Global PN Fellowship

Abstract Title: A Quality Improvement Initiative to Understand Barriers to Obtaining Weight Measurements in a Pediatric Intensive Care Unit

Authors: Tracy Walton, RN, MSN, CPNP; Samuel Hickey, BS; Kelsey Hodge, RD, LDN, CNSC; Meghan Keenan, RD, MS, LDN, CNSC; Jessica Saleeba, MSN, RN, CCRN; Darlene Whitney, BSN, RN, CCRN; Nilesh Mehta, MD; Enid Martinez, MD

Summary/review

The authors present findings from a quality improvement initiative exploring barriers to obtaining weights in the pediatric ICU (PICU). Nutrition and growth are essential to pediatric care and necessitate reliable and timely anthropometric measurements. Unfortunately, challenges obtaining basic anthropometrics in hospitalized patients are well documented in the literature. This study highlights the ongoing challenges at a large, quaternary care center PICU and explores barriers and solutions to improving clinical practices. Audits were completed over 6 weeks to assess adherence to institutional targets. Although no common barriers were identified, a number of quality improvement targets and practice challenges were noted. In speaking to the lead author, there is ongoing work to increase education on the importance of anthropometric measurements and address logistical challenges to obtaining timely measurements. This is especially important given the vast majority of patients without measurements were eligible for a bed with weighing capacity, suggesting education and practice gaps.

This study outlines an important clinical challenge that has been a concern at our institution as well. These findings help identify possible quality improvement targets that can be generalized to other institutions, and something I plan to share with our local quality teams. A key theme appears to be gaps in education on the importance of these measurements, given most institutions already have policies outlining the frequency and timing of measurements. Additional studies such as this one, will help strengthen the literature however, evidence connecting missing measurements to adverse clinical outcomes is significantly lacking. Future studies should focus on this area to link clinical outcomes and emphasize the importance of anthropometric measurements to daily practices and care.

Abstract Title: Utilizing Vasopressor Dose Equivalence Score‐Guided Enteral Nutrition Initiation for Patients with Hemodynamic Instability

Authors: Emily Brumsted, MS, RD, CNSC; Amber Antonopoulos, RD, CNSC

Summary/Review

This study at UCSF Medical Center evaluated a practice shift from Vasoactive-Inotropic Score (VIS) to the Vasopressor Dose Equivalence (VDE) score for guiding enteral nutrition (EN). Analysis of 197 patients revealed that VDE-guided protocols allowed 16.5% of patients to initiate EN earlier without increasing complications. Non-occlusive mesenteric ischemia (NOMI) incidence was only 0.5% (1/197), with the single case occurring 48 hours after feeds were held for non-nutritional reasons, confirming the protocol’s safety.

The findings prove EN is safe at low-to moderate vasopressor doses (VDE<30) when MAP and lactate are stable. This research shifts clinical practice from a subjective fear regarding vasopressors to an objective, data-driven decision tree tailored to individual hemodynamic stability. It provides a standardized framework to reduce malnutrition in the ICU.

Emily emphasized that the project was driven by a need to eliminate “unnecessary feeding delays” based on outdated data. A key insight is prioritizing
patient stability and vasopressor de-escalation rather than a static number. Their protocol initiates a 10ml/hr “trickle” rate for maximum gut protection. She clarified that their NOMI case was likely unrelated to feeding, as the patient was not receiving EN at the time of diagnosis and recovered well thereafter, reinforcing the safety of early EN.

In my Egyptian practice, I will introduce VDE calculation to assess stability objectively. In our resource-limited setting, I will adapt the VDE<30 threshold by using small, frequent manual boluses to mimic “trickle feeds.” This approach aims to reduce feeding delays and improve recovery rates for hemodynamically
unstable patients by focusing on clinical perfusion markers.

Abstract Title: Tolerance and Weight Gain With 100% Whey Protein Peptide Based Enteral Formulas in Pediatric Population: A Retrospective Review

Authors: Osman Mohamed Elfadil, MBBS; Vidit Jogani, MBBS; Danelle Johnson, MS, RD-AP, LDN, CNSC; Jithinraj Edakkanambeth Varayil, MD; Ryan Hurt, MD, PhD; Dana Steien, MD, PNS; Manpreet Mundi, MD, FASPEN

Summary/review

This retrospective chart review evaluated tolerance, nutritional adequacy, and growth outcomes in 37 pediatric patients receiving a 100% whey protein peptide-based formula for ≥30 days (mean age 7.8 ± 5.6 years). The cohort was heterogeneous including children with congenital/developmental delays, malignancy-related conditions, and dysmotility. Forty-three percent initiated enteral nutrition with a whey peptide formula, while 57% transitioned due to intolerance of a prior formula.

