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The positive impact of dietitians in paediatric health care
SYMPOSIUM: NUTRITION
The positive impact of dietitians in paediatric health care
treatment of disease e as undergraduates, dietitians gain an indepth understanding of nutrition and metabolism and other related topics. The scientific aspects of this are combined with study of the psychosocial factors which affect food intake. All this would be worthless if not combined with communication, leadership and research skills which enable dietitians to interpret and communicate, in practical understandable ways, the science of nutrition and the complexities of disease to patients, their families and their carers. In addition to the generic standards of dietetic proficiency, paediatric dietitians will undertake postgraduate education to acquire the specific paediatric knowledge and advanced communication skills necessary to effectively provide the specialized nutritional care required across the paediatric age range.
Ruth M Watling
Abstract Paediatric dietitians possess a unique set of skills which they bring to the multidisciplinary care team (MDT). This enables them to play a pivotal role in the detection, diagnosis and treatment of many paediatric diseases. Children in hospital are at risk of being malnourished, and this is more likely in children where there is established disease. An increasing number of children with a range of both acute and chronic diseases derive benefit from nutritional support. Paediatric dietitians can contribute to increased effectiveness in the detection and treatment of disease-related under-nutrition and faltering growth. Additionally, in a number of childhood diseases dietetic intervention is an important component of symptom or disease management, and a small but specific number of conditions can be resolved by dietetic intervention. For paediatric dietitians to be most effective they themselves must promote and utilize fully all of their acquired knowledge and skills and practise at the pinnacle of their profession specific standards of proficiency. Other health professionals should ensure that they are aware of, and acknowledge, the clinical expertise of dietitians if effective nutrition and dietetic services are to be achieved and children are to attain an optimum nutritional outcome.
Nutritional risk screening In adult practice there are validated and widely accepted nutritional risk screening tools. In paediatric care, where children could be considered to be at greater nutritional risk because of the greater protein and energy requirements of growth, generic nutritional risk screening tools remain in the development and validation process. Current education of paediatricians and nurses in nutrition is insufficient to ensure that they can appropriately assess for nutritional risk. Dietitians, on the other hand, are uniquely trained in nutritional assessment, and included in the standards of proficiency is the requirement to be able to choose and undertake the most appropriate method of dietary and nutritional assessment using appropriate techniques and equipment. It would be impossible and inappropriate for the limited dietetic resources to carry out generic nutrition risk assessments in all areas of paediatric hospital care; nonetheless, their skills can be used to good effect in this area. One example is to ensure that, when working in a diseasespecific MDT, the dietitian takes responsibility for consistently applying and acting on nutritional risk assessments. To illustrate this, in cystic fibrosis (CF) there are a number of published standards and consensus guidelines which include assessment of nutritional risk (Table 1). A proficient paediatric dietitian will be responsible for the delivery of nutritional assessment in accordance with these standards. If this is carried out consistently and thoroughly, then all children within this specific disease group will have ongoing assessment of their nutritional status; those at nutritional risk should be identified and treated appropriately, and nutritional risk will be minimized. Furthermore, if the methods of nutritional assessment and the results and implications are clearly communicated to the other members of the care team, then this may enhance awareness of nutritional risk and improve identification of those at risk in wider clinical areas. Finally, if the dietitian critically appraises these suggested guidelines, then problems are likely to be identified. Again using the example of CF, a review of the literature would identify flaws in the use of weight for height and therefore consider alternative methods of nutritional assessment. Effective nutritional risk screening in disease-specific areas will not prevent failure to identify malnutrition across paediatric hospital populations or replace the need for a generic nutrition risk assessment tool, but if used within disease-specific areas it
Keywords multidisciplinary care teams; nutritional risk screening; nutrition support; paediatric dietitian
Introduction Nutritional status assessment, nutrition support, and clinical dietetic interventions are all important components of paediatric health care. Many health professionals have some knowledge of nutrition, although this is often limited. One of the barriers to the effective provision of nutritional care is this lack of nutritional knowledge. In addition to identifying this knowledge deficit, the Council of Europe has also recommended a more central role for dietitians, particularly in the area of nutrition support. If dietitians are to achieve the best possible outcome for their patients, other members of the multidisciplinary care team (MDT) must acknowledge and utilize the specific knowledge and skills of the dietitians. To do so, there must be a wider understanding both of the knowledge acquired in undergraduate dietetic study and the regulated standards of proficiency that result from this. To achieve the overarching aim of dietetics e namely the application of the science of nutrition for the prevention and
Ruth M Watling BSc RD is Head of Nutrition & Dietetics at the Department of Nutrition & Dietetics, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK.
PAEDIATRICS AND CHILD HEALTH 19:9
400
Ó 2009 Elsevier Ltd. All rights reserved.
