Malnutrition increases the risk of 30-day complications after surgery in pediatric patients with Crohn disease

Background

Pediatric patients with Crohn disease (CD) are frequently malnourished, yet how this affects surgical outcomes has not been evaluated. This study aims to determine the effects of malnourishment in children with CD on 30-day outcomes after surgery.

Protein energy malnutrition and nutritional anaemia in preschool children in rural KwaZulu.

The prevalence of protein energy malnutrition (PEM) and nutritional anaemia was investigated in 392 black children, aged 13--60 months, living in a poor rural area. Breast feeding was practised extensively in the population (median duration 14 months). The overall prevalence of PEM was 16,4%, but severe PEM occurred in only 2,7% of the children. Anaemia was present in 6,7% of children, and was almost invariably associated with iron deficiency. Biochemical evidence of iron, folate and vitamin B12 deficiency was detected in 36%, 14,8%, and 0,3% of children respectively. Anaemia was almost confined to the 1-year-old group, but biochemical evidence of iron deficiency, while highest in this age group, continued into the 2-4-year age group. No relationship was found between ecological factors such as income, educational status, etc. and any of the anthropometric, biochemical or haematological variables. The prevalence of PEM and anaemia in these poor rural children is lower than that of a comparable group of underprivileged urban children, thus emphasizing that city slum conditions are producing considerable nutritional problems in their wake. It is of importance to investigate further why some children who are severely deprived in many ways do not necessarily manifest a proportional degree of nutritional deprivation.     

Hyponatremic dehydration: An analysis of 78 cases

Our purpose was to determine the frequency of convulsion in children with hyponatremic dehydration (HD). We also investigated whether or not there was a relationship between the severity of hyponatremia and the degrees of malnutrition in our region (Eastern Anatolia of Turkey) in where malnutrition is frequently observed. In this study, the clinical and laboratory findings of 78 patients with diarrhoea (acute, persistent or chronic diarrhoea) and HD were studied. When diarrhoea lasts longer than 2 and 4 weeks they were accepted as persistent and chronic diarrhoea, respectively. Patients were said to have HD if they had the clinical findings of dehydration associated with hyponatremia [Serum sodium (SNa) <130 mmol/L)]. Nutritional status of the children was assessed by the Gomez classification using weight for age; it was accepted as normal those were between 90%-110%, mild malnutrition 75%-89%, moderate malnutrition 60%-74% and severe malnutrition <60%. Of 78 patients, 40 were boys, 38 were girls. The age and weight of the patients ranged from 40 days to 36 months (8.94 +/- 5.49 months) and from 2000 to 10,300 g (5535.25 +/- 1702.10 g) respectively. All patients except four had malnutrition; 15 (20.3%) had mild malnutrition, 30 (40.5%) had moderate malnutrition and 29 (39.2%) had severe malnutrition. Forty-seven patients had acute, 16 patients had persistent, and 15 patients had chronic diarrhoea. SNa levels were between 104 and 129 mmol/L (121.21 +/- 6.12 mmol/L). There was not statistically a significant difference between SNa level and the degree of malnutrition, and SNa level and the types (acute, persistent or chronic) of diarrhoea (p > 0.05). Of 78 patients, 12 (15.3%) patients had convulsion, of whom eight had convulsion associated with fever. Convulsion was noted in nine (19.1%) and three (18.7%) patients with acute and persistent diarrhoea, respectively (p > 0.05). Also, we observed that when hyponatremia was severer, convulsions tended to be more occuring (p < 0.05). Five (6.4%) children died and all of them had severe malnutrition and septicemia. We determined that the frequency of convulsion in HD was 15.3% (12/78), and there was not a difference between the cases of acute, persistent and chronic diarrhoea for the frequency of convulsion. We also found a significant difference was not present between SNa level and the degree of malnutrition, and between SNa level and the types (acute, persistent or chronic) diarrhoea. However, we observed that when hyponatremia was severer, convulsions tended to be more occuring.     

