Comparison of predictive accuracy of knee height equations in children.

Knee height can be a proxy for height when standing height cannot be reliably measured. We compared two commonly used equations (Chumlea and Rumapea) that estimate standing height from knee height. We prospectively enrolled 210 children without scoliosis or kyphosis aged 7-12 years (mean age: 10.2 years, 47.6% males) and measured their knee heights and standing heights. A two-tailed T-test was used to compare predicted heights from each of the equations to actual standing height. Chumlea equation was found to be unreliable (p = 0.0376) while Rumapea equation was found to be reliable in estimating standing height (p = 0.878). Additionally, Rumapea equation was also found to be more accurate than Chumlea equation when results were segregated based on gender and race. In conclusion, the Rumapea equation yields more accurate estimates of standing heights than the Chumlea equation in US children aged 7-12 years.

Are dietitian recommendations followed? A descriptive study of paediatric hospitalised and ambulatory patients.

BACKGROUND: The primary objective of this cross-sectional retrospective study was to describe the implementation of dietitian prescribed nutrition recommendations in malnourished paediatric patients in the hospital and ambulatory settings. We also aimed to investigate other characteristics that could be associated with differences in implementation. METHODS: Data were collected from 186 hospitalised and 565 ambulatory patients between February 2020 and January 2021. Data included age, hospital or ambulatory specialty departments, primary diagnosis, malnutrition status, hospital length of stay (LOS), and medical nutrition therapy recommendations. Implementation by the medical team in the hospital setting and adherence by the family in the outpatient setting were categorised as "Full", "Partial" or "None". "Partial" and "None" were combined for analysis. RESULTS: Dietitian prescribed recommendations were implemented in 79.6% of hospitalised patients. In the ambulatory population, 46.4% of patients were adherent with nutrition recommendations. Within the hospital, there was a significant difference in implementation of nutrition recommendations based on age (p = 0.047), hospital department (p = 0.002) and LOS (p = 0.04), whereas, in the ambulatory population, there were no significant differences in the rate of adherence among any of the studied characteristics. CONCLUSIONS: Dietitian recommendations are frequently implemented in the hospital, whereas adherence to such recommendations is poor in the outpatient population. Interventions to improve adherence to nutrition recommendations in the ambulatory setting are needed.

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.

Nutrition considerations in the transgender and gender-diverse patient.

The nutrition professional is increasingly providing care to individuals who identify as transgender. However, there are few definitive guidelines on providing medical nutrition care to this population. It is becoming better understood that this population is at elevated nutrition risk secondary to significant health disparities. More recently, the increasing prevalence of gender-affirming medical intervention has resulted in uncertainty when providing medical nutrition assessments and therapies, as many standardized guidelines and assessment tools are sex-specific. This review aims to provide clarity in exploring various gender-affirming methods to providing nutrition care to the transgender and gender-diverse population.

Electronic health record time-tracking provides real-time data to measure and benchmark dietitian productivity.

BACKGROUND: Traditional methods for benchmarking dietitian productivity are time-consuming and fail to accurately measure the total time spent providing nutrition care. An electronic health record (EHR)-based tool that allows for daily tracking of both face-to-face and patient care coordination time for dietitians was created. We assessed whether it provided consistent, continuous measurement of time and productivity. METHODS: This tool was created in an independent paediatric academic healthcare system in the USA. Time spent by dietitians in face-to-face settings and care coordination were tracked. Changes in time spent between the years 2013-2016 versus 2018-2019 were also analysed. RESULTS: The outpatient dietitian spent a mean total of 66.4 min per patient (37.8 ± 6.0 min in face-to-face care and 28.6 ± 5.2 min in care coordination). The total times and fractions spent on face-to-face and care coordination time varied by specialty. Comparison of the two periods of time revealed 75% more productivity on average of dietitians in different outpatient settings after including care coordination tracking. In addition, dietitians were more likely to document time spent in 5-min increments after the institution of this methodology as opposed to 15-min increments. CONCLUSIONS: An EHR-based tool that facilitates the documentation of both face-to-face time and patient care coordination time is feasible and enables consistent, continuous measurement of time and productivity. The real-time data from this tool can be used to support adequate dietitian staffing and be used to create a multicentre database to measure the actual time dietitians need to provide care and generate consistent staffing benchmarks.

