Whey-Based Partially Hydrolyzed Formula Versus Polymeric Formula On Undernourished Neurologically Impaired Children: Open-Label Randomized Study

Whey-Based Partially Hydrolyzed Formula Versus Polymeric Formula On Undernourished Neurologically Impaired Children: Open-Label Randomized Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Whey-Based Partially Hydrolyzed Formula Versus Polymeric Formula On Undernourished Neurologically Impaired Children: Open-Label Randomized Study Aml Mahfouz, Ahmed F. Khalil, Sara Saad, Marwa Abd Elmaksoud This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8165537/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Undernutrition is common in neurologically impaired children. It increases the burden of comorbidities and affects the quality of life of these children. This study aimed to compare the efficacy of whey-based partially hydrolyzed formula (WPHF) versus isocaloric polymeric formula on the nutritional status of undernourished children with neurological impairment (NI). The secondary aim was to follow up on the changes in these parameters after using WPHF for 3 and 6 months. Methods: In this 6-month prospective, open-label, randomized study, children with NI aged 2–6 years were assigned to two groups. Group I received 50% of their caloric needs as an isocaloric polymeric formula and 50% of their standard nutritional feeding, as per ESPGHAN guidelines. Group II received 50% of their caloric needs as WPHF, with the remaining 50% from standard feeding. Anthropometric measurements, feeding intolerance symptoms, and chest infection frequency were assessed at baseline, 3 months, and 6 months. Results: A total of 100 children (50 per group) were included, with cerebral palsy being the most common cause of NI. After 3 months, Group II showed significant improvement in anthropometric measures and fewer symptoms of feeding intolerance. These benefits were further enhanced after 6 months of continued WPHF use. Conclusion: In undernourished children with NI, WPHF significantly improves nutritional status, growth parameters, and feeding tolerance compared to the standard polymeric formula. Notable improvements were observed within 3 months and increased with prolonged intervention. This study was registered at ClinicalTrial.gov (ID: NCT06356103) on 16th March 2024. “Retrospectively registered. https://register.clinicaltrials.gov/prs/app/template/EditRecord.vm?epmode=View&listmode=Edit&uid=U00076LH&ts=62&sid=S000EAYY&cx=-bryze2 Neurological Impairment Children Feeding tolerance Partially Hydrolyzed Formula Anthropometric measurements Introduction Neurological impairment (NI) occurs when there is damage to the nervous system, which can affect the way it processes information and communicates with the rest of the body. This is associated with a wide range of disorders such as cerebral palsy, learning disabilities, and autism. [ 1 ] The etiology of malnutrition in children with NI is multifactorial including both nutritional and non-nutritional factors. The main nutritional factor is caused by inadequate dietary intake and feeding intolerance as a consequence of a swallowing disorder, GERD, and constipation. [ 2 ] The type and severity of underlying NI, ambulatory and cognitive status, as well as the use of anti-epileptic drugs that may affect appetite, are important non-nutritional factors. [ 3 ] Adequate nutritional support for children with NI may restore linear growth, normalize weight, decrease irritability and spasticity, improve wound healing and peripheral circulation, reduce the frequency of hospitalization, and hence improve overall health and quality of life. [ 3 ] For most children with NI over the age of one, a standard formula with fiber is sufficient. However, for those who have symptoms of feeding intolerance, enteral nutrition (EN) using a high-energy whey-based formula may be needed. [ 4 ] Whey-based partially hydrolyzed formula (WPHF) contains peptides of varying lengths, including di- and tri-peptides and amino acids. This helps improve absorption and tolerance compared to protein systems composed entirely of free amino acids or intact protein. [ 5 ] The use of WPHF is associated with enhanced gastric emptying, reduction in vomiting, and aspiration of feeds, resulting in improved feeding tolerance and easier fulfillment of nutritional needs. This may also decrease the feeding