Pediatric nutrition support is inherently complex because of the constant evolution of the basic nutritional requirements for children. In addition, there are a number of conditions that require nutrition support such as therapy, including obesity, cystic fibrosis, celiac disease, intestinal failure, eosinophilic gastrointestinal disorders, and inflammatory bowel disease (1). Enteral nutrition, a large component of nutrition support, continues to become more specialized. Intravenous nutrition constitutes a newer yet intricate delivery system that is able to provide supportive or primary nutrition for a variety of conditions (2). The complexity of enteral and parenteral nutrition, coupled with the variety of conditions that use nutrition as therapy, highlights the need for pediatric nutrition support practitioners. Despite this, nutrition education is often lacking within medical schools (3,4) and fewer physicians are entering into a practice model that focuses on clinical nutrition (5).
The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) has established pediatric gastroenterology fellowship core curriculum topics (6,7). In a survey of pediatric gastroenterology fellowship programs, only 31% of NASPGHAN core curriculum nutrition topics were covered by most of the programs (8). Gastroenterology fellows have identified a lack of perceived knowledge in multiple areas of nutrition education (9). A recent survey of pediatric gastroenterology physicians and fellows indicated a strong interest in additional nutrition support education, with a continuing medical education (CME) review course the most preferred format of education delivery (10). In response, the NASPGHAN Nutrition Committee developed a CME-based course entitled “NASPGHAN Nutrition University” or “N2U” through educational grants provided through the NASPGHAN Foundation and Nutricia North America. Through N2U, our aims included improving nutrition knowledge acquisition and dissemination. Using postcourse evaluations, our goal is to further develop and refine N2U as an effective educational resource. We hope N2U will serve as an example for the development of a live educational resource based on the responses of a targeted group of physicians.
N2U Course Design
The learning objectives and CME lecture format (Table 1) were developed based on the response by survey participants (10). Core nutrition support topics were also identified by the NASPGHAN Nutrition Committee. The initial N2U course was directed toward pediatric gastroenterology fellows and pediatric gastroenterologists who completed fellowship within the last 10 years. Speakers were invited based on professional expertise and developed assessment questions for each topic. A team of 3 physicians reviewed the course materials for CME credit.
Application to Attend N2U
Application packets included general demographic information, curriculum vitae, and 4 short response questions (Table 2). Applications were scored on a 5-point scale following the National Institutes of Health format with a score from 1.0 (excellent) to 5.0 (poor). Review criteria included analysis of curriculum vitae, geographic and practice diversity, and response to application questions (Table 2), which indicated an interest in nutrition support and additional nutrition education. Applicants with a score of 2.2 or better were invited to the N2U course. Of 101 applications reviewed, 29 applicants were invited and attended the N2U course. A limited-attendance 1-day course design was desired for initial course planning and to allow refinement of future courses based on postcourse evaluations. A stipend was provided to course attendees to help with costs of travel and lodging.
At the start of the N2U course, a pretest on topics to be covered in the course was administered (Table 1). A separate posttest was given following completion of the N2U course. Administered tests included questions from at least 12 of the 14 topics covered (Table 1). A 6-month follow-up evaluation was sent to course participants as a means to evaluate the effect of N2U on knowledge use and dissemination as well as to evaluate effectiveness of the N2U CME course format.
N2U Attendee Demographics
Of the 29 individuals who attended N2U, 9 of 29 (31%) were within their fellowship training. Of the remaining individuals, the average year of fellowship completion was 2008 (year range 2003–2011). Six individuals (21%) listed present practice as outside the continental United States, with practices represented from Canada and Puerto Rico. Attendees from the United States represented 15 different states from coast to coast.
Pre- and Posttest Questions
The average participant pretest score was 74% (Table 3). The average test score improved by 16% on the immediate posttest, with large improvements seen within cystic fibrosis, failure to thrive, and energy/protein metabolism topics (Table 3). Four topics showed <5% improvement in posttest scores, including obesity/bariatric nutrition, food allergy/eosinophilic esophagitis, critical care nutrition, and nutrition and the gastroenterologist.
Immediate Course Evaluations
Twenty-three evaluation forms were received. Overall, 95% (22/23) of respondents believed that N2U was relevant to their work and 95% believed that the content matched stated objectives. Participants’ feedback was centered on lengthening the course to allow for case-based learning and small group sessions. Suggested future course topics included obesity management, nonalcoholic fatty liver disease, and celiac disease.
Of N2U course participants, 61% (14/23) reported learning a great deal, 30% (7/23) learned quite a bit, and 4% (1/23) learned some. One participant reported learning very little. Participants identified time constraints, lack of support staff, and reluctance of patients as barriers to implementation of the knowledge acquired during the N2U course.
