Nutrition considerations in the transgender and gender-diverse patient

The nutrition professional is increasingly providing care to individuals who identify as transgender. However, there are few definitive guidelines on providing medical nutrition care to this population. It is becoming better understood that this population is at elevated nutrition risk secondary to significant health disparities. More recently, the increasing prevalence of gender-affirming medical intervention has resulted in uncertainty when providing medical nutrition assessments and therapies, as many standardized guidelines and assessment tools are sex-specific. This review aims to provide clarity in exploring various gender-affirming methods to providing nutrition care to the transgender and gender-diverse population.

Are dietitian recommendations followed? A descriptive study of paediatric hospitalised and ambulatory patients

BACKGROUND

The primary objective of this cross-sectional retrospective study was to describe the implementation of dietitian prescribed nutrition recommendations in malnourished paediatric patients in the hospital and ambulatory settings. We also aimed to investigate other characteristics that could be associated with differences in implementation.

METHODS

Data were collected from 186 hospitalised and 565 ambulatory patients between February 2020 and January 2021. Data included age, hospital or ambulatory specialty departments, primary diagnosis, malnutrition status, hospital length of stay (LOS), and medical nutrition therapy recommendations. Implementation by the medical team in the hospital setting and adherence by the family in the outpatient setting were categorised as "Full", "Partial" or "None". "Partial" and "None" were combined for analysis.

RESULTS

Dietitian prescribed recommendations were implemented in 79.6% of hospitalised patients. In the ambulatory population, 46.4% of patients were adherent with nutrition recommendations. Within the hospital, there was a significant difference in implementation of nutrition recommendations based on age (p = 0.047), hospital department (p = 0.002) and LOS (p = 0.04), whereas, in the ambulatory population, there were no significant differences in the rate of adherence among any of the studied characteristics.

CONCLUSIONS

Dietitian recommendations are frequently implemented in the hospital, whereas adherence to such recommendations is poor in the outpatient population. Interventions to improve adherence to nutrition recommendations in the ambulatory setting are needed.

Electronic health record time-tracking provides real-time data to measure and benchmark dietitian productivity

BACKGROUND

Traditional methods for benchmarking dietitian productivity are time-consuming and fail to accurately measure the total time spent providing nutrition care. An electronic health record (EHR)-based tool that allows for daily tracking of both face-to-face and patient care coordination time for dietitians was created. We assessed whether it provided consistent, continuous measurement of time and productivity.

METHODS

This tool was created in an independent paediatric academic healthcare system in the USA. Time spent by dietitians in face-to-face settings and care coordination were tracked. Changes in time spent between the years 2013-2016 versus 2018-2019 were also analysed.

RESULTS

The outpatient dietitian spent a mean total of 66.4 min per patient (37.8 ± 6.0 min in face-to-face care and 28.6 ± 5.2 min in care coordination). The total times and fractions spent on face-to-face and care coordination time varied by specialty. Comparison of the two periods of time revealed 75% more productivity on average of dietitians in different outpatient settings after including care coordination tracking. In addition, dietitians were more likely to document time spent in 5-min increments after the institution of this methodology as opposed to 15-min increments.

CONCLUSIONS

An EHR-based tool that facilitates the documentation of both face-to-face time and patient care coordination time is feasible and enables consistent, continuous measurement of time and productivity. The real-time data from this tool can be used to support adequate dietitian staffing and be used to create a multicentre database to measure the actual time dietitians need to provide care and generate consistent staffing benchmarks.

Perioperative nutrition in the setting of pediatric inflammatory bowel disease

BACKGROUND

Optimization of nutrition prior to inflammatory bowel disease (IBD)-related surgery could improve outcomes. The aim of this study was to assess the perioperative nutrition status and management of children undergoing intestinal resection for treatment of their IBD.

METHODS

We identified all patients with IBD who underwent primary intestinal resection. We identified malnutrition using established criteria and methods of nutrition provision at various time points (preoperative outpatient evaluation, admission, and postoperative outpatient follow-up) for elective cases (who underwent their procedure at a scheduled admission) and urgent cases (who underwent an unplanned surgical intervention). We also recorded data on postsurgical complications.

RESULTS

A total of 84 patients were identified in this single-center study (male sex: 40%, mean age: 14.5 years, Crohn's disease: 65%). Thirty-four patients (40%) had some degree of malnutrition. Prevalence of malnutrition in the urgent and elective cohorts was similar (48% vs 36%; P = 0.37). Of these patients, 29 (34%) were noted to be on some type of nutrition supplementation prior to surgery. Postoperatively, BMI z scores increased (-0.61 vs -0.42; P = 0.0008), but the percentage of patients who were malnourished did not change from preoperative status (40% vs 40%; P = 0.10). Despite this, use of nutrition supplementation was only noted in 15 (17%) patients at postoperative follow-up. Complications were not associated with nutrition status.

CONCLUSION

Utilization of supplemental nutrition decreased postprocedure despite no change in malnutrition prevalence. These findings support the development of a pediatric-specific perioperative nutrition protocol in the setting of IBD-related surgery.

Implementation and participation of an online nutrition curriculum for pediatric gastroenterology fellows

Our team of nutrition experts developed an online nutrition curriculum consisting of 21 modules to serve as a resource for a stand-alone nutrition curriculum or as a supplement to existing nutrition electives during the Pediatric Gastroenterology fellowship. From April 2020 through January 2023, 2090 modules were completed by 436 fellows from 75 different programs across North America. The program was accessed most during tight restrictions on in-person learning during the COVID-19 pandemic. Overall, participants posttest scores improved from baseline pretest scores indicating retention of information from the modules. The overall success of this program suggests that there should be continued efforts to develop and offer online learning opportunities in clinical nutrition. There is an opportunity to expand the audience for the curriculum to include pediatric gastroenterologists from across the globe.

