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.

Chronic Mucosal Inflammation in Pediatric Intestinal Failure Patients-A Unique Phenomenon.

INTRODUCTION/OBJECTIVES: As intestinal failure (IF) management improves and long-term survival rate increases, its physiological complications have become more apparent. The development of chronic intestinal inflammation resembling inflammatory bowel disease (IBD) in this population has been reported, but the literature describing it in detail is sparse. The present study was designed to characterize children with IF who developed chronic intestinal inflammation and identify the potential predisposing clinical factors. METHODS: This retrospective study was based on the electronic medical records of pediatric patients seen at the Cincinnati Children's Hospital Medical Center between January 2000 and July 2022. Demographic and medical history data were collected and compared between children with IF that developed chronic intestinal inflammation and children with IF that did not develop chronic intestinal inflammation. RESULTS: During the follow-up period, 23 children were diagnosed with chronic intestinal inflammation. Of these, 12 (52%) were males, with a median age of 4.5 (3-7) years at diagnosis. Nearly one-third of the patients had gastroschisis (31%), followed by necrotizing enterocolitis (26%), and malrotation and volvulus (21.7%). More children in the chronic intestinal inflammation group lacked an ileocecal valve (ICV) and adjoining distal ileum as compared to the short bowel syndrome (SBS)-IF control group (15 patients, 65% vs 8 patients, 33%). Moreover, more children in the chronic intestinal inflammation group had undergone a prior lengthening procedure than the SBS-IF control group (5 patients, 21.7% vs. 0, respectively). DISCUSSION: SBS patients are at risk of relatively early onset chronic intestinal inflammation. The absence of an ICV (and adjoin ileum) and prior lengthening procedures emerge as factors associated with the risk of IBD in these patients.

Evaluation and Management of Iron Deficiency in Children Undergoing Intestinal Rehabilitation-A Position Paper From the NASPGHAN Intestinal Rehabilitation Special Interest Group.

Iron deficiency (ID) is the most common nutritional deficiency affecting children undergoing intestinal rehabilitation (IR). Patients may be asymptomatic or present with nonspecific symptoms including fatigue, irritability, and dizziness. The diagnosis of ID in this population can be complicated by the coexistence of systemic inflammation or other nutritional deficiencies which may mimic ID. Many routinely available laboratory tests lack specificity and no consensus on screening is available. Success in oral and enteral treatment is impeded by poor tolerance of iron formulations in a population already challenged with intolerance. Newer parenteral iron formulations exhibit excellent safety profiles, but their role in repletion in this population remains unclear. The following report, compiled by a multidisciplinary group of providers caring for children undergoing IR and representing the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Special Interest Group for Intestinal Rehabilitation, seeks to address these challenges. After discussing iron physiology and population-specific pathophysiology, we make recommendations on iron intake, iron status assessment, and evaluation for alternative causes of anemia. We then provide recommendations on iron supplementation and treatment of ID anemia specific to this nutritionally vulnerable population.

Pitfalls of iron supplementation in parenteral nutrition admixtures for children with intestinal failure.

BACKGROUND: Pediatric patients with intestinal failure are at increased risk for iron deficiency. Supplementation is not routinely included in parenteral nutrition solutions. There is currently limited research related to the safety of iron supplementation in parenteral nutrition and for intravenous forms used in patients with intestinal failure. Current American Society for Parenteral and Enteral Nutrition and ESPGHAN guidelines promote the use of enteral iron, acknowledging the risks of using iron supplementation within parenteral nutrition admixtures. METHODS: We review a patient case and the current available literature related to iron in parenteral nutrition. RESULTS: Five major concerns are identified: peroxidation reactions, incompatibility, hypersensitivity, infection risk, and iron overload. CONCLUSION: We propose an argument against the preferential use of iron supplementation within parenteral nutrition in children with intestinal failure when enteral supplementation or intermittent parenteral infusion may be sufficient.

Neurologic Complications due to Severe Micronutrient Deficiencies in an American Adolescent.

Micronutrient deficiencies are a major global health problem but are less common in developed nations. If left unidentified and untreated, micronutrient deficiencies can lead to serious, sometimes irreversible, sequelae such as with vitamin A deficiency and vision loss. Providers should recognize these issues not only in chronically ill and hospitalized patients but in those with non-illness-related malnutrition due to parent/child-selected restricted diets. Herein, we present a case of unrecognized chronic, severe, malnutrition due to severe behavioral food selectivity with associated neurologic deficits due to hypovitaminosis (vitamins A and B2 ). With adequate enteral nutrition and vitamin repletion, our patient's neurologic deficits have partially recovered.

Effects of Immigration on Infant Feeding Practices in an Inner City, Low Socioeconomic Community.

OBJECTIVE: Infant feeding practices have been shown to differ between immigrants and non-immigrants in the United States. Our study characterizes feeding practices of infants of immigrant versus American-born mothers followed in an inner city Pediatric continuity clinic serving predominantly low socioeconomic status families. METHODS: A survey was given to 102 parents of infants ranging from 12 to 15 months of age who attended the clinic. Parents were asked about their country of origin, ethnic background and time since immigration to the US. They were also asked about their breastfeeding and early infant feeding practices. Statistical significance was estimated using chi-squared tests. RESULTS: Not only were breastfeeding rates higher among immigrant mothers compared to American-born mothers (88% vs. 63%, p-value 0.008) but they introduced commercially available baby food less frequently (37% vs. 52%, p-value 0.03) and rarely fed their infants fast food (22% vs. 50%, p-value<0.001). Moreover, breast feeding rates decreased with duration of residence in the United States. 53% of immigrant mothers who have been in the United States for less than 5 years breastfed for over 6 months versus 22% of immigrant mothers who resided more than 5 years in the United States (p-value 0.02). The vast majority of immigrant mothers who switched to formula did so because they felt their milk production was insufficient (93%) whereas the vast majority of American-born mothers stopped breastfeeding because they perceived it to be painful (64%, p value 0.001). CONCLUSIONS: Infant feeding practices differ between immigrant and American-born mothers and the differences diminish the longer the mothers reside in the United States. These differences stem from differences in cultural perceptions of breastfeeding. Therefore, in educating mothers about infant feeding, physicians should strongly consider cultural and ethnic factors.

Insights into medical management of pediatric intestinal failure.

Medical management of children with Intestinal failure continues to evolve. The development of specialized teams focused on the management of these children has made the most significant impact in improving outcomes. Medical management strategies are centered on the provision of adequate fluid electrolytes and calories to allow for appropriate growth and neurological development. Enteral therapy and drugs are required to enhance bowel adaptation while parenteral nutrition is the main source of nutrients, electrolytes and fluid. Modification in parenteral nutrition with the availability of lipid alternatives are contributing to decreasing incidence of Intestinal failure associated liver disease. Utilization of patient centered central line care bundles has also significantly contributed to the decrease in morbidity and mortality. This review provides insight into the current medical therapy available for managing intestinal failure in children.

Diagnosis and management of inflammatory bowel disease in children.

Inflammatory bowel diseases (IBD), including Crohn's disease and ulcerative colitis, are lifelong conditions that often begin in childhood. The implications of IBD are of particular importance in children because of the potential negative effects on growth, development, psychosocial function, and overall wellbeing. The key management strategy is to achieve sustained control of intestinal inflammation and monitor for potential complications of the disease and side effects of therapies. Overall, the evidence on the management of IBD in children is less extensive than in adults, but good quality multicenter studies and various guidelines and society consensus statements are available. This review summarizes the evidence on the pathophysiology, diagnosis, and approaches to management of children and adolescents with IBD.