Growth Delay in Inflammatory Bowel Diseases: Significance, Causes, and Management.

Growth delay with height and weight impairment is a common feature of pediatric inflammatory bowel diseases (PIBD). Up to 2/3 of Crohn Disease patients have impaired weight at diagnosis, and up to 1/3 have impaired height. Ulcerative colitis usually manifests earlier with less impaired growth, though patients can be affected. Ultimately, growth delay, if not corrected, can reduce final adult height. Weight loss, reduced bone mass, and pubertal delay are also concerns associated with growth delay in newly diagnosed PIBD patients. The mechanisms for growth delay in IBD are multifactorial and include reduced nutrient intake, poor absorption, increased fecal losses, as well as direct effects from inflammation and treatment modalities. Management of growth delay requires optimal disease control. Exclusive enteral nutrition (EEN), biologic therapy, and corticosteroids are the primary induction strategies used in PIBD, and both EEN and biologics positively impact growth and bone development. Beyond adequate disease control, growth delay and pubertal delay require a multidisciplinary approach, dependent on diligent monitoring and identification, nutritional rehabilitation, and involvement of endocrinology and psychiatry services as needed. Pitfalls that clinicians may encounter when managing growth delay include refeeding syndrome, obesity (even in the setting of malnutrition), and restrictive diets. Although treatment of PIBD has improved substantially in the last several decades with the era of biologic therapies and EEN, there is still much to be learned about growth delay in PIBD in order to improve outcomes.

Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection.

Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20-50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.

Nutrition of neonates with congenital heart disease: existing evidence, conflicts and concerns.

Introduction: Congenital heart disease is one of the most of the groups of congenital anomalies with an incidence of about 1 per 100 live births. Almost one-third of these infants require some type of intervention, usually in the first year of life and increasingly often in the neonatal period. Innovative reparative and palliative surgical procedures and advanced medical support in the Neonatal Intensive Care Unit have significantly reduced the mortality related to congenital heart disease. Achieving survival is not the only target of clinicians for these patients. Appropriate growth, development, and improved quality of life are also very important. Growth failure is a very common problem of these children and nutritional support and management are a challenge for health care providers. Early intervention and identification of at-risk patients have the potential to decrease morbidity and mortality related to malnutrition.Aim/methods: The purpose of this article is to analyze the existing evidence and common concerns about perioperative and postdischarge nutritional management of neonates with congenital heart disease based on the special issues or complications that may arise. Furthermore, we reviewed the recent literature about current practices and proposed policies that could prevent malnutrition and improve the outcomes of neonates with congenital heart disease.Results/conclusion: A standardized institutional protocol and clear guidelines referring to feeding initiation, prompt estimation of caloric needs and provision of adequate and appropriate nutrient intake is likely to benefit these patients. Clear definitions for the nutritional approach in the setting of medical complications and close assessment of growth by pediatricians and specialized nutritionists are crucial for the long-term outlook and quality of life of these infants.

Undernutrition in children & critical windows of opportunity in Indian context.

It is intriguing to note that majority of the wasting among the under 5 yr in India is present at birth. The National Family Health Survey 4 (NFHS-4) data analysis shows 31.9 per cent wasting at birth, which is decreasing to 17.7 per cent in the under five children; clearly suggesting that any reduction in wasting should come from improvement in foetal growth. In addition, children with both severe wasting and severe stunting, in whom the risk of mortality increases many folds, are <1 per cent in almost all the States; and these are the children in whom special care is required under the community-based management of severe acute malnutrition. This article presents an overview of nutrition status in children, their antecedents, and the critical phases; especially, nutrition status before pregnancy that plays a crucial role in all the nutrition status indicators of children. More attention on the critical phases is crucial to maximize the benefits from national programmes.

Treatment with Geranylgeranylacetone Induces Heat Shock Protein 70 and Attenuates Neonatal Hyperoxic Lung Injury in a Model of Bronchopulmonary Dysplasia.

