Parental Nutrition Research Articles

P4.28: Renal function outcomes in paediatric intestinal transplant recipients

Background: Renal dysfunction after intestinal transplantation is a well recognised complication. Calcineurin inhibitors have a direct impact on the kidney with post-operative day 7 tacrolimus associated with kidney function at 1yr. Catheter related sepsis, prolonged usage of intravenous fluid, parental nutrition, diabetes and graft failure have all been associated with chronic kidney disease. Methods: Review of first-time paediatric intestinal graft recipients at a single centre between August’09-June’18. CKD was defined as Cystatin-C(CysC)>1mg/l measured at baseline, 6mths,1yr,2yr and 5yr post-transplant. Demographic and data associated with CKD post-transplantation were collected (Tac lvls at POD 7,3,6 and 12mths). Immunosuppression protocol consisted of Basiliximab induction then maintenance with tacrolimus and prednisolone +/- sirolimus. Target tacrolimus levels were between 12–15µ/L in the first 3wks, 8–12µ/L 3wks -3mths, 5–8µ/L out to1yr post transplantation. Statistical analysis was applied when appropriate, and analyses performed using SPSS. Results: 21 paediatric patients(53% male; 43%short gut syndrome, 38%paediatric intestinal pseudo-obstruction), median age of 5 yrs(4,7.8) underwent either isolated intestinal(43%), liver and intestinal(28%) or multivisceral transplantation(29%). 38% continued with tacrolimus and steroids alone, 57% sirolimus added. 4 patients required re-transplantation at a median time from first transplantation of 33.5mths (3.5,80). 4 patients died at a median time of 9.5mths(4.8,16). CysC level of all patients at baseline was 1.01(0.8,1.2), with 38% of children having evidence of pre-existing CKD (CysC lvl 1.16(1.1,1.5). There was significant association with CysC level at 6mth and Tacrolimus lvl at 3mths, r=-0.5 p=0.03. CysC lvl improved between 6mths and 1yr post transplant. No significant association was found between CKD at 6mths or 1yr and type of immunosuppression, prolonged use of intravenous fluids, parental nutrition, diabetes, graft failure, line sepsis or Tac lvl POD 7. Conclusion: Renal dysfunction is already prevalent at the time of intestinal transplantation therefore continuing close monitoring of renal function and tacrolimus levels is advisable. In our cohort renal dysfunction peaked at 6mths post transplant then improved following titration of tacrolimus level. A larger prospective study is required to identify paediatric variables that effect renal function following intestinal transplantation.

767 – Lrh1 Agonist Has Anti-Inflammatory Properties that Alleviate Lps Effect During Parental Nutrition Associated Cholestasis

767 – Lrh1 Agonist Has Anti-Inflammatory Properties that Alleviate Lps Effect During Parental Nutrition Associated Cholestasis

Extended drip infusion of peripheral parental nutrition containing amino acids might be associated with Bacillus cereus bloodstream infection

In some Japanese hospitals, patients using infusion bags for parenteral nutrition containing amino acids have developed Bacillus cereus bloodstream infections. We considered that proliferation of contaminated B cereus in the bag during prolonged drip infusion might be one of the causes of infection. This study indicated that 8 h is the maximum appropriate drip infusion time for peripheral parental nutrition containing amino acids to prevent B cereus bloodstream infections.

