The impact of ongoing audit on nutritional support in paediatric intensive care

Thesis (Mnutr)--Stellenbosch University, 2004.ENGLISH ABSTRACT: Objective: To assess the impact of a continuous auditing process on nutritional support in a tertiary paediatric intensive care unit. Design: Prospective, longitudinal audit initiated in 1994. Re-auditing took place almost every 2 years: 1994-1995, 1997-1998 and 2001, leading to completion of the audit cycle. Setting: An 8 bed Paediatric Intensive Care Unit (PICU) in StMary's Hospital London. Subjects: All ventilated patients admitted for more than a complete 24-hour period were included in the audit. The units' standard daily fluid charts were used for data collection. Data was collected until discharge from PICU or a maximum of 10 days. Incomplete and imprecise data was disregarded during the data analysis process. Outcome measures and interventions: The outcome measures include time taken to initiate nutritional support, the route of feeding and delivery of calories by day 3, judged by the Estimated Average Requirements (EAR) for energy. Feeding algorithms and protocols introduced after each audit: nasogastric feeding algorithm following the 1994-1995 audit, blind nasojejunal tube insertion technique and related feeding algorithms after the audit in 1997-1998. Results: Time taken to initiate enteral feeding was reduced from 15 hours (1994- 1995) to 5.5 hours (2001). The proportion of parenterally fed patients fell from 11% (1994-1995) to 1% (200 1 ). The proportion of enterally fed patients via the nasojejunal route rose from 1% (1994-1995) to 20% (2001). An increase was noticed in patients reaching 50% and 70% of energy requirement by day 3 following admission was documented: 7% in1994-1995 to 35% in 2001 for 70% of EAR (p = 0.0008) and 18% in 1994-1995 to 58% in 2001 for 50% of EAR. (p< 0.0001) Conclusion: This audit process demonstrates the effectiveness of continuous auditing in an intensive care unit in improving the quality of nutritional support. This is possible only with a multi-disciplinary team approach.AFRIKAANSE OPSOMMING: Doel: Om die impak van 'n deurlopende ouditerings proses op die voedingsondersteuning in 'n tersi~re pediatriese intensiewesorg-eenheid te evalueer. · Studie Ontwerp: 'n Prospektiewe, longetudinale oudit is in 1994 geYnisieer. Herouditee·ring het ongeveer elke 2 jaar plaasgevind: 1994-1995, 1997-1998 en 2001. Dit het tot die voltooiing van 'n ouditering siklus gelei. Plek: 'n Agt-bed Pediatriese lntensiewesorgeenheid (PISE) in StMary's Hospitaal London, Engeland. Pasiente: Alle geventilleerde pasiente wat opgeneem was vir !anger as 'n volledige 24 uur-periode is by die oudit ingesluit. Die eenheid se standard daaglikse vogkaarte dokumentasie is gebruik vir data-insameling. Data-insameling het plaasgevind tot en met ontslag vanuit die PISE vir 'n maksimum van 10 dae. Onvolledige en onakkurate data is uitgesluit tydens die data analise proses. Uitkomste en Intervensie: Die uitkomste is gemeet deur die impak van die ouditerings proses te evalueer ten opsigte van tydsduur voordat daar voedings geYnisieer is, die voedingsroete en die hoeveelheid energie gelewer teen dag 3, vergelyk met die geskatte gemiddelde energie behoefte. Voedings-algoritmes en protokolle is geYmplementeer na elke oudit: nasogastriese voedings-algoritmes is na die 1994-1995 oudit geYmplimenteer, 'n blinde nasojejunale buisinplasingstegniek en I relevante voedings algoritmes het na die 1997-1998 oudit gevolg. Resultate: Die tydsduur om voedingondersteuning te inisieer het van 15 ure (1994- 1995) tot 5.5 ure (2001) verminder. Die persentasie pasiente wat parenterale voeding ontvang het, het gedaal van 11% (1994-1995) tot 1% (2001), met 'n toename in enterale voeding via die nasojejunale roete van 1 %(1994) tot 20% (2001). 'n Toename in pasiente wat meer as 50% en 70% van hul energie behoefte bereik het teen dag 3 is opgemerk: 7% in 1994-1995 en 35% in 2001 het meer as 70% van die geskatte gemiddelde behoefte vir energie ontvang. (p=0.0008) Agtien persent het in 1994-1995 en 58% in 2001 meer as 50% van hul gemiddelde energie behoeftes bereik (p < 0.0001). Gevolgtrekking: Hierdie ouditerings proses demonstreer die effektiewiteit van deurlopende ouditering in 'n intensiewesorg-eenheid deur die verbetering van die kwalitiet van voedingondersteuning. Dit is slegs moontlik met 'n multidissiplinere span benadering

Nutritional status and clinical outcome in postterm neonates undergoing surgery for congenital heart disease.

