nutr clin pract 2014 asfaw 192 200

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http://ncp.sagepub.com/ Nutrition in Clinical Practice http://ncp.sagepub.com/content/29/2/192 The online version of this article can be found at: DOI: 10.1177/0884533614521242 2014 29: 192 originally published online 12 February 2014 Nutr Clin Pract Meheret Asfaw, Jillian Mingle, Jessica Hendricks, Maegan Pharis and Anita M. Nucci Nutrition Management After Pediatric Solid Organ Transplantation Published by: http://www.sagepublications.com On behalf of: The American Society for Parenteral & Enteral Nutrition can be found at: Nutrition in Clinical Practice Additional services and information for http://ncp.sagepub.com/cgi/alerts Email Alerts: http://ncp.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: What is This? - Feb 12, 2014 OnlineFirst Version of Record - Mar 13, 2014 Version of Record >> at SAINT LEO UNIVERSITY LIBRARY on July 28, 2014 ncp.sagepub.com Downloaded from at SAINT LEO UNIVERSITY LIBRARY on July 28, 2014 ncp.sagepub.com Downloaded from

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Page 1: Nutr Clin Pract 2014 Asfaw 192 200

http://ncp.sagepub.com/Nutrition in Clinical Practice

http://ncp.sagepub.com/content/29/2/192The online version of this article can be found at:

 DOI: 10.1177/0884533614521242

2014 29: 192 originally published online 12 February 2014Nutr Clin PractMeheret Asfaw, Jillian Mingle, Jessica Hendricks, Maegan Pharis and Anita M. Nucci

Nutrition Management After Pediatric Solid Organ Transplantation  

Published by:

http://www.sagepublications.com

On behalf of: 

  The American Society for Parenteral & Enteral Nutrition

can be found at:Nutrition in Clinical PracticeAdditional services and information for    

  http://ncp.sagepub.com/cgi/alertsEmail Alerts:

 

http://ncp.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

What is This? 

- Feb 12, 2014OnlineFirst Version of Record  

- Mar 13, 2014Version of Record >>

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Nutrition in Clinical PracticeVolume 29 Number 2 April 2014 192 –200© 2014 American Societyfor Parenteral and Enteral NutritionDOI: 10.1177/0884533614521242ncp.sagepub.comhosted at online.sagepub.com

Invited Review

Transplantation of the liver, kidney, and heart has been suc-cessfully performed in the pediatric population for several decades.1 Survival rates of solid organ transplant recipients have appreciably improved over this period with greater than 80% of patients now surviving into adolescence and young adulthood.2-6 Advancements in surgical techniques and immu-nosuppressive therapies have contributed greatly to these improved rates. While transplant patients face many complica-tions following surgery, the success of solid organ transplanta-tion has transformed what once was an end-stage disease into a more manageable clinical situation.

The diagnoses that lead to the majority of liver transplants in children include biliary atresia, acute hepatic necrosis, and metabolic disease.1 Children with kidney dysplasia, obstruc-tive uropathy, or glomerular sclerosis may be considered can-didates for kidney transplant while congenital disease and cardiomyopathies are the most common indications for heart transplantation.1 A distinct challenge to the pediatric transplant population and their healthcare providers is achieving normal growth following transplantation. The essential immunosup-pressive drugs and steroids needed for posttransplant patients and allograft survival are accompanied by growth-inhibiting side effects.7 Oftentimes, the pediatric patient has already experienced a degree of growth delay due to his or her pre-transplant disease state.8 Optimal nutrition, both pre- and post-transplant, is imperative for posttransplant recovery and continued growth and development. Medical nutrition therapy is an essential component of postoperative pediatric transplant

patient care to support catch-up growth, neurodevelopment, and quality of life.

Children’s Healthcare of Atlanta has performed more than 1000 pediatric transplants since the inception of the transplant services program and is one of the leading pediatric hospitals in the United States for pediatric transplantation.9 Clinical dietitians in the hospital Department of Clinical Nutrition par-ticipate in the interdisciplinary care of these children during hospitalization and outpatient clinic visits. The purpose of this study is to review posttransplant nutrition assessment, nutrition requirements, and nutrition management approaches with each of the following solid organs: liver, kidney, and heart. In addi-tion, 3 case studies will highlight nutrition problems com-monly encountered in this population.