SUN-268 Severe Infantile Insulin Resistance: A Novel Feature of MIRAGE Syndrome

Background MIRAGE syndrome is a rare multisystem disorder characterized by myelodysplasia, infection, growth restriction, adrenal hypoplasia, genital phenotypes, and enteropathy. The syndrome is associated with mutations in Sterile Alpha Motif Domain Containing 9 (SAMD9) gene, encoding an endosome fusion facilitator protein with additional function in growth factor signaling. To date, there are no reported cases of MIRAGE syndrome associated with severe insulin resistance in infancy. Clinical Case The patient was a premature female infant born at 30 6/7 weeks gestation with a history of IUGR and brain abnormalities. Her hospital course was complicated by respiratory failure, impaired immune function, chronic diarrhea due to pancreatic exocrine deficiency, anemia, and primary adrenal insufficiency. Whole exome sequencing revealed a novel, de novo missense mutation in SAMD9 (R1293Q), confirming the clinical diagnosis of MIRAGE syndrome. At 5 months of age, she developed severe hyperglycemia with insulin resistance (insulin 303 µIU/mL, normal < 13 µIU/mL, and C-peptide 18.2 ng/mL, normal < 2.2 ng/mL). Markers of insulin receptor defects were normal, including adiponectin, IGFBP-1, and SHBG, and no mutations were identified in INSR by whole exome sequencing. The patient had no episodes of diabetic ketosis or metabolic acidosis, and had no lipodystrophy or acanthosis nigricans on exam. Initially, an insulin infusion of 0.1-0.2 U/kg/hr was sufficient to maintain euglycemia. By age 6 months, persistent hyperglycemia led to a rapid increase of the insulin infusion to 18 U/kg/hr over the course of 3 days. On day 2 of insulin up titration, glucophage was started at 15 mg/kg/day. After 72 hours of escalating insulin doses and 48 hours of glucophage, both her hyperglycemia and insulin resistance rapidly improved, with insulin requirements decreasing to < 0.5 U/kg/hr over the next 2 days to maintain glucose in the 100-200 mg/dL range. In the following months, her insulin requirement varied greatly. While fasting, no insulin was needed to maintain euglycemia. However, while on parental nutrition or enteral feeds, insulin infusion requirement varied at 0.03 U/kg/hr - 0.5 U/kg/hr. At 8 months, she transitioned to subcutaneous insulin while enteral feeds were optimized and condensed. Subcutaneous insulin doses were gradually increased to 20-24 U/kg/day in an effort to maintain blood glucose <200 mg/dl. Unfortunately, at 9 months of age, the patient expired from sepsis. Conclusion This is the first case of severe insulin resistance presenting as a manifestation of MIRAGE syndrome due to a missense mutation in SAMD9. This patient had improvement in glycemic control after treatment with glucophage and insulin. SAMD9 mutations should be considered in patients with multiple endocrinopathies including adrenal hypoplasia, severe insulin resistance, and pancreatic exocrine deficiency.

Family-Centered Care Improves Clinical Outcomes of Very-Low-Birth-Weight Infants: A Quasi-Experimental Study.

Background: Survival of very-low-birth-weight infants is improving in neonatology and family-centered-care might contribute to premature infants' clinical outcomes.Aim: To evaluate a family-centered care intervention on clinical outcomes of very-low-birth-weight infants.Methods: A quasi-experimental study was conducted in a Chinese NICU between June 2016 and June 2017. The intervention included parental education of basic care knowledge and skills followed by active participation in care for at least 4 h a day. A total of 319 very-low-birth-weight infants were recruited by convenience sampling; intervention group n = 156 and control group n = 163. Primary outcome measures were weight at discharge, length-of-stay, breastfeeding, nasal feeding, total parental nutrition, re-admission, hospital expenses. Secondary outcome measures were infant complications.Results: Infants' weight at discharge was higher in the interventions group (2,654 g vs. 2,325 g, p < 0.001). Nutritional outcomes improved significantly: breastfeeding rate 139 vs. 91, p < 0.001; days of total parental nutrition 25 d vs. 32 d, p < 0.001; gastric feeding days 23 d vs. 35 d, p < 0.001. Length-of-stay and hospital expenses did not differ between both groups. Improved infants' complications were bronchopulmonary dysplasia (32 vs. 51, p = 0.031), retinopathy of prematurity (between groups no/mild and moderate/severe, p = 0.003), necrotizing enterocolitis (6 vs. 18, p = 0.019), and re-admission rate (21 vs. 38, p = 0.023). No differences were observed in intraventricular hemorrhage and nosocomial infections.Conclusion: Very-low-birth-weight premature infants might experience improved clinical health outcomes when parents are present and caring from them. Family-centered care is as a beneficial care model for premature infants and should be recognized and implemented by NICUs where parents have currently limited access.

Efficacy of Enteral Nutrition by Double Elementary Diet Tube after Pylorus-Preserving Pancreatoduodenectomy

Nutritional support after pylorus-preserving pancreaticoduodenectomy (PpPD) is still controversial. This study aimed to evaluate the efficacy of enteral nutrition (EN) via the double elementary diet (W-ED) tube after PpPD. One hundred two patients who received EN by the W-ED tube were compared with 52 patients who received total parental nutrition (TPN) previously. Clinicopathological and postoperative features were analyzed among the two groups. Patients with EN by the W-ED tube after PpPD had a lower incidence of postoperative pancreatic fistula than those with TPN. The total protein and albumin levels on discharge in the EN group were significantly higher than those in the TPN group. In the case without complication, decreasing rate of the third lumbar vertebra skeletal muscle area was significantly lower in the EN group. In the cases of soft pancreas, drainage volume by the W-ED tube until four postoperative day was significantly larger in the case without postoperative pancreatic fistula. The W-ED tube offers the advantages of reducing gastrointestinal pressure and enabling reduction of complications after PpPD surgery.

