What Is Known
- The European Society for Paediatric Gastroenterology, Hepatology and Nutrition Training Syllabus considers nutrition integral to training. It suggests broad exposure of nutritional disease in children and working as part of a multidisciplinary nutrition team addressing dietetic, psychosocial, and nursing aspects.
What Is New
- A median of 20% was spent for nutrition training during fellowship, but only 14 (28%) enjoyed regular teaching with a frequency of once weekly to once annually.
- The European Society for Paediatric Gastroenterology, Hepatology and Nutrition syllabus, which 14 (28%) followed for nutrition training, suggests that trainees work in a multidisciplinary nutrition team. Thirty-four (68%) did so.
Knowledge of nutritional assessment and support is essential in paediatric medicine. Nutritional support and intervention are important in management of many paediatric diseases, not only those involving gastrointestinal and hepatobiliary tracts. Nutrition training varies between countries and even among different programmes within a country (1,2).
The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) acknowledges nutrition training as an important part of paediatric gastroenterology, hepatology, and nutrition (PGHN) training and is one of the major pillars of training in the recently updated ESPGHAN training syllabus (3). The syllabus provides a core curriculum defining the minimum knowledge and technical skills to be acquired during training. The updated ESPGHAN syllabus, which was completed in December 2018, was approved by the European Union of Medical Specialists in April 2019, permitting the inference that countries with a national PGHN society should comply with the syllabus. In addition, ESPGHAN has produced an abundance of nutrition-related guidelines on enteral, parenteral, and complementary nutrition (4–10) and these valuable sources should be disseminated during educational events.
Multidisciplinary teams have emerged as key in the care of children needing nutritional intervention. The composition of a multidisciplinary nutrition team varies according to type of institution, the tasks of the team, and the availability of staff and funding. Typically included are a physician, a dietician, a nurse, and if possible a pharmacist (5,11); these may be joined by a psychologist, a social worker, a speech and language therapist, and a surgeon. Implementation of care through multidisciplinary nutrition teams significantly improves paediatric nutrition (11–13).
To assess the status of paediatric nutrition training, the Young ESPGHAN committee surveyed European PGHN trainees and young professionals. The survey was conducted before the introduction of the updated ESPGHAN syllabus to provide baseline data. The goal of the survey was to assess the importance of nutrition training within PGHN training, the availability and composition of multidisciplinary nutrition teams, the availability and possibility to participate in training courses, and the topics covered during nutrition training.
An online questionnaire (https://www.surveymonkey.com) designed by the Young ESPGHAN Committee was sent to Young ESPGHAN members between February 2015 and May 2016. The questionnaire was approved by the ESPGHAN Committee on Nutrition.
The survey (Supplementary Table 1, Supplemental Digital Content, https://links.lww.com/MPG/B796) comprised 17 questions. A first set addressed general information on country of origin, year of training, structure of PGHN training programs, and time devoted to nutrition training. The second set of questions investigated the availability of teaching sessions and the presence and composition of multidisciplinary nutrition teams. In a third set of questions, the most frequent topics treated during training were addressed. Finally, a fourth set of questions assessed participation in nutrition courses and e-learning, and desired future support of ESPGHAN. Data were exported into a spreadsheet and tabulated manually.
Fifty-six PGHN trainees from 24 countries, of which 19 were European (including Israel and Russia), participated in the survey (response rate 56/125 trainees or 45%) (Table 1). Six participants were excluded from further analysis as they were trained out with Europe, Israel, or Russia. Twenty-one participants were still in PGHN training and 26 participants had finished their training; 3 did not answer that question. Among all European participants, 38 (76%) reported being enrolled in an official PGHN training programme leading to a subspecialty certification for 35 (70%). The duration of PGHN training was a median of 30 months (interquartile range [IQR] 24, 36). Twenty-two participants (46%) had their entire time devoted to PGHN training and 22 (46%) between 50% and 99% of their time; in 4 participants (8%) <50% of their time was dedicated to PGHN training; 2 did not answer that question. The time dedicated to nutrition during training was a median of 20% (IQR 10, 30).
Nutrition Teaching and Multidisciplinary Nutrition Teams
Overall 14 participants (28%) had nutrition teaching sessions in their hospital during training. The frequency of these teaching sessions ranged between once a week and once a year.
Thirty-four participants (68%) had a multidisciplinary nutrition team at their institution. The team consisted of a dietician (79%), trainee (73%), consultant (70%), (parenteral nutrition) nurse (45%), psychologist (39%), pharmacist (33%), stoma nurse (30%), speech and language therapist (30%), surgeon (21%), and social worker (3%).
Topics Covered During Training
The ESPGHAN syllabus–guided nutrition training for 24% of trainees (n = 12). In a median of 14% of participating trainees (IQR 7; 26) the topics within the ESPGHAN syllabus were covered during nutrition training (Fig. 1; Supplementary Table 1, Supplemental Digital Content, https://links.lww.com/MPG/B796).
