Examining Risk Factors of Health-Related Quality of Life Impairments Among Adolescents with Inflammatory Bowel Disease.

Inflammatory Bowel Disease (IBD) is a chronic, costly, and burdensome disease that is typically diagnosed during adolescence. Despite the use of effective treatments, rates of relapse and intestinal inflammation remain high and put patients at risk for long term physical and psychosocial health complications. Given the costs associated with IBD, it is critical to examine potential risk factors of poor health-related quality of life (HRQoL) among patients for the enhancement and further development of interventions. As such, the aim of the current study was to examine how sociodemographic and disease characteristics, psychosocial problems, and adherence behaviors impact HRQoL among a sample of youth with IBD. 107 adolescents with IBD and their caregiver completed self- and parent-report measures as part of a psychosocial screening service. Medical records were reviewed to obtain information regarding diagnosis, insurance, medication use, illness severity, and disease activity. Results revealed lower HRQoL scores among adolescents with more psychosocial problems (Est. = -3.08; p < .001), greater disease severity (Est. = -.40; p = .001), and those who identified as Black (Est. = -.38; p < .05). Greater disease severity (Est. = .13 p = .004), use of nonpublic insurance (Est. = .32 p = .004), and fewer psychosocial problems (Est. = -.13 p = .04) were associated with greater adherence behaviors. These findings suggest that implementing individually tailored, evidence-based psychological interventions focused on coping with psychosocial problems and symptoms may be important in enhancing adherence behaviors and HRQoL among adolescents with IBD.

Food Insecurity and Pediatric Malnutrition Related to Under- and Overweight in the United States: An Evidence Analysis Center Systematic Review.

Both food insecurity and malnutrition are associated with adverse health outcomes in the pediatric population. However, the research on the relationship between these factors has been inconsistent, leading to uncertainty regarding whether or how evaluation of food insecurity should be incorporated into nutrition screening or the nutrition care process. The objective of this systematic review was to determine the association between food insecurity and malnutrition related to undernutrition or overnutrition (defined by anthropometrics) in the pediatric population in the United States. A literature search was conducted using Medline, Embase, and CINAHL databases for studies published from January 2002 through November 2017. A total of 23 studies (19 cross-sectional and 4 prospective cohort studies) met inclusion criteria and were included in qualitative analysis. In 6 studies, there was no overall relationship between food insecurity and underweight. All included studies examined the relationship between food insecurity status and overweight/obesity and results were mixed, with large cross-sectional studies demonstrating a positive relationship between food insecurity and overweight/obesity. There were no clear patterns according to subpopulation. Evidence quality was graded as fair due to heterogeneity in how food insecurity was measured and populations included as well as inconsistency in results. Use of a 2-item food insecurity screening tool may allow for efficient, effective screening of food insecurity in order to identify potential contributors overweight and obesity.

The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper.

Serum albumin and prealbumin, well-known visceral proteins, have traditionally been considered useful biochemical laboratory values in a nutrition assessment. However, recent literature disputes this contention. The aim of this document is to clarify that these proteins characterize inflammation rather than describe nutrition status or protein-energy malnutrition. Both critical illness and chronic illness are characterized by inflammation and, as such, hepatic reprioritization of protein synthesis occurs, resulting in lower serum concentrations of albumin and prealbumin. In addition, the redistribution of serum proteins occurs because of an increase in capillary permeability. There is an association between inflammation and malnutrition, however, not between malnutrition and visceral-protein levels. These proteins correlate well with patients' risk for adverse outcomes rather than with protein-energy malnutrition. Therefore, serum albumin and prealbumin should not serve as proxy measures of total body protein or total muscle mass and should not be used as nutrition markers. This paper has been approved by the American Society for Parenteral and Enteral Nutrition Board of Directors.

Outcomes Associated With Early vs Late Initiation of Exclusive Enteral Feeding Regimens Following Laparoscopic Gastrostomy Tube Placement in the Pediatric Patient.

