Multidisciplinary Nutrition Care Research Articles

Gender-Affirming Nutrition: An Overview of Eating Disorders in the Transgender Population.

Transgender individuals are vulnerable to many nutrition-related conditions, especially eating disorders due to gender dysphoria. This review aims to summarize the current literature on eating disorders in transgender individuals. The issues that should be considered in nutrition care for the transgender population are discussed regarding public health. Transgender individuals can exhibit disordered eating behaviors to overcome the stress they experience due to stigma, discrimination, social exclusion, and abuse. Recent studies showed that disordered eating and clinical eating disorders are more prevalent among transgender than cisgender people. It is very important for a multidisciplinary team working in the clinic to understand the epidemiology, etiology, diagnostic criteria, and treatment of eating disorders in the transgender population. However, multidisciplinary nutritional care is limited due to the lack of transgender-specific nutrition guidelines. It is safe to say that adhering to a generally healthy nutritional pattern and using standardized nutrition guidelines. We recommend that health professionals working with patients/clients with eating disorders receive continuing education in transgender health, be empowering and inclusive, address patients/clients with their gender identity nouns and pronouns, and develop nutritional treatment plans that are not gender-specific. Eating disorders are a significant public health problem in the transgender population. Therefore, clinical screening and early intervention are necessary to identify and treat eating disorders in transgender people. Eating disorders in the transgender population should be monitored routinely, and gender-affirming care should be provided as well as treatment of eating disorders.

Nutrition practices with a focus on parenteral nutrition in the context of enhanced recovery programs: An exploratory survey of gastrointestinal surgeons.

Ensuring patients have adequate physiological reserves to meet the demands of major surgery may necessitate nutritional prehabilitation and perioperative medical nutrition therapy (MNT). Parenteral nutrition (PN) via central or peripheral routes is indicated when requirements cannot be met orally or enterally. While patients undergoing major gastrointestinal (GI) surgery are at high nutritional and catabolic risk, guidance on PN is limited in Enhanced Recovery After Surgery (ERAS) protocols. This survey-based study characterized MNT practices among GI surgeons, and the challenges and opportunities for MNT within the context of ERAS. This on-line survey comprised questions and attitudinal statements centred on MNT, particularly PN, for major GI surgery patients, and encompassed the spectrum of the surgical pathway (prehabilitation to postoperative care). GI surgeons in Europe were invited to complete the survey. Respondents described their current clinical practices, while their perceptions, unmet needs, and opportunities to improve nutritional management were explored via Likert-scale responses to statements. GI surgeons (N=130) from different centres in France, Germany, Italy, Poland, and Spain completed the survey. Enhanced recovery protocols (75%) and multidisciplinary nutritional care teams (72%) were established in the centres of most respondents; surgeons, dieticians/nutritionists, and nurses were most frequently involved in MNT. Nutritional risk screening was common in the centres surveyed prior to surgery (range: 62% in Italy to 96% in Poland) and undertaken less frequently postoperatively (range: 19% in Poland to 54% in Germany) with varied screening methods. Enteral nutrition insufficiency was the most common reason for prescribing PN (83%) and 56% of surgeons prescribed PN when enteral nutrition (EN) was not feasible. Overall, 71% of respondents agreed that peripherally administered PN (PPN), which does not require a central access route, lessens invasive procedures and benefits selected patients who are in a catabolic state, malnourished, or at nutritional/metabolic risk when oral intake/EN is insufficient. However, only 35% of surgeons used PPN in this scenario and only 47% utilized PPN when a central venous catheter is not available. Most surgeons (69%) agreed that PPN is in line with the ERAS concept of using minimally invasive approaches. The respondents raised a need for increasing awareness of PPN indications (81%), inclusion of PPN recommendations in clinical guidelines (79%), implementation of nutritional support teams (79%), and increased PPN-trained personnel (78%) to improve PPN delivery. PPN is perceived by surgeons (with ≥10 patients per month who receive PN) as a favourable strategy to support timely nutritional support in selected patients undergoing major GI surgery. However, from this clinical practice survey it seems PPN is underutilized in nutritional care practices. Findings from this survey of GI surgeons in Europe emphasize the need to improve early identification of patients who are malnourished or at nutritional/metabolic risk and integrate PPN into ERAS GI surgical pathways, within the framework of minimally invasive approaches.

Preferences for oral nutritional supplement therapy among postoperative patients with gastric cancer: a discrete choice experiment.

