Impact of psychosocial factors on medication level variability index and outcomes in pediatric liver transplant recipients.

BACKGROUND: Caregivers play an important role in maintaining a functioning graft after pediatric liver transplantation. Therefore, the psychosocial factors of both patients and caregivers can have a critical impact on transplant outcomes. Appropriate assessment and recognition of these factors pre-transplantation may allow transplant teams to better define the needs of pediatric organ recipients and develop specific countermeasures, which may then contribute toward improving transplant outcomes. METHODS: We studied 136 pediatric LT recipients followed at Texas Children's Hospital. Licensed social workers conducted comprehensive pre-transplant assessments on each patient, consisting of 22 psychosocial variables that were thought to impact adherence, which were reviewed during our study period. Non-adherence was determined using the MLVI for up to 4 years after transplantation. Biopsy-confirmed rejection episodes were assessed in the first 3 years after liver transplantation. RESULTS: Factors significantly associated with non-adherence (defined as MLVI >2) included parental age and parental education level at assessment, type of insurance, and household income. The number of ACR episodes trended higher in patients with non-adherence, and these patients had a higher number of moderate to severe rejection episodes but this trend was not statistically significant. CONCLUSIONS: Psychosocial characteristics such as parental age, education level, insurance, and household income may contribute significantly to suboptimal adherence to medications after transplantation. Identification of these psychosocial factors and early intervention is essential to the success and equitable care of our pediatric LT recipients.

Management of Wilson Disease Diagnosed in Infancy: An Appraisal of Available Experience to Generate Discussion.

Increased access to molecular genetic testing is changing the demographics for diagnosing inherited disorders and imposing new challenges for medical management. Wilson disease (WD), typically diagnosed in older children and adults, can now be detected in utero and in infants (children younger than 24 months, including neonates) via genetic testing. An evidence-based approach to management of these neonates and extremely young children, who are typically asymptomatic, has been hampered by lack of clinical experience. We present a case of an infantile diagnosis of WD, review available experience, and discuss current trends in antenatal genetic testing of parents and fetus that may lead to a very early diagnosis of WD. Based on physiological and nutritional considerations, we propose an algorithmic approach to management of infantile WD as a starting point for further discussion. Future collaboration amongst specialists is essential to identify evidence-based approaches and best practice for managing treatment of infants with genetically diagnosed WD.

A Standardized Framework for Transplant-Specific Competencies for Dietitians.

Dietitians have extensive training and are considered the experts in medical nutrition therapy (MNT). Although dietitian competencies for MNT are well established, competencies that account for the expanded roles of dietitians working in transplantation have not been developed. These expanded roles require a better understanding of transplant processes, regulations, and even the business side of transplant, novel concepts to most dietitians. Therefore, we proposed a standardized framework of transplant-specific competencies for dietitians practicing in transplantation. These competencies can help improve and standardize initial and ongoing training for transplant dietitians moving forward, ultimately leading to improved patient care for transplant candidates, recipients, and donors.

Malnutrition, sarcopenia, and frailty assessment in pediatric transplantation.

Nutrition assessment can be challenging in children with end-stage organ disease and in those requiring an organ transplant. The effect of poor nutrition status can exert long-lasting effects on children with end-stage organ disease requiring transplantation. Malnutrition, sarcopenia, and frailty are conditions that require provision of optimal nutrition to prevent or support the treatment of these conditions. Unfortunately, the literature on the assessment of malnutrition, sarcopenia, and frailty in pediatric end-stage organ disease is scarce, thus leading to confusion on how to effectively identify them. Recently, the addition of a variety of validated nutrition and functional assessment techniques has assisted with appropriate assessment of these conditions. The objective of this narrative review is to provide an overview of the current literature for pediatric assessment of malnutrition, sarcopenia, and frailty in the setting of solid organ transplantation and provide practicing nutrition clinicians a solid foundation for learning how to effectively assess these conditions with the current literature available.

Malnutrition Risk in Hospitalized Children: A Descriptive Study of Malnutrition-Related Characteristics and Development of a Pilot Pediatric Risk-Assessment Tool.