PURPOSE: Bronchopulmonary dysplasia (BPD) is a respiratory complication characterized by abnormal alveolar development in premature infants. Geranylgeranylacetone (GGA) can induce heat shock protein (HSP) 70, which has cytoprotective effects against various stressors. Here, we investigated whether GGA protected neonatal lungs from hyperoxic stress in a murine BPD model, and measured the serum HSP70 levels in preterm humans treated with oxygen. METHODS: Newborn mice were exposed to >90% oxygen and administered GGA or vehicle alone orally on days 1, 2, and 3 of life. At 2 days of age, HSP70 expression in the lung was determined by western blotting. At 8 days of age, the lungs were processed for histological analysis. Radial alveolar count (RAC) and mean linear intercept (MLI) were measured as parameters of alveolarization. Apoptosis was evaluated by the terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) method and cleaved caspase-3 immunohistochemistry. Serum HSP70 levels in preterm humans treated with oxygen were measured by enzyme-linked immunosorbent assay. RESULTS: GGA administration enhanced the HSP70 expression to two-fold compared with normoxia-exposed and vehicle-treated mice. Hyperoxia reduced HSP70 expression, whereas GGA abrogated the effects. Hyperoxia-exposed mice exhibited more apoptotic cells in lung parenchyma and a more simplified alveolar structure with less RAC and larger MLI than normoxia-exposed mice. GGA suppressed the increase in apoptotic cells and the structural changes of the lungs induced by hyperoxia. Serum HSP70 levels of preterm human infants gradually decreased with age. CONCLUSIONS: GGA may attenuate hyperoxic injury in neonatal lungs and thereby may prevent the development of BPD.

[Supraglottoplasty for pediatric laryngomalacia : Results from 71 cases]. / Supraglottoplastik bei kindlicher Laryngomalazie : Ergebnisse aus 71 Fällen.

Laryngomalacia is the most common cause of stridor in infants. The stridor is caused by an inward collapse of supraglottic structures during inspiration resulting in an inspiratory stridor. The exact etiology still remains unclear. The surgical procedure of choice for laryngomalacia is supraglottoplasty. From 2009 to 2016 a total of 71 children were treated by supraglottoplasty in the department for pediatric otorhinolaryngology of the Stuttgart Hospital. The indications for supraglottoplasty were laryngomalacia with severe inspiratory stridor, oxygen desaturation, suprasternal or chest retraction, feeding difficulties and/or failure to thrive. The overall success rate was 86 % but there was a clear difference between children with isolated laryngomalacia and the group with associated comorbidities. The success rate for patients with isolated laryngomalacia was 98 % and for patients with associated comorbidities 57 %. Supraglottoplasty is therefore an effective and safe treatment for symptomatic laryngomalacia and a reduction in the success rate showed a clear correlation with the presence of congenital comorbidities.

Interventional Closure of Secundum Type Atrial Septal Defects in Infants Less Than 10 Kilograms: Indications and Procedural Outcome.

AIMS: This study set out to assess indications, feasibility, complications, and clinical outcome of percutaneous transcatheter device closure of atrial septal defects (ASDs) in infants with a bodyweight below 10 kg. METHODS AND RESULTS: Retrospective single center chart and echocardiography review study from 8/2005-12/2013. Twenty-eight children with ASD (13 female) with a median age of 1.15 years (0.2-2.8) and a median weight of 7.2 kg (4.5-9.9) were analyzed. Indications for early ASD closure were failure to thrive (n = 15, 54%), bronchopulmonary dysplasia (BPD) with supplemental oxygen dependency (n = 7, 25%), and genetic syndromes with suspected pulmonary hypertension (n = 12, 43%). Device implantation was successful in all patients without any periprocedural mortality or major complication. Clinical outcome after a median follow-up period of 2.1 years (0.25-7.3) revealed no residual shunt and a significant decrease of right ventricular volume load. Patients with pulmonary hypertension experienced a significant reduction of pulmonary artery/RV pressure. Patients also showed decreased supplemental oxygen dependency and less cardiac medications, but no significant "catch-up growth" in those with failure to thrive. CONCLUSION: Interventional ASD closure in children weighing less than 10 kg can be performed without any additional major risks and shows a favorable outcome, especially in selected patients with significant non cardiac co-morbidities.

Investigating Transitional Care to Decrease Post-pancreatectomy 30-Day Hospital Readmissions for Dehydration or Failure to Thrive.

BACKGROUND: Current literature emphasizes post-operative complications as a leading cause of post-pancreatectomy readmissions. Transitional care factors associated with potentially preventable conditions such as dehydration and failure to thrive (FTT) may play a significant role in readmission after pancreatectomy and have not been studied. METHODS: Thirty-one post-pancreatectomy patients, who were readmitted for dehydration or FTT between 2009 and 2014, were compared to 141 nonreadmitted patients. Medical record review and a questionnaire-based survey, specifically designed to assess transitional care, were used to identify predictors of readmissions for dehydration or FTT. Logistic regression models were used to evaluate outcomes. RESULTS: On multivariable analysis, the strongest predictors of readmission for dehydration and FTT were the patient's lower educational level (P = 0.0233), the absence of family during the delivery of discharge instructions (P = 0.0098), episodic intermittent nausea at discharge (P = 0.0019), uncertainty about quantity, quality, or frequency of fluid intake (P = 0.0137), and the inability or failure to adhere to the clinician's instructions in the outpatient setting (P = 0.0048). CONCLUSION: Transitional-care-related factors are found to be associated with post-pancreatectomy readmission for dehydration and FTT. Using these results to identify high-risk patients and implement focused preventive measures combining efficient communication and optimal inpatient and outpatient management could potentially decrease readmission rates.