Nutrition status of pre-school children in a Cape Town township

An anthropometric study evaluated the nutritional state of pre-school children in the Site C squatter area of Khayelitsha township in Cape Town. A cluster sampling method was used and the weight for age, height for age, weight for height and mid-upper arm circumference of 872 children between the ages of 1 and 5 years were recorded. The National Centers for Health Statistics percentile charts were used as a reference standard. There was a low level of acute malnutrition with 13.7% of children below the 3rd percentile for weight for age. Acute severe malnutrition was not a problem with only 1.0% below the 3rd percentile weight for height. The figure of 47.2% below the 3rd percentile for height for age indicates high levels of chronic malnutrition. Only 42.2% of children had a 'Road to Health' card. The need for further research, nutritional surveillance and health care intervention is highlighted.     

Reliability of mini nutritional assessment in hemodialysis compared with subjective global assessment.

Protein-energy malnutrition (PEM) is common in hemodialysis patients. Subjective Global Assesment (SGA) and Mini Nutritional Assessment (MNA) are two tools for monitoring PEM. Our aim was to determine reliability of MNA in detecting malnutrition in hemodialysis patients in comparison with SGA. The study population consisted of 137 patients with pure PEM with no signs of chronic inflammation. Nutritional statuses of patients were assessed concomitantly by SGA and MNA. Ninety-two patients were in SGA-A, 40 patients were in SGA-B, and 5 patients were in SGA-C. Forty-seven patients were in MNA-1, 77 patients were in MNA-2, and 13 patients were in MNA-3. Albumin (P = .0001), prealbumin (P = .0001), body mass index (P = .01), creatinine (P = .0001), and nPNA (P = .04) were statistically different between SGA groups. Creatinine (P = .001), blood urea nitrogen (P = .017), albumin (P = .001), prealbumin (P = .005), body mass index (P = .0001), and nPNA (P = .005) were statistically different between MNA groups. Fifty-two patients who had no evidence of malnutrition according to SGA were defined as having moderate malnutrition according to MNA. Seven patients who were in a state of moderate malnutrition determined by SGA were in good nutritional status according to MNA. SGA identified 8 patients as moderately malnourished; the same patients were defined as having severe malnutrition in MNA. Our results suggest that MNA might underestimate the nutritional status of hemodialysis patients who are not in an inflammatory state and may not be a reliable method for detecting moderate malnutrition when compared with SGA.     

Bacteraemia in children in the south-western Cape. A hospital-based survey.

During 1989, of the 8,524 children admitted to the paediatric wards of Tygerberg Hospital, 165 (1.96%) had bacteraemia. The incidence of community-acquired bacteraemias was 1.6% and that of nosocomial bacteraemias 0.5%. The most important community-acquired isolates were Streptococcus pneumoniae, Staphylococcus aureus and Neisseria meningitidis. The most important nosocomial isolates were Klebsiella and Salmonella spp. Both bacteraemia (relative risk (RR) = 2.08) and severe malnutrition (RR = 3.01) were more common in black patients. Overall, severe malnutrition was more common than mild malnutrition or a normal nutritional status in bacteraemic patients (odds radio (OR) = 3.17). Nineteen patients with bacteraemia died, there was a significantly higher case-fatality rate in patients with extreme malnutrition (P = 0.03; OR = 3.7). Gram-negative bacilli were found more commonly in patients with extreme malnutrition (OR = 5.4) and patients with nosocomial bacteraemia (OR = 4.6). Three of 39 patients (7.6%) with nosocomial bacteraemia had suppurative thrombophlebitis.     

Evaluating the clinical management of severely malnourished children--a study of two rural district hospitals.

BACKGROUND: Severe malnutrition is an important cause of preventable mortality in most South African hospitals. Work recently done in two rural Eastern Cape hospitals supports the literature which shows that many deaths occur as a result of outdated clinical practices and that improving these practices reduces case fatality rates. Rapid assessment of clinical management in paediatric wards is necessary to highlight areas for improvement. OBJECTIVE: To assess the management of severely malnourished children in two rural district hospitals and to recommend improvements for their care. METHODS: Based on draft World Health Organisation (WHO) guidelines for inpatient care of children with severe malnutrition, data collection instruments were developed in conjunction with the district nutrition team to assess the quality of care given to malnourished children in two Mount Frere hospitals, Eastern Cape. Data were collected through retrospective review of case records, with detailed studies of selected cases, structured observations of the paediatric wards, and interviews with ward sisters and doctors. RESULTS: The combined case fatality rate for severe malnutrition was 32%. Inadequate feeding, poor management of rehydration and infection, lack of resources, and a lack of knowledge and motivation among staff were identified as areas that need attention. CONCLUSION: The clinical management of severely malnourished children can be rapidly assessed to highlight areas for improvement. Involving staff in the assessment process has led to their active involvement in improving the management of malnourished children in their hospitals.     