time and hence the burden on caregivers. [ 6 ] Data concerning the value of using WPHF in children with NI are limited to a few studies that included small groups of children for a short duration. [ 7 , 8 ] This study aimed primarily to compare the efficacy of WPHF versus PF (standard) on the nutritional status which is reflected by growth parameters and feeding tolerance in undernourished children with NI. The secondary aim was to follow up on the changes in these parameters after using WPHF for 3 and 6 months. Patients and methods This work was conducted as an open-labelprospective randomized study over 6 months, including children with NI presented to the Clinical Nutrition Clinic at Alexandria University Children’s Hospital. This study was approved by the Faculty of Medicine, Alexandria University Research Ethics Committee (protocol ID 0107060) following the Declaration of Helsinki and registered at ClinicalTrial.gov (ID NCT06356103) in April 2024. Written consent was taken from the parents or caregivers of all included children. The sample size calculation was estimated using G*Power 3.1.9.7 software. The calculation was based on the study by Ibrahim et al., [9] . The estimated minimum sample size at a 5% level of significance to achieve 90% power was 50 children in each group. One hundred undernourished children with NI aged 2-6 years were included. Inclusion criteria were one or more of the following signs for identification of undernutrition in the studied children: weight for age z score <–2, triceps skinfold thickness <10th centile for age, mid-upper arm fat or muscle area <10th percentile for age, faltering weight and/or failure to thrive or physical signs of undernutrition such as decubitus skin problems and poor peripheral circulation. [4] Children with NI due to metabolic diseases were excluded. Children were randomly assigned to either study group with a 1:1 ratio as per a computer-generated randomization schedule. Group I received 50% of their caloric requirements as isocaloric polymeric formula (standard) and 50% standard nutritional feeding according to ESPGHAN [ 4 ] guidelines. Group 2 received 50% of their caloric requirements as WPHF, and the other 50% as standard nutritional feeding. Pre-intervention phase: All studied children were evaluated according to ESPGHAN guidelines. [4] The following history parameters were recorded at the start of the study including demographic data, family history, medical history, and treatment history. Demographic data included age, sex, residency, and social status. The etiology of NI and the clinical characteristics of the disease were reported including duration, manifestations, expected course, and severity of NI by assessing the degree of intellectual disability by IQ test and the degree of motor impairment by gross motor function classification system (GMFS). History of nutritional intake was taken by a 3-day record of actual food consumption. [10] The physical examination focused on motor and skeletal systems examination (the presence of contractures and scoliosis, which affects positioning during meals). Estimation of caloric needs was performed using dietary reference standards. [ 1 1 ] Nutritional assessments were conducted for all patients by the same observer. The anthropometric measurements were obtained at the start of the study by using standardized techniques and equipment for all studied children, including weight, height/length, body mass index (BMI), head circumference (HC), mid-upper arm circumference (MUAC), and triceps skinfold thickness (TSF). Weight was measured using the double weighing method (weight of the parent subtracted from the combined weight of parent and child) on a digital scale. [ 1 2 ] Height/length was measured by a stadiometer. In children with joint contractions, spasticity, and/or scoliosis, the length was measured by segmental length measurements using sliding calipers. Then the length was estimated by simple equations such as knee-heel length (L = (2.69 x KH) + 24.2), tibia length (L = (3.26 x TL) + 30.8), and upper arm length (L = (4.35 x UAL) + 21.8). [13] BMI was calculated as [weight in kg]/ [height in m] 2 . HC in children younger than 3 years was measured by non-stretchable tape. MUAC was measured by non-stretchable tape at the midpoint between the tip of the shoulder and the tip of the elbow. TSF was measured by a skinfold