Perioperative nutrition in the setting of pediatric inflammatory bowel disease.

BACKGROUND: Optimization of nutrition prior to inflammatory bowel disease (IBD)-related surgery could improve outcomes. The aim of this study was to assess the perioperative nutrition status and management of children undergoing intestinal resection for treatment of their IBD. METHODS: We identified all patients with IBD who underwent primary intestinal resection. We identified malnutrition using established criteria and methods of nutrition provision at various time points (preoperative outpatient evaluation, admission, and postoperative outpatient follow-up) for elective cases (who underwent their procedure at a scheduled admission) and urgent cases (who underwent an unplanned surgical intervention). We also recorded data on postsurgical complications. RESULTS: A total of 84 patients were identified in this single-center study (male sex: 40%, mean age: 14.5 years, Crohn's disease: 65%). Thirty-four patients (40%) had some degree of malnutrition. Prevalence of malnutrition in the urgent and elective cohorts was similar (48% vs 36%; P = 0.37). Of these patients, 29 (34%) were noted to be on some type of nutrition supplementation prior to surgery. Postoperatively, BMI z scores increased (-0.61 vs -0.42; P = 0.0008), but the percentage of patients who were malnourished did not change from preoperative status (40% vs 40%; P = 0.10). Despite this, use of nutrition supplementation was only noted in 15 (17%) patients at postoperative follow-up. Complications were not associated with nutrition status. CONCLUSION: Utilization of supplemental nutrition decreased postprocedure despite no change in malnutrition prevalence. These findings support the development of a pediatric-specific perioperative nutrition protocol in the setting of IBD-related surgery.

Nutrition Screening in the Pediatric Intensive Care Unit: Evaluation of an Electronic Medical Record-Based Tool.

Hospitalized, critically ill children are at increased risk of developing malnutrition. While several pediatric nutrition screening tools exist, none have been validated in the pediatric intensive care units (PICU). The Children's Wisconsin Nutrition Screening Tool (CWNST) is a unique nutrition screening tool that includes the Pediatric Nutrition Screening Tool (PNST) and predictive elements from the electronic medical record and was found to be more sensitive than the PNST in acute care units. The aim of this study was to assess the performance of the tool in detecting possible malnutrition in critically ill children. The data analysis, including the results of the current nutrition screening, diagnosis, and nutrition status was performed on all patients admitted to PICUs at Children's Wisconsin in 2019. All 250 patients with ≥1 nutrition assessment by a dietitian were included. The screening elements that were predictive of malnutrition included parenteral nutrition, positive PNST, and BMI-for-age/weight-for-length z-score. The current screen had a sensitivity of 0.985, specificity of 0.06, positive predictive value (PPV) of 0.249, and negative predictive value of 0.929 compared to the PNST alone which had a sensitivity of 0.1, specificity of 0.981, PPV of 0.658, and NPV of 0.749. However, of the 250 included patients, 97.2% (243) had a positive nutrition screen. The CWNST can be easily applied through EMRs and predicts the nutrition risk in PICU patients but needs further improvement to improve specificity.

A Cross-Sectional Study of Pediatric Feeding Disorder in Children with Cystic Fibrosis.

