Nutrition support in the pediatric surgical patient

Impact of malnutrition on the outcome and length of hospital stay in elective pediatric surgical patients: prospective cohort study at tertiary hospitals in Ethiopia

BACKGROUND

Pediatric surgical patients in low and middle-income countries suffer from malnutrition on top of the surgical pathology and post-operative stress which increases post-operative morbidity and mortality. Malnutrition is highly prevalent in Africa and is expected to impact the outcome of surgical patients. The study was aimed at determining the impact of malnutrition on the outcome and length of hospital stay in elective pediatric surgical patients.

METHODS

A prospective study was done on children, aged one month to fourteen years, who had undergone elective general surgery. Upon admission, nutritional assessment using an anthropometric indicator was undertaken and used to derive the WHO Anthro Z scores. Malnutrition was defined as a binary outcome: severely/moderately malnourished (Z < -2) versus well nourished (Z ≥ -2). After surgery, postoperative complications were documented. Chi-squared tests and t-tests were used to assess associations.

RESULTS

Of the 109 enrolled children, 49 (45%) had malnutrition preoperatively. Infants had a higher prevalence of malnutrition (65% versus 35%, p-value = 0·028) compared to older children. Postoperative infection was relatively more common in malnourished children (27·1% versus 20%). The mean post-operative stays were 5·69 days (SD 0.46) for well-nourished children and 6.89 days (SD 0·9) for malnourished patients but the difference was not statistically significant.

CONCLUSION

We observed neither significant long hospital stays nor a higher incidence of postoperative infection among children with malnutrition. Further investigations with a larger sample size are warranted.

Nutrition considerations in pediatric surgical patients

Children who require surgical interventions are subject to physiologic stress, necessitating a period of healing when nutrition needs may temporarily change. Providing appropriate nutrition to children before and after surgery is an important part of minimizing surgical morbidity. There is a clear link between poor nutrition and surgical outcomes, therefore providing good reason for ensuring an appropriate nutrition plan is in place for children requiring surgery. This review will address recent research investigating nutrition considerations for pediatric surgical patients with a focus on practical tools to guide decision making in the preoperative, intraoperative, and postoperative periods.

Using Quality Improvement to Improve Identification and Documentation of Malnutrition in Hospitalized Pediatric Patients

Recent publications have highlighted the importance and impact of recognizing malnutrition in hospitalized children. After noting that patients with malnutrition frequently went unrecognized in our facility, we implemented an interprofessional intervention comprising hospital medicine physicians, dietitians, and the clinical documentation improvement team to improve recognition and documentation of malnutrition in these patients, thereby facilitating earlier intervention.

[Nutritional recovery after discharge in hospitalized children with malnutrition]

OBJECTIVE

To investigate the nutritional recovery status of children with moderate or severe malnutrition during hospitalization after discharge.

METHODS

The children with moderate or severe malnutrition were given nutrition support during hospitalization. They received a regular follow-up and nutrition guidance after discharge. The weight-for-age and height-for-age Z-scores reaching above -2 SD were considered the nutrition criterion for ending follow-up.

RESULTS

Among the 298 children with moderate or severe malnutrition, 174 (58.4%) reached the criterion for ending follow-up, 100 (33.6%) were lost to follow-up, 18 (6.0%) died, and 6 (2.0%) did not reach the criterion for ending follow-up after 18 months of follow-up. The children with malnutrition in the department of surgery had a significantly higher proportion of children reaching the criterion for ending follow-up than those in the department of internal medicine (P<0.05). The children with severe malnutrition had a significantly higher loss to follow-up rate than those with moderate nutrition (P<0.05). The majority of children with emaciation reached the criterion for ending follow-up at month 3 after discharge, while those with growth retardation reached such the criterion at months 3-6 after discharge. Up to 1 year after discharge, more than 80% of the children with different types of malnutrition reached the nutrition criterion for ending follow-up.

CONCLUSIONS

Most of the children with malnutrition who adhere to follow-up can reach the expected nutrition criterion within 1 year after discharge. The children with growth retardation have slower nutritional recovery than those with emaciation.

Impact of Nutrition Support Team on Postoperative Nutritional Status and Outcome of Patients with Congenital Gastrointestinal Anomalies

BACKGROUND The aim of this study was to evaluate postoperative nutritional status in patients who underwent operations due to congenital gastrointestinal anomalies in surgical neonatal intensive care units (NICUs) and to investigate the role of nutrition support teams (NSTs) on the outcome. METHODS A retrospective clinical study was carried out at two NICUs in Dr. Sheikh Pediatric Hospital, Mashhad, Iran. One of the NICUs was supported by NST and the other was not. A total of 120 patients were included through a non-random simple sampling. Different variables such as age, sex, prematurity, type of anomaly, birth weight, use of vasoactive drugs, weight gain in NICU, length of NICU stay, postoperative enteral nutrition initiation, duration of mechanical ventilation, mortality rate, maximum of blood sugar, the amount of calorie delivered to the calorie requirement ratio, and distribution of energy from enteral or parenteral roots were compared between the patients of two NICUs. RESULTS Median weight gain and the amount of calorie delivered during NICU stay in subjects of NSTsupported NICU was significantly more than other NICU. There was no significant difference in the length of NICU stay, enteral nutrition initiation after the operation, ventilation days, and percent of mortality between the two groups. The percentage of enteral feeding was also increased by about 2.8%, which was not significant. CONCLUSION NST could increase post-operative weight gain and calorie delivery in patients as well as providing an increase in enteral feeding rather than parenteral.