OBJECTIVES: Despite frequent placement of pediatric laparoscopic gastrostomy tubes (GTs), no rigorous evaluation of initial feeding and advancement regimens exists. Therefore, the aim of this study was to determine whether early enteral feeding after GT placement is associated with increased symptoms, procedural complications, or length of stay (LOS). METHODS: In this retrospective cohort study, the records of all patients at a tertiary care pediatric hospital who had gastrostomy placement were reviewed. Only patients fed exclusively via gastrostomy were included. Feeding was monitored starting with the first postoperative feed and subsequently in 24-hour increments. Adverse events were recorded based on clinical documentation. RESULTS: A total of 480 patients met inclusion criteria. Patients who started feeds between 24 and 36 hours had a shorter LOS compared with those who started at 36-48 hours (P = .0072) or >48 hours (P < .0001). Patients requiring ≥60 hours to reach goal feeds had significantly longer LOS than the other groups. There was no difference in the distribution of the LOS based on percentage of goal feeds initiated. Patients who required ≥60 hours to attain goal feeds had the most feeding complications. CONCLUSIONS: More aggressive feeding advancement and earlier initiation of feeds were associated with decreased LOS without an associated increase in adverse clinical events.

Validity and Reliability of Pediatric Nutrition Screening Tools for Hospital, Outpatient, and Community Settings: A 2018 Evidence Analysis Center Systematic Review.

BACKGROUND: Nutrition screening tools are used to identify risk of malnutrition or change in risk of malnutrition. However, it is unclear which tools have demonstrated high validity, reliability, and agreement. OBJECTIVE: Our aim was to conduct a systematic review of valid and reliable pediatric nutrition screening tools for identifying malnutrition risk (under- or overnutrition), and to determine whether there are differences in validity and reliability according to users of the tools. METHODS: A literature search using Medline, Embase, and CINAHL databases was conducted to identify relevant research published between 1995 and May 2017 examining validity and reliability of nutrition screening tools in the pediatric population. A multidisciplinary workgroup developed eligibility criteria, data were extracted and summarized, risk of bias was assessed, and evidence strength was graded, according to a standard process. RESULTS: Twenty-nine studies met inclusion criteria. Thirteen pediatric nutrition screening tools designed for various settings were included in the review (seven inpatient/hospital, three outpatient or specialty setting, and three community). The most frequently examined tools were the Screening Tool for the Assessment of Malnutrition in Pediatrics, Screening Tool for Risk on Nutritional Status and Growth (13 studies each), and Paediatric Yorkhill Malnutrition Score (nine studies). No tools demonstrated high validity. Reliability and agreement were reported infrequently. CONCLUSIONS: Nutrition screening tools with good/strong or fair evidence and moderate validity included the Screening Tool for the Assessment of Malnutrition in Pediatrics, Screening Tool for Risk on Nutritional Status and Growth, and Paediatric Yorkhill Malnutrition Score in the inpatient setting and Nutrition Risk Screening Tool for Children and Adolescents with Cystic Fibrosis in the specialty setting. No tools in the community setting met these criteria. While differences in validity and reliability measures among tool users were found, the significance of these findings is unclear. Limitations included few studies examining each tool, heterogeneity between studies examining a common tool, and lack of tools that included currently recommended indicators to identify pediatric malnutrition.

Aluminum Effects in Infants and Children.

Aluminum has no known biological function; however, it is a contaminant present in most foods and medications. Aluminum is excreted by the renal system, and patients with renal diseases should avoid aluminum-containing medications. Studies demonstrating long-term toxicity from the aluminum content in parenteral nutrition components led the US Food and Drug Administration to implement rules for these solutions. Large-volume ingredients were required to reduce the aluminum concentration, and small-volume components were required to be labeled with the aluminum concentration. Despite these rules, the total aluminum concentration from some components continues to be above the recommended final concentration. The concerns about toxicity from the aluminum present in infant formulas and antiperspirants have not been substantiated but require more research. Aluminum is one of the most effective adjuvants used in vaccines, and a large number of studies have documented minimal adverse effects from this use. Long-term, high-concentration exposure to aluminum has been linked in meta-analyses with the development of Alzheimer disease.

Outcomes from a 12-Week, Open-Label, Multicenter Clinical Trial of Teduglutide in Pediatric Short Bowel Syndrome.

