Home enteral nutrition does not decrease oral feeding in children during the first year of nutritional support.

BACKGROUND: Enteral nutrition is necessary when nutritional status is poor and oral intake is insufficient or impossible. Although it has been suspected to reduce spontaneous oral feeding, no study has formally assessed the influence of enteral nutrition on pediatric oral intake. The present study aimed to evaluate variation in oral feeding intake after enteral nutrition initiation, and to identify factors influencing oral feeding. METHODS: This retrospective cohort study included 149 pediatric patients from two French tertiary care hospitals, who received home enteral nutrition from 2009 to 2022. The patients were aged 2 months to 17 years (median age 3 years, interquartile range 1.3-9.2). Oral and enteral intakes were assessed when enteral nutrition was initiated (M0), and again at M3 (n = 123), M6 (n = 129), and M12 (n = 134) follow-ups, based on dieticians' and home services' reports. Oral feeding and body mass index z score variations during follow-ups were evaluated using a linear mixed regression model, including "time" as a fixed effect and "patient" as a random effect. Factors associated with oral feeding changes were assessed using a model interaction term. RESULTS: Oral intake did not vary significantly (P = 0.99) over time and accounted for 47.4% ± 27.4%, 46.9% ± 27.4%, 48.4% ± 28.2%, and 46.6% ± 26.9% of the ideal recommended daily allowance (calculated for the ideal weight for height) at M0, M3, M6, and M12, respectively. Delivery method (nasogastric tube versus gastrostomy), prematurity, underlying disease, history of intrauterine growth retardation, and speech therapy intervention did not influence oral intake. Administration (i.e., exclusively continuous nocturnal infusion versus daytime bolus) led to different oral intake development, although oral intake also differed at M0. CONCLUSIONS: Enteral nutrition, although increasing total energy intake, does not alter oral feeding during the first year of administration. Only the mode of administration might influence oral intake.

"Baby-led weaning" - Progress in infant feeding or risky trend?

Baby-led weaning (BLW), proposed as a new form of complementary feeding, has emerged as a real trend phenomenon in the media. Infants are seated at the family table from the age of 6 months, facing the foods they grab and bring to their mouth: they decide which foods they want to eat and what amount. The consumption of mashed foods and the use of a spoon are totally discouraged. BLW is increasingly used in nurseries and centers of young children. A bibliographic search carried out between 2000 and 2021 found 423 articles, of which 38 were selected. The clinical studies selected are 11 cross-sectional observational studies and two randomized controlled studies. BLW promotes breastfeeding, the early introduction of morsels, the respect of the child's appetite, the use of unprocessed foods, and the choice of "homemade" and friendliness. These benefits can nonetheless be reached with usual complementary feeding (SCF), according to current recommendations. Other benefits are claimed without scientific evidence such as easier achievement of dietary complementary feeding and an optimal growth with prevention of excess weight gain. BLW has some obvious downsides. The infant may not get enough energy, iron, zinc, vitamins, and other nutrients, or too much protein, saturated fat, salt, or sugar. The risk of choking, which must be distinguished from the physiological gagging reflex, has not been ruled out by scientific studies. Currently, the Nutrition Committee of the French Pediatric Society considers that the data published to date in terms of benefits and risks of BLW do not lend themselves to advice for this practice in preference over SCF carried out according to current recommendations.

The role of nutrition in non-alcoholic fatty liver disease treatment in obese children.

Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent chronic liver disease that occurs mostly in the context of insulin resistance and obesity. It has rapidly evolved into the most common cause of liver disease among children. The incidence is high in obese children and a greater risk of disease progression is associated with severe obesity, highlighting the role of nutrition. To date, there is no consensus on NAFLD management. This is a narrative review of clinical studies on the potential benefit of nutritional interventions, including lifestyle modifications, vitamins, docosahexaenoic acid, and probiotics in children with NAFLD. The Comité de nutrition de la Société Française de Pédiatrie (CN-SFP) emphasizes the effect of limiting added sugar intake, i.e., fructose or sucrose-containing beverages, and promoting physical activity in the care of NAFLD.