A prospective multicentre study of the nutritional status in children on chronic peritoneal dialysis.

The anthropometry-bioimpedance analysis-nutrition (ABN) score is a recently proposed objective method of assessing malnutrition in children on chronic peritoneal dialysis (CPD) that uses nine parameters based on anthropometry, skinfold thickness and bioimpedance analysis. The aim of this prospective, cross-sectional study was to apply it to children treated with CPD in seven Italian paediatric nephrology centres, with a score of < 10.33 (the 3rd percentile in a population of 264 healthy children) classifying the children as malnourished. The other considered parameters were age, age at the start of dialysis and duration of dialysis; serum haemoglobin, urea, creatinine, total protein, albumin, transferrin, bicarbonate and C-reactive protein; residual urine output; urinary and peritoneal creatinine clearance; and daily protein and energy intake. The study enrolled 43 patients (mean age 10.2 +/- 4.2 years), 21 of whom (48.8%) had an ABN score of < 10.33: 15 with mild, five with moderate, and one with severe malnutrition. The malnourished patients started CPD at a younger age (P < 0.05) and had a longer duration of dialysis (P < 0.01), and a significant worsening in nutritional status was observed in those treated for more than 12 months of dialysis; they also had significantly lower serum albumin, creatinine and haemoglobin levels. In conclusion, protein-calorie malnutrition is common in children receiving CPD. A younger age at the start of dialysis and a longer duration of treatment are clear risk factors, and counterbalance the long-term viability of CPD in paediatric age.     

Nutritional assessment of children on haemodialysis: value of IGF-I, TNF-&agr; and IL-1{beta}

Background: Protein-energy malnutrition (PEM) is associated with increased morbidity and mortality in haemodialysis (HD) patients. Insulin-like growth factor I (IGF-I) has proved to be a sensitive marker of malnutrition, while interleukin-1 (IL-1{beta}) and tumour necrosis factor (TNF) have been found to be raised in catabolic states. Methods: We have investigated the nutritional status of 17 chronic renal failure (CRF) paediatric patients (8 boys, 9 girls) on maintenance HD. Eight predialysis CRF children (5 boys and 3 girls; mean creatinine 5.1±3.2 mg/dl) and 10 healthy children served as control groups. PEM was defined according to anthropometric measurements (triceps skinfold thickness (TST), mid-arm circumference (MAC), and mid-arm muscle circumference (MAMC). These were correlated with serum IGF-I, IL-1 TNF-&agr; transferrin, and albumin (all sampled before the HD session). Results: In the HD group, TST was reduced in 41.2% of the patients, whereas MAC and MAMC were reduced in 82.4 and 76.5% respectively. TST was depleted in only one of the predialysis CRF children. The degree of reduction in MAC and MAMC were 62.5 and 62.5% respectively. Median serum IGF-I level was decreased in both HD and predialysis CRF patients (205.1 interquartile range (IQR) 194.4 &mgr;g/l and 258.8 IQR 155.0 &mgr;g/l respectively) compared to the healthy children (418.0 IQR 310.5&mgr;g/l) (P=0.0009 and P=0.01 respectively). Within the HD group, IGF-I levels were lower in patients with malnutrition defined according to TST (145.0 IQR 125.5 &mgr;g/l) compared to children with normal TST (201.2 IQR 218.8 &mgr;g.l) (P=0.05). IGF-I levels of the HD patients with malnutrition according to TST was also lower than predialysis CRF patients and healthy children (P=0.04 and P=0.002 respectively). Serum IL-1{beta} was undetectable in all groups. Median serum TNF-&agr; levels were higher in HD and predialysis CRF patients compared to healthy children, albeit statistically insignificant. There was no correlation between TNF-&agr;, transferrin or albumin and anthropometric parameters. Conclusions: Our results support the high prevalence of malnutrition in CRF children, which becomes more pronounced when treatment by HD is initiated. We suggest that determination of IGF-I levels in childhood HD patients in conjunction with anthropometric measurements is useful for identification of malnutrition. We have not been able to demonstrate the catabolic effects of cytokines on this state of protein-energy malnutrition.     