OBJECTIVE: To determine safety and pharmacodynamics/efficacy of teduglutide in children with intestinal failure associated with short bowel syndrome (SBS-IF). STUDY DESIGN: This 12-week, open-label study enrolled patients aged 1-17 years with SBS-IF who required parenteral nutrition (PN) and showed minimal or no advance in enteral nutrition (EN) feeds. Patients enrolled sequentially into 3 teduglutide cohorts (0.0125 mg/kg/d [n = 8], 0.025 mg/kg/d [n = 14], 0.05 mg/kg/d [n = 15]) or received standard of care (SOC, n = 5). Descriptive summary statistics were used. RESULTS: All patients experienced ≥1 treatment-emergent adverse event; most were mild or moderate. No serious teduglutide-related treatment-emergent adverse events occurred. Between baseline and week 12, prescribed PN volume and calories (kcal/kg/d) changed by a median of -41% and -45%, respectively, with 0.025 mg/kg/d teduglutide and by -25% and -52% with 0.05 mg/kg/d teduglutide. In contrast, PN volume and calories changed by 0% and -6%, respectively, with 0.0125 mg/kg/d teduglutide and by 0% and -1% with SOC. Per patient diary data, EN volume increased by a median of 22%, 32%, and 40% in the 0.0125, 0.025, and 0.05 mg/kg/d cohorts, respectively, and by 11% with SOC. Four patients achieved independence from PN, 3 in the 0.05 mg/kg/d cohort and 1 in the 0.025 mg/kg/d cohort. Study limitations included its short-term, open-label design, and small sample size. CONCLUSIONS: Teduglutide was well tolerated in pediatric patients with SBS-IF. Teduglutide 0.025 or 0.05 mg/kg/d was associated with trends toward reductions in PN requirements and advancements in EN feeding in children with SBS-IF. TRIAL REGISTRATION: ClinicalTrials.gov:NCT01952080; EudraCT: 2013-004588-30.

Why Is Diagnosing Pediatric Malnutrition Important?

The literature indicates that pediatric malnutrition is more common than the number of times it is actually diagnosed. A new pediatric malnutrition definition is now available with criteria to make the diagnosis. If pediatric malnutrition is present, it should be diagnosed for financial, educational, and research purposes as well as the effects on patient development and mortality. These reasons extend beyond the health of an individual patient to potential impacts on society as a whole. When all of these reasons are examined and added, making the diagnosis of pediatric malnutrition becomes an obligation of the pediatric caregiver.

Nutrition in Children and Adolescents.

Nutrition is a critical factor for appropriate child and adolescent development. Appropriate nutrition changes according to age. Nutrition is an important element for prevention of disease development, especially for chronic diseases. Many children and adolescents live in environments that do not promote optimum nutrition. Families must work to provide improved food environments to encourage optimum nutrition. Early primordial prevention of risk factors for chronic disease, such as cardiovascular disease, is important, and dietary habits established early may be carried through adult life.

Characteristics of Hospitalized Children With a Diagnosis of Malnutrition: United States, 2010.

INTRODUCTION: Malnutrition is common in hospitalized patients in the United States. In 2010, 80,710 of 6,280,710 hospitalized children <17 years old had a coded diagnosis of malnutrition (CDM). This report summarizes nationally representative, person-level characteristics of hospitalized children with a CDM. METHODS: Data are from the 2010 Healthcare Cost and Utilization Project, which contains patient-level data on hospital inpatient stays. When weighted appropriately, estimates from the project represent all U.S. hospitalizations. The data set contains up to 25 ICD-9-CM diagnostic codes for each patient. Children with a CDM listed during hospitalization were identified. RESULTS: In 2010, 1.3% of hospitalized patients <17 years had a CDM. Since the data include only those with a CDM, malnutrition's true prevalence may be underrepresented. Length of stay among children with a CDM was almost 2.5 times longer than those without a CDM. Hospital costs for children with a CDM were >3 times higher than those without a CDM. Hospitalized children with a CDM were less likely to have routine discharge and almost 3.5 times more likely to require postdischarge home care. Children with a CDM were more likely to have multiple comorbidities. CONCLUSIONS: Hospitalized children with a CDM are associated with more comorbidities, longer hospital stay, and higher healthcare costs than those without this diagnosis. These undernourished children may utilize more healthcare resources in the hospital and community. Clinicians and policymakers should factor this into healthcare resource utilization planning. Recognizing and accurately coding malnutrition in hospitalized children may reveal the true prevalence of malnutrition.

Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition).

The Academy of Nutrition and Dietetics (the Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), utilizing an evidence-informed, consensus-derived process, recommend that a standardized set of diagnostic indicators be used to identify and document pediatric malnutrition (undernutrition) in routine clinical practice. The recommended indicators include z scores for weight-for-height/length, body mass index-for-age, or length/height-for-age or mid-upper arm circumference when a single data point is available. When 2 or more data points are available, indicators may also include weight gain velocity (<2 years of age), weight loss (2-20 years of age), deceleration in weight for length/height z score, and inadequate nutrient intake. The purpose of this consensus statement is to identify a basic set of indicators that can be used to diagnose and document undernutrition in the pediatric population ages 1 month to 18 years. The indicators are intended for use in multiple settings (eg, acute, ambulatory care/outpatient, residential care). Several screening tools have been developed for use in hospitalized children. However, identifying criteria for use in screening for nutritional risk is not the purpose of this paper. Clinicians should use as many data points as available to identify and document the presence of malnutrition. The universal use of a single set of diagnostic parameters will expedite the recognition of pediatric undernutrition, lead to the development of more accurate estimates of its prevalence and incidence, direct interventions, and promote improved outcomes. A standardized diagnostic approach will also inform the prediction of the human and financial responsibilities and costs associated with the prevention and treatment of undernutrition in this vulnerable population and help to further ensure the provision of high-quality, cost-effective nutritional care.

