Differences between WHO AND CDC early growth measurements in the assessment of Cystic Fibrosis clinical outcomes

Improving growth in infants with CF

Cystic fibrosis (CF) results in chronic pulmonary infections, inflammation, pancreatic insufficiency, and multiple gastrointestinal manifestations. Malnutrition and poor growth are hallmarks of CF, and strongly associated with poor outcomes. Through newborn screening, many infants can be diagnosed within a few days of life, which allows for early initiation of nutritional counseling and close clinical follow-up. Obstacles to growth for infants with CF start in utero, as newborns with CF can have a lower birth weight than the general population. Improving infant growth has been linked to improved clinical outcomes and survival. It remains a top priority and challenge for caregivers and healthcare teams. An interdisciplinary approach, including registered dietitian and social work support, is essential to optimize health for infants with CF. Remaining barriers to normalcy include deficits in linear growth, lack of accurate nutrition biomarkers, persistence of inequities related to social determinant of health, particularly in the global CF community.

ESPEN-ESPGHAN-ECFS guideline on nutrition care for cystic fibrosis

BACKGROUND

Nutritional status is paramount in Cystic Fibrosis (CF) and is directly correlated with morbidity and mortality. The first ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with CF were published in 2016. An update to these guidelines is presented.

METHODS

The study was developed by an international multidisciplinary working group in accordance with officially accepted standards. Literature since 2016 was reviewed, PICO questions were discussed and the GRADE system was utilized. Statements were discussed and submitted for on-line voting by the Working Group and by all ESPEN members.

RESULTS

The Working Group updated the nutritional guidelines including assessment and management at all ages. Supplementation of vitamins and pancreatic enzymes remains largely the same. There are expanded chapters on pregnancy, CF-related liver disease, and CF-related diabetes, bone disease, nutritional and mineral supplements, and probiotics. There are new chapters on nutrition with highly effective modulator therapies and nutrition after organ transplantation.

Ataxia-telangiectasia clinical trial landscape and the obstacles to overcome

INTRODUCTION

Ataxia telangiectasia (A-T) is a life-limiting autosomal recessive disease characterized by cerebellar degeneration, ocular telangiectasias, and sinopulmonary disease. Since there is no cure for A-T, the standard of care is primarily supportive.

AREAS COVERED

We review clinical trials available in PubMed from 1990 to 2023 focused on lessening A-T disease burden. These approaches include genetic interventions, such as antisense oligonucleotides, designed to ameliorate disease progression in patients with select mutations. These approaches also include pharmacologic treatments that target oxidative stress, inflammation, and mitochondrial exhaustion, to attenuate neurological progression in A-T. Finally, we discuss the use of biological immunotherapies for the treatment of malignancies and granulomatous disease, along with other supportive therapies being used for the treatment of pulmonary disease and metabolic syndrome.

EXPERT OPINION

Barriers to successful genetic and pharmacologic interventions in A-T include the need for personalized treatment approaches based on patient-specific ATM mutations and phenotypes, lack of an animal model for the neurologic phenotype, and extreme rarity of disease making large-scale randomized trials difficult to perform. Ongoing efforts are needed to diagnose patients earlier, discover more effective therapies, and include more individuals in clinical trials, with the goal to lessen disease burden and to find a cure for patients with A-T.

Eating disorders and body image in cystic fibrosis

Eating disorders and disturbed body image have been reported in individuals with cystic fibrosis (CF) and may contribute to poor weight gain, reduced lung function and increased mortality. CF individuals often look and feel different from their peers and bear the additional burden of body-altering side effects of treatment. As a result, the impact of disorders such as binge eating, anorexia nervosa, and bulimia nervosa may adversely affect the social, emotional, and physical development of those with CF.

Multiple risk factors may contribute to the development of an eating disorder in CF. Growth failure is affected by the physical impairments of CF, including pancreatic insufficiency, high energy demands, respiratory infections, and delayed and stunted growth and puberty. Psychological factors, such as CF associated depression and anxiety, intense focus on BMI, lack of control in a chronic disease, and preoccupation with morbidity and mortality, likely further contribute. Exercise inefficiency, secondary to poor lung function, low BMI and pulmonary exacerbations, and the potential for medication manipulation are also additional risk factors.

The intense scrutiny around BMI may lead to a poor relationship with food, including disordered eating habits, abnormal mealtime behaviors, and stressful caregiver-patient interactions regarding meals. This further contributes to a discrepancy between ideal CF nutritional standards and the reality of the challenges of appropriate daily energy intake for an individual with CF.

It is imperative that CF providers are equipped to identify potential eating disorders and disturbed body image in their CF patients. Improved screening and monitoring practices should be developed and implemented, with multidisciplinary support from all CF care team members, including dietitians, mental health professionals, and social workers, to best support holistic care and optimize outcomes. Increased attention to these concerns may help reduce CF related morbidity and mortality.