Ancestral and offspring nutrition interact to affect life-history traits in Drosophila melanogaster.

Ancestral environmental conditions can impact descendant phenotypes through a variety of epigenetic mechanisms. Previous studies on transgenerational effects in Drosophila melanogaster suggest that parental nutrition may affect the body size, developmental duration and egg size of the next generation. However, it is unknown whether these effects on phenotype remain stable across generations, or if specific generations have general responses to ancestral diet. In the current study, we examined the effect on multiple life-history phenotypes of changing diet quality across three generations. Our analysis revealed unforeseen patterns in how phenotypes respond to dietary restriction. Our generalized linear model showed that when considering only two generations, offspring phenotypes were primarily affected by their own diet, and to a lesser extent by the diet of their parents or the interaction between the two generations. Surprisingly, however, when considering three generations, offspring phenotypes were primarily impacted by their grandparents' diet and their own diet. Interactions among different generations' diets affected development time, egg volume and pupal mass more than ovariole number or wing length. Furthermore, pairwise comparisons of diet groups from the same generation revealed commonalities in strong responses to rich versus poor diet: ovariole number, pupal mass and wing length responded more strongly to poor diet than to rich diet, while development time responded strongly to both rich and poor diets. To improve investigations into the mechanisms and consequences of transgenerational, epigenetic inheritance, future studies should closely examine how phenotypes change across a higher number of generations, and consider responses to broader variability in diet treatments.

Parental Nutrition Knowledge, Iron Deficiency, and Child Anaemia in Rural China

Anaemia is a factor that could affect health and school performance of students and shed a shadow on poverty in the long-run, particularly in rural China. In response, the current literature mainly pays attention to the effect of direct payments such as money and food. Although some literature indicates that a key to children’s nutritional improvement is to increase their parents’ nutrition knowledge, it has not been well studied. The main purpose of this paper is to test whether nutrition knowledge training for parents can significantly decrease anaemia in their children. This article uses a randomised control trial of information intervention for parents of more than 2000 fourth and fifth grade students in 42 randomly selected rural primary schools in northwest China and confirms that parental nutrition knowledge training has a positive effect on students’ haemoglobin level, through the channel of knowledge improvement and dietary change. Specifically, the programme could reduce children’s anaemia by 6.1 per cent in probability, and increase haemoglobin values by 2.8 on average.

Behavior change communication model enhancing parental practices for improved early childhood growth and development outcomes in rural Armenia - A quasi-experimental study.

The latest evidence demonstrates the importance of nurturing care from conception to lay a strong foundation for children's cognitive, socio-emotional and physical well-being. The interventions enhancing parental practices in children's health and growth, protection from neglect, abuse, and injury have lifelong impact on health, learning, economic productiveness outcomes. Existing maternal and child health delivery platforms might potentially be utilized to integrate Early Childhood Development interventions. However, there is a dearth of studies demonstrating the feasibility and effectiveness of an integrated MCH and ECD model. ECD component was integrated into MCH program activities, implemented and tested in Armenia. For 14 months, all mothers of children aged 0 to 23 months (1300) living in 43 communities in Gegharkunik province (Armenia) participated in the study. Twenty-three intervention communities (680 children) received added ECD package to MCH intervention, and 20 control communities (630 children) received only MCH intervention. We used a quasi-experimental intervention-control design, with pre-and post-data collected. Variables measured and compared were related to child development, nutrition status, parental child care (stimulation, discipline) and nutrition practices.Intervention sites showed 83% higher odd of total ECD composite score (cognitive, language, motor) compared to children in the control sites. Child caregivers had better child care, nutrition practices and early learning support than controls. No change was found in discipline practices and stunting rates. MCH-ECD integrated model is an effective delivery platform for improving parenting behavior, child growth, and development.