caliper at the midway between the shoulder and the elbow joints in the vertical direction on the center of the back of the upper arm. The standard deviation (SD) and Z-score (X-m)/SDwere then calculated for all growth parameters. [ 1 4 ] Symptoms of feeding intolerance, such as swallowing difficulties, choking, GERD, constipation, and other conditions associated with the NI, like recurrent chest infections, were identified by careful history taking and review of the previous relevant investigations, if they were performed. Treatment of GERD was initiated in all children if they had suggestive symptoms (excessive vomiting, hematemesis, and refusal of feeding) or a confirmed diagnosis by contrast upper GI study or upper GI endoscopy. Proton pump inhibitors (PPIs) were used to treat suspected or confirmed GERD (Esomeprazole 1-2 mg/kg/day for 4-8 weeks). [ 1 5 ] Constipation was diagnosed using the Rome IV criteria. [ 1 6 ] All the children with constipation were treated by the standard protocol as in typically developing children. [4] Swallowing difficulties were diagnosed by swallowing specialists and treatment was received according to their recommendations. Nutritional intervention phase : Group I received 50% of their caloric requirements as isocaloric polymeric formula (standard) and 50% standard nutritional feeding according to ESPGHAN guidelines. [4] Group II received 50% of their caloric requirements in the form of WPHF and the other 50 % was given as standard nutritional feeding for 6 months. The WPHF used during the study was Peptamen Junior, 100 kcal/100 ml (Nestlé Health Science, Vevey, Switzerland). Energy requirements were calculated by the dietary reference intake standard for the BEE method. Energy intake (kcal/day) = BEE × 1.1, where BEE is: Male: 66.5 + (13.75× weight in kg) + (5.003× height in cm) – (6.775 × age) Female: 65.1 + (9.56 × weight in kg) + (1.850 × height in cm) – (4.676× age) The amount of formula, frequency, duration, and route of feeding were adjusted according to the condition of each child. All the studied children received protein and micronutrient requirements according to the recommended dietary allowance (RDA). [ 1 7 ] The patients used regular homemade food with the appropriate thickness for each child. Post interventional phase : Growth parameters and symptoms of feeding intolerance and recurrent chest infections were reassessed after 3 and 6 months of the nutritional intervention and compared between the two groups. In group II (WPHF), the changes in the aforementioned parameters at 3 months were compared to those at 6 months of using WPHF. Improvement in feeding tolerance was considered when there was an absence or decrease of symptoms and better weight gain. Statistical analysis of the data Data was fed to the computer and analyzed using the IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp) Qualitative data were described using numbers and percentages. The Shapiro-Wilk test was used to verify the normality of the distribution. Quantitative data were described using range (minimum and maximum), mean, standard deviation, median, and interquartile range (IQR). Chi-square test for categorical variables, to compare between different groups. Monte Carlo correction for chi-square when more than 20% of the cells have an expected count of less than 5. Student The student t-test for normally distributed quantitative variables, to compare between two studied groups. Mann-Whitney test for abnormally distributed quantitative variables, to compare between two studied groups. Cochran's test is used for a non-parametric test for binary response variables, and Post Hoc Test (Dunn's) for pairwise comparisons. The Friedman test is used for abnormally distributed quantitative variables, to compare between more than two periods or stages, and Post Hoc Test (Dunn's) for pairwise comparisons. The significance of the obtained results was judged at the 5% level. Results Demographic data and clinical characteristics of the disease showed male predominance in both studied groups. The mean age was 3.5 ±1.1 years in group I versus a mean age of 3.8 ±1.3 years in group II. The demographic data and clinical characteristics of the disease were matched in both groups at the start of the study (Table 1). Tube feeding was used in 14% of group I versus 18% of group II. Table (1): Demographic data and clinical