Appropriate use of total parenteral nutrition in children with perforated appendicitis

BACKGROUND

Total parenteral nutrition (TPN) is often used in children with perforated appendicitis, despite the absence of clear indications. We assessed the validity of specific clinical indications for initiation of TPN in this patient cohort.

METHODS

Data were gathered prospectively on duration of nil per os (NPO) status and TPN use in a cohort of children treated under a perforated appendicitis protocol during a 19-month period. TPN was started in the immediate postoperative period in patients who had generalized peritonitis and severe intestinal dilatation at operation, or later per the discretion of the attending surgeon. At discharge, TPN was considered to have been used appropriately, according to consensus guidelines, if the patient was NPO≥7days or received TPN≥5days.

RESULTS

During the study period, TPN was initiated in 31 (25.4%) of 122 patients operated for perforated appendicitis. Sixteen (51.6%) received TPN per operative finding indications and 15 (48.4%) for prolonged ileus. The operative indications demonstrated 47% sensitivity, 86% specificity, a positive predictive value (PPV) of 35%, and a negative predictive value (NPV) of 91%, when adherence to TPN consensus guidelines was considered the gold standard.

CONCLUSION

Patients without severe intestinal dilatation and generalized peritonitis at operation should not be placed on TPN in the immediate postoperative period. Refinement of selection criteria is necessary to further decrease inappropriate TPN use in children with perforated appendicitis.

TYPE OF STUDY

Diagnostic Test.

LEVEL OF STUDY

II.

Optimal Nutrition for Acute Rehabilitation in the PICU

Achieving optimal nutrition for a child who is receiving acute rehabilitation in the pediatric intensive care unit requires an individualized approach. Nutrition screening and assessment is necessary to identify children at high risk for complications who require targeted interventions. Early enteral nutrition can improve outcomes, and is thus preferred over parenteral nutrition in the absence of gastrointestinal contraindications. Measurement of caloric requirements with indirect calorimetry is essential to accurately prescribe nutrition support, while monitoring body composition can determine efficacy of nutrition therapies employed. The complex care of critically ill children receiving acute rehabilitation is composed of treatments that compete with delivery of prescribed nutrition. Repeated feeding interruptions can lead to nutrition deficits and prolonged recovery. Nutrition bundles that incorporate evidenced-based nutrition algorithms, methods to overcome nutrition barriers, and nutrition monitoring parameters can direct and optimize nutrition care for critically ill children in need of acute rehabilitation.

Lactobezoar formation in two premature infants receiving medium-chain triglyceride formula

We describe two cases of premature infants who developed clinical and radiologic evidence of gastric lactobezoars within the same month in our neonatal intensive care unit while both were receiving medium-chain triglyceride-rich formula as part of the management of chylothoraces.

Review of nutritional assessment and clinical outcomes in pediatric surgical patients: does preoperative nutritional assessment impact clinical outcomes?

INTRODUCTION

Malnourished adult patients who undergo surgical procedures tend to have worse clinical outcomes compared to well-nourished patients. In the pediatric surgical patient, nutritional assessment is considered a critical aspect of the initial evaluation, but a correlation between preoperative malnutrition and poor surgical outcomes is not clear. We hypothesized that an evidence-based review would reveal that measures of nutritional assessment in children would not correlate pre-operative malnutrition with poor surgical outcomes.

MATERIALS AND METHODS

A search of major English language medical databases (Medline, Cochrane, SCOPUS) was conducted for the key words nutritional assessment, pediatric, children, surgery, and outcomes. All methods of nutritional assessment in pediatric surgery were evaluated for their relevance and relation to outcomes after surgery. The Oxford Center for Evidence Based Medicine (CEBM) classification for levels of evidence was used to develop grades of clinical recommendation for each variable studied.

RESULTS

35 articles were evaluated after an exhaustive literature search, of which six met inclusion criteria for this review. There is a paucity of high quality evidence correlating preoperative malnutrition in pediatric surgical patients with clinical outcomes. Factors contributing to the low level of evidence include a lack of high quality randomized controlled trials, a lack of consensus in study design and methods, and utilization of incongruous methods of nutritional assessment, including methods that may be unproven in the study population.

CONCLUSION

Larger multi center randomized studies are needed to offer higher level of evidence to support nutritional intervention prior to major elective pediatric surgery.