate the adjusted associations between the nutrition plan at discharge and growth outcomes at 18-28 months CA follow-up.

RESULTS

Two hundred and fifty-one VLBW/VP infants were included. Compared with BM-S, infants discharged on BM-F were more likely to continue receiving BM at 8-12 months CA, and had lower head circumference, weight-for-length z scores, and higher incidence of moderate malnutrition (p ≤ 0.01). After adjusting for confounders, discharge on BM-F was associated with a lower incidence of overweight/obesity at 18-28 months CA (odds interval: 0.45; confidence interval: 0.21-0.96; p = 0.04).

CONCLUSIONS

This retrospective study suggests that VLBW/VP infants discharged on BM-F received BM longer, had lower growth parameter and were less likely to be overweight/obese at 18-28 months CA. Further studies are needed to evaluate the role of postdischarge nutrition on preterm born children's growth, metabolic disease, and neurodevelopmental outcomes.

Completion of a Nutrition-Focused Physical Exam with hospitalized adults and pediatric patients: Secondary analysis of a prospective cohort study

BACKGROUND

Nutrition-Focused Physical Exam (NFPE) feasibility is not well-studied. We describe registered dietitian nutritionist (RDN)-reported NFPE completion for hospitalized adult and pediatric patients overall and by assessment parameters.

METHODS

Trained RDNs systematically conducted NFPEs for hospitalized adult and pediatric patients during the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition Indicators to diagnose Malnutrition multisite cohort study (ClinicalTrials.gov: NCT03928548). RDNs reported their ability to evaluate assessment sites for subcutaneous fat and muscle loss, fluid accumulation, and micronutrient status and to complete handgrip strength (adults and children ≥6 years) and mid-upper arm circumference measurements (children). RDNs noted if they could complete the full NFPE; if not, they noted challenges. We descriptively summarized results and used multilevel logistic regression models to examine relationships between patient characteristics and NFPE completion.

RESULTS

RDNs from 39 adult and 29 pediatric US hospitals conducted NFPEs for 327 adults and 214 children aged 1 month to 17.9 years. RDNs reported completing the examination for 44% (n = 145) of adults and 15% (n = 33) of children. They successfully evaluated 25 of 27 and 19 of 26 unique NFPE components in >80% of adults and children, respectively. Common reasons the full NFPE was not completed were limited mobility in adults and patient refusal in children. RDNs had lower odds of completing NFPEs in adults with lower vs higher education levels or higher vs lower nutrition complexity and in younger vs older children.

CONCLUSION

RDNs evaluated NFPE components for a high proportion (>80%) of hospitalized patients.

Knowledge, attitude, and practice regarding malnutrition amongst patients with chronic kidney disease in China: A qualitative study

BACKGROUND

Chronic kidney disease (CKD) can be complicated by malnutrition, which has adverse implications on patients' health outcomes and quality of life. CKD patients from different sociocultural contexts may have varying perceptions of knowledge, attitudes, and practices of malnutrition. However, information on the perception of malnutrition in patients with CKD is limited. This study aimed to explore and describe the knowledge, attitude, and practice of patients with CKD disease regarding malnutrition.

MATERIALS AND METHODS

A qualitative-descriptive design was used. Thirteen participants were selected through a purposive sampling technique among malnourished CKD patients from a hospital in Xi'an Provincial Hospital of Traditional Chinese Medicine between November 2022 and January 2023. Data were collected through face-to-face semistructured interviews until data saturation. All participants were informed about the study. Data obtained were analyzed by content analysis.

RESULTS

Three main categories and seven subcategories were extracted from the data analysis: 1) knowledge (basic knowledge acquisition and understanding, knowledge misconceptions, and confusion, nutrition knowledge, and culture collision); 2) attitude (negative attitudes and adverse situations, positive attitude and self-awareness); 3) practice (disadvantageous and passive practice, favorable practice).

CONCLUSION

This study provided insight into the knowledge, attitude, and practice of malnutrition in patients with CKD. Our findings can serve as important baseline data for the development of future interventions that can help reduce the risk of malnutrition, slow disease progression, and improve the quality of life in patients with CKD.

Oral nutritional supplementation with dietary counseling improves linear catch-up growth and health outcomes in children with or at risk of undernutrition: a randomized controlled trial

Introduction

Childhood undernutrition is associated with increased morbidity, mortality and a high socio-economic burden.

Methods

Supporting Pediatric GRowth and Health OUTcomes (SPROUT) is a randomized, controlled trial evaluating the effects of an oral nutritional supplement (ONS) with dietary counseling (DC; n = 164) compared to a DC-only group who continued consuming their habitual milk (n = 166; NCT05239208). Children aged 24-60 months who were at risk or with undernutrition, as defined by weight-for-age [WAZ] < -1 and height-for-age [HAZ] < -1 according to the WHO Growth Standards, and who also met the criterion of weight-for-height [WHZ] < 0, were enrolled in Vietnam.

Results

ONS + DC had a larger WAZ increase at day 120 (primary endpoint) vs. DC (least squares mean, LSM (SE): 0.30 (0.02) vs. 0.13 (0.02); p < 0.001), and larger improvements in all weight, BMI and weight-for-height indices at day 30 and 120 (all p < 0.01). Height gain was larger in ONS + DC in all indices, including height-for-age difference [HAD; cm: 0.56 (0.07) vs. 0.10 (0.07); p < 0.001], at day 120. ONS + DC had larger arm muscle but not arm fat indices, higher parent-rated appetite, physical activity and energy levels, longer night sleep, fewer and shorter awakenings, and better sleep quality than DC.

Conclusion

Adding ONS to DC, compared to DC-alone, improves growth in weight and height, linear catch-up growth, and health outcomes in children with or at risk of undernutrition.

Factors influencing gastrostomy tube feeding duration and nutrition outcomes in pediatric patients with Down syndrome: A descriptive cohort study

BACKGROUND

Feeding difficulty is widely recognized in patients with Down syndrome, and many patients require gastrostomy tube (G-tube) placement for nutrition. No reliable factors have been identified to predict the expected duration of G-tube feeds in patients with Down syndrome. This descriptive cohort study aimed to determine the factors affecting the duration of G-tube feeds. We also investigated change in body mass index (BMI) from G-tube placement to discontinuation.

METHODS

Medical records of patients with Down syndrome seen by a pediatric gastroenterologist at a tertiary care center between September 1986 and December 2021 were reviewed. Data collection included demographics, anthropometrics, comorbidities, and feeding route. Comparison was performed between patients who discontinued G-tube feeds and those who did not.

RESULTS

Two hundred twenty patients (45% female) were included. The median age at G-tube placement was 5 months (interquartile range [IQR]: 0.2-1.3 years). There were 113 (51%) patients who discontinued G-tube feeds, after a median duration of 31.6 months (IQR: 15.6-55.7 months). Tracheostomy was the only covariant associated with a longer duration of G-tube feeds (158 months vs 53 months; P = 0.002). Neither age at G-tube placement nor any comorbidities were associated with BMI status at discontinuation of G-tube.

CONCLUSION

In our cohort of patients with Down syndrome, age at placement of G-tube did not impact the duration of G-tube feeds. Most patients who had a G-tube placed were likely to require enteral feeds for at least 1 year. Those who had a tracheostomy needed their G-tube for a longer time.

A Dedicated Multidisciplinary Growth and Feeding Clinic for Infants with Cleft Lip and/or Palate Demonstrates Need for Intervention

OBJECTIVE

A Growth and Feeding Clinic (GFC) focused on early intervention around feeding routines in patients with cleft lip and/or palate (CL/P) was implemented.

