Nutritional evaluation of children with chronic cholestatic disease

Silva, Francislaine Veiga da; Ferri, Priscila Menezes; Queiroz, Thaís Costa Nascentes; Barbosa, Pamela de Souza Haueisen; Oliveira, Maria Cristina Cassiano de; Pereira, Laura Jácome de Melo; Simões e Silva, Ana Cristina; Penna, Francisco José; Fagundes, Eleonora Druve Tavares; Ferreira, Alexandre Rodrigues

doi:10.1016/j.jped.2015.07.006

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Original articles • J. Pediatr. (Rio J.) 92 (2) • Mar-Apr 2016 • https://doi.org/10.1016/j.jped.2015.07.006 copy

Nutritional evaluation of children with chronic cholestatic disease^☆ ☆ Please cite this article as: Silva FV, Ferri PM, Queiroz TC, Barbosa PS, Oliveira MC, Pereira LJ, et al. Nutritional evaluation of children with chronic cholestatic disease. J Pediatr (Rio J). 2016;92:197-205.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To evaluate the nutritional status of children with persistent cholestasis and to compare the anthropometric indices between children with and without liver cirrhosis and children with and without jaundice.

Methods:

Children with persistent cholestasis, i.e. increased direct bilirrubin or changes in the canalicular enzyme gamma-glutamyl transferase (GGT), were included. The anthropometric measures were weight (W), height or length (H), arm circumference (AC), triceps skinfold thickness (TST), arm muscle circumference (AMC), and body mass index (BMI).

Results:

Ninety-one children with cholestasis, with current median age of 12 months, were evaluated. W/age (A) and H/A indices below −2 Z-scores were observed in 33% and 30.8% of patients, respectively. Concerning the W/H index and BMI, only 12% and 16% of patients, respectively, were below −2 Z-scores. Regarding AC, 43.8% of 89 evaluated patients had some depletion. Observing the TST, 64% of patients had depletion, and 71.1% of the 45 evaluated patients had some degree of depletion regarding the ACM index.

Conclusion:

Evaluation using weight in patients with chronic liver diseases may overestimate the nutritional status due to visceromegaly, subclinical edema, or ascites. Indices that correlate weight and height, such as W/H and BMI, may also not show depletion because of the chronic condition in which there are depletion of both weight and height. TST, AC, and ACM are parameters that better estimate nutritional status and should be part of the management of patients with liver diseases and cholestasis.

Keywords
Neonatal cholestasis; Nutrition; Chronic liver disease; Anthropometry

		General (91 children)	With cirrhosis	Without cirrhosis
			(25 children)	(66 children)
Age (months) ^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		12 [6.0 to 40.0]	11 [5.0 to 38.5]	12 [6 to 40.5]
Visceromegaly, n (%)		61 (67%)	24 (96%)	37 (56.1%)
Splenomegaly, n (%)		42 (46.2%)	21 (84%)	21 (31.8%)
Hepatomegaly, n (%)		57 (62.6%)	22 (88%)	35 (53%)
Hepatosplenomegaly, n (%)		38 (41.8%)	17 (68%)	19 (28.8%)
Ascites, n (%)		7 (7.7%)	5 (20%)	2 (3%)
Albumin (g/dL)		4.1 [3.8 to 4.5]	4 [3.47 to 4.40]	4.2 [3.8 to 4.5]
Z-score W/A^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		−1.10 [−2.40 to 0.36]	−1.39 [−2.72 to 0.12]	−0.93 [−2.2 to 0.54]
Z-score H/A^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		−0.80 [−2.30 to −0.03]	−1.6 [−2.57 to −0.62]	−0.70 [−2.4 to 0.30]
Z-score W/H^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		−0.05 [−1.30 to 0.80]	−0.52 [−1.85 to 0.76]	−0.03 [−1.23 to 0.86]
Z-score BMI ^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		−0.24 [−1.40 to 0.90]	−0.52 [−2.24 to 0.87]	0.03 [−1.30 to 0.87]
Z-score TST ^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		−0.40 [−1.70 to 0.80]	−1.35 [−2.65 to 0.30]	−0.12 [−1.43 to 1.00]
Dietary record ^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		91.4% [79.0% to 104.6%]	92.9% [72.9% to 105.8%]	90.5% [80.8% to 103.4%]

Dietary record, n (%)
	<60%	2 (2.2%)	1 (4%)	1 (1.5%)
	60% to <95%	50 (55%)	13 (52%)	37 (56.1%)
	95% to 105%	17 (18.7%)	4 (16%)	13 (19.7%)
	105% to <140%	20 (22%)	7 (28.0%)	13 (19.7%)
	>140%	2 (2.2%)	0 (0.0%)	2 (3.0%)