521242 NCPXXX10.1177/0884533614521242Nutrition in Clinical PracticeAsfaw et al.research-article2014Asfaw et al

From the 1Department of Clinical Nutrition, Children’s Healthcare of Atlanta, Atlanta, Georgia, and 2Department of Nutrition, Georgia State University, Atlanta, Georgia.

Financial disclosure: None declared.

This article originally appeared online on February 12, 2014.

Corresponding Author:Anita M. Nucci, PhD, MPH, RD, LD, Department of Nutrition, Georgia State University, PO Box 3995, Atlanta, GA 30302-3995, USA. Email: [email protected]

Nutrition Management After Pediatric Solid Organ Transplantation

Meheret Asfaw, MMSc, RD, CSP, CNSC, LD1; Jillian Mingle, MS, RD, CSP, LD1; Jessica Hendricks, MS, RD, CSP, LD1; Maegan Pharis, MS, RD, LD1; and Anita M. Nucci, PhD, MPH, RD, LD2

AbstractSurvival rates for pediatric transplant recipients and organ grafts have increased due to improvements in surgical techniques and with immunosuppressant treatment therapies. Interdisciplinary management after pediatric organ transplantation is essential to assist not only with the complex medical issues and complications that can result from immunosuppressant therapy but also with the achievement of normal growth and development. Impaired growth is a complication frequently experienced by pediatric transplant patients. The presence or absence of impaired growth is affected by the length of illness prior to transplant, graft function, the use of corticosteroids, and the development of infectious complications after surgery. A review of posttransplant nutrition assessment, nutrition requirements, and nutrition goals is provided. In addition, a case series of experiences with nutrition management of pediatric solid organ transplant recipients is described. (Nutr Clin Pract. 2014;29:192-200)

Keywordspediatrics; nutrition assessment; nutrition therapy; nutritional support; organ transplantation

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Nutrition Assessment

A thorough pretransplant nutrition assessment is essential to determine anthropometric status; evaluate signs of nutrient deficiency; assess biochemical tests to determine the need to adjust nutrients and electrolytes in the oral, enteral nutrition (EN), or parenteral nutrition (PN) prescription; and obtain a dietary history for preferences and tolerances. This process will help to maximize a child’s nutrition status and increase the chance of successful outcome after transplantation. Anthropometric measures, including weight, recumbent length (until 2 years of age) or height, weight-for-length or height, and occipital head circumference (if <3 years of age), should be plotted over time using the World Health Organization growth standards for children 0–2 years of age and the Centers for Disease Control and Prevention growth standards for children 2 years and older in the United States.10 Body mass index (BMI) should also be calculated and moni-tored in children >2 years of age. In addition, z scores should be calculated as they provide a more precise description of anthropometric status than percentiles. The severity of malnu-trition can be classified using newly published cutoffs as fol-lows: mild malnutrition or at risk of malnutrition (z score <–1), moderate malnutrition (z score between –2 and –3), or severe malnutrition (z score <–3).11

Feeding Assessment

A feeding assessment may be warranted for children who have received long-term EN or PN as normal feeding and swallowing development may have been missed. Maintaining oral stimulation before and after transplant may assist with the transition from enteral to oral feedings. Children with oral aversion or other feeding problems should undergo a thor-ough feeding evaluation and therapy by a specialist in feeding disorders.12

Nutrition Requirements

Energy requirements for children on oral nutrition or EN are generally based on the Dietary Reference Intakes (DRI) for age with adjustments made to maintain or support catch-up growth and development.13 Calorie requirements for children receiv-ing a combination of EN or PN are generally estimated to be 5%–10% lower than requirements for oral/enteral intake alone. Children receiving only PN will likely require even fewer calo-ries. Indirect calorimetry is the most accurate method to assess basal metabolic requirements.14,15 Protein requirements are generally based on the DRI for age with adjustments made based on the child’s liver and renal function.16 While these gen-eral recommendations apply to most pediatric transplant recip-ients, there are some organ transplant–specific nutrition concerns as outlined below.