A Cross-Sectional Study of Pediatric Feeding Disorder in Children with Cystic Fibrosis

BACKGROUND

The exact prevalence of feeding problems in children with cystic fibrosis (CF) is unknown. Pediatric feeding disorder (PFD) encompasses poor oral intake with associated medical, nutrition, psychosocial, or feeding skill dysfunction. We hypothesized that PFD is common in CF and aimed to categorize feeding dysfunction across various domains in children with CF.

METHODS

An observational cross-sectional study was conducted in children with CF. Data collected included anthropometrics, nutrition data (including need for tube feeding/enteral nutrition [EN] or high-energy beverages, dietary diversity), feeding skills (Pediatric version of the Eating Assessment tool [pEAT]), and psychosocial function (About Your Child's Eating questionnaire [AYCE] in children 2-17 years of age/Behavioral Pediatric Feeding Assessment Scale [BPFAS] in children 12-23 months of age). PFD was defined as poor oral intake with: (a) pEAT score > 5; and/or (b) AYCE or BPFAS score > 2 standard deviation of normative controls; and/or (c) nutrition dysfunction (body mass index/weight-for-length z score < -1 and/or preference of oral high energy beverages or dependence on EN and/or decreased dietary diversity).

RESULTS

Of 103 children in the study, 62 (60.1%) had PFD, 7 children (6.8%) were malnourished, 10 needed EN (9.7%), and 30 (29.1%) needed oral high-energy beverages. Dietary diversity was decreased in 42 children (41.5%), 1 child had feeding skill dysfunction, and 11 (10.8%) met criteria for psychosocial dysfunction.

CONCLUSION

Almost 2/3rd of children with CF have PFD and many have poor dietary diversity. A significant percentage of children rely on EN and oral supplements, but psychosocial dysfunction is less prevalent.

Thickness of commercial blenderized formulas adversely affects successful delivery via enteral feeding pumps

BACKGROUND

There has been a renewed focus on offering commercial formulas made with real-food ingredients because of their perceived health benefits, such as improved feeding tolerance and gut health. Children receiving enteral nutrition through these formulas often are fed via feeding pumps. Because these formulas vary in thickness, we aimed to explore the relationship between formula thickness and prescribed formula delivery via feeding pumps. We hypothesized that inaccurate volumes of commercial blenderized formula (CBF) are delivered via feeding pumps and that these inaccuracies are directly proportional to the thickness of the formula.

METHODS

We performed International Dysphagia Diet Standardisation Initiative (IDDSI) tests for six de-identified CBFs. We then ran these formulas over three feeding pumps using nasogastric and gastric tubes and simulated continuous and bolus feeds. We calculated the difference between programmed volume and actual delivered volume.

RESULTS

Moderate and extremely thick formulas (IDDSI level 3-4) delivered a median of 22.5% less volume than programmed in the pump (P < 0.001). In addition, there was a 25.5% reduction in delivered volume for thick formulas compared with thin formulas. This occurred despite using the manufacturer's recommendations for suggested tube size.

CONCLUSION

Thicker CBF can provide inaccurate volumes via feeding pumps, which may contribute to poor weight gain when children are switched to these formulas. Based on these findings, we recommend best practices for using these formulas. More studies are needed to investigate the best formula consistency to optimize delivery and caloric intake.

Current topics in pediatric enteral nutrition safety

Enteral nutrition is a cornerstone of nutrition support therapy in patients of all ages and across the care continuum. Safe delivery of enteral nutrition to patients is paramount. This review article will focus on current topics in enteral nutrition safety primarily in children including safety with home-made blenderized feeds, recent infant and enteral formula shortages largely due to formula contamination at the manufacturer level, and concerns with importing infant formulas.

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.

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.

Evaluation and Management of Reduced Dietary Diversity in Children with Pediatric Feeding Disorder

Pediatric Feeding Disorder, a common problem in children, is commoner in children with various developmental disorders. Children with pediatric feeding disorder can have food selectivity and lack dietary diversity (DD). In this paper, an understanding of DD in these children is provided along with a dietary diversity index that can be helpful in measuring and understanding the risks posed by this lack of DD. An overview of a management strategy to address decreased DD is proposed. In these children, improving DD can improve growth, micronutrient status, long-term metabolic health, and potentially quality of life.

Toward Better Understanding of Pediatric Feeding Disorder: A Proposed Framework for Patient Characterization

To establish a foundation for methodologically sound research on the epidemiology, assessment, and treatment of pediatric feeding disorder (PFD), a 28-member multidisciplinary panel with equal representation from medicine, nutrition, feeding skill, and psychology from seven national feeding programs convened to develop a case report form (CRF). This process relied upon recent advances in defining PFD, a review of the extant literature, expert consensus regarding best practices, and review of current patient characterization templates at participating institutions. The resultant PFD CRF involves patient characterization in four domains (ie, medical, nutrition, feeding skill, and psychosocial) and identifies the primary features of a feeding disorder based on PFD diagnostic criteria. A corresponding protocol provides guidance for completing the assessment process across the four domains. The PFD CRF promotes a standard procedure to support patient characterization, enhance methodological rigor, and provide a useful clinical tool for providers and researchers working with these disorders.

Novel Pediatric Height Outlier Detection Methodology for Electronic Health Records via Machine Learning With Monotonic Bayesian Additive Regression Trees

OBJECTIVE

To create a new methodology that has a single simple rule to identify height outliers in the electronic health records (EHR) of children.

METHODS

We constructed 2 independent cohorts of children 2 to 8 years old to train and validate a model predicting heights from age, gender, race and weight with monotonic Bayesian additive regression trees. The training cohort consisted of 1376 children where outliers were unknown. The testing cohort consisted of 318 patients that were manually reviewed retrospectively to identify height outliers.

RESULTS

The amount of variation explained in height values by our model, R2 , was 82.2% and 75.3% in the training and testing cohorts, respectively. The discriminatory ability to assess height outliers in the testing cohort as assessed by the area under the receiver operating characteristic curve was excellent, 0.841. Based on a relatively aggressive cutoff of 0.075, the outlier sensitivity is 0.713, the specificity 0.793; the positive predictive value 0.615 and the negative predictive value is 0.856.