SYMPOSIUM: NUTRITION
Disease-specific (cystic fibrosis) example of nutrition screening and intervention <2 years
2e18 years
Preventative counselling Dietetic referral
90e110% weight for height Any evidence of failure to thrive
90e110% weight for height 85e89% weight for height. Weight loss over 4e6 months. Static weight for 6 months
Invasive nutritional support
Failure to thrive despite usual dietetic strategies (e.g. oral supplements)
<85% weight for height or decrease of 2 centile positions for weight
Table 1
will heighten awareness of the importance of nutrition in general within paediatrics. Good-quality evidence to support this view is lacking in paediatric practice, but a recent large questionnaire study from Scandinavia does support the hypothesis that greater access to clinical dietitians significantly increases the focus on clinical nutrition amongst medical and nursing staff. Dietitians should also create and welcome opportunities to teach other health professionals; this is another opportunity to increase awareness and understanding of the importance of nutrition in paediatric practice. From the author’s own experience these opportunities include undergraduate medical student teaching (Table 2) and support with special study modules, undergraduate nurse teaching, postgraduate medical teaching, and ward-based teaching on a variety of nutrition and dietetic topics.
aims. These include knowledge of nutrition, biochemistry, food hygiene, microbiology, physiology and pharmacology. Nutrition support involves decision making on the validity of differing types of nutrition support, and selection and adjustment of both feed choice and route of delivery for intensive enteral feeding that is appropriate to the age, clinical condition, biochemistry and physiology of the child. There may also drug and nutrient interaction to consider, and there are issues of microbiological safety when planning enteral feeding. Other members of the team have diverse responsibilities for the child, but the dietitian’s primary focus is on evidence-based individualized nutrition. One study showed that in the neonatal setting the inclusion of a dietitian in the care team improved nutritional care in terms of weight at discharge and total weight gained, and significant differences in the supply of parenteral nutrients. At the other end of the spectrum a study of enterally fed adults found that patients were more likely to achieve recommended energy intake when the dietitian’s recommendations were instituted, and a further study of critically ill adults showed significantly greater weight gain and decreased length of hospitalization when dietitian’s rather than physician’s recommendations for enteral feeds were followed. Whilst adult studies from the US cannot be directly extrapolated to UK paediatric care, there is an indication, confirmed by neonatal data, that as a result of their specific focus on nutrition dietitians are more likely than other professionals to achieve the recommended nutritional intake in their patients, and this is associated with improved nutritional status outcomes. Many children will require long-term or even lifelong nutrition support. This is confirmed by data on home enteral tube feeding from the British Artificial Nutrition Survey showing a point prevalence of 5250 in 2007 compared to 3374 in 2000, the most commonly cited indications being neurological disease, cancer, cardiac disease, gastrointestinal diseases and respiratory disease. A component of paediatric dietetic care is to involve children and young people and their carers in the planning of treatment. In the area of long-term nutrition support this is linked to quality of life, as the dietitian will ensure that the nutritional care plan is practical, achievable and appropriate to the usual daily routine of the family. Numerous apparently minor, but important, issues such as equipment and feed supply, holiday and respite feed plans, can be resolved and ease the parental burden of care through good working relationships with the family, the dietitian, and providers of home enteral feeding services.
Nutritional support Nutritional risk assessment (by whatever means) coupled with increasing awareness of the importance of nutrition support in a huge range of paediatric disorders has led to a significant increase in the number of children receiving nutrition support. Nutrition support e both enteral and parenteral e is therefore an increasing feature of both acute and chronic paediatric disease management across the spectrum from the preterm neonate to the young person in transition to adult care. The aims of nutritional support are to maintain growth and nutritional well-being and to achieve optimum quality of life. Paediatric dietitians have wide-ranging knowledge, understanding and skills which can support the achievement of these
Outline of undergraduate medical student teaching C C C C C C C C
Determinants of nutritional requirements Normal growth and weight gain in infancy and childhood Assessment and monitoring of growth Breast milk Infant formulas Nutrient deficiencies: iron, vitamin D Failure to thrive in infancy and early childhood Nutrition support in chronic childhood disease
Table 2
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Ó 2009 Elsevier Ltd. All rights reserved.
SYMPOSIUM: NUTRITION
Nutrition product selection
Dietary counselling
There is a huge range of nutritional products available on prescription in the UK. There are four categories of product (Table 3), and in paediatrics the range of products includes postdischarge neonatal formulas, nutrient-dense infant formulas for failure-to-thrive babies, nutritionally complete enteral feeds in a range of energy densities with or without the addition of fibre, specialized infant formulas, metabolic products, and gluten-free and low-protein staple food stuffs. The range of products has expanded rapidly in recent years, and products are subject to frequent changes in composition. Critical review and comparison of nutritional composition, taste, and practical aspects (such as mixing or presentation) will be most effectively carried out by a dietitian both at an individual patient level and in conjunction with others at hospital-wide level to ensure consistent practice and value for money. To highlight this with a specific example: although the exact essential fatty acid requirements of artificially fed infants is unknown, the current recommendation is that infant formulas, including those used for malabsorption, contain 4.5e10.8% energy as linoleic acid and have a ratio of linoleic acid to alinolenic acid of 5:15. Of the common specialized formulas used for malabsorption in infancy, the composition varies from 5.1 to 12% linoleic acid, and the ratio of linoleic acid to a-linolenic acid varies from 6.4 to 64. Within these formulas there are other nutritional differences, and a paediatric dietitian has the skills to undertake a detailed analysis on which to base a choice for each infant depending on nutritional requirements and clinical condition. Aside from the nutritional aspects of product selection, families often face enormous practical difficulties with the prescribing and supply of products. This is especially true of the staple gluten-free products for coeliac disease and low-protein foods for phenylketonuria and other disorders of protein metabolism. Without an adequate supply of such products, children’s diets can be low in energy, fibre, and variety which can significantly impact on adherence. It is difficult to imagine the practical aspects of obtaining these products, which involves having a GP prescribe a variety of foods ranging from bread to pasta and biscuits, getting the prescription from the GP to the pharmacy, the pharmacy obtaining the products from a wholesaler, revisiting the pharmacy to collect the product, and all so that your child can have toast, sandwiches and biscuits! Dietitians involved in the care of these children make significant efforts to facilitate for families the acquisition of an adequate supply of basic, staple foods via this cumbersome National Health Service (NHS) system.