BACKGROUND: The exact prevalence of feeding problems in children with cystic fibrosis (CF) is unknown. Pediatric feeding disorder (PFD) encompasses poor oral intake with associated medical, nutrition, psychosocial, or feeding skill dysfunction. We hypothesized that PFD is common in CF and aimed to categorize feeding dysfunction across various domains in children with CF. METHODS: An observational cross-sectional study was conducted in children with CF. Data collected included anthropometrics, nutrition data (including need for tube feeding/enteral nutrition [EN] or high-energy beverages, dietary diversity), feeding skills (Pediatric version of the Eating Assessment tool [pEAT]), and psychosocial function (About Your Child's Eating questionnaire [AYCE] in children 2-17 years of age/Behavioral Pediatric Feeding Assessment Scale [BPFAS] in children 12-23 months of age). PFD was defined as poor oral intake with: (a) pEAT score > 5; and/or (b) AYCE or BPFAS score > 2 standard deviation of normative controls; and/or (c) nutrition dysfunction (body mass index/weight-for-length z score < -1 and/or preference of oral high energy beverages or dependence on EN and/or decreased dietary diversity). RESULTS: Of 103 children in the study, 62 (60.1%) had PFD, 7 children (6.8%) were malnourished, 10 needed EN (9.7%), and 30 (29.1%) needed oral high-energy beverages. Dietary diversity was decreased in 42 children (41.5%), 1 child had feeding skill dysfunction, and 11 (10.8%) met criteria for psychosocial dysfunction. CONCLUSION: Almost 2/3rd of children with CF have PFD and many have poor dietary diversity. A significant percentage of children rely on EN and oral supplements, but psychosocial dysfunction is less prevalent.

Current topics in pediatric enteral nutrition safety.

Enteral nutrition is a cornerstone of nutrition support therapy in patients of all ages and across the care continuum. Safe delivery of enteral nutrition to patients is paramount. This review article will focus on current topics in enteral nutrition safety primarily in children including safety with home-made blenderized feeds, recent infant and enteral formula shortages largely due to formula contamination at the manufacturer level, and concerns with importing infant formulas.

Thickness of commercial blenderized formulas adversely affects successful delivery via enteral feeding pumps.

BACKGROUND: There has been a renewed focus on offering commercial formulas made with real-food ingredients because of their perceived health benefits, such as improved feeding tolerance and gut health. Children receiving enteral nutrition through these formulas often are fed via feeding pumps. Because these formulas vary in thickness, we aimed to explore the relationship between formula thickness and prescribed formula delivery via feeding pumps. We hypothesized that inaccurate volumes of commercial blenderized formula (CBF) are delivered via feeding pumps and that these inaccuracies are directly proportional to the thickness of the formula. METHODS: We performed International Dysphagia Diet Standardisation Initiative (IDDSI) tests for six de-identified CBFs. We then ran these formulas over three feeding pumps using nasogastric and gastric tubes and simulated continuous and bolus feeds. We calculated the difference between programmed volume and actual delivered volume. RESULTS: Moderate and extremely thick formulas (IDDSI level 3-4) delivered a median of 22.5% less volume than programmed in the pump (P < 0.001). In addition, there was a 25.5% reduction in delivered volume for thick formulas compared with thin formulas. This occurred despite using the manufacturer's recommendations for suggested tube size. CONCLUSION: Thicker CBF can provide inaccurate volumes via feeding pumps, which may contribute to poor weight gain when children are switched to these formulas. Based on these findings, we recommend best practices for using these formulas. More studies are needed to investigate the best formula consistency to optimize delivery and caloric intake.

Evaluation of an electronic medical record-based Paediatric Nutrition Screening Tool.

BACKGROUND: Nutrition screening is recommended to identify children at risk for malnutrition. A unique screening tool was developed based on American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations and embedded in the electronic medical record to assess for nutrition risk. METHODS: The components of the tool included the Paediatric Nutrition Screening Tool (PNST) and other elements recommended by ASPEN. To evaluate the screening tool, retrospective data were analysed on all patients admitted to acute care units of Children's Wisconsin in 2019. Data collected included nutrition screen results, diagnosis and nutrition status. All patients who received at least one full nutrition assessment by a registered dietitian (RD) were included in analysis. RESULTS: One thousand five hundred seventy-five patients were included in analysis. The following screen elements were significantly associated with a diagnosis of malnutrition: any positive screen (p < 0.001), >2 food allergies (p = 0.009), intubation (p < 0.001), parenteral nutrition (p = 0.005), RD-identified risk (p < 0.001), positive risk per the PNST (p < 0.001), BMI-for-age or weight-for-length z-score (p < 0.001), intake <50% for 3 days (p = 0.012) and NPO > 3 days (p = 0.009). The current screen had a sensitivity of 93.9%, specificity of 20.3%, positive predictive value (PPV) of 30.9% and negative predictive value (NPV) of 89.8%. This is compared with the PNST which had a sensitivity of 32%, specificity of 94.2%, PPV of 71% and NPV of 75.8% in this study population. CONCLUSION: This unique screening tool is useful for predicting nutrition risk and has a greater sensitivity than the PNST alone.