CONCLUSIONS

We have developed a new reliable, largely automated, outlier detection method which is applicable to the identification of height outliers in the pediatric EHR. This methodology can be applied to assess the veracity of height measurements ensuring reliable indices of body proportionality such as body mass index.

Nasogastric Bridles are Associated with Improved Tube-Related Outcomes in Children

OBJECTIVE

To compare tube-related outcomes in children with standard tape versus nasal bridle securement of nasogastric tubes (NGTs).

STUDY DESIGN

Single-center, retrospective, correlational study of outcomes from the time of NGT placement until full oral feeds or durable-tube placement. Outcomes of interest included NGT dislodgements, length of stay, emergency department (ED) encounters, radiographic exposures, and adverse skin outcomes. Negative binomial regression and logistic regression were used to analyze differences between groups.

RESULTS

582 children had NGTs secured traditionally [43% female; age at therapy initiation 2.6 months (SD 8.1)] and 173 received nasal bridles [55.5% female; age at therapy initiation 8.4 months (SD 11.8)]. Children with bridled NGTs were 16.67 times less likely to experience ≥1 dislodgement (OR=0.06, 95% CI 0.04, 0.09); 2.5 times less likely to have one more ED visit (OR=0.4, 95% CI 0.19, 0.82), and 4.76 times less likely to require one more radiographic exposure (OR=0.21, 95% CI 0.14, 0.33) than their non-bridled NGT counterparts (all p values <0.02). The mean initial hospital length of stay was 28 and 54 days in the bridled and standard care group respectively (p<0.001). Overall, 62.4% children with bridled NGTs and 77.1% children with unbridled NGTs progressed to full oral feedings and required no further therapy (p<0.001). Adverse skin outcomes were rare in both groups.

CONCLUSION

Children with bridled NGTs experienced fewer dislodgements, days in the hospital, ED encounters, and radiographic exposures than children with traditionally secured NGTs. The majority of children in both groups progressed to full oral feedings. This article is protected by copyright. All rights reserved.

Energy- and protein-enriched formula improves weight gain in infants with malnutrition due to cardiac and non-cardiac etiologies

Background

We aimed to assess safety, tolerability, and improvement in weight gain with an energy‐ and protein‐enriched formula (EPEF) in infants with poor growth.

Methods

Infants aged 1–8 months with poor growth received EPEF for 16 weeks. Our primary objective was improvement in weight as measured by change in weight‐for‐age z‐score (WAZ) and weight gain velocity (grams per day) ≥ median for age. Secondary objectives included improvement in other anthropometric z‐scores, formula tolerance, and safety.

Results

Twenty‐six patients with poor growth due to congenital heart disease (n = 15), other organic causes (n = 9), and nonorganic causes (n = 2) completed the study per protocol. Mean daily energy intake was 123 ± 32 kilocalories per kilogram of body weight, with >90% of energy coming from EPEF. Weight gain velocity exceeded the median for 83% (20 of 24) and 67% (16 of 24) of infants at ≥1 time point and for the overall study period, respectively. Mean ± SD WAZ improved from −2.92 ± 1.04 at baseline to −2.01 ± 1.12 at 16 weeks (P = 0.0001). Z‐scores for weight‐for‐length and head circumference (P = 0.0001) and for length‐for‐age (P = 0.003) improved significantly at 16 weeks. Compared with baseline, stool consistency was different at 2, 4, and 16 weeks (P < 0.05). There were no significant differences in vomiting, fussiness, or daily number of stools while there was a decrease or no change in spit‐up, flatulence, crying, or gassiness.

Conclusion

EPEF is safe, well tolerated, and improves weight gain in infants with poor growth.

Texture Consumption Patterns of 8- to 12-Month-Old Infants: A Reflection of Typical Feeding Development

Purpose The lack of age-appropriate expectations for the acquisition of feeding skills and consumption of textured food in early childhood inhibits early and accurate identification of developmental delay in feeding and pediatric feeding disorder. The objective of this study was to describe texture intake patterns in a cohort of typically developing infants between 8 and 12 months of age, with the aim of informing future research to establish targets for feeding skill acquisition. Method Using cross-sectional methodology, we studied the presence of liquid and solid textures and drinking methods in the diet, consumption patterns by texture and drinking methods, and caloric intake by texture via caregiver questionnaire and 3-day dietary intake record in 63 healthy infants between 8 and 12 months of age. Descriptive statistics and a one-way analysis of variance were conducted to compare the effect of age on texture intake patterns. Results Findings reveal rapid advancement of intake patterns for texture overall and for energy intake by texture between 8 and 12 months of age. Whereas liquids continue to provide a large proportion of total energy through this time, solids contribute an equal proportion of energy by 12 months of age. Conclusions This study describes texture intake patterns in a cohort of typically developing infants between 8 and 12 months of age by examining the presence of texture and drinking methods, liquid and solid consumption patterns, and energy intake by texture. When applied to data from a future population sample, findings will provide a threshold for age expectations for typical and disordered feeding development to aid in the detection of developmental delay in feeding and pediatric feeding disorder. What Is Known: Expectations regarding early feeding development have been focused on nutrition parameters. Lack of standardized, age-appropriate expectations for texture progression in infancy and early childhood inhibits early and accurate identification and treatment of pediatric feeding disorder. What Is New: We have described changes in dietary composition by texture and drinking method in healthy infants. Together with nutritional composition, this study describes a more comprehensive assessment of infant feeding, particularly to clinicians who need to diagnose feeding skill deficits. Supplemental Material https://doi.org/10.23641/asha.16879615.