Paediatric conditions as diverse as diabetes, cystic fibrosis, renal disease, and food allergy require an element of dietetic intervention. Some e such as inherited disorders of metabolism and coeliac disease e are treated entirely by dietetic intervention. Amongst the required competencies of the dietitian is a need to demonstrate sensitivity to the factors which shape food choice and lifestyle, and to understand the significance and potential impact of non-dietary factors when helping individuals make informed choices about their dietary treatment. When this is coupled with a knowledge base of biochemistry, nutrition, clinical medicine, and good verbal and written communication skills, this will result in effective counselling on dietary change. When dietary counselling by dietitians has been studied, patients have reported positive outcomes from counselling which suited their needs, increased knowledge of what to eat, and an increased sense of control of their condition. To take the example of evidence-based recommendations for the treatment of diabetes, these include the need to achieve optimal blood glucose control and blood pressure levels; to modify nutrient intake to prevent obesity, dyslipidaemia, cardiovascular disease, hypertension and nephropathy; to improve health through healthy food choices; and to address nutritional needs taking into consideration personal and cultural preferences and lifestyle. This will require the interpretation and explanation of the science of carbohydrate type and quantity, glycaemic indices, protein, and the range of dietary fats into understandable, practical food choices suited to each individual. The planning and education about such adjustments to food intake, whilst maintaining normal growth and development and dietary adequacy, are entirely matched to the knowledge and skills of a paediatric dietitian. Not infrequently the dietary change can be difficult, usually because of a host of social and psychosocial factors which influence food choice and behaviour. Specific examples of these are the young person with coeliac disease who finds adherence to a gluten-free diet incompatible with their lifestyle, or the parent of a child with an inherited metabolic disease where the diet is complex and significantly different to that of the rest of the family and the child’s peers. In these situations the communication, health behaviour change, and psychology aspects of the undergraduate curriculum are key to the dietitian helping children and their families to achieve and sustain the dietary changes required to contribute to the attainment of a positive outcome. A recent study has shown the possible value of the use of advanced behavioural change skills by dietitians to engage with families of obese children, and given the rising levels of childhood obesity
Categories of nutrition products available in the UK C C C C C C
Nutritionally complete non-disease-specific enteral tube feeds Sip feeds and nutritionally incomplete non-disease-specific supplements and modules Disease-specific formulations Products designed for the specific management of inherited metabolic disorders Staple foods designed to optimize nutritional status as part of the clinical management of formally diagnosed chronic disease states Products designed to enhance the safety and/or acceptability of foods or feeds which are prescribable in any of the above categories
Table 3
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Ó 2009 Elsevier Ltd. All rights reserved.
SYMPOSIUM: NUTRITION
and the apparent failure of standard care to change behaviour this may be a welcome addition to paediatric practice.
within well-organized MDTs that dietitians can focus on and optimize the nutritional aspects of care. Specifically in the field of nutrition support the team approach has been supported, as it appears to have the ability to effectively assess nutritional needs, prescribe a nutrition support plan, and reduce the incidence of nutrition-related complications. The studies reviewed for this paper indicate enhanced nutritional outcomes when the dietitian is an integral part of the care team. Aside from nutrition support, many paediatric conditions, as a result of the multifactorial nature of the diseases, require a team approach, and it has been shown that MDTs can aspire to a profound level of collaboration. In addition to direct patient benefit, health-care team working has been shown to increase learning and development of people, improve resource utilization and future planning of services, and improve work performance, all of which would be supportive of effective paediatric dietetic services. A
Extended dietetic practice There are various other aspects of health-care provision both at the individual patient level and in terms of service provision and planning that can be undertaken by dietitians. At an individual patient level, one of these is the area of medicines management. Many medications work in synergy with food, and a recent survey by the British Dietetic Association showed that over 3000 patients are treated by dietitians working under Patient Group Directions (PGD) with 62% advising on dose adjustment. The commonest drugs involved are insulin, pancreatic enzymes, and phosphate binders. Other medications such as vitamin and mineral supplements are used to ensure nutritional adequacy in restricted diets, and again these should be linked to the accurate assessment of dietary intake. Although a poorly researched area, it seems sensible that advice regarding such medications is given by a dietitian as they are most experienced in accurately assessing the nutritional content of the food and therefore its relationship to the medication. Studies of the coefficient of fat absorption in CF have shown that this can be improved when pancreatic enzyme dosage is adjusted to match the fat content of the food; coupled with this a further study confirmed that dietitians more accurately assessed fat intake and matched pancreatic enzyme dose to this assessed intake. Evidence is emerging from adult studies that, with suitable additional training, dietitians can safely prescribe parenteral nutrition. Given the concerns about the adequacy of nutrition training in undergraduate medicine and changes to medical working practices, this is an area of extended practice where, with additional training, safe and clinically effective nutrition support could be prescribed by a dietitian to those children requiring parenteral nutrition. Research and audit skills are a component of undergraduate dietetic programmes, but within the health-care setting there is limited time for dietitians to undertake research, and dietitians are reported, correctly, to prioritize direct patient care over other activities. However, there are significant gaps in the evidence base for paediatric dietetics. Individually or within the MDT, dietitians should be seeking opportunities to undertake research to extend the evidence base of dietetic treatments and improve patient outcome. This article has explored some of the ways in which effective paediatric dietetic practice can wholly or partly contribute to clinical care. Although paediatrics is one of the three largest practice areas for UK dietitians, the resource is extremely limited and therefore services must be planned and resourced to be effective. Dietitians as leaders can assist in this process by stating the case for their services, ensuring that their services are identified in health-care planning and that funding arrangements take account of their vital role.
