Association between Eosinophilic Esophagitis and Food Protein-Induced Enterocolitis Syndrome in Children

Background: The prevalence of food allergy in the pediatric population is increasing. Classic IgE-mediated allergies have been well studied. However, less is known about non-IgE-mediated allergies. Eosinophilic Esophagitis (EoE), a mixed IgE and non-IgE-mediated allergy, and Food Protein-Induced Enterocolitis Syndrome (FPIES), a non-IgE-mediated allergy, have similar symptoms but different ages of presentation (any age vs.age; respectively). The purpose of this study is to determine the odds of developing EoE in children previously diagnosed with FPIES or who exhibited symptoms characteristic of FPIES. Methods: Analysis of retrospectively reviewed medical record data included demographic, clinical, and nutrition characteristics as well as history of gastrointestinal symptoms, diagnosis of EoE, and diagnosis or symptoms of FPIES (history of vomiting) in a large cohort of children receiving care at an urban pediatric gastroenterology clinic. Nutrition characteristics included infant feeding regimen (breast fed vs. formula fed) and age of complementary food introduction. The population sample was provided by the GI Care for Kids Clinical Dietitian. Medical records were reviewed for all patients diagnosed with FPIES between March 1, 2016 and May 30, 2018 and an equivalent number of patients diagnosed with EoE in the same time frame. Results: The majority of the population (N=148) was male (57.4%) and Caucasian (97.7%). The odds of developing EoE (mean age 9.3 + 5.4 years) by prior diagnosis of FPIES (median age 0.83 [Interquartile range; 0.6, 1.2]) or symptoms of FPIES was 0 and 0.25 (95% Confidence Interval; 0.109, -0.575), respectively. Logistic regression analysis revealed that gender, previous history of food allergy and intolerance, and history of vomiting explain 23% to 31% of the variation in EoE diagnosis. Conclusions: A history of symptoms characteristic of FPIES reported in the first year of life were observed to be protective for the development of EoE during childhood. The treatment for FPIES or its symptoms includes the elimination of common food allergens. Additional studies are needed to evaluate the effect of early infant diet on the future development of EoE

Implementation of a Finger Foods Diet for Adults with Dementia

Dementia is a general term for a decline in mental ability severe enough to affect memory, thinking, behavior and the ability to accurately perform everyday activities. Seniors’ eating habits are impacted depending on which stage of dementia they are experiencing. Common signs and symptoms in early-stage dementia include forgetfulness, difficulty communicating thoughts, anxiety and depression, loss of concentration, being unable to recognize spoiled food, changes in food preferences, and an inability to hold attention through a meal. In middle-stage dementia, solutions include: constant redirection to meals and snacks, introducing tablemates as they may not remember their names from last meal, planning a menu to include foods and liquids suitable to this stage of dementia (e.g., finger foods, mechanically altered items, and foods to eat on the go ), maintaining a calm and unhurried environment, serving meals with only a fork or spoon, and continuing to serve meal one course at a time. A finger food diet is regular diet consistency which can be easily eaten with the fingers and not requiring silverware. A Finger Food Diet Menu was developed using similar menu options as a Regular/No Added Salt diet. The existing menu foods were used for two reasons, 1) so that residents did not feel segregated, and 2) to make the best use of foods currently being purchased/utilized. The head chef and registered dietitian worked together on the Finger Food Diet Menu. The limitation to the Finger Food Diet Menu is that it is not appropriate for residents on a mechanical soft or pureed diet

Review of Nutrition Requirements and Growth after Pediatric Intestinal Transplantation

Intestinal failure is characterized by malnutrition, malabsorption, and growth retardation. The most common cause of intestinal failure is short bowel syndrome. If the remaining bowel is unable to adapt to allow weaning from parenteral nutrition and achievement of enteral autonomy, then intestinal transplantation should be considered. Energy and macro- and micronutrient intakes are closely monitored pre-transplant to optimize nutrition prior to surgery. Few studies have been conducted to examine the nutritional requirements and nutritional status post-transplant. Of the studies that have been done, results have been inconsistent. The purpose of this review is to summarize the current literature related to nutrition requirements and growth after pediatric intestinal transplant. Monitoring of vitamin and mineral status is also essential in ensuring proper growth and preventing deficiencies post-transplant. Five out of six studies showed a positive growth trend at the one-year mark post-transplant. One study showed that children with a weight and height z-score of less than -2.0 had a faster catch-up growth post-transplant. Other studies reported positive growth progression within the first two years after transplant. There is still a great deal of information unknown about nutrition and growth post-transplant. Further studies need to be conducted to determine if and how nutrition requirements change post-transplant

Length of Exclusive Breastfeeding and Obesity Risk in Children at Risk for Type 1 Diabetes