DESIGN

This study assessed the effect of preoperative feeding interventions provided by the GFC.

SETTING

Tertiary academic center.

METHODS

This study evaluated patients with CL/P who were cared for by the GFC and a control group of patients with CL/P. Weight-for-age (WFA) Z-score of less than -2.00 was used as a cutoff to classify patients who were underweight during the preoperative period.

MAIN OUTCOME MEASURE

The number of underweight patients who were able to reach normal weight by the time of their cleft lip repair was used as the primary outcome measure.

RESULTS

Within both the GFC and control groups, 25% of patients with CL/P were underweight as determined by WFA Z-score. GFC patients who were underweight received more clinic visits (P < .001) and GFC interventions (P < .001) compared to GFC patients who were normal weight. At the time of cleft lip surgery, 64.1% of GFC underweight patients were normal weight compared to 31.8% of control group underweight patients (P = .0187).

CONCLUSION

This study showed that multidisciplinary care provided by the GFC was able to target preoperative nutritional interventions to the highest-risk patients, resulting in double the percentage of patients who were of normal weight at the time of their cleft lip repair. These results provide objective proof supporting the assertion that multidisciplinary team care of the infant with cleft leads to measurable improvement in outcomes.

Feasibility of Achieving Nutritional Adequacy in Critically Ill Children with Critical Neurological Illnesses (CNIs)?-A Quaternary Hospital Experience

The literature on the nutritional needs and outcomes of critically ill children is scarce, especially on those with critical neurological illnesses (CNIs). Current evidence shows a lower mortality in patients who achieve two-thirds of their nutritional needs during the first week of pediatric intensive care unit (PICU) admission. We hypothesized that achieving 60% of the recommended dietary intake during the first week of a PICU stay is not feasible in patients with CNI. We designed an observational retrospective cohort study where we included all index admissions to the PICU in our institution of children (1 month to 18 years) with CNI from January 2018 to June 2021. We collected patient demographics, anthropometric measures, and caloric and protein intake (enteral and parenteral) information during the first week of PICU admission. Goal adequacy for calories and protein was defined as [(intake/recommended) × 100] ≥ 60%. A total of 1112 patients were included in the nutrition assessment, 12% of whom were underweight (weight for age z score < -2). Of this group, 180 met the criteria for nutrition support evaluation. On the third day of admission, 50% of the patients < 2 years achieved caloric and protein goal adequacy, compared to 25% of patients > 2 years, with p-values of 0.0003 and 0.0004, respectively. Among the underweight patients, 60% achieved both caloric and protein goal adequacy by day 3 vs. 30% of non-underweight patients with p-values of 0.0006 and 0.002, respectively. The results show that achieving 60% of the recommended dietary intake by days 5 and 7 of admission was feasible in more than half of the patients in this cohort. Additionally, children who were evaluated by a clinical dietician during the first 48 h of PICU admission reached higher nutrition adequacy.

Education and documentation strategies to improve malnutrition diagnosis in hospitalized children: A quality improvement project

BACKGROUND

The Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN) published malnutrition guidelines in 2014. In 2015, our institution implemented a quality improvement project focused on malnutrition identification with the goal to improve the diagnosis of malnutrition in hospitalized children.

METHODS

Our project included three approaches: education, nutrition assessment, and documentation initiatives. Education initiatives focused on physicians at all levels of training. Nutrition screening was completed on all patients admitted to our institution. Registered dietitians (RDs) conducted nutrition assessments and identified and documented malnutrition based on AND/ASPEN guidelines. Documentation initiatives included development of automatic text and template changes to allow import of RD-assigned malnutrition diagnosis into physician documentation. We met with members of our clinical documentation integrity team regularly to review the results of these initiatives starting in 2016.

RESULTS

The total diagnosed cases of malnutrition increased from 208 cases in 2016 at the start of our monitoring to >800 cases per year in 2020-2022. Unspecified (no severity assigned) protein calorie malnutrition as a percentage of total malnutrition diagnoses decreased from 36.9% in 2016 to <10% since 2018. Children with severe malnutrition have remained the largest portion of children with a malnutrition diagnosis, with >40% of children with malnutrition diagnosed with severe malnutrition.

CONCLUSION

Our education and documentation initiatives have led to both improved diagnosis of malnutrition and accurate identification and documentation of malnutrition severity. These initiatives could be utilized to improve malnutrition diagnosis and documentation at other institutions caring for hospitalized children.

Measuring body composition in pediatric patients with complex diagnoses: Acceptability, practicality, and validation of different techniques

BACKGROUND

Body composition could help identify malnutrition in pediatric patients, but there is uncertainty over which techniques are most suitable and prevailing opinion that measurements are difficult to obtain in practice. This study examined the acceptability, practicality, reliability, and validity of different anthropometric and body composition measurements in patients with complex diagnoses in a tertiary pediatric hospital.

METHODS

A total of 152 children aged 5-18 years had weight, height, body mass index (BMI), mid-upper arm circumference (MUAC), 4-site skinfold thicknesses (SFT), bioelectrical impedance analysis (BIA), and dual-energy x-ray absorptiometry (DXA) assessed on admission and discharge. Acceptability was assessed in a continuous scale, practicality with number/percentage of successful measurements, reliability with intraclass correlation coefficients and coefficients of repeatability, and validity between "simpler" techniques and DXA with Bland-Altman analysis of agreement and Cohen kappa.

RESULTS

Techniques were overall acceptable. Measurements were successful in >50%, with patient refusal uncommon. Coefficients of repeatability were good (0.3 cm MUAC and height, 0.2 kg weight, and 1.0 mm SFTs). All techniques significantly overestimated DXA fat mass, but BMI and triceps SFT better identified abnormal fat mass (κ = 0.46 and 0.49). BIA fat-free mass was not significantly different from DXA, with substantial agreement between techniques (κ = 0.65).

CONCLUSION

Body composition by a range of techniques is acceptable, practical, and reliable in a diverse group of children with complex diagnoses. BIA seems a good alternative to DXA for assessing fat-free mass, triceps SFT, and BMI for fat mass but should be used with care as it could overestimate total fat mass in individuals.

Developing a nutrition screening tool for children with cystic fibrosis ages 0 to 2 years: Children with cystic fibrosis nutrition screening tool

BACKGROUND

For children with cystic fibrosis (CF), achieving and maintaining optimal growth by the age of 2 years is critical for future health outcomes. A standardized nutrition screening is needed to identify growth problems, enable timely interventions, and improve nutritional outcomes for children (0 to 2 years) with CF. The purpose of this study was to develop a nutrition screening tool for children (0 to 2 years) with CF to identify nutrition risk at every clinical encounter.

METHODS

A retrospective cross-sectional study was used to develop a nutrition screening tool to determine if nutrition interventions needed to change (at-risk) or continue (not at-risk). Retrospective data for pertinent nutrition factors were collected for 99 children attending an accredited CF clinic. The nutrition factors were compared to a dietitian assessment. A stepwise discriminant analysis determined weight-for-age (WFA) and weight-for-length (WFL) z-scores were significant. Then anthropometric data and corresponding dietitian assessment results were collected for children with CF attending two other accredited CF clinics (n = 29, n = 30). Discriminant analysis was used to determine sensitivity and specificity of the nutrition factors and to create a nutrition screening tool equation.

RESULTS

The nutrition screening model that included WFA z-score, LFA z-score, WFL z-score, and weight change velocity adequacy determined nutrition risk the best. The sensitivity was 89.7 %, specificity 83.2 %, NPV 93.3 %, and PPV 75.4 % for this model.