全结肠型巨结肠患儿术后远期疗效及营养状况评估

目的评估全结肠型巨结肠（TCA）患儿术后远期疗效及营养状况。方法对1999年1月至2010年12月广州市妇女儿童中心收治的11例TCA患儿进行随访调查．通过体格测量及实验室检查进行营养评估：采用问卷进行直肠肛门功能Kelly评分及生活质量评分;分析远期疗效及营养状况的影响因素。结果11例患儿获得8．147个月的随访,其中有10例获得较满意的肛门功能（Kellv评分5-6分）,另1例Kellv评分为3分;随访时间不足48个月的患儿Kelly评分明显高于随访时间48个月以上者（P〈0．05）。生活质量评估为优者（9～10分）9例,良者（7～8分）2例。按年龄别体质量（WFA）：术后正常者2例,轻度营养不良6例,中度营养不良3例;按年龄别身高（HFA）：术后正常者6例．轻度营养不良3例,中度营养不良2例。家长接受过高等教育（13年以上）的患儿血清白蛋白为（49．0±2．7）g／L,明显高于家长受教育程度低的患儿（44．3±1．9）g／L（P〈0．05）。结论TCA患儿术后远期疗效满意．能获得较满意的直肠肛门功能和生活质量。患儿术后体质量不足较身高不足更为多见。父母受过高等教育的儿童营养状态较佳。     

A comparison of the outcomes of two clinical audits of burn pressure garment satisfaction and compliance in Saudi Arabia

The treatment of burns is very important in Saudi Arabia given the high incidence of these injuries and the large proportion of children involved. Currently there are insufficient numbers of Saudi nationals to meet these and other health care needs, and consequently, a large investment in expatriate health care workers continues to be made. Expatriate workers have imported the use of the burn pressure garment (BPG), which is widely accepted as an effective intervention within western countries. However, evidence of effectiveness specific to the unique cultural context of Saudi Arabia is lacking. This paper compares the findings of two audits conducted regarding BPG treatments in two similar hospitals in Saudi Arabia. Although both hospitals were alike in structure, location and client population, Hospital A patient compliance rate was only 15.3% compared to Hospital B's 81.3%. Dissatisfaction was reported by 77% of the Hospital A group but by only 35% of the Hospital B patients. Hospital A lacked the clear guidelines for practice and follow-up procedures evidenced at the second facility and poorer outcomes could possibly be attributed to this short-coming. However, cross-cultural issues related to skill transfer, the auditing process and the impact of expatriate health care workers were also identified as warranting further exploration.     

Nutritional consequences of total gastrectomy.

Nutritional status was investigated in 10 patients who had previously undergone total gastrectomy without evidence of malignancy. The ability of these patients to ingest and absorb adequate amounts of nutrients was examined. Metabolic balance studies were also performed to discover how effectively these patients could accumulate and use the absorbed nutrients. In the controlled hospital situation, the amount of food ingested was greater than the amount required for maintenance of Ideal Body Weight. Although mild malabsorption of fat and nitrogen was documented, weight gain and positive nitrogen balance occurred. In direct contrast, food intake significantly decreased when the patients returned to their home environment. While severe malabsorption may contribute to malnutrition in the individual patient, the most common mechanism responsible for postoperative malnutrition was inadequate intake. In the occasional patient with severe malabsorption, the universal demonstration of jejunal anaerobic bacterial overgrowth offers important therapeutic implications. The relative importance of pancreatico-biliary insufficiency in promoting malabsorption remains to be determined. Construction of a Hunt-Lawrence jejunal pouch was not found to favorably affect caloric intake, weight gain, degree of malabsorption, or dumping symptoms. Although some degree of malnutrition does result from total gastric resection, in most cases it is mild and potentially correctable. Avoidance of indicated total gastrectomy due to fears of progressive postoperative malnutrition is unwarranted.     

Intradialytic parenteral nutrition treatment and biochemical marker assessment for malnutrition in adolescent maintenance hemodialysis patients.

