Abstract
Background
Nutrition education is one the essential components of any paediatric residency training. However, many paediatricians world-wide have suboptimal knowledge in core clinical nutritional topics. The purpose of our study is to assess the perceived effectiveness of nutrition training among physicians, including paediatric residents, paediatric trainees and paediatricians; identify areas of need for additional education resources and the preferred method of teaching for nutritional topics for medical education.
Material and Methods
A survey-questionnaire was sent to our physicians in our centre to assess general nutrition education via self-assessment of current nutritional knowledge across 12 distinct topics; importance of teaching amongst these topics and the preferred method of teaching.
Results
A total of 64 physicians completed the survey with an overall response rate of 88%. Most responders reported having average or above-average knowledge base in all nutritional topics except for nutritional aspects of special diets. Poorest knowledge base (either below average or poor) was reported in special diet (n = 38, 59.4%), inflammatory bowel disease (n = 17, 26.6%) and gastrointestinal allergy (n = 16, 25.0%). There was strong interest in additional teaching needs for the topics of failure to thrive (n = 38, 59.4%), nutritional assessment (n = 34, 53.1%) and infant feeding (n = 31, 48.4%). Most popular teaching methods were clinical case review (31.7%) followed by didactic lectures (29.8%) for overall clinical nutritional education.
Conclusions
Physicians identified gaps in their nutrition knowledge base and multiple topics were identified for additional nutrition education. Preferred methods of teaching for nutritional education were clinical case reviews and didactic lectures.
Keywords
Introduction
Nutrition education is one of the main pillars in paediatric residency training. Paediatricians have the responsibility to promote healthy nutritional habits from early childhood. Many parents rely on their paediatrician as a source of nutritional information and for anticipatory advice. Thus, a robust and comprehensive nutrition education curriculum in paediatric residency is imperative to equip future paediatricians with the knowledge and skills they need to promote healthy nutrition habits and prevent diet-related health issues in their patients.
Nutrition education has been well-established to be inadequate in medical schools and residency programs for many years. 1 Previous studies have shown wide variability in the training curriculum causing gaps in nutritional knowledge. 2 Previous surveys have found that physicians do not feel comfortable or adequately prepared to provide nutrition counselling to their patients.3–5 Part of this problem is related to inadequate nutrition knowledge. 6 In today’s world, the increasing prevalence of overweight and obese children pose a major health burden worldwide. 7 This global epidemic is here to stay for the next few decades. We need to ensure that our trainee paediatricians are equipped with essential skills and knowledge to manage this increasing health burden. Well-constructed objectives and targeted teaching would be required to intervene for any knowledge gaps during a busy residency programme to ensure adequate knowledge attrition. Our paediatric residents undergo rigorous and systematic training during their formative years in our centre at KK Women's and Children's Hospital, Singapore; which is a 827-bed Joint Commission International (JCI)-accredited hospital with a 365-bed dedicated children’s facility. Our post-graduate Paediatric residency training spans over a minimum of 6 years and is overseen by the United States (US) based Accreditation Council for Graduate Medical Education (ACGME). 8 Our paediatric residency programme has established training requirements for our residents which provides a framework of expected clinical competencies at various levels of training. The residents are expected to undergo formative work-based assessment during the course of their training to demonstrate their proficiency. They are assessed annually on their medical knowledge and clinical skills when they participate for the mandatory In-training Examinations (ITE), a US-based Boards-style multiple-choice question (MCQ) exam in Paediatric Medicine. 8 Nutrition education is a significant portion of our paediatric curriculum. Nutrition training is conducted during residency through regular didactic lectures while alongside daily teaching ward rounds when appropriate clinical cases are encountered by the medical team. They are exposed to clinical nutritional education during rotations such as general paediatics, ambulatory paediatrics, gastroenterology, adolescent medicine and neonatology. For general paediatric consultants; we conduct regular peer-reviewed learning (PRL) sessions which keeps us abreast with important nutrition and growth topics and any recent developments in general paediatrics.
The purpose of this study was to investigate the current knowledge levels, relative importance and preferred teaching methods of various nutrition topics and growth disorders.
