Development of the Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC) using a modified Delphi technique.

One in three hospitalized children have disease-related malnutrition (DRM) upon admission to hospital, and all children are at risk for further nutritional deterioration during hospital stay; however, systematic approaches to detect DRM in Canada are lacking. To standardise and improve hospital care, the multidisciplinary pediatric working group of the Canadian Malnutrition Taskforce aimed to develop a pediatric, inpatient nutritional care pathway based on available evidence, feasibility of resources, and expert consensus. The working group (n = 13) undertook a total of four meetings: an in-person meeting to draft the pathway based on existing literature and modelled after the Integrated Nutrition Pathway for Acute Care (INPAC) in adults, followed by three online surveys and three rounds of online Delphi consensus meetings to achieve agreement on the draft pathway. In the first Delphi survey, 32 questions were asked, whereas in the second and third rounds 27 and 8 questions were asked, respectively. Consensus was defined as any question/issue in which at least 80% agreed. The modified Delphi process allowed the development of an evidence-informed, consensus-based pathway for inpatients, the Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC). It includes screening <24 h of admission, assessment with use of Subjective Global Nutritional Assessment (SGNA) <48 h of admission, as well as prevention, and treatment of DRM divided into standard, advanced, and specialized nutrition care plans. Research is necessary to explore feasibility of implementation and evaluate the effectiveness by integrating P-INPAC into clinical practice.

Update to the pediatric Subjective Global Nutritional Assessment (SGNA).

Lack of a standardized method of identifying and defining pediatric malnutrition has led to an inability to fully understand the prevalence of and impact that malnutrition has on pediatric patients and the healthcare system. The Subjective Global Nutritional Assessment (SGNA) is an assessment tool meant to determine presence and severity of malnutrition in pediatric populations. However, the anthropometric section of the tool contains some out-dated parameters. This has limited its clinical practicality. The aim of this paper is to propose updates to the anthropometrics section of the SGNA. A retrospective analysis of 153 SGNA's performed on children aged 1 month to 16 years was completed, comparing the original SGNA results to SGNA results incorporating updated anthropometric parameters for percentiles and ideal body weight. The category of length/height for age was updated to include z score cutoffs rather than percentiles, and ideal body weight was updated to z scores for weight for length or body mass index (BMI). Two serial growth questions were updated in wording only, to reflect z score trends. The results of the analysis showed these updates would have changed the rankings of eight patients (5%) for length/height for age, and 20 patients (13%) for ideal body weight to weight for length or BMI. Adjustments to these questions did not impact the overall SGNA rating. This study shows updates to the SGNA are not expected to have a significant impact on the validity of the tool and has the potential to improve its applicability to current day practice.

Canadian Nationwide Survey on Pediatric Malnutrition Management in Tertiary Hospitals.

Background: Disease-associated malnutrition (DAM) is common in hospitalized children. This survey aimed to assess current in-hospital practices for clinical care of pediatric DAM in Canada. Methods: An electronic survey was sent to all 15 tertiary pediatric hospitals in Canada and addressed all pillars of malnutrition care: screening, assessment, treatment, monitoring and follow-up. Results: Responses of 120 health care professionals were used from all 15 hospitals; 57.5% were medical doctors (MDs), 26.7% registered dietitians (RDs) and 15.8% nurses (RNs). An overarching protocol for prevention, detection and intervention of pediatric malnutrition was present or "a work in progress", according to 9.6% of respondents. Routine nutritional screening on admission was sometimes or always performed, according to 58.8%, although the modality differed among hospitals and profession. For children with poor nutritional status, lack of nutritional follow-up after discharge was reported by 48.5%. Conclusions: The presence of a standardized protocol for the clinical assessment and management of DAM is uncommon in pediatric tertiary care hospitals in Canada. Routine nutritional screening upon admission has not been widely adopted. Moreover, ongoing nutritional care of malnourished children after discharge seems cumbersome. These findings call for the adoption and implementation of a uniform clinical care pathway for malnutrition among pediatric hospitals.

Predicting Enrollment in Multidisciplinary Clinical Care for Pediatric Weight Management.

OBJECTIVES: To characterize the children who were referred, determine the proportion of referred children who enrolled, and examine factors associated with enrollment in multidisciplinary clinical care for pediatric weight management. STUDY DESIGN: This cross-sectional study included the population of children (2-17 years of age; body mass index of ≥85th percentile) referred to 1 of 3 hospital-based multidisciplinary weight management clinics in Alberta, Canada, from April 2013 to April 2016. Referral and enrollment data were obtained from Alberta Health Services databases. Bivariate and multivariable logistic regression models were used to determine the independent and combined effects of predictors of enrollment. RESULTS: Of the 2014 children (51.8% male; mean body mass index z-score: 3.42 ± 0.03) referred to multidisciplinary clinical care, 757 (37.6%) enrolled in care. Most referred children had severe obesity and were referred by physicians. Several factors independently predicted enrollment; however, in our most parsimonious multivariable model, only the time gap (OR, 0.94; 95% CI, 0.88-0.99; P = .03) between the attendance date of the orientation session and the booking date of initial appointment predicted enrollment for all children. Body mass index z-score (OR, 0.81; 95% CI, 0.67-0.98; P = .03) and time gap (OR, 0.92; 95% CI, 0.85-0.99; P = .02) predicted enrollment in children with severe obesity exclusively. CONCLUSIONS: Fewer than 40% of referred children enrolled in multidisciplinary clinical care. Reducing the duration of enrollment and providing additional support for treatment initiation to children with severe obesity may enhance treatment uptake for pediatric weight management.