Protein-energy malnutrition (PEM) is a significant cause of morbidity and mortality for patients receiving maintenance hemodialysis. Minimal study has evaluated therapeutic options for and biochemical marker assessment of pediatric patient PEM. In 2001, we expanded the indications for intradialytic parenteral nutrition (IDPN) treatment of PEM to all maintenance hemodialysis patients, regardless of etiology, who had a >10% weight loss and were at less than the 90th percentile of ideal body weight. Nine patients received thrice weekly IDPN from 3 to 22 months with minimal side effects. Six patients had weight and body mass index increase, 1 patient stopped losing weight, and 2 patients continued to lose weight during the initial 5 months of IDPN therapy. Cohort subanalysis showed that all patients with organic PEM responded to IDPN therapy, whereas patients with psychosocial causes of PEM did not. The normalized protein catabolic rate increased significantly for patients whose condition responded to IDPN therapy, whereas serum albumin did not change. The current study suggests that IDPN is effective treatment of organic causes of PEM in pediatric patients receiving maintenance hemodialysis and that normalized protein catabolic rate may be superior to serum albumin as a marker of nutrition status. The observation that IDPN was not sufficient to reverse PEM in patients with psychosocial PEM causes should direct caregivers to address the relevant underlying causes as well as to provide intensive nutrition therapy.     

Behavioural changes in children following day-case surgery: a 4-week follow-up of 551 children

The purpose of this prospective multicentre survey was to evaluate the occurrence and the type of changes in children's behaviour during the first 4 weeks following the day of surgery, and to assess the significance of some patient-related factors on the incidence. Pre- and postoperative questionnaires were completed by the parents of 551 children aged 4 months to 13.4 years in five hospitals incorporating nine operative units in Northern Finland. The overall incidence of problematical behavioural changes was 47% and that of beneficial changes 17%. Problematical changes were most common in the 1.0 to 2.9 year olds and the incidence decreased significantly from 46% on the day of the operation to 9% 4 weeks later (p < 0.0001). Predictors by multiple logistic regression analysis were age, mild pain at home following surgery, severe pain and a previous bad experience of health care which had adversely affected the attitude of the child towards doctors or nurses. Hospital influenced playing was a significant factor 3 and 4 weeks after the operation. By the 4th week, beneficial and problematical changes were equally common (9%). Gender, previous operations and experience of repeated paracenteses (for treatment of middle ear infection) did not have a significant effect on the incidence. Pain on the day of the operation predicted the occurrence of behavioural problems up to the 4th week, 2–4 weeks longer than the duration of pain itself. The results emphasise the importance of effective prevention of postoperative pain as well as the importance of avoiding unpleasant experiences in all contacts children have with health care. Playing could perhaps be used to help children cope with a short hospital experience.     

Evaluation of high-protein supplements in children with protein energy malnutrition.

The present study was designed to test the comparative efficacy of cow's milk, a protein, vitamin and mineral mixture (PVM) and soybean textured vegetable protein (SOMOS) as supplements to maize meal porridge in the dietary treatment of children with protein energy malnutrition (PEM). Each diet was designed to provide approximately 480 kJ/kg with 2 protein/kg from the test protein, and 1,8 g protein/kg from maize. Response to treatment was measured by loss of oedema, subsequent weight gain, rate of generation of serum albumin, and serum amino acid patterns. In 36 children studied to date the three dietary regimens all produced satisfactory rates of cure of PEM. The clinical and economic implications of these results are discussed.     

Risk factors affecting nutritional status of dialysis patients: a quality improvement project

People with chronic kidney disease on dialysis are at very high risk for protein energy malnutrition (PEM). It is well documented that malnourished patients have increased frequency of hospital admissions, longer hospital stays, lower quality of life, and increased risk of death. Serum albumin level is a valid measure for nutritional status of PEM. Clinical practice guidelines for nutrition, established by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI), recommend that patients on dialysis achieve an albumin of 3.7 g/dL (BCP) to ensure optimal nutrition and decrease risks of PEM. At Mercy Dialysis Center, it was determined that only 6% (n=97) of patients at Mercy Dialysis Center met this recommended albumin level. This led to an extensive continuous quality improvement project to improve these results. The nephrologist, nurse practitioner, dietitian, social worker, nurses, and dialysis technicians all contributed to this team project. PROJECT SUMMARY: Eleven risk factors for low serum albumin levels were identified. All patients at Mercy Dialysis Center were assessed for each risk factor. Interventions were implemented to reduce these risks. Serum albumin levels were tracked at the beginning of our study, at six months, and at one year on all patients. RESULTS: At the end of the study, 36% of the patients met the KDOQI recommendations for serum albumin levels (compared to only 6% prior to the project), and albumin levels overall improved. The risk factors that affected our patients the most included: dentition, infections or sepsis, multiple medications, and pain. It was determined that these, and all other risk factors had an impact on the nutritional status of our patients and need to be addressed on a regular basis.     