Nutrition Screening and Assessment in Hospitalized Patients: A Survey of Current Practice in the United States.

Background: The Joint Commission has mandated universal screening and assessment of hospitalized patients for malnutrition since 1995. Although various validated and nonvalidated tools are available, implementation of this mandate has not been well characterized. We report results of a survey of hospital-based professionals in the United States describing their perspective on the current range of nutrition screening and assessment practices as well as associated gaps in knowledge. Methods and Materials: Data from a 2012-2013 cross-sectional, web-based survey targeting members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), the Academy of Medical-Surgical Nurses, and the Society of Hospital Medicine were collected with non-hospital-based members excluded. Descriptive statistical analysis was performed. Results: Survey data from 1777 unique email addresses are included in this report. A majority of respondents were dietitians, nearly half were A.S.P.E.N. members, and 69.4% reported caring for a mix of adult and pediatric patients. Most respondents answered affirmatively about nutrition screening being performed in alignment with The Joint Commission mandate, but only 50% were familiar with the 2012 Consensus Statement from the Academy of Nutrition and Dietetics/A.S.P.E.N. on adult malnutrition. In most cases, nurses were primarily responsible for nutrition screening, while dietitians had primary responsibility for assessment. No one specific assessment tool or International Classification of Diseases, Ninth Revision code was identified as being used a majority of the time in assessing or coding a patient for malnutrition. Conclusions: The survey findings affirmed compliance with accreditation standards in completing a nutrition screen within 24 hours of admission, and most hospitals appear to have a process to perform a nutrition assessment once a screen is completed. However, there is considerable heterogeneity in both use of tools and mechanisms for coding capture. Opportunities exist to improve education around nutrition screening and assessment and to identify ideal practices for these processes in hospitalized patients.

Malnutrition diagnoses in hospitalized patients: United States, 2010.

Malnutrition is common among hospitalized patients in the United States, and its coded prevalence is increasing. Malnutrition is known to be associated with increased morbidity, mortality and healthcare costs. Although national data indicate that the number of malnutrition diagnoses among hospital discharges has been steadily rising, an in-depth examination of the demographic and clinical characteristics of these patients has not been conducted. We examined data from the 2010 Healthcare Cost and Utilization Project (HCUP), the most recent nationally-representative data describing U.S. hospital discharges. Using ICD-9 codes, we constructed a composite variable indicating a diagnosis of malnutrition. Based on our definition, 3.2% of all U.S. hospital discharges in 2010 had this diagnosis. Relative to patients without a malnutrition diagnosis, those with the diagnosis were older, had longer lengths of stay and incurred higher costs. These patients were more likely to have 27 of 29 comorbidities assessed in HCUP. Finally, discharge to home care was twice as common among malnourished patients, and a discharge of death was more than 5 times as common among patients with a malnutrition diagnosis. Taken together, these nationally representative, cross-sectional data indicate that hospitalized patients discharged with a diagnosis of malnutrition are older and sicker and their inpatient care is more expensive than their counterparts without this diagnosis.

Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions.

Lack of a uniform definition is responsible for underrecognition of the prevalence of malnutrition and its impact on outcomes in children. A pediatric malnutrition definitions workgroup reviewed existing pediatric age group English-language literature from 1955 to 2011, for relevant references related to 5 domains of the definition of malnutrition that were a priori identified: anthropometric parameters, growth, chronicity of malnutrition, etiology and pathogenesis, and developmental/ functional outcomes. Based on available evidence and an iterative process to arrive at multidisciplinary consensus in the group, these domains were included in the overall construct of a new definition. Pediatric malnutrition (undernutrition) is defined as an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes. A summary of the literature is presented and a new classification scheme is proposed that incorporates chronicity, etiology, mechanisms of nutrient imbalance, severity of malnutrition, and its impact on outcomes. Based on its etiology, malnutrition is either illness related (secondary to 1 or more diseases/injury) or non-illness related, (caused by environmental/behavioral factors), or both. Future research must focus on the relationship between inflammation and illness-related malnutrition. We anticipate that the definition of malnutrition will continue to evolve with improved understanding of the processes that lead to and complicate the treatment of this condition. A uniform definition should permit future research to focus on the impact of pediatric malnutrition on functional outcomes and help solidify the scientific basis for evidence-based nutrition practices.