PurposesPatients after gastrectomy have poor compliance with oral nutritional supplement (ONS) therapy. Incorporating patient preferences into treatment decisions allows possible product improvements or treatment focus adjustments. The purpose of this research was to investigate the preferences for ONS therapy among postoperative patients with gastric cancer, and to provide person-centered oral nutrition management strategies.MethodsA discrete choice experiment was designed and implemented within a Chinese cancer population. The survey was administered via paper-based questionnaires during face-to-face interviews with assistance from health professionals. A mixed logit model was used to estimate respondents’ preferences for different levels of nutrition therapy attributes.ResultsOne hundred ninety respondents valued “Adverse reactions-almost none” (β 3.43 [SE, 0.28]) the most, followed by “Flavor-good taste” (β 0.68 [SE, 0.13]) and “Follow-up frequency-once every 2 weeks” (β 0.52 [SE, 0.13]), and were willing to pay more for these attribute levels. Respondents would be 93.73% more likely to accept a nutrition therapy program if there were almost no adverse reactions compared to the frequent adverse reactions.ConclusionsHealth professionals should pay attention to the management and prevention of adverse reactions when prescribing nutritional products, and provide diversified ONS products when necessary to meet patient preferences. When formulating intervention strategies, health professionals should also consider the different characteristics of patients, acknowledge the importance of the role of nurse specialists in a novel model of multidisciplinary nutritional care, standardize ONS information, follow up regularly, and encourage patients’ families to participate in daily nutrition care.Supplementary informationThe online version contains supplementary material available at 10.1007/s00520-022-07154-8.

Multidisciplinary Provision of Food and Nutritional Care to Hospitalized Adult In-Patients: A Scoping Review.

PurposeMultidisciplinary approaches to nutritional care are increasingly emphasized and recommended. However, there is little evidence of how different disciplines work together collaboratively to deliver optimum quality care to adult in-patients. This scoping review aimed to describe the existing literature on multidisciplinary collaboration to identify the various disciplines involved and the features that influence collaborative working in implementing multidisciplinary food and nutritional care with adult in-patients.MethodsMultiple databases were searched, including MEDLINE Complete, Embase, CINAHL Complete, HMIC, and Scopus, from their inception to December 2019. Data were retrieved from eligible studies. A narrative description of findings is reported with respect to the disciplines involved, the aspects of nutritional care explored, and the collaborative processes categorized using the input, process, and outcome framework.ResultsThirty-one studies with heterogeneous study designs met the eligibility criteria. Studies were undertaken in six countries. Findings show a wide diversity of multidisciplinary collaborations in various aspects of nutritional care in all studies. Multidisciplinary nutritional care provision was facilitated by several processes, including training and development, communication and information sharing, and clinical leadership and management support. Outcomes were reported at the patient, team, and organizational levels.ConclusionThis review reveals the significance of the interrelationship between different disciplines and their complementary contributions towards the delivery of optimal food and nutritional care. Key aspects include the involvement of different disciplines, the clarification of roles and multidisciplinary interrelationships, communication, information sharing, clinical leadership, and management support, all of which facilitated collaborative working. Our review uncovered that these features can significantly influence multidisciplinary working. This review is the first to present literature concerning the attributes that affect collaborative working. Further research is recommended specifically around multidisciplinary nutritional care processes and conditions that allow for better collaborative working.

Mealtime care and dietary intake in older psychiatric hospital inpatient: A multiple case study.

To investigate the energy and protein adequacy of meals and dietary intake of older psychiatric inpatients and describe patient and mealtime factors potentially influencing intake. Multiple case studies. Psychiatric inpatients aged 65years and older, admitted to a single mental health ward during the 6-week study period (April-May 2019) were eligible for inclusion. Dietary intake was observed for two consecutive days each week (minimum four observation days). Visual plate waste methods were used to estimate patients' dietary intake at mealtimes, with energy and protein intake calculated using known food composition data and compared with estimated requirements. Medical records were reviewed weekly to collect information on potential factors related to intake and mealtime care. Data from all sources were first summarized in a case record for within-case analysis using descriptive statistics, followed by cross-case analysis. Eight participants (five men, age 67-90years, two underweight and one overweight, and four requiring some mealtime assistance) had 5-12days of observation data recorded. Three met their estimated daily energy and protein requirements throughout the study period, while the remaining five participants did not. The main barriers identified as contributing to insufficient energy and protein intake were as follows: missing meals (asleep and treatment); inadequate food provided (insufficiency of the standard hospital menu); and need for increased mealtime assistance. Poor dietary intake may be common among older psychiatric patients, suggesting that they may also need nursing and multidisciplinary nutrition care interventions shown to effectively prevent and treat malnutrition in other older inpatient groups. Older psychiatric patients experience similar nutrition and mealtime issues to other older inpatients. This study highlights the need for nurses and the multidisciplinary team to ensure patients order and receive adequate food, especially when they miss meals and that they receive proactive mealtime assistance.