Nutritional risks of ARFID (avoidant restrictive food intake disorders) and related behavior.

Avoidant/restrictive food intake disorder (ARFID) has recently been added to the DSM V (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) as a new class of eating disorders (EDs). ARFID is characterized by a lack of interest in eating or avoiding specific types of foods because of their sensory characteristics. This avoidance results in decreased nutritional intake, eventually causing nutritional deficiencies. In severe cases, ARFID can lead to dependence on oral nutritional supplements, which interferes with psychosocial functioning. The prevalence of ARFID can be as high as 3% in the general population, and it is often associated with gastrointestinal symptoms and mainly appears in children with anxiety disorders. Given the high prevalence of ARFID, a rapid and systematic nutrition survey should be conducted during every pediatric consultation. Its treatment should also be adapted depending on the severity of the nutritional problem and may involve hospitalization with multidisciplinary care (pediatrician, nutritional therapist, dietitian, psychologists, and speech therapists).

Better early outcome with enteral rather than parenteral nutrition in children undergoing MAC allo-SCT.

There is no consensus on the type of nutritional support to introduce in children undergoing allogeneic stem cell transplantation (allo-SCT) after myeloablative conditioning (MAC). This retrospective, multicenter, observational study compared the early administration of enteral nutrition (EN group, n = 97) versus parenteral nutrition (PN group, n = 97) in such patients with matching for important covariates. The primary endpoint was the study of day 100 overall mortality. The early outcome at day 100 was better in EN group regarding mortality rate (1% vs. 13%; p = 0.0127), non relapse mortality (1% vs. 7%; p = 0.066), acute GVHD grades II-IV (37% vs. 54%; p = 0.0127), III-IV (18% vs. 34%; p = 0.0333) and its gut localization (16% vs. 32%; p = 0.0136). Platelet engraftment was better in EN group than in PN group for the threshold of 20 G/L (97% vs. 80% p < 0.0001) and 50 G/L (92% vs. 78%, p < 0.0001). The length of stay was shorter in EN group (28 vs. 52 days, p < 0.0001). There were no differences between the two groups regarding the polynuclear neutrophil engraftment, infection rate or mucositis occurrence. These results suggest that, in children undergoing MAC allo-SCT, PN should be reserved to the only cases when up-front EN is insufficient or impossible to perform.

[Organization of collaborative deliberation for limiting or withholding treatments in children]. / Comment organiser la délibération collégiale pour limiter ou arrêter les traitements en pédiatrie?

In 2005, the French law on patients' rights at the end of life required that decisions to withdraw or withhold life-sustaining treatments be made and carried out by the physician in charge of the patient, after obtaining advice from an independent consulting colleague and the caregiving team. The purpose of this study was to identify theoretical and practical obstacles to this collaborative deliberation and to propose practical guidelines to organize it.

Micronutrient status of children receiving prolonged enteral nutrition.

BACKGROUND AND AIMS: The aim of this study was to assess the micronutrient status of children receiving prolonged enteral nutrition. METHODS: This cross-sectional single-center study included all 64 children (median age 6.8 years) receiving enteral nutrition providing >50% of daily energy intake for more than 6 months (median duration of enteral nutrition 43 months). The characteristics of the patients and mode of enteral nutrition were recorded. The concentrations of iron, zinc, copper, selenium and vitamins A, D, E and C were measured in plasma. RESULTS: Twelve children (19%) had iron deficiency. A high 25-hydroxyvitamin D concentration was recorded in 20% of the children, but none had associated hypercalcemia. Fifty-two children (81%) had low zinc concentrations in both plasma and erythrocytes. Plasma zinc, calcium, phosphorus and vitamin D concentrations were significantly lower in children receiving fiber supplementation. Abnormal micronutrient concentrations were found more frequently in the children receiving fiber supplementation. No other predisposing factors were associated with micronutrient deficiencies. CONCLUSION: Long-term enteral nutrition can lead to micronutrient deficiencies in children, whose micronutrient concentrations may require regular checking. Fiber supplementation might reduce the bioavailability of zinc, calcium, phosphorus and vitamin D.