Evaluation and Management of Reduced Dietary Diversity in Children with Pediatric Feeding Disorder.

Pediatric Feeding Disorder, a common problem in children, is commoner in children with various developmental disorders. Children with pediatric feeding disorder can have food selectivity and lack dietary diversity (DD). In this paper, an understanding of DD in these children is provided along with a dietary diversity index that can be helpful in measuring and understanding the risks posed by this lack of DD. An overview of a management strategy to address decreased DD is proposed. In these children, improving DD can improve growth, micronutrient status, long-term metabolic health, and potentially quality of life.

Toward Better Understanding of Pediatric Feeding Disorder: A Proposed Framework for Patient Characterization.

To establish a foundation for methodologically sound research on the epidemiology, assessment, and treatment of pediatric feeding disorder (PFD), a 28-member multidisciplinary panel with equal representation from medicine, nutrition, feeding skill, and psychology from seven national feeding programs convened to develop a case report form (CRF). This process relied upon recent advances in defining PFD, a review of the extant literature, expert consensus regarding best practices, and review of current patient characterization templates at participating institutions. The resultant PFD CRF involves patient characterization in four domains (ie, medical, nutrition, feeding skill, and psychosocial) and identifies the primary features of a feeding disorder based on PFD diagnostic criteria. A corresponding protocol provides guidance for completing the assessment process across the four domains. The PFD CRF promotes a standard procedure to support patient characterization, enhance methodological rigor, and provide a useful clinical tool for providers and researchers working with these disorders.

Novel Pediatric Height Outlier Detection Methodology for Electronic Health Records via Machine Learning With Monotonic Bayesian Additive Regression Trees.

OBJECTIVE: To create a new methodology that has a single simple rule to identify height outliers in the electronic health records (EHR) of children. METHODS: We constructed 2 independent cohorts of children 2 to 8 years old to train and validate a model predicting heights from age, gender, race and weight with monotonic Bayesian additive regression trees. The training cohort consisted of 1376 children where outliers were unknown. The testing cohort consisted of 318 patients that were manually reviewed retrospectively to identify height outliers. RESULTS: The amount of variation explained in height values by our model, R2 , was 82.2% and 75.3% in the training and testing cohorts, respectively. The discriminatory ability to assess height outliers in the testing cohort as assessed by the area under the receiver operating characteristic curve was excellent, 0.841. Based on a relatively aggressive cutoff of 0.075, the outlier sensitivity is 0.713, the specificity 0.793; the positive predictive value 0.615 and the negative predictive value is 0.856. CONCLUSIONS: We have developed a new reliable, largely automated, outlier detection method which is applicable to the identification of height outliers in the pediatric EHR. This methodology can be applied to assess the veracity of height measurements ensuring reliable indices of body proportionality such as body mass index.

Nasogastric bridles are associated with improved tube-related outcomes in children.

OBJECTIVE: To compare tube-related outcomes in children with standard tape vs nasal bridle securement of nasogastric tubes (NGTs). STUDY DESIGN: This was a single-center, retrospective, correlational study of outcomes from the time of NGT placement until full oral feeds or durable-tube placement. Outcomes of interest included NGT dislodgments, length of stay, emergency department (ED) encounters, radiographic exposures, and adverse skin outcomes. Negative binomial regression and logistic regression were used to analyze differences between groups. RESULTS: Five hundred eighty-two children had NGTs secured traditionally (43% female; age at therapy initiation of 2.6 months [SD 8.1]), and 173 received nasal bridles (55.5% female; age at therapy initiation of 8.4 months [SD 11.8]). Children with bridled NGTs were 16.67 times less likely to experience one or more dislodgments (odds ratio [OR] = 0.06; 95% CI, 0.04-0.09); 2.5 times less likely to have one more ED visit (OR = 0.4; 95% CI, 0.19-0.82), and 4.76 times less likely to require one more radiographic exposure (OR = 0.21; 95% CI, 0.14-0.33) than unbridled children (all P values < 0.02). The mean initial hospital length of stay was 28 and 54 days in the bridled-NGT and standard-care groups, respectively (P < 0.001). Overall, 62.4% children with bridled NGTs and 77.1% children with unbridled NGTs progressed to full oral feedings and discontinued therapy (P < 0.001). Adverse skin outcomes were rare in both groups. CONCLUSION: Children with bridled NGTs experienced fewer dislodgments, hospital days, ED encounters, and radiographic exposures than unbridled NGTs. Most children in both groups progressed to full oral feedings.

