Virginia A. Stallings

Consensus report on nutrition for pediatric patients with cystic fibrosis.

Laura K. Bachrach, M.D. Robert J. Beall, Ph.D. Preston W. Campbell, III, M.D. Susan C. Casey, B.S., R.D. Mitchell B. Cohen, M.D. Mary Corey, Ph.D. W. Hobart Davies, Ph.D. Judy A. Fulton, R.D. Richard J. Grand, M.D. John E. Grunow, M.D. Dana S. Hardin, M.D. Lesles Hendeles, Pharm.D. James E. Heubi, M.D. Van S. Hubbard, M.D. Hui-Chuan Kai, Ph.D. Sheila Innis, Ph.D. Elisabeth Luder, Ph.D., R.D. Karen MacGuiness, R.D. Richard K. Mathis, M.D. Annie McKenna, M.S., R.D., C.N.S. Antoinette Moran, M.D. Laurie Moyer-Mileur, Ph.D., R.D. Kimberly O. O’Brien, Ph.D. Hebe Quinton, M.S. Lynne M. Quittell, M.D. Ross W. Shepherd, M.D., FRACP Ronald J. Sokol, M.D. Lori J. Stark, Ph.D. John N. Udall, Jr., M.D., Ph.D. Babette Zemel, Ph.D. INTRODUCTION

Weight Gain in the First Week of Life and Overweight in Adulthood A Cohort Study of European American Subjects Fed Infant Formula

Background—Successful prevention of obesity and related cardiovascular risk factors requires a clear understanding of its determinants over the life course. Rapid infancy weight gain is associated with childhood obesity, whereas low infancy weight is associated with coronary heart disease. Our aim was to identify during which periods in infancy weight gain is associated with adult obesity. Methods and Results—A cohort of European American formula-fed subjects, measured on 7 occasions during infancy as part of several infant formula studies, were contacted at age 20 to 32 years, when they reported usual adult weight and height. A life-course plot was used to identify critical periods of weight gain associated with adulthood overweight (body mass index ≥25 kg/m2). These associations were tested with logistic regressions. Data were available for 653 subjects (72% of eligible subjects). Approximately 32% of them were overweight adults. The period between birth and age 8 days was identified as potentially critical. After adjustment for important confounding factors, weight gain during the first week of life was associated with adulthood overweight status (OR for each 100-g increase 1.28, 95% CI 1.08 to 1.52), as was weight gain during the first 112 days of life (OR 1.04, 95% CI 1.01 to 1.08). Similar results were obtained after standardization with z scores from a reference population. Conclusions—In formula-fed infants, weight gain during the first week of life may be a critical determinant for the development of obesity several decades later. These results contribute to the understanding of chronic disease programming and suggest new approaches to obesity prevention.

Evidence-Based Practice Recommendations for Nutrition-Related Management of Children and Adults with Cystic Fibrosis and Pancreatic Insufficiency: Results of a Systematic Review

The Cystic Fibrosis Foundation established a process of systematic review of evidence to inform the development of clinical care guidelines and encourage evidence-based practice. The Subcommittee on Growth and Nutrition reviewed the evidence in two areas: energy intake and dosing for pancreatic enzyme replacement therapy. Evidence-based recommendations are presented here. Also, an ad hoc working group conducted a review of the literature and performed new analyses using the Cystic Fibrosis Foundation Patient Registry to update the recommendations for growth and weight-status monitoring. These Registry data-based recommendations are presented.

Parental feeding attitudes and styles and child body mass index: prospective analysis of a gene-environment interaction.

Background. Parental feeding styles were linked to child weight in cross-sectional studies, which were unable to test the direction of effect. Prospective studies can best establish causal relationships among such variables. Objective. We tested the 2-year stability of parental feeding attitudes and styles and investigated whether these variables predict child body mass index (BMI) z scores 2 years later. We evaluated whether these associations were dependent on children’s predisposition to obesity. Methods. Participants were 57 families enrolled in an Infant Growth Study of children born at high risk or low risk for obesity, on the basis of maternal prepregnancy overweight or leanness. Children were evaluated for weight and height at 3, 5, and 7 years of age. Measures of parental feeding attitudes and styles were ascertained with the Child Feeding Questionnaire at 5 and 7 years of age. Correlation and multiple regression analyses tested whether parental feeding styles at age 5 predicted increased child BMI z scores 2 years later. Results. Parental feeding attitudes and styles were stable for child ages of 5 to 7 years. With respect to feeding attitudes, perceived responsibility at age 5 predicted reduced child BMI z scores at age 7 among low-risk families, whereas child weight concern and perceived child weight predicted increased child BMI z scores among high-risk families. With respect to feeding styles, monitoring predicted reduced child BMI z scores at age 7 among low-risk children. In contrast, restriction predicted higher BMI z scores and pressure to eat predicted reduced BMI z scores among high-risk children. These associations remained significant after controlling for child weight status at age 3. Conclusions. The relationship between parental feeding styles and child BMI z scores depends on child obesity predisposition, suggesting a gene-environment interaction. Among children predisposed to obesity, elevated child weight appears to elicit restrictive feeding practices, which in turn may produce additional weight gain. Parenting guidelines for overweight prevention may benefit from consideration of child characteristics such as vulnerability to obesity and current weight status.

