Nutritional Support Best Practices in Pediatric Blood and Marrow Transplant Patients: An Integrative Review

Nutrition is vital to the long-term survival of children undergoing blood and marrow transplantation (BMT), but there is no standardization on how to optimize the nutritional status of these patients. A literature search was performed to evaluate nutritional support approaches currently in practice for pediatric patients who are undergoing BMT. CINAHL, Embase, and Cochrane databases were searched for peer-reviewed articles evaluating nutritional interventions for BMT recipients aged 20 or younger. Nine articles published between 2019 and 2023 were found and reviewed. The nutritional support varied between enteral nutrition, parenteral nutrition, a combination of both, and prophylactic feeding tube placement. The post-transplant outcomes identified as associated with alterations in nutritional regimens included length of stay, date of platelet engraftment, incidence of acute graft-versus-host disease, infection rate, and overall survival. The use of any amount of enteral nutrition compared to parenteral alone was beneficial. Complications during BMT can potentially be decreased via prioritizing enteral nutrition over parenteral. The paucity of literature on this topic highlights an unmet need in the field. Future research should focus on ways to optimize the nutritional support of transplant recipients, including increasing the likelihood of enteral feeding tube placement and utilization.

Feature selection and association rule learning identify risk factors of malnutrition among Ethiopian schoolchildren

Introduction

Previous studies have sought to identify risk factors for malnutrition in populations of schoolchildren, depending on traditional logistic regression methods. However, holistic machine learning (ML) approaches are emerging that may provide a more comprehensive analysis of risk factors.

Methods

This study employed feature selection and association rule learning ML methods in conjunction with logistic regression on epidemiological survey data from 1,036 Ethiopian school children. Our first analysis used the entire dataset and then we reran this analysis on age, residence, and sex population subsets.

Results

Both logistic regression and ML methods identified older childhood age as a significant risk factor, while females and vaccinated individuals showed reduced odds of stunting. Our machine learning analyses provided additional insights into the data, as feature selection identified that age, school latrine cleanliness, large family size, and nail trimming habits were significant risk factors for stunting, underweight, and thinness. Association rule learning revealed an association between co-occurring hygiene and socio-economical variables with malnutrition that was otherwise missed using traditional statistical methods.

Discussion

Our analysis supports the benefit of integrating feature selection methods, association rules learning techniques, and logistic regression to identify comprehensive risk factors associated with malnutrition in young children.

Evolution of nutritional status and associated factors among formula-fed infants with cow's milk protein allergy in a government program

BACKGROUND

Cow's milk protein allergy (CMPA) is a common allergy in infants and can affect proper growth and development. This study verified factors associated with the evolution of the nutritional status (NS) among infants with CMPA fed with hypoallergenic formulas (HF).

METHODS

This is a longitudinal study of infants (n = 1036) participating on a governmental program in Brazil. Researchers assessed Nutritional status before HF treatment (T1) and after HF treatment (T2). The causality of exposure variables on the evolution of NS was verified by Multinomial Logistic Regression (MLR).

RESULTS

We observed an increase in anthropometric indexes analyzed with statistically significant results (p < 0.01). The weight/age and height/age scores showed a significant reduction in infants with nutritional deficit. The Body Mass Index (BMI) showed a decrease in the number of infants with nutritional deficit (< -2 z-score). On the other hand, there was an increase in those classified as at risk of overweight, overweight and obese. MLR showed that those who remained < 12 months in the program had a lower odds ratio (95% CI = 0.355-0.906; p = 0.018) to have inadequate NS with increasing BMI. Preterm infants were 4 times more likely (CI 95% = 1.520-10.694; p = 0.005) to have their BMI decreased and those who received nutritional counseling had a lower odds ratio (CI 95% = 0.411-0.953; p = 0.029) to maintain adequate NS.

CONCLUSION

The program has a significant impact on the NS of infants with CMPA. The constant management and implementation of differentiated criteria according to the evolution of NS for the supply of HF is fundamental in the continuity of this public policy.