FURTHER READING Aggett PJ, Haschke F, Heine W, et al. Comment on the content and composition of lipids in infant formulas. ESPGAN Committee on Nutrition. Acta Paediatr Scand 1991; 80: 887e96. Agostoni C, Axelson I, Colomb V, et al. The need for nutrition support teams in paediatric units: a commentary by the ESPGHAN committee on nutrition. ESPGHAN committee on nutrition; European society for paediatric gastroenterology. J Pediatr Gastroenterol Nutr 2005; 41: 8e11. Braga JM, Hunt A, Pope J, Molaison E. Implementation of dietitian recommendations for enteral nutrition results in improved outcomes. J Am Diet Assoc 2006; 106: 281e4. Burton H, Sanderson S, Dixon M, et al. Review of specialist dietitian services in patients with inherited metabolic disease in the United Kingdom. J Hum Nutr Diet 2007; 20: 84e92. Costantini D, Padoan R, Curcio L, Giunta A. The management of enzymatic therapy in cystic fibrosis patients by an individualized approach. J Pediatr Gastroenterol Nutr 1988; 7: S36e9. Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 2002; 25: 148e98. http://www.hpc-uk.org/assets/documents/1000050CStandards_of_ Proficiency_Dietitians.pdf (accessed 21 June 2009). Johansson U, Rasmussen HH, Mowe M, Staun M. Clinical nutrition in medical gastroenterology: room for improvement. Clin Nutr 2009; 28: 129e33. ¨rnell A, Ivarsson A, Synder YM. The everyday life of adolesOlsson C, Ho cent coeliacs: issues of importance for compliance with the gluten-free diet. J Hum Nutr Diet 2008; 21: 359e67. Pawellek I, Dokoupil K, Koletzko B. Prevalence of malnutrition in paediatric hospital patients. Clin Nutr 2008; 27: 72e6. Poustie VJ, Russell JE, Watling RM, et alCALICO trial collaborative group. Oral protein energy supplements for children with cystic fibrosis: CALICO multicentre randomised controlled trial. BMJ 2006; 332: 632e6. Poustie VJ, Watling RM, Ashby D, Smyth RL. Reliability of percentage ideal weight for height. Arch Dis Child 2000; 83: 183e4. Schiller MR, Miller M, Moore C, et al. Patients report positive nutrition counselling outcomes. J Am Diet Assoc 1998; 98: 977e82.
Conclusion This review has highlighted some of the many unique skills of a paediatric dietitian and how they can be used for patient benefit. Teamwork is the key to achieving these aims, and it is
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SYMPOSIUM: NUTRITION
Sermet-Gaudelus I, Poisson-Salomon AS, Colomb V, et al. Simple paediatric nutritional risk score to identify children at risk of malnutrition. Am J Clin Nutr 2000; 72: 64e70. Shaw V, Lawson M, eds. Clinical paediatric dietetics. 3rd edn. Blackwell Publications; 2007. Sinaasappel M, Stern M, Littlewood J, et al. Nutrition in patients with cystic fibrosis: a European Consensus. J Cyst Fibros 2002; 1: 51e75. Sneve J, Kattelmann K, Ren C, Stevens DC. Implementation of a multidisciplinary team that includes a registered dietitian in a neonatal intensive care unit improved nutrition outcomes. Nutr Clin Pract 2008; 23: 630e4. Stallings VA, Stark LJ, Robinson KA, et al. Evidence-based practice recommendations for nutrition-related management of children and adults with cystic fibrosis and pancreatic insufficiency: results of a systematic review. J Am Diet Assoc 2008; 108: 832e9. Stewart L, Chapple J, Hughes AR, et al. The use of behavioural change techniques in the treatment of paediatric obesity: qualitative evaluation of parental perspectives on treatment. J Hum Nutr Diet 2008; 21: 464e73.
PAEDIATRICS AND CHILD HEALTH 19:9
Swift JA, Sheard C, Rutherford M. Trainee health care professionals’ knowledge of the health risks associated with obesity. J Hum Nutr Diet 2007; 20: 599e604. Thoresen L, Rothenberg E, Beck AM, Irtun Ø. Doctors and nurses on wards with greater access to clinical dietitians have better focus on clinical nutrition. J Hum Nutr Diet 2008; 21: 239e47. www.bapen.org.uk (accessed 28 Apr 2009).
Practice points C
C
C
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Dietitians have the skills and knowledge to carry out comprehensive assessment of nutritional status in paediatric health care Children and their families can be educated and supported with dietary change by dietitians using a combination of communication and behavioural change skills Optimum nutritional outcome can be achieved by dietitians working in close collaboration with other members of the multidisciplinary care team
Ó 2009 Elsevier Ltd. All rights reserved.
