Vasopressors and Enteral Nutrition in the Survival Rate of Children During Extracorporeal Membrane Oxygenation.

OBJECTIVES: Nutrition support is essential in improving outcome and survival in children on extra corporal membranous support (ECMO). We aim to evaluate the association between the timing of enteral nutrition (EN) initiation and its impact on outcome. METHODS: We retrospectively reviewed the electronic health records of children (≤18 years) from November 2014 to November 2019 who were on veno-arterial ECMO for ≥48 hours. Abstracted data included demographics, ECMO indication and duration, timing of EN initiation, change in weight-for-age z score (WAZ), and survival rate. The vasoactive-inotropic score (VIS) was calculated to assess illness acuity. RESULTS: We identified 76 children with median age (interquartile range [IQR]) of 0.3 years (0-2.6), 46 of which were infants (59%) who required ECMO for a median (IQR) of 10 days (6-22). Thirty-six (47%) survived to hospital discharge. EN was initiated in 55 (72%) of patients while on ECMO. EN initiation by day 3 of ECMO was positively associated with survival ( P = 0.0438). VIS at the time of EN initiation was lower in surviving infants ( P = 0.022). Children who achieved enteral autonomy were more likely to survive ( P = 0.0024). Survivors had greater WAZs at ECMO completion ( P = 0.0004). CONCLUSIONS: Initiation of EN by day 3 of ECMO and at a lower VIS is associated with greater likelihood of survival.

Fluid management in hospitalized pediatric patients.

The proper use of intravenous fluids has likely been responsible for saving more lives than any other group of substances. Proper use includes prescribing an appropriate electrolyte and carbohydrate solution, at a calculated rate or volume, for the right child, at the right time. Forming intravenous fluid plans for hospitalized children requires an understanding of water and electrolyte physiology in healthy children and how different pathology deviates from the norm. This review highlights fluid management in several disease types, including liver disease, diabetic ketoacidosis, syndrome of inappropriate antidiuretic hormone, diabetes insipidus, kidney disease, and intestinal failure as well as in those with nonphysiologic fluid losses. For each disease, the review discusses specific considerations, evaluations, and management strategies to consider when customizing intravenous fluid plans. Ultimately, all hospitalized children should receive an individualized fluid plan with recurrent evaluations and fluid modifications to provide optimal care.

Transition to peptide-based diet improved enteral nutrition tolerance and decreased healthcare utilization in pediatric home enteral nutrition.

BACKGROUND: Home enteral nutrition (HEN) use continues to increase in children unable to meet nutritional needs through oral intake. Some patients do not tolerate standard polymeric formula (SPF), which may lead to malnutrition. Use of peptide-based diet (PBD) has demonstrated benefits in adults, however there remains a paucity of data in pediatric population. METHODS: Retrospective review of medical records of children receiving HEN between October 2015 and October 2019 was conducted. Nutrition, tolerance, and healthcare utilization was tracked through May 2020. Children receiving PBD as initial formula or transitioned to PBD from SPF were included. Our objective was to assess gastrointestinal tolerance and impact on healthcare utilization in children receiving PBD. RESULTS: During study period, 30 children (mean age, 9 ± 5.44 years; 20 of 30 [66.7%] male) utilized PBDs. Twenty-one patients started PBD directly with malnutrition as primary indication. Nine patients transitioned from SPF to PBD, most often due to intolerance of SPF (66%). After transition to PBD, no symptoms were reported in 6 of 9 (66.7%) patients, and symptoms of SPF intolerance resolved in 4 of 9 (44.5%) patients. Healthcare utilization declined significantly after transition to PBD, including mean numbers of emergency room visits (0.78 ± 1.09 to 0.11 ± 0.33; P = .025), provider visits (1.67 ± 1.32 to 0.56 ± 0.73; P = .007), and phone calls (1.22 ± 1.39 to 0.33 ± 0.50; P = .026). CONCLUSIONS: PBD is well tolerated and can result in significant reduction in healthcare utilization in children intolerant to SPF.

Assessing Pediatric Feeding Disorders by Domain in Complex Aerodigestive Patients.

OBJECTIVE: Pediatric feeding disorder (PFD) is defined as impaired oral intake, associated with dysfunction in at least one of four domains: medical, nutritional, feeding skill, and/or psychosocial. The pediatric aerodigestive patient presents with conditions impacting airway, breathing, feeding, swallowing, or growth. The objective of the study was to determine the prevalence of PFD and dysfunctional domain, in the aerodigestive patient presenting to a tertiary aerodigestive clinic. METHODS:  Twenty-five charts from patients enrolled in Mayo Clinic Children's Center Aerodigestive Program were retrospectively reviewed for documentation of dysfunction within the four feeding disorder domains. Results from the aerodigestive triple scope, functional endoscopic evaluation of swallow (FEES), and videofluoroscopic swallow study (VFSS) were recorded. Height and weight z-scores were compared between the initial assessment and 6-12 months later. RESULTS: Median age was 20 months (range 2-81 months). Of the patients, 100% (n = 25) had dysfunction in at least one PFD domain. The domain identified most frequently was medical dysfunction (96%; n = 24). Feeding dysfunction was observed in 76% (n = 19). Psychosocial dysfunction was observed in 76% (n = 19). Nutritional dysfunction was observed in 60% (n = 15). Dysfunction in three or greater domains was seen in 80% (n = 20). Weight z-score increased in 76% (n = 19) of patients 6 to 12 months after the initial aerodigestive evaluation. CONCLUSION:  Aerodigestive patients frequently have PFD and utilizing the consensus definition of PFD at intake may enhance clinical assessment and therapeutic evaluation, and provide a framework to measure outcomes in this heterogeneous patient population.

Morphometric Changes in Children With Small Bowel Crohn Disease During Induction of Therapy: A Pilot Study.

OBJECTIVE: Children and adolescents with Crohn disease (CD) commonly gain weight during treatment induction, which is thought to be a marker of better health. Body composition is, however, rarely assessed at diagnosis, and changes during early treatment are not often quantified. Therefore, it is unknown if these gains are truly healthy. We sought to evaluate skeletal muscle changes during initial treatment for CD by using routine imaging. METHODS: Single-center prospective study. Pediatric patients diagnosed with small bowel CD underwent serial magnetic resonance enterography (MRE) imaging, laboratory testing, and disease-activity assessment, at diagnosis, 1 and 6 months of treatment. MRE-based cross-sectional morphometry was used to measure psoas muscle cross sectional area (CSA). Psoas CSA z-scores were calculated using normative data. RESULTS: We enrolled 30 children (ages 9--17 years). Twenty-eight of 30 (93%) received anti-tumor necrosis factor therapy and 4 required surgical resection. Children with below-average psoas CSA and body mass index (BMI) z-scores at diagnosis were much more likely to fail treatment or undergo surgery by 6 months compared with those with higher z-scores (55% vs 0%; P = 0.001). Children with no activity limitations at diagnosis had significantly larger muscle gains in the first month, compared with those whose activity was limited at diagnosis (P = 0.012). Most patients had higher psoas CSA z-scores by 6 months, and these increases were associated with weight and BMI z-score increases. CONCLUSIONS: Skeletal muscle growth contributes to weight gain during treatment induction in most patients with CD. Psoas muscle CSA on diagnostic imaging may have prognostic value in children with CD.