The significance of MUAC z-scores in diagnosing pediatric malnutrition: A scoping review with special emphasis on neurologically disabled children

This review by a panel of pediatric gastroenterology-hepatology-nutrition and pediatric neurology experts aimed to address the significance of mid-upper arm circumference (MUAC) assessment in diagnosis of pediatric malnutrition. Specifically, the potential utility of recently developed MUAC z-score tape in clinical practice for larger patient populations was addressed including the neurologically disabled children. In accordance with the evidence-based data, four statements were identified by the participating experts on the utility of MUAC z-score tape, including (1) MUAC z-scores correlate with body mass index (BMI) and weight for height/length (WFH/l) z-scores in diagnosing malnutrition; (2) MUAC z-score tape offers a higher sensitivity to diagnose the mild and moderate malnutrition and better ability to track the changes in nutritional status over time than the other single datapoint measurements; (3) Using single-step MUAC z-score tape in children with cerebral palsy (CP) seems to provide more reliable data on anthropometry; and (4) The clinical value of the tool in classifying secondary malnutrition in CP should be investigated in large-scale populations. In conclusion, enabling single-step estimation of nutritional status in a large-scale pediatric population regardless of age and within a wide range of weight, without formal training or the need for ancillary reference charts and calculators, MUAC z-tape offers a favorable tool for easier and earlier diagnosis of pediatric malnutrition. Nonetheless, further implementation of MUAC z-score screening in larger-scale and/or special populations is necessary to justify its utility in relation to other primary anthropometric indicators in diagnosis of malnutrition as well as in treatment monitoring in the community and hospital setting.

Proximity matrix indicates heterogeneity in the ability to face child malnutrition and pandemics in Brazil: An ecological study

Background

Among the social inequalities that continue to still surpasses the basic rights of several citizens, political and environmental organizations decisively "drag" the "ghost" of hunger between different countries of the world, including Brazil. The COVID-19 pandemic has increased the difficulties encountered in fighting poverty, which has led Brazil to a worrying situation regarding its fragility in the fight against new pandemics.

Objectives

The present study aims to estimate, compare, and report the prevalence of mortality due to child malnutrition among the macro-regions of Brazil and verify possible associations with the outcome of death by COVID-19. This would identify the most fragile macro-regions in the country with the greatest need for care and investments.

Methods

The prevalence of mortality was determined using data from the federal government database (DataSus). Child malnutrition was evaluated for the period from 1996 to 2017 and COVID-19 was evaluated from February to December 2020. The (dis)similarity between deaths from malnutrition and COVID-19 was evaluated by proximity matrix.

Results

The North and Northeast regions have above average number of deaths than expected for Brazil (p < 0.05). A prospective analysis reveals that the distribution of the North and Northeast macro-regions exceeds the upper limit of the CI in Brazil for up to the year 2024 (p < 0.05). The proximity matrix demonstrated the close relationship between deaths from COVID-19 and malnutrition for the Northern region followed by the Northeast region.

Conclusions

There are discrepancies in frequencies between macro-regions. Prospective data indicate serious problems for the North and Northeast regions for the coming years. Therefore, strategies to contain the outcome of health hazards must be intensified in the macro-regions North and Northeast of the country.

Low calf circumference can predict nutritional risk and mortality in adults with metabolic syndrome aged over 80 years

BACKGROUND

Metabolic disorders and malnutrition are a double burden worldwide. The aim was to determine whether low calf circumference (CC) could predict nutritional risk and the cut-off values of CC for predicting nutritional risk in metabolic syndrome (MetS) patients aged over 80 years. We aimed to evaluate the risk factors for predicting mortality in MetS.

METHODS

A total of 514 patients aged over 80 years with MetS were enrolled and followed for 2.5 years. On admission, demographic data, CC, and laboratory parameters were obtained. Patients with a Nutritional Risk Screening 2002 (NRS 2002) total score ≥ 3 were considered to have nutritional risk.

RESULTS

The CC level was significantly lower in the nutritional risk group than in the non-nutritional risk with MetS group (27.1 ± 4.0 cm vs. 30.8 ± 3.9 cm). Logistic regression analysis of nutritional risk revealed that increasing CC (adjusted OR, 0.81; 95% CI, 0.74-0.88) was an independent protective factor against nutrition risk. The best CC cut-off value for predicting nutritional risk according to the NRS 2002 was 28.8 cm. Cox regression multivariate models showed nutritional risk (HR, 2.48; 95% CI, 1.22-5.04) and decreased CC (HR, 2.78; 95% CI, 1.27-5.98) remained independent risk factors for mortality.

CONCLUSION

Decreased CC could predict not only nutritional risk but also mortality in MetS patients aged over 80 years. The elderly who had MetS with nutritional risk should be discovered early, early intervention and early treatment. CC may be a valuable index to screen out this population.