CONCLUSION

The nutrition screening tool equation developed in this study standardizes the process to identify children (0 to 2 years) with CF at nutrition risk. Further validation is needed.

Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative

Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.

Risk factors in underweight older children with sickle cell anemia: a comparison of low- to high-income countries

Previously, we demonstrated that older children with sickle cell anemia (SCA) living in Nigeria are at increased risk of death if they are underweight (weight-for-age z score < -1). We now conducted a cross-sectional study in low- and high-income settings to determine the risk factors for being underweight a in children aged 5 to 12 years with SCA. The children from low- and high-income settings were eligible participants for the Primary Prevention of Stroke in Children with Sickle Cell Disease in Nigeria (SPRING; N = 928) and the Silent Cerebral Infarct (SIT, North America/Europe; N = 1093) trials, respectively. The median age in the SPRING and SIT cohorts was 8.1 and 8.5 years, respectively (P < .001). A total of 87.9% (n = 816) of participants in the SPRING trial (low-income) met the study criteria for being underweight (weight-for-age z score < -1), and 22.7% (n = 211) for severely underweight (weight-for-age z score < -3), significantly higher than the SIT (high-income) cohort at 25.7% underweight (n = 281) and 0.7% severely underweight (n = 8; P < .001 for both comparisons). In the combined cohort, older age (odds ratio [OR], 1.24; P < .001) and lower hemoglobin level (OR, 0.67; P < .001) were associated with being underweight. Age and hemoglobin level remained statistically significant in separate models for the SPRING and SIT cohorts. Older age and lower hemoglobin levels in children aged 5 to 12 years with SCA are associated with being underweight in low- and high-income settings.

Looking Beyond the Growth Curve: A Retrospective Study on Nutrient Deficient Diets in Children with Severe Food Selectivity

Severe food selectivity places children at risk for nutrient deficiencies and long-term medical complications, if unaddressed. However, poor nutrition in highly selective eaters is often overlooked when considering other behavioral or medical concerns. Additionally, studies regarding food selectivity are sparse and limited to children with developmental delays. This study further investigates the nutritional deficiencies and growth characteristics of children with severe food selectivity to assist pediatricians in the earlier identification of patients for nutrition screening. A retrospective chart review was completed for 13 patients admitted to a pediatric feeding program solely for table-textured food selectivity. Nutrition and anthropometric data from the medical record were analyzed. All patients were determined to be following an age-appropriate growth curve but had multiple micronutrient deficiencies. Additionally, 6 children were typically developing outside of the feeding context. Results suggest that children with food selectivity may require more intensive and earlier nutrition screening beyond their growth patterns.

Pediatric growth faltering: Evaluation and management in primary care

ABSTRACT

Pediatric growth faltering (GF), previously known as failure to thrive and now also called pediatric malnutrition and weight faltering, is a common clinical finding in primary care. Most pediatric GF cases are caused by inadequate caloric intake, not organic disease states. Evaluation requires clinicians to obtain detailed nutritional, medical, psychosocial, and family histories; take accurate anthropometric measurements; and perform a careful physical examination. Evaluation findings should be analyzed to determine whether targeted diagnostic workup, specialty referral, or a trial of nutritional counseling is indicated. Management includes caregiver education about childhood nutrition and frequent monitoring of growth parameters. A multidisciplinary approach that includes nutritionist, developmental therapist, and other specialty team member involvement is desirable.

Geriatric Nutritional Risk Index as a Prognostic Factor for Renal Progression in Patients with Type 2 Diabetes Mellitus

The aim of this study was to evaluate whether the geriatric nutritional risk index (GNRI) is associated with chronic kidney disease (CKD) progression in patients with type 2 diabetes mellitus (DM). In total, 1100 patients with type 2 DM with a follow-up duration > 1 year were included in this longitudinal study. The risk of CKD progression was assessed according to GNRI quartiles. Patients in the lowest GNRI quartile exhibited a significantly lower estimated glomerular filtration rate (eGFR), compared with those in quartile four. Moreover, these patients had poorer glycemic control and lower hemoglobin levels, body mass index, and albumin levels. Additionally, they exhibited a greater annual decline in eGFR. Multivariate logistic regression analysis showed that old age (>60 years), baseline eGFR, the presence of proteinuria, the use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and low GNRI were significantly associated with CKD progression. GNRI may serve as a valuable predictive tool for identifying the risk of adverse renal outcomes in patients with type 2 DM. It may potentially serve as a more feasible measure for assessing the nutritional status of these patients, as well as for predicting their clinical outcomes.

Nutrition Screening in the Pediatric Intensive Care Unit: Evaluation of an Electronic Medical Record-Based Tool

Hospitalized, critically ill children are at increased risk of developing malnutrition. While several pediatric nutrition screening tools exist, none have been validated in the pediatric intensive care units (PICU). The Children's Wisconsin Nutrition Screening Tool (CWNST) is a unique nutrition screening tool that includes the Pediatric Nutrition Screening Tool (PNST) and predictive elements from the electronic medical record and was found to be more sensitive than the PNST in acute care units. The aim of this study was to assess the performance of the tool in detecting possible malnutrition in critically ill children. The data analysis, including the results of the current nutrition screening, diagnosis, and nutrition status was performed on all patients admitted to PICUs at Children's Wisconsin in 2019. All 250 patients with ≥1 nutrition assessment by a dietitian were included. The screening elements that were predictive of malnutrition included parenteral nutrition, positive PNST, and BMI-for-age/weight-for-length z-score. The current screen had a sensitivity of 0.985, specificity of 0.06, positive predictive value (PPV) of 0.249, and negative predictive value of 0.929 compared to the PNST alone which had a sensitivity of 0.1, specificity of 0.981, PPV of 0.658, and NPV of 0.749. However, of the 250 included patients, 97.2% (243) had a positive nutrition screen. The CWNST can be easily applied through EMRs and predicts the nutrition risk in PICU patients but needs further improvement to improve specificity.

Feasibility trial for the management of severe acute malnutrition in older children with sickle cell anemia in Nigeria

Children with sickle cell anemia (SCA) living in Nigeria are at an increased risk of malnutrition, which contributes to increased morbidity and mortality. However, evidence-based guidelines for managing malnutrition in children with SCA are lacking. To address this gap, we conducted a multicenter, randomized controlled feasibility trial to assess the feasibility and safety of treating children with SCA aged from 5 to 12 years and having uncomplicated severe acute malnutrition (body mass index z score of <-3.0). Children with SCA and uncomplicated severe acute malnutrition were randomly allocated to receive supplemental ready-to-use therapeutic food (RUTF) with or without moderate-dose hydroxyurea therapy (20 mg/kg per day). Over a 6-month enrollment period, 3190 children aged from 5 to 12 years with SCA were evaluated for eligibility, and 110 of 111 children who were eligible were enrolled. During the 12-week trial, no participants withdrew or missed visits. One participant died of unrelated causes. Adherence was high for hydroxyurea (94%, based on pill counts) and RUTF (100%, based on the number of empty sachets returned). No refeeding syndrome event or hydroxyurea-related myelosuppression occurred. At the end of the trial, the mean change in body mass index z score was 0.49 (standard deviation = 0.53), and 39% of participants improved their body mass index z score to ≥-3.0. Our findings demonstrate the feasibility, safety, and potential of outpatient treatment for uncomplicated severe acute malnutrition in children with SCA aged from 5 to 12 years in a low-resource setting. However, RUTF sharing with household and community members potentially confounded the response to malnutrition treatment. This trial was registered at clinicaltrials.gov as #NCT03634488.