Materials and methods
A survey-questionnaire was created using an online secure survey platform which would keep the respondents anonymous. Our target group included paediatric trainees (paediatric residents, medical officers, clinical associates) and paediatricians. We excluded junior doctors undergoing internship or housemanship training as they are rotating through our centre for a brief period of 3–4 months and are not expected to have in-depth level of knowledge and proficiency in paediatric topics. We also excluded paediatric consultants who are sub-specialized such as those in paediatric neurology, paediatric cardiology, paediatric rheumatology etc as they have received additional training on specific areas of nutrition relevant to their discipline. Participants were informed of this survey and the online survey link was distributed via emails. Participation was voluntary and responses were collected over 6 weeks. Survey questions were developed through discussions with an expert focus group consisting of paediatric residency educators, general paediatricians and paediatric gastroenterologists. We performed extensive literature search and evaluated previous studies which focussed on nutrition curriculum for paediatric residents to finalize the main topics needed for a robust nutritional curriculum development.9–11 We modelled our survey and focussed on nutritional topics based on the local residency curriculum, previous validated questionnaire and audits which were similarly conducted amongst paediatric trainees.12–14 We divided the concepts under 12 main topics based on a combination of current nutritional concerns in paediatrics, guidelines for residency curriculum, clinical nutritional education topics based on ACGME and Royal College of Paediatrics and Child Health (RCPCH) guidelines for paediatric residency.
The questionnaire comprised of 4 parts: demographic information, consisting of 3 questions; self-assessment of current nutritional knowledge across 12 distinct topics; importance of teaching and the preferred method of teaching for each individual topic.
The 12 topics included the following: (1) Basic nutritional physiology: Physiology of digestion and absorption of carbohydrates, lipids, fats and micronutrients. (2) Nutritional Assessment: Dietary history, clinical assessment using growth charts, physical examination findings related to malnutrition, anthropometry, weight and height measurement for age, weight for height, body-mass-index (BMI) measurements and limits for overweight and obesity in children, head circumference, haematologic and biochemical indices of nutritional status. (3) Infant feeding: Physiology of lactation, basic concepts of breastfeeding and troubleshooting, composition of human milk and infant/children’s formulas, nutritional requirements for preterm and term infants, appropriate weaning diet/introduction of solid foods and common feeding problems. (4) Failure to thrive: Differential diagnosis, management of individual causes and treatment. (5) Feeding Difficulties: Basic assessment of feeding difficulties in outpatient clinics, types of intervention/testing available for food aversion, dysphagia or picky eating, specific conditions such as cleft palate, swallowing dysfunction, and gastro-esophageal reflux disease (GERD) associated with feeding difficulties. (6) Special Diet and nutrition: Ketogenic, vegetarian, vegan, low-fat, gluten-free, lactose-free, organic diet and their specific nutritional aspects and deficiencies. (7) Enteral nutrition support: Management of enteral devices (Nasogastric/Gastrostomy/Jejunal tubes): indications and complications, enteral nutrition formulas, formula modifications and drug interactions. (8) Parenteral nutrition support: Indications, composition, administration, metabolic effects, complications. (9) Obesity: Evaluation and management of overweight and obese children (Diagnosis, risk factors, complications of obesity, interventions available) (10) Gastrointestinal tract Allergy: presentation, diagnosis, management, special nutritional considerations and requirements for Cow’s milk protein allergy (CMPA), Food protein induced enterocolitis (FPIES), eosinophilic gastrointestinal disorders. (11) Inflammatory bowel disease (IBD): presentation, complications, management, special nutritional considerations and requirements. (12) Eating Disorders: Principles of nutritional support, re-feeding syndrome and complications. Types of eating disorders and specialized management.
The ranking of these 12 topics was done on a five-point Likert scale for rating current knowledge levels (1 = poor, 2 = below average, 3 = average, 4 = above average, 5 = excellent) and for importance of teaching for that particular topic (1 = Not Important, 2 = Less Important, 3 = Important, 4 = Very Important, 5 = Extremely Important). For each topic; we also enquired regarding the most suitable teaching methods: the options were didactic lectures, small group discussions, journal reviews, clinical case reviews, bedside teaching and Zoom teaching sessions. A pilot survey was administered to 6 paediatricians for clarity and reliability and were not included in the final results. To maintain anonymity, there was no coding of the survey forms.