Safety of mucous fistula refeeding in neonates with functional short bowel syndrome: A retrospective review

PurposeMucous fistula (MF) refeeding of proximal stoma effluent in neonates after small bowel resection can promote nutrient absorption and prevent atrophy of the unused distal bowel. This study aimed to assess the safety of this practice in neonates. MethodsA retrospective chart review of all patients admitted to the neonatal intensive care unit (NICU) between 2009 and 2015 who underwent a laparotomy with creation of an enterostomy and mucous fistula was performed. Patients were included if they were refed proximal stoma effluent into the MF. ResultsThirty-one patients were identified that were refed. There were no major complications (perforation, stricture, death) related to refeeding. Patients were refed for an average of 41 days (± 22), with patients gaining an average of 25.7 g/day (± 10.1) while being refed. Total parental nutrition (TPN) was administered for an average of 55 days (± 31.4) between resection and reanastomosis, with only 7 (23%) developing cholestasis and 15 (48%) reaching full feeds in this time. Mean time to full feeds after reanastomosis was 36 days (± 58.6) with two patients having anastomotic leaks. ConclusionMF refeeding is a safe technique that has the potential to contribute to significant weight gain and a decreased dependence on total parenteral nutrition. Level of evidenceII

P016 META-ANALYSIS OF DIETARY INTERVENTION EFFECTS IN CROHN’S DISEASE AND ULCERATIVE COLITIS

Inflammatory Bowel Disease (IBD) is becoming a global health issue as incidence rates are rising throughout the world. The two most common inflammatory bowel diseases are Crohn’s Disease (CD) and Ulcerative Colitis (UC). The main goal of medical treatment for IBD is to reduce symptoms and induce a state of remission by regulating the immune system with pharmaceutical therapies. For many individuals, medication alone is insufficient to maintain remission and live a ‘normal’ life. Diet is believed to play a significant role in disease management, but the effect of diet as treatment for CD and UC is unknown. This meta-analysis seeks to assess the collective effectiveness of dietary interventions on health outcomes related to Crohn’s Disease and Ulcerative Colitis. A literature search was conducted using PubMed, Web of Science, and Medline (Ovid). Search terms included ‘Crohn’s Disease’, ‘Ulcerative Colitis’, ‘Inflammatory Bowel Disease’, ‘Nutrition’, ‘Diet’, ‘Dietary Treatment’, and ‘Intervention’. Randomized controlled trials and observational studies with human subjects were included. Studies on irritable bowel syndrome, enteral or parental nutrition therapy, or food-related supplements were excluded. Outcome measures were categorized as either clinical measures or patient-reported outcomes. A meta-analysis calculated an overall summary effect size with a moderator analysis assessing differences in effects for clinical measures versus patient-reported outcomes. Twenty three studies were identified as eligible for inclusion. A summary effect size of 0.716 (95% CI, 0.379-1.054) indicates a moderately large positive effect. A positive effect size implies dietary interventions improve disease conditions, indicated by fewer symptoms, decreased inflammation, and decreased activity index scores. Moderator analysis showed effect sizes of 0.630 (95% CI, 0.257-1.004) and 0.878 (95% CI, 0.553-1.204) for clinical measures and patient reported outcomes, respectively. Findings suggest that while diet positively impacts IBD overall, individuals may perceive greater disease improvement than clinical measures suggest. This may be due to the effects of healthier food choices on overall health and well-being. These findings suggest a need for increased attention to the dietary lifestyles of individuals with Inflammatory Bowel Diseases and support for diet-based interventions among this population. Implementing dietary changes may lead to improved disease conditions, greater success in maintaining remission, and increased quality of life.

Comparison of Parenteral Nutrition Usage in Pediatric Bone Marrow Transplant Patients with and without Gastrostomy Tubes

Purpose To determine whether placement of gastrostomy tubes (GT) in pediatric bone marrow transplant patients prior to transplant and provision of enteral nutrition (EN) can decrease the duration/necessity of parental nutrition (PN) usage during time of treatment related mucositis and nausea/vomiting. Methods We retrospectively reviewed the medical records of pediatric bone marrow transplant patients admitted to the Medical University of South Carolina (MUSC) Children's Hospital from July 2014 through July 2018. We collected data on type of transplant, chemotherapy regimen, presence of GT, PN initiation and duration, diagnosis of veno-occlusive disease (VOD), and hospital length of stay (LOS). Results We analyzed 63 transplant occurrences in 53 patients including 23 allogeneic, 35 autologous and 5 haplo-identical stem cell transplants. In 28 of 63 (44%) transplant occurrences, the patients had a GT placed prior to admission. PN was administered in 22 of 28 (79%) in the GT group and 28 of 35 (80%) in the no GT group. The average duration of PN was 10 days in the GT group (range 4 to 20 days) and 17 days in the no GT group (range 1 to 65 days). The incidence of VOD was 14% in both GT and no GT groups. The average length of stay was 36 days (range 23 to 59) in the GT group and 44 days (range 23 to 83) in the no GT group. Conclusion Placement of gastrostomy tubes and provision of EN in pediatric bone marrow transplant patients did not eliminate the need for PN but decreased the number of days patients require PN during the transplant process. Our data did not show a decrease in the incidence of VOD in patients with GT. Though many factors play a role, we demonstrated an association between GT placement and decreased length of stay.

