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Thai JD, Liu J, Toney-Noland C, Breault CC, Speziale MV, Burke SL, O'Toole GM, Chen PP, Tay CC, Profit J, Ahmad I. Reducing growth impairment in infants undergoing intestinal surgery: A quality improvement initiative. JPEN J Parenter Enteral Nutr 2025. [PMID: 40355905 DOI: 10.1002/jpen.2765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Revised: 04/02/2025] [Accepted: 04/03/2025] [Indexed: 05/15/2025]
Abstract
BACKGROUND Infants undergoing intestinal surgery are at risk for impaired growth. Our objective was to reduce growth impairment in these infants by 20% in a 12-month period and sustain over 12 months. METHODS Eight neonatal intensive care units (NICUs) participated in the California Perinatal Quality Care Collaborative-led multisite quality improvement (QI) project, comprising a baseline, active, and sustainability phase. Eligible infants underwent intestinal surgery in the NICU between January 2021 to June 2023. Outcome measure was infants leaving the NICU with a weight z-score decline exceeding (>)1.2 standard deviations from birthweight. Process measures included adherence to parenteral nutrition (PN) guidelines, nutrition rounds, and feeding guidelines. Balancing measures included necrotizing enterocolitis, metabolic acidosis, and feeding intolerance rates. Multisite learning sessions and meetings were held. Each NICU implemented local QI strategies. Measures were analyzed in control charts. RESULTS 581 infants were included. During the active phase, growth impairment remained unchanged at 25%. Adherence to PN guidelines increased from 49% to 68%, nutrition rounds increased from 82% to 91%, and feeding guideline increased from 28% to 68%. In the sustainability phase, growth impairment worsened to 27%. Adherence to nutrition rounds decreased to 82%, PN guidelines increased to 95%, and feeding guidelines sustained at 68%. Balancing measures remained unchanged. CONCLUSION Despite no change in growth impairment, multiple centers implemented strategies to optimize nutrition in infants who underwent surgery. Additional data on nutrient delivery, other anthropometrics, and nonnutrition factors should be considered in future studies.
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Affiliation(s)
- Julie D Thai
- Department of Pediatrics, Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jessica Liu
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, California, USA
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Caroline Toney-Noland
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, California, USA
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Courtney C Breault
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, California, USA
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Mark V Speziale
- Department of Pediatrics, Division of Neonatology, Rady Children's Hospital, University of California San Diego, San Diego, California, USA
| | - Shannon L Burke
- Department of Nutrition and Food Services, University of California San Francisco, San Francisco, California, USA
| | - Gina M O'Toole
- Department of Pediatrics, Newborn Medicine, Children's Hospital Orange County, University of California, Irvine, Irvine, California, USA
| | - Peggy P Chen
- Department of Pediatrics, Division of Neonatology, MemorialCare Miller Children's and Women's Hospital, Long Beach, California, USA
| | - Ching Ching Tay
- Department of Pediatrics, Division of Neonatology, MemorialCare Miller Children's and Women's Hospital, Long Beach, California, USA
| | - Jochen Profit
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, California, USA
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Irfan Ahmad
- Department of Pediatrics, Newborn Medicine, Children's Hospital Orange County, University of California, Irvine, Irvine, California, USA
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Tzeng TH, Pritha Nayak S, Huff KA. Nutritional Considerations in Neonates Requiring Gastrointestinal Surgery. Neoreviews 2025; 26:e172-e185. [PMID: 40020747 DOI: 10.1542/neo.26-3-021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Accepted: 11/18/2024] [Indexed: 03/03/2025]
Abstract
Neonates who require gastrointestinal surgery are a complex group of patients that require special consideration with regard to nutritional supplementation and growth. During the acute postoperative phase, a major stress response causes catabolism with degradation of the body's nutrient stores leading to poor growth. Following surgery, parenteral nutrition is often required to support the surgical neonate; although, enteral nutrition, if feasible, is critical because it helps improve intestinal adaptation. However, the best type, mode, and duration of feeding is not established in the current literature. It is important to factor in the individual patient anatomy and site of intestinal resection when considering intestinal absorptive ability because these patients are at high risk for nutrient malabsorption, with the risk persisting even when enteral autonomy is achieved. The neonate undergoing gastrointestinal surgery requires close growth and nutritional monitoring both during the neonatal period but also into later life because risks of abnormalities persist. In this review, we summarize the impact of gastrointestinal surgery and postoperative intestinal changes on infant growth and nutrition.
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Affiliation(s)
- Tony H Tzeng
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sujir Pritha Nayak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katie A Huff
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Wu D, Van Oerle R, Martinez A, Piper HG. Risk Factors for Infection in Neonates With Intestinal Failure. J Pediatr Surg 2024; 59:854-857. [PMID: 38365474 DOI: 10.1016/j.jpedsurg.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/18/2024] [Indexed: 02/18/2024]
Abstract
PURPOSE Neonates with intestinal failure (IF) are at risk for infection due to central venous access, and intestinal surgery. Infection can cause systemic inflammation and sepsis, potentially affecting growth. The purpose of this study was to identify risk factors for, and the potential impact of infection to help with preventative strategies. METHODS A retrospective review of infants with IF, at a single centre from 2018 to 2022 was conducted. Clinical characteristics, intestinal pathology, nutritional intake, and growth were compared among infants with bloodstream infection (BSI), other infection (OI) (urinary, respiratory, or wound), or no infection (NI) within 2 months of diagnosis. Mann-Whitney and Kruskal-Wallis tests were used for comparisons with p-values <0.05 considered significant. RESULTS Eighty-six infants were included, with gastroschisis (41%) and necrotizing enterocolitis (26%) the most common diagnoses. Fifty-nine % of infants developed infection (22% BSI and 37% OI). Those with BSI or OI had a lower gestational age and birthweight, and were more likely to have a stoma. All infants with complex gastroschisis developed infection compared to 38% of infants with simple gastroschisis. Median daily weight gain was suboptimal across all groups and did not differ over 6 weeks following infection. CONCLUSION Most infants with IF develop infection shortly after diagnosis. Risk factors include prematurity, complex gastroschisis, and the presence of a stoma. Growth was suboptimal but did not differ among infants with or without infection. TYPE OF STUDY Retrospective Review. LEVEL OF EVIDENCE Level III Retrospective Comparative Study.