Nutrition Recommendations for Liver Transplant Recipients

The nutrition recommendations for pediatric liver transplant recipients are shown in Table 1. PN may be required if the child is malnourished, has had complications, or if a lengthy recovery period is anticipated.17 An enteral tube feeding can be used to provide total nutrition or in conjunction with an oral diet if enteral intake is suboptimal. Oral aversion may occur in those who required long-term EN, PN, or mechanical ventila-tion.17 Energy requirements during both the acute posttrans-plant phase and chronic/stable phase should be individualized based on the child’s age, activity, and pattern of growth.17,18 Calories in excess of the DRI may be needed in children with severe growth delay.18 Protein intake during the chronic/stable period should provide 15%–20% of total energy consumed and be restricted only in the case of significant renal insuffi-ciency.17,18 Glucose intolerance is a complication of immuno-suppressive medication use in the early posttransplant period19 and may require dietary restriction of simple sugars. The inci-dence of diabetes mellitus in the liver transplant population has been reported to be between 7% and 30% with predictors that include glucose intolerance prior to transplant, central obesity, and long-term use of corticosteroids.20 A healthy balanced diet for age consistent with the 2010 Dietary Guidelines for Americans21 is recommended with adjustments given for com-plications, including renal impairment, hypertension, hyperka-lemia, and diabetes mellitus.17 Intake of solid fats such as saturated or trans fatty acids should limited to <10% of energy and replaced with polyunsaturated or monounsaturated fats. Cholesterol intake should not exceed 300 mg/d. A dietary sodium restriction may be necessary if the child becomes hypertensive. In a population of 167 children who have sur-vived >10 years after liver transplantation, Ng et al22 reported rates of hypercholesterolemia and hypertriglyceridemia at 20% and 26%, respectively. Moreover, elevated blood pressure measurements have been reported in 17.5%–27.5% of liver transplant recipients between 5 and 10 years posttransplant.23 Therefore, it is important to monitor both cardiovascular and renal disease risk factors in liver transplant recipients to avoid long-term complications.24

Chronic anemia, which can affect growth and development as well as quality of life, has been reported in a high percentage (24%) of pediatric liver transplant recipients during the first 5 years posttransplant.25 Factors associated with anemia include the presence of gastrointestinal (GI) bleeding, persis-tent leukopenia, corticosteroid use, cyclosporine A–based immunosuppressive therapy, and reduced renal function. Vitamin and mineral supplementation may be necessary if dietary intake is inadequate. Vitamin D insufficiency and defi-ciency is common in children with end-stage liver disease and has been shown to remain during the initial posttransplant period.26 Liver transplant recipients should be monitored and

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treated for vitamin D insufficiency and deficiency to maintain serum levels >20 ng/mL. Fluid intake after transplant is gener-ally unrestricted but may need to be modified based on weight and renal and cardiopulmonary function.17

Nutrition Recommendations for Kidney Transplant Recipients

The nutrition recommendations for pediatric kidney transplant recipients are shown in Table 2.17 Complications such as hypertension, hyperglycemia, hyperlipidemia, and anemia27 may be caused by medications or preexisting conditions. Hypertension can be treated with a sodium-restricted diet, diuretics, and antihypertensive drugs. Simple sugars should be avoided in the presence of hyperglycemia until glucose levels return to normal. A moderate-fat diet with an emphasis on healthy fats such as olive oil, fish, and nuts is indicated with hyperlipidemia, and lipid profiles should be monitored regu-larly. Brodersen et al28 reported a high prevalence of hypovita-minosis D (54%) in a population of 35 pediatric kidney

transplanted patients. Vitamin D deficiency in children with renal failure may be the result of renal insufficiency, as the kidney transforms the circulating form of vitamin D (25-dihy-droxyvitamin D) into the biologically active form (1,25-dihy-droxyvitamin D), and lack of sun exposure. After transplant, patients are advised to avoid sun exposure due to the increased risk of skin cancer with immunosuppressive therapy. The authors suggested that vitamin D status be monitored biannu-ally in children and adolescents who have received a kidney transplant so that vitamin D deficiency can be corrected and that the associated detrimental effects of hypovitaminosis D on calcium-phosphate homeostasis and bone metabolism can be avoided.

Nutrition Recommendations for Heart Transplant Recipients

As it is the case with other organ transplant recipients, hyper-tension, hyperglycemia, hyperlipidemia, and weight gain are common side effects of medications and immunosuppression

Table 1. Nutrition Recommendations for Pediatric Liver Transplant Recipients.

