Heather Gilbertson

Barriers to Adequate Nutrition in Critically Ill Children

OBJECTIVE The study assessed the adequacy of nutrition support in critically ill infants and children and identifies barriers impeding the delivery of estimated energy requirement (EER). METHODS Forty-two children (median age, 6.6 mo; range, 0-198) who were admitted to a tertiary-level pediatric intensive care unit (PICU) were studied prospectively over a 6-mo period. Patients staying in the PICU longer than a full 3 d and who received enteral or a combination of enteral and parenteral nutrition were eligible for inclusion. Patients were assigned to one of two groups: patients after cardiac surgery (n = 18) and all other diagnoses (n = 24). EERs were compared with actual energy intake, and clinical information was collected throughout the PICU admission. RESULTS Patients in the PICU received a median of 37.7% (range, 0.2-130.2%) of their EERs. The cardiac group achieved significantly lower energy intakes than did the non-cardiac group (P = 0.02). Only 22 of 42 patients (52%) achieved full EERs at any time during their admission, and this was more likely in non-cardiac patients (67% versus 33%, P = 0.03) Children undergoing cardiac surgery had a significant fall in weight-for-age Z scores (WAZ) from PICU admission to discharge (median WAZ, -1.44 versus -2.14; P < 0.001). In both groups, the major barrier to achieving EER was fluid volume restriction. Interruption of feeding for procedures and feeding intolerance reduced energy intake to a lesser degree. CONCLUSIONS This study highlights the inadequacy of nutrition support in critically ill children in the PICU. Restriction of fluid intake was the main barrier to the delivery of adequate nutrition, particularly in infants undergoing cardiac surgery.

Does Aggressive Refeeding in Hospitalized Adolescents With Anorexia Nervosa Result in Increased Hypophosphatemia

PURPOSE Concerns about refeeding syndrome have led to relatively conservative nutritional rehabilitation in malnourished inpatients with anorexia nervosa (AN), which delays weight gain. Compared to other programs, we aggressively refed hospitalized adolescents. We sought to determine the incidence of hypophosphatemia (HP) in 12-18-year-old inpatients in order to inform nutritional guidelines in this group. METHODS A 1-year retrospective chart review was undertaken of 46 admissions (29 adolescents) with AN admitted to the adolescent ward of a tertiary childrens hospital. Data collected over the initial 2 weeks included number of past admissions, nutritional intake, weight, height, body mass index, and weight change at 2 weeks. Serum phosphorus levels and oral phosphate supplementation was recorded. RESULTS The mean (SD) age was 15.7 years (1.4). The mean (SD) ideal body weight was 72.9% (9.1). Sixty-one percent of admissions were commenced on 1,900 kcal (8,000 kJ), and 28% on 2,200 kcal (9,300 kJ). Four patients were deemed at high risk of refeeding syndrome; of these patients, three were commenced on rehydration therapy and one on 1,400 kcal (6,000 kJ). All patients were graded up to 2,700 kcal (11,400 kJ) with further increments of 300 kcal (1,260 kJ) as required. Thirty-seven percent developed mild HP; no patient developed moderate or severe HP. Percent ideal body weight at admission was significantly associated with the subsequent development of HP (p = .007). CONCLUSIONS These data support more aggressive approaches to nutritional rehabilitation for hospitalized adolescents with AN compared to current recommendations and practice.

Improving the estimation of mealtime insulin dose in adults with type 1 diabetes: the Normal Insulin Demand for Dose Adjustment (NIDDA) study.

OBJECTIVE Although carbohydrate counting is routine practice in type 1 diabetes, hyperglycemic episodes are common. A food insulin index (FII) has been developed and validated for predicting the normal insulin demand generated by mixed meals in healthy adults. We sought to compare a novel algorithm on the basis of the FII for estimating mealtime insulin dose with carbohydrate counting in adults with type 1 diabetes. RESEARCH DESIGN AND METHODS A total of 28 patients using insulin pump therapy consumed two different breakfast meals of equal energy, glycemic index, fiber, and calculated insulin demand (both FII = 60) but approximately twofold difference in carbohydrate content, in random order on three consecutive mornings. On one occasion, a carbohydrate-counting algorithm was applied to meal A (75 g carbohydrate) for determining bolus insulin dose. On the other two occasions, carbohydrate counting (about half the insulin dose as meal A) and the FII algorithm (same dose as meal A) were applied to meal B (41 g carbohydrate). A real-time continuous glucose monitor was used to assess 3-h postprandial glycemia. RESULTS Compared with carbohydrate counting, the FII algorithm significantly decreased glucose incremental area under the curve over 3 h (–52%, P = 0.013) and peak glucose excursion (–41%, P = 0.01) and improved the percentage of time within the normal blood glucose range (4–10 mmol/L) (31%, P = 0.001). There was no significant difference in the occurrence of hypoglycemia. CONCLUSIONS An insulin algorithm based on physiological insulin demand evoked by foods in healthy subjects may be a useful tool for estimating mealtime insulin dose in patients with type 1 diabetes.