Type 1 diabetes (T1D) is an autoimmune disease that occurs when T lymphocyte cells attack and destroy beta cells in the pancreas.1 The cause of T1D is considered to be a combination of genetic predisposition and environmental or lifestyle risk factors. Early introduction of diet is thought to play a role in the development of T1D as it is less common in people who were breastfed and who were introduced to solid foods at later ages. The protection that breastfeeding can offer against the development of childhood obesity and T1D in children at risk for T1D is unknown and may be related to many different factors. The purpose of this project is to review the literature on the association between infant diet, including breastfeeding and complementary foods, and the development of obesity and T1D. This information will be used to prepare a secondary analysis proposal to examine the association between length of exclusive breastfeeding and obesity risk in children at risk for T1D for submission to the Presentations and Publications Committee of the Trial to Reduce IDDM in the Genetically at Risk (TRIGR) study

Nutritional Outcome Measures of Preadolescents and Adolescents Diagnosed with Anorexia Nervosa after Receiving Nasogastric Feedings versus Oral Diet upon Hospitalization

The purpose of this project was to review the literature related to the demographic, clinical, anthropometric, and nutrition therapy characteristics of inpatient preadolescents and adolescents diagnosed with anorexia nervosa (AN). The literature review includes an overview of the prevalence and diagnostic criteria for AN, screening and evaluation of patients, inpatient treatment protocols, the complications associated with AN, and nutrition treatment options (oral diet, enteral feeding, and parenteral nutrition)

Methods of Determining Energy Requirements in Critically Ill Adults Before the Publication of New Critical Care Guidelines

Background: Energy requirements can be difficult to determine in the critically ill population due to the presence of catabolic stress. The 2009 Guidelines for the Provision and Assessment of Nutrition Support Therapy Parenteral and Enteral Nutrition and in the Adult Critically Ill Patient recommend that energy requirements be calculated by predictive equations or weight-based equations or measured by indirect calorimetry (IC) and that nutrition efficacy may be monitored through nitrogen balance (24-hour Urinary Urea Nitrogen) or non-protein calorie:nitrogen ratio. Very few studies have reported the required energy assessment methods used by Registered Dietitian Nutritionists (RDNs) in the critical care setting and no studies have reported the use of laboratory tests to monitor efficacy of nutrition. The purpose of the study is to examine practices for estimating energy requirements in critically ill patients by RDNs prior to publication of the updated critical care guidelines in 2016. Methods: The study sample included patients currently included in the trauma registry at Grady Memorial Hospital (GMH). Patients who were in motor vehicle accidents (excluding trains), who were admitted to the Intensive Care Unit at GMH between July 4, 2014 and September 28, 2015, and who required at least five days of mechanical ventilation during admission were included. Demographic characteristics (gender, race, and age), anthropometric characteristics (body mass index classification), clinical characteristics (number of days on the ventilator, ICU days, time to death)), and nutrition assessment methods (energy assessment method used, weight used in assessment, and laboratory monitoring recommendations) were extracted from the electronic medical record. Results: The vast majority of Registered Dietitian Nutritionists (98%) used a simple weight-based equation during the initial nutrition assessment. Approximately 1/3 of the Registered Dietitian Nutritionists used the actual patient body weight (36.8%) with the remaining primarily using a recommended body weight based on a selected BMI. Nine different weight-based equations were used with the equation 25-30 kcal/kg used most often (87.9%). Indirect calorimetry was not recommended by the RDNs during the first two weeks of admission for any patient. RDNs recommended prealbumin to monitor nutrition status (within 2 weeks of admission) in 21.6% of patients. Conclusions: We observed inconsistencies in the equations, weights, and monitoring laboratory tests used by RDNs. This variability can be attributed to a lack of specificity in the 2009 critical care guidelines, which justifies the need for updated recommendations in 2016. Future studies should examine change in nutrition assessment practices by RDNs since publication of the 2016 guidelines

Comparison of Nutrition Outcomes by Enteral Nutrition Feeding Method during Weaning from Parenteral Nutrition in Children with Intestinal Failure

Objective: To evaluate the difference in time to achieve enteral autonomy, survival, and linear growth velocity by parenteral nutrition (PN) weaning strategy in children with intestinal failure. Methods: Analysis of retrospectively reviewed medical record data included comparison of time to PN wean since the date of the first clinic visit, survival time, and differences in height z-scores between PN wean and two-years post-wean by whether an enteral tube feeding (TF) was used during the weaning process. Results: 32 of 49 children (65%) received an enteral TF with or without oral diet during the two-year follow-up period. Median time to weaning did not differ significantly between those who received a TF (21.5 months [IQR;10.3, 37.8]) vs. oral diet alone (19.0 months [IQR; 14.5, 40.0]). The probability of survival did not differ by TF status with only one death in the TF group. Linear growth velocity between the time of PN weaning to two-years post-wean did not significantly differ by TF status. Children who weaned via oral diet alone had a similar decrease in height z-score vs. those who received a TF (-0.14 vs. -0.15, respectively); however, a greater increase in z-score between years 1 and 2 post-wean was observed (+0.27 vs. +0.11, respectively). Conclusions: No association between weaning strategy and outcomes in children with IF was observed. Linear growth velocity declines during the first year after PN weaning but rebounds in year two. Future studies should examine the long-term benefits of oral feeding vs. TF on intestinal adaptation

The Effectiveness of a Volume-Based Enteral Feeding Protocol to Provide Energy Intake in Hospitalized Critically Ill Adults