Energy- and protein-enriched formula improves weight gain in infants with malnutrition due to cardiac and noncardiac etiologies.

BACKGROUND: We aimed to assess safety, tolerability, and improvement in weight gain with an energy- and protein-enriched formula (EPEF) in infants with poor growth. METHODS: Infants aged 1-8 months with poor growth received EPEF for 16 weeks. Our primary objective was improvement in weight as measured by change in weight-for-age z-score (WAZ) and weight gain velocity (grams per day) ≥ median for age. Secondary objectives included improvement in other anthropometric z-scores, formula tolerance, and safety. RESULTS: Twenty-six patients with poor growth due to congenital heart disease (n = 15), other organic causes (n = 9), and nonorganic causes (n = 2) completed the study per protocol. Mean daily energy intake was 123 ± 32 kilocalories per kilogram of body weight, with >90% of energy coming from EPEF. Weight gain velocity exceeded the median for 83% (20 of 24) and 67% (16 of 24) of infants at ≥1 time point and for the overall study period, respectively. Mean ± SD WAZ improved from -2.92 ± 1.04 at baseline to -2.01 ± 1.12 at 16 weeks (P = 0.0001). Z-scores for weight-for-length and head circumference (P = 0.0001) and for length-for-age (P = 0.003) improved significantly at 16 weeks. Compared with baseline, stool consistency was different at 2, 4, and 16 weeks (P < 0.05). There were no significant differences in vomiting, fussiness, or daily number of stools while there was a decrease or no change in spit-up, flatulence, crying, or gassiness. CONCLUSION: EPEF is safe, well tolerated, and improves weight gain in infants with poor growth.

Texture Consumption Patterns of 8- to 12-Month-Old Infants: A Reflection of Typical Feeding Development.

Purpose The lack of age-appropriate expectations for the acquisition of feeding skills and consumption of textured food in early childhood inhibits early and accurate identification of developmental delay in feeding and pediatric feeding disorder. The objective of this study was to describe texture intake patterns in a cohort of typically developing infants between 8 and 12 months of age, with the aim of informing future research to establish targets for feeding skill acquisition. Method Using cross-sectional methodology, we studied the presence of liquid and solid textures and drinking methods in the diet, consumption patterns by texture and drinking methods, and caloric intake by texture via caregiver questionnaire and 3-day dietary intake record in 63 healthy infants between 8 and 12 months of age. Descriptive statistics and a one-way analysis of variance were conducted to compare the effect of age on texture intake patterns. Results Findings reveal rapid advancement of intake patterns for texture overall and for energy intake by texture between 8 and 12 months of age. Whereas liquids continue to provide a large proportion of total energy through this time, solids contribute an equal proportion of energy by 12 months of age. Conclusions This study describes texture intake patterns in a cohort of typically developing infants between 8 and 12 months of age by examining the presence of texture and drinking methods, liquid and solid consumption patterns, and energy intake by texture. When applied to data from a future population sample, findings will provide a threshold for age expectations for typical and disordered feeding development to aid in the detection of developmental delay in feeding and pediatric feeding disorder. What Is Known: Expectations regarding early feeding development have been focused on nutrition parameters. Lack of standardized, age-appropriate expectations for texture progression in infancy and early childhood inhibits early and accurate identification and treatment of pediatric feeding disorder. What Is New: We have described changes in dietary composition by texture and drinking method in healthy infants. Together with nutritional composition, this study describes a more comprehensive assessment of infant feeding, particularly to clinicians who need to diagnose feeding skill deficits. Supplemental Material https://doi.org/10.23641/asha.16879615.

