NeoCHIRP: A model for intestinal rehabilitation in the neonatal intensive care unit.

Multidisciplinary intestinal rehabilitation (IR) teams have transformed care in pediatric intestinal failure (IF).1 Although most children with IF are identified in the neonatal intensive care unit (NICU), IR teams may not be involved at this stage. We describe our collaborative model, blending NICU and IR expertise to optimize care. Over 6 years, the NeoCHIRP (Neonatal Children's IR Program) team followed 164 babies for weekly visits (median, 8; range, 1-27). Bedside rounds included CHIRP team physician and surgeons, neonatologist champion, attending neonatologist and fellow, NICU dietitian, bedside nurse, and family. Medical and nutrition status, nutrition history, and laboratory data were discussed, and a nutrition plan to support IR, considering the child's other medical needs, was created to guide the next week's management. Typical issues addressed included parenteral nutrition (PN) composition, enteral nutrition plan, oral feeding, management of small-intestinal bacterial overgrowth and sodium status, and cholestasis. A total of 164 babies were followed by the NeoCHIRP team. Of 153 survivors, IF resolved by discharge in 89% (136 of 153). Seventeen of 153 babies (11%) went on to require home PN and were transferred from NICU directly to the CHIRP team. By discharge, 99% of babies were orally fed (69/136, 50% fully, 67/136, 49% partially), and cholestasis improved or resolved in 80/105 (76%). Eleven babies (7%) died; four deaths were unrelated to IF, but in seven babies, IF was at least a contributing factor. In this high-risk cohort, most babies achieved good outcomes, and those who required longer-term IR transitioned smoothly to the CHIRP team.

Nutritional evaluation of the neurologically impaired child.

Nutrition is of key importance in optimizing function and health in children with neurological impairment. Challenges in quantifying individual needs and assessing nutritional status are barriers to determining the nutritional prescription. This practice point addresses common questions faced by clinicians caring for this population and uses available evidence to provide strategies to address these challenges.

Mucous fistula refeeding in neonates with enterostomies.

BACKGROUND/PURPOSE: Neonates with intestinal pathology may require staged surgery with creation of an enterostomy and mucous fistula (MF). Refeeding (MFR) of ostomy output may minimize fluid and electrolyte losses and reduce dependence on parenteral nutrition (PN), though a paucity of evidence exists to support this practice. The purpose of this study was to assess the outcomes of infants undergoing MFR and document associated complications. METHODS: With REB approval, infants with intestinal failure undergoing MFR between January 2000 and December 2012 were identified. A chart review was conducted and relevant data were collected. Descriptive statistics were used. RESULTS: Twenty-three neonates underwent MFR. Mean gestational age and birth weight were 35weeks and 2416grams. Pathologies included intestinal atresia (n=12), necrotizing enterocolitis (n=5), meconium ileus (n=4), and other (n=6). Seven patients were able to wean from PN. Four patients had complications: 3 had perforation of the MF, 1 had bleeding. Four patients died, with one death directly attributable to MFR. CONCLUSIONS: In this cohort MF refeeding was associated with significant complications and ongoing PN dependence. With advances in intestinal rehabilitation and PN, the benefit of MF refeeding must be weighed against the potential complications.

A randomized, double-blind, placebo-controlled clinical trial of megestrol acetate as an appetite stimulant in children with weight loss due to cancer and/or cancer therapy.

BACKGROUND: Megestrol acetate (MA) is an appetite stimulant with efficacy in promoting weight gain in adults with cancer-associated anorexia-cachexia. Studies documenting MA efficacy in children, however, are limited. We present the first randomized, double-blind, placebo-controlled clinical trial of MA versus placebo in children with cancer and weight loss. METHODS: Subjects <18 years of age with weight loss (minimum 5% from highest previous weight; or %ideal body weight <90%) due to cancer and/or cancer therapy were randomized to either MA (7.5 mg/kg/day) or placebo for a planned study duration of 90 days. Primary outcome was the difference between groups in mean percent weight change from beginning to end of the study period. Secondary outcomes included effects on anthropometrics, body composition, need for tube feeding or parenteral nutrition, and toxicities. RESULTS: Twenty-six patients were randomly assigned (13 MA, 13 placebo). The MA group experienced a mean weight gain of +19.7% compared to a mean weight loss of -1.2% in the placebo group, for a difference of +20.9% (95%CI: +11.3% to +30.5%, P = 0.003) in favor of MA over placebo. MA subjects experienced significant increases in weight for age z-scores, body mass index z-scores, and mid upper arm circumference compared to placebo. DXA scanning suggested disproportionate increases in fat accrual. Adrenal suppression was the main toxicity of MA. CONCLUSION: In children with high-risk malignancies, MA resulted in significant increases in mean percent weight change compared to placebo. Further studies of MA should be pursued to better delineate the effect on nutritional status.