OBJECTIVE: Poor growth is a common complication in infants with congenital heart disease. There has been much focus on low birth weight as having increased risk of adverse outcomes following neonatal heart surgery. In this study, we examined whether preoperative nutritional status, measured by admission weight-for-age z score, was associated with postoperative clinical outcome. DESIGN: Retrospective case series. SETTING: Pediatric Cardiac ICU at the Royal Brompton Hospital. PATIENTS: Neonates undergoing surgery for congenital heart disease. Those undergoing ductus arteriosus ligation alone were excluded. Children with coexisting noncardiac morbidity were excluded. Outcome variables included prevalence of postoperative complications (including sepsis, delayed chest closure, renal impairment, and necrotizing enterocolitis), duration of ventilation, intensive care stay, postoperative mortality, and mortality at 1 year after surgery. INTERVENTIONS: None. Analysis of patient data only. MEASUREMENTS AND MAIN RESULTS: Two hundred forty-eight neonates fulfilled the entry criteria. Median (interquartile range) age was 7 days (2-15 d), median (interquartile range) weight was 3.3 kg (2.91-3.6 kg), and median weight-for-age z score was -0.77 (-1.44 to 0.01). Twenty-eight children (11%) had a weight-for-age z score of less than -2. There was no evidence that children with lower weight-for-age z score had less severe surgery as measured by the Risk Adjustment for Congenital Heart Surgery 1 score. In multivariable regression analysis, the weight-for-age z at admission had strong correlation with the number of days free of respiratory support (invasive and noninvasive ventilation) at 28 days (p < 0.0001) and with all-cause mortality at 1 year (p = 0.001). CONCLUSIONS: Poor nutritional status as measured by weight-for-age z is associated with adverse short- and long-term outcomes in neonates undergoing surgery for congenital heart disease.This is the accepted manuscript. The final version is available at http://journals.lww.com/pccmjournal/Abstract/2015/06000/Nutritional_Status_and_Clinical_Outcome_in.7.aspx

Catch-up Growth in Infants and Young Children with Faltering Growth: Expert Opinion to Guide General Clinicians

Faltering growth (FG) is a problem regularly seen by clinicians in infants and young children (<2 years of age). It can occur due to non-disease related and disease-related causes and is associated with a wide range of adverse outcomes, including shorter-term effects such as impaired immune responses and increased length of hospital stay, and longer-term consequences, including an impact on schooling and cognitive achievements, short stature, and socioeconomic outcomes. It is essential to detect FG, address underlying causes and support catch-up growth where this is indicated. However, anecdotal reports suggest misplaced fear of promoting accelerated (too rapid) growth may deter some clinicians from adequately addressing faltering growth. An invited international group of experts in paediatric nutrition and growth reviewed the available evidence and guidelines on FG resulting from disease-related and non-disease-related effects on nutritional status in healthy term and small for gestational age (SGA) infants and children up to the age of two years in low-, middle- and high-income countries. Using a modified Delphi process, we developed practical consensus recommendations to provide clarity and practical recommendations for general clinicians on how faltering growth should be defined in different young child populations at risk, how faltering growth should be assessed and managed and the role of catch-up growth after a period of faltering growth. We also suggested areas where further research is needed to answer remaining questions on this important issue

Catch-Up Growth in Infants and Young Children With Faltering Growth:Expert Opinion to Guide General Clinicians

