Paediatric Dietitians Research Articles

Nutritional support of children with chronic liver disease.

Anorexia, malabsorption and metabolic derangements contribute to the malnutrition that occurs in most children with chronic liver disease. Nutritional support should be started early in the management of these children with the co-operation of a paediatric dietitian to improve quality of life and decrease post-transplant mortality. Nutritional assessment entails a detailed dietary history, physical examination and anthropometry. Weight-based anthropometric measures are unreliable while mid-upper-arm circumference and skinfold thickness provide more reliable estimates of nutritional status. Special investigations such as serum vitamin levels and skeletal X-rays further guide management. High energy (130 - 150% of recommended daily intake (RDI)) and protein (3 - 4 g/kg/day) intakes are recommended. Diets are usually enriched with medium-chain fatty acids because of their better absorption in cholestatic liver disease. High-dose fat-soluble vitamin supplements are given while care is taken to avoid toxicity. Initial doses are two to three times the RDI and then adjusted according to serum levels or international normalised ratio (INR) in the case of vitamin K. Children with good appetites are fed orally. Feeds should be more regular than for other children to avoid prolonged periods of fasting and improve energy intake. Some children require supplementary nasogastric feeds to increase energy intake and avoid overnight fasting

P6 – 2654: Clinical spectrum of cerebral palsy in Durban, South Africa

Objective To evaluate the clinical spectrum of cerebral palsy children in South Africa and their need. Methods The study was done in a tertiary children's outpatient hospital from July 2013 to December 2014. This was a retrospective, descriptive chart review of cerebral palsy patients. Background Few comprehensive studies have been done in South Africa. Results 30 children were analyzed. The average age was 5.8 years. The range was 2 to 13.5 years. The male to female ratio was 1.5:1. Children were classified according to the type of cerebral palsy. A paediatric neurologist, occupational therapist, physiotherapist, speech therapist, dietitian and psychologist examined them. 53% had bilateral spastic, 26.7% unilateral spastic, 13% dyskinetic, one ataxic and one mixed cerebral palsy. Common comorbidities (average 4 per child) were epilepsy, cognitive impairment, contractures, reflux, constipation, drooling and behaviour problems. Two had fractures and two precocious puberty. Twenty children (66%) had Epilepsy and twelve (40%) abnormal EEGs. There were 13 MRI brains done. The number of children with abnormal radiology, which included Ct brain, was 25 (83%). Two were unrecorded. Aetiology ranged from perinatal hypoxic ischaemic encephalopathy (43%), 13% brain malformations, 16.7% prematurity related complications, 23% post natal complications, including TB meningitis and jaundice, and one patient with no identified cause. Only nine children (30%) could walk. There was a high degree of disability with the GMFCS above 4 in 63%. The children were on an average of 4 medications and none were on Botulin toxin injections. Only 6 were in special schools. Conclusion The number of bilateral spastic cerebral palsy is still very high. The aetiology includes high number of preventable causes. There is a very high degree of comorbidity in children with cerebral palsy in South Africa and a high need for other therapy like botulin toxin, anti-drooling medication and special schools.

Food, Fiber, and Formula

A term infant who failed to pass meconium and developed bilious emesis on the first day of life underwent a suction rectal biopsy, which revealed the absence of ganglion cells consistent with Hirschsprung’s disease. His final postoperative pathology report indicated an absence of ganglion cells in the anorectal mucosa but some eosinophils in the myenteric plexus and surrounding smooth muscle of the transition zone, aganglionic sigmoid colon, and rectum. These findings are consistent with diagnosis of eosinophilic myenteric ganglionitis. At 6 months old, he had a Soave endorectal pull-through with resection. He had significant, prolonged explosive diarrhea leading to severe perianal breakdown and weight loss. An amino-acid-based infant formula was trialed, and the diarrhea resolved quickly. Ongoing nutrition counseling was needed because of milk sensitivity. He was prone to constipation, and a high-fiber diet was needed. This case shows how collaboration between the pediatric dietitian and pediatric surgical team can lead to better nutritional outcomes including optimal growth, improved formula tolerance, and decreased gastrointestinal (GI)-related complications after surgery. It also reinforces how long-term follow-up is critical from both a nutrition and surgical standpoint, to address the long-term nutrition issues that can ensue from surgical intervention of Hirschsprung’s disease in infancy. This particular case is especially interesting as the patient is the youngest documented case found in the literature with a case of eosinophilic myenteric ganglionitis occurring with Hirschsprung’s disease.