Catch-down growth in infants born large for gestational age.

Infants born large for gestational age (LGA) not exhibiting catch-down growth (a decline of weight z-score by 1) have a higher likelihood of future obesity. We aimed to identify the term LGA infants in our neonatal intensive care unit (NICU) and document nutrition interventions that may influence growth. Our 10-year retrospective review identified 47 term LGA infants who had a NICU length of stay (LOS) ≥7 days. We obtained demographic data, nutrition interventions in the NICU, and data regarding growth patterns. Of the 47 infants, 31 (66%), demonstrated catch-down growth at discharge at ≥7 days. Overall, 39 of 47 patients (83%) received interventions during their NICU stay, including 32 (69%) who had nasogastric tubes placed, and 24 (51%) had formula fortification to augment weight gain. Among patients with LOS ≥14 days, 23 of 23 patients without catch-down growth and four of five patients with catch-down growth had nutrition interventions performed. Of the overall population, only 38% of those who did not demonstrate catch-down growth had an LOS of ≥14 days vs 77% of all infants that did exhibit catch-down growth (P = .01). Our data suggest that nutrition interventions in LGA infants are common in the NICU. Our study highlights the need for further clinical studies to help direct care in this population of infants.

Reining in Nasogastric Tubes: Implementation of a Pediatric Bridle Program.

Nasogastric tubes (NG) used for enteral nutrition support of medically complex children (MCC) are often inadvertently removed, risking frequent replacements. Bridles have been shown to provide a safe securement method for NGs in adult patients, but are not widely used in pediatrics. Furthermore, nutritional management of MCC is often fragmented. We established a pediatric NG bridle program to bridge the gap amongst disciplines and improve patient outcomes. In January 2018, a multidisciplinary work group involving nurses, physicians, clinical dietitians, advanced practice providers, and speech-language pathologists was established to develop criteria for patient referral and policies, procedures, and order sets for nutritional management of MCC children with bridled NG tubes. Formal teaching sessions engaged clinicians and administrators to participate in building a successful program. Relevant outcomes of interest are tracked continuously for process performance improvement measures and are reviewed quarterly by the core work group. Patient enrollment began in May 2018 and to date, 244 patients have been enrolled. Adhering to strict enrollment criteria, competency modules and review of patient status provided a solid core for the program and process review. Successful implementation of an NG Bridle program was achieved. Outcomes of interest continue to be monitored for process improvement. Balancing measures are also being tracked for potential downstream effects.

Pediatric Feeding Disorder in Children With Short Bowel Syndrome.

OBJECTIVE: We aimed to characterize the prevalence of pediatric feeding disorder (PFD) in short bowel syndrome (SBS) and study factors contributing to the persistence of PFD. METHODS: Single-center retrospective study of patients diagnosed with SBS at age 6 months or younger. Data were collected in 3-month intervals through age 2 years, and every 6 months through age 4 years. Demographic information, anthropometric data, and details regarding nutrition support were recorded and analyzed. RESULTS: We reviewed 28 patients. Of the 21 patients who were weaned off parenteral nutrition, 57.1%, 81.0%, 90.5%, and 100.0% achieved this by 12, 24, 36, and 48 months of age, respectively. Of the 13 patients who were weaned off enteral nutrition, 30.8%, 69.2%, 76.9%, and 100.0% achieved this by 12, 24, 36, and 48 months, respectively. DISCUSSION: The prevalence of PFD was 100.0%, 76.5%, 68.8%, and 70.0% at 1, 2, 3, and 4 years of age, respectively. All patients who exhibited resolution of PFD had an underlying etiology of necrotizing enterocolitis. Median small bowel percentage remaining was greater in patients who exhibited resolution of PFD compared to those who did not. Except for the group of patients seen at 4 years of age, a larger percentage of patients with vomiting/history of requirement of postpyloric feeds were seen among patients with PFD compared to those without PFD. CONCLUSION: PFD is prevalent in children with SBS. Although prevalence decreases over time, children with PFD will continue to require more medical attention than children that do not.