[The consulting physician for withdrawal of life-sustaining treatments in children]. / Le médecin consultant pour les limitations et les arrêts de traitement en pédiatrie.

In 2005, the French law on patients' rights at the end of life ratified that decisions to withdraw or withhold life-sustaining treatments must be made and carried out by the physician in charge of the patient, after obtaining the advice of an independent consulting colleague. The purpose of this text is to put forward the perspective of a pediatric multidisciplinary workshop regarding the role of the consulting physician and to propose guidelines to help choose this consultant.

Enteral nutrition: a first option for nutritional support of children following allo-SCT?

Parenteral nutrition (PN) is the treatment of choice for nutritional support of patients undergoing allo-SCT following myeloablative conditioning (MAC). Here we prospectively assessed the outcomes of early enteral nutrition (EN) in a paediatric cohort. From 2003 to 2010, all 65 consecutive children undergoing MAC allo-SCT at our referral centre began EN the day after transplantation. Post-transplant and nutritional outcomes of patients receiving only EN (EN group, n=50) were compared with those of patients requiring additional PN (EN-PN group, n=15). In the EN group time to platelet recovery (P=0.01) and length of hospitalisation (P<0.001) were shorter, while in the EN-PN group the proportion of unrelated donors (P=0.02) and the frequency of severe acute GVHD (aGVHD; P=0.004) were higher. All patients were alive at day 100. PN was started 14 days after transplant because of poor digestive tolerance to EN or severe gut aGVHD. The body mass index Z-score in the EN-PN group decreased from transplant to discharge (P=0.02). In only 23% of cases was PN required for severely ill patients. Our results suggest that EN might be considered to be an option for nutritional support in children undergoing MAC allo-SCT, while PN should be used only as a rescue option, possibly in combination with EN.

[Per and post-natal medical management of congenital diaphragmatic hernia]. / Prise en charge médicale per et post-natale de la hernie congénitale du diaphragme.

Congenital diaphragmatic hernia (CDH) is a 1 out of 3500 live-born malformation with persistent 30-40% mortality rate, related to severe pulmonary hypoplasia and hypertension. Better knowledge on the mechanisms inducing failure of adaptation at birth is a prerequisite for improving CDH prognosis. CDH is also associated with longterm morbidity, including prolonged respiratory failure, failure to growth, oral aversion, and scoliosis. Early prevention starting as soon as the first hours of life are required to reduced long term morbidity. The aims of the management are not only to reduce early mortality, related to persistent pulmonary hypertension, but also to prevent late morbidity.

Efficacy and tolerance of gastrostomy feeding in Duchenne muscular dystrophy.

Undernutrition occurs often in individuals with Duchenne muscular dystrophy (DMD). Between 1997 and 2007, a gastrostomy was placed in 25 patients with DMD (median: 23 years old; range, 11-38 years) for weight loss (n=22) and/or swallowing disorders (n=13). We evaluated nutritional status using the weight-for-age (W/A) ratio, comparing the values to the reference curve for DMD patients. During the first 9 months, nutritional status improved: the W/A ratio increased and reached a plateau. The W/A ratio was 69% (range, 45-128%) at the start and increased to 87% (range, 49-164%) at the maximal follow-up of 22 months (P<0.001). However, the W/A ratio did not reach the median value for age. Complications occurred in 21 patients (84%), but caused no mortality. Our data suggest that gastrostomy is well tolerated by, and effective for improving the nutritional status of, individuals with DMD.

[Effect of the adaptation of the food of the hospitalized child on the cover of the nutritional needs]. / Effet de l'adaptation de l'alimentation de l'enfant hospitalisé sur la couverture des besoins nutritionnels.

