Nutritional support practices and opinions toward gastrostomy use in pediatric bone marrow transplant centers: A national survey.

OBJECTIVE: Previous surveys have shown deviations in nutritional practices from international guidelines during bone marrow transplant (BMT). Guidelines recommend enteral nutrition first-line and nasogastric tubes are the mainstay for its provision. Gastrostomies provide an alternative, yet their use is less common. This national survey investigated nutrition support practices in pediatric allogeneic BMT centers and compared clinicians' opinions on gastrostomy use. The aim of this study was to identify the national picture of nutritional support practices across pediatric allogeneic BMT centers, including use and opinions of dietitians, clinical nurse specialists, and physicians, toward gastrostomy feeding. METHODS: An online survey was administered to 12 centers. The lead dietitian answered questions regarding nutritional counseling, screening, assessment, and interventions. Questions regarding current use, perceived advantages, and problems of gastrostomies were answered by the dietitian, lead clinical nurse specialist, and physician. RESULTS: A 100% response rate was achieved from 12 centers (N = 36 clinicians). Nutritional counseling was provided in 92% of centers before and routinely throughout admission, 83% screened on and regularly throughout admission, 83% assessed nutritional status before transplant, and 92% used enteral nutrition first-line. Forty-two percent of the centers used gastrostomies. In those not using gastrostomies, 76% of clinicians felt some children should be offered a gastrostomy. Clinicians perceived less displacements (78%) and cosmetic appearance (69%) as the most common advantages of gastrostomies over nasogastric tubes. Risks associated with surgery (92%) and tube/stoma complications (58%) were the most common perceived problems. CONCLUSIONS: A similar approach was shown on many aspects of nutritional support. Gastrostomy use divided opinion with differences in use and perceived advantages, but agreement on potential complications. Despite their risks, clinicians wanted to use gastrostomies more. Placement requires careful consideration of the risks, benefits, and family preferences.

Hypervitaminosis A is prevalent in children with CKD and contributes to hypercalcemia.

BACKGROUND: Vitamin A accumulates in renal failure, but the prevalence of hypervitaminosis A in children with predialysis chronic kidney disease (CKD) is not known. Hypervitaminosis A has been associated with hypercalcemia. In this study we compared dietary vitamin A intake with serum retinoid levels and their associations with hypercalcemia. METHODS: We studied the relationship between vitamin A intake, serum retinoid levels, and serum calcium in 105 children with CKD stages 2-5 on dialysis and posttransplant. Serum retinoid measures included retinol (ROH), its active retinoic acid (RA) metabolites [all-trans RA (at-RA) and 13-cis RA] and carrier proteins [retinol-binding protein-4 (RBP4) and transthyretin (TTR)]. Dietary vitamin A intake was assessed using a food diary. RESULTS: Twenty-five children were in CKD 2-3, 35 in CKD 4-5, 23 on dialysis and 22 posttransplant; 53 % had vitamin A intake above the Reference Nutrient Intake (RNI) value. Children receiving supplemental feeds compared with diet alone had higher vitamin A intake (p = 0.02) and higher serum ROH (p < 0.001). Notably, increased ROH was seen as early as CKD stage 2. For every 10 ml/min/1.73 m(2) fall in estimated glomerular filtration rate (eGFR), there was a 13 % increase in ROH. RBP4 levels were increased in CKD 3-5 and dialysis patients. The lowest ratios of ROH:RBP4 were seen in dialysis compared with CKD 2-3 (p = 0.03), suggesting a relative increase in circulating RBP4. Serum ROH, RBP4 and at-RA were associated with serum calcium. On multivariable analysis RBP4 levels and alfacalcidol dose were significant predictors of serum calcium (model R (2) 32 %) in dialysis patients. CONCLUSIONS: Hypervitaminosis A is seen in early CKD, with highest levels in children on supplemental feeds compared with diet alone. Serum retinoid levels significantly predict hypercalcemia.