BACKGROUND: Underrecognition of pediatric malnutrition may affect nutrition interventions and outcomes. Pediatric malnutrition uses more specific etiology-based criteria but lacks clarity in implementation guidelines. Study goals were to identify malnutrition and risk among hospitalized patients, characterize malnutrition risk factors, and assess reliability of criteria against outcome measures. MATERIALS AND METHODS: All children 44 weeks postmenstrual age-18 years, admitted for 48 hours during a 16-day period, were included (n = 528). Trained dietitians assessed patients in physical assessments (PA), growth, energy intake, increased nutrient losses (IL), altered absorption of nutrients (AA), hypermetabolism and inflammation, laboratory information, micronutrient deficiency, and functional status. Outcome data assessed were length of stay (LOS), intensive care unit (ICU) LOS, ventilation days, nutrition support, and dietitian intervention. RESULTS: Malnutrition prevalence upon admission was 19.7%. Weight/length or BMI/age z-score (ZS) had no effect on LOS. AA and IL upon admission were independently associated with malnutrition (both, P<.01). Wasting and hypermetabolism were independently associated with longer LOS (P<.01). Other factors associated with longer LOS included IL and inflammation (P < .05). Those with hypermetabolism had significant ZS improvements if followed by a dietitian (P < .05). Wasting via PA was the only factor associated with longer ICU LOS (P < .05). CONCLUSIONS: Identification of risk factors (wasting, hypermetabolism, AA, IL) beyond anthropometrics to define malnutrition and risk is important in prioritizing care in a tertiary pediatric facility. Of great significance is the ability of dietitian-based PA to predict LOS and need for intervention.

Central line-associated bloodstream infection among children with biliary atresia listed for liver transplantation.

BACKGROUND: Pre-transplant nutrition is a key driver of outcomes following liver transplantation in children. Patients with biliary atresia (BA) may have difficulty achieving satisfactory weight gain with enteral nutrition alone, and parenteral nutrition (PN) may be indicated. While PN has been shown to improve anthropometric parameters of children with BA listed for liver transplantation, less is known about the risks, particularly infectious, associated with this therapy among this specific group of patients. AIM: To describe the incidence, microbiology, and risk factors of central line-associated bloodstream infection (CLABSI) among children with BA listed for liver transplantation. METHODS: Retrospective review of children aged ≤ 2-years of age with BA who were listed for primary liver transplantation at Texas Children's Hospital from 2008 through 2015 (n = 96). Patients with a central line for administration of PN (n = 63) were identified and details of each CLABSI event were abstracted. We compared the group of patients who experienced CLABSI to the group who did not, to determine whether demographic, clinical, or laboratory factors correlated with development of CLABSI. RESULTS: Nineteen of 63 patients (30%, 95%CI: 19, 43) experienced 29 episodes of CLABSI during 4800 line days (6.04 CLABSI per 1000 line days). CLABSI was predominantly associated with Gram-negative organisms (14/29 episodes, 48%) including Klebsiella spp., Enterobacter spp., and Escherichia coli. The sole polymicrobial infection grew Enterobacter cloacae and Klebsiella pneumoniae. Gram-positive organisms (all Staphylococcus spp.) and fungus (all Candida spp.) comprised 9/29 (31%) and 6/29 (21%) episodes, respectively. No demographic, clinical, or laboratory factors were significantly associated with an increased risk for the first CLABSI event in Cox proportional hazards regression analysis. CONCLUSION: There is substantial risk for CLABSI among children with BA listed for liver transplantation. No clinical, demographic, or laboratory factor we tested emerged as an independent predictor of CLABSI. While our data did not show an impact of CLABSI on the short-term clinical outcome, it would seem prudent to implement CLABSI reduction strategies in this population to the extent that each CLABSI event represents potentially preventable hospitalization, unnecessary healthcare dollar expenditures, and may exact an opportunity cost, in terms of missed allograft offers.

Malnutrition among Hospitalized Children in the United States: Changing Prevalence, Clinical Correlates, and Practice Patterns between 2002 and 2011.

