Nutritional intake and status in children with cystic fibrosis: does age matter?

Academy of Nutrition and Dietetics: 2020 Cystic Fibrosis Evidence Analysis Center Evidence-Based Nutrition Practice Guideline

The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based practice guideline for primary nutrition issues in cystic fibrosis (CF). This guideline is designed to complement and build upon existing evidence-based CF nutrition guidelines. The objective of this guideline was to provide recommendations for registered dietitian nutritionists in the United States delivering medical nutrition therapy to individuals with CF and their families that fill gaps in current evidence-based guidelines on topics that are crucial in order to improve health and prevent disease progression. This guideline provides 28 nutrition recommendations to guide medical nutrition therapy, including nutrition screening, nutrition assessment, and dietary intake. For topics outside the scope of this guideline, practitioners are referred to external, evidence-based recommendations. The CF landscape is evolving rapidly with breakthroughs in cystic fibrosis transmembrane regulator modulators changing CF at a cellular level. Medical nutrition therapy for individuals with CF from infancy through advanced age requires novel and individualized approaches. The Academy Evidence Analysis Library CF guidelines provide a framework for expanding upon current knowledge to determine effective nutrition strategies for individuals with CF through long and healthy futures.

Dietary Macronutrient Distribution and Nutrition Outcomes in Persons with Cystic Fibrosis: An Evidence Analysis Center Systematic Review

Cystic fibrosis (CF) increases risk for undernutrition and malabsorption. Individuals with CF traditionally have been counseled to consume a high-fat diet. However, a new era of CF care has increased lifespan and decreased symptoms in many individuals with CF, necessitating a re-examination of the high-fat CF legacy diet. A literature search was conducted of Medline (Ovid), Embase, and CINAHL (EBSCO) databases to identify articles published from January 2002 to May 2018 in the English language examining the relationships between dietary macronutrient distribution and nutrition outcomes in individuals with CF. Articles were screened, risk of bias was assessed, data were synthesized narratively, and each outcome was graded for certainty of evidence. The databases search retrieved 2,519 articles, and 7 cross-sectional articles were included in the final narrative analysis. Three studies examined pediatric participants and 4 examined adults. None of the included studies reported on outcomes of mortality or quality of life. Very low certainty evidence described no apparent relationship between dietary macronutrient distribution and lung function, anthropometric measures, or lipid profile in individuals with CF. The current systematic review demonstrates wide ranges in the dietary macronutrient intakes of individuals with CF with little to no demonstrable relationship between macronutrient distribution and nutrition-related outcomes. No evidence is presented to substantiate an outcomes-related benefit to a higher fat-diet except in the context of achieving higher energy intakes in a lesser volume of food.

Micronutrient intake in children with cystic fibrosis in Sydney, Australia

BACKGROUND

Children with CF have been reported to consume significantly more energy-dense, nutrient-poor foods than controls where there are now concerns of inadequate micronutrient intake. There are no current or comprehensive dietary studies assessing micronutrient intake in CF children.

OBJECTIVES

To evaluate micronutrient intake in children with CF compared to recommended dietary intakes (RDIs).

METHODS

Dietary intake of 13 micronutrients was measured in CF children aged 2-18 years and age- and sex-matched controls using a validated food frequency questionnaire (The Australian Child and Adolescent Eating Survey).

RESULTS

CF children (n = 82) consumed significantly more energy than controls (n = 82) [3142(2531-3822) kcal vs 2216(1660-2941) kcal; p < .001]. Absolute intake in CF children was significantly higher in all micronutrients except vitamin C and folate, however energy-adjusted intake was significantly lower for all micronutrients except vitamin A, sodium, calcium and phosphorous. Energy-adjusted intake in primary school CF children was significantly less than controls in 8/13 micronutrients. Overall, median intakes exceeded the RDIs for all micronutrients however CF children fell short of the RDIs for folate (26.8%), iron (15.9%) and calcium (9.8%). In pre-school, 50% of CF children and 91.7% of controls did not meet the iron RDI. High school CF and control children failed to meet RDIs for 7/13 and 9/13 micronutrients respectively.

CONCLUSION

Increased intake of most micronutrients in CF children was largely attributed to higher energy consumption. However, micronutrient density of the diet declined with increasing age, where high school children failed to meet RDIs for most key micronutrients.

The relationship between energy intake and body-growth in children with cystic fibrosis

BACKGROUND & AIMS

Body-growth, expressed as weight- and height gain, is a strong predictor of morbidity and mortality in patients with cystic fibrosis (CF). Whether current historically based recommendations on a high-energy diet are sufficient for optimal growth is questionable. We therefore assessed the longitudinal relation between body-growth and routine energy intake in paediatric CF patients.

METHODS

Included were patients with CF, aged 2-10 years of whom we obtained 969 measurements of weight and height along with dietary records, and 786 coefficient of fat absorption measurements (CFA). We described body-growth, energy intake, macronutrient intake and the long-term effect of energy intake and coefficient of fat absorption on body-growth during the 8-year follow-up period.

RESULTS

Enrolled were 191 children with CF who had a compromised growth when compared to healthy children. The dietary intake was ≥110% estimated average requirement (EAR) in 47% of the measurements (457/969) and did not (fully) achieve the recommended high-energy level (110-200% EAR). Further, the intake expressed as EAR decreased with increasing age. Cross-sectionally, boys and girls with higher caloric intakes had higher weight-for-age (WFA). The caloric intake explained 18 and 6% of the variation. Further, boys with higher caloric intakes had also higher height-for-age-adjusted-for-target-height (HFA/TH) or BMI. The caloric intake explained 6 or 7% of the variation. Longitudinally, caloric intake was associated with both WFA in boys and girls, and with BMI in boys. Each 100 calories increased intake would result in a 0.01 (girls)-0.02 increase in z-score WFA and 0.03 increase in z-score BMI. We found no significant association between CFA and WFA, HFA/TH or BMI. The contribution of protein, fat and carbohydrates was not associated with WFA, nor with HFA/TH or BMI.