Nutrient Acute Posttransplant Phase Chronic/Stable Phase

Energy DRI for age (individualized for wound healing and growth) DRI for ageProtein 15%–20% of total energy

Enteral:Infants: 3–3.5 g/kg dry body weight1–2 years: 2.5–3.5 g/kg dry body weight3–13 years: 1.5–2.5 g/kg dry body weightAdolescents: 1.5–2 g/kg dry body weightParenteral:Infants: 3–3.5 g/kg dry body weight1–2 years: 2.5–3 g/kg dry body weight3–13 years: 1.5–2.5 g/kg dry body weightAdolescents: 1–1.5 g/kg dry body weightBegin at 1 g/kg dry body weight and advance by 0.5 g/kg/d to goal

15%–20% of total energy

Carbohydrate 45%–55% of energyLimit simple sugars

50%–60% of energyEncourage intake of complex carbohydrates

Fat Enteral:30%–40% of energyParenteral:2–3 g/kg dry body weightBegin at 0.5 g/kg dry body weight for infants <1 year of age and at 1 g/

kg dry body weight for children 1 year and older; advance by 0.5 g/kg/d dry body weight to goal

2010 Dietary Guidelines for Americans

Electrolytes Mild sodium restriction may be necessary to prevent corticosteroid-induced fluid retention; potassium restriction if blood level is elevated

Sodium is unrestricted unless hypertensive

Vitamins Supplement with age-appropriate multivitamin with minerals; additional vitamin D may be required

Multivitamin with minerals if dietary intake is inadequate

Fluids Unrestricted Unrestricted

DRI, Dietary Reference Intakes. From Nucci A, Strohm S, Katyal N, Lytle B. Organ transplantation. In: Corkins MR, ed. The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2010:172. Reprinted with permission from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

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therapy in pediatric heart transplant recipients.29,30 Therefore, dietary modifications such as limiting sweets and foods high in concentrated sugar; reducing foods high in total fat, saturated fat, and cholesterol; and limiting salt intake may be necessary. Osteoporosis is also common among pediatric transplant recip-ients due to the combined effects of nutrition status before transplant and the decreased calcium absorption and bone for-mation that result from the use of immunosuppressive medica-tions and steroids.31 Supplemental vitamin D and calcium may be required.

Nutrition Goals

General goals for pediatric transplant recipients are to support growth and physical development, transition to an oral diet, and prevent nutrition-related posttransplant complications. While there are common problems and treatments among all pediatric transplant populations, there are some specific rec-ommendations for these complications based on the type of organ transplanted.

Liver Transplant Recipients

Goals for patients after liver transplant include optimization of linear growth and physical development and resuming par-ticipation in daily activities.17 Linear growth delay is common after liver transplant due to the nutrition impact of the original illness and corticosteroid usage. In the presence of adequate graft function, weight gain generally recovers after transplan-tation.32 Energy requirements should be based on age, activity, and rate of growth. Children with linear growth impairment should have their energy goals based on the DRI for height age. Pediatric liver transplant recipients who were obese at transplant have been found to be at an increased long-term

mortality risk.33 Perito et al34 found that 20%–50% of children transplanted between 1987 and 2010 were overweight or obese 10 years after transplant. The factor found to be most consistently associated with overweight/obesity after liver transplant was weight status at transplant, with those over-weight/obese at transplant likely to remain so at 1, 2, and 5 years posttransplant.

Kidney Transplant Recipients

Long-term goals for pediatric patients after kidney transplant include promoting adequate growth, minimizing side effects of medications, maintaining serum mineral and electrolyte bal-ance, and maintaining blood pressure within normal limits.17 Although the development of immunosuppression protocols that minimize the use of corticosteroids aids in the prevention of obesity and stunted growth posttransplant, children trans-planted at a young age (<5 years) have been found to have the greatest improvement in linear growth velocity.35 This empha-sizes the need to maximize growth prior to transplant. An age-appropriate diet can be started once bowel function has resumed after surgery. If gastrostomy tube (GT) feedings were required prior to transplant, it may be necessary to continue the tube feeding after surgery and gradually wean to oral diet. The GT should not be removed until fluid and energy require-ments are met orally.36

Heart Transplant Recipients

Most heart transplant patients progress to a full oral diet within 1 week after transplant. However, children who were receiving EN prior to transplant will require a gradual transition to an oral diet and may require oral rehabilitation therapy. Failure to thrive is common in children with congenital heart disease or

Table 2. Nutrition Recommendations for Pediatric Kidney Transplant Recipients.