Severity of Mucositis Determines Cyclosporine Levels after Allogeneic Transplantation

Introduction Intestinal mucosal injury is a common complication following allogeneic stem cell transplant (alloHSCT), especially with myeloablative and TBI-based (total body irradiation) conditioning regimens. Prospective evaluation studies have shown that intestinal malabsorption persists for several weeks following conditioning, beyond visible resolution of mucositis and bowel integrity. Serum cyclosporine levels in the early to intermediate post-transplant period (when patients are taking oral cyclosporine) may be affected by reduced gut absorption and could influence early transplant related outcomes. Objective To determine the relationship between mucositis severity, cyclosporine levels, and post-transplant outcomes. Methods 169 patients who received myeloablative (BuCy, CyTBI, EtoTBI) or reduced-intensity (FluMel) allo-HSCT at the Royal Melbourne Hospital were studied. Serum cyclosporine levels were measured at 2 hours post oral dosing. Days of post-transplant total parental nutrition (TPN) were used as a surrogate for severity of gastrointestinal mucositis. To determine degree of renal impairment, creatinine values were recorded at baseline, D+30, D+60 and D+100. Percentage increase of mean creatinine above baseline was taken as an index of renal impairment. The incidence and severity of acute graft-versus-host disease (aGVHD) was recorded before D+100. The incidence of CMV viraemia before D+100 was recorded and analysed according to serum viral load. Patients with recurrence of disease were compared with patients without recurrence ( 6 months). Results Linear regression analysis showed an inverse correlation between days requiring TPN with the post SCT 100-day median cyclosporine level (p Higher median cyclosporine level was associated with a greater percentage increase of creatinine above baseline (p=0.004, R2= 0.051). There was no significant correlation between incidence (p=0.05) and severity (p=0.47) of aGVHD with lower cyclosporine levels. CMV reactivation was associated with higher cyclosporine levels (p Conclusion Our data suggest that patients who have significant mucositis have lower serum cyclosporine levels with oral cyclosporine dosing, which in turn impact upon post-transplant outcomes, in particular renal impairment and CMV reactivation.

P551 Use of preoperative total parenteral nutrition is associated with clinical and laboratory remission in severe active Crohn’s disease

Crohn’s disease (CD) patients with active penetrating and stricturing disease have a high prevalence of malnutrition that has been shown to increase post-operative complications. The effect of 1–3 months of pre-operative exclusive total parental nutrition (TPN) in active CD patients is not well established. We investigated the efficacy of exclusive TPN in active CD patients. From our IBD Centre database (prospectively collected data) we identified all patients with complicated, active CD who were candidates for bowel resection between January 2016 and October 2018. CD location and activity were recorded based on the modified Montreal classification. Inclusion required exclusive preoperative home TPN without additional oral intake for the 1–3 months prior to surgery. The Harvey–Bradshaw Index (HBI), body mass index (BMI), C-reactive protein (CRP) and albumin levels were recorded at baseline and at the end of TPN therapy. Seventeen pre-operative CD patients (58.8% male, 41.2% female) on exclusive TPN were identified. The mean age of the cohort was 31.5 ± 11.8 years with median disease duration of 8 years (IQR 3–12). Mean duration of pre-operative TPN treatment was 69 days (range 24–110). Most patients had ileocolonic (35.3%) or terminal ileal CD (23.5%), and the stricturing and/or stenotic (B2) phenotype (94.1%) was the most common. During TPN treatment, 70.6% were on stable doses of medication (immunomodulators and/or biologics) and 29.4% had no medical treatment. All 17 patients had significant clinical improvement in all disease activity indices at the end of preoperative TPN (baseline vs. post TPN): HBI 16.3 ± 7 vs. 6.1 ± 6.1 (p = 0.001); BMI 19.7 ± 3.3 vs. 20.8 ± 3.2 (p = 0.017); CRP 58.5 (IQR 33–149) vs. 12.5 (IQR 6–30) (p = 0.001); and albumin 2.8 ± 0.6 vs. 3.7 ± 0.5 (p = 0.001). Two patients (11.7%) no longer required bowel resections after completion of exclusive TPN. Exclusive pre-operative TPN was associated with weight gain, decreased inflammatory biomarkers, and improved clinical disease activity markers and nutrition. While these initial results are encouraging, additional studies are needed before a recommendation can be made regarding longer duration of exclusive pre-operative TPN for severe, refractory CD to decrease disease activity and improve nutritional status before elective surgery.