CONCLUSION

Even at this relatively early age, a compromised growth in children with CF was found when compared to healthy children. The energy intake was below 110% EAR in 47% of the measurements, and appeared to be insufficient to prevent suboptimal body-growth over the 8-years of follow-up.

Nutrional status and dietary factors in cystic fibrosis patients with delta F508 mutation

Objective To examine the association between nutritional status and dietary factors in children and adolescents with cystic fibrosis that are carriers of delta F508 mutation. Methods Cross-sectional study of cystic fibrosis children and adolescents. Nutritional status (body mass index percentile) and dietary intake (3-day diet records presented as a percentage of estimated energy requirement) were assessed. Results Thirty six patients (median of 8.6; interquartile range 6.8-12.5 years; 50% male). The Poisson regression analysis showed that the carriers for delta F508 mutation had 60% lower prevalence ratio of body mass index ≥25° (PR=0.4; 95%IC=0.2-0.8) and 90% lower prevalence ratio (PR=0.1; confidence interval 95%IC=0.02-0.3) of ≥150% of estimated energy requirement when compared with non-delta F508 mutation carriers. The model was adjusted for lung function, estimated energy requirement, and body mass index. Conclusion Carriers for delta F508 mutation showed lower body mass index percentile and lower daily caloric consumption when compared with patients without this mutation.

Parenting adolescents with cystic fibrosis: the adolescents' and young adults' perspectives

BACKGROUND

When suffering from cystic fibrosis (CF), a number of problems may arise during adolescence; for example, poor adherence. The problems may be attributed to the adolescent being insufficiently prepared for adult life. Research on different ways of parenting adolescents with CF and the influence of different parenting styles on the adolescents' adherence to treatment is still limited.

AIM

The aim of this study was to identify the types of parental support that adolescents and young adults with CF want and find helpful in terms of preparing them for adult life.

METHODS

Sixteen Danish adolescents with CF, aged 14-25, participated in the study. Two focus group interviews were carried out, one for 14-18-year-olds and one for 19-25-year-olds. Individual interviews were conducted, with three subjects. Using interpretive description strategy, a secondary analysis of the interview data was conducted.

RESULTS

The adolescents and young adults wanted their parents educated about the adolescent experience. They wanted their parents to learn a pedagogical parenting style, to learn to trust them, and to learn to gradually transfer responsibility for their medical treatment. Additionally, the adolescents noted that meeting other parents may be beneficial for the parents.

CONCLUSION

The findings of this study suggest that adolescents and young adults with CF want their parents to be educated about how to handle adolescents with CF and thereby sufficiently prepare them for adult life.

Cognitive and behavioral functioning of children listed for heart and/or lung transplantation

The objective of the study was to assess cognitive function and behavior in a group of children listed for heart and/or lung transplantation. Ninety-nine children (3.7-16.8 years) listed for heart and/or lung transplant for congenital heart disease (CHD), cardiomyopathy (CM), cystic fibrosis (CF) or primary pulmonary hypertension (PPH) were evaluated with standardized measures of cognitive function, academic ability and behavior. Results were compared with a historical cohort of healthy children and comparisons were made between the four diagnostic subgroups. Mean subtest scores, overall IQ and achievement scores were within the normal range for the total group but were significantly lower than those of the healthy group. Although there were few significant differences between the diagnostic subgroups children with CHD or CF tended to perform at a lower level than those with CM or PPH. There were some significant issues with behavior for all diagnostic subgroups, particularly in the domain of social competence. Patients with end-stage heart or lung disease are at increased risk for cognitive and/or behavioral problems, particularly those with CHD. Follow-up of these patients after transplant is important to determine the role that psychological functioning prior to surgery has in the longer term after surgery.

Nutritional considerations in patients with cystic fibrosis

Nutritional status is strongly associated with pulmonary function and survival in cystic fibrosis patients. Attainment of a normal growth pattern in childhood and maintenance of adequate nutritional status in adulthood represent major goals of multidisciplinary cystic fibrosis centers. International guidelines on energy intake requirements, pancreatic enzyme-replacement therapy and fat-soluble vitamin supplementation are of utmost importance in daily practice. The present review summarizes the most up-to-date information on early nutritional management in newly diagnosed patients and evaluates the benefits of aggressive nutritional support, assessment of nutritional status, recommendations for nutrition-related management in pancreatic-insufficient patients and the possible therapeutic impact of fat intake modulation upon inflammatory status.

CYSTIC FIBROSIS – A GUIDE FOR CLINICIANS IN REPRODUCTIVE AND OBSTETRIC MEDICINE

Cystic Fibrosis (CF) is the most common life-shortening recessive genetic disease in the UK. Far from being a condition managed exclusively by paediatricians with sufferers dying in early childhood, CF is now a condition in which adults outnumber children with the condition, and the death of a child in a paediatric centre is rare. As increasing numbers of young people grow up relatively healthy it is unsurprising they begin to ask about relationships, sex, fertility and the possibility of having a child. This paper briefly describes the genetics, pathophysiology and clinical features of CF with an emphasis on how it pertains to female reproduction. The management of women with CF considering having a baby including contraception, preparation for pregnancy, the pregnancy itself, delivery and the post natal period will be discussed. Contraindications to pregnancy, method of termination, and pregnancy after transplantation will also be considered. Much of the detailed management is given in the European Guidelines for the Management of Pregnancy in Women with CF on which this paper is based.