Refeeding Syndrome in the Critically Ill: a Literature Review and Clinician's Guide.

To provide an overview of current methods of diagnosis and management of refeeding syndrome in the critically ill patient population. Despite recent publications indicating refeeding syndrome (RFS) is an ongoing problem in critically ill patients, there is no standard for the diagnosis and management of this life-threatening condition. There is not a "gold standard" nutrition assessment tool for the critically ill. Currently, the National Institute for Health and Clinical Excellence criteria represent the best clinical assessment tool for RFS. Diagnosis and management with the help of a multidisciplinary metabolic team can decrease morbidity and mortality. Although a universal definition of RFS has yet to be defined, the diagnosis is made in patients with moderate to severe malnutrition who develop electrolyte imbalance after beginning nutritional support. The imbalances potentially can lead to cardiac, pulmonary, and gastrointestinal complications and failure. Standardizing a multidisciplinary nutrition care plan and formulating a protocol for critically ill patients who develop RFS can potentially decrease complication rates and overall mortality.

Clinical and Economic Value of Nutrition in Healthcare: A Nurse's Perspective.

In the US healthcare system, malnutrition is a common condition, yet it remains underreported and underdiagnosed. The financial costs of disease-associated malnutrition are substantial; hospital-acquired conditions, readmissions, and prolonged lengths of stay are reported to cost as much as $150 billion per year. By contrast, nutrition-focused quality improvement programs for inpatients can help reduce the negative impact of disease-associated malnutrition. Such programs include systematic screening for malnutrition risk on admission, timely malnutrition diagnoses, and prompt nutrition interventions, which have been shown to lower rates of hospital-acquired infections, shorten lengths of stay, reduce readmissions, and lessen costs of care. Nurses are ideally positioned to play critical roles in nutrition-related care-screening for malnutrition on admission, monitoring for and addressing conditions that impede nutrition intake, and ensuring that prescribed nutrition interventions are delivered and administered or consumed. Such nursing support of multidisciplinary nutrition care contributes to better patient outcomes at lower costs.

Use of an electronic malnutrition screening tool in a hospital setting: effects on knowledge, attitudes and perceived practices of healthcare staff.

Malnutrition risk screening is essential for the adequate identification and treatment of malnourished hospitalised patients. The aim of this study was to determine the effect of the use of an electronic malnutrition screening tool on the knowledge, attitudes and perceived practices (KAP) of a pool of nurses, nurses' aides and physicians. A controlled study using a pre-test-post-test design was carried out in two Austrian hospitals. The hospital that was assigned to the intervention group used the Graz malnutrition screening tool. The hospital that was assigned to the control group received no intervention. To collect data, a questionnaire was filled out by the study participants at baseline (T0) and 1 month after the implementation (T1) to assess KAP. All data were analysed using descriptive statistics, χ 2 tests, Wilcoxon signed-rank tests and Student's t tests. A total of 269 nurses, nurses' aides and physicians participated in the study and completed the questionnaires at T0, and 190 people at T1. The sum score for the KAP questionnaire changed significantly after the implementation of the malnutrition screening tool in the intervention group (P<0·001), but not in the control group. The use of a valid and reliable malnutrition screening tool effectively improved the KAP of healthcare staff. The KAP described here are essential for providing successful nutritional care in malnourished patients, and improving these factors may result in improved patient outcomes. To attain these outcomes, stakeholders, as well as members of all professions involved in multidisciplinary nutritional care, must invest significant efforts.

Nutritional status and interventions in hospice: physician assessment of cancer patients.