Toward enteral nutrition for the treatment of pediatric Crohn disease in Canada: a workshop to identify barriers and enablers.

The treatment armamentarium in pediatric Crohn disease (CD) is very similar to adult-onset CD with the notable exception of the use of exclusive enteral nutrition (EEN [the administration of a liquid formula diet while excluding normal diet]), which is used more frequently by pediatric gastroenterologists to induce remission. In pediatric CD, EEN is now recommended by the pediatric committee of the European Crohn's and Colitis Organisation and the European Society for Paediatric Gastroenterology Hepatology and Nutrition as a first-choice agent to induce remission, with remission rates in pediatric studies consistently >75%. To chart and address enablers and barriers of use of EEN in Canada, a workshop was held in September 2014 in Toronto (Ontario), inviting pediatric gastroenterologists, nurses and dietitians from most Canadian pediatric IBD centres as well as international faculty from the United States and Europe with particular research and clinical expertise in the dietary management of pediatric CD. Workshop participants ranked the exclusivity of enteral nutrition; the health care resources; and cost implications as the top three barriers to its use. Conversely, key enablers mentioned included: standardization and sharing of protocols for use of enteral nutrition; ensuring sufficient dietetic resources; and reducing the cost of EEN to the family (including advocacy for reimbursement by provincial ministries of health and private insurance companies). Herein, the authors report on the discussions during this workshop and list strategies to enhance the use of EEN as a treatment option in the treatment of pediatric CD in Canada.

Significant inconsistency among pediatric oncologists in the use of the neutropenic diet.

The role of the neutropenic diet in the development of infections in oncology and stem cell transplant (SCT) patients is controversial. There is no data on the use of the neutropenic diet among pediatric oncologists. A self-administered electronic survey was sent to 1,639 pediatric oncologists at 198 institutions who are members of Children's Oncology Group. A pediatric dietitian and pediatric oncologists developed, pretested, and modified the survey for item clarification. Five hundred fifty-seven physicians (34%) responded representing 174 (87%) of the 198 member institutions. More than half of respondents (57%) report implementing the neutropenic diet at their facility. In a multivariate analysis, being a stem cell transplant (SCT) center was the only significant factor associated with implementing a neutropenic diet (OR: 6.06, 95% CI, 2.88-12.738, P < 0.001) after controlling for years in practice, gender, center size, and academic versus private practice. Among physicians who implemented a neutropenic diet, absolute neutrophil count was the trigger for initiating the diet in oncology patients (72%) while admission and start of preparative regimen was used for SCT patients (84%). The majority of respondents (82%) stop the neutropenic diet when oncology patients are no longer neutropenic while the practice varied significantly with SCT patients. Providers at the same institution were not consistent with implementation of the diet, patient populations placed on the neutropenic diet and parameters for initiation, discontinuation of the diet and specific food restrictions. The implementation of the neutropenic diet by pediatric oncologists remains quite variable even among those at the same institution.

Hemodialysis for infants, children, and adolescents.

Children with chronic kidney disease stage 5 requiring dialysis can be treated by peritoneal or hemodialysis. In the United Kingdom nearly twice as many children receive peritoneal dialysis compared with hemodialysis. Technical aspects of pediatric hemodialysis are challenging and include the relative size of extracorporeal circuit and child's blood volume, assessment of adequacy,technical and complications of vascular access. Alternatives to standard hospital-based hemodialysis are also increasingly available. Optimizing nutritional status with the support of specialist pediatric dietitians is key to the management of children receiving hemodialysis. The effects of chronic illness on growth and school achievement, as well as the psychological, emotional, and social development of the child should not be underestimated. This review focuses on the above elements and highlights common pediatric practice in the United Kingdom.