Surgical fasting guidelines in children: Are we putting them into practice?

BACKGROUND: Patients are traditionally kept fasting (NPO) from midnight prior to surgery, to prevent aspiration during anesthesia. NPO time is continued postoperatively, out of concern for ileus. Prolonged periods of NPO place the pediatric population at risk for under-nutrition. Published guidelines for preoperative NPO times have been shown to be safe. The aim of this study was to investigate current pre- and postoperative feeding practices of children at a pediatric tertiary care hospital. METHODS: Medical charts were used to extract data prospectively from 53 patients undergoing general, neurosurgical, or urological procedures. Date and time of NPO periods were recorded as well as the physician's postoperative diet orders and diet progression. Surgical procedures were classified as complex or noncomplex by the surgeons. Data were summarized and compared to published recommendations. RESULTS: Preoperative NPO times were greater than recommended in 70% of patients studied (n=37). Median time spent NPO preoperatively was not significantly different between complex (11.5h) and noncomplex groups (10.8h). Postoperative NPO time was significantly greater for complex procedures than for noncomplex. Most patients received some postoperative NPO time, even when it was not included in the physician diet order. CONCLUSION: Observed preoperative NPO time exceeded current recommendations in this study.

Prevalence of inadequate vitamin d status and associated factors in children with cystic fibrosis.

BACKGROUND: This study aimed to determine the prevalence of inadequate serum 25-hydroxyvitamin D (25(OH)D) levels in a pediatric Canadian cystic fibrosis (CF) population and to assess the effectiveness of a vitamin D supplementation protocol on improving vitamin D status. A secondary objective was to analyze factors that may be associated with inadequate 25(OH)D levels. METHODS: Vitamin D supplementation, 25(OH)D levels, and factors hypothesized to be associated with 25(OH)D levels were collected through a retrospective chart review (2010 and 2011) of 96 patients (1-18 years) at one CF clinic in Canada. Adequacy of 25(OH)D was set at ≥75 nmol/L. Patients with inadequate 25(OH)D levels in 2010 were prescribed an additional 1000 IU/d for levels <60 nmol/L or 400 IU/d for levels 60-75 nmol/L. RESULTS: Inadequate 25(OH)D levels were observed in 26% of patients in 2010 and 23% in 2011. After supplementation was increased for those with inadequate 25(OH)D levels in 2010 (n = 20), a significant increase in 25(OH)D levels was observed in 2011 (P = .03). Adequate status was achieved in 50% of these patients (n = 10). Age was significantly negatively associated with 25(OH)D levels in both years (P = .002). Percentage of forced expiratory volume in 1 second was significantly positively associated with 25(OH)D levels in 2011 (P = .03). CONCLUSION: While vitamin D supplementation was effective at increasing serum 25(OH)D, this protocol did not achieve optimal serum 25(OH)D levels in 25% of the population. Increasing age had the strongest association with 25(OH)D. Current supplementation protocols may require reevaluation based on emerging evidence and revised Cystic Fibrosis Foundation guidelines.

Epidemiology of interruptions to nutrition support in critically ill children in the pediatric intensive care unit.

BACKGROUND: Nutrition support is often delayed or interrupted. The aim of this study is to identify reasons for and quantify time spent without nutrition in a mixed medical-surgical-cardiac pediatric intensive care unit (PICU). METHODS: Data were prospectively collected to describe the patient cohort (anthropometrics and diagnostic category) and nutrition practices (time to nutrition initiation; frequency, duration, and causes of interruptions; and overall caloric intake). Descriptive statistics were used; comparisons of groups were performed using an independent t test and P < .05 as significance. RESULTS: The mean (standard deviation) time to nutrition initiation was 22.8 (16.6) hours following admission; 35% of patients were initiated after >24 hours. Nutrition was interrupted 1.2 (2.0) times per patient. Time spent without nutrition due to interruptions was 11.6 (23.0) hours, up to 102 hours. Patients spent 42.4% (28.2%) of their median (range) PICU admission of 2.9 days (0.25-39 days) without any form of nutrition. Patients aged 0-6 months had a significantly higher mean number and duration of interruptions (P = .001 and P < .001, respectively) compared with children >6 months. Interruptions due to surgery and planned extubation lasted significantly longer than all other interruptions (P < .001 and P = .001, respectively). Pediatric Risk of Mortality (PRISM) III scores were not correlated with percentage of length of stay spent without nutrition (r = 0.137). CONCLUSIONS: Prolonged time to nutrition initiation and interruptions in delivery caused pediatric patients to spend a high proportion of admission without nutrition support, preventing most from meeting energy requirements. Further research addressing specific patient outcomes is required to define optimal initiation times and appropriate procedural-specific fasting times.