Feeding Dysfunction is Associated with Poor Growth and Health Status in Children with Cerebral Palsy

OBJECTIVE To describe parent-reported feeding dysfunction and its association with health and nutritional status in children with cerebral palsy. DESIGN Anthropometry was measured and z scores calculated. The Child Health Questionnaire was used to assess health status, and a categorical scale (none to severe) was used to classify subjects according to severity of feeding dysfunction. SUBJECTS 230 children (9.7+/-4.6 years; 59% boys) with moderate to severe cerebral palsy were recruited from 6 centers in the United States and Canada. STATISTICAL ANALYSES Descriptive statistics, the Kruskal-Wallis and Pearson chi2 tests. RESULTS Severity of feeding dysfunction was strongly associated with indicators of poor health and nutritional status. The mean weight z scores were -1.7, -2.5, -3.3, and -1.8 among children with none, mild, moderate, or severe (largely tube-fed) feeding dysfunction, respectively (P= .003). Similar results were observed for height z score (P=.008), triceps z score (P=.03), and poor Global Health score (part of the Child Health Questionnaire) (P<.001). Subjects who were tube fed were taller (P=.014) and had greater body fat stores (triceps z score, P=.001) than orally fed subjects with similar motor impairment. For subjects exclusively fed by mouth, a dose-response relationship was observed between feeding dysfunction severity and poor nutritional status. Subjects with only mild feeding dysfunction had reduced triceps z score (-0.9) compared with those with no feeding problems (-0.3). CONCLUSION For children with moderate to severe cerebral palsy, feeding dysfunction is a common problem associated with poor health and nutritional status. Even children with only mild feeding dysfunction, requiring chopped or mashed foods, may be at risk for poor nutritional status. Parental report of feeding dysfunction with a structured questionnaire may be useful in screening children for nutritional risk.

NUTRITION‐RELATED GROWTH FAILURE OF CHILDREN WITH QUADRIPLEGIC CEREBRAL PALSY

Growth failure and nutritional status were evaluated in 141 children with quadriplegic cerebral palsy, aged between two and 18 years. Linear growth was assessed by upper‐arm and lower‐leg lengths: both means were significantly reduced. Mean bodyweight and triceps skinfold thickness fat stores were reduced to 65 per cent medians and subscapular skinfold fat stores to 81 per cent median. Muscle stores were the most preserved and reduced to 88 per cent median. Examination of the sample by age‐group showed significant reductions in growth and nutrition status indicators, even at two to four years, except for muscle area. TO determine the degree to which nutritional status affected linear growth, a set of two‐step regression analyses was conducted. The linear growth measures were significantly correlated with the measures of nutritional status.

Health status of children with moderate to severe cerebral palsy

The aim of the study was to evaluate the health of children with cerebral palsy (CP) using a global assessment of quality of life, condition-specific measures, and assessments of health care use. A multicenter population-based cross-sectional survey of 235 children, aged 2 to 18 years, with moderate to severe impairment, was carried out using Gross Motor Function Classification System (GMFCS) levels III (n = 56), IV (n = 55), and V (n = 122). This study group scored significantly below the mean on the Child Health Questionnaire (CHQ) for Pain, General Health, Physical Functioning, and Impact on Parents. These children used more medications than children without CP from a national sample. Fifty-nine children used feeding tubes. Children in GMFCS level V who used a feeding tube had the lowest estimate of mental age, required the most health care resources, used the most medications, had the most respiratory problems, and had the lowest Global Health scores. Children with the most severe motor disability who have feeding tubes are an especially frail group who require numerous health-related resources and treatments. Also, there is a relationship among measures of health status such as the CHQ, functional abilities, use of resources, and mental age, but each appears to measure different aspects of health and well-being and should be used in combination to reflect childrens overall health status.