AIMS: Denutrition remains a major concern in hospitalized children. Daily experience suggests that the meals proposed by hospital dietetic service, although well-balanced and in accordance with the recommendations, may be poorly accepted and consumed by children. The aims of this study were to assess the effect of modification of foods offer on energy intakes as well as nutriments and minerals and trace elements in hospitalized children. PATIENTS AND METHODS: During a 1-month period, 25 consecutive children (range 4-17 years; 13 girls), hospitalized in our pediatric department were included in the study (reasons for hospitalisation comprised: medical reasons [n=7], orthopedic problem [n=16] or surgery [n=2]). They had no restricted diet and received the usual pediatric hospital feeding according to the French recommended dietary allowances (RDA) (D1). They were compared to 21 children--matched for age, sex, nutritional status and pathology, hospitalized during the following 1-month period--who received a modified diet (D2), elaborated by dieticians according to the child's preference and excluded or limited food usually nonconsumed by the children. Food consumption was prospectively measured for 24h by analysis of the nonconsumed foods, as well as browsing and extra food brought by the family. Analysis of energy, carbohydrate, lipid, protein, iron and calcium intake was made using Bilnut 3 software (Nutrisoft, France). RESULTS: D2 covered 119+/-37% of the median energy needs versus 89+/-37% for D1 (p<0.05). The median energy needs were more often reached with D2 as compared to D1 (62% versus 32%, p<0.05). Protein intake was high in both groups, more importantly with D2 (266+/-111% of RDA versus 193+/-77% with D1, p<0.05). We observed no difference between the 2 diets in regards of fat/carbohydrate balance and iron intake. Calcium intake was increased with the adapted diet: 68+/-26% of RDA with D2 versus 49+/-26% with D1 (p<0.01). CONCLUSION: Adapting food offers to preference influences food and caloric intakes in hospitalized children. This could be an efficient strategy to prevent acute undernutrition in hospital.

[Errors for delivery medications through gastrostomy devices: study of 109 children]. / Erreurs dans l'administration des médicaments par les dispositifs des gastrostomies: étude chez 109 enfants.

UNLABELLED: Gastrostomy is frequently used in clinical practice for drug administration. However modalities of drug administration via a gastrostomy device have been poorly studied and remain uncodified. AIM: To assess the mode of administration of drugs as well as errors associated with the use of a gastrostomy devices for drug delivery in children. PATIENTS AND METHODS: Mode of administration of drugs was studied in 109 children (mean age 8.4+/-5.5 years, 72% neurologically impaired, 41% institutionalized children). A questionnaire was filled in by parents and/or caregivers. Errors of administration were classified as follows: galenic, due to preparation, physico-chemical interaction, lack of flushing the tube. Factors influencing the occurrence of errors were studied: living at home or in an institution, underlying disease, number of drugs administered via gastrostomy device. RESULTS: Errors were frequently observed: galenic (47%), due to preparation (42%), physico-chemical interaction (51%), lack of flushing (10%). Errors occurred more frequently in institutionalized children compared to children living at home (78 versus 25%, P<0.0005). Galenic errors were more frequent in neurologically impaired children (57 versus 30%, P<0.005). CONCLUSION: Many medications are administrated via gastrostomy tube in children. Errors are frequently observed and potentially dangerous.

[An excessive diagnosis of constipation in children complaining of abdominal pain in a pediatric emergency department: an example of practice patterns]. / Une prévalence excessive du diagnostic de constipation chez les enfants consultant pour douleurs abdominales aux urgences: un exemple d'évaluation des pratiques.