Nutrition Courses, E-learning, and Support by ESPGHAN
Twenty-seven of 50 participants (54%) had participated in 1 or more nutrition courses. Thirteen of these nutrition courses (48%) were organized locally, that is, within the trainee's institution, 6 of these nutrition courses (22%) were organized by a company, and 8 of these nutrition courses (30%) were organized by ESPGHAN. Seven of 27 courses (26%) were funded and 2 of 27 courses (7%) were mandatory.
Eighteen percent of the participants (n = 9) had taken part in e-learning modules. The participants wished ESPGHAN to be supportive during nutrition training in organizing ESPGHAN nutrition schools (n = 34 or 68%), e-learning modules (n = 30 or 60%), and distance-learning programmes (n = 23 or 46%).
Nutrition education is an integral part of PGHN training. The updated ESPGHAN Syllabus (3) provides a curriculum with broad requirements for nutrition training.
In our survey, we showed that a median of 20% of time spent in PGHN training was dedicated to nutrition (IQR 10, 30). Only one-third of the participating trainees, however, had nutrition teaching sessions in their hospital, with frequency of these sessions ranging widely (between once a week and once a year).
We showed that gaps in nutrition education are substantial. Only in a median of 14% of participating trainees (IQR 7; 26) the topics as mentioned in the ESPGHAN Syllabus (14) were covered during nutrition training. The topics most frequently covered were diagnosis and investigation of a patient with failure to thrive (63% of trainees) and indications and contraindications for commencing enteral feeds (47% of trainees) and benefits and risks of enteral and parenteral nutrition (47% of trainees). Topics on parenteral nutrition were, however, covered only in a minority of participating trainees (5%–19% of trainees). Practical knowledge regarding different nasogastric tubes and gastrostomy devices was treated in only 21% of the participating trainees.
In our survey, 63% had participated in nutrition courses and 21% had taken part in e-learning modules. Many participants wished ESPGHAN to support nutrition training by organizing nutrition schools (34% or 68%), e-learning modules (30% or 60%), and distance learning programmes (23% or 46%). Concerning funding, the survey did not specify how the courses were funded (company, hospital, etc). Furthermore, it was not specified, if mandatory courses were free of charge.
Two-thirds of the trainees (34% or 68%) had a multidisciplinary nutrition team at their institution, which mainly consisted of a dietician, a consultant, and a trainee.
Strengths and Limitations
The survey shows paediatric nutrition training in Europe varies importantly. PGHN training in Europe varies in length between 18 and 48 months, as shown (14); however, by far most of those trained learn about nutrition (Table 1).
A limitation of this survey is that the response rate is moderate (45%). Respondents were few, unsurprisingly so, as numbers of PGHN trainees are far lower than those of adult gastroenterology trainees, especially in smaller countries.
The PGHN trainees who are ESPGHAN members were our primary target group, because they will be preferentially able to participate in ESPGHAN educational events.
The strength of this study, however, is that trainees from 19 European countries responded making it a representative survey on nutrition training in Europe. Furthermore, as this is the first survey of European PGHN trainees on nutrition training, the data presented are new.
Comparisons With Existing Studies
Few surveys on paediatric nutrition training have been published, namely 3 by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (1,2,15) and 1 by the American Society for Clinical Nutrition (16).
All reported gaps in paediatric nutrition training mainly due to lack of a well-structured nutrition curriculum. That by American Society for Clinical Nutrition reported declining numbers of clinical nutrition fellowship programmes in the United States and called for integration of nutrition into PGHN subspecialty training (16). Obstacles to more structured and standardized nutrition training are that paediatric gastroenterologists and trainees in academic settings may rely solely on highly specialized dieticians, who are not called on to teach PGHN trainees, and that few clinicians are well-trained in paediatric nutrition and that those who are well-trained have too little teaching time (15).
Therefore, the development of a structured core curriculum and learning modules has been suggested (1), including topics such as obesity management (2).
Implications for the Future
Successful nutrition training requires a clinically relevant curriculum, instruction by nutrition experts, the opportunity to work as a member of a multidisciplinary nutrition team, learning tools such as teaching sessions and nutrition courses, and adequate assessment strategies.
An updated ESPGHAN syllabus (3) exists with which national PGHN societies should comply, but only about one third of participating trainees report that it has been implemented in their institution. The survey was conducted before the introduction of the updated ESPGHAN syllabus to provide baseline data. Dissemination and implementation of the syllabus will permit nutrition training to become more structured. All aspects of nutrition should be covered during training, as set out in the ESPGHAN syllabus (3). This should be encouraged and enforced national PGHN societies. Acquisition of competence in clinical nutrition should be evaluated during and at the end of training. Competence in aspects of nutrition can be gained in various ways training by an inpatient feeding team, an outpatient lactation consultation service, an eating disorder service; writing parenteral nutrition orders; and by structured didactic sessions utilizing the knowledge of other members of the multidisciplinary nutrition team such as dieticians and pharmacists.