Faltering growth (FG) is a problem regularly seen by clinicians in infants and young children (&lt;2 years of age). It can occur due to non-disease-related and disease-related causes and is associated with a wide range of adverse outcomes, including shorter-term effects such as impaired immune responses and increased length of hospital stay, and longer-term consequences, including an impact on schooling and cognitive achievements, short stature, and socioeconomic outcomes. It is essential to detect FG, address underlying causes and support catch-up growth where this is indicated. However, anecdotal reports suggest misplaced fear of promoting accelerated (too rapid) growth may deter some clinicians from adequately addressing FG. An invited international group of experts in pediatric nutrition and growth reviewed the available evidence and guidelines on FG resulting from disease-related and non-disease-related effects on nutritional status in healthy term and small for gestational age infants and children up to the age of 2 years in low-, middle-, and high-income countries. Using a modified Delphi process, we developed practical consensus recommendations to provide clarity and practical recommendations for general clinicians on how FG should be defined in different young child populations at risk, how FG should be assessed and managed, and the role of catch-up growth after a period of FG. We also suggested areas where further research is needed to answer remaining questions on this important issue.</p

The Cow’s Milk-Related Symptom Score (CoMiSS™): A Useful Awareness Tool

The Cow’s Milk-related Symptom Score (CoMiSS™) was developed as a clinical tool aimed at increasing the awareness of health care professionals for the presence and intensity of clinical manifestations possibly related to cow’s milk (CM) intake. This review summarizes current evidence on CoMiSS. We found twenty-five original studies, one pooled analysis of three studies, and two reviews on CoMiSS. Infants exhibiting symptoms possibly related to CM, present with a higher median CoMiSS (6 to 13; 16 studies) than apparently healthy infants (median from 3 to 4; and mean 3.6–4.7; 5 studies). In children with cow’s milk allergy (CMA), 11 studies found that a CoMiSS of ≥12 predicted a favorable response to a CM-free diet; however, sensitivity (20% to 77%) and specificity (54% to 92%) varied. The decrease of CoMiSS during a CM elimination diet was also predictive of a reaction to an oral food challenge to diagnose CMA. A low CoMiSS

The Cow’s Milk-Related Symptom Score (CoMiSS™): A Useful Awareness Tool

The Cow’s Milk-related Symptom Score (CoMiSS™) was developed as a clinical tool aimed at increasing the awareness of health care professionals for the presence and intensity of clinical manifestations possibly related to cow’s milk (CM) intake. This review summarizes current evidence on CoMiSS. We found twenty-five original studies, one pooled analysis of three studies, and two reviews on CoMiSS. Infants exhibiting symptoms possibly related to CM, present with a higher median CoMiSS (6 to 13; 16 studies) than apparently healthy infants (median from 3 to 4; and mean 3.6–4.7; 5 studies). In children with cow’s milk allergy (CMA), 11 studies found that a CoMiSS of ≥12 predicted a favorable response to a CM-free diet; however, sensitivity (20% to 77%) and specificity (54% to 92%) varied. The decrease of CoMiSS during a CM elimination diet was also predictive of a reaction to an oral food challenge to diagnose CMA. A low CoMiSS

The Cow’s Milk Related Symptom Score: The 2022 Update

CoMiSS® was developed 7 years ago to increase the awareness of health care professionals towards the possibility that symptoms presented by infants could be related to cow’s milk. While CoMiSS was conceived mostly on theoretical concepts, data is now available from 25 clinical trials. Based on this extensive research using the tool since 2015, we aim to propose an updated CoMiSS. The evidence was reviewed, debated and discussed by 10 experts, of whom seven were part of the original group. The panel concluded that the cut-off previously proposed to indicate the likelihood that symptoms may be cow’s milk related should be lowered from ≥12 to ≥10. Data in healthy infants > 6 months are missing. Since the Brussels Infant and Toddlers Stool Scale (BITSS) was recently developed for non-toilet trained children, the Bristol Stool Scale was changed to the BITSS without changing the impact of stool characteristics on CoMiSS. Overall, CoMiSS raises awareness that symptoms might be cow’s milk related. New studies are needed to determine if the change in cut-off and other small adaptions improve its sensitivity and specificity. Data for CoMiSS is still needed in presumed healthy infants between 6 and 12 months old. There may also be regional differences in CoMiSS, in healthy infants as well as in those with cow’s milk allergy. Finally, we emphasize that CoMiSS is an awareness tool and not a diagnostic test