Background: Patients determined to be at high nutrition risk are most likely to benefit from early enteral nutrition (EN) therapy. The use of enteral feeding protocols has been associated with significant improvements in nutrition practice and overall nutrition adequacy. The effect of a combined-approach volume-based enteral feeding protocol on the percent of calories received by patients is unknown. Objective: The aim of this study was to determine if a newly implemented combined-approach volume-based enteral feeding (VBF) protocol is more effective in the delivery of EN volume and calories in intensive care unit (ICU) patients compared with the previous rate-based protocol where 88% of patients achieved 85% of their caloric requirements. Participants/setting: Eighteen critically ill adults hospitalized in either the burn or neurological ICU at a large urban hospital. Main outcome measure: The percentage of calories delivered for each patient after a minimum of 7 days of protocol compliance. Results: Ten patients (50% male, 70% Caucasian) received VBF in compliance with protocol for a median of 5.5 days (Interquartile Range; 4.8, 14.0). The percent of goal volume delivered for those who received at least 7 days of treatment (n = 4) was 104.2 ± 7.9. Conclusions: The delivery of goal EN volume using VBF exceeded the average volume provided by the previous rate-based approach in a small sample of critically ill adults. This study supports the use of feeding protocols in order to increase overall percentage of volume delivered. Additional research in a larger patient population is needed to determine the impact of this increase in volume delivery on patient outcomes

The Impact of Breastfeeding Education on Infant Feeding Outcomes

Background: Breastfeeding (BF) is widely recognized as the ideal infant feeding method with a multitude of well-known infant and maternal benefits. However, current BF rates, particularly in the southeastern United States, fail to meet current BF recommendations. BF education interventions have shown to be successful at improving BF outcomes, as well as maternal knowledge and self-efficacy. The purpose of this study was to examine the association between BF education and infant BF outcomes based upon World Health Organization recommendations, with a secondary aim of determining the impact of BF education on maternal BF knowledge and self-efficacy. Methods: Sixty adult female clients of PeaPod Nutrition and Lactation Support in the Atlanta, Georgia area, being the primary caregiver of an infant (12 months of age or younger) completed a short, anonymous, electronic questionnaire about any BF education they received and infant feeding outcomes. Outcome measures include BF rates and exclusivity. Secondary outcome measures include maternal BF knowledge and self-efficacy. The chi-square statistic was used to evaluate any associations between BF education and outcome measures. Results: Study participants had a median age of 34 years, 70% self-reported as Caucasian with a median income between $100,000 -$150,000, and all participants held a college degree. Fifty-five of the 60 participants that completed the survey received BF education either during their pregnancy or in the postnatal period. The education received occurred in a variety of settings and topics, and mainly consisted of in-person/hands-on instruction, with limited virtual/telephone education. Twenty-three of the 60 respondents (38.3%) are currently BF, of which, 65.2% are exclusively BF and 52.2% have been BF for more than 6 months. No statistically significant association was found between those that received BF education and BF duration (p = .838) nor rate of exclusive BF (Fisher’s Exact Test p = .350). Of participants that are currently exclusively BF, 50% reported receiving some form of BF education. Of individuals that previously breastfed for 6 months or more, approximately 74% reported receiving some form of BF education. All 55 participants that received BF education agreed that the BF education that they received increased their knowledge of BF, with 60% strongly agreeing and most participants (90.9%) agreed that their confidence in BF improved because of their BF education, 52.7% of which strongly agreed. Conclusion: Overall, high rates of BF and exclusive BF of infants 6 months of age and older were observed among study participants. All participants agreed that BF education improved their BF knowledge and the majority agreed that their self-efficacy improved as a result of the education that they received

Maternal Determinants of the Timing of Introduction of Complementary Food to Infants

Background: Recommendations from most United States professional and public health organizations in indicate that infants should begin eating complementary foods (CF) at 6 months of age. Despite this recommendation, parents frequently introduce CF to their infants earlier. To our knowledge, no previous studies have assessed maternal awareness of feeding guidelines, and whether this knowledge influences decision making around infant feeding. We hypothesized that the majority of mothers introduce CF before the recommended age or appropriate developmental milestones due to limited awareness of current feeding guidelines. Methods: This observational cross-sectional study surveyed the maternal factors that influenced the timing of introduction of CF in infants in a sample of mothers who sought counseling at the Atlanta-based non-profit, Peapod Nutrition and Lactation Support. Results: Fourteen mothers completed the survey on feeding practices, and over half of the mothers indicated that they waited until 6 months to introduce CF to their infants. All of the mothers knew the correct age recommendation for the introduction of CF. Some of the mothers indicated that they used professional organization recommendations to decide when to feed their infants, but some of the other reasons included influence from a pediatrician, developmental readiness, and the desire for their infant to sleep longer or go longer between breastfeeding sessions. Because all mothers were aware of the guidelines, we failed to reject the null hypothesis that there is no association between early introduction of CF and limited knowledge of the recommendations. Conclusion: This study found that mothers choose to introduce CF for various reasons beyond public health guidelines. Future studies investigating similar questions would benefit from a larger sample size and a longer duration