characteristics of both groups Group I (n = 50) Group II (n = 50) Test of Significant P No. (%) No. (%) Male gender 26 (52%) 27 (54%) χ 2 = 0.040 0.841 Age (years) 3.5 ± 1.1 3.8 ± 1.3 t=1.144 0.256 Rural residency 39 (78%) 37 (74%) χ 2 =0.219 0.640 Causes of NI χ 2 =6.353 0.853 Post-HIE 19 (38%) 19 (38%) Genetic syndrome 10 (20%) 9 (18%) Structural brain deformity 10 (20%) 6 (12%) Demyelinating disease 4 (8%) 2 (4%) Post-meningitic CP 3 (6%) 4 (8%) Neuro-degenerative disease 2 (4%) 4 (8%) Neuro-metabolic disease 2 (4%) 2 (4%) Post-TORCH infections 0 (0%) 2 (4%) Post intracranial hemorrhage 0 (0%) 1 (2%) Post kernicterus 0 (0%) 1 (2%) Duration of disease 3 years 24 (48%) 28 (56%) Expected course of disease Stationary 34 (68%) 37 (75%) χ 2 =0.440 0.803 Regressive 10 (20%) 8 (16%) Progressive 6 (12%) 5 (10%) Seizures present 33 (66%) 25 (50%) χ 2 =2.627 0.105 IQ test Moderate (42 – 55) 5 (10%) 6 (12%) χ 2 =5.424 0.064 Severe (25 – 41) 0 (0%) 5 (10%) Profound (<25) 45 (90%) 39 (78%) GMFS Grade III 0 (0%) 1 (2%) c 2 =3.056 0.162 Grade IV 9 (18%) 15 (30%) Grade V 41 (82%) 34 (68%) Feeding route Oral feeding 43(86.0) 41(82.0) c 2 =0.298 0.585 Tube feeding 7(14.0) 9(18.0) Energy need (kcal/day) 686.3 ±62.2 687.4 ±60.6 t=-0.103 0.918 Fiber needs (gm/day) 21.5±2.9 22.0±3.0 t=-0.897 0.372 Abbreviations: NI: neurological impairment; post-HIE: post-hypoxic ischemic encephalopathy; GMFS= gross motor function classification system; c 2 : Chi-square test; t: Student t-test; MC: Monte Carlo; p: p-value for comparing between the two studied groups At the start of the study, the nutritional assessment showed that all growth parameters were matching in group I and group II (Weight Z-score; -4.08 in group I vs -3.95 in group II) and (Length Z-score; -2.19 in group I vs -2.58 in group II). After nutritional intervention, children in group II showed improvement in all growth parameters compared to children in group I after the initial 3 months of intervention. The weight (p=0.005), BMI (p<0.001), MUAC (p<0.001), and TSF (p<0.001) showed statistically significant and continuous improvement as early as the first 3 months. (Table 2) Table (2): Growth parameters in both groups before and after nutritional intervention Growth parameters Group I Group II Test P Weight Z score Pre-intervention -4.08 (-4.45 – -3.28) -3.95 (-4.21 - -2.98) U=1209.0 0.777 Post 3 months -3.92 (-4.58 – -3.39) -3.27 (-3.64 - -2.44) U=840.0 * 0.005 * Post 6 months -4.13 (-4.81 – -3.34) -2.52 (-3.39 – -1.59) U=466.50 * <0.001 * Length Z-Score Pre-intervention -2.19 (-3.72 - -1.19) -2.58 (-3.64 – -1.31) U=1100.5 0.302 Post 3 months -2.26 (-3.36 - -1.27) -2.32 (-3.59 – -1.51) U=1132.5 0.418 Post 6 months -2.21 (-2.67 – -1.58) -2.38 (-3.53 – -1.52) U=1158.0 0.526 BMI Z-Score Pre-intervention -3.97 (-4.85 – -3.24) -3.47 (-5.69 - -3.22) U=1030.0 0.129 Post 3 months -3.91 (-4.90 – -3.22) -2.50 (-3.75 - -1.19) U=607.50 * <0.001 * Post 6 months -3.86 (-4.93 – -3.11) -1.19 (-2.28 – -0.30) U=250.50 * <0.001 * HC Z-Score Pre-intervention -3.12 (-5.58 – -1.49) -3.14 (-5.22 – -1.95) U=145.0 0.688 Post 3 months -4.08 (-5.67 - -1.80) -2.93 (-5.13 – -1.88) U=91.0 0.472 Post 6 months -4.20 (-5.8 - -1.77) -2.93 (-5.28 – -1.67) U=94.0 0.553 MUAC Z-Score Pre-intervention -3.56 (-4.18 --3.0) -3.05 (-3.93 – -2.74) U=770.0 0.073 Post 3 months -3.77 (-4.30 – -3.16) -2.77 (-3.64 – -2.36) U=631.0 * <0.001 * Post 6 months -3.76 (-4.34 – -3.13) -2.34 (-3.20 – -1.90) U=453.0 * <0.001 * TSF Z-Score Pre-intervention -4.25 (-4.45 – -3.37) -3.42 (-4.48 – -3.24) U=1028.50 0.127 Post 3 months -4.13 (-4.39 – -3.35) -2.93 (-3.45 – -2.34) U=650.0 * <0.001 * Post 6 months -4.13 (-4.47 – -3.33) -2.36 (-3.33 – -1.87) U=358.5 * <0.001 * Abbreviations: BMI: body mass index; HC: head circumference; MUAC: mid-upper arm circumference; TSF: triceps skinfold thickness; SD: U: Mann Whitney test; c 2 : Chi square test; FE: Fisher Exact test; p: p value for comparing between the two studied groups; *: Statistically significant at p ≤ 0.05. At the start of the study, there was no significant difference between both groups in the symptoms of feeding intolerance and chest infections. After nutritional intervention, there was a statistically significant and continuous improvement in feeding tolerance (improved choking, GERD and constipation) and chest infections in group II compared to group I as early as the first 3 months. (Table 