Changes in leukocyte subsets: clinical implications for children with chronic renal failure

Increased systemic inflammation and an impaired immune response are features of adult chronic renal failure (CRF). These patients have increased rates of infection, cardiovascular disease, anemia, and malnutrition. We measured inflammatory and immunological markers in a group of children with pre-dialytic CRF. No prior studies have explored these markers even though children with non-dialysed CRF exhibit similar complications to those seen in adults with CRF. Blood was collected from children with mild, moderate, or severe CRF and an age-matched control group. Functional leukocyte subsets were determined using flow cytometry. Circulating levels of interleukin (IL)-1, IL-6, IL-8, IL-12, IL-10, and tumor necrosis factor- were measured using a flow cytometric bead assay. Children with severe CRF showed significantly reduced total white cell count and absolute neutrophil and lymphocyte counts. Absolute numbers of CD3+/CD45RO+ memory T cells and CD3+/CD45RO+/CD62L+ memory Th2 cells were significantly reduced in all CRF groups versus controls. Children with severe CRF showed increased CD11b expression on neutrophils and monocytes. Some patients showed increases in pro-inflammatory cytokines that were not related to their level of residual renal function. As CD11b expression mediates leukocyte adhesion to vascular endothelium, upregulation may contribute to the increased endothelial dysfunction observed in children with CRF. L-selectin mediates extravasation of leukocytes into tissue and homing of peripheral blood lymphocytes to lymph nodes. The reduction in L-selectin may inhibit these actions and predispose patients to increased infection later in life. This is the first study to comprehensively investigate leukocyte functional molecules and inflammatory cytokine profiles in children with pre-dialytic CRF and provides new immunological evidence for the clinical manifestations associated with the disease.     

Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines

BACKGROUND: American Pediatric Surgical Association consensus guidelines for children with blunt spleen injuries have been defined and validated in children's hospitals, but large administrative data sets indicate that only 10% to 15% of children with blunt spleen injuries are treated at children's hospitals. We sought to identify the frequency and compare the treatment of children with spleen injury in hospitals with and without recognized trauma expertise, with the aim of identifying a meaningful target for dissemination of benchmarks and consensus guidelines. STUDY DESIGN: State health departments' administrative data sets from California, Florida, New Jersey, and New York were analyzed for 2000, 2001, and 2002. All children with head injury or other nonspleen abdominal injuries requiring surgery were excluded. Injury Severity Scores were determined by ICDMAP-90. RESULTS: There were 3,232 patients with blunt spleen injury. Trauma centers had a significantly lower rate of operation for both multiply injured patients (15.3% versus 19.3%, p < 0.001) and those with isolated injury (9.2% versus 18.5%, p < 0.0001) when compared with nontrauma centers. The operative rates at both trauma centers and nontrauma centers exceed published American Pediatric Surgical Association benchmarks for all children with spleen injury (5% to 11%) and the subset with isolated spleen injury (0% to 3%). Independent risk factors for splenectomy included ages 15 to 19 years (p < 0.002), spleen injury severity (p < 0.0001), and presence of multiple injuries (p < 0.04). Adjusted odds ratio for risk of splenic operation in all patients with spleen injury was 2.122 (95% CI:1.455- 3.096) when treated at a nontrauma center (p < 0.0001). CONCLUSIONS: These multistate discharge data indicate that treatment of children with blunt spleen injury differs significantly when comparing trauma centers and nontrauma centers. Because nearly two-thirds of these children were treated at trauma centers, dissemination of American Pediatric Surgical Association guidelines and benchmarks through state or regional trauma systems may reduce the number of children having operations for splenic injury.