When Reality and Research Collide: Guidelines Are Essential for Optimal Nutrition Care in Pediatric Oncology

Nutritional problems are common in pediatric oncology due to the side effects of the disease and treatment. Nutrition intervention can be challenging, and little is known about the current clinical practice of registered dietitian nutritionists. An online questionnaire emailed to members of the pediatric, oncology nutrition, and clinical manager practice groups of the Academy of Nutrition and Dietetics, consisted of items related to current nutrition practice. Our questionnaire results suggest that the field of pediatric oncology is employed with relatively new dietitians (62% had <5 y of experience). Many registered dietitian nutritionists (60%) are providing care across the cancer care continuum (standard therapy, transplant, and survivorship) versus specializing in a particular area. Approximately half (52%) felt that their center had inadequate staffing, many reporting little in the outpatient setting. Barriers to providing optimal patient care included inadequate staffing, lack of time for research initiatives, and lack of evidence-based guidelines. Future studies should determine follow-up guidelines and appropriate staffing ratios for nutrition care in pediatric oncology. Approaches should be developed to support less experienced dietitians. Collaboration between dietitians at different facilities will likely be key in developing essential evidence-informed guidelines.

Severe Hypernatremia in a Significantly Underweight Female Child

In this study, we present the case of a 5-year-old female who presented for evaluation of dehydration with labs that revealed significant hypernatremia concerning for diabetes insipidus (DI). Further evaluation revealed that she had underlying chronic malnutrition. Her diagnostic work up for DI produced some evidence consistent with DI while other data indicated otherwise, bringing up the possibility of partial DI. She was ultimately diagnosed with sporadic vasopressin release secondary to her chronic malnutrition. This case illustrates another effect chronic malnutrition can have on pediatric patients along with the importance of a broad differential for patients with severe hypernatremia.

Is overweight/obesity a risk factor for atopic allergic disease in prepubertal children? A case-control study

OBJECTIVES

It is unclear whether body weight status (underweight/normal weight/overweight/obese) is associated with allergic disease. Our objective was to investigate the relationship between body weight status (body mass index; BMI) and atopic allergic disease in prepubertal children, and to compare children with atopic allergic diseases with non atopic healthy children.

METHODS

A prospective cross sectional study of 707 prepubertal children aged 3-10 years was performed; the participants were 278 atopic children with physician-diagnosed allergic disease (allergic rhinitis and asthma) (serum total IgE level >100 kU/l and eosinophilia >4%, or positivity to at least one allergen in skin test) and 429 non atopic healthy age- and sex-matched controls. Data were collected between December 2019 and November 2020 at the Pediatric General and Pediatric Allergy Outpatient Clinics of Bezmialem Vakıf University Hospital.

RESULTS

Underweight was observed in 11.6% of all participants (10.8% of atopic children, 12.2% of healthy controls), and obesity in 14.9% of all participants (18.0% of atopic children, 12.8% of controls). Obese (OR 1.71; 95% CI: 1.08-2.71, p=0.021), and overweight status (OR 1.62; 95% CI: 1.06-2.50, p=0.026) were associated with an increased risk of atopic allergic disease compared to normal weight in pre-pubertal children. This association did not differ by gender. There was no relationship between underweight status and atopic allergic disease (OR 1.03; 95% CI: 0.63-1.68, p=0.894).

CONCLUSIONS

Overweight and obesity were associated with an increased risk of atopic allergic disease compared to normal weight among middle-income and high-income pre pubertal children living in Istanbul.

Effects of Cashew Nut (Anacardium occidentale L.) Seed Flour in Moderately Malnourished Children: Randomized Clinical Trial

The monitoring and combined use of dietary supplements to restore adequate growth are paramount and highly recommended in child malnutrition, an important public health problem. The objective of this study was to analyze the effects of cashew nut seed flour in children with moderate malnutrition, treated at primary healthcare services. This is a randomized clinical trial conducted from April to October 2017 in the city of Imperatriz, Brazil. The sample comprised 30 children born at term, aged between 2 and 5 years, and newly diagnosed with malnutrition (60 days or less), randomized into experimental and control groups. The intervention consisted of daily intake of cashew nut seed flour. There was intragroup statistically significant difference in the glucose levels of children who were assigned to the control group (p=0.02) and in the glycated hemoglobin in the experimental group (p < 0.01). Intergroup analysis of glycated hemoglobin levels showed statistically significant differences in favor of the experimental group (p=0.01). HDL and LDL had, respectively, increased and decreased in the experimental group. The use of cashew nut seed flour in a 24-week period had positive effects on glycated hemoglobin, HDL, and LDL parameters in moderately malnourished children.