The positive impact of dietitians in paediatric health care
treatment of disease e as undergraduates, dietitians gain an indepth understanding of nutrition and metabolism and other related topics. The scientific aspects of this are combined with study of the psychosocial factors which affect food intake. All this would be worthless if not combined with communication, leadership and research skills which enable dietitians to interpret and communicate, in practical understandable ways, the science of nutrition and the complexities of disease to patients, their families and their carers. In addition to the generic standards of dietetic proficiency, paediatric dietitians will undertake postgraduate education to acquire the specific paediatric knowledge and advanced communication skills necessary to effectively provide the specialized nutritional care required across the paediatric age range.
Ruth M Watling
Abstract Paediatric dietitians possess a unique set of skills which they bring to the multidisciplinary care team (MDT). This enables them to play a pivotal role in the detection, diagnosis and treatment of many paediatric diseases. Children in hospital are at risk of being malnourished, and this is more likely in children where there is established disease. An increasing number of children with a range of both acute and chronic diseases derive benefit from nutritional support. Paediatric dietitians can contribute to increased effectiveness in the detection and treatment of disease-related under-nutrition and faltering growth. Additionally, in a number of childhood diseases dietetic intervention is an important component of symptom or disease management, and a small but specific number of conditions can be resolved by dietetic intervention. For paediatric dietitians to be most effective they themselves must promote and utilize fully all of their acquired knowledge and skills and practise at the pinnacle of their profession specific standards of proficiency. Other health professionals should ensure that they are aware of, and acknowledge, the clinical expertise of dietitians if effective nutrition and dietetic services are to be achieved and children are to attain an optimum nutritional outcome.
Nutritional risk screening In adult practice there are validated and widely accepted nutritional risk screening tools. In paediatric care, where children could be considered to be at greater nutritional risk because of the greater protein and energy requirements of growth, generic nutritional risk screening tools remain in the development and validation process. Current education of paediatricians and nurses in nutrition is insufficient to ensure that they can appropriately assess for nutritional risk. Dietitians, on the other hand, are uniquely trained in nutritional assessment, and included in the standards of proficiency is the requirement to be able to choose and undertake the most appropriate method of dietary and nutritional assessment using appropriate techniques and equipment. It would be impossible and inappropriate for the limited dietetic resources to carry out generic nutrition risk assessments in all areas of paediatric hospital care; nonetheless, their skills can be used to good effect in this area. One example is to ensure that, when working in a diseasespecific MDT, the dietitian takes responsibility for consistently applying and acting on nutritional risk assessments. To illustrate this, in cystic fibrosis (CF) there are a number of published standards and consensus guidelines which include assessment of nutritional risk (Table 1). A proficient paediatric dietitian will be responsible for the delivery of nutritional assessment in accordance with these standards. If this is carried out consistently and thoroughly, then all children within this specific disease group will have ongoing assessment of their nutritional status; those at nutritional risk should be identified and treated appropriately, and nutritional risk will be minimized. Furthermore, if the methods of nutritional assessment and the results and implications are clearly communicated to the other members of the care team, then this may enhance awareness of nutritional risk and improve identification of those at risk in wider clinical areas. Finally, if the dietitian critically appraises these suggested guidelines, then problems are likely to be identified. Again using the example of CF, a review of the literature would identify flaws in the use of weight for height and therefore consider alternative methods of nutritional assessment. Effective nutritional risk screening in disease-specific areas will not prevent failure to identify malnutrition across paediatric hospital populations or replace the need for a generic nutrition risk assessment tool, but if used within disease-specific areas it
Keywords multidisciplinary care teams; nutritional risk screening; nutrition support; paediatric dietitian
Introduction Nutritional status assessment, nutrition support, and clinical dietetic interventions are all important components of paediatric health care. Many health professionals have some knowledge of nutrition, although this is often limited. One of the barriers to the effective provision of nutritional care is this lack of nutritional knowledge. In addition to identifying this knowledge deficit, the Council of Europe has also recommended a more central role for dietitians, particularly in the area of nutrition support. If dietitians are to achieve the best possible outcome for their patients, other members of the multidisciplinary care team (MDT) must acknowledge and utilize the specific knowledge and skills of the dietitians. To do so, there must be a wider understanding both of the knowledge acquired in undergraduate dietetic study and the regulated standards of proficiency that result from this. To achieve the overarching aim of dietetics e namely the application of the science of nutrition for the prevention and
Ruth M Watling BSc RD is Head of Nutrition & Dietetics at the Department of Nutrition & Dietetics, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK.
PAEDIATRICS AND CHILD HEALTH 19:9
400
Ó 2009 Elsevier Ltd. All rights reserved.