Nutrient Immediately Posttransplant Later After Transplant

Calories DRI for height-age. May need additional calories if patient is underweight prior to transplant

DRI for height-age

Protein 125%–150% DRI for age DRI for ageCarbohydrates Avoid simple sugars Unrestricted unless obesity is presentFat 30%–40% of total calories 30%–40% of total caloriesPhosphorus May need higher intakes, provide supplementation as

necessaryMay need higher intakes, provide supplementation as

necessaryCalcium Unrestricted UnrestrictedPotassium Unrestricted unless necessary UnrestrictedSodium Mildly restricted Unrestricted unless hypertension or edema is presentIron Supplement as indicated by serum values Supplement as indicated by serum valuesFluids Unrestricted UnrestrictedVitamins DRI. Supplementation usually not necessary unless

severely malnourished prior to transplant, vitamin D if indicated

DRI. Supplementation usually not necessary unless severely malnourished prior to transplant, vitamin D if indicated

DRI, Dietary Reference Intakes.

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cardiomyopathy with end-stage heart failure and may continue in those who progress to transplantation without intervention. In a population of 105 children who underwent heart transplan-tation between 1985 and 2004, Rossano et al37 reported that 21% were underweight (<5th percentile) and 8% were over-weight (≥95th percentile) at the time of transplant. Peterson et al38 observed a significant gain in z scores for weight and BMI but not length/height in a population of 46 infants and children within 6 months posttransplant. The authors reported that 17% of the population became overweight by 2 years post-transplant and noted that increases in weight without corre-sponding height may result in obesity. In a more recent study of 130 pediatric heart transplant recipients, Bannister et al39 reported that enteral feeding support during the posttransplant period significantly improved rates of weight and height gain. However, anthropometric measures did not reach normal values during the study follow-up period (median 4.4 years after transplantation).

In all types of transplantation, studies support the need to routinely monitor growth parameters in the early and later posttransplant period so that alterations in diet can be made if necessary to achieve and maintain ideal body weight.

Nutrition and Growth Effects of Immunosuppressive Medications

Immunosuppressive medications commonly used include tacrolimus, cyclosporine, prednisone, mycophenolate, siroli-mus, and azathioprine (Table 3).40-48 The side effects

associated with medications and immunosuppressant therapy that are common in liver and kidney transplant patients (hyper-tension, hyperglycemia, and hyperlipidemia) are also common in posttransplant pediatric heart recipients.49-52 Medication doses are measured in the blood, and adjustments are deter-mined from these levels. Food can alter the absorption of these drugs. Therefore, patients and families are instructed to admin-ister these medications either fasting or with meals on a consis-tent basis. Vomiting or diarrhea can influence the drug level, and other medications such as antacids, antibiotics, and anti-fungals can also interfere with immunosuppressant levels. Grapefruit, grapefruit juice, or juice that contains grapefruit juice is discouraged because it has also been shown to alter levels.53

Food Safety

Most transplant recipients are receiving immunosuppressive medications and are susceptible to foodborne illness caused by food contaminated with bacteria and other pathogens.54 Therefore, it is important to educate patients and families on the Food Safety and Inspection Service of the U.S. Department of Agriculture 4 basic steps to food safety: (1) always wash food, hands, counters and cooking tools as bacteria can be spread from surfaces to food; (2) separate meat, poultry, sea-food, and eggs from ready-to-eat foods to avoid cross-contam-ination; (3) cook foods to safe temperatures (140°F or above); and (4) refrigerate or freeze foods within 2 hours of cooking or buying from the store. It is also important to adhere to

Table 3. Description of Common Immunosuppressive Medications used in Organ Transplantation.

Medication Name Brand Name Mechanism of Action Diet Instructions

Tacrolimus Prograf (Astellas Pharma, Northbrook, IL)

Inhibits T-cell lymphocyte activation; exact mechanism of action is not known

Avoid eating grapefruit or drinking grapefruit juice

Cyclosporine Gengraf (Abbvie, Inc, North Chicago, IL)

Neoral (Novartis Pharmaceuticals Corporation, East Hanover, NJ)

Inhibits T-cell activation Avoid eating grapefruit or drinking grapefruit juice; foods high in potassium may need to be restricted

Prednisone Inhibits antigen presentation, cytokine production, and proliferation of lymphocytes

Foods high in salt may be restricted; a diet high in potassium or calcium or a potassium or calcium supplement may be prescribed

Mycophenolate CellCept (Genentech, Inc, San Francisco, CA)

Myfortic (Novartis Pharmaceuticals Corporation)

Inhibits an enzyme required for the growth of T cells and B cells

No restrictions

Sirolimus Rapamune (Pfizer, Inc, New York, NY)

Inhibits proliferation of T cells, B cells, and antibody production

Avoid drinking grapefruit juice

Azathioprine Imuran (Pharmaceutics International, Inc, Hunt Valley, MD)

Azasan (salix Pharmaceuticals, Inc, Raleigh, NC)

Unknown No restrictions

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manufacturer “Sell-by” and “Use-by” dates when purchasing and consuming foods. Caution should be used when eating out, and buffet-style meal service should be avoided. Transplant recipients should avoid consuming unpasteurized milk, juices, and ciders; soft cheeses made from unpasteurized milk; raw sprouts; and raw or undercooked meat, poultry, fish, or eggs or prepared products containing these items. They should care-fully wash all produce before peeling, slicing, juicing, or eat-ing, including uneaten rinds of products such as melons and mangoes.