Reining in Nasogastric Tubes: Implementation of a Pediatric Bridle Program

Nasogastric tubes (NG) used for enteral nutrition support of medically complex children (MCC) are often inadvertently removed, risking frequent replacements. Bridles have been shown to provide a safe securement method for NGs in adult patients, but are not widely used in pediatrics. Furthermore, nutritional management of MCC is often fragmented. We established a pediatric NG bridle program to bridge the gap amongst disciplines and improve patient outcomes. In January 2018, a multidisciplinary work group involving nurses, physicians, clinical dietitians, advanced practice providers, and speech-language pathologists was established to develop criteria for patient referral and policies, procedures, and order sets for nutritional management of MCC children with bridled NG tubes. Formal teaching sessions engaged clinicians and administrators to participate in building a successful program. Relevant outcomes of interest are tracked continuously for process performance improvement measures and are reviewed quarterly by the core work group. Patient enrollment began in May 2018 and to date, 244 patients have been enrolled. Adhering to strict enrollment criteria, competency modules and review of patient status provided a solid core for the program and process review. Successful implementation of an NG Bridle program was achieved. Outcomes of interest continue to be monitored for process improvement. Balancing measures are also being tracked for potential downstream effects.

Catch-down growth in infants born large for gestational age

Infants born large for gestational age (LGA) not exhibiting catch-down growth (a decline of weight z-score by 1) have a higher likelihood of future obesity. We aimed to identify the term LGA infants in our neonatal intensive care unit (NICU) and document nutrition interventions that may influence growth. Our 10-year retrospective review identified 47 term LGA infants who had a NICU length of stay (LOS) ≥7 days. We obtained demographic data, nutrition interventions in the NICU, and data regarding growth patterns. Of the 47 infants, 31 (66%), demonstrated catch-down growth at discharge at ≥7 days. Overall, 39 of 47 patients (83%) received interventions during their NICU stay, including 32 (69%) who had nasogastric tubes placed, and 24 (51%) had formula fortification to augment weight gain. Among patients with LOS ≥14 days, 23 of 23 patients without catch-down growth and four of five patients with catch-down growth had nutrition interventions performed. Of the overall population, only 38% of those who did not demonstrate catch-down growth had an LOS of ≥14 days vs 77% of all infants that did exhibit catch-down growth (P = .01). Our data suggest that nutrition interventions in LGA infants are common in the NICU. Our study highlights the need for further clinical studies to help direct care in this population of infants.

Pediatric Feeding Disorder: A Nationwide Prevalence Study

OBJECTIVE

To assess the prevalence of pediatric feeding disorder (PFD) in US children.

STUDY DESIGN

We conducted a retrospective cohort study of Medicaid Databases from Arizona (2009-2017) and Wisconsin (2005-2014) (public insurance databases) and The Truven Health Analytics MarketScan Commercial Claims and Encounters Database (2009-2015) (a nationwide private insurance database). Diagnoses and procedures were identified from inpatient and outpatient claims using the International Classification of Diseases (ICD)-9 and ICD-10 diagnostic codes and ICD and Current Procedural Terminology-4 procedure codes. Children with PFD were identified by presence of 1 or more PFD diagnosis and absence of any eating disorder diagnoses within a calendar year.

RESULTS

We identified 126 002 and 367 256 children 5 years of age or younger with PFD with public and private insurance, respectively. Over a 5-year period (2009-2014) the prevalences of PFD in children with public insurance in Arizona and Wisconsin were 32.91 (95% CI, 32.61-33.20) and 34.73 (95% CI, 34.37-35.09) children per 1000 child-years, respectively. Similarly, the prevalence of PFD in private insurance carriers was 21.07 (95% CI, 21.00-21.14) children per 1000 child-years. The prevalence trends showed a significant linear increase in children within both insurance cohorts. In 2014, the annual prevalence of PFD was 1 in 23, 1 in 24, and 1 in 37 in children under 5 years in the publicly insured cohorts in Wisconsin, Arizona, and the privately insured cohort, respectively.

CONCLUSIONS

The prevalence of feeding disorders in the US rivals that of commonly diagnosed conditions such as eating disorders and autism.

Feeding Disorders in Children With Tracheostomy Tubes

BACKGROUND

We aimed to describe feeding dysfunction in a group of children with tracheostomy.

METHODS

Single-center, retrospective chart review of all children with a tracheostomy who were evaluated by our interdisciplinary feeding program. Demographic and diagnostic data, nutrition variables, acceptance of food consistencies, as well as 2 validated psychometric instruments for assessment of feeding dysfunction were analyzed.

RESULTS

Thirteen tracheostomy-dependent children (5/13; 38% ventilator dependent) were evaluated at a median age of 51 months (interquartile range [IQR], 26-69). The majority of children (8/13; 62%) underwent evaluation after decannulation. Four children (30%) had a history of a cuffed tracheostomy tube. Eleven children (85%) used a speaking valve prior to decannulation, only 2 of whom started before initial discharge with a tracheostomy. Children with a tracheostomy had low-median weight- and height-for-age z-scores (-1.27 and -1.73, respectively), with normal-median body mass index (BMI)-for-age z-score (0.175). Children received 75% of feedings via tube feeding (IQR, 13%-97%). Compared with other children with feeding disorders, children with tracheostomy had delays in initial acceptance of most food textures and general diet, and the Mealtime Behavior Questionnaire showed significantly worse overall scores (P = .01), and the About Your Child's Eating survey showed significantly higher parental perception of resistance to eating (P = .0001).

CONCLUSION

Requirement of enteral nutrition, poor oral-feeding skills, chronic malnutrition, and worse mealtime behaviors are associated with tracheostomy. A history of ventilator dependence, cuffed tracheostomy, and inpatient speaking valve-use were infrequently associated with interdisciplinary feeding-program evaluation.

Nutritional Advancement in the Hospitalized Child After NPO: A Retrospective Cohort Study

OBJECTIVES

A clear-liquid diet is commonly used after a nil per os (NPO) order in children recovering from acute gastrointestinal (GI) illnesses. Our purpose for this study was to compare outcomes in patients receiving a clear-liquid diet after an NPO order with outcomes in those receiving a regular diet.

METHODS

In this retrospective cohort study, patients aged 1 to 18 years admitted to a tertiary care children's hospital between 2016 and 2017 were screened to identify those who had an NPO order placed for acute GI illnesses. Patients with complex medical needs, a feeding disorder, or chronic GI disorders were excluded.