3) Table (3) Symptoms of feeding intolerance and chest infections in both groups before and after nutritional intervention. Symptoms Group I Group II χ 2 P Swallowing difficulties Pre-intervention 45 (90%) 43 (86%) 0.379 0.538 Post 3 Months 45 (90%) 43 (86%) 0.379 0.538 Post 6 Months 45 (90%) 43 (86%) 0.379 0.538 Choking Pre-intervention 36 (72%) 27 (54%) 3.475 0.062 Post 3 Months 36 (72%) 15 (30%) 17.647 * <0.001 * Post 6 Months 34 (68%) 11 (22%) 21.374 * <0.001 * GERD Pre-intervention 19 (38%) 17 (34%) 0.174 0.677 Post 3 Months 18 (36%) 9 (18%) 4.110 * 0.043 * Post 6 Months 18 (36.7%) 2 (4%) 16.450 * <0.001 * Dysphagia Pre-intervention 17 (34%) 15 (30%) 0.184 0.668 Post 3 Months 17 (34%) 14 (28%) 0.421 0.517 Post 6 Months 17 (34%) 14 (28%) 0.421 0.517 Constipation Pre-intervention 46 (92%) 48 (96%) 0.709 FE p= 0.678 Post 3 Months 42 (84%) 22 (44%) 17.361 * <0.001 * Post 6 Months 36 (72%) 11 (22%) 25.090 * <0.001 * Chest infections Pre-intervention 24 (48%) 21 (42%) 0.364 0.546 Post 3 Months 23 (46%) 8 (16%) 10.519 * 0.001 * Post 6 Months 17 (34%) 5 (10%) 8.392 * 0.004 * Abbreviations: GERD: gastro-esophageal reflux disease; c 2 : Chi square test; FE: Fisher Exact test; p: p value for comparing between the two studied groups; *: Statistically significant at p ≤ 0.05 In group II, the improvement in most of the anthropometric measurements namely: weight, BMI, MUAC and TSF, GERD and constipation after 6 months of nutritional intervention was statistically significant when compared to the improvement achieved at the initial 3 months. After 6 months of using WPHF, the percentage of children with choking and/or recurrent chest infections had dropped markedly when compared to the initial 3 months (Table 4) Table (4): Growth parameters, symptoms of feeding intolerance, and chest infections in group II (WPHF) after 3 and 6 months of nutritional intervention Pre-intervention Post 3 months Post 6 months Test p Weight Z-Score -3.95 (-4.60 – -2.90) -3.27 (-3.64 - -2.44) -2.52 (-3.39 – -1.59) Fr=64.432 * <0.001 * P* p 1 =0.002 * , p 2 <0.001 * , p 3 <0.001 * Length Z-Score -2.58 (-3.64 – -1.31) -2.32 (-3.59 – -1.51) -2.38 (-3.53 – -1.52) Fr=3.283 0.194 BMI Z-Score -3.47 (-4.56 – -2.62) -2.50 (-3.75 - -1.19) -1.19 (-2.28 – -0.30) Fr=69.160 * <0.001 * P* p 1 <0.001 * , p 2 <0.001 * , p 3 <0.001 * HC Z-Score -3.14 (-5.22 – -1.95) -2.93 (-5.13 – -1.88) -2.93 (-5.28 – -1.67) Fr=1.088 0.580 MUAC Z-Score -3.05 (-3.93 – -2.74) -2.77 (-3.64 – -2.36) -2.34 (-3.20 – -1.90) Fr=68.677 * <0.001 * P* p 1 =0.001 * , p 2 <0.001 * , p 3 <0.001 * TSF Z-Score -3.42 (-4.48 – -3.24) -2.93 (-3.45 – -2.34) -2.36 (-3.33 – -1.87) Fr=80.708 * <0.001 * P* p 1 <0.001 * , p 2 <0.001 * , p 3 <0.001 * Swallowing difficulties 43 (86%) 43 (86%) 43 (86%) Q = 0.000 1.000 Choking 27 (54%) 15 (30%) 11 (22%) Q = 23.111 * <0.001 * P* p 1 =0.001 * ,p 2 <0.001 * ,p 3 =0.248 GERD 17 (34%) 9 (18%) 2 (4%) Q = 19.882 * <0.001 * P* p 1 =0.017 * ,p 2 <0.001 * ,p 3 =0.038 * Dysphagia 15 (30%) 14 (28%) 14 (28%) Q = 0.667 0.717 Constipation 48 (96%) 22 (44%) 11 (22%) Q = 58.541 * <0.001 * P* p 1 <0.001 * ,p 2 <0.001 * ,p 3 =0.027 * Chest infections 21 (42%) 8 (16%) 5 (10%) Q = 27.125 * <0.001 * P* p 1 <0.001 * ,p 2 <0.001 * ,p 3 =0.358 Abbreviations: BMI: body mass index; HC: head circumference; GERD; gastro-esophageal reflux disease; MUAC: mid-upper arm circumference; TSF: triceps skinfold thickness; Fr: Friedman test, significant between periods was done using Post Hoc Test (Dunn's); Q: Cochran's test, significant between periods was done using Post Hoc Test (Dunn's); p: p value for comparing between the three studied periods; p 1 : p value for comparing between Pre and after 3 Months; p 2 : p value for comparing between Pre and after 6 Months; p 3 : p value for comparing between 3 and 6 Months; P*= significant between periods. Discussion The results of this study showed that undernourished children with NI receiving WPHF showed significant improvement in most of the anthropometric parameters during the study course. They also had better feeding tolerance with significant improvement in GERD, choking, and constipation. They experienced fewer chest infections due to improved nutrition and better feeding tolerance. We reported a direct relation between the duration of use of WPHF and the magnitude of improvement of all the aforementioned parameters. In children with NI, growth and