Case Presentations

Case 1

Growth failure is a common occurrence in children with end-stage liver disease and is due to malnutrition secondary to fat malabsorption, abnormal nitrogen metabolism, increased energy expenditure, and possibly growth hormone resis-tance.32,55,56 Although prolonged exposure to corticosteroids posttransplant is associated with a reduced rate of catch-up growth, the best predictor of catch-up growth is weight and height z score at the time of transplant.56 A 9-month-old appropriate for gestational age female infant had undergone a whole-organ orthotopic liver transplant with Roux-en-Y cho-ledochojejunostomy for extra hepatic biliary atresia with a failed Kasai. Preoperative nutrition management included the switch from a standard infant formula to a more easily digest-ible product that contained partially hydrolyzed protein and 55% medium-chain triglyceride (MCT) at approximately 4 weeks of age, which was progressively advanced to 30 calo-ries/oz to promote growth. Due to inadequate weight gain with oral feeding, supplemental nocturnal continuous drip feedings to supply 75 kcal/kg or ~50% of estimated caloric needs was provided. At the time of transplant, her length-for-age, weight-for-age, and weight-for-length plotted below the third percen-tile (z scores = –2.23, –2.5, and –2.19, respectively). Her head circumference was at the 25th percentile. The physical exami-nation revealed an enlarged abdomen with wasted extremities.

On posttransplant day 4, one day after extubation, oral feed-ing was initiated with a polymeric age-appropriate cow’s milk–based formula at 20 calories/oz ad libitum, and a daily liquid multivitamin supplement was restarted. However, because her intake of formula on the first 2 days of observation was very low, the formula concentration was advanced to 24 calories/oz. In addition, a nasogastric nocturnal drip feeding was started and progressively increased to provide ~40% of her estimated daily requirements of 130 kcal/kg and 2.5 g protein/kg (~130% and 150% of the DRI for calories and protein, respectively). At the time of discharge, 14 days after transplant, the overnight tube feeding was discontinued because oral intake had signifi-cantly improved. The infant was sent home on a 24-calorie/oz formula and an age-appropriate oral diet, as well as a daily liquid multivitamin supplement.

Although weight gain may recover in children with a fully functioning graft who were previously malnourished, linear catch-up growth may not occur until the second year and is largely dependent on steroid exposure.32 The Studies of Pediatric Liver Transplantation (SPLIT) registry has revealed that up to 25% of pediatric liver transplant recipients have height measures at less than the 5th percentile over the long term.56 After the patient in case 1 was discharged from the hos-pital, she was followed closely by nutrition during the initial 6 months to assess diet history and growth and to provide dietary guidance to maximize energy and nutrient intake. By 8 months posttransplant, some catch-up growth was observed with weight, length, and head circumference measures plotting at the 5th, 10th, and 50th percentiles, respectively. On long-term follow-up, 120 months posttransplant, her weight has fol-lowed the 10th percentile curve, but height has essentially remained at the third percentile. Her most recent BMI was cal-culated to be 16.9, which is at approximately the 50th percentile for age. Mid-parental height is calculated to be at the 75th per-centile. Endocrinology was consulted to assess short stature.

To encourage growth, immunosuppression should be mini-mized during the first 6–12 months after transplantation and growth parameters should be routinely monitored to identify those who may benefit from reduced corticosteroid exposure.32 The infant received immunosuppressive medications, includ-ing parenteral corticosteroids, during the initial postoperative period and upon very infrequent hospitalizations for rejection. Her maintenance immunosuppressive regimen included tacro-limus, mycophenolate mofetil, and oral corticosteroids with doses ranging between 2.5 and 5 mg daily. Some of the side effects of these medications that the infant experienced included infections and mildly elevated serum levels of potas-sium, serum urea nitrogen, and creatinine as well as acidosis. Nutrition interventions used to treat these biochemical imbal-ances included increasing fluids, and instruction was given to avoid foods high in potassium. Acidosis was treated with an oral alkalinizing agent.