Improving growth in preterm infants during initial hospital stay: principles into practice.

Despite recent innovations in nutritional care, postnatal growth failure between birth and hospital discharge remains a significant problem in preterm infants. Whether or not it is entirely preventable is unclear. What is clear is that feeding practices and growth outcomes vary widely between neonatal intensive care units (NICUs). This partly reflects lack of data in key areas but it also reflects inconsistent translation of principles into practice and limitations in the way infants are fed and growth monitored in the NICU. These issues will be reviewed, in the process underline the key roles that audit, standardised feeding protocol, individualised nutritional care and a nutritional support team play in improving outcome in these high-risk infants.

Nutrition in the Cardiac Newborns: Evidence-based Nutrition Guidelines for Cardiac Newborns.

Both protein and energy malnutrition are common in neonates and infants with congenital heart disease (CHD). Neonates with CHD are at increased risk of developing necrotizing enterocolitis (NEC), particularly the preterm population. Mortality in patients with CHD and NEC is higher than for either disease process alone. Standardized feeding protocols may affect both incidence of NEC and growth failure in infants with CHD. The roles of human milk and probiotics have not yet been explored in this patient population.

Parenteral Nutrition in Very Low Birth Weight Preterm Infants.

Parenteral nutrition (PN) must be initiated as soon as possible after delivery in very low birth weight (VLBW) preterm infants in order to prevent postnatal growth failure and improve neurodevelopmental outcome. When administered early, high levels of parenteral amino acids (AA) are well tolerated and prevent negative nitrogen balance. Although proteins are the driving force for growth, protein synthesis is energy-demanding. Intravenous lipid emulsions (ILE) constitute a good energy source because of their high energy density and provide essential fatty acids (FA) along with their long-chain polyunsaturated fatty acid (LC-PUFA) derivatives necessary for central nervous system and retinal development. Early supply of ILE is not associated with increased morbidity. No significant differences were found between ILE based on soybean oil only and mixed ILE containing soybean oil in combination with other fat sources, except for a reduction in the incidence of sepsis with non-pure soybean ILE, and possibly less PN-associated liver disease with mixed ILE containing some fish oil. In preterm infants glucose homeostasis is still immature in the first days of life and abnormalities of glucose homeostasis are common. VLBW infants may not tolerate high levels of glucose infusion without hyperglycemia. Administering lower levels of glucose infusion as part of full early PN seems more successful than insulin at this stage. Postpartum there is a transition period when the water and electrolyte balance may be severely disturbed and should be closely monitored. Avoiding fluid overload is critical for preventing respiratory and other morbidities.

Vitamin Supplementation in the Elderly.

Vitamin supplementation is fairly common among the elderly. Supplements are often used to prevent disease and improve health. In the United States, the use of dietary supplements has continued to increase over the last 30 years, and more than half of adults report using one or more dietary supplements. Epidemiologic evidence suggests that a diet rich in fruits and vegetables does have a protective effect on health. However, clinical trials on the use of vitamin supplements for promotion of health and prevention of disease have failed to demonstrate the strong associations seen in observational studies.

Nutrition management for the promotion of growth in very low birth weight premature infants.

Premature infants are highly susceptible to extrauterine growth restriction. Without early and adequate nutrition support, nutrition deficits of energy and protein can quickly accrue. Growth failure has been implicated in poor neurodevelopmental outcomes and long-term morbidity, creating a major focus on neonatal nutrition alongside medical management. Optimal nutrition is paramount for optimal growth outcomes. The purpose of this article is to review the implications and long-term effects of growth failure in premature infants, specifically, those with very low birth weights. In addition, nutrition interventions and treatments will be presented to manage and improve growth outcomes of the neonate.

Weight for length/height percentiles in infants and young children in Kayseri/Turkey.