Evaluation of an electronic medical record-based Paediatric Nutrition Screening Tool

BACKGROUND

Nutrition screening is recommended to identify children at risk for malnutrition. A unique screening tool was developed based on American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations and embedded in the electronic medical record to assess for nutrition risk.

METHODS

The components of the tool included the Paediatric Nutrition Screening Tool (PNST) and other elements recommended by ASPEN. To evaluate the screening tool, retrospective data were analysed on all patients admitted to acute care units of Children's Wisconsin in 2019. Data collected included nutrition screen results, diagnosis and nutrition status. All patients who received at least one full nutrition assessment by a registered dietitian (RD) were included in analysis.

RESULTS

One thousand five hundred seventy-five patients were included in analysis. The following screen elements were significantly associated with a diagnosis of malnutrition: any positive screen (p < 0.001), >2 food allergies (p = 0.009), intubation (p < 0.001), parenteral nutrition (p = 0.005), RD-identified risk (p < 0.001), positive risk per the PNST (p < 0.001), BMI-for-age or weight-for-length z-score (p < 0.001), intake <50% for 3 days (p = 0.012) and NPO > 3 days (p = 0.009). The current screen had a sensitivity of 93.9%, specificity of 20.3%, positive predictive value (PPV) of 30.9% and negative predictive value (NPV) of 89.8%. This is compared with the PNST which had a sensitivity of 32%, specificity of 94.2%, PPV of 71% and NPV of 75.8% in this study population.

CONCLUSION

This unique screening tool is useful for predicting nutrition risk and has a greater sensitivity than the PNST alone.

Optimized Nutrition in Mitochondrial Disease Correlates to Improved Muscle Fatigue, Strength, and Quality of Life

We sought to prospectively characterize the nutritional status of adults ≥ 19 years (n = 22, 27% males) and children (n = 38, 61% male) with genetically-confirmed primary mitochondrial disease (PMD) to guide development of precision nutritional support strategies to be tested in future clinical trials. We excluded subjects who were exclusively tube-fed. Daily caloric requirements were estimated using World Health Organization (WHO) equations to predict resting energy expenditure (REE) multiplied by an activity factor (AF) based on individual activity levels. We developed a Mitochondrial Disease Activity Factors (MOTIVATOR) score to encompass the impact of muscle fatigue typical of PMD on physical activity levels. PMD cohort daily diet intake was estimated to be 1,143 ± 104.1 kcal in adults (mean ± SEM, 76.2% of WHO-MOTIVATOR predicted requirement), and 1,114 ± 62.3 kcal in children (86.4% predicted). A total of 11/22 (50%) adults and 18/38 (47.4%) children with PMD consumed ≤ 75% predicted daily Kcal needs. Malnutrition was identified in 16/60 (26.7%) PMD subjects. Increased protein and fat intake correlated with improved muscle strength in those with insufficient daily Kcal intake (≤ 75% predicted); higher protein and fat intake correlated with decreased muscle fatigue; and higher protein, fat, and carbohydrate intake correlated with improved quality of life (QoL). These data demonstrate the frequent occurrence of malnutrition in PMD and emphasize the critical need to devise nutritional interventions to optimize clinical outcomes.

Exploring the host factors affecting asymptomatic Plasmodium falciparum infection: insights from a rural Burkina Faso study

BACKGROUND

Asymptomatic Plasmodium falciparum parasitaemia forms a reservoir for the transmission of malaria disease in West Africa. Certain haemoglobin variants are known to protect against severe malaria infection. However, data on the potential roles of haemoglobin variants and nongenetic factors in asymptomatic malaria infection is scarce and controversial. Therefore, this study investigated the associations of iron homeostasis, inflammation, nutrition, and haemoglobin mutations with parasitaemia in an asymptomatic cohort from a P. falciparum-endemic region during the high transmission season.

METHODS

A sub-study population of 688 asymptomatic individuals (predominantly children and adolescents under 15 years, n = 516) from rural Burkina Faso previously recruited by the NOVAC trial (NCT03176719) between June and October 2017 was analysed. Parasitaemia was quantified with conventional haemocytometry. The haemoglobin genotype was determined by reverse hybridization assays targeting a selection of 21 HBA and 22 HBB mutations. Demographics, inflammatory markers (interleukins 6 and 10, hepcidin), nutritional status (mid upper-arm circumference and body mass index), and anaemia (total haemoglobin, ferritin, soluble transferrin receptor) were assessed as potential predictors through logistic regression.

RESULTS

Malaria parasites were detected in 56% of subjects. Parasitaemia was associated most strongly with malnutrition. The effect size increased with malnutrition severity (OR = 6.26, CI95: 2.45-19.4, p < 0.001). Furthermore, statistically significant associations (p < 0.05) with age, cytokines, hepcidin and heterozygous haemoglobin S were observed.

CONCLUSIONS

According to these findings, asymptomatic parasitaemia is attenuated by haemoglobin S, but not by any of the other detected genotypes. Aside from evidence for slight iron imbalance, overall undernutrition was found to predict parasitaemia; thus, further investigations are required to elucidate causality and inform strategies for interventions.

Parental self-efficacy: Longitudinal impact on clinical outcomes across levels of care in adolescent anorexia nervosa

OBJECTIVE

Parental self-efficacy in the domain of weight restoration for adolescents with restrictive eating disorders is central to success in family-based interventions. We sought to characterize this parental self-efficacy during a brief hospitalization for medical stabilization and follow-up among patients with anorexia nervosa (AN) or atypical AN (AAN) enrolled in the StRONG clinical trial to understand the potential impact of inpatient treatment on caregiver empowerment.

METHODS

Patients were enrolled upon hospital admission and refed per protocol. We examined correlates of the Parents Versus Anorexia (PVA) scale, a measure of parental self-efficacy in the domain of weight restoration, at admission, discharge, 10-days, 1-month, and 3-months post-discharge. Multi-level models evaluated associations among PVA scores and change in %median BMI and Eating Disorder Examination-Questionnaire (EDE-Q) global scores over 3-months post-discharge.

RESULTS

Parents of N = 67 adolescents and young adults M(SD) age 15.79 (2.20) years and 85.00 (11.86) %median BMI participated. PVA scores did not change significantly during hospitalization (p = .053), which lasted on average 10.7 ± 4.5 days. PVA scores increased post-discharge (p = .009), with significant increase between discharge and 1-month post-discharge (p = .045). PVA scores were not associated with subsequent clinical outcomes. Rather, a main effect of time significantly predicted higher %median BMI and improved EDE-Q scores (p < .001).

DISCUSSION

The finding that parental self-efficacy did not deteriorate during the inpatient stay is promising given the medical necessity of hospitalization to ensure short-term safety in some cases and the importance of parental self-efficacy to support long-term recovery.

PUBLIC SIGNIFICANCE

Family-based treatment is the recommended treatment for young people with AN and AAN, serious psychiatric illnesses that may require inpatient medical stabilization. Prior evidence suggests that parental self-efficacy in the outpatient setting is a key component of treatment success. The current study suggests that parental self-efficacy and longer-term treatment outcomes are not undermined by a brief inpatient hospitalization.

MyKid'sNutrition mobile application trial: a randomized controlled trial to promote mothers' nutritional knowledge and nutritional status of preschool children with undernutrition-a study protocol

BACKGROUND

Childhood malnutrition is a crucial public health issue in developing countries. Mothers' nutritional knowledge significantly affects children's nutritional status. It also appears that mothers with low health literacy are unable to adequately meet their children's nutritional needs because they do not clearly understand their children's nutrition and malnutrition status.