BACKGROUND: Pediatric malnutrition has been associated with adverse clinical outcomes, longer lengths of stay, and higher health care costs. OBJECTIVE: To characterize prevalence, temporal trends, and short-term clinical outcomes of coded diagnoses of pediatric malnutrition (CDM) across sociodemographic, clinical, and hospital characteristics from 2002 to 2011. DESIGN: This study is a retrospective cross-sectional analysis of nationally representative data from the Nationwide Inpatient Sample and the Kids' Inpatient Database. PARTICIPANTS/SETTING: The study sample included pediatric inpatient hospitalizations in the United States. MAIN OUTCOME MEASURES: International Classification of Diseases-9th Revision-Clinical Modification diagnosis codes were used to identify CDM and coded malnutrition subtypes based on an etiology-related definition of pediatric malnutrition. STATISTICAL ANALYSES: The national frequency and prevalence of CDM overall and across patient- and hospital-level characteristics were estimated for children aged 1 month to 17 years. Logistic regression was used to assess the association between CDM and each characteristic. Analyses evaluated conditions associated with the highest burden and risk of CDM, and compared clinical outcomes across malnutrition subtypes. Joinpoint regression was used to describe temporal trends in CDM. RESULTS: Of the 2.1 million pediatric patients hospitalized annually, more than 54,600 had CDM, a national prevalence of 2.6%. Considerable variation was observed based on primary diagnosis, with fluid and electrolyte disorders contributing the most malnutrition cases. Highest CDM rates were among patients with stomach cancer, cystic fibrosis, and human immunodeficiency virus. Patients with CDM experienced worse clinical outcomes, longer lengths of stay, and increased costs of inpatient care. The overall prevalence of CDM increased from 1.9% in 2002 to 3.7% in 2011, an 8% annual increase, and temporal increases were observed in nearly all population subgroups. CONCLUSIONS: Despite improvements, pediatric malnutrition remains underdiagnosed in inpatient settings when relying exclusively on International Classification of Diseases-based codes, which underscores the need for a national benchmarking program to estimate the true prevalence, clinical significance, and cost of pediatric malnutrition.

Neuropsychological functioning in preschool-aged children undergoing evaluation for organ transplant.

OBJECTIVE: The purpose of this study was to review the current literature on neuropsychological functioning in two groups of children requiring organ transplants (liver or heart) and present recent clinical data collected through the liver and cardiac transplantation programs at a large pediatric academic medical center. METHOD: Data included in this study came from 18 patients who completed evaluations for heart transplant (n = 8) or liver transplant (n = 10) between the ages of 2 and 6 years (inclusive). Measures examining neurocognitive, emotional-behavioral, and adaptive functioning were collected as part of standard pre-transplant clinical neuropsychological evaluations. Within each organ group, mean scores were calculated and compared with normative population mean scores using one sample t-tests. In addition, non-parametric binomial tests were calculated to examine whether the proportion of individuals falling more than one standard deviation below the population mean was significantly greater in the patient groups than the normative population base rate of 16%. RESULTS: Patients in both groups performed below normative expectation in several neurocognitive and adaptive domains. However, neither group showed significant difficulties in behavioral or emotional regulation. CONCLUSIONS: Results from this study document cognitive delays in preschool-aged children undergoing evaluations for liver transplant or heart transplant, highlighting the importance of intervention and long-term monitoring of these two patient populations, as well as the need for neuropsychologist involvement with transplant teams.

Pediatric Malnutrition: Putting the New Definition and Standards Into Practice.

In recent years, much effort has been directed at redefining malnutrition in the pediatric population to include the acute clinical population in addition to the more traditional ambulatory populations. In 2013, an expert panel convened to perform a critical review of available literature to craft a new approach to malnutrition. Closely thereafter, the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition published recommended indicators for the identification and documentation of malnutrition in pediatric populations. The purpose of this article is to review the domains within the new definition of malnutrition in pediatric practice, describe populations in which the recommended indicators for identification and management are problematic in clinical practice, give case studies that apply the new definition, and finally describe the implementation of a malnutrition identification program within a large tertiary care children's hospital.

Green tea extract: a potential cause of acute liver failure.

The use of herbal products has increased significantly in recent years. Because these products are not subject to regulation by the Food and Drug Administration and are often used without supervision by a healthcare provider, the indication for and consumption of these supplements is quite variable. Moreover, their use is generally regarded as safe and natural by the lay-public. Unfortunately, there has been an increase in the number of reported adverse events occurring with the use of herbal products. We present a case of acute impending liver failure in an adolescent male using a weight-loss product containing green tea extract. Our case adds to the growing concern surrounding the ingestion of green tea extract and serves to heighten healthcare provider awareness of a potential green tea extract hepatotoxicity. Despite the generally touted benefits of green tea as a whole, clinical concern regarding its use is emerging and has been linked to its concentration in multiple herbal supplements. Interestingly, the suspected harmful compounds are those previously proposed to be advantageous for weight-loss, cancer remedy, and anti-inflammatory purposes. Yet, we emphasize the need to be aware of not just green tea extract, but the importance of monitoring patient use of all dietary supplements and herbal products.