SYMPOSIUM: NUTRITION
Disease-specific (cystic fibrosis) example of nutrition screening and intervention <2 years
2e18 years
Preventative counselling Dietetic referral
90e110% weight for height Any evidence of failure to thrive
90e110% weight for height 85e89% weight for height. Weight loss over 4e6 months. Static weight for 6 months
Invasive nutritional support
Failure to thrive despite usual dietetic strategies (e.g. oral supplements)
<85% weight for height or decrease of 2 centile positions for weight
Table 1
will heighten awareness of the importance of nutrition in general within paediatrics. Good-quality evidence to support this view is lacking in paediatric practice, but a recent large questionnaire study from Scandinavia does support the hypothesis that greater access to clinical dietitians significantly increases the focus on clinical nutrition amongst medical and nursing staff. Dietitians should also create and welcome opportunities to teach other health professionals; this is another opportunity to increase awareness and understanding of the importance of nutrition in paediatric practice. From the author’s own experience these opportunities include undergraduate medical student teaching (Table 2) and support with special study modules, undergraduate nurse teaching, postgraduate medical teaching, and ward-based teaching on a variety of nutrition and dietetic topics.
aims. These include knowledge of nutrition, biochemistry, food hygiene, microbiology, physiology and pharmacology. Nutrition support involves decision making on the validity of differing types of nutrition support, and selection and adjustment of both feed choice and route of delivery for intensive enteral feeding that is appropriate to the age, clinical condition, biochemistry and physiology of the child. There may also drug and nutrient interaction to consider, and there are issues of microbiological safety when planning enteral feeding. Other members of the team have diverse responsibilities for the child, but the dietitian’s primary focus is on evidence-based individualized nutrition. One study showed that in the neonatal setting the inclusion of a dietitian in the care team improved nutritional care in terms of weight at discharge and total weight gained, and significant differences in the supply of parenteral nutrients. At the other end of the spectrum a study of enterally fed adults found that patients were more likely to achieve recommended energy intake when the dietitian’s recommendations were instituted, and a further study of critically ill adults showed significantly greater weight gain and decreased length of hospitalization when dietitian’s rather than physician’s recommendations for enteral feeds were followed. Whilst adult studies from the US cannot be directly extrapolated to UK paediatric care, there is an indication, confirmed by neonatal data, that as a result of their specific focus on nutrition dietitians are more likely than other professionals to achieve the recommended nutritional intake in their patients, and this is associated with improved nutritional status outcomes. Many children will require long-term or even lifelong nutrition support. This is confirmed by data on home enteral tube feeding from the British Artificial Nutrition Survey showing a point prevalence of 5250 in 2007 compared to 3374 in 2000, the most commonly cited indications being neurological disease, cancer, cardiac disease, gastrointestinal diseases and respiratory disease. A component of paediatric dietetic care is to involve children and young people and their carers in the planning of treatment. In the area of long-term nutrition support this is linked to quality of life, as the dietitian will ensure that the nutritional care plan is practical, achievable and appropriate to the usual daily routine of the family. Numerous apparently minor, but important, issues such as equipment and feed supply, holiday and respite feed plans, can be resolved and ease the parental burden of care through good working relationships with the family, the dietitian, and providers of home enteral feeding services.
Nutritional support Nutritional risk assessment (by whatever means) coupled with increasing awareness of the importance of nutrition support in a huge range of paediatric disorders has led to a significant increase in the number of children receiving nutrition support. Nutrition support e both enteral and parenteral e is therefore an increasing feature of both acute and chronic paediatric disease management across the spectrum from the preterm neonate to the young person in transition to adult care. The aims of nutritional support are to maintain growth and nutritional well-being and to achieve optimum quality of life. Paediatric dietitians have wide-ranging knowledge, understanding and skills which can support the achievement of these
Outline of undergraduate medical student teaching C C C C C C C C
Determinants of nutritional requirements Normal growth and weight gain in infancy and childhood Assessment and monitoring of growth Breast milk Infant formulas Nutrient deficiencies: iron, vitamin D Failure to thrive in infancy and early childhood Nutrition support in chronic childhood disease
Table 2
PAEDIATRICS AND CHILD HEALTH 19:9
401
Ó 2009 Elsevier Ltd. All rights reserved.
SYMPOSIUM: NUTRITION
Nutrition product selection
Dietary counselling
There is a huge range of nutritional products available on prescription in the UK. There are four categories of product (Table 3), and in paediatrics the range of products includes postdischarge neonatal formulas, nutrient-dense infant formulas for failure-to-thrive babies, nutritionally complete enteral feeds in a range of energy densities with or without the addition of fibre, specialized infant formulas, metabolic products, and gluten-free and low-protein staple food stuffs. The range of products has expanded rapidly in recent years, and products are subject to frequent changes in composition. Critical review and comparison of nutritional composition, taste, and practical aspects (such as mixing or presentation) will be most effectively carried out by a dietitian both at an individual patient level and in conjunction with others at hospital-wide level to ensure consistent practice and value for money. To highlight this with a specific example: although the exact essential fatty acid requirements of artificially fed infants is unknown, the current recommendation is that infant formulas, including those used for malabsorption, contain 4.5e10.8% energy as linoleic acid and have a ratio of linoleic acid to alinolenic acid of 5:15. Of the common specialized formulas used for malabsorption in infancy, the composition varies from 5.1 to 12% linoleic acid, and the ratio of linoleic acid to a-linolenic acid varies from 6.4 to 64. Within these formulas there are other nutritional differences, and a paediatric dietitian has the skills to undertake a detailed analysis on which to base a choice for each infant depending on nutritional requirements and clinical condition. Aside from the nutritional aspects of product selection, families often face enormous practical difficulties with the prescribing and supply of products. This is especially true of the staple gluten-free products for coeliac disease and low-protein foods for phenylketonuria and other disorders of protein metabolism. Without an adequate supply of such products, children’s diets can be low in energy, fibre, and variety which can significantly impact on adherence. It is difficult to imagine the practical aspects of obtaining these products, which involves having a GP prescribe a variety of foods ranging from bread to pasta and biscuits, getting the prescription from the GP to the pharmacy, the pharmacy obtaining the products from a wholesaler, revisiting the pharmacy to collect the product, and all so that your child can have toast, sandwiches and biscuits! Dietitians involved in the care of these children make significant efforts to facilitate for families the acquisition of an adequate supply of basic, staple foods via this cumbersome National Health Service (NHS) system.