METHODS

This randomized controlled trial aims to describe the development and study protocol of the MyKid'sNutrition application, a smartphone-based intervention for mothers of preschool (2-6 years old) children. The application contains several contents on children's healthy eating, childhood underweight, children's loss of appetite, and child growth assessment. As part of the MyKid'sNutrition trial, a total of 116 participants will be randomized 1:1 either to (a) treatment as usual and MyKid'sNutrition or (b) treatment as usual alone. The results of this trial will be based on changes in growth indicators and mothers' nutritional knowledge, attitude, and practice within the groups and the differences between them.

DISCUSSION

Due to their widespread availability throughout society, smartphones can be used to deliver educational content on a large scale at a low cost. In addition, they can provide novel ways for patients to receive support. Hence, it is essential to conduct research studies on these types of interventions. MyKid'sNutrition application offers dietary solutions for such nutritional problems as underweight, loss of appetite, and malnutrition in children. Meanwhile, it provides detailed instructions on how to interact with the child.

TRIAL REGISTRATION

IRCT.ir IRCT20140907019082N11. Registered on February 19, 2022.

Nutritional Intervention Through Ketogenic Diet in GLUT1 Deficiency Syndrome

Glucose transporter type 1 (GLUT1) deficiency syndrome (DS) is a metabolic brain disorder caused by a deficiency resulting from SLC2A1 gene mutation and is characterized by abnormal brain metabolism and associated metabolic encephalopathy. Reduced glucose supply to the brain leads to brain damage, resulting in delayed neurodevelopment in infancy and symptoms such as eye abnormalities, microcephaly, ataxia, and rigidity. Treatment options for GLUT1 DS include ketogenic diet (KD), pharmacotherapy, and rehabilitation therapy. Of these, KD is an essential and the most important treatment method as it promotes brain neurodevelopment by generating ketone bodies to produce energy. This case is a focused study on intensive KD nutritional intervention for an infant diagnosed with GLUT1 DS at Gangnam Severance Hospital from May 2022 to January 2023. During the initial hospitalization, nutritional intervention was performed to address poor intake via the use of concentrated formula and an attempt was made to introduce complementary feeding. After the second hospitalization and diagnosis of GLUT1 DS, positive effects on the infant's growth and development, nutritional status, and seizure control were achieved with minimal side effects by implementing KD nutritional intervention and adjusting the type and dosage of anticonvulsant medications. In conclusion, for patients with GLUT1 DS, it is important to implement a KD with an appropriate ratio of ketogenic to nonketogenic components to supply adequate energy. Furthermore, individualized and intensive nutritional management is necessary to improve growth, development, and nutritional status.

Healthcare Burden Associated with Malnutrition Diagnoses in Hospitalized Children with Critical Illnesses

Our primary study objectives were to (i) determine the proportion of children admitted to the Pediatric Intensive Care Unit (PICU) with malnutrition diagnoses, (ii) compare healthcare utilization by malnourished and non-malnourished PICU patients, and (iii) examine the impact of implementing malnutrition screening and coding practices at a major academic urban tertiary care medical center. Using patient records, we conducted a retrospective analysis of 4106 children admitted to the PICU for severe illnesses between 2011 and 2019. Patients were identified as malnourished if records showed an ICD-9 or ICD-10 code for malnutrition. We compared malnourished and non-malnourished patients by age, admitting diagnoses, number of comorbid conditions, and clinical outcomes (length of stay, hospital readmission). About 1 of every 5 PICU-admitted patients (783/4106) had a malnutrition diagnosis. Patients with malnutrition were younger (mean age 6.2 vs. 6.9 years, p < 0.01) and had more comorbid conditions (14.3 vs. 7.9, p < 0.01) than those without. Malnourished patients had longer hospital stays (26.1 vs. 10.0 days, p < 0.01) and higher 30-day readmission rates (10% vs. 7%, p = 0.03). Implementation of malnutrition screening and coding practices was associated with an increase in malnutrition diagnosis. In this study of children admitted to the PICU, malnourished patients had more comorbid diagnoses and used more healthcare resources (prolonged hospitalizations and higher 30-day readmission rates), leading to higher healthcare costs. Such findings underscore the need for policies, training, and programs emphasizing identification and treatment of malnutrition at hospitals caring for critically ill children.

Evaluating the Relationship Between Nutrition and Post-colectomy Pouchitis in Pediatric Patients with Ulcerative Colitis

BACKGROUND

Pouchitis is the most frequent complication following restorative proctocolectomy and ileal pouch anal anastomosis (RP-IPAA) in patients with Ulcerative colitis (UC). Pediatric data on nutritional status during RP-IPAA and in patients with pouchitis are limited.

AIMS

We aimed to delineate nutritional changes in children undergoing 2-stage and 3-stage surgeries and to evaluate the association between nutrition and the development of recurrent or chronic pouchitis.

METHODS

This single-center retrospective study involved 46 children with UC who underwent a RP-IPAA. Data were collected at each surgical stage and for up to 2-year post-ileostomy takedown. We used Wilcoxon matched-pairs signed-rank test to evaluate the differences in nutritional markers across surgical stages and logistic regression to identify the factors associated with recurrent or chronic pouchitis.

RESULTS

Twenty patients (43.5%) developed recurrent or chronic pouchitis. Children who underwent a 3-stage procedure had improvements in albumin, hematocrit, and body mass index (BMI)-for-age Z-scores (p < 0.01) between the first two stages. A positive trend in BMI-for-age Z-scores (p = 0.08) was identified in children with 2-stage procedures. All patients showed sustained nutritional improvement during the follow-up period. Among patients who underwent 3-stage surgeries, BMI worsened by 0.8 standard deviations (SDs) (p = 0.24) between the initial stages in those who developed recurrent or chronic pouchitis and improved by 1.1 SDs (p = 0.04) in those who did not.

CONCLUSIONS

Early improvement in BMI-for-age Z-scores following the initial stage was associated with lower rates of recurrent or chronic pouchitis. Larger prospective studies are needed to validate these findings.

Clinical Features of Transient Growth Hormone Deficiency

Background: Most patients with idiopathic growth hormone deficiency (iGHD) in childhood have normal GH stimulation test results in adulthood. The present study aimed to investigate the characteristics and possible etiology of transient iGHD. Methods: Patients with childhood-onset iGHD who completed their GH treatment between March 2010 and March 2021 were retrospectively studied. Patients with a clear history of child abuse or constitutional delay of growth and puberty were excluded. Ten patients with a diagnosis of iGHD based on a decreased growth rate and growth hormone stimulation test findings at the time of onset were included. Retesting demonstrated that these patients had a normal GH level. Results: Five patients had insufficient weight gain (BMI SD score < −1.0 at the start of treatment or a decrease in BMI SD score > 1.0 from one year before treatment to the start of treatment). The other five patients had no remarkable clinical features. One patient had decreased height velocity at the same time as their sibling. Conclusion: Insufficient pre-treatment weight gain or a familial cluster of cases may be related to low GH peaks of GHST, leading to a diagnosis of transient GHD.

Evaluation of Nutritional Characteristics Reveals Similar Prevalence of Malnutrition in Patients with Ulcerative Colitis and Crohn's Disease

BACKGROUND

Inflammatory bowel disease (IBD) is associated with an increased risk of malnutrition and sarcopenia.

AIMS

To evaluate the nutritional status of patients with IBD and determine the threshold values of different parameters of nutritional assessment to identify malnutrition.