Neurodevelopmental outcomes of infants with intestinal failure at 12 and 26 months corrected age.

Survival rates of infants with intestinal failure (IF) are increasing, yet multiple medical factors may impact development. This study examines neurodevelopmental outcomes at 12-15 and 26-32 months corrected age in a cohort of children with IF. Prospective single centre neurodevelopmental assessments of children admitted to an intestinal rehabilitation program between 2011 and 2013. Outcome measures include: Mullen Scales of Early Learning (12 and 26 months), and Vineland-II Adaptive Behaviour Scales - Caregiver Report (26 months). Standard scores were correlated with medical and demographic factors. Thirty-one children (17 males), median gestational age 34 weeks (IQR 30-36) with birth weight (BW) 2.12 kg (IQR 1.24-2.52). Ten (32.2%) were dependent on parental nutrition (PN) at the second assessment. At 12 months, 11/30 (36.7%) scored below average (>1SD below mean) on the early learning composite and 24/30 (80%) were below average on the gross motor subscale. Comparatively, at 26 months, mean early learning scores were significantly lower with >50% scoring below average. Mean gross motor scores remained low, and 14/27 (51.9%) were below average on the Vineland-II motor domain. At 12 months, factors significantly associated with lower scores are primarily related to prematurity. At 26 months, the impact of IF-related variables such as bowel length and PN days are more apparent. Children with IF are at risk of developmental delay in multiple domains. While gross motor skills appear to be most significantly affected, cognitive deficits become more apparent at 26 months, highlighting the importance of early developmental follow up.

Nutrition in critically Ill pediatric patients: a systemic review

Objective The study aimed to review the different types of nutrition in critically ill pediatric patients. Data sources Medline databases (PubMed, Medscape, Science Direct, EMF-Portal, Google Scholar) and all materials available in the Internet from 2001 to 2014 were searched. Study selection The initial search presented 150 articles of which 50 met the inclusion criteria. The articles studied the role of nutritional management in critically ill pediatric patients. Data extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, adequate information provided, and assessment measures defined. Data synthesis Comparisons were made by structured review with the results tabulated. Findings In total, 50 studies indicated that ICU patients who present with malnutrition or at a high probability of developing malnutrition during their hospital stay and those who are not expected to be on a full oral diet within 3 days should receive specialized enteral and/or parenteral nutritional support. Feeding should be started early within the first 24–48 h to facilitate diet tolerance and reduce the risk of intestinal barrier dysfunction and infections. Conclusion This review found that critically ill pediatric patients are at risk of malnutrition. Enteral nutrition is the preferred mode of nutrition and should be used whenever possible. Total parental nutrition is used only if the gastrointestinal tract is unable to meet the nutritional requirements for 1–3 days in infants and 4–5 days in children and adolescents.

A Novel Care Model for Neonatal Intestinal Failure Patients Is Associated With Cost Savings and Improved Outcomes.