The Cow’s Milk Related Symptom Score: The 2022 Update

CoMiSS® was developed 7 years ago to increase the awareness of health care professionals towards the possibility that symptoms presented by infants could be related to cow’s milk. While CoMiSS was conceived mostly on theoretical concepts, data is now available from 25 clinical trials. Based on this extensive research using the tool since 2015, we aim to propose an updated CoMiSS. The evidence was reviewed, debated and discussed by 10 experts, of whom seven were part of the original group. The panel concluded that the cut-off previously proposed to indicate the likelihood that symptoms may be cow’s milk related should be lowered from ≥12 to ≥10. Data in healthy infants > 6 months are missing. Since the Brussels Infant and Toddlers Stool Scale (BITSS) was recently developed for non-toilet trained children, the Bristol Stool Scale was changed to the BITSS without changing the impact of stool characteristics on CoMiSS. Overall, CoMiSS raises awareness that symptoms might be cow’s milk related. New studies are needed to determine if the change in cut-off and other small adaptions improve its sensitivity and specificity. Data for CoMiSS is still needed in presumed healthy infants between 6 and 12 months old. There may also be regional differences in CoMiSS, in healthy infants as well as in those with cow’s milk allergy. Finally, we emphasize that CoMiSS is an awareness tool and not a diagnostic test

The impact of the elimination diet on growth and nutrient intake in children with food protein induced gastrointestinal allergies

Background: Non immunoglobulin E (IgE) mediated allergies affecting the gastrointestinal tract require an elimination diet to aid diagnosis. The elimination diet may entail multiple food eliminations that contribute significantly to macro-and micro-nutrient intake which are essential for normal growth and development. Previous studies have indicated growth faltering in children with IgE-mediated allergy, but limited data is available on those with delayed type allergies. We therefore performed a study to establish the impact on growth before and after commencing an elimination diets in children with food protein induced non-IgE mediated gastrointestinal allergies. Methods: A prospective, observational study was performed at the tertiary gastroenterology department. Children aged 4 weeks-16 years without non-allergic co-morbidities who were required to follow an elimination diet for suspected food protein induced gastrointestinal allergies were included. Growth parameters pre-elimination were taken from clinical notes and post-elimination measurements (weight and height) were taken a minimum of 4 weeks after the elimination diet. A 3-day estimated food diary was recorded a minimum of 4 weeks after initiating the elimination diet, including also any hypoallergenic formulas or over the counter milk alternatives that were consumed. Results: We recruited 130 children: 89 (68.5 %) boys and a median age of 23.3 months [IQR 9.4-69.2]. Almost all children (94.8 %) in this study eliminated CM from their diet and average contribution of energy in the form of protein was 13.8 % (SD 3.9), 51.2 % (SD 7.5) from carbohydrates and 35 % (SD 7.5) from fat. In our cohort 9 and 2.8 % were stunted and wasted respectively. There was a statistically significant improvement in weight-for-age (Wtage) after the 4 week elimination diet. The elimination diet itself did not improve any of the growth parameters, but achieving energy and protein intake improved Wtage and WtHt respectively, vitamin and/or mineral supplements and hypoallergenic formulas were positively associated with WtHt and Wtage. Conclusion: With appropriate dietary advice, including optimal energy and protein intake, hypoallergenic formulas and vitamins and mineral supplementation, growth parameters increased from before to after dietary elimination. These factors were positively associated with growth, irrespective of the type of elimination diet and the numbers of foods eliminated.Great Ormond Street Hospital CharityGreat Ormond St Hosp Children NHS Fdn Trust, Dept Gastroenterol, London, EnglandChelsea & Westminster Hosp NHS Fdn Trust, Dept Nutr & Dietet, London, EnglandNino Jesus Univ Children Hosp, Madrid, SpainUniv Fed Sao Paulo UNIFESP, Paediat Gastroenterol, Sao Paulo, BrazilAmer Univ Beirut, Dept Nutr & Food Sci, Fac Agr & Food Sci, Beirut, LebanonUCL, Inst Child Hlth, London, EnglandUniv Fed Sao Paulo UNIFESP, Paediat Gastroenterol, Sao Paulo, BrazilWeb of Scienc