METHODS

This was a single-centre cross-sectional analysis of adult patients with IBD [ulcerative colitis (UC) and Crohn's disease (CD)] who underwent anthropometry [body mass index (BMI), mid upper arm circumference (MUAC) and triceps-fold thickness (TSF)], body composition analysis and assessment for sarcopenia [hand-grip strength and skeletal muscle index (SMI) at L3 vertebral level)]. Age- and gender-matched healthy adults served as controls. Malnutrition was defined according to the European Society of Clinical Nutrition and Metabolism (ESPEN) criteria.

RESULTS

A total of 406 patients [336 (82.76%) UC and 70 (17.24%) CD; mean age 40.56 ± 13.67 years; 215 (52.95%) males] with IBD and 100 healthy controls (mean age 38.69 ± 10.90 years; 56 (56%) males) were enrolled. The mean BMI, MUAC, TSF thickness, fat and lean mass, hand-grip strength, and SMI at L3 vertebral level were lower in patients with IBD compared to controls. The prevalence of malnutrition was similar in UC and CD [24.40% (n = 82) and 28.57% (n = 20), respectively (p = 0.46)]. Thresholds for fat mass in females (15.8 kg) and visceral fat index in males (0.26) were both sensitive and specific to detect malnutrition. The cutoff values of MUAC and TSF thickness to identify malnutrition were 23.25 cm and 25.25 cm, and 16.50 mm and 8.50 mm, in females and males, respectively.

CONCLUSION

Malnutrition and sarcopenia were common in patients with IBD, with the prevalence being similar in patients with both UC and CD.

Effect of feeding with standard or higher-density formulas on anthropometric measures in children with congenital heart defects after corrective surgery: a randomized clinical trial

OBJECTIVES

The aim of the present study was to assess the efficacy of feeding a higher-density formula (HDF) in infant with congenital heart disease (CHD).

METHODS

In a parallel randomized trial, infants (6 to 12 months) who underwent CHD corrective surgery received either a standard-density formula (SDF, 67 kcal /100 ml) or an HDF (90 kcal/100 ml) after discharge from the intensive care unit for 8 weeks. In addition to the formula, infants could receive breast milk or complementary food. Anthropometry, biochemistry, and formula intake were collected.

RESULT

Sixty-four infants completed the study (n = 32 in each group). All infants gained weight. The mean ± standard deviation (SD) of weight z score at baseline and week-8 were -2.38 ± 10.04 to -1.38 + 0.97 in the SDF group and -2.69 ± 1.19 to -0.89 ± 0.90 in the HDF group (between-group p = 0.0001). Both groups gained length, but showed a decline in length z-score which was significant in the SDF group but not significant in the HDF group. Mid-upper arm circumference and its z score improved in both groups, with more improvement in the HDF group. Serum albumin level was higher in the HDF than the SDF group at week-8, but no significant between-group differences were observed in hemoglobin, serum ferritin, or iron. Symptoms of gastrointestinal intolerance were not reported, but parents of 4 infants in the HDF group complained of their infants' constipation.

CONCLUSION

Feeding infants using a concentrated formula could increase infants' weight gain and growth, and improve the nutritional status after CHD surgery.

Does a child's mid-upper arm circumference-for-age z-score represent another nutritional indicator of childhood malnutrition status?

Child wasting is defined as a weight-for-height/length z-score (WLZ/WHZ) < -2, and this indicator of nutritional status is used worldwide. However, a precise measurement is required for the assessment of a child's nutritional status, which may not always be possible due to expensive instruments, especially in poor resource settings. In some instances, mid-upper arm circumference-for-age z-score (MUACZ) is also being used for screening purposes, which is a simple and useful nutritional indicator. The objective of this paper is to identify the optimal cut-off point for the MUACZ to identify wasted children, and also to determine if the same factors are associated with MUACZ and wasting. Data were derived from the Suchana evaluation data. The optimal cut-off value was estimated via receiver operating characteristic (ROC) curve analysis using acute malnutrition as a gold standard with maximum sensitivity and specificity. Multiple logistic regression was used to assess the associated factors with the MUACZ. Using the gold standard indicator of nonwasting (WLZ ≥ -2), a positive outcome, the optimal cut-off point for the MUACZ was -1.27. The area under the ROC curve was 0.88, indicating that the model had a power of 88% to differentiate between the positive and negative classes. It implies that a child's MUACZ was correlated with WLZ, and a MUACZ below -1.27 appeared to accurately identify wasting among children aged 3-23 months. MUACZ < -1.27 might be another useful indicator of childhood wasting than a WLZ < -2.

Mini Nutritional Assessment for Adult Cancer Patients: A Systematic Review and Meta-Analysis

Early assessment of malnutrition in cancer patients is very important. The Mini Nutritional Assessment (MNA) is often used to assess malnutrition in adult cancer patients. However, the diagnostic values of MNA are controversial. We aimed to analyze the diagnostic values of MNA in assessing malnutrition in adult cancer patients. A systematic search was performed using Embase, Web of Science, PubMed, the Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Database, and China Science and Technology Journal Database (VIP). Studies comparing MNA with other tools or criteria in cancer patients were included. The quality of the included studies was assessed by the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). The pooled sensitivity, specificity, the area under the receiver-operating characteristic curve (AUC), and the diagnostic odds ratio (DOR) were calculated using Stata 17.0 and Meta-DiSc1.4. In addition, sensitivity, subgroup, meta-regression, and publication bias analyses were conducted. In total, 11 studies involving 1367 patients involving MNA were included. The pooled sensitivity, specificity, ROC, and DOR were 0.84 (95% CI: 0.81-0.87), 0.66 (95% CI: 0.63-0.69), 0.84 (95% CI: 0.81-0.87), and 16.11 (95% CI: 7.16-36.27), respectively. In the assessment of malnutrition in adult cancer patients, MNA has high sensitivity and moderate specificity.

The Effect of Different Nutritional Nursing Support on the Nutritional Status and Disease Recovery of Elderly Patients with Gastrointestinal Tumors during the Perioperative Period

Objective

This study explored the effect of different nutritional nursing support on nutritional status, immune function, postoperative bowel motility, and complications in elderly patients with gastrointestinal tumors during the perioperative period.

Methods

300 patients with gastrointestinal tumors treated in the Department of Gastroenterology and anorectal surgery of Hangzhou First People's Hospital Affiliated with the Medical College of Zhejiang University from February 2018 to March 2020 were selected as the research objects in this study. Patients were divided into the early enteral nutrition (EEN) and total parenteral nutrition (TPN) groups (150 cases in each group) according to the principle of odd and even admission numbers. The patients in the EEN and TPN groups were given enteral nutrition nursing support and parenteral nutrition nursing support, respectively. The nutritional status, immune function, postoperative bowel motility, and complication rate of the two groups were evaluated 7 days after the operation.

Results

The nutritional indexes decreased 3 days after the operation and gradually recovered 7 days after the operation in both groups with different nutritional nursing support. The Hb, TRF, PAB, and ALB indexes in the TPN group were significantly lower than those in the EEN group (P < 0.01). On the 7th day after the operation, the indexes of peripheral blood immunoglobulin (IgG, IgM, and IgA) were significantly lower than those in the TPN group, and T lymphocyte subsets (CD4, CD8, and CD4/CD8) demonstrated that the immunological indexes of patients in the EEN group were significantly higher than those in the TPN group (P < 0.01). In terms of intestinal peristalsis, the time of first exhaust and first defecation in the EEN group was significantly shorter than that in the TPN group (P < 0.01) during the perioperative period. Furthermore, both groups had different degrees of complications, while patients demonstrated a lower complication rate in the EEN group compared to those in the TPN group, suggesting a safer postoperative mode. The results of subgroup analysis showed that the nutritional indexes of the gastric cancer group 7 days after operation were significantly higher than those of the colorectal cancer group under EEN and TPN nutritional support modes.