anthropometric measurements reflect the child's nutritional status. [18] Studies investigating the efficacy of WPHF on the growth parameters in undernourished children with NI are very limited. In the present study, all the growth parameters, especially the weight improved significantly in children who received WPHF compared to the children on PF. Our results are in line with the study by Minor et al., [ 7 ] who reported that all children with developmental delay and poor weight gain achieved an increase in weight after switching to whey-based formula. Nutritional assessment in children with NI should not be based solely on weight and height measurements. Routine assessment of MUAC which reflects lean body mass and TSF which reflects reserve fat are recommended. [4] In the current work, assessment of BMI, MUAC, and TSF were performed before and after nutritional intervention. All of these parameters showed significant improvement in children who received WPHF. The study by Minor et al., [ 7 ] was conducted on a small group of children (13 cases) only focused on weight and height assessment and did not investigate the effect of WPHF on body fat reserve or lean body mass. There is a lack of data about the value of the long-term use of WPHF in the nutritional rehabilitation of undernourished children with NI. The current study highlighted that there is a direct relation between the duration of use of WPHF and the magnitude of improvement in all growth parameters. Therefore, the use of WPHF for more prolonged periods may be a valid recommendation. We reported a considerable improvement in choking and GERD in children who received WPHF compared to children on PF. Similar findings were observed by Minor et al., [ 7 ] who reported that 92% of children with NI had improvement in GERD symptoms, specifically vomiting. In a 24-hour pH probe study, Khoshoo et al., [ 1 9 ] reported a significant reduction in the episodes and duration of GERD in 14 children with NI who consumed a whey-based formula compared to the standard casein-based formula (p<0.05). Improvement of GERD in children with NI consuming WPHF was even more noticeable when the use of WPHF was extended to 6 months. The role of WPHF in alleviating the symptoms of GERD may be explained by the enhanced gastric emptying time. This explanation can be supported by the finding of study by Brun et al., [20] . The median gastric half-emptying time was faster with a whey formula than with the casein formula. Based on the above, WPHF may be considered as an additional tool in the management of GERD in children with NI, especially when pharmacotherapeutic interventions alone fail to alleviate the symptoms or when a surgical alternative may not be desirable or feasible. The delay in colonic transit time which is more frequent in children with NI, may explain the frequent prevalence of constipation in those children. [ 2 1 ] The current work showed a significant and rapid improvement in constipation in children with NI who used WPHF compared to children who used PF along the study course. Also, there was a remarkable decrease in the use of laxatives. The rate of improvement increased with the prolongation of the use of WPHF to 6 months. Pediatric studies performed by Minor et al., [ 7 ] and Mundi et al., [8] reported that the majority of children with NI showed significant improvement in constipation within the first few weeks after the transition to whey-based formula. The mechanism of constipation relief in children with NI using WPHF is not completely understood, but it may be related to its easier digestion and absorption when compared to PF due to the higher contents of medium‐chain triglycerides (MCTs) and hydrolyzed proteins. [ 8 ] Further studies may be needed to confirm these possible mechanisms and to assess the need and dosage of laxatives in children with NI using WPHF. Children with NI are more susceptible to recurrent chest infections due to increased secretions, poor cough, GERD, choking, decreased mobility, skeletal deformities, and malnutrition. In the current study, there was a significant reduction in chest infections and hospitalizations in children who received WPHF. The observed improvement in this group increased when the WPHF was used for a more prolonged period (6 months). The reduction in chest infections may be explained by the improvement in gastric emptying