BackgroundNeonates with intestinal failure (IF) have prolonged admissions in the neonatal intensive care unit (NICU) and require lifelong follow-up with gastroenterology (GE) as outpatients. Inpatient management of these patients typically relies on many rotating practitioners and currently discharge criteria do not exist. We sought to create standardized discharge criteria with a continuity care model for neonatal IF patients.MethodsInpatient care was streamlined to two GE physicians with weekly consultations. We implemented standardized discharge goals for both enteral and total parental nutrition (TPN) by: 1) Enteral feedings of at least 5 mL/h were tolerated; 2) Stable central venous access was intact; 3) TPN was cycled to 20 h/day or less; and 4) No other medical issues required NICU admission. Patient records were reviewed after 18 months of implementing standardized discharge criteria and we compared their outcomes to a historical cohort of IF patients.ResultsOptimal discharge criteria were met in 12 patients and a cohort of 26 historical patients was used for comparison. Patients in optimal versus historical groups had similar baseline characteristics (medians, all P values = non-significant (NS)): gestational age (36 vs. 35 weeks), birth weight (1,990 vs. 2,076 g), birth length (45 vs. 44 cm), and small bowel length after definitive surgery (63 vs. 55 cm). Compared to the historical group, the optimal cohort was discharged earlier (median length of stay 69 vs. 126 days, P < 0.01), with a reduced total stay of 684 NICU days, fewer central line-associated bloodstream infections (CLABSIs) (4 vs. 10 per 1,000 patient days, P = 0.04), and had fewer readmissions (7 vs. 17 per 1,000 patient days, P < 0.01), respectively.ConclusionsConcentrating the care of IF patients to a GE team invested in long-term care, while implementing safe discharge criteria, resulted in a dramatic length of stay reduction with fewer CLABSIs and readmissions compared to historical management. At approximately 4,000 dollars per day in NICU hospital charges, this program saved over 2.7 million dollars in care costs while allowing families and their infants more time at home. The safety and applicability of the optimal discharge criteria presented here should be studied further. Similar programs may be effective at other large NICUs.

Clinical safety of Parental Nutrition

Clinical safety of Parental Nutrition

Transanastomotic tube in intestinal atresia: How beneficial are they?

Introduction:Intestinal atresia requires multiple surgeries and long hospital stay. We tried managing these cases by primary anastomosis with transanastomotic tube (TAT) for early feeding.Aims:The aim of the study was to analyse the outcomes in patients of intestinal atresia who underwent primary anastomosis with a TAT.Materials and Methods:The records between June 2014 and November 2017 were analysed. Those with incomplete data or unclear final outcome were excluded. Patients managed by primary anastomosis with TAT (Group A) or without TAT (Group B) were included. The TAT was kept for 6 weeks. Oral feeds were started after 2 weeks in all the cases. P < 0.05 was considered as statistically significant.Results:Forty-eight cases were included. There were two duodenal atresia, 29 jejunal atresia and 17 ileal atresia. The mean age at surgery was 2 days (range: 1–16 days). There were 42 cases in Group A (with TAT) and six in Group B (without TAT). The average duration of start of feeds was 78 h (range: 72–96 h) in Group A and 402 h (range: 360–504 h) in Group B (P = 0.01). The mean duration of hospital stay was 7 days (range: 5–15 days) and 27 days (range: 19–48 days) in Group A and B, respectively (P = 0.02). The overall survival was 38 (91%) and 3 (50%) in Group A and B, respectively (P = 0.01). Reexploration was required in 2/42 and 2/6 cases in Group A and B, respectively (P = 0.4). Total parental nutrition was required in 2/42 and all cases in Group A and B, respectively.Conclusion:Primary repair in intestinal atresia with a TAT is a practical option. The overall outcome is better.

A Web-Based Gamification Program to Improve Nutrition Literacy in Families of 3- to 5-Year-Old Children: The Nutriscience Project

Assess the impact of a web-based gamification program on nutrition literacy of families and explore differences in impact by socioeconomic status. Quasi-experimental. Thirty-seven kindergartens from Portugal. Eight hundred seventy-seven families. Web-based social network of participants' interactions, educational materials, apps and nutritional challenges, focused on fruit, vegetables, sugar, and salt. Parental nutrition literacy (self-reported survey - 4 dimensions: Nutrients, Food portions, Portuguese food wheel groups, Food labeling). General linear model - Repeated measures was used to analyze the effect on the nutrition literacy score. Families uploaded 1267 items (recipes, photographs of challenges) and educators uploaded 327 items (photographs, videos) onto the interactive platform. For the intervention group (n = 106), the final mean (SD) score of nutrition literacy was significantly higher than the baseline: 78.8% (15.6) vs 72.7% (16.2); P < .001, regardless of parental education and perceived income status. No significant differences in the scores of the control group (n = 83) were observed (final 67.8% [16.1] vs initial 66.4% [15.6]; P = .364). Gamified digital interactive platform seems to be a useful, easily adapted educational tool for the healthy eating learning process. Future implementations of the program will benefit from longer time intervention and assessment of the eating habits of families before and after intervention.