UNLABELLED: Prescriptions of abdominal x-ray and diagnosis of constipation seemed too frequent in children evaluated for abdominal pain (AP) in a paediatric emergency unit. OBJECTIVE: To evaluate the prevalence of constipation in children with AP, to determine clinical and radiological signs related to this diagnosis, and to compare frequencies of clinical criteria of functional chronic constipation (FCC) in children with AP with those of controls (children with mild traumatisms without AP). METHODS: This prospective observational study included children older than 4 years of age consulting for AP. RESULTS: Among 196 patients with AP, 53% had a diagnosis of constipation on discharge (28% isolated and 25% associated with an other diagnosis), and 88% had a plain abdominal x-ray. A faecal retention was considered by emergency practitioners in 92% of children with the diagnosis of constipation vs 22% with other diagnosis (OR=38; CI 95%: 15-101). Clinical criteria of FCC were associated with the diagnosis of constipation (OR=2.7; CI 95%: 1.4-5.2). A FCC was as prevalent in the control population as in AP population (32 vs 34%). CONCLUSION: An excessive prevalence of diagnosis of constipation was mainly associated with contestable x-ray diagnosis of faecal retention secondary to inappropriate indications of abdominal x-ray.

Mitomycin C: an alternative conservative treatment for refractory esophageal stricture in children?

BACKGROUND AND STUDY AIMS: Mitomycin C is an antiproliferative agent that has been used successfully as an adjunct treatment in ophthalmological procedures, in the management of laryngeal and tracheal stenosis, and more recently to prevent the recurrence of caustic esophageal strictures in children. The aim of this study was to assess the efficacy and safety of local application of mitomycin C to refractory esophageal strictures in children. PATIENTS AND METHODS: We performed a preliminary prospective study of local application of mitomycin C in four children, aged between 1 year and 6 years, who had refractory esophageal strictures. Two of the children presented with strictures caused by caustic ingestion and the other two children had anastomotic strictures following surgical repair of congenital esophageal atresia. The patients had required between four and ten esophageal dilations over a 5-24-month period before mitomycin C application. After an endoscopic dilation, mitomycin C was applied onto the dilation wound using a rigid endoscope. RESULTS: No complications were observed after the procedure. One child required a second application of mitomycin C 2 weeks after the first application because of recurrence of dysphagia. All the children remained asymptomatic and none of them required further dilation over a mean follow-up period of 24 months. Radiological control examinations revealed that there was no recurrence of the esophageal strictures and esophageal biopsies performed during follow-up showed no signs of dysplasia. CONCLUSIONS: Local application of mitomycin C is a potential alternative to iterative dilations, surgery, or stent placement for the treatment of refractory esophageal strictures in children. However, prospective, long-term assessment of outcomes is needed before any definitive conclusion can be drawn about the usefulness of mitomycin C in these patients.

[Malnutrition screening in hospitalized children: influence of the hospital unit on its management]. / Dépistage de la malnutrition chez l'enfant hospitalisé: influence de la structure d'accueil dans la prise en charge.

OBJECTIVES: The aims of this study were to assess the prevalence of malnutrition in a pediatric population hospitalized in a French regional hospital and to evaluate the influence of type of hospital unit (pediatric or not) in the screening and the management of malnutrition. PATIENTS AND METHODS: This one-day cross-sectional survey was performed in three different seasons during 2003. Every child aged 2 months to 16 years old, hospitalized for more than 48 hours was included. Weight for height, Z-score and Body Mass Index Z-score were used for nutritional assessment. Type of hospitalisation unit, date of admission, associated diagnosis, screening and treatment of malnutrition were also taken into account. RESULTS: Two hundred and eighty hospitalized children were undernourished (11%) and thirty-one children were obese (11%) with no difference in prevalence of malnutrition between pediatric and non-pediatric units. At the time of the study, malnutrition was recognized in one third of the children, at a similar rate whatever the type of hospitalized unit. The children hospitalized in pediatrics wards benefited more frequently from nutritional intervention, i.e. dietician care (43 vs. 16% P < 0.01). CONCLUSION: Prevalence of malnutrition in hospitalized children is low and the same in pediatric or non-pediatric units. Screening of malnutrition remains unsatisfactory in hospital. However, malnutrition is more frequently treated in pediatric unit compared with non-pediatric unit.