Cancer cachexia is a multifactorial syndrome characterised by a progressive loss of skeletal muscle mass. It adversely influences quality of life, treatment response and survival. Early identification and multimodal interventions can potentially treat cancer cachexia. However, healthcare professionals demonstrate a lack of understanding and the ability to identify cancer cachexia early. The present study aimed to evaluate the assessment by physicians of nutritional status in cancer patients admitted to hospice. A retrospective medical record review was conducted on all cancer admissions to a specialist in-patient palliative care unit over a 4-month period between October 2016 and January 2017. Charts were reviewed for evidence of documented nutritional assessment by physicians. Data were collected from the referral letter, admission notes, drug kardex and discharge letter. The information extracted included: (i) patient demographics and characteristics; (ii) terms used by physicians to describe nutritional status; (iii) any record of nutritional impact symptoms (NIS) experienced by the patient; and (iv) nutritional interventions prescribed. One hundred and forty admissions were evaluated. Nutritional terminology and NIS were most commonly documented on the admission notes. Only 41% of documents recorded any nutritional term used by physicians to assess nutritional status. Furthermore, 71% of documents recorded at least one NIS experienced by the patient. Fatigue was the most frequent NIS. We identified an inadequate nutritional assessment of cancer patients admitted to hospice. Implementation of a nutritional symptom checklist and nutrition screening tools, along with enhanced physician education and multidisciplinary nutrition care, could improve the identification and management of cancer cachexia in the palliative care setting.

Implementing best practice in hospital multidisciplinary nutritional care: an example of using the knowledge-to-action process for a research program.

BackgroundProspective use of knowledge translation and implementation science frameworks can increase the likelihood of meaningful improvements in health care practices. An example of this creation and application of knowledge is the series of studies conducted by and with the Canadian Malnutrition Task Force (CMTF). Following a cohort study and synthesis of evidence regarding best practice for identification, treatment, and prevention of malnutrition in hospitals, CMTF created an evidence-informed, consensus-based pathway for nutritional care in hospitals. The purpose of this paper is to detail the steps taken in this research program, through four studies, as an example of the knowledge-to-action (KTA) process.The KTA processThe KTA process includes knowledge creation and action cycles. The steps of the action cycle within this program of research are iterative, and up to this point have been informed by three studies, with a fourth underway. The first study identified the magnitude of the malnutrition problem upon admission to hospital and how it is undetected and undertreated (study 1). Knowledge creation resulted in an evidence-based pathway established to address care gaps (study 2) and the development of monitoring tools (study 3). The study was then adapted to local context: focus groups validated face validate the evidence-based pathway; during the final phase, study site implementation teams will continue to adapt the pathway (studies 2 and 4). Barriers to implementation were also assessed; focus groups and interviews were conducted to inform the pathway implementation (studies 1, 2, and 4). In the next step, specific interventions were selected, tailored, and implemented. In the final study in this research program, plan–do–study–act cycles will be used to make changes and to implement the pathway (study 4). To monitor knowledge use and to evaluate outcomes, audits, staff surveys, patient outcomes, etc will be used to record process evaluations (studies 3 and 4). Finally, a sustainability plan will be incorporated into the final study of the program (study 4) to sustain knowledge use.DiscussionUse of frameworks can increase the likelihood of meaningful and sustainable improvements in health care practice. The example of this program of research demonstrates how existing evidence has been used to identify, create, and adapt knowledge, and how multidisciplinary teams have been used to effect changes in the hospital setting.ConclusionEffective implementation is essential in nutritional health care, and this multidisciplinary program of research provides an example of how the KTA process can facilitate implementation and promote sustainability.

Multidisciplinary, multi-modal nutritional care in acute hip fracture inpatients – Results of a pragmatic intervention

Malnutrition is highly prevalent and resistant to intervention following hip fracture. This study investigated the impact of individualised versus multidisciplinary nutritional care on nutrition intake and outcomes in patients admitted to a metropolitan hospital acute hip fracture unit. A prospective, controlled before and after comparative interventional study aligning to the CONSORT guidelines for pragmatic clinical trials. Randomly selected patients receiving individualised nutritional care (baseline) were compared with post-interventional patients receiving a new model of nutritional care promoting nutrition as a medicine, multidisciplinary nutritional care, foodservice enhancements, and improved nutrition knowledge and awareness. Malnutrition was diagnosed using the Academy of Nutrition and Dietetics criteria. Fifty-eight weighed food records were available for each group across a total of 82 patients (n=44, n=38). Group demographics were not significantly different with predominantly community dwelling (72%), elderly (82.2 years), female (70%), malnourished (51.0%) patients prone to co-morbidities (median 5) receiving early surgical intervention (median D1). Multidisciplinary nutritional care reduced intake barriers and increased total 24-henergy (6224 vs. 2957kJ; p<0.001) and protein (69.0 vs. 33.8g; p<0.001) intakes, reduced nutritional deterioration over admission (5.4 vs. 20.5%; p=0.049), and increased discharge directly back to the community setting (48.0 vs. 17.6%; p=0.012). Trends suggested a reduction in median length of stay (D13 vs. D14). Inpatient mortality remained low across groups (5.2%, 2.3%). Multidisciplinary nutritional care improves nutrition intake and outcomes in acute hip fracture inpatients. Similar pragmatic study designs should be considered in other elderly inpatient populations perceived resistant to nutritional intervention.