A New Approach to Comprehensive Growth and Nutrition Assessment in Children

A new approach to comprehensive growth and nutrition assessment of infants, children, and adolescents that is etiology based and relatively simple to implement is now available. It encompasses five domains: anthropometry (growth measurements), assessment of change in growth (growth dynamism), duration of the growth abnormalities, etiology of the nutritional imbalance, and impact of the nutritional state on functional outcomes. Its increased use will help to standardize the screening, diagnosis, and documentation of malnutrition in both ambulatory and hospitalized patients. [Pediatr Ann. 2019;48(11):e425-e433.].

Malnutrition in Children With Chronic Disease

Malnutrition occurs when nutrient intake does not meet the needs for normal body functions and as a consequence leads to alterations of growth and development in children. Chronic illness puts children at risk for developing malnutrition. Because of children's rapid periods of growth and development, early diagnosis, prevention, and management of malnutrition are paramount. The reasons for malnutrition in children with chronic disease are multifactorial and are related to the underlying disease and non-illness-associated factors. This review addresses the causes, evaluation, and management of malnutrition in pediatric congenital heart disease, chronic kidney disease, liver disease, and cystic fibrosis.

Malnutrition Risk in Hospitalized Children: A Descriptive Study of Malnutrition-Related Characteristics and Development of a Pilot Pediatric Risk-Assessment Tool

BACKGROUND

Underrecognition of pediatric malnutrition may affect nutrition interventions and outcomes. Pediatric malnutrition uses more specific etiology-based criteria but lacks clarity in implementation guidelines. Study goals were to identify malnutrition and risk among hospitalized patients, characterize malnutrition risk factors, and assess reliability of criteria against outcome measures.

MATERIALS AND METHODS

All children 44 weeks postmenstrual age-18 years, admitted for 48 hours during a 16-day period, were included (n = 528). Trained dietitians assessed patients in physical assessments (PA), growth, energy intake, increased nutrient losses (IL), altered absorption of nutrients (AA), hypermetabolism and inflammation, laboratory information, micronutrient deficiency, and functional status. Outcome data assessed were length of stay (LOS), intensive care unit (ICU) LOS, ventilation days, nutrition support, and dietitian intervention.

RESULTS

Malnutrition prevalence upon admission was 19.7%. Weight/length or BMI/age z-score (ZS) had no effect on LOS. AA and IL upon admission were independently associated with malnutrition (both, P<.01). Wasting and hypermetabolism were independently associated with longer LOS (P<.01). Other factors associated with longer LOS included IL and inflammation (P < .05). Those with hypermetabolism had significant ZS improvements if followed by a dietitian (P < .05). Wasting via PA was the only factor associated with longer ICU LOS (P < .05).

CONCLUSIONS

Identification of risk factors (wasting, hypermetabolism, AA, IL) beyond anthropometrics to define malnutrition and risk is important in prioritizing care in a tertiary pediatric facility. Of great significance is the ability of dietitian-based PA to predict LOS and need for intervention.

Screening tools for paediatric malnutrition: are we there yet?

PURPOSE OF REVIEW

The development of nutritional screening tools has done much to raise the profile of nutrition and encourage healthcare practitioners to consider how to identify children at nutritional risk. However, the next challenge is to ensure nutritional screening accurately identifies those who have immediate and ongoing risk and therefore the potential to impact on it.

RECENT FINDINGS

In this article, we review recent evidence which suggests that the large-scale use of these tools outside of a research setting is not always helpful. Most are highly sensitive but not particularly specific and therefore cases may be 'overdiagnosed' but also missed. It may therefore be time for nutritional screening to evolve into a process which is able to better consider the cause of risk and requirements for nutrition support with referral criteria, defined goals and outcome measures and exit criteria using a 'measure, plot, think, act' approach embedded into physician rounds. Key challenges relate to improving compliance around nutritional screening within the hospital setting and comparison of nutrition risk between centres, as well as an understanding of the barriers which prevent nutritional screening and assessment from occurring.

SUMMARY

It remains to be elucidated as to whether returning to a process which embeds nutritional assessment within the medical review rather than relying on a 'nutrition score' from a screening tool is a more effective way in which to identifying those patients that are malnourished or at risk of malnutrition during their hospital stay.