RESULTS

Of 39 total patients, 17 (44%) received a clear-liquid diet after an NPO order. There was no difference in diet tolerance between patients receiving a clear-liquid diet and those receiving a regular diet on the basis of emesis in the first 12 hours (P = .40), pain scores after the first oral intake (P = .86), return to clear-liquid diet (P = .57), or return to NPO status (P > .99). Patients started on a clear-liquid diet had a longer length of stay (LOS) after diet initiation compared with those receiving a regular diet (median: 43.7 hours [interquartile range: 29.8-53.4] vs median: 20.8 hours [interquartile range 6.7-47.3]), both in the univariate analysis (P = .01) and after controlling for age, diagnosis category, and pain score before and after the first oral intake (P = .03).

CONCLUSIONS

Patients transitioned to a clear-liquid diet after NPO status have a longer LOS after the first oral intake independent of patient age, diagnosis, and pretransition abdominal pain. Both groups had similar diet tolerance, suggesting that transition to a regular diet after NPO status may decrease LOS without significant adverse effects.

Nutrition Management in Pediatric Gastrointestinal Motility Disorders

Gastrointestinal (GI) motility disorders are associated with suboptimal nutrition in children, mainly because of malabsorption and symptoms limiting dietary intake. Apart from medical therapy, nutrition support has a crucial role in maintaining growth and improving clinical outcomes in children. Based on recent data and guidelines, this review provides an overview of nutrition assessment and specific interventions for common pediatric GI disorders including gastroesophageal reflux disease, esophageal motility disorders, gastroparesis, chronic intestinal pseudo-obstruction, and constipation. Several approaches including diet modification, enteral nutrition (gastric vs post-pyloric, temporary vs permanent access, bolus vs continuous), and parenteral nutrition need to be tailored based on patient's nutrition and clinical assessment.

A clinical description of children with solid organ transplants who present with feeding disorder

Pediatric solid organ transplant recipients have long-standing malnutrition concerns related to their pretransplant medical status. The targeted nutrition therapy utilized pre-, peri-, and post-transplantation may have the adverse effect of impeding normally developing feeding skills, particularly in very young children. Little is known about the relationship between transplantation and feeding disorders of childhood. The purpose of this study was to describe severity of feeding disorder and parental stress in patients with transplant compared to children followed in a specialty feeding clinic and the general community. Sixty-four children, comprised of 32 children with solid organ transplant ages 2 months to 12 years and 32 matched control patients diagnosed with a feeding disorder without history of solid organ transplant, were reviewed. All children were from the Feeding, Swallowing, and Nutrition Clinic at a single children's hospital. Findings indicate that patients who received a transplant and presented with a feeding problem had worse symptoms of feeding disorder than are typically found in the general community. These feeding problems disrupt mealtime behavior, caregiver and child relationship within a mealtime context, and may result in maladaptive feeding strategies used by families. When transplanted children present with feeding disorders, they are severe and have multiple effects on both the child and the feeding dynamic between the child and the child's caregivers. Further investigation may help us to better understand the relationship between transplantation and symptoms of feeding disorder.

Defining Pediatric Failure to Thrive in the Developed World: Validation of a Semi-Objective Diagnosis Tool

There is no concordance between current diagnostic criteria for failure to thrive (FTT). We analyzed validity of the Semi-Objective Failure to Thrive (SOFTT) diagnosis tool, which uses a combination of subjective and objective components to make the diagnosis of FTT. The tool was used to diagnose FTT in 94 patients who met 1 of 7 accepted criteria for FTT. Concurrent and predictive validity were demonstrated using anthropometric z-scores and change in anthropometric z-scores, respectively. SOFTT results correlated with differences in anthropometric z-scores for length ( P = .011), weight, weight-for-length, body mass index, mid-upper arm circumference, and triceps skinfold thickness ( P < .0001) between those diagnosed as normal and those with FTT. At follow-up, children with FTT compared with children rated as normal had significantly higher change in weight ( P ≤ .001) and body mass index ( P = .026) z-scores. The SOFTT tool leads to the accurate diagnosis of FTT demonstrated by concurrent and predictive validity.

A Systematic Review of Micronutrient Deficiencies in Pediatric Inflammatory Bowel Disease

BACKGROUND

This systematic review critically analyzes the current research on micronutrient deficiency in children with inflammatory bowel disease (IBD) and synthesizes these data to provide evidence-based guidelines for nutritional surveillance in this population.

METHODS

We searched 5 databases (Ovid Medline, PubMed, Scopus, CINAHL, and Cochrane Library) for studies evaluating micronutrients in patients with IBD using the following inclusion criteria: 1) original research, 2) published 1996 or later; 3) published in English; 4) human subjects; and 5) containing pediatric data. Studies were reviewed and included based on the strength of research methods. Data on the prevalence of micronutrient deficiencies in pediatric patients with IBD and risk factors for micronutrient deficiency in these patients were extracted from included studies and compared and discussed in preparation of the proposed guidelines and manuscript.

RESULTS

A total of 39 studies were included in the final review. The data presented in these studies show that iron deficiency and vitamin D deficiency are common in pediatric patients with IBD. Vitamin B12 and folate deficiency are rare. Zinc deficiency, while not common, occurs at a higher rate in patients with Crohn's disease than in healthy controls. There was limited data on vitamins A, E, and C, and selenium, but deficiency of these micronutrients seems rare.

CONCLUSIONS

We recommend annual surveillance of iron and vitamin D in pediatric patients with IBD regardless of disease activity or phenotype. Zinc should be monitored annually in patients with Crohn's disease. There is insufficient evidence to support routine screening for other micronutrient deficiencies.