Restrictive Eating Disorders Among Adolescent Inpatients

BACKGROUND AND OBJECTIVES: Clinicians are increasingly observing adolescents who have lost large amounts of weight, experience typical cognitions and acute medical complications of anorexia nervosa (AN), yet do not meet diagnostic criteria for AN owing to weight. We refer to this category of Eating Disorder Not Otherwise Specified as EDNOS-Wt. We set out to describe the changing incidence of EDNOS-Wt compared with AN, and to compare the characteristics of these 2 groups in a cohort that required hospitalization after weight loss. METHODS: A 6-year retrospective cohort study (2005 to 2010) was undertaken of first admissions of 12- to 19-year-old patients to a tertiary children’s hospital using Diagnostic Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) AN or EDNOS-Wt. Clinical, biochemical, and nutritional data were collected up to day 28 of admission. RESULTS: Ninety-nine adolescents were admitted; 73 had AN and 26 had EDNOS-Wt. Mean (SD) age at admission was 15.2 years (1.3) and 87% were female. In 2005, EDNOS-Wt represented 8% of admissions; by 2009 this proportion had increased to 47%. Hypophosphatemia developed in 41% of AN and in 39% of EDNOS-Wt patients. The lowest mean pulse rate in AN was 45.1 bpm compared with 47.1 bpm in EDNOS-Wt patients. CONCLUSIONS: We have experienced more than a fivefold increase in the proportion of adolescents who have EDNOS-Wt admitted over this 6-year period. Despite not being underweight, EDNOS-Wt patients experienced a similar profile of life-threatening complications of weight loss as patients who have AN. Higher-weight adolescents who have extensively lost weight require careful medical assessment.

Dietary patterns and retinal vascular calibre in children and adolescents with type 1 diabetes

To examine the association between dietary patterns and retinal vascular calibre in children and adolescents with type 1 diabetes.

Is bedtime supper necessary for older children with diabetes using glargine insulin in multiple daily injection regimens

Diabet. Med. 27, 238–241 (2010)

A new phenotype of anorexia nervosa: the changing shape of eating disorders

Background and aims Adolescents are increasingly referred to our specialist eating disorder (ED) program having lost large amounts of weight and having the diagnostic features of anorexia nervosa (AN) with the exception of underweight. Many of these adolescents with EDNOS-AN[wt] were premorbidly overweight. We aimed to identify the changing prevalence of this phenotype from 2005-2010 in an inpatient sample, and compare the associated complications with adolescents with AN.

An audit of the dietary intake of Australian children with type 1 diabetes

To understand what children with type 1 diabetes in a representative tertiary hospital clinic are eating compared to their peers and explore dietary intake impact on HbA1c outcome. An open cross-sectional dietary audit of children and adolescents with diabetes aged 2–17 years attending the Royal Children’s Hospital, Melbourne was conducted using an age-appropriate validated Food Frequency Questionnaire. Total energy, macronutrient intake and diet quality were calculated and compared to dietary advice provided and national intake data. Body weight, and dietary intake influences on glycaemic control were investigated. Overall, 785 patients were recruited, from which 429 dietary surveys were completed. Dietary intakes were overall nutritionally adequate with macronutrient distribution (% total energy intake) being lower carbohydrate (48.6%), higher total sugars (22.4%), fat (32.9%), saturated fat (14.9%) and protein intake (19.1%) than recommendations, but similar to their peers. Energy intakes were excessive compared to their peers in the 4–13 year olds. Rates of overweight (30%) were significantly higher than national data (18%). Overall, 43% achieved optimal glycaemic control (HbA1c < 7.5%; <58 mmol/mol). HbA1c prediction via linear regression indicated that the following factors were associated with lower HbA1c values: being male, on pump regimen, lower rates of insulin per kg, shorter duration of disease. This audit has identified areas requiring targeted education/support to improve health outcomes including dietary adherence, rates of overweight/obesity, appropriate energy intakes and optimal glycaemic targets. Furthermore, it provides baseline data to evaluate efficacy of future interventions.