Follow-up Course Evaluations
Only 9 of 28 course attendees (32%) completed the 6-month follow-up survey. Of those surveyed, all (9/9) agreed or strongly agreed with the following statements: N2U provided strategies I could use in my professional practice; N2U improved my professional performance; patient outcomes improved because of knowledge I acquired at N2U. Respondents stated they had incorporated knowledge from N2U primarily in outpatient clinic setting (78%) or inpatient hospital setting (67%). Respondents reported sharing knowledge from N2U with medical students (44%), residents/fellows (56%), faculty physicians (56%), nurses (78%), and dietitians (56%). Lectures (55%), case presentations (89%), and workshops (67%) were identified as preferred formats for future education.
Nutrition is one of the essential components of pediatric gastroenterology fellowship training as identified by NASPGHAN training guidelines (7); however, few fellowship programs use a defined core curriculum in nutrition education of trainees (8). Live and interactive education opportunities directed toward nutrition support topics are uncommon. The Nutrition in Medicine project has developed an extensive on-line module-based curriculum that has been expanded to include courses for both medical students and practicing physicians (4). Success of live education courses has been described for medical students (11) and adult gastroenterology fellows (12). A survey of NASPGHAN members identified a strong interest in continuing education opportunities in childhood nutrition, with a CME course format preferred for additional education (10). This led the NASPGHAN Nutrition Committee to develop N2U to provide education in pediatric nutrition support to pediatric gastroenterology fellows and junior faculty.
The N2U course was well received and effective, as reflected by a 16% increase in immediate postcourse testing scores. Eleven course topics included questions represented in both pre- and postcourse tests, 8 of which showed an increase in postcourse test scores (Table 3). Four topics showed either no improvement or an improvement of <5% (Table 3). This was likely related to high pretest averages within critical care nutrition, nutrition, and the gastroenterologist, and food allergy/eosinophilic esophagitis. These areas may be candidates for more in-depth coverage in future sessions. Obesity/bariatric nutrition failed to show improvement and was identified as an area of continued educational need in immediate postcourse evaluations.
During immediate postcourse evaluations, the vast majority (91%) of N2U attendees reported learning either a great deal or quite a bit and this pattern was also seen in 6-month follow-up surveys, with all of the individuals who responded reporting use of knowledge gained at N2U along with the improvement in patient outcomes. Limitations in course evaluation include coordination of pre- and posttest questions. Test size was limited to 20 questions to limit testing fatigue; however, this limited our ability to compare improvement in knowledge acquisition because some lecture topics were not represented in either the pre- or posttest, or may have only been represented by 1 question. Six-month follow-up course evaluation was limited by poor response rate; we plan to ask future N2U attendees to specifically agree to fill out follow-up course evaluations in an effort to improve response rate and analysis of educational effect, knowledge use, and dissemination of knowledge.
Although the initial N2U course was designed in a didactic format, recent strategies for effective adult learning have suggested that the traditional didactic models may not be as high yield. Along with this, course feedback suggested that some type of increased interaction with course facilitators is needed. Team-based training is gaining popularity as a means to improve knowledge acquisition and implementation through a model that simulates the modern health care environment (13). This suggests a role for a more interactive approach to future N2U sessions, such as small group sessions in which expert nutrition-support physicians act more as facilitators in addressing a clinical problem as a team. For classroom-based learning, new education strategies have focused on modalities to maximize time invested in learning. The flipped classroom model is one to be considered. In the flipped classroom, students prepare beforehand by reading, listening, or watching a short presentation on the topic followed by an interactive, inquiry-based classroom session and that is designed for the integration of knowledge (14). Use of these or similar interactive methods within a model of a live CME session is planned for future N2U courses based on the collected physician feedback. Despite this, challenges will still exist in maximizing knowledge acquisition for individuals of varied clinical expertise within a limited time frame.
We hope that future courses and subsequent physician feedback will allow continued refinement of the N2U course content and format and allow for future courses with more widespread attendance opportunity. At the present time, archived audiovisual N2U lecture modules have been made available with free access through the NASPGHAN Web site (www.naspghan.org).
In summary, NASPGHAN Nutrition University represents a continuing education resource that was developed in response to an identified need for additional nutrition education within the field of pediatric gastroenterology (8). The format and content of N2U was developed following direct responses gathered from the targeted physician group through a national survey (10), with future N2U course content developed in response to physician attendee feedback. N2U may serve as a model for the development of continuing education for various other medical subspecialties and topics.
Special thanks to the following individuals who were instrumental in the development of the 2012 N2U course: Application Reviewers: Maria Mascarenhas, Ann Scheimann, Valeria Cohran, William Balistreri, Sandeep Gupta, Jean Molleston, Charles Vanderpool. CME Reviewers: Ed Hoffenberg, Sunny Hussain, Deepali Tewari. Speakers: Ann Scheimann, Robert Shulman, Maria Mascarenhas, Praveen Goday, Valeria Cohran, Sam Kocoshis, Mark Corkins, Glenn Furuta. NASPGHAN Foundation: Margaret Stallings, Amy Manela.
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