Systematic Review of Hypersensitivity to Parenteral Nutrition

Hypersensitivity to the components of parenteral nutrition (PN) is a rare but important complication of PN. We performed a systematic review of hypersensitivity to PN to enable us to build an approach to the individual patient who presents with PN hypersensitivity. A systematic literature search was performed in Ovid Medline, CINAHL, Scopus, and Web of Science using terms for "hypersensitivity" AND "parenteral nutrition" and relevant synonyms. A total of 28 articles were analyzed, and 33 hypersensitivities to PN or components of PN were reported in these 28 articles. Reports of hypersensitivity and subsequent conclusions were based on the clinical observations made by each reporting author. These reactions were evenly split between pediatric and adult patients. Hypersensitivity to PN occurred on day of starting PN in 60.6% patients and after that time in 36.3% patients (range: 1-21 days). Of the hypersensitivities that occurred on day 1 of PN, 70% occurred in the first 30 minutes of initiation of PN. Cutaneous manifestations were the most common, followed by anaphylaxis, respiratory symptoms, and hemodynamic instability. The components most frequently identified as allergens were intravenous fat emulsion (48.4%), multivitamin solution (33.3%), and amino acid solution (9%). Based on this review, an algorithm was created to guide the practitioner on management of PN after the occurrence of such a reaction.

Early Enteral Nutrition Is Associated With Significantly Lower Hospital Charges in Critically Ill Children

BACKGROUND

Previous studies have shown that early enteral nutrition (EEN) is associated with lower mortality in critically ill children. The purpose of this study was to determine the association between EEN (provision of 25% of goal calories enterally over the first 48 hours) and pediatric intensive care unit (PICU) and hospital charges in critically ill children.

METHODS

We conducted a supplementary study to our previous multicenter retrospective study of nutrition and outcomes in critically ill patients who had a PICU length of stay (LOS) ≥96 hours for the years 2007-2008. From 2 centers, we obtained additional data for all charges incurred during the PICU and hospital stay, respectively, from administrative data sets at each institution.

RESULTS

We obtained data for 859 patients who met the inclusion criteria (615 from the first center and 244 from the second center). In the combined data from both centers, total (P = .0006, adjusted for Pediatric Index of Mortality-2 [PIM-2] and center) and daily hospital charges (P < .001, adjusted for PIM-2 and center) were significantly lower in patients who met the EEN goal than in patients who did not. Hospital LOS did not differ between patients who met the EEN goal and patients who did not. A significant interaction between EEN and centers prevented any comparison of PICU charges, daily PICU charges, and PICU LOS between those patients who met the EEN goal and those who did not.

CONCLUSION

In critically ill children who stay in the PICU >96 hours, EEN is associated with significantly lower hospital charges.

Laboratory Monitoring of Children on Home Parenteral Nutrition: A Prospective Study

BACKGROUND

The primary hypothesis of this article is that a team approach in creating a protocolized laboratory monitoring schedule for home parenteral nutrition (PN) patients improves patient safety by decreasing the occurrence of nutrition deficiencies and is cost-effective.

METHODS

In this prospective cohort study of home PN patients, each patient followed an established protocol of laboratory monitoring and weekly review by an interdisciplinary team of dietitians, nurses, and physicians. Data collected included anthropometric measurements, laboratory results, deviations from laboratory protocols, laboratory charges, PN shortage information, and means of ameliorating such shortages. Cost-effectiveness analysis was only performed for nonmicronutrient laboratory tests.

RESULTS

Fifteen children (male, n = 6) with a median age of 59 months (range, 19-216) were included in this study. Primary diagnoses included short bowel syndrome (47%) and intestinal pseudo-obstruction (40%). Patients received PN mixtures from 6 different infusion companies and experienced 60 different shortages in the PN formulation requiring adjustments or substitutions (mean, 4 shortages per patient). All patients had appropriate growth and complete micronutrient monitoring. No patient experienced any clinical symptoms due to shortages. The median number of laboratory draws/patient per month was 2.9 preprotocol compared with 1.14 postprotocol (P = .003). The median per patient per month charges were $2014 (interquartile range [IQR], 1471-2780) preprotocol compared with $792 (IQR, 435-1140) postprotocol (P = .002).

CONCLUSIONS

A structured team approach to laboratory monitoring of home PN patients can simplify PN management, significantly decrease monthly laboratory costs, and lead to fewer laboratory draws while improving micronutrient monitoring and preventing deficiencies.

Contemporary Dietary Practices: FODMAPs and Beyond

There is no diet that is recommended for all individuals. Some special diets (eg, gluten-free for celiac disease) are necessary for health and quality of life. Other diets may be recommended for a short period of time to aid in symptom relief but may not be recommended for the long- term (eg, LFD). Popular diets continue to come and go with varying levels of success. When considering adolescents, continued growth and development are most important, and restrictive diets can lead to nutrient inadequacies and poor growth. Before making any recommendation, it is important to consider the goal of the diet and the cost versus benefits associated with following the diet. Adherence is always a challenge, regardless of the type of diet implemented. If a special diet is not warranted for the health, safety, and desired quality of life of the individual, it should not be implemented.

Safety of Enteral Feedings in Critically Ill Children Receiving Vasoactive Agents

BACKGROUND

The objective of this retrospective study was to evaluate the safety of enteral feeding in children receiving vasoactive agents (VAs).

METHODS

Patients aged 1 month to 18 years with a pediatric intensive care unit stay for ≥96 hours during 2007 and 2008 who received any VA (epinephrine, norepinephrine, vasopressin, milrinone, dopamine, and dobutamine) were included and categorized into fed and nonfed groups. Their demographics, clinical characteristics, type and dose of VA, and presence of gastrointestinal (GI) outcomes were obtained. GI outcomes were compared between the groups by the χ(2) test, Mann-Whitney test, and logistic regression.

RESULTS

In total, 339 patients were included. Of these, 55% were in the fed group and 45% in the nonfed group. Patients in the fed group were younger (median age, 1.05 vs 2.75 years, respectively; P < .001) and tended to have a lower Pediatric Index of Mortality 2 (PIM2) risk of mortality (ROM) than those in the nonfed group (median, 3.33% vs 3.52%, respectively; P = .106). Mortality was lower in the fed group than the nonfed group (6.9% vs 15.9%, respectively; odds ratio [OR], 0.39; 0.18-0.84; P < .01, 95% CI), while GI outcomes did not differ between the groups. The vasoactive-inotropic score (VIS) did not differ between the groups except on day 1 (P = .017). The ROM did not differ between the groups after adjusting for age, PIM2 ROM, and VIS on day 1 (OR, 0.58; 0.26-1.28; P = .18, 95% CI).