Effectiveness of multidisciplinary nutritional care on nutritional intake, nutritional status and quality of life in patients with hip fractures: A controlled prospective cohort study

The purpose of this study was to determine the effectiveness of a multidisciplinary intervention program on nutritional intake and of nutritional intake on nutritional status and quality of life in older patients treated for a hip fracture. A controlled prospective cohort study included 66 patients in the control group and 61 patients in the intervention group, aged over 65 and sustaining a hip fracture with subsequent operative intervention. Postoperatively, the control group received standard nutritional care and the intervention group multidisciplinary nutritional care that focused on nutritional support during hospitalisation and a transfer of nutritional care after discharge. Nutrient intakes were monitored with food records. Nutritional status was determined by the Mini Nutritional Assessment (MNA), and bioelectrical impedance analysis was used to assess body cell mass (BCM). The EuroQol (EQ-5D) was used to assess quality of life. Patients were evaluated at admission and three months postoperatively. There was a significant difference in the daily energy intake of patients between both groups during the first seven days postoperatively: 1127kcal (±309) in the control group and 1292kcal (±280) (P=0.002) in the intervention group. Mean protein intake in the intervention group (57g (±12)) was significantly higher than in the control group (48g (±14), P=0.000). The intervention group demonstrated a significantly lower reduction of EQ-5D index scores compared with the control group (P=0.004) after three months. At three months, significantly fewer patients in the intervention group were classified as malnourished or at risk of malnutrition. Among elderly patients with a hip fracture, a multidisciplinary postoperative approach of nutritional care was associated with an increase of energy and protein intake during hospitalisation. After three months follow-up there were fewer malnourished patients in the intervention group, and the decline in quality of life was lower than in the control group. There were no advantages of multidisciplinary nutritional care on body cell mass.

P1163* A COMPARATIVE MULTI-DISCIPLINARY REVIEW OF HOME PARENTERAL SERVICES PROVIDED AND AUDITED IN 1993 AND 2003.

Introduction: Training of families for home parenteral nutrition (HPN) is extremely challenging for multi-disciplinary professionals. The need to evaluate and review programmes and learn from clinical care initiatives and families is paramount. Our 16-year HPN programme for children with intestinal failure continues to be evaluated by the multi-disciplinary nutritional care team. 48 children have commenced HPN. Diagnostic categories: short gut syndrome (n=24), mucosal disorders (n=17) and motility disorders (n=7). It is well recognised that functioning of families receiving HPN is sub optimal with increased tension, social dysfunction and limitations in family activities. Home care packages (HCP) were developed and initiated by the team in response to families’ needs. The aim of the current study was to compare and contrast service needs and treatments of children requiring HPN in 1993 and after the introduction of HCP ten years later in 2003. Methods: Clinical data was reviewed from case notes and discussion with team members, and analysis of community needs of families was instigated. Results: In 1993, 7 patients were on HPN: short gut syndrome (n=4) pseudo obstruction (n=3). 2 females and 5 males. 2 children were <2 yrs and 5 <10 yrs. 28% of children received enteral feeding and all 7 had HPN 7-nights a week. In 2003, 17 children were on HPN; short gut syndrome n=9,pseudo obstruction n=4, microvillous inclusion n=2, protracted diarrhoea n=2. 8 females and 9 males. 6 children <2 yrs old and 13 <10 yrs. 75% of children had nasogastric feeding at the time of review, and less than 50% had nocturnal infusions for <6 nights per week. HCPs were not available in the home in 1993, but in 2003, 82% of families had regular support. This inlcudes setting up HPN and a 24-hr on-call nursing service. HPN is now funded by the Primary Care Trust (PCT). Conclusion: There is an increased diversity of clinical indications for children requiring HPN in 2003 and the dependency of children and their families is higher. This is due to a predominance of children under 10 years. There is a reduction in the number of days for children receiving HPN, alongside increased impetus to push enteral feeds. This is helpful in the prevention of liver disease and gives families additional flexibility but leads to an increased need for nutritional review and biochemical monitoring. This has marked implications for the hospital and community teams and families. HCPs have evolved and progressed over the ten-year period and funding has been redirected from GP to PCT funding. It is essential that these packages are audited and meet the needs of families, providing both medical, nursing and dietetic support.