Case 2

PN or EN support is rarely needed after kidney transplant.17 However, children who were fed via GT prior to transplant may require continued support to promote anabolism and achieve or maintain adequate growth until a full oral diet is established. A 2-year-old girl with bilateral congenital cystic renal dysplasia was admitted for a cadaveric donor kidney transplant. She had been maintained on hemodialysis for 15 months prior to transplant. Her past medical history is signifi-cant for failure to thrive and GT placement. She was small for age with a weight-for-age at the 5th percentile (z score = –1.56) and a height-for-age <5th percentile (z score = –2.42) with mild stunting. BMI was within normal limits. At the time of admission, she was receiving a diluted adult renal formula (29 calories/oz) through her GT, which was supplying 100% of

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her estimated calorie and protein requirements (97 kcal/kg/d and 1.2 g protein/kg/d or 1.2 times the DRI for age).10 She would only take sips of liquids orally. Children who receive long-term enteral feedings are at risk for oral aversion due to the lack of oral feeding, since normal feeding and swallowing development during infancy may have been missed. Providing small amounts of food of varying tastes and textures to chil-dren who are able to swallow should be encouraged. Maintaining oral stimulation prior to transplant may assist with the transition from enteral to oral feeding after surgery.17

The child was started on a clear liquid diet on postoperative day 2. GT feedings of a pediatric oral electrolyte solution were started on postoperative day 3, and she was transitioned to a pediatric enteral formula with fiber (1 kcal/mL) on postopera-tive day 4. She had difficulty achieving the goal feeding vol-ume secondary to abdominal distention. An x-ray of the kidneys, ureters, and bladder (KUB) was performed and did not show obstruction. The differential included mass effect from new kidney, opioids, or postsurgical ileus, although she was having bowel movements. The enteral formula prescrip-tion was changed from a fiber-containing formula to a standard pediatric formula (1 kcal/mL) on postoperative day 7 and toler-ance improved. She reached her goal formula volume of 1020 mL/d on postoperative day 10 and was transitioned to a home schedule of 135-mL bolus feedings every 3 hours during the day (4 times) plus night continuous feedings of 60 mL/h over 8 hours on postoperative day 11. She was discharged home meet-ing 100% of her nutrition requirements (102 kcal/kg/d and 2–3 g protein/kg/d)57 through her GT. Speech therapy was con-sulted for a feeding trial and did not find any clinical signs of aspiration or aversive behaviors. The speech therapist did note that there were self-limiting behaviors and that she presented with a mild speech-language delay. The recommendation was made for early intervention services through the state Babies Can’t Wait program.58 The child had loose stools throughout the admission, which was thought to be related to mycopheno-late mofetil, but the condition was not significant enough to warrant changing her immunosuppression therapy.

At her 3-month posttransplant visit, she was receiving approximately 90%–100% of her estimated nutrition require-ments via GT. Her growth was excellent as she had a weight velocity for age at the 50th–75th percentile.59 The child’s mother stated that she wanted to wait until the patient was fur-ther out from her transplant before pursuing outpatient speech therapy. At her 5-month posttransplant visit, the mother reported her child was consuming 3 meals per day by mouth, including drinking whole milk, and that she discontinued the daytime bolus feedings. Nighttime continuous feedings were supplying ~40% of her estimated nutrition needs. By 10 months posttransplant, she was eating a variety of regular table foods and drinking 1 can of a pediatric enteral formula per day. Therefore, the nighttime tube feedings were discontin-ued. Her anthropometric measures were as follows: weight-for-age = 13 kg (25th percentile; z score = –0.61), height-for-age

= 89 cm (<5th percentile; z score = –1.76), and BMI = 16.4 (~75th percentile; z score = 0.75). She exhibited excellent catch-up growth with a weight gain of 3 kg and linear growth of 9 cm in 10 months. The patient’s mother reported that she wished to have the GT removed. After 3 additional months of appropriate weight gain, the decision was made to remove the enteral feeding tube.