OBJECTIVE: To produce weight for length/height (WLH) percentiles to be used for the screening of growth and assessment of failure to thrive in infancy and early childhood. METHODS: The data (2009-2010) of the Anthropometry of Turkish Children aged 0-6 years (ATCA-06) study were used. A cross-sectional study was designed to calculate the WLH references. Reference weight values for each 5-cm LH intervals were determined using the LMS Chart Maker Pro version 2.3 software program (The Institute of Child Health, London). RESULTS: A total of 3123 children (1573 female, 1550 male) aged 0-6 years were included in the calculation of the 3rd, 5th, 10th, 25th, 50th, 75th, 85th, 90th, 95th, and 97th WLH percentiles. The difference between the 3rd and the 97th percentiles for males was 2.02 cm to 12.64 cm in the 50-54.99 cm and 125-130 cm LH ranges. In the girls, the differences between the 3rd-97th percentiles ranged from 2.02 cm to 12.64 cm in the 50-54.99 cm and 125-130 cm LH groups. The maximum difference between the 3rd and 97th percentiles was about half the variation of mean WLH throughout the first six years of life. The most rapid change in WLH was observed in the 0-2-year period. Turkish references for WLH were not different from the World Health Organization standards. CONCLUSIONS: This is the first study in Turkey presenting WLH references in 0-6 year old children. We suggest that the use of WLH in the first two years of life may be more useful than age-adjusted references in assessment of nutritional status and diagnosis of failure to thrive.

Normal interstage growth after the norwood operation associated with interstage home monitoring.

After stage 1 palliation (S1P) with a Norwood operation, infants commonly experience growth failure during the initial interstage period. Growth failure during this high-risk period is associated with worse outcomes. This study evaluated the growth patterns of patients enrolled in the authors' interstage home-monitoring program (HMP), which uses a multidisciplinary team approach to nutrition management. From 2000 to 2009, 148 infants were enrolled in the HMP after S1P. Families recorded daily weights during the interstage period and alerted the interstage monitoring team about protocol violations of nutritional goals. Interstage monitoring and inpatient data from the S1P hospitalization were reviewed to identify risk factors for poor growth. Growth outcomes were compared with published norms from the Centers for Disease Control. Interstage survival for patients in the HMP was 98 % (145/148). Growth velocity during the interstage period was 26 ± 8 g/day. The weight-for-age z-scores decreased from birth to discharge after S1P (-0.4 ± 0.9 to -1.3 ± 0.9; p < 0.001) but then increased during the interstage period to the time of S2P (-0.9 ± 1; p < 0.001). The factors associated with improved growth during the interstage period included male gender, greater birth weight, full oral feeding at S1P discharge, and a later birth era. After S1P, infants enrolled in an HMP experienced normal growth velocity during the interstage period. Daily observation of oxygen saturation, weight change, and enteral intake together with implementation of a multidisciplinary feeding protocol is associated with excellent interstage growth and survival.

Interprofessional group intervention for parents of children age 3 and younger with feeding difficulties: pilot program evaluation.

BACKGROUND: Feeding difficulties are common with an estimated prevalence of 25%-45% in normally developing children. Clinicians and researchers emphasize the need for timely and effective treatment because a proportion of children develop failure to thrive with possible long-term impairments. Interprofessional assessment and treatment has emerged as an optimal approach to reduce parental anxiety and increase children's acceptance of a wider variety of foods. METHODS: Participants, including 30 children (mean age of 26 ± 8.2 months) meeting inclusion/exclusion criteria and their families, attended a program consisting of 4 sessions, and a 1-month follow-up. Parents completed the Behavioral Pediatrics Feeding Assessment Scale pre- and posttreatment and Goal Attainment Scaling (GAS). RESULTS: Paired t tests indicate that the composite scores for frequency of feeding difficulties were on average significantly less posttreatment compared with pretreatment, and composite scores for frequency of parental problems with feeding were also significantly less posttreatment. These results were reflected in the composite scores for both feeding difficulties and parental problems with feeding on child- and parent-related items. The median for the GAS was +2 (range, -2 to +2). Written parental responses in the GAS reflected 2 major themes: satisfaction with the program and a desire for more individualized attention. CONCLUSIONS: These results offer preliminary evidence suggesting that an interprofessionally led parent group, with contributions from clinical nutrition, occupational therapy, psychology, and speech-language pathology professionals, is effective in treating young children with feeding difficulties.

Effects of placement type on the language developmental trajectories of maltreated children from infancy to early childhood.

This study describes the developmental trajectories of language skills in infants with substantiated maltreatment histories over a 5-year period and evaluates the effect of three different custodial placements on their language trajectories over time: in-home (remaining in the care of the biological parent/parents), nonkin foster care, and nonparental kinship care. Participants included 963 infants reported to child protective services prior to their first birthday and whose maltreatment was substantiated. Results from covariate-controlled growth modeling revealed no significant placement effects. Across all groups, children's auditory and expressive communication scores decreased significantly from Wave 1 (intake) in the infants' first year to Wave 4, when children were about 3.5 years of age, then improved to baseline levels by Wave 5, when children were about 6 years old. Despite these fluctuations, children's average language scores in each placement group remained below the population mean at each wave of the study.