The authors reported that nutritional delivery was high, meeting 95% of energy and 92% of protein targets. Patients demonstrated median weight gains of 0.41% per week and 5.9% per 100 EN days, with corresponding improvements in weight-for-age z-scores.  The authors concluded that whey peptide-based formulas were well tolerated, supported growth, and facilitated improved feeding outcomes in this pediatric cohort.

Despite the small sample, the cohort’s heterogeneity across ages, diagnoses, and clinical indications supports the generalizability of these findings. Steady gains in growth and favorable tolerance outcomes suggest whey peptide-based formulas can be effectively used across diverse pediatric populations rather than narrowed to specific disease indications. One author noted during our discussion that formula selection was driven by hospital formulary availability rather than intentional focus on being 100% whey protein-based; nevertheless, this study augments the literature supporting whey peptide-based formulas as a practical and effective nutritional strategy in pediatric patients. In my practice, these findings reinforce considering these formulas as a first-choice option for children needing EN support. Future studies could further clarify whey protein’s role in optimizing pediatric nutrition across diverse populations.

Abstract Title: Infant hospitalization and breast feeding outcomes: A retrospective cohort study on the impacts of illness and inpatient lactation support on long term feeding trajectories.

Authors: Calisha Allen, MD

Summary/review

The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of life, yet little is known about how infant hospitalization affects long-term breastfeeding. This retrospective cohort study examined 96 previously healthy breastfeeding infants (0–6 months) admitted with common infectious illnesses. Over one-third (35%) were made NPO, and most (83%) received some form of lactation support, including breast pumps, meal trays, or formal consults. At six-month follow-up, 65% of infants were still receiving breastmilk, and nearly half experienced no decrease in breastfeeding after hospitalization. Statistical analysis found no significant association between NPO status, lactation support measures, or multiple support interventions and breastfeeding continuation or reduction at six months. However, a small but concerning subgroup emerged: among NPO infants who did not receive lactation support, all had decreased breastmilk intake at follow-up, and only one continued breastfeeding at six months. Although limited by small sample size and retrospective design, this trend suggests a potentially vulnerable population.

During my interview with the author, Calisha Allen, MD, a pediatric specialist at Duke University Medical Center, she clearly mentioned how the stress of illness and the availability of inpatient lactation support influence feeding trajectories for infants who require hospital care and highlighted the importance of proactively maintaining lactation support during infant hospitalization—particularly for NPO patients.

With the insight I will be able to incorporate these findings to standardize family-centered lactation protocols in hospital care services to protect breastfeeding goals and optimize long-term nutrition outcomes.

Abstract Title: Long‐Term Treatment With Once‐Weekly Apraglutide Reduces Parenteral Support Dependency and Allows to Reach Enteral Autonomy in Some Patients With Short Bowel Syndrome and Intestinal Failure

Authors: Palle Bekker Jeppesen, MD, PhD; Kelly Tappenden, PhD, RD; Donald Kirby, MD; Simon Lal, MD, PhD; Tim Vanuytsel, MD, PhD; Chang Ming, PhD; Tomasz Masior, MD; Mena Boules, MD; Francisca Joly, MD, PhD; Kishore Iyer, MBBS, MSc, FRCS(Eng)

Summary/review

Glucagon-like peptide-2 (GLP-2) analogs are used in short bowel syndrome (SBS) with parenteral support (PS) dependance to help achieve enteral autonomy (EA) past the adaptation phase despite standard therapy. Teduglutide is the only FDA approved GLP-2 analog for SBS. Its half-life is 2-6 hours, and it’s administered once daily. Apraglutide (APRA) has a longer half‐life of 72 hours, only requiring once weekly use. Its efficacy is being evaluated in a clinical trial started in 2021, showing decreased PS requirements in phase 2/3 (STARS trial).  STARS Extend, a long-term extension study, reveals PS reduction of at least 1 day per week when comparing APRA patients previously on APRA or placebo during the prior phase (49.1% APRA/APRA, 55.3%; PBO/APRA) at week 52. 20.2% of APRA/APRA and 23.4% of PBO/APRA achieved EA at least once, and 83.3% and 90.9% of those maintained continuous EA through last follow‐up; 100% and 90.9%, and 83.3% and 72.2% (APRA/APRA and PBO/APRA) maintained EA for ≥3 and ≥6 months.

More investigation will be conducted on extrapolating the efficacy of APRA based on the specific underlying SBS cause, which will be useful in selecting the appropriate target population. Achieving EA at least once followed by PS relapse may be problematic and potentially interpreted as ineffective by participants. A head-to-head trial in well-matched patient would be interesting to see.

PS can be burdensome when used daily, affecting quality of life (QoL) adversely. GLP-2 analogs can improve QoL by reducing PS support and promoting EA. Currently, administration is once daily. Once weekly administration would create less medication burden and further improve QoL.

The study still underway. Once APRA becomes commercially available with more information on the specific target population that benefits most from the drug, I will consider using APRA for patients whose QoL is adversely impacted by daily GLP-2 analog administration.