Managing Children With Complex Nutrition Needs

For pediatric gastroenterologist and physician nutrition specialist Senthil SankaraRaman, MD, nutrition-focused management has been his keen clinical interest since medical school.

He joined Cleveland Clinic Children’s in 2024 as the Co-Director of Advanced Pediatric Nutrition Support and Intestinal Rehabilitation Program. He has extensive experience in this field and has authored multiple peer-reviewed articles, book chapters, and has given several presentations on optimizing nutrition for pediatric patients with complex nutritional needs.

In a wide-ranging interview with Consult QD, Dr. SankaraRaman details his work in pediatric nutrition, focusing on managing complex nutritional needs in children. He discusses the importance of early nutritional support, the challenges in pediatric nutrition, the future of the Advanced Pediatric Nutrition Support and Intestinal Rehabilitation Program at Cleveland Clinic Children’s, and much more.

What sparked your interest in pediatric nutrition?

I was drawn to the complexity of managing nutrition in a pediatric patient population. Even though less prevalent, malnutrition in children is not uncommon, even in resource-rich countries. The causes of malnutrition (synonymous for undernutrition) are multifactorial and include reduced food intake, increased nutrient loss, and increased metabolic demands.

The presence of an acute, severe illness or underlying chronic conditions result in an increased risk of malnutrition. Medical nutritional management involves careful application of nutritional skills in appropriate clinical scenarios for optimizing outcome. Working with various specialists in multidisciplinary team approach is the key here to achieve great success, and it is an area that has always been appealing to me.

Why optimizing nutrition is so crucial in children?

Infants, young children and teens are particularly vulnerable to malnutrition as they are growing rapidly with higher nutrition needs. It is very important to optimize nutrition in children so that they can reach important appropriate developmental milestones in a timely manner. Specifically, nutrition in the first 1,000 days of life (from conception to 2 years old) is directly tied to their brain development and neurological outcome.

If nutritional goals are not reached in early life, the effects can be long-lasting. These may include increased susceptibility to infections, worse outcomes if hospitalized, weak bones, and increased risk of cardiovascular and metabolic disorders later in life.

Why might a patient be referred to you?

Patients with ongoing gastrointestinal symptoms and requiring complex nutritional needs will be ideal patients for referral to our program. My practice is a combination of managing both inpatients and outpatients. In the inpatient setting, I am part of an advanced nutrition support team, which comprises gastroenterologists with nutrition expertise, advanced pediatric registered nurse practitioners, registered dietitians, nurse coordinators, and clinical pharmacists.

We manage patients in the ICUs (both neonatal and pediatric) and inpatient floors and identify patients with high nutritional needs, such as those with severe malnutrition, patients who require enteral nutrition (EN) via nasogastric tube, gastrostomy tube, or postpyloric feeding or who are on parenteral nutrition (PN) support. This includes patients with complex heart diseases, intestinal failure, aerodigestive or other feeding problems, pulmonary issues, surgical patients, or with hemato-oncological disorders.

Many studies have highlighted the importance of optimizing nutritional therapy in these hospitalized children. If we optimize nutrition earlier, the mortality rates and length of hospitalization decline in an impressive manner.

How are patients’ nutritional needs addressed in an outpatient setting?

Upon discharge, we follow the above-mentioned patients in the outpatient settings for continuity of care and provide ongoing support to manage them before they proceed to more advanced stages of malnutrition.

For outpatient care, we have many multidisciplinary clinics with specialists who partner to deliver patient-centered care, manage nutritional deficiencies, and foster collaboration with other healthcare professionals—like pediatricians, subspecialists, registered dietitians, social workers, psychologists, and feeding therapists.

What are some challenges in the pediatric nutrition arena?

There are so many factors that influence nutrition in children. In the medical field, we commonly say that children are not just small-sized adults; and they have a unique set of needs and challenges due to their age and developmental.

Additional factors such as food insecurity, sociocultural factors, and lack of available resources such as multidisciplinary team-based patient-centered nutrition programs could impede improving children’s nutrition.

Tell us about the pediatric intestinal rehabilitation and transplant program

For patients with intestinal failure (often referred to as short bowel syndrome), a condition where the small intestine is not working adequately to sustain growth, our primary goal is to optimize growth and development by the provision of nutrition via IV (referred to as PN).

We manage optimizing their oral nutrition and fluid needs both orally as well as via enteral feeding. This is best done in a multidisciplinary program that consists of gastroenterologists, surgeons, registered dietitians, nurse coordinators, pharmacists, and feeding therapists.

We will consider intestinal transplantation in intestinal failure patients if we cannot optimize their nutritional status with EN and PN or if they develop life-threatening complication(s) with PN. Our program at Cleveland Clinic is one of the most comprehensive pediatric intestinal rehabilitation programs of its kind in the U.S. and one of the few centers to perform intestinal transplants in both adults and children.

What’s on the horizon for the program?

On the clinical side, we have many newer emerging therapies in the EN and PN arena to address the above-mentioned challenges. Some of the notable mentions include the use of glucagon-like peptide-2 (GLP-2) analogs, like Teduglutide, which can stimulate intestinal growth and potentially reduce dependence on PN. Several specialized enteral nutrition formulas are being developed, and novel strategies to optimize nutrient absorption, such as enzyme (lipase) cartridges, are also available.

Apart from clinical care, we love to train the next generation of budding physicians and support them with evidence-based practice. We are in the process of creating an advanced pediatric nutrition fellowship program. This one-year program is for those who have completed their gastroenterology/other subspecialty fellowships, and the curriculum will focus on evaluating nutritional challenges and management of nutritional disorders and issues.

Do you have advice for primary care pediatricians about when to refer?

Pediatricians always engage in nutritional assessment and monitor growth as part of the visit. If they encounter concerns for growth delay or issues with nutritional needs, that is the best time to reach out to us or refer to our program.