time with WPHF, which results in a decrease in GERD and choking. Improved nutritional status after diet modification and increased caregiver's awareness of the importance of physiotherapy during the study are also important contributing factors in the reduction of chest infections. No studies have assessed this point in children with NI. Huang et al., [22] used a peptide-based formula in mechanically ventilated well-developed children with pneumonia and reported significant improvement in mechanical ventilation and hospital stay in the group who received the peptide-based formula. Still, more studies are needed in children with NI to explore the value of WPHF in the reduction of chest infections. Among the strengths of this work is its prospective design. All the possible growth parameters were evaluated and monitored before starting the intervention and at least twice during the study period which allowed a complete and comprehensive assessment of nutritional status. Assessment and treatment of causes of feeding intolerance in the recruited children is an additional strength of this study. One of the limitations of our study was the lack of use of laboratory or imaging techniques to assess nutritional status. Additionally, the open-label nature of the study is considered as another limitation to the current trial. Future studies that include more prolonged periods of nutritional support and more advanced markers of nutritional assessment may be more confirmatory. To demonstrate the efficacy of WPHF, we recruited undernourished children, but given the efficacy proven by our work, we recommend the inclusion of WPHF in the nutritional rehabilitation of children with NI as a part of their initial therapeutic management before they develop undernutrition. In conclusion . Compared to PF , WPHF is linked to improved nutritional status and most growth parameters in undernourished children with NI. Additionally, WPHF lessens the incidence of related chest infections while improving feeding intolerance symptoms such as GERD, choking, and constipation in comparison to the other group with PF. Many of these benefits were noticed within the first three months of WPHF feeding; however, using it for an extra three months was linked to even more notable improvements. Abbreviations BEE =Basal energy expenditure. CP= Cerebral palsy. ESPGHAN= European Society for Pediatric Gastroenterology, Hepatology and Nutrition. GERD= Gastroesophageal reflux disease. GI= Gastrointestinal GMFS= Gross motor function classification system. HC= Head circumference. KH= Knee-heel length. L= Length. MCTs= Medium‐chain triglycerides. MUAC= Mid-upper arm circumference. NI= Neurological impairment. P*= Significant between periods. PPIs= Proton pump inhibitors. RDA= Recommended dietary allowance. SD= Standard deviation. TL= Tibia length TSF= Triceps skinfold thickness. UAL= Upper arm length. WPHF = Whey-based partially hydrolyzed formula. PF = Polymeric formula Declarations Acknowledgments: The authors thank the staff members of the Pediatric Neurology and Gastroenterology Clinic for their collaboration during data collection. The authors would also like to thank the children who participated in this work and their parents. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Competing interests: No potential conflict of interest was reported by the authors. Ethics approval: Ethical approval for the study was obtained from the local Faculty of Medicine Ethics Committee Consent to participate: Written informed consent was obtained from the patient’s parents before study participation. Consent for publication: 'N/A' Availability of data and material: All data used are included in this article. Further data that support the findings of this study are available from the corresponding author upon reasonable request by mail. Code availability: 'N/A' This study adheres to CONSORT 2010 guidelines Authors’ contributions: All authors contributed to the study's conception and design. Material preparation, data collection and analysis were performed by Sara Saad. The first draft of the manuscript was written by Aml Mahfouz, Sara Saad, and Ahmed Foad. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Queensland Government. My child has neurological impairment: Information for Queensland families of young children. 