Alexander, Erin

Abstract Home parenteral nutrition (HPN) is a life‐sustaining therapy traditionally used as a bridge to enteral autonomy or intestinal transplantation. Increasingly, it is used for intractable feeding intolerance (IFI), which can occur near the end of life (EOL) in children with severe neurological impairment (SNI). In these cases, HPN use differs from its historical role and requires tailored outpatient planning. We report a retrospective case series of four children with SNI who developed IFI and received HPN as part of their EOL care. The pediatric palliative care team (PPCT) was involved in all cases during HPN decision‐making and planning. The pediatric nutrition support team (PNST) and PPCT collaborated to provide individualized, goal‐directed care. Patients ranged from 1 to 12 years old, with HPN durations between 5 weeks and 2 years. All were enrolled in hospice while receiving HPN. Plans were made through shared decision‐making, reflecting each family's values, and included tailored approaches to laboratory monitoring, febrile episodes, line care, growth assessment, and follow‐up. HPN at EOL requires careful ethical consideration, particularly of autonomy because families often find comfort in providing nutrition. IFI is often unanticipated, and prognoses are uncertain. With the combined expertise of PNST and PPCT, HPN can be used meaningfully at EOL, supporting family values, easing suffering, and creating space for peace and connection.

AbstractObjectivesChildren with inflammatory bowel disease (IBD) often have low body mass index (BMI). BMI does not distinguish between fat and lean mass. Body composition deficits may be associated with worse clinical outcomes. We examined the prevalence of risk factors associated with body composition deficits in youth with pediatric‐onset IBD, and factors associated with low lean mass in the presence of a normal BMI Z‐score (BMI‐Z).MethodsNewly diagnosed IBD patients ages 5–20 years with whole body dual energy x‐ray absorptiometry scans acquired between 2014 and 2019 were included. Appendicular lean soft tissue mass index (AppLSTMI) and fat mass index (FMI) were expressed as age and sex‐specific Z‐scores. Clinical and demographic data were collected retrospectively. Logistic regression was used to assess associations with body composition outcomes.ResultsFive hundred sixteen patients were included, 26% had AppLSTMI Z‐score (AppLSTMI‐Z) < −2, 4% had BMI‐Z < −2, and none had FMI Z‐score (FMI‐Z) < −2. Increased risk of low AppLSTMI‐Z associated with Crohn's diagnosis, Asian ethnicity, disease activity, elevated platelets, and glucocorticoid use. Females had lower FMI‐Z. Low AppLSTMI‐Z within the context of BMI‐Z (n = 112) was associated with Crohn's disease, Asian (odds ratio [OR] = 3.77, p = 0.001) and Black identity (OR = 0.32, p = 0.02), and elevated platelets (OR = 1.76, p = 0.02) compared to those with normal BMI‐Z and normal AppLSTMI‐Z.ConclusionsBMI is a poor indicator of body composition in children with IBD as it masks lean mass deficits which are highly prevalent. Future studies regarding the long‐term consequences and reversibility of this deficit are warranted.

Objectives:Patients with Trisomy 21 (T21) commonly have gastrointestinal symptoms and diseases that prompt evaluation with esophagogastroduodenoscopy (EGD). Our objective is to characterize duodenal histological abnormalities in these patients when undergoing EGD. A secondary aim is to explore associations of histologic findings with different therapies.Methods:Patients 30 years old or younger with T21 who underwent EGD from 2000 to 2020 at 6 hospitals were included in this retrospective cohort study. Duodenal biopsies were categorized based on reported histopathology findings as normal or abnormal. Abnormal pathology reports were reviewed and categorized into villous atrophy (VA) and duodenitis without VA. The VA group was further categorized based on the presence or absence of celiac disease (CD).Results:We identified 836 patients with T21 who underwent EGD, 419 (50.1%) of whom had duodenal histologic abnormalities. At the time of the first (index) abnormal duodenal biopsy, 290 of 419 had VA and of those, 172 of 290 met CD diagnostic criteria, while 118 of 290 did not meet CD criteria (nonspecific VA). Among the patients with an abnormal biopsy, acid suppression at the time of the index biopsy was less common in patients with VA‐CD compared to patients without VA or patients with nonspecific VA (12.2% vs 45.7% vs 44.9%).Conclusions:Half of the T21 patients in this cohort had abnormal duodenal biopsies including a subgroup with nonspecific VA. In this cohort, acid suppression use was more prevalent in patients with abnormalities other than CD.

AbstractThe proper use of intravenous fluids has likely been responsible for saving more lives than any other group of substances. Proper use includes prescribing an appropriate electrolyte and carbohydrate solution, at a calculated rate or volume, for the right child, at the right time. Forming intravenous fluid plans for hospitalized children requires an understanding of water and electrolyte physiology in healthy children and how different pathology deviates from the norm. This review highlights fluid management in several disease types, including liver disease, diabetic ketoacidosis, syndrome of inappropriate antidiuretic hormone, diabetes insipidus, kidney disease, and intestinal failure as well as in those with nonphysiologic fluid losses. For each disease, the review discusses specific considerations, evaluations, and management strategies to consider when customizing intravenous fluid plans. Ultimately, all hospitalized children should receive an individualized fluid plan with recurrent evaluations and fluid modifications to provide optimal care.

Objectives:Nutrition support is essential in improving outcome and survival in children on extra corporal membranous support (ECMO). We aim to evaluate the association between the timing of enteral nutrition (EN) initiation and its impact on outcome.Methods:We retrospectively reviewed the electronic health records of children (≤18 years) from November 2014 to November 2019 who were on veno‐arterial ECMO for ≥48 hours. Abstracted data included demographics, ECMO indication and duration, timing of EN initiation, change in weight‐for‐age z score (WAZ), and survival rate. The vasoactive‐inotropic score (VIS) was calculated to assess illness acuity.Results:We identified 76 children with median age (interquartile range [IQR]) of 0.3 years (0–2.6), 46 of which were infants (59%) who required ECMO for a median (IQR) of 10 days (6–22). Thirty‐six (47%) survived to hospital discharge. EN was initiated in 55 (72%) of patients while on ECMO. EN initiation by day 3 of ECMO was positively associated with survival (P = 0.0438). VIS at the time of EN initiation was lower in surviving infants (P = 0.022). Children who achieved enteral autonomy were more likely to survive (P = 0.0024). Survivors had greater WAZs at ECMO completion (P = 0.0004).Conclusions:Initiation of EN by day 3 of ECMO and at a lower VIS is associated with greater likelihood of survival.