This study was exempted from consent-taking by the Singhealth Centralised Institutional Review Board (CIRB reference no: 2022/2759).
Statistical analyses
Results were collected and exported into spreadsheet and tabulated manually. Statistical analysis was performed using the SPSS 28.0 (IBM Corp.) statistical software program. Data are reported as frequency (%) when applicable. Subgroup analysis was done using Chi square tests with statistical significance level set at p < .05.
Results
Demographic characteristics of survey participants. N (%).
Current knowledge levels of the various nutritional topics. N(%).
Number of respondents with below-average to poor rating for self-assessment in nutrition education. N (%).
Importance of additional teaching for the various nutritional topics. N (%).
Type of teaching methods preferred for nutritional topics. N (%).
Discussion
Paediatricians have the power to alter the trajectory of a child’s risk for lifestyle diseases by advocating for early healthy nutritional habits. We need to empower parents by providing them with reassurance and guidance to individualize the nutritional needs of their children. 15
Education in nutrition and growth is an essential part of any paediatric training; they form the backbone of paediatrics which every trainee should have expertise in. Majority of residency education occurs during daily inpatient ward rounds and rotations in specialized clinics for training in nutrition. Certain clinics seem to have a more important contribution than others to the teaching of specific nutritional topics. In our centre, we have feeding clinics, weight management clinics, IBD clinics, allergy clinics and eating disorders clinics on top of the general paediatric clinics that are run by our consultants. To depend on these clinics for majority of the nutritional education will be a fallacy as teaching is dependent on the clinic patient mix and motivation of the physicians running the clinics.9,12 Ideally, we should standardize teaching for the residents based on their preference and requirements. This can only be done by identifying our current knowledge acquisition and gaps and the various teaching methods preferred by the residents themselves. 9
Certain conditions encountered more frequently in clinical practice would be considered important as they are very common such as FTT and nutritional assessment which paediatricians encounter on a daily basis. 11 However, certain conditions are rarer but are still clinically important. Of the 12 topics in nutrition, FTT was the only topic in which >50% of respondents noted above-average to excellent knowledge base. Furthermore, >25% of all respondents report below-average knowledge base in 3 of 12 nutrition topics including nutritional aspects of special diet, gastrointestinal allergy disorders, IBD. These findings are concerning as being in a teaching hospital, paediatricians in-training should possess an above-average knowledge base in these topics as it is part of the residency curriculum. Furthermore, there is increasing prevalence of allergic disorders and IBD in the paediatric population compared to past decades and thus it is even more critical for every resident to be confident and well-versed in these topics.16,17 Majority of the respondents had major knowledge gap on the nutritional aspects for special diets (n = 38, 59.4%) and they also considered it important to extremely important to have additional teaching (n = 49, 76.6%) reflecting the urgent need to cater to these knowledge gaps.
In today’s modern evolving times; we have a variety of special dietary preferences in different families and increasingly encounter children on specialized meal plans with its associated nutritional complications. It is vital for all trainees to be aware of such possibilities and to actively look out for complications when handling such patients. There is a rise in the prevalence of vegan or vegetarian diet in children which has been associated with vitamin D and Vitamin B12 deficiency.18,19 Despite coeliac disease being less prevalent locally, there has been a rise in interest for gluten-free diet due to its supposed beneficial effects. Gluten-free diet in children puts them at risk of consuming excessive fat, insufficient fibre, lack of iron and vitamin D intake with increased glycaemic index.20–22 These are important factors to consider when reviewing patients with such restricted diets.
A large proportion of respondents (≥25%) felt they had insufficient knowledge base in IBD and allergy although it is part of our residency curriculum. This could be explained as residents only spend 2 months out of the 6 years in training rotating under paediatric gastroenterology; thus the exposure to sub-speciality clinics where patients with IBD and allergic conditions are reviewed is also significantly reduced. These 2 topics (allergy 42.2%; IBD 39.1%) are very or extremely important for additional teaching according to our survey.