Paediatric conditions as diverse as diabetes, cystic fibrosis, renal disease, and food allergy require an element of dietetic intervention. Some e such as inherited disorders of metabolism and coeliac disease e are treated entirely by dietetic intervention. Amongst the required competencies of the dietitian is a need to demonstrate sensitivity to the factors which shape food choice and lifestyle, and to understand the significance and potential impact of non-dietary factors when helping individuals make informed choices about their dietary treatment. When this is coupled with a knowledge base of biochemistry, nutrition, clinical medicine, and good verbal and written communication skills, this will result in effective counselling on dietary change. When dietary counselling by dietitians has been studied, patients have reported positive outcomes from counselling which suited their needs, increased knowledge of what to eat, and an increased sense of control of their condition. To take the example of evidence-based recommendations for the treatment of diabetes, these include the need to achieve optimal blood glucose control and blood pressure levels; to modify nutrient intake to prevent obesity, dyslipidaemia, cardiovascular disease, hypertension and nephropathy; to improve health through healthy food choices; and to address nutritional needs taking into consideration personal and cultural preferences and lifestyle. This will require the interpretation and explanation of the science of carbohydrate type and quantity, glycaemic indices, protein, and the range of dietary fats into understandable, practical food choices suited to each individual. The planning and education about such adjustments to food intake, whilst maintaining normal growth and development and dietary adequacy, are entirely matched to the knowledge and skills of a paediatric dietitian. Not infrequently the dietary change can be difficult, usually because of a host of social and psychosocial factors which influence food choice and behaviour. Specific examples of these are the young person with coeliac disease who finds adherence to a gluten-free diet incompatible with their lifestyle, or the parent of a child with an inherited metabolic disease where the diet is complex and significantly different to that of the rest of the family and the child’s peers. In these situations the communication, health behaviour change, and psychology aspects of the undergraduate curriculum are key to the dietitian helping children and their families to achieve and sustain the dietary changes required to contribute to the attainment of a positive outcome. A recent study has shown the possible value of the use of advanced behavioural change skills by dietitians to engage with families of obese children, and given the rising levels of childhood obesity
Categories of nutrition products available in the UK C C C C C C
Nutritionally complete non-disease-specific enteral tube feeds Sip feeds and nutritionally incomplete non-disease-specific supplements and modules Disease-specific formulations Products designed for the specific management of inherited metabolic disorders Staple foods designed to optimize nutritional status as part of the clinical management of formally diagnosed chronic disease states Products designed to enhance the safety and/or acceptability of foods or feeds which are prescribable in any of the above categories
Table 3
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and the apparent failure of standard care to change behaviour this may be a welcome addition to paediatric practice.
within well-organized MDTs that dietitians can focus on and optimize the nutritional aspects of care. Specifically in the field of nutrition support the team approach has been supported, as it appears to have the ability to effectively assess nutritional needs, prescribe a nutrition support plan, and reduce the incidence of nutrition-related complications. The studies reviewed for this paper indicate enhanced nutritional outcomes when the dietitian is an integral part of the care team. Aside from nutrition support, many paediatric conditions, as a result of the multifactorial nature of the diseases, require a team approach, and it has been shown that MDTs can aspire to a profound level of collaboration. In addition to direct patient benefit, health-care team working has been shown to increase learning and development of people, improve resource utilization and future planning of services, and improve work performance, all of which would be supportive of effective paediatric dietetic services. A
Extended dietetic practice There are various other aspects of health-care provision both at the individual patient level and in terms of service provision and planning that can be undertaken by dietitians. At an individual patient level, one of these is the area of medicines management. Many medications work in synergy with food, and a recent survey by the British Dietetic Association showed that over 3000 patients are treated by dietitians working under Patient Group Directions (PGD) with 62% advising on dose adjustment. The commonest drugs involved are insulin, pancreatic enzymes, and phosphate binders. Other medications such as vitamin and mineral supplements are used to ensure nutritional adequacy in restricted diets, and again these should be linked to the accurate assessment of dietary intake. Although a poorly researched area, it seems sensible that advice regarding such medications is given by a dietitian as they are most experienced in accurately assessing the nutritional content of the food and therefore its relationship to the medication. Studies of the coefficient of fat absorption in CF have shown that this can be improved when pancreatic enzyme dosage is adjusted to match the fat content of the food; coupled with this a further study confirmed that dietitians more accurately assessed fat intake and matched pancreatic enzyme dose to this assessed intake. Evidence is emerging from adult studies that, with suitable additional training, dietitians can safely prescribe parenteral nutrition. Given the concerns about the adequacy of nutrition training in undergraduate medicine and changes to medical working practices, this is an area of extended practice where, with additional training, safe and clinically effective nutrition support could be prescribed by a dietitian to those children requiring parenteral nutrition. Research and audit skills are a component of undergraduate dietetic programmes, but within the health-care setting there is limited time for dietitians to undertake research, and dietitians are reported, correctly, to prioritize direct patient care over other activities. However, there are significant gaps in the evidence base for paediatric dietetics. Individually or within the MDT, dietitians should be seeking opportunities to undertake research to extend the evidence base of dietetic treatments and improve patient outcome. This article has explored some of the ways in which effective paediatric dietetic practice can wholly or partly contribute to clinical care. Although paediatrics is one of the three largest practice areas for UK dietitians, the resource is extremely limited and therefore services must be planned and resourced to be effective. Dietitians as leaders can assist in this process by stating the case for their services, ensuring that their services are identified in health-care planning and that funding arrangements take account of their vital role.