Case 3

Children with coronary heart disease or cardiomyopathy with end-stage heart failure are at risk for failure to thrive due to multiple hospitalizations for surgical procedures,39 feeding intolerance and malabsorption,60 and possibly increased energy requirements.61 The effect of undernutrition on adverse out-comes is unclear. Children who are underweight at the time of transplant have been found to develop acute rejection earlier and have decreased graft survival62 and overall survival.63 However, in a multicenter study with more than 2300 pediatric heart transplant patients >2 years of age, morbidity and mortal-ity outcomes did not differ between those who were wasted (23%; BMI <5th percentile) or obese (8%; >95th percentile) vs those who had a normal BMI (5th–95th percentile) at the time of transplant.64 A 4-year-old girl was admitted to the hospital with edema, feeding intolerance, and decreased ventricular function noted on echocardiogram. Her past medical history included hypoplastic left heart syndrome, aortic and mitral atresia, dysphagia, and seizure disorder. Prior to admission, she had undergone several palliative surgical procedures, includ-ing Norwood/Sano shunt, bidirectional Glenn, tricuspid valve replacements, and an epicardial pacemaker. Growth parame-ters on admission were marginal, with a medication dosing weight of 12 kg (~10th percentile; z score = –1.25) and a height-for-age of 83.8 cm (<5th percentile; z score = –3.11) that was indicative of mild chronic stunting (height was 90% of the standard at the 50th percentile). On physical examination, the child presented with a swollen face and abdomen, but she had minimal subcutaneous tissue in her extremities. She was not a candidate for further palliative operations (eg, Fontan procedure) given the severity of her ventricular function.

In a cohort of 130 pediatric heart transplant recipients (median age at transplant = 2.7 years), Bannister et al39 reported that the use of enteral feeding support prior to pediatric heart transplant was not associated with anthropometric growth. Although posttransplant enteral feeding support was associ-ated with a faster increase in weight and height z scores over the 4-year follow-up period, values plateaued at 18 months posttransplant and the measures did not reach normative val-ues. Prior to transplant, the child was receiving enteral tube feedings as her primary source of nutrition. Due to a history of feeding intolerance and oral aversion, the enteral prescription included bolus feedings of a pediatric peptide formula diluted to 20 calories/oz at 100 mL every 3 hours during the day (4 feedings) in addition to continuous overnight feedings at

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56 mL/h × 9 hours. This feeding regimen provided 50 kcal/kg/d, which was equivalent to her estimated basal metabolic requirements based on the Schofield equation.65 Approximately 1 month after admission, her heart function had worsened, which led to increased feeding intolerance and weight loss (11.2 kg). Due to the weight loss, energy requirements were increased to 80 kcal/kg/d based on the DRI. The enteral for-mula volume was decreased and met only 21% of her estimated energy requirements. PN support was initiated to provide the remaining 80% of her caloric requirements until transplanta-tion occurred.

Following heart transplant, the child was extubated on post-operative day (POD) 2 and trophic enteral feedings were started on POD 3. Between POD 10 and 12, the continuous enteral feeding prescription was advanced to goal (45 mL/h). She was discharged home on POD 24 with a feeding regimen that included boluses of 105 mL every 3 hours during the day (4 feedings) in addition to continuous overnight feeds at 55 mL/h × 10 hours of a full-strength (30 calories/oz) pediatric peptide formula that provided 80 kcal/kg/d (based on a weight of 12 kg).

At 6 months postoperatively, the child was admitted for 24-hour observation after a cardiac catheterization and biopsy. At that time, weight gain averaged 12 g/d and had increased 2.1 kg from discharge with percentiles tracking just below the 25th percentile weight-for-age. Although EN still served as the patient’s primary source of nutrition, a diet recall obtained from her mother revealed increased oral intake. Now at 1 year and 2 months posttransplant, her weight-for-age continues to trend between the 10th and 25th percentile. Although length-for-age percentile remains low, her BMI is within normal limits at the 70th percentile. Analysis of her 3-day food record revealed that she is con-suming 65%–70% of her estimated energy requirements. Her remaining calories are provided via supplemental overnight low-volume tube feedings. The nutrition goal for the next 3–6 months is to continue weaning overnight enteral formula volume until it is discontinued. The child will continue to receive nutrition follow-up through the outpatient transplant clinic.

Conclusions

Our experience with pediatric solid organ transplant is consis-tent with that reported in the literature. We observed delayed growth and the need for supplemental EN at the time of trans-plant and a continued requirement for enteral support after transplant. Although each case presented weaned to an oral diet after transplantation, catch-up growth remains a concern. Improvements in immunosuppressant therapies with reduc-tion or elimination of corticosteroid usage will result in improved growth and quality of life in this medically chal-lenging population.

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