A review of staffing levels and activity in paediatric dietetics

AbstractBackgroundThe present study was undertaken to review how much time paediatric dietitians spend in direct contact with patients and to determine what levels of staffing are available throughout paediatric dietetic departments in Ireland and the UK.MethodsA work sampling tool was devised to capture paediatric dietetic activity for a period of 1 day. A semi‐structured questionnaire was sent to paediatric dietitian managers to provide demographic information on their facility.ResultsFourteen questionnaires were returned by paediatric dietitian managers and 86 work sampling tools were returned for analysis by dietitians working in the various departments. Paediatric dietitians spend 23% of the working day in direct patient contact, although up to 58% of the day in direct patient‐related activities, of which communication comprised 25.2%. Staffing levels are below clinical recommendations in four out of five specialties. National activity reports focus on the number of patient contacts but do not include information on the complexity of patient care.ConclusionsWork sampling is a useful tool in the assessment of activity in healthcare. Inadequate staff levels and limitations in activity reporting in paediatric dietetics will affect estimations for future service developments. Information obtained from the present study could contribute to the supply analysis of a workforce planning exercise in paediatric services in the future.

Food allergy competencies of dietitians in the United Kingdom, Australia and United States of America.

BackgroundA knowledgeable and competent dietitian is an integral part of the food allergy multidisciplinary team, contributing to effective diagnosis and management of food allergic disorders. Little is currently known about the food allergy training needs and preferences of dietitians. The purpose of this paper is to measure and compare self-reported food allergy competencies of dietitians based in the UK, Australia and USA.MethodsA survey of USA-based paediatric dietitians was developed to measure self-reported proficiency and educational needs in the area of food allergy. The survey was modified slightly and circulated online to paediatric and adult dietitians in the UK and Australia. Descriptive statistics and Pearson correlations are presented.ResultsA total of 797 dietitians completed the questionnaire. Competency in “developing food challenge protocols” and “managing feeding problems” were rated the poorest overall across all three settings. A higher level of competency was significantly positively associated with length of practice as a dietitian, percentage of caseload composed of patients with food allergy and training in food allergy. The most popular topics for further training were food additives, pharmacological reactions and oral allergy syndrome.ConclusionsThere is a need amongst dietitians to increase their knowledge in different aspects of food allergy diagnosis and management, specifically the areas of developing food challenge protocols and management of feeding problems. This study provides valuable information for designing targeted food allergy education for dietitians.Electronic supplementary materialThe online version of this article (doi:10.1186/2045-7022-4-37) contains supplementary material, which is available to authorized users.

Consenso nacional sobre dieta cetogénica

Epilepsy is a chronic disease with onset in infancy affecting 0.5-1% of the population. One third of the patients is refractory to antiepileptic drugs and they pose a challenge for the health care team. The ketogenic diet is an effective, non-pharmacological, alternative treatment for the management of refractory epilepsy. There is a need to establish guidelines for the adequate and increased use of the ketogenic diet in Spanish-speaking countries. The National Committee on the Ketogenic Diet, consisting of paediatric neurologists, clinical nutritionists, and dietitians, of the Argentine Society of Child Neurology has developed this consensus statement to standardize the use of the ketogenic diet based on the literature and clinical experience. Patient selection, pre-treatment family counseling, drug interactions, micronutrient supplementation, adverse effects, and discontinuation of the diet are discussed. The ketogenic diet is an effective treatment for children with refractory epilepsy. Education and collaboration of the patient and their family is essential. The patient should be managed by an experienced multidisciplinary team using a protocol. The formation of a national multidisciplinary team and the publication of this document provide possibilities for new centers to integrate the ketogenic diet into their treatment options.