CONCLUSIONS

Enteral feeding in patients receiving VAs is associated with no difference in GI outcomes and a tendency towards lower mortality. Prospective studies are required to confirm the safety of enteral feedings in patients receiving VAs.

Early enteral nutrition is associated with lower mortality in critically ill children

BACKGROUND

The purpose of this study was to examine the association of early enteral nutrition (EEN), defined as the provision of 25% of goal calories enterally over the first 48 hours of admission, with mortality and morbidity in critically ill children.

METHODS

We conducted a multicenter retrospective study of patients in 12 pediatric intensive care units (PICUs). We included patients aged 1 month to 18 years who had a PICU length of stay (LOS) of ≥96 hours for the years 2007-2008. We obtained patients' demographics, weight, Pediatric Index of Mortality-2 (PIM2) score, LOS, duration of mechanical ventilation (MV), mortality data, and nutrition intake data in the first 4 days after admission.

RESULTS

We identified 5105 patients (53.8% male; median age, 2.4 years). Mortality was 5.3%. EEN was achieved by 27.1% of patients. Children receiving EEN were less likely to die than those who did not (odds ratio, 0.51; 95% confidence interval, 0.34-0.76; P = .001 [adjusted for propensity score, PIM2 score, age, and center]). Comparing those who received EEN to those who did not, adjusted for PIM2 score, age, and center, LOS did not differ (P = .59), and the duration of MV for those receiving EEN tended to be longer than for those who did not, but the difference was not significant (P = .058).

CONCLUSIONS

EEN is strongly associated with lower mortality in patients with PICU LOS of ≥96 hours. LOS and duration of MV are slightly longer in patients receiving EEN, but the differences are not statistically significant.

Systematic review of nutrient intake and growth in children with multiple IgE-mediated food allergies

BACKGROUND

Food allergies affect up to 8% of American children. The current recommended treatment for food allergies is strict elimination of the allergens from the diet. Dietary elimination of nutrient-dense foods may result in inadequate nutrient intake and impaired growth. The purpose of this review was to critically analyze available research on the effect of an elimination diet on nutrient intake and growth in children with multiple food allergies.

METHODS

A systematic review of the literature was conducted and a workgroup was established to critically analyze each relevant article. The findings were summarized and a conclusion was generated.

RESULTS

Six studies were analyzed. One study found that children with food allergies are more likely to be malnourished than children without food allergies. Three studies found that children with multiple food allergies were shorter than children with 1 food allergy. Four studies assessed nutrient intake of children with multiple food allergies, but the inclusion and comparison criteria were different in each of the studies and the findings were conflicting. One study found that children with food allergies who did not receive nutrition counseling were more likely to have inadequate intake of calcium and vitamin D.

CONCLUSION

Children with multiple food allergies have a higher risk of impaired growth and may have a higher risk of inadequate nutrient intake than children without food allergies. Until more research is available, we recommend monitoring of nutrition and growth of children with multiple food allergies to prevent possible nutrient deficiencies and to optimize growth.

Risks and benefits of prophylactic cyclic parenteral nutrition in surgical neonates

BACKGROUND

Cyclic parenteral nutrition (PN) is used for both the treatment and prevention of parenteral nutrition-associated liver disease (PNALD). Early initiation of prophylactic cyclic PN may not be well tolerated in young neonates. Our objective was to test the hypothesis that prophylactic cyclic PN initiated prior to the onset of hyperbilirubinemia is associated with younger age at initiation, lower bilirubin levels, and similar rates of adverse events compared to therapeutic cyclic PN initiated after established cholestasis in surgical neonates.

METHODS

A retrospective review of infants with gastrointestinal disorders requiring surgical intervention who received cyclic PN 2006-2011 was performed.

RESULTS

Of the 43 infants eligible for analysis, 23 received prophylactic and 20 received therapeutic cyclic PN. Infants in both groups were comparable in demographics, surgical diagnoses, and illness severity. At initiation of cyclic PN, infants with prophylactic cyclic PN were significantly younger in chronologic (P = .003) and postmenstrual age (P = .029). Prophylactic cyclic PN was associated with a significantly lower incidence of hyperbilirubinemia (P = .001), lower maximum conjugated bilirubin (P < .0001), and lower last checked conjugated bilirubin (P = .032) compared to the therapeutic cyclic PN. The incidence of hypoglycemia, hyperglycemia, and hypertriglyceridemia was similar for the 2 groups.

CONCLUSIONS

There may be a potential benefit to initiating cyclic PN prior to the development of hyperbilirubinemia in surgical neonates. Early initiation of prophylactic cyclic PN does not appear to increase the risk for adverse events.

Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions

Lack of a uniform definition is responsible for underrecognition of the prevalence of malnutrition and its impact on outcomes in children. A pediatric malnutrition definitions workgroup reviewed existing pediatric age group English-language literature from 1955 to 2011, for relevant references related to 5 domains of the definition of malnutrition that were a priori identified: anthropometric parameters, growth, chronicity of malnutrition, etiology and pathogenesis, and developmental/ functional outcomes. Based on available evidence and an iterative process to arrive at multidisciplinary consensus in the group, these domains were included in the overall construct of a new definition. Pediatric malnutrition (undernutrition) is defined as an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes. A summary of the literature is presented and a new classification scheme is proposed that incorporates chronicity, etiology, mechanisms of nutrient imbalance, severity of malnutrition, and its impact on outcomes. Based on its etiology, malnutrition is either illness related (secondary to 1 or more diseases/injury) or non-illness related, (caused by environmental/behavioral factors), or both. Future research must focus on the relationship between inflammation and illness-related malnutrition. We anticipate that the definition of malnutrition will continue to evolve with improved understanding of the processes that lead to and complicate the treatment of this condition. A uniform definition should permit future research to focus on the impact of pediatric malnutrition on functional outcomes and help solidify the scientific basis for evidence-based nutrition practices.