The Alberta Pregnancy Outcomes and Nutrition (APrON) cohort study: rationale and methods.

The Alberta Pregnancy Outcomes and Nutrition (APrON) study is an ongoing prospective cohort study that recruits pregnant women early in pregnancy and, as of 2012, is following up their infants to 3 years of age. It has currently enrolled approximately 5000 Canadians (2000 pregnant women, their offspring and many of their partners). The primary aims of the APrON study were to determine the relationships between maternal nutrient intake and status, before, during and after gestation, and (1) maternal mood; (2) birth and obstetric outcomes; and (3) infant neurodevelopment. We have collected comprehensive maternal nutrition, anthropometric, biological and mental health data at multiple points in the pregnancy and the post-partum period, as well as obstetrical, birth, health and neurodevelopmental outcomes of these pregnancies. The study continues to follow the infants through to 36 months of age. The current report describes the study design and methods, and findings of some pilot work. The APrON study is a significant resource with opportunities for collaboration.

Prospective cohort study of the outcome of and risk factors for intravascular catheter-related bloodstream infections in children with intestinal failure.

BACKGROUND: Children with intestinal failure (IF) have frequent catheter-related bloodstream infections (CRBSIs). The purpose of this study was to prospectively study the clinical course of CRBSIs and to seek modifiable risk factors for CRBSIs in children with IF. MATERIALS AND METHODS: Children with IF were enrolled prospectively and data on potential risk factors collected monthly. Additional data were collected when they had CRBSIs. RESULTS: Sixteen children were enrolled, yielding 223 months of data. The rate of CRBSIs was 4.6 per 1000 catheter days. The most consistent symptom at onset of CRBSI was fever (28 of 32 cases). Elevated C-reactive protein (CRP) was the only laboratory abnormality that was consistently associated with the onset of CRBSI (elevated in 15 of the 18 cases where it was measured). Combining all episodes in the cases that relapsed, the catheter salvage rate was 17 of 29 (59%), including 4 of 11 polymicrobial CRBSIs. Risk factors for CRBSI included double lumen tunneled central venous catheter (CVC), jugular placement of CVC, higher doses of intralipid, and having <50 cm small bowel postresection. CONCLUSION: The diagnosis of CRBSI should be questioned in the absence of fever and/or elevated CRP. Salvage of catheters should be attempted with all bacterial CRBSIs, assuming that the child is stable since the CVC can be retained in the majority of cases.

Predominant breast-feeding from birth to six months is associated with fewer gastrointestinal infections and increased risk for iron deficiency among infants.

Iron deficiency (ID) is prevalent among infants world-wide and may be more likely among infants born to women living in disadvantaged environments. A strategy to address ID in this context is to feed iron-fortified formula, but this may create risk for gastrointestinal (GI) infection. Our objective was to investigate the relationship between infant feeding practices, iron status, and likelihood of a GI infection in the first 6 mo of life. We conducted a prospective study at a public hospital in Guadalajara, Mexico. Healthy women who gave birth to a healthy term infant were eligible to participate. Each month, mothers (n = 154) provided information on infant feeding methods and symptoms of GI infection. At 6 mo of age, infants' iron status was assessed [hemoglobin (Hb) and serum ferritin concentration]. When compared with nonpredominantly breast-fed [partially breast-feeding (PBF) and formula feeding (FF) combined], predominantly breast-fed (PRBF) infants to 6 mo had a lower incidence of GI infection from 0-6 mo [18 vs. 33%; P = 0.04; adjusted odds ratio (OR) = 0.4; 95% CI = 0.2, 1.0] but a higher risk for ID (serum ferritin < 12 microg/L) at 6 mo (22 vs. 4%; P = 0.001; adjusted OR = 9.2; 95% CI = 2.3, 37.0). Anemia (Hb < 110 g/L) prevalence did not differ among feeding groups (13% for PRBF, 19% for PBF, and 4% for FF; P = 0.09). In this low-income population, our results suggest that PRBF should be promoted and the risk for ID managed using public health and nutrition strategies.