Managing children with coeliac disease in the community

Coeliac disease is an autoimmune condition caused by sensitivity to gluten-containing foods. It affects around 1% of children, although many cases may remain undiagnosed. Health visitors should be aware of the classic gastrointestinal features of coeliac disease and make an early referral to medical professionals. Breastfeeding is considered to have a protective role. Suspicion of coeliac disease should lead to antibody screening tests and the diagnosis is confirmed by an intestinal biopsy. A gluten-free diet (GFD) should always be started by paediatric dietitians, but health visitors can play an important role in educating and supporting families. Extra-intestinal manifestations (e.g. severe iron-deficiency anaemia or short stature) can pose a diagnostic challenge, and a suspicion of coeliac disease should always be discussed with a medical professional. Strict adherence to a GFD is essential to maintain good health and to prevent development of long-term complications.

G79 Nutritional Status of Infants with Congenital Heart Disease

AimsTo assess the nutritional status of infants with congenital heart disease (CHD) who were managed jointly by the medical and dietetic teams and required either high calorie feeds or nasgastric...

Helping children stop or avoid enteral feeding.

Long term enteral feeding is widely used to provides vital support for infants and children unable to feed orally, but once medically stable the transition to a normal diet can be difficult. Other children may need to commence tube feeding later in childhood because of difficulties associated with neurodisability, but recognising which children will benefit from tube feed is not straightforward. The Royal Hospital for Sick Children, Yorkhill set up a multidisciplinary feeding team in 2002 to help avoid unnecessary tube feeding.We accept only children who are either artificially fed or with severe nutritional problems and only after attempted uni-disciplinary management. The team members are a clinical psychologist, paediatric dietitian and consultant paediatrician, supported by a specialist paediatric registrar, assistant psychologist and administrative support. We can see only a small proportion of all with complex feeding problems, but aim to improve the care of such children generally. We disseminate the lessons learned within the Feeding Clinic via education locally and nationally and have an active programme of research.Over the first ten years of the clinic we have seen 222 patients of whom 67% were initially either tube or oral supplement fed, while only 29% remain so at follow up. In the first three years of the clinic tube fed children had spent a median of seven years on feeds before they were successfully weaned, but since then that has fallen to a median of 2.7 years. Of 53 other children referred for possibly tube feeding, 32 (60%) remain well on a normal diet and only ten (19%) have needed to start tube feeding.The service is highly cost effective. Salary costs are only around £65,000 per year, while weaning five children per year, reducing their years on feeds by four years, saves the NHS £130,000.

Factors Contributing to Initial Weight Loss Among Adolescents with Polycystic Ovary Syndrome

Study ObjectiveTo evaluate the impact of a multidisciplinary clinic on weight management among adolescents with PCOS. Design140 adolescent females were evaluated in a multidisciplinary PCOS clinic from March 2005 to December 2008. The team included a pediatric endocrinologist, health psychologist, dietitian, and pediatric gynecologist. 110 were diagnosed with PCOS based on the Rotterdam Criteria. Height, weight, BMI, number of subspecialists seen, use of metformin, and compliance with return visits were obtained from medical records. SettingAmerican Family Children's Hospital in Madison, Wisconsin. Participants110 adolescent females with polycystic ovary syndrome. InterventionsConsultation with a dietitian and health psychologist. Main Outcome MeasureChange in weight. ResultsThe average age at first visit was 15.9 years. The average BMI was 34.7 kg/m2 (range 18.1-55.5). Seventy-six percent had an initial BMI above the 95th percentile. Interactions with providers at the initial visit included a pediatric endocrinologist (100%), health psychologist (60.9%), dietitian (75.5%) and gynecologist (70.9%). Seventy one percent returned for a follow-up visit, (average time of 4.5 months between visits) with 57% achieving weight loss (average 3.5 kg) and an additional 12.6% demonstrating no significant weight gain (< 1.5 kg). Thus, 69.6% demonstrated weight loss/stabilization. ConclusionsIn this multidisciplinary clinic for adolescents with PCOS, nearly 70% of patients succeeded in short-term weight stabilization, with 57% demonstrating weight loss. Interactions with the health psychologist and dietitian appeared to play a key role in successful weight control, supporting the importance of psychology and nutrition expertise in the management of this disorder.