Conclusion

Clinical results have suggested that enteral nutrition nursing support can improve the perioperative nutritional status of elderly patients with gastrointestinal tumors by enhancing the immune function and promoting intestinal peristalsis. Meanwhile, the postoperative EEN mode reduces the rate of complications and demonstrates higher safety. Therefore, it has a high clinical application value.

Underweight in the First 2 Years of Life and Growth in Later Childhood

IMPORTANCE

Few studies have examined the association between underweight in the first 2 years and growth in later childhood in high-income countries.

OBJECTIVE

To evaluate the associations of underweight in the first 2 years of life with body mass index (calculated as weight in kilograms divided by height in meters squared) z score (zBMI), weight-for-age z score (WAZ), and height-for-age z score (HAZ) from ages 2 to 10 years.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study was conducted between February 2008 to September 2020 in The Applied Research Group for Kids! practice-based research network in Toronto, Canada. Participants included healthy children aged 0 to 10 years. Data were analyzed from October 2020 to December 2021.

EXPOSURES

Underweight (ie, zBMI less than -2, per the World Health Organization) in the first 2 years of life.

MAIN OUTCOMES AND MEASURES

The primary outcome was zBMI from ages 2 to 10 years. Linear mixed-effects models were used to account for multiple growth measures over time.

RESULTS

A total of 5803 children were included in the primary analysis. At baseline, the mean (SD) age was 4.07 (5.62) months, 2982 (52.2%) were boys, and 550 children (9.5%) were underweight. Underweight in the first 2 years was associated with lower zBMI (difference, -0.39 [95% CI, -0.48 to -0.31]) at 10 years and lower HAZ (difference, -0.24 [95% CI, -0.34 to -0.14]) at age 2 years. Stratified by sex, at age 10 years, girls and boys with underweight in the first 2 years both had lower zBMI (girls: difference, -0.47 [95% CI, -0.59 to -0.34]; boys: difference, -0.32 [95% CI, -0.44 to -0.20]). At age 10 years, children with underweight and a lower zBMI growth rate in the first 2 years had lower zBMI (difference, -0.64 [95% CI, -0.77 to -0.53) and HAZ (difference, -0.12 [-0.24 to -0.01]), while children with underweight and a higher zBMI growth rate in the first 2 years had similar zBMI (difference, -0.11 [95% CI, -0.22 to 0.001]) and higher HAZ (difference, 0.16 [95% CI, 0.05 to 0.27]) compared with children who did not have underweight in the first 2 years.

CONCLUSIONS AND RELEVANCE

In this prospective cohort study, children with underweight in the first 2 years of life had lower zBMI and HAZ in later childhood. These associations were attenuated among children with a higher growth rate in the first 2 years.

Pre-operative nutritional status and its association with short-term post-operative outcomes in Iranian children with CHD

BACKGROUND

Nutritional assessment appears to be an essential component of the evaluation of children with CHD undergoing surgery because nutritional status may impact corrective surgery-associated morbidity.

METHODS

A prospective single-centre cohort study with children between 6 and 24 months of age. Patients who had genetic syndromes or those who were premature or low birthweight at birth were excluded. Pre-operative nutritional parameters included anthropometric measurements and serum concentrations of total protein, vitamin D, iron, and ferritin. Outcome measures included ICU length of stay, mechanical ventilation, vasoactive-inotropic score, and duration of inotropes. Linear regression analysis was performed to determine whether pre-operative variables were associated with outcomes.

RESULTS

Analysis was performed on 120 patients (median age of 8 months), of whom 67 were male. Prior to surgery, 50.8% of patients had reduced (z ≤ -2.0) weight-for-age z score, 23.3% had reduced length-for-age z score, and 59.2% had reduced mid-upper arm circumference z score. Pre-operative serum total protein levels were 59.36 ± 9.16 g/L. Multiple regression analysis showed that low serum protein was associated with longer ICU length of stay and length of mechanical ventilation, while mid-upper arm circumference z score ≤ -2 was associated with longer ICU length of stay and mechanical ventilation and inotropes duration.

CONCLUSIONS

Pre-operative assessment of nutritional status by performing anthropometric and biochemical measurements including mid-upper arm circumference z score and serum protein concentrations in children undergoing CHD surgery appears to be predictors of some post-operative short-term outcomes and could be used as a guide to highlight patients needing appropriate perioperative nutritional interventions.

Hypokalemia-Induced Rhabdomyolysis in a Child with Autism Affected by the COVID-19 Pandemic

OBJECTIVE

Pediatric patients with autism spectrum disorder (ASD) often have coexisting feeding disorders. We hope to emphasize the significant implications that these feeding disorders can have on this patient population through a unique case of hypokalemia-induced rhabdomyolysis.

METHOD

We present a unique case of a 3-year-old boy with ASD and a longstanding history of food selectivity whose routine was disrupted during the COVID-19 pandemic resulting in avoidant/restrictive food intake disorder and severe undernutrition, who presented with profound hypokalemia and was subsequently found to have elevated muscle enzymes consistent with rhabdomyolysis despite only subtle complaints of difficulty walking.

RESULTS

The patient was treated with aggressive hydration, electrolyte therapy, and nasogastric tube feeds, which resulted in clinical and biochemical evidence of improvement. He was also reconnected to ASD-related care services that had lapsed during the COVID-19 pandemic.

CONCLUSION

This case exemplifies the adverse impact that feeding disorders can have on patients with ASD, particularly in the setting of stressors such as a global pandemic, and is also the first documented pediatric case of rhabdomyolysis secondary to hypokalemia from severe undernutrition. It demonstrates that physicians should have a low threshold to assess for clinical and laboratory evidence of rhabdomyolysis in patients with profound hypokalemia because symptoms of hypokalemia-induced rhabdomyolysis can often be subtle, which can delay diagnosis and thereby increase the risk for life-threatening complications from extensive muscle damage.

Update to the pediatric Subjective Global Nutritional Assessment (SGNA)

Lack of a standardized method of identifying and defining pediatric malnutrition has led to an inability to fully understand the prevalence of and impact that malnutrition has on pediatric patients and the healthcare system. The Subjective Global Nutritional Assessment (SGNA) is an assessment tool meant to determine presence and severity of malnutrition in pediatric populations. However, the anthropometric section of the tool contains some out-dated parameters. This has limited its clinical practicality. The aim of this paper is to propose updates to the anthropometrics section of the SGNA. A retrospective analysis of 153 SGNA's performed on children aged 1 month to 16 years was completed, comparing the original SGNA results to SGNA results incorporating updated anthropometric parameters for percentiles and ideal body weight. The category of length/height for age was updated to include z score cutoffs rather than percentiles, and ideal body weight was updated to z scores for weight for length or body mass index (BMI). Two serial growth questions were updated in wording only, to reflect z score trends. The results of the analysis showed these updates would have changed the rankings of eight patients (5%) for length/height for age, and 20 patients (13%) for ideal body weight to weight for length or BMI. Adjustments to these questions did not impact the overall SGNA rating. This study shows updates to the SGNA are not expected to have a significant impact on the validity of the tool and has the potential to improve its applicability to current day practice.