Growth and Health in Children With Moderate-to-Severe Cerebral Palsy

BACKGROUND. Children with cerebral palsy frequently grow poorly. The purpose of this study was to describe observed growth patterns and their relationship to health and social participation in a representative sample of children with moderate-severe cerebral palsy. METHODS. In a 6-site, multicentered, region-based cross-sectional study, multiple sources were used to identify children with moderate or severe cerebral palsy. There were 273 children enrolled, 58% male, 71% white, with Gross Motor Function Classification System levels III (22%), IV (25%), or V (53%). Anthropometric measures included: weight, knee height, upper arm length, midupper arm muscle area, triceps skinfold, and subscapular skinfold. Intraobserver and interobserver reliability was established. Health care use (days in bed, days in hospital, and visits to doctor or emergency department) and social participation (days missed of school or of usual activities for child and family) over the preceding 4 weeks were measured by questionnaire. Growth curves were developed and z scores calculated for each of the 6 measures. Cluster analysis methodology was then used to create 3 distinct groups of subjects based on average z scores across the 6 measures chosen to provide an overview of growth. RESULTS. Gender-specific growth curves with 10th, 25th, 50th, 75th, and 90th percentiles for each of the 6 measurements were created. Cluster analyses identified 3 clusters of subjects based on their average z scores for these measures. The subjects with the best growth had fewest days of health care use and fewest days of social participation missed, and the subjects with the worst growth had the most days of health care use and most days of participation missed. CONCLUSIONS. Growth patterns in children with cerebral palsy were associated with their overall health and social participation. The role of these cerebral palsy-specific growth curves in clinical decision-making will require further study.

Discrepancies in pediatric bone mineral density reference data: Potential for misdiagnosis of osteopenia

OBJECTIVE To evaluate published pediatric dual-energy x-ray absorptiometry bone mineral density (BMD) reference data by comparing the diagnostic classification of measured BMD in children at risk for osteopenia as healthy or osteopenic according to reference source. STUDY DESIGN Spine BMD was measured in 95 children, ages 9 to 15 years, at risk for osteopenia because of childhood disease. The BMD results were converted to age-specific z scores for each of the 5 reference data sets, and the z -score distributions were compared. RESULTS Between 11% and 30% of children were classified as osteopenic (z score < -2.0) depending on the reference data set. The 2 sex-specific reference data sets yielded similar diagnostic classification of boys and girls: 10% of boys and 11% to 16% of girls were osteopenic (P =.4). The 3 sex-nonspecific reference data sets classified 9% to 13% of girls and 24% to 44% of boys as osteopenic; the diagnosis of osteopenia was significantly greater in boys (P <.01). CONCLUSIONS The use of different published reference data for the assessment of children at risk for osteopenia results in inconsistent diagnostic classification of BMD results. These inconsistencies can be partially attributed to sex-nonspecific reference data that result in misclassification of boys as osteopenic.

Risk factors for low bone mineral density in children and young adults with Crohn's disease.

OBJECTIVE Low bone mineral density (BMD) is a recognized complication of Crohns disease (CD). The aim of this study was to identify the risk factors for low BMD in pediatric patients with CD. STUDY DESIGN One hundred nineteen subjects with CD ranging in age from 5 to 25 years were enrolled. BMD of the lumbar spine was measured by dual-energy x-ray absorptiometry. Growth parameters were assessed by examination. Disease-specific variables and use of selected medications were determined by chart review. RESULTS Powerful risk factors for low BMD z-score included hypoalbuminemia, exposure to nasogastric tube feeds, total parenteral nutrition, 6-mercaptopurine, and corticosteroids. Corticosteroid dosing at a level >7.5 mg/d, 5000 mg lifetime cumulative dose, or >12 months of lifetime exposure were significant risk factors for low BMD z-score. Weaker but significant associations with low BMD z-scores included measures of disease severity such as pediatric Crohns disease activity index, hospital admissions, and length of hospital stay. Site and duration of disease were not predictive. CONCLUSIONS The presence of several clinically available factors was predictive of poor bone mineral status in this sample of subjects with CD. Hypoalbuminemia, corticosteroid exposure, nasogastric tube feeds, total parenteral nutrition, and 6-mercaptopurine were the most powerful risk factors for low bone mineral status.