Antimigraine (Low‐Amine) Diet May Be Helpful in Children With Cyclic Vomiting Syndrome

To the Editor: Cyclic vomiting syndrome (CVS) is considered to be a functional gastrointestinal disorder characterised by stereotypical episodes of acute vomiting lasting <1 week with ≥3 discrete episodes in the previous year and absence of nausea and vomiting between the episodes. CVS has been managed with antiemetics and intravenous fluids with reasonable success (1,2). CVS is increasingly being recognised as a brain–gut disorder and has been associated with a high familial prevalence of migraine or considered to be a migraine variant in children (2,3). As with migraine, CVS has been associated with the ingestion of foods such as cheese, chocolate, citrus fruits, caffeine, yeast extract, and pork (2). A study in Italy showed improvement with the exclusion diet in CVS symptoms in 7 of 8 children. These children showed positive skin prick tests and specific immunoglobulin E to cow's-milk protein, egg whites, and soya; however, there was no history of specific food allergies (4). We describe a low-amine diet (LAD) as prophylactic therapy for CVS, which avoids all of the food groups previously implicated as migraine triggers (5). The food groups that need to be avoided include cheese, chocolate, citrus fruit and their juices, pork and pork products, peas, broad beans, game, shellfish, yeast extract, beef extract, gravies, drinks containing caffeine (tea, coffee, cola-based drinks), and alcohol (5). The single-centre cohort consisted of 21 children (9 girls [43%]) between 2 and 16 years who presented to the paediatric gastroenterology clinic with recurrent stereotypic episodes of frequent vomiting. A total of 17 children (81%) were reported as having abdominal pain and 6 children (29%) had nausea during the episodes. A total of 16 children (76%) came from families with a strong history of migraine. These children remained symptom free between the episodes. The rationale of LAD and expected benefits were discussed by a paediatric dietitian with the family before starting the therapy, which was continued for a minimum of 6 to 8 weeks. If adverse effects such as worsening of frequency or severity of vomiting or abdominal pain were noted, then the therapy was stopped earlier. A total of 18 children (86%) responded to the LAD therapy and the results are shown in Figure 1. In the group of children who had complete resolution of vomiting, 2 of 13 children continued to have abdominal pain and 1 child developed migraine symptoms later. In the 5 children who showed partial resolution of symptoms, the episodes of CVS were less frequent, less severe, and of shorter duration. Our preliminary findings suggest that LAD may be useful in some children with CVS.FIGURE 1: Response to low-amine diet on vomiting.

Preschool Nutrition Risk in Calgary

Nutrition and lifestyle habits in early childhood may be key to supporting healthy growth. The Nutrition Screening Tool for Every Preschooler (NutriSTEP®), a validated screening questionnaire for preschool nutrition risk, was implemented in two community health centres. Study objectives were to identify the proportion of children at nutrition risk and to assess acceptance and impact of dietitian referrals. Parents attending preschool immunization clinics were asked to complete a consent form, NutriSTEP®, and a parent questionnaire to gather demographics and perceptions of NutriSTEP®. Follow-up counselling by a dietitian was offered for parents of high-risk children, and parents who attended completed a follow-up questionnaire. Seven percent of the children screened were at high risk. Almost 50% of parents reported adverse feeding environment behaviours. When a parent's reported daily frequency of a child's consumption was used as a proxy for daily servings, the majority of children fell short in most food groups. Thirty-three percent of 30 parents of high-risk children completed dietitian counselling. Most parents (75%, n=6) who were counselled reported making changes as a result of counselling and were satisfied with the service (63%). NutriSTEP® was an effective tool for identifying preschool children at risk. Although few parents accepted referral to a pediatric dietitian, most who did made changes to improve nutrition and lifestyle risk factors.