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Affiliation(s)
- Dana Wu
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Rhonda Van Oerle
- Division of Neonatology, University of British Columbia/BC Women's Hospital and Health Center, Vancouver, BC, Canada
| | - Andrea Martinez
- Division of Gastroenterology, University of British Columbia/BC Children's Hospital, Vancouver, BC, Canada
| | - Hannah G Piper
- Division of Pediatric Surgery, University of British Columbia/BC Children's Hospital, Vancouver, BC, Canada.
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Bijlsma A, van Beijsterveldt IALP, Vermeulen MJ, Beunders VAA, Dorrepaal DJ, Boeters SCM, van den Akker ELT, Vlug LE, de Koning BAE, Bracké KFM, Dieleman GC, Scheffers LE, Hagenaar DA, Affourtit P, Bindels-de Heus KGCB, Hokken-Koelega ACS, Joosten KFM. Challenges in body composition assessment using air-displacement plethysmography by BOD POD in pediatric and young adult patients. Clin Nutr 2023; 42:1588-1594. [PMID: 37478812 DOI: 10.1016/j.clnu.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND & AIMS Air-Displacement-Plethysmography (ADP) by BOD POD is widely used for body fat assessment in children. Although validated in healthy subjects, studies about use in pediatric patients are lacking. We evaluated user experience and usability of ADP measurements with the BOD POD system in healthy children and pediatric and young adult patients. METHODS Using the experiences of seven cohort studies, which included healthy children and patients aged 2-22 years, we retrospectively evaluated the user experience with the User Experience Questionnaire (UEQ) (n = 13) and interviews (n = 7). Technical performance was studied using the quality control data collected by the ADP-system. RESULTS From 2016 to 2022, 1606 measurements were scheduled. BOD POD was mostly rated 'user-friendly', with a generally neutral evaluation on all scales of the UEQ. However, questionable reliability and validity of the results were frequently (86%) reported. We found a high technical failure-rate of the device, predominantly in stability (17%) and accuracy of the measurement (12%), especially in the 'pediatric option' for children aged <6 years. Measurement failure-rate was 38%, mostly due to subject's fear or device failure, especially in young and lean children, and in children with physical and/or intellectual disabilities. CONCLUSION We conclude that ADP by BOD POD in children and young adults is non-invasive and user-friendly. However, in specific pediatric populations, BOD POD has several limitations and high (technical) failure-rates, especially in young children with aberrant body composition. We recommend caution when interpreting body composition results of pediatric patients as assessed with BOD POD using the current default settings.
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Affiliation(s)
- Alja Bijlsma
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Inge A L P van Beijsterveldt
- Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands; Dutch Growth Research Foundation, Rotterdam, the Netherlands
| | - Marijn J Vermeulen
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Victoria A A Beunders
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Demi J Dorrepaal
- Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sanne C M Boeters
- Obesity Center CGG, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands; Dept. of Dietetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Erica L T van den Akker
- Obesity Center CGG, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands; Department of Pediatrics, Division of Endocrinology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Lotte E Vlug
- Department of Pediatrics, Division of Gastroenterology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Barbara A E de Koning
- Department of Pediatrics, Division of Gastroenterology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Katrien F M Bracké
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Gwen C Dieleman
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Linda E Scheffers
- Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Doesjka A Hagenaar
- Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus MC, Rotterdam, the Netherlands
| | - Philine Affourtit
- Dept. of Dietetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Karen G C B Bindels-de Heus
- Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands; ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus MC, Rotterdam, the Netherlands
| | - Anita C S Hokken-Koelega
- Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands; Dutch Growth Research Foundation, Rotterdam, the Netherlands
| | - Koen F M Joosten
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Riddle S, Karpen H. Special Populations-Surgical Infants. Clin Perinatol 2023; 50:715-728. [PMID: 37536774 DOI: 10.1016/j.clp.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Congenital gastrointestinal disorders and other surgical diagnoses share many common problems: increased nutritional requirements to prevent catabolism, enhance wound healing, and provide optimal growth; impaired motility and altered intestinal flora leading to feeding intolerance requiring long-term parenteral nutrition; gastroesophageal reflux and poor feeding mechanics requiring tube feedings and support; growth failure; poor barrier function and risk of infection; and other long-term sequelae. Consequently, the surgical "at-risk" infant requires specialized nutritional support to meet their increased requirements to ensure adequate growth and meet the increased demands from critical illness.
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Affiliation(s)
- Stefanie Riddle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| | - Heidi Karpen
- Emory University School of Medicine/Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, ECC Room 324, Atlanta, GA 30322, USA
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