Outcomes of continuous process improvement of a nutritional care program incorporating TTR measurement.

Early assessment of protein calorie malnutrition (PCM) can improve the outcome for hospitalized patients by allowing the initiation of nutrition support if required. In addition, monitoring nutritional status during the hospital stay can identify a decline in or improvement of PCM so that alterations to treatment regimens can be made if needed. The visceral protein albumin is the traditional laboratory indicator of PCM. In the past decade another protein has been lauded as a superior marker that can be used in conjunction. We undertook several studies to test the effectiveness of TTR as an aid in nutritional assessment. We found TTR to be a sensitive measure of nutritional status, allowing for earlier assessment and intervention, thus reducing length of stay and other hospital associated costs. Based on these findings, our hospital generated and implemented a multidisciplinary nutrition care program. Transthyretin is an integral portion of this program; levels are determined on admission and repeated twice weekly until discharge.

6 Short bowel syndrome

Short bowel syndrome has significant morbidity and is potentially lethal especially when intestinal loss is extensive. The pathophysiology of short bowel syndrome, its aetiology, prognosis and our understanding of the mechanisms of adaptation are reviewed. Management by a multi-disciplinary nutritional care team is advocated and should be directed to the maintenance of growth and development, the promotion of intestinal adaptation, the prevention of complications and the establishment of enteral nutrition. The choice of enteral feed, the role of drugs and the use of pro-adaptive nutrients and agents are discussed. Complications including cholestasis and catheter related sepsis are outlined with strategies to reduce them. Finally the roles of secondary surgical interventions including transplantation are discussed.

Nutritional support at home: Accessing the gut

Delivery of nutrients by tube is now used in a wide range of paediatric disorders ~ reflecting growing awareness of the importance of good nutrition in severe illness. 2 Enteral tube feeding is indicated in the child who, despite a functional gastrointestinal tract, is unable to ingest sufficient food to maintain or restore normal nutritional status. This definition includes premature infants with immature suck and swallow, as well as older children in whom these mechanisms are either temporarily or permanently impaired. There are a number of additional indications listed in Box 1. The need for reliable and safe enteral nutritional support continues to stimulate innovation both in the field of tube design and the methods for establishing gastrointestinal access. For long-term enteral nutritional support a gastrostomy tube, inserted using a percutaneous endoscopic technique, is increasingly preferred over a nasogastric (NG) tube. The management of complex nutritional problems, including planning, implementation and supervision of tube feeding, is best coordinated by a multi-disciplinary nutritional care team? This brings together the particular expertise of a paediatric surgeon, a paediatric gastroenterologist, a dietitian, a pharmacist and a nutrition nurse specialist. Joint decisions are made about the most suitable approach and type of tube to be used for each patient. Whilst life threatening complications of tube feeding are relatively unusual,

Outcomes of continuous process improvement of a nutritional care program incorporating serum prealbumin measurements

It has been reported that the risk of protein-calorie malnutrition (PCM) for hospitalized patient populations can be as high as 50%. Left undiagnosed, PCM can lead to serious consequences, including increased morbidity and mortality. Visceral protein albumin is the traditional laboratory indicator of PCM. In the past few years, however, several other visceral proteins have been lauded as superior markers. We undertook several studies to test the effectiveness of using one of these, prealbumin, as an aid in nutritional assessment. We found prealbumin to be a sensitive measure of nutritional status, allowing for earlier assessment and intervention, and thus reducing length of stay. Based on these findings, our hospital has generated and implemented a multidisciplinary nutrition care program that meets the 1995 Joint Commission on Accreditation of Healthcare Organizations' Nutrition Care Standards. Prealbumin testing is an integral portion of this program; levels are determined on admission and repeated semiweekly until discharge. Use of this program has led to improved patient care and financial benefit to the hospital.

Nutritional care and candidates for small bowel transplantation.

Twenty two children were evaluated for small bowel transplantation between 1989 and 1994. Eight were unfit for transplantation and died within three months; a raised plasma bilirubin concentration (> 200 mumol/l) predicted death from liver failure within six months (p = 0.0001). The 11 children who were not managed by a multidisciplinary nutritional care team were less well nourished at referral, had more complications with intravenous feeding catheters, and greater early mortality while awaiting transplantation (p < 0.05). It is recommended that children with chronic intestinal failure be referred for assessment early, before liver dysfunction is established.