		General (91 children)	With jaundice	Without jaundice
			(70 children)	(21 children)
Age (months) ^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		12 [6.0 to 40.0]	10 [5.0–34.25]	31 [10–56.5]
Cirrhosis		25	22	3
Visceromegaly, n (%)		61 (67%)	51 (72.9%)	10 (47.6%)
Splenomegaly, n (%)		42 (46.2%)	37 (52.9%)	05 (23.8%)
Hepatomegaly, n (%)		57 (62.6%)	48 (68.6%)	09 (42.9%)
Hepatosplenomegaly, n (%)		38 (41.8%)	29 (41.4%)	09 (42.9%)
Ascites, n (%)		7 (7.7%)	7 (10%)	0 (0%)
Total bilirubin (md/dL)		2.1 [0.5 to 5.68]	3.4 [1.7 to 7.45]	0.5 [0.25 to 0.7]
Direct bilirubin (mg/dL)		1.4 [0.2 to 3.3]	2.0 [1.37 to 5.6]	0.2 [0.1 to 0.32]
GGT (U/L)		495 [244 to 587]	402 [180 to 686.8]	234 [180 to 554]
Albumin (g/dL)		4.1 [3.8 to 4.5]	4.1 [3.7 to 4.45]	4.2 [4.0 to 4.6]
Z-score W/A^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		−1.10 [−2.40 to 0.36]	−1.52 [−2.5 to −0.95]	0.36 [−0.46 to 1.14]
Z-score H/A^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		−0.80 [−2.30 to −003]	−1.15 [−2.53 to −0.28]	−0.12 [−1.18 to 0.44]
Z-score W/H^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		−0.05 [−1.30 to 0.80]	−0.71 [−1.4 to 0.45]	0.83 [0.02 to 1.3]
Z-score BMI ^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		−0.24 [−1.40 to 0.90]	−0.52 [−2.24 to 0.87]	0.87 [0.11 to 1.13]
Z-score TST ^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		−0.40 [−1.70 to 0.80]	−0.71 [−1.41 to 0.67]	0.15 [−0.39 to 1.08]
Dietary record ^a a For some data, median and interquartile range (IQ 25th–75th) were used; for dietary record the calculation used was: (dietary intake record/recommended for age) × 100.		91.4% [79.0% to 104.6%]	89.9% [77.6% to 105.6%]	93.14% [86.2% to 100.8%]
Dietary record, n (%)
	<60%	2 (2.2%)	1 (1.4%)	1 (4.8%)
	60% to <95%	50 (55%)	39 (55.7%)	11 (52.4%)
	95% to 105%	17 (18.7%)	11 (15.7%)	6 (28.6%)
	105% to 140%	20 (22%)	17 (24.3%)	3 (14.3%)
	>140%	2 (2.2%)	2 (2.9%)	0 (0%)

Index		General (91 patients), n (%)	With cirrhosis (25 patients), n (%)	Without cirrhosis (66 patients), n (%)
Height/age
	Very low	16 (17.6%)	5 (20.0%)	11 (16.7%)
	Low	12 (13.2%)	3 (12.0%)	9 (13.6%)
	Adequate	63 (69.2%)	17 (68.0%)	46 (69.7%)

Weight/age
	Very low	11 (12.1%)	4 (16.0%)	7 (10.6%)
	Low	19 (20.9%)	5 (20.0%)	14 (21.2%)
	Adequate	59 (64.8%)	15 (60.0%)	44 (66.7%)
	High	2 (2.2%)	1 (4.0%)	1 (1.5%)

Weight/height
	Very low	6 (6.6%)	2 (8%)	4 (6.1%)
	Low	5 (5.5%)	3 (12%)	2 (15.2%)
	Adequate	66 (72.50%)	16 (64%)	50 (75.8%)
	High	14 (15.4%)	4 (25%)	10 (15.2%)

Body mass index
	Very low	7 (7.7%)	3 (12%)	4 (6.1%)
	Low	8 (8.8%)	4 (16%)	4 (6.1%)
	Adequate	56 (61.5%)	12 (48%)	44 (66.7%)
	Overweight risk	19 (20.8%)	5 (20%)	14 (21.2%)
	Overweight	1 (1.1%)	1 (4.0%)	0 (0.0%)

Arm circumference ^a a The total number of patients evaluated in this index was 89.
	Severe depletion	3 (3.4%)	1 (4.0%)	2 (3.1%)
	Moderate depletion	7 (7.9%)	5 (20.0%)	2 (3.1%)
	Mild depletion	29 (32.6%)	11 (44.0%)	18 (28.1%)
	Eutrophy	42 (47.2%)	7 (28.0%)	35 (54.7%)
	Overweight	8 (8.9%)	1 (4.0%)	7 (10.9%)
	Obesity	0 (0.0%)	0 (0.0%)	0 (0%)