Copper levels in cholestatic infants on parenteral nutrition.

BACKGROUND: Copper levels are primarily regulated by biliary excretion. In cholestatic patients, there is a concern that the standard dose of copper in parenteral nutrition (PN) will result in excessive copper levels. This study looked retrospectively at cholestatic infants receiving PN with measured copper levels to ascertain if this is an actual clinical concern. METHODS: All infants from the previous 10 years receiving PN who had a copper level checked and were cholestatic were reviewed. Children with metabolic or liver structural anomalies were excluded from the review. Of the 28 patients found, 26 had gastrointestinal disorders, and 82% of these infants were on the standard PN copper dose (20 µg/kg/d). RESULTS: Only one elevated copper level was found in a child with congenital heart disease, but 13 low levels were found. A smaller number of follow-up copper levels demonstrated that despite cholestasis, some patients require copper supplementation above standard recommendations. CONCLUSION: Cholestasis does not appear to impair copper excretion enough to result in elevated levels. In fact, infants with gastrointestinal disorders may require higher than standard dosing. Monitoring copper levels appears to be necessary to appropriately regulate copper dosing for cholestatic infants receiving PN.

Copper metabolism and pediatric cholestasis.

PURPOSE OF REVIEW: Copper is an essential trace mineral but both deficiency and toxicity need to be avoided. Copper is regulated via excretion by the biliary system and caution was recommended when administered in patients with cholestasis. Recent clinical reports indicate that despite the cholestasis, copper should not be withheld from parenteral nutrition. RECENT FINDINGS: Transporters involved in regulating copper levels have been identified. This explains the processes that regulate copper levels and the diseases that result from transporter defects. Monitoring copper ideally requires a liver biopsy but there are reports that in infants serum copper levels correlate with the liver copper. The published cautions about copper in cholestatic patients on parenteral nutrition led to the removal of copper from the solutions. Subsequently, multiple reports of clinical copper deficiency developing in these patients including infants were published. Newer literature indicates no elevation in infant copper levels despite normal copper parenteral nutrition supplementation in the presence of cholestasis. SUMMARY: Copper is essential and levels are regulated in response to an individual's needs. The liver excretion of copper is the primary regulating method but clinically cholestasis does not result in elevated levels in infants. The best clinical approach to parenteral nutrition copper is careful monitoring even in the presence of cholestasis.

Exploring potential noninvasive biomarkers in eosinophilic esophagitis in children.

BACKGROUND AND AIMS: Eosinophilic esophagitis (EE) continues to present clinical challenges, including a need for noninvasive tools to manage the disease. To identify a marker able to assess disease status in lieu of repeated endoscopies, we examined 3 noninvasive biomarkers, serum interleukin (IL)-5, serum eosinophil-derived neurotoxin (EDN), and stool EDN, and examined possible correlations of these with disease phenotype and activity (symptoms and histology) in a longitudinal study of children with EE. SUBJECTS AND METHODS: Children with EE were studied for up to 24 weeks (12 weeks on 1 of 2 corticosteroid therapies and 12 weeks off therapy). Twenty children with normal esophagogastroduodenoscopies with biopsies were enrolled as controls. Serum IL-5, serum EDN, and stool EDN were measured at weeks 0, 4, 12, 18, and 24 in children with EE, and at baseline alone for controls. Primary and secondary statistical analyses (excluding and including outlier values of the biomarkers, respectively) were performed. RESULTS: Sixty subjects with EE (46 [75%] boys, mean age 7.5 ±â€Š4.4 years) and 20 normal controls (10 [50%] boys, mean age 6.7 ±â€Š4.1 years) were included. Significant changes in serum EDN (significant decrease from baseline to week 4, and then rebound from week 4 to week 12) occurred. Serum EDN levels were stable after week 12. Serum IL-5 and stool EDN levels in subjects with EE were not statistically different from those of the control subjects when each time point for the cases was compared with the controls' 1-time measurement. CONCLUSIONS: Serum EDN levels were significantly higher in subjects with EE than in controls, and the results suggest a possible role, after additional future studies, for serum EDN in establishing EE diagnosis, assessing response to therapy, and/or monitoring for relapse or quiescence.