Development and Validation of a New Screening Tool with Non-Invasive Indicators for Assessment of Malnutrition Risk in Hospitalised Children

There is no evidence of the most effective nutritional screening tool for hospitalized children. The present study aimed to develop a quick, simple, and valid screening tool for identifying malnutrition risk of hospital admission with non-invasive indicators. A cross-sectional study was conducted. Children`s nutritional baseline using a questionnaire, subjective malnutritional risk, and Subjective Global Nutritional Assessment were assessed on admission. Concurrent validity was assessed using American Society for Parenteral and Enteral Nutrition (ASPEN)and Academy of Nutrition and Dietetics assessment and Subjective Global Nutritional Assessment tool. A new screening tool Simple Pediatric Nutritional risk Screening tool (SPENS) was developed, and sensitivity, specificity and reliability were evaluated. A total of 180 children aged from 1 month to 18 years were included (142 in the development phase and 38 in the validation phase). SPENS consist of four variables and shows almost perfect agreement with subjective malnutritional risk assessment (κ = 0.837) with high sensitivity and specificity (93.3% and 91.3% respectively). Compared with Subjective Global Nutritional Assessment and ASPEN and Academy of Nutrition and Dietetics assessment, SPENS had sensitivity 92.9% and 86.7%, a specificity of 87.5% and 87.0%, and an overall agreement of 0.78 and 0.728, respectively. Due to the fast, simple, easy, and practical to use, screening the SPENS can be performed by nurses, physicians, and dieticians.

Chronic Intestinal Failure in Children: An International Multicenter Cross-Sectional Survey

Background: The European Society for Clinical Nutrition and Metabolism database for chronic intestinal failure (CIF) was analyzed to investigate factors associated with nutritional status and the intravenous supplementation (IVS) dependency in children. Methods: Data collected: demographics, CIF mechanism, home parenteral nutrition program, z-scores of weight-for-age (WFA), length or height-for-age (LFA/HFA), and body mass index-for-age (BMI-FA). IVS dependency was calculated as the ratio of daily total IVS energy over estimated resting energy expenditure (%IVSE/REE). Results: Five hundred and fifty-eight patients were included, 57.2% of whom were male. CIF mechanisms at age 1−4 and 14−18 years, respectively: SBS 63.3%, 37.9%; dysmotility or mucosal disease: 36.7%, 62.1%. One-third had WFA and/or LFA/HFA z-scores < −2. One-third had %IVSE/REE > 125%. Multivariate analysis showed that mechanism of CIF was associated with WFA and/or LFA/HFA z-scores (negatively with mucosal disease) and %IVSE/REE (higher for dysmotility and lower in SBS with colon in continuity), while z-scores were negatively associated with %IVSE/REE. Conclusions: The main mechanism of CIF at young age was short bowel syndrome (SBS), whereas most patients facing adulthood had intestinal dysmotility or mucosal disease. One-third were underweight or stunted and had high IVS dependency. Considering that IVS dependency was associated with both CIF mechanisms and nutritional status, IVS dependency is suggested as a potential marker for CIF severity in children.

Evaluation of the risk of malnutrition in hospitalized children by PYMS, STAMP, and STRONGkids tools and comparison with their anthropometric indices: a cross-sectional study

Background

Malnutrition is a determining factor of pediatric mortality and morbidity, especially in low and middle-income countries. Hospitalized children are at a higher risk of malnutrition. Several malnutrition screening tools have been used, among which STAMP, PYMS, and STRONGkids are valid tools with high sensitivity and specificity. The aim of this study was to compare these screening tools to find the best ones in identifying the risk of malnutrition in hospitalized children.

Methods

This is a cross-sectional study performed on hospitalized children aged 1 to 16 years. The questionnaires of PYMS, STAMP, STRONGkids malnutrition risk assessment tools were filled. The weight for height and BMI for age Z-scores were calculated. The data were analyzed by SPSS. Sensitivity, specificity, positive predictive value, and negative predictive values of the risk scores based on weight for height and BMI for age Z-scores were calculated.

Results

Ninety-three patients with a mean age of 5.53 ± 3.9 years were included. The frequency of malnutrition was reported as 26% and 39% according to weight for height and BMI for age Z-scores, respectively. A significant relationship was found between PYMS and Weight for height Z-score (P-value < 0.001), and BMI for age Z-score (P-value < 0.001). Moreover, STRONGkids was found to be associated with weight for height Z-score (P-value: 0.017).

Conclusion

The PYMS is a practical and beneficial tool in early identifying the risk of severe malnutrition in hospitalized patients. It is a suitable method for patients in our settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-022-00525-8.

Malnutrition Risk and Kidney Function and Decline in Community-Dwelling Older Adults

OBJECTIVES

The association of malnutrition with chronic kidney disease (CKD) is well established. However, there is a paucity of studies of the effect of malnutrition risk (MR) on kidney function decline among older persons who do not have end-stage or dialyzable CKD. This study aimed to examine the association between MR status and kidney function, and future risks of kidney function decline and CKD progression in community-dwelling older adults.

DESIGN AND METHODS

Nutrition Screening Initiative's DETERMINE Your Nutritional Health Checklist and estimated glomerular filtration rate (eGFR) were assessed at baseline among 5,122 participants free of end-stage renal failure or dialyzed CKD in the Singapore Longitudinal Aging Studies (SLAS-1 and SLAS-2). Follow-up eGFR was assessed in a subcohort of SLAS-2 participants without CKD (eGFR > 60 mL/min/1.73 m²) at baseline (N = 786) who were followed up at 3-5 years.

RESULTS

In baseline cross-sectional analyses adjusting for other risk factors, low, moderate, and high MR was significantly associated with decreasing eGFR coefficients of -1.5, -3.3, and -5.0 mL/min/1.73 m² respectively, and increasing CKD odds ratios of 1.81, 2.18, and 3.11 respectively. In longitudinal analysis, low, moderate, and high MR was significantly associated with increased risk of eGFR (>25%) decline (odds ratio of 2.37, 3.34, and 2.18 respectively).

CONCLUSIONS

Among older adults without advanced kidney disease, MR is associated with poor kidney function and increased risk of kidney function decline and CKD. Preventive interventions to modify MR may help to reduce the deterioration of renal function in older people.

Late effects in survivors of high-risk neuroblastoma following stem cell transplant with and without total body irradiation

BACKGROUND

Neuroblastoma is the most common extracranial solid tumor in children. Those with high-risk disease are treated with multimodal therapy, including high-dose chemotherapy, stem cell transplant, radiation, and immunotherapy that have led to multiple long-term complications in survivors. In the late 1990s, consolidation therapy involved myeloablative conditioning including total body irradiation (TBI) with autologous stem cell rescue. Recognizing the significant long-term toxicities of exposure to TBI, more contemporary treatment protocols have removed this from conditioning regimens. This study examines an expanded cohort of 48 high-risk neuroblastoma patients to identify differences in the late effect profiles for those treated with TBI and those treated without TBI.

PROCEDURE

Data on the study cohort were collected from clinic charts, provider documentation in the electronic medical record of visits to survivorship clinic, including all subspecialists, and ancillary reports of laboratory and diagnostic tests done as part of risk-based screening at each visit.

RESULTS

All 48 survivors of BMT for high-risk neuroblastoma had numerous late effects of therapy, with 73% having between five and 10 late effects. TBI impacted some late effects significantly, including growth hormone deficiency (GHD), bone outcomes, and cataracts.

CONCLUSION

Although high-risk neuroblastoma survivors treated with TBI have significant late effects, those treated without TBI also continue to have significant morbidity related to high-dose chemotherapy and local radiation. A multidisciplinary care team assists in providing comprehensive care to those survivors who are at highest risk for significant late effects.