For respondents who had below-average to poor knowledge of nutritional education across the 12 topics; we noticed there were no statistical differences between the seniority of the respondents (Table 4). Interestingly, obesity was the only topic that had no respondent who rated their knowledge as below-average or poor. This is likely linked to the rising prevalence of obesity and the requirement for multi-disciplinary care, which exposes more physicians to repeated and multiple learning encounters for the nutritional topics related to obesity. Paediatric obesity has been a worldwide epidemic and its incidence has risen since the recent coronavirus 2019 (COVID-19) pandemic. 23 As a growing health concern, it is thus reassuring to see that obesity is well-versed with most of our respondents.
The priority for topics (∼50% of respondents rating them as very or extremely important) needing additional teaching were FTT, nutritional assessment and infant feeding. Interestingly, there exists a dichotomy between the responses for perceived knowledge base and need for additional teaching especially in the topic of FTT and special diet. Although the respondents were highly rating their knowledge base, FTT was still the most sought-after topic for additional teaching. Similarly, nutritional aspects of special diet which was most poorly rated for knowledge base was the lowest priority for additional teaching needs amongst the 12 nutritional topics. It is possible that the topics identified as important for additional teaching are topics which paediatric trainees encounter more frequently in clinical practice. Thus, the desire for additional teaching requirements may reflect the goal to stay ahead of issues important for clinical management rather than a true deficit of knowledge. Another possibility is that the need for additional teaching is a reflection of the constant learning nature of medicine and participant perceptions of inadequate knowledge may not directly correlate with functional knowledge base. Patients with FTT is one of the commonest presentations in paediatric clinical settings, which places it at a high level of importance for the need to keep up with up-to-date knowledge. Similarly, patients with special nutritional dietary choices are infrequently encountered and thus even with inadequate knowledge; it is placed at the lowest priority for additional teaching.
To address the growing need for paediatric trainees to be comfortable practicing nutrition medicine, we must first overcome self-imposed barriers to improving educational opportunities. We need to identify suitable format for teaching these topics. All nutritional topics in medicine should be important for learning but the challenge is deciding which topics to teach and assess in more depth relative to the others. 11 To prioritize, tutors should consider placing more emphasis on those listed as important by majority of the trainees.
Most physicians are motivated to learn by addressing patient-specific problems and thus Case-based teaching examples should be used as often as possible. 24 This is reflected similarly in our survey as clinical case-reviews are the most preferred method of teaching (31.7%) across all nutritional topics (Table 5). In view of the above findings, we have identified potential areas for improvement. The creation of a series of didactic lectures focusing on clinical case reviews with the option of zoom participation seems to be the most preferred and inclusive method for structured education in nutrition. We hope that the current observations will assist us and other centres to revise and improve the delivery of nutritional education and identify key areas that would need higher focus.
Limitations of our cross-sectional study include its single specialty, single program and institution nature, which affects generalizability of results. There was poor response rate amongst the paediatricians (16/47, 34.0%) which may not represent a true reflection of the current requirements of this target group. Furthermore, the possibility of selection bias must be considered as physicians with a keen interest in nutrition may be more likely to respond to the survey thus skewing the results. We assessed respondents’ knowledge based on self-reflection rather than an objective assessment of the nutritional topics which could lead to an over-estimation of one’s ability. Finally, we did not assess if the respondents previously rotated through any nutrition courses which could have skewed the self-assessment and the need for additional teaching requirements. Nonetheless, we have a good response rate from paediatric residents (37/42, 88.1%) which is a good reflection of their current needs, and this is vital information to form the basis of further education initiatives and provides a guide for further curriculum development.
Conclusions
Topics relating to nutrition and growth are an integral part of paediatric training. Paediatricians need to recognize the importance of effective nutrition counselling and this requires a solid nutritional knowledge base and training. Patterns of diseases change independently of each other as time progresses. Thus, the relative importance of nutritional clinical topics should be re-assessed on a regular basis to be updated on prevailing trends and knowledge gaps to ensure a robust curriculum.
Footnotes
Author contributions
SRC, MCSY and CHWW performed the research. SRC and CHWW designed the research study. SRC and CHWW analysed the data. SRC, MCSY and CHWW wrote the paper. All authors reviewed and edited the manuscript and approved the final version of the manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical statement
Data Availability Statement
The datasets generated and/or analysed during the current study are available from Dr Sudipta Roy Chowdhury.