Food Allergy Educational Needs of Pediatric Dietitians: A Survey by the Consortium of Food Allergy Research

Objective To determine pediatric dietitians' self-reported proficiency, educational needs, and preferences regarding food allergy (FA) management. Design and Setting An Internet-based, anonymous survey was distributed to the Pediatric Nutrition Practice Group (PNPG) of the American Dietetic Association. Participants Respondents (n = 311) were registered dietitians and members of the PNPG. Analysis Results are presented using descriptive statistics. Chi-square tests were applied for subgroup analyses. Percentage responses were calculated per question based on the number of respondents answering the question. Results On a 4-point scale of proficiency (“high,” “moderate,” “low,” and “none”), respondents primarily rated themselves “moderate” for educating families, creating diets, and evaluating safe food items, and “low” for creating diagnostic food challenges. Education was primarily self-taught (75%). Preferences for future resources included handbooks (77%) and Web-based instructional programs (53%). On a 4-point scale (“very” to “not at all” needed) among practices that included >10% patients with FA, ratings of “very” were defined as need resources to update FA knowledge (87%) and need for a FA “tool kit” (84%). Conclusions and Implications Pediatric dietitians manage FA for a substantial patient base although their self-reported proficiency is overall only moderate. Dietitians would prefer and likely benefit from Internet-accessible management handbooks and patient handouts.

The D&amp;T report

The D&amp;T report

Use of the ketogenic diet and dietary practices in the UK

In 2000, a survey showed that use of the ketogenic diet as a treatment for intractable epilepsy in the UK was low. Subsequently, the number of medical publications supporting its efficacy has increased and demand from parents for this treatment has also increased. This survey was undertaken to determine whether there had been an increase in the use of the ketogenic diet and the necessary resources to provide it. A survey of paediatric dietitians in the UK was undertaken. Data were collected on their experience of implementing a ketogenic diet, the type of diet used, patient caseloads, other members of the care team, the process for initiation of the diet and funding. Twenty-eight hospitals offered the ketogenic diet treatment with a total of 152 patients. The caseload per dietitian ranged from 1-36 patients. The classical diet was prescribed for 74% cases. The majority of patients began the diet as outpatients. Six dietitians were specifically funded to provide the treatment. Fifty more dietitians had experience of implementing the diet but currently had no patients. The reasons given for this were no referrals, no funding or not working with patients with epilepsy. The number of patients on the ketogenic diet had increased since 2000. However, numbers remained low and the main reasons given were the lack of referrals and a lack of funding. Recommendations are made to improve the dietetic and funding resources available so that an efficacious treatment for intractable epilepsy of childhood can be made more widely available.

Optimal clinical management of children receiving the ketogenic diet: Recommendations of the International Ketogenic Diet Study Group

The ketogenic diet (KD) is an established, effective nonpharmacologic treatment for intractable childhood epilepsy. The KD is provided differently throughout the world, with occasionally significant variations in its administration. There exists a need for more standardized protocols and management recommendations for clinical and research use. In December 2006, The Charlie Foundation commissioned a panel comprised of 26 pediatric epileptologists and dietitians from nine countries with particular expertise using the KD. This group was created in order to create a consensus statement regarding the clinical management of the KD. Subsequently endorsed by the Practice Committee of the Child Neurology Society, this resultant manuscript addresses issues such as patient selection, pre-KD counseling and evaluation, specific dietary therapy selection, implementation, supplementation, follow-up management, adverse event monitoring, and eventual KD discontinuation. This paper highlights recommendations based on best evidence, including areas of agreement and controversy, unanswered questions, and future research.

Commentary on “Optimal clinical management of children receiving the ketogenic diet: Recommendations of the international ketogenic diet study group”

The ketogenic diet (KD) is an established, effective nonpharmacologic treatment for intractable childhood epilepsy. The KD is provided differently throughout the world, with occasionally significant variations in its administration. There exists a need for more standardized protocols and management recommendations for clinical and research use. In December 2006, The Charlie Foundation commissioned a panel comprised of 26 pediatric epileptologists and dietitians from nine countries with particular expertise using the KD. This group was created in order to create a consensus statement regarding the clinical management of the KD. Subsequently endorsed by the Practice Committee of the Child Neurology Society, this resultant manuscript addresses issues such as patient selection, pre-KD counseling and evaluation, specific dietary therapy selection, implementation, supplementation, follow-up management, adverse event monitoring, and eventual KD discontinuation. This paper highlights recommendations based on best evidence, including areas of agreement and controversy, unanswered questions, and future research.