FURTHER READING Aggett PJ, Haschke F, Heine W, et al. Comment on the content and composition of lipids in infant formulas. ESPGAN Committee on Nutrition. Acta Paediatr Scand 1991; 80: 887e96. Agostoni C, Axelson I, Colomb V, et al. The need for nutrition support teams in paediatric units: a commentary by the ESPGHAN committee on nutrition. ESPGHAN committee on nutrition; European society for paediatric gastroenterology. J Pediatr Gastroenterol Nutr 2005; 41: 8e11. Braga JM, Hunt A, Pope J, Molaison E. Implementation of dietitian recommendations for enteral nutrition results in improved outcomes. J Am Diet Assoc 2006; 106: 281e4. Burton H, Sanderson S, Dixon M, et al. Review of specialist dietitian services in patients with inherited metabolic disease in the United Kingdom. J Hum Nutr Diet 2007; 20: 84e92. Costantini D, Padoan R, Curcio L, Giunta A. The management of enzymatic therapy in cystic fibrosis patients by an individualized approach. J Pediatr Gastroenterol Nutr 1988; 7: S36e9. Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 2002; 25: 148e98. http://www.hpc-uk.org/assets/documents/1000050CStandards_of_ Proficiency_Dietitians.pdf (accessed 21 June 2009). Johansson U, Rasmussen HH, Mowe M, Staun M. Clinical nutrition in medical gastroenterology: room for improvement. Clin Nutr 2009; 28: 129e33. ¨rnell A, Ivarsson A, Synder YM. The everyday life of adolesOlsson C, Ho cent coeliacs: issues of importance for compliance with the gluten-free diet. J Hum Nutr Diet 2008; 21: 359e67. Pawellek I, Dokoupil K, Koletzko B. Prevalence of malnutrition in paediatric hospital patients. Clin Nutr 2008; 27: 72e6. Poustie VJ, Russell JE, Watling RM, et alCALICO trial collaborative group. Oral protein energy supplements for children with cystic fibrosis: CALICO multicentre randomised controlled trial. BMJ 2006; 332: 632e6. Poustie VJ, Watling RM, Ashby D, Smyth RL. Reliability of percentage ideal weight for height. Arch Dis Child 2000; 83: 183e4. Schiller MR, Miller M, Moore C, et al. Patients report positive nutrition counselling outcomes. J Am Diet Assoc 1998; 98: 977e82.
Conclusion This review has highlighted some of the many unique skills of a paediatric dietitian and how they can be used for patient benefit. Teamwork is the key to achieving these aims, and it is
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Sermet-Gaudelus I, Poisson-Salomon AS, Colomb V, et al. Simple paediatric nutritional risk score to identify children at risk of malnutrition. Am J Clin Nutr 2000; 72: 64e70. Shaw V, Lawson M, eds. Clinical paediatric dietetics. 3rd edn. Blackwell Publications; 2007. Sinaasappel M, Stern M, Littlewood J, et al. Nutrition in patients with cystic fibrosis: a European Consensus. J Cyst Fibros 2002; 1: 51e75. Sneve J, Kattelmann K, Ren C, Stevens DC. Implementation of a multidisciplinary team that includes a registered dietitian in a neonatal intensive care unit improved nutrition outcomes. Nutr Clin Pract 2008; 23: 630e4. Stallings VA, Stark LJ, Robinson KA, et al. Evidence-based practice recommendations for nutrition-related management of children and adults with cystic fibrosis and pancreatic insufficiency: results of a systematic review. J Am Diet Assoc 2008; 108: 832e9. Stewart L, Chapple J, Hughes AR, et al. The use of behavioural change techniques in the treatment of paediatric obesity: qualitative evaluation of parental perspectives on treatment. J Hum Nutr Diet 2008; 21: 464e73.
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Swift JA, Sheard C, Rutherford M. Trainee health care professionals’ knowledge of the health risks associated with obesity. J Hum Nutr Diet 2007; 20: 599e604. Thoresen L, Rothenberg E, Beck AM, Irtun Ø. Doctors and nurses on wards with greater access to clinical dietitians have better focus on clinical nutrition. J Hum Nutr Diet 2008; 21: 239e47. www.bapen.org.uk (accessed 28 Apr 2009).
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Dietitians have the skills and knowledge to carry out comprehensive assessment of nutritional status in paediatric health care Children and their families can be educated and supported with dietary change by dietitians using a combination of communication and behavioural change skills Optimum nutritional outcome can be achieved by dietitians working in close collaboration with other members of the multidisciplinary care team
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