Nutrition teaching mainly takes part in the local hospital during PGHN training, but participation in intensive nutrition courses confers additional benefit. For many years, ESPGHAN has been organizing Nutrition Summer Schools. These offer almost a week of intensive nutrition training. ESPGHAN has also produced a bounty of guidelines on enteral, parenteral, and complementary nutrition (4–10).
The implementation of multidisciplinary nutrition teams improves the nutritional care for ambulatory and hospitalized children, including reduced mortality and lower expenses (11–13). Without multidisciplinary nutrition teams, responsibility for managing the nutritional needs of patients falls mainly to individual clinicians. The composition of the multidisciplinary nutrition team depends on the type of institution and the availability of staff and funding. The role of multidisciplinary nutrition teams consists of screening paediatric patients at nutritional risk, identification of patients requiring nutritional management, nutritional assessment and determination of macro- and micronutrient needs, management of nutritional intervention, education of clinical staff, and monitoring and evaluation of nutritional practice (11). The success of the team largely depends on good communication among its members. Therefore, the team requires regular, optimally weekly, team meetings to evaluate patients’ clinical course and nutritional requirements (11). At these trainees can learn about current nutritional practices, individual parenteral and enteral nutrition requirements, and set-up of nutritional plans (11). For trainees to be part of the multidisciplinary nutrition team thus confers great benefit.
In summary, our survey tried to address different issues of nutrition education in PGHN training. The general aim of such education is to improve the nutritional care of ambulatory and hospitalized paediatric patients. This will be achieved if we advance in improving the education of trainees by harmonizing nutrition training throughout Europe according to the updated ESPGHAN training syllabus; fostering participation in nutritional training courses, Web-based learning and distance learning programmes; and promoting the development of multidisciplinary nutrition teams.
1. Martinez JA, Koyama T, Acra S, et al. Nutrition education for pediatric gastroenterology, hepatology, and nutrition fellows: survey of NASPGHAN fellowship training
programs. J Pediatr Gastroenterol Nutr
2. Lin HC, Kahana D, Vos MB, et al. Assessment of nutrition education among pediatric gastroenterologists: a survey of NASPGHAN members. J Pediatr Gastroenterol Nutr
4. Mihatsch WA, Braegger C, Bronsky J, et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition. Clin Nutr Edinb Scotl
5. Braegger C, Decsi T, Dias JA, et al. Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr
6. Heuschkel RB, Gottrand F, Devarajan K, et al. ESPGHAN position paper on management of percutaneous endoscopic gastrostomy in children and adolescents. J Pediatr Gastroenterol Nutr
7. Broekaert I, Falconer J, Bronsky J, et al. The use of jejunal tube feeding in children: a position paper by the gastroenterology and nutrition committees of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition 2019. J Pediatr Gastroenterol Nutr
8. Romano C, Van Wynckel M, Hulst J, et al. European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the evaluation and treatment of gastrointestinal and nutritional complications in children with neurological impairment. J Pediatr Gastroenterol Nutr
9. Mouzaki M, Bronsky J, Gupte G, et al. Nutrition support of children with chronic liver diseases: a joint position paper of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr
10. Abu-El-Haija M, Uc A, Werlin SL, et al. Nutritional considerations in pediatric pancreatitis: a position paper from the NASPGHAN Pancreas Committee and ESPGHAN Cystic Fibrosis/Pancreas Working Group. J Pediatr Gastroenterol Nutr
11. Agostoni C, Axelson I, Colomb V, et al. The need for nutrition support teams in pediatric units: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr
12. Jeong E, Jung YH, Shin SH, et al. The successful accomplishment of nutritional and clinical outcomes via the implementation of a multidisciplinary nutrition support team in the neonatal intensive care unit. BMC Pediatr
13. Merritt RJ, Cohran V, Raphael BP, et al. Intestinal rehabilitation programs in the management of pediatric intestinal failure and short bowel syndrome. J Pediatr Gastroenterol Nutr
14. D’Antiga L, Nicastro E, Papadopoulou A, et al. European Society for Pediatric Gastroenterology, Hepatology and nutrition syllabus for subspecialty training
: moving towards a European standard. J Pediatr Gastroenterol Nutr
15. Shaikhkhalil A, Jump C, Goday PS. Development and pilot implementation of a nutrition curriculum and rotation in pediatric gastroenterology fellowships. J Pediatr Gastroenterol Nutr
16. Heimburger DC, Stallings VA, Routzahn L. Survey of clinical nutrition training
programs for physicians. Am J Clin Nutr