Subjective global nutritional assessment in critically ill children

BACKGROUND

Underweight children admitted to the pediatric intensive care unit (PICU) have a higher risk of mortality than normal-weight children. The authors hypothesized that subjective global nutrition assessment (SGNA) could identify malnutrition in the PICU and predict nutrition-associated morbidities.

METHODS

The authors prospectively evaluated the nutrition status of 150 children (aged 31 days to 5 years) admitted to the PICU with the use of SGNA and commonly used objective anthropometric and laboratory measurements. Each child was administered the SGNA by a dietitian while anthropometric measurements were performed by an independent assessor. To test interrater reproducibility, 76 children had SGNA performed by another dietitian. Occurrence of nutrition-associated complications was documented for 30 days after admission.

RESULTS

SGNA ratings of well nourished, moderately malnourished, or severely malnourished demonstrated moderate to strong correlation with several standard anthropometric measurements (P < .05). The laboratory markers did not demonstrate any correlation with SGNA. Interrater agreement showed moderate reliability (κ = 0.671). Length of stay, pediatric logistic organ dysfunction, and Pediatric Risk of Mortality III were not significantly different across the groups and did not correlate with SGNA.

Pancreatic insufficiency in Toriello-Carey syndrome: report of a second patient

Toriello-Carey syndrome is characterized by multiple congenital anomalies. Pancreatic insufficiency is suspected when patients present with poor weight gain, diarrhea, or maldigestion. The diagnosis is confirmed by low stool elastase and pancreatic stimulation testing. To our knowledge, only one patient with Toriello-Carey syndrome has been reported to have pancreatic insufficiency. We report on a second patient with Toriello-Carey syndrome and pancreatic insufficiency, and describe the management of pancreatic insufficiency in patients with this syndrome.

Obesity is not associated with increased mortality and morbidity in critically ill children

AIM

To evaluate the effect of obesity on mortality, length of mechanical ventilation, and length of stay (LOS) in critically ill children.

METHODS

Retrospective cohort study in 2- to 18-year-olds, admitted to the pediatric intensive care unit (PICU) at the Children's Hospital of Wisconsin from 2005-2009 who required invasive ventilation. Weight z score was used to categorize patients as normal (-1.89 to 1.04), overweight (1.05-1.65), obese (1.66-2.33), and severely obese (>2.33). Underweight patients were excluded. Age, gender, admission type, Pediatric Index of Mortality 2 score, operative status, trauma status, admission Pediatric Outcome Performance Category, and diagnosis categories were also collected. The outcomes were mortality, total ventilator days, and PICU LOS. Univariate analysis was used to compare the groups, and multivariate logistic regression was used to compare mortality. Total ventilation days and LOS were modeled with linear regression.

RESULTS

In total, 1030 patients were included in the study, with 753 normal weight, 137 overweight, 76 obese, and 64 severely obese. The risk-adjusted mortality rates in overweight (odds ratio [OR], 1.06; 95% confidence interval [CI], 0.62-1.82), obese (OR, 0.68; 95% CI, 0.31-1.48), and severely obese patients (OR, 1.02; 95% CI, 0.45-2.34) were not significantly different compared with the normal-weight group. Total ventilation days (P = .9628) and PICU LOS (P = .8431) were not significantly different between the groups after adjusting for risk factors.

CONCLUSION

Critically ill overweight, obese, and severely obese children who require invasive mechanical ventilation have similar mortality, length of stay in the PICU, and ventilator days as compared with normal-weight children.

Allergic enterocolitis and protein-losing enteropathy as the presentations of manganese leak from an ingested disk battery: a case report

Introduction

Disk battery ingestions can lead to serious complications including airway or digestive tract perforation, blood vessel erosions, mediastinitis, and stricture formation.

Case presentation

We report a 20-month-old Caucasian child who developed eosinophilic enterocolitis and subsequent protein-losing enteropathy from manganese that leaked from a lithium disk battery. The disk battery was impacted in her esophagus for 10 days resulting in battery corrosion. We postulate that this patient's symptoms were due to a manganese leak from the 'retained' disk battery; this resulted in an allergic response in her gut and protein-losing enteropathy. Her symptoms improved gradually over the next 2 weeks with conservative management.

Conclusion

This is the first case report to highlight the potential complication of allergic enterocolitis and protein-losing enteropathy secondary to ingested manganese. Clinicians should be vigilant about this rare complication in managing patients with disk battery ingestions.

Acute pancreatitis in children

OBJECTIVES

Currently, there is no scoring system for predicting severity in acute pancreatitis in children. Our intent was to evaluate the performance of existing scoring systems in children, to develop a system for children, and to examine the etiology of acute pancreatitis in children.

METHODS

A chart review of children with acute pancreatitis was conducted at six centers, three serving as criterion centers and three as validation centers. Ranson and Glasgow scores were calculated for each admission. Additional clinical data were collected, and parameters correlating with severity were incorporated into a new scoring system. Performance characteristics were calculated for each system.

RESULTS

A total of 301 admissions were reviewed, 202 in the criterion group and 99 in the validation group. Eight parameters were included in a new scoring system for children. The parameters were as follows: age (<7 yr), weight (<23 kg), admission WBC (>18,500), admission LDH (>2,000), 48-h trough Ca2+ (<8.3 mg/dl), 48-h trough albumin (<2.6 g/dl), 48-h fluid sequestration (>75 ml/ kg/48 h), and 48-h rise in BUN (>5 mg/dl). When the cut-off for predicting a severe outcome was set at 3 criteria, the new system had better sensitivity versus Ranson and Glasgow scores (70% vs 30% and 35%, respectively) and a better negative predictive value (91% vs 85% and 85%). The specificity (79% vs 94% and 94%) and positive predictive value (45% vs 57% and 61%) fell slightly.

CONCLUSION

The new scoring system performs better in this group than do existing systems.