Triceps skinfold thickness
	Severe depletion	21 (23.1%)	12 (48.0%)	9 (13.6%)
	Moderate depletion	15 (16.5%)	2 (8.0%)	13 (19.7%)
	Mild depletion	6 (6.6%)	2 (8.0%)	4 (6.0%)
	Eutrophy	17 (18.7%)	4 (16.0%)	13 (19.7%)
	Overweight	11 (12.1%)	1 (4.0%)	10 (15.1%)
	Obesity	21 (23.1%)	4 (16.0%)	17 (25.8%)

Arm muscle circumference ^b b The total number of patients evaluated in this index was 45.
	Severe depletion	6 (13.3%)	2 (16.7%)	4 (12.1%)
	Moderate depletion	10 (22.2%)	4 (33.3%)	6 (18.2%)
	Mild depletion	16 (35.6%)	4 (33.3%)	12 (36.4%)
	Eutrophy	13 (28.9%)	2 (16.7%)	11 (33.3%)

	Index	General (91 patients), n (%)	With jaundice (70 patients), n (%)	Without jaundice (21 patients), n (%)
Height/age
	Very low	16 (17.6%)	14 (20%)	2 (9.5%)
	Low	12 (13.2%)	11 (15.7%)	1 (4.8%)
	Adequate	63 (69.2%)	45 (64.3%)	18 (85.7%)

Weight/age
	Very low	11 (12.1%)	9 (12.9%)	2 (9.5%)
	Low	19 (20.9%)	17 (24.3%)	2 (9.5%)
	Adequate	59 (64.8%)	42 (60%)	17 (81%)
	High	2 (2.2%)	2 (2.9%)	0 (0%)

Weight/height
	Very low	6 (6.6%)	5 (7.1%)	1 (4.8%)
	Low	5 (5.5%)	5 (7.1%)	0 (0%)
	Adequate	66 (72.5%)	53 (75.7%)	13 (61.9%)
	High	14 (15.4%)	7 (10%)	7 (33.3%)

Body mass index
	Very low	7 (7.7%)	6 (8.6%)	1 (4.8%)
	Low	8 (8.8%)	8 (11.4%)	0 (0%)
	Adequate	59 (64.8%)	48 (68.6%)	11 (52.4%)
	Overweight risk	16 (17.6%)	7 (10%)	9 (42.9%)
	Overweight	1 (1.1%)	1 (1.4%)	0 (0%)

Arm circumference ^a a The total number of patients evaluated in this index was 89.
	Severe depletion	3 (3.4%)	3 (4.4%)	0 (0%)
	Moderate depletion	7 (7.9%)	7 (10.3%)	0 (0%)
	Mild depletion	29 (32.6%)	24 (35.3%)	5 (23.8%)
	Eutrophy	42 (47.2%)	29 (42.6%)	13 (61.9%)
	Overweight	8 (8.9%)	5 (7.4%)	3 (14.3%)
	Obesity	0 (0.0%)	0 (0%)	0 (0%)

Triceps skinfold thickness
	Severe depletion	21 (23.1%)	19 (27.1%)	2 (9.5%)
	Moderate depletion	15 (16.5%)	15 (21.4%)	0 (0%)
	Mild depletion	6 (6.6%)	5 (7.1%)	1 (4.8%)
	Eutrophy	17 (18.7%)	8 (11.4%)	9 (42.9%)
	Overweight	11 (12.1%)	8 (11.4%)	3 (14.3%)
	Obesity	21 (23.1%)	15 (21.4%)	6 (28.6%)

Arm muscle circumference ^b b The total number of patients evaluated in this index was 45.
	Severe depletion	6 (13.3%)	6 (20%)	0 (0%)
	Moderate depletion	10 (22.2%)	6 (20%)	4 (26.7%)
	Mild depletion	16 (35.6%)	12 (40%)	4 (26.7%)
	Eutrophy	13 (28.9%)	6 (20%)	7 (46.7%)

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[1] * Corresponding author. E-mails:pmferri.liu@gmail.com (P.M. Ferri), alexfer1403@gmail.com (A.R. Ferreira).

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Nutritional evaluation of children with chronic cholestatic disease☆ ☆ Please cite this article as: Silva FV, Ferri PM, Queiroz TC, Barbosa PS, Oliveira MC, Pereira LJ, et al. Nutritional evaluation of children with chronic cholestatic disease. J Pediatr (Rio J). 2016;92:197-205.

Abstract

Objective:

Methods:

Results:

Conclusion:

Nutritional evaluation of children with chronic cholestatic disease^☆ ☆ Please cite this article as: Silva FV, Ferri PM, Queiroz TC, Barbosa PS, Oliveira MC, Pereira LJ, et al. Nutritional evaluation of children with chronic cholestatic disease. J Pediatr (Rio J). 2016;92:197-205.