Academy of Nutrition and Dietetics: 2020 Cystic Fibrosis Evidence Analysis Center Evidence-Based Nutrition Practice Guideline

The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based practice guideline for primary nutrition issues in cystic fibrosis (CF). This guideline is designed to complement and build upon existing evidence-based CF nutrition guidelines. The objective of this guideline was to provide recommendations for registered dietitian nutritionists in the United States delivering medical nutrition therapy to individuals with CF and their families that fill gaps in current evidence-based guidelines on topics that are crucial in order to improve health and prevent disease progression. This guideline provides 28 nutrition recommendations to guide medical nutrition therapy, including nutrition screening, nutrition assessment, and dietary intake. For topics outside the scope of this guideline, practitioners are referred to external, evidence-based recommendations. The CF landscape is evolving rapidly with breakthroughs in cystic fibrosis transmembrane regulator modulators changing CF at a cellular level. Medical nutrition therapy for individuals with CF from infancy through advanced age requires novel and individualized approaches. The Academy Evidence Analysis Library CF guidelines provide a framework for expanding upon current knowledge to determine effective nutrition strategies for individuals with CF through long and healthy futures.

The measurement properties of tests and tools used in cystic fibrosis studies: a systematic review

There is no consensus on how best to measure responses to interventions among children and adults with cystic fibrosis (CF). We have systematically reviewed and summarised the characteristics and measurement properties of tests and tools that have been used to capture outcomes in studies among people with CF, including their reliability, validity and responsiveness. This review is intended to guide researchers when selecting tests or tools for measuring treatment effects in CF trials. A consensus set of these tests and tools could improve consistency in how outcomes are captured and thereby facilitate comparisons and synthesis of evidence across studies.

Reference Values Matter: Fewer Patients With Malnutrition Using American Compared to More Recent German Growth Charts

ABSTRACT

Reference values are important for patient care as well as for comparisons between different centers or countries. We investigated two anthropometric reference datasets, the US Centers for Disease Control (CDC) growth charts and the German Health Interview and Examination Survey for Children and Adolescents Study (KiGGS) percentiles, which were established in Germany between 2003 and 2006. A smaller proportion of children with cystic fibrosis had decreased z scores <-2 with CDC (5.0% for weight and 3.0% for height) compared to KiGGS (7.4% for weight and 6.3% for height) values (P < 0.0001). Median z scores were higher using the CDC reference data. Thus, the choice of growth reference is important, may influence clinical management and must be considered when comparing the outcomes of different institutions.

What is normal, healthy growth? Global health, human biology, and parental perspectives

OBJECTIVES

The widespread variation seen in human growth globally stands at odds with the global health perspective that young child growth should not vary across populations if nutritional, environmental and care needs are met. This paper: (1) evaluates the idea that a single standard of "healthy" growth characterizes children under age 5, (2) discusses how variation from this standard is viewed in global health, in human biology and by parents, and (3) explores how views of "normal" growth shape biomedical and parental responses.

METHODS

This paper reviews the anthropological, public health and clinical literature on the nature of child growth and the applicability of World Health Organization Multicenter Growth Reference Study growth standards across contexts.

RESULTS

The considerable variability in child growth across contexts makes it unlikely that any one framework, with issues of sample selection and representativeness, can serve as the model of healthy growth. Global health, human biology and parents differ in the emphasis they place on heredity versus environmental context in understanding this variability, but human biologists and parents tend to view a wider range of growth as "normal." Since both biomedicine and parents base their care decisions on their perceptions of normal, healthy growth, the comparative framework used has important implications for medical treatment and feeding practices.

CONCLUSIONS

A more nuanced approach that incorporates the biology of growth and its association with health outcomes across contexts is critical to identify patterns of healthy growth and to avoid over-reliance on a single standard that may pathologize variability.

A Retrospective Cohort Study of Growth in the First 2 Years of Life in Preterm Infants With Cystic Fibrosis

BACKGROUND

Late preterm infants (born 34-36 weeks gestation) without cystic fibrosis (CF) are at risk for growth failure during the first 2 years of life. Infants with CF are at risk of being born premature, and thus at risk for growth failure. The aim for this study was to assess weight-for-length (WFL) at 2 years of age for late preterm infants compared with term infants with CF.

METHODS

Data were collected from the US CF Foundation Patient Registry. We compared growth parameters between late preterm and term infants with CF born from 2010 to 2013. Our primary outcome was WFL <10 and <50 percentile at 2 years of age. A multivariate logistical regression analysis evaluated late preterm gestation and WFL<10 or <50 percentile.

RESULTS

A total of 2955 infants were born from 2010 to 2013 with CF. Eight percentage late preterm. Forty-five percentage late preterm versus 43% term were below the 50th percentile for WFL at age 2 years (P = 0.75). Twelve percentage late preterm versus 6% term for WFL <10 percentile at age 2 years (P = 0.010). The multivariate regression model identified 2-fold increased odds of being <10th percentile for WFL at age 2 years (P = 0.025) for preterm over term. Late preterm infants used higher calorie dense feeds and more feeding tubes (P = 0.035 and P = 0.006).

CONCLUSIONS

Late preterm infants with CF are at higher risk of being below the 10th percentile for WFL at 2 years of age compared with their term peers. This indicates a population that is at risk for growth failure.