2014. Available from: file:///C:/Users/Rada/Downloads/my-child-has-neurological-impairment.pdf. [Accessed in: Feb, 2024]. Sullivan PB, McIntyre E. Gastrointestinal problems in disabled children. Curr. Paediatr. 2005; 15(4):347-353. Penagini F, Mameli C, Fabiano V, Brunetti D, Dilillo D, Zuccotti GV. Dietary Intakes and Nutritional Issues in Neurologically Impaired Children. Nutrients 2015; 7(11):9400-9415. Romano C, van Wynckel M, Hulst J, Broekaert I, Bronsky J, Dall'Oglio L, 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. 2017; 65(2):242-264. Nelson JL. A pilot intervention study to evaluate compliance to a peptide-based oral nutritional supplement in an adult population with impaired gastrointestinal function. Clin. Nutr. Exp. 2019; 28:123-130. Savage K, Kritas S, Schwarzer A, Davidson G, Omari T. Whey- vs casein-based enteral formula and gastrointestinal function in children with cerebral palsy. J. Parenter. Enteral. Nutr. 2012; 36(1 Suppl):118s-123s. Minor G, Ochoa JB, Storm H, Periman S. Formula Switch Leads to Enteral Feeding Tolerance Improvements in Children With Developmental Delays. Glob. Pediatr. Health 2016; 3:2333794x16681887. Mohamed Elfadil O, Steien DB, Narasimhan R, Velapati SR. Transition to peptide-based diet improved enteral nutrition tolerance and decreased healthcare utilization in pediatric home enteral nutrition. J. Parenter. Enteral. Nutr. 2022; 46(3):626-634. Ibrahim H, Mansour M, El Gendy YG. Peptide-based formula versus standard-based polymeric formula for critically ill children: is it superior for patients’ tolerance? Archives of Medical Science : AMS [Internet]. 2020 Apr 6;16(3):592–6. Sullivan PB, Juszczak E, Lambert BR, Rose M, Ford-Adams ME, Johnson A. Impact of feeding problems on nutritional intake and growth: Oxford Feeding Study II. Dev. Med. Child Neurol. 2002; 44(7):461-467. Food and Nutrition Board. Dietary Reference Intakes (DRIs): Estimated Average Requirements. Institute of Medicine, National Academies, United State. 2011. Vessey JA, Stueve DL. A comparison of two techniques for weighing young children. Pediatr. Nurs. 1996; 22(4):327-330. Haapala H, Peterson MD, Daunter A, Hurvitz EA. Agreement Between Actual Height and Estimated Height Using Segmental Limb Lengths for Individuals with Cerebral Palsy. Am. J. Phys. Med. Rehabil. 2015; 94(7):539-546. World Health Organization (WHO). Child growth standards. WHO, Geneva, Switzerland. 2021. Ayerbe JI, Hauser B, Salvatore S, Vandenplas Y. Diagnosis and Management of Gastroesophageal Reflux Disease in Infants and Children: from Guidelines to Clinical Practice. Pediatr. Gastroenterol. Hepatol. Nutr. 2019; 22(2):107-121. ROME Foundation. ROME IV diagnostic criteria for disorders of gut-brain interaction (DGBI). 2021. Available from: https://theromefoundation.org/rome-iv/rome-iv-criteria/. [Accessed in: Feb, 2024]. National Institute of Health (NIH). Nutrient Recommendations: Dietary Reference Intakes (DRI). Available from: https://ods.od.nih.gov/HealthInformation/nutrientrecommendations.aspx. [Accessed in: Fec, 2024]. Sánchez-Lastres J, Eirís-Puñal J, Otero-Cepeda JL, Pavón-Belinchón P, Castro-Gago M. Nutritional status of mentally retarded children in north-west Spain. I. Anthropometric indicators. Acta Paediatr. 2003; 92(6):747-753. Khoshoo V, Zembo M, King A, Dhar M, Reifen R, Pencharz P. Incidence of gastroesophageal reflux with whey- and casein-based formulas in infants and in children with severe neurological impairment. J. Pediatr. Gastroenterol. Nutr. 1996; 22(1):48-55. Brun AC, Størdal K, Johannesdottir GB, Bentsen BS, Medhus AW. The effect of protein composition in liquid meals on gastric emptying rate in children with cerebral palsy. Clin. Nutr. 2012; 31(1):108-112. Park ES, Park CI, Cho SR, Na SI, Cho YS. Colonic transit time and constipation in children with spastic cerebral palsy. Arch. Phys. Med. Rehabil. 2004; 85(3):453-456. Huang XJ, Guo FF, Li F, Zhao JC, Fan YZ, Wang N, et al. Nutritional support in children with pneumonia on mechanical ventilation by short-peptide enteral nutrition formula. Zhongguo Dang Dai Er Ke Za Zhi 2020; 22(11):1209-1214. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8165537","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":570762865,"identity":"f221427e-6d1c-4fd6-b509-6ffd42a55423","order_by":0,"name":"Aml Mahfouz","email":"","orcid":"","institution":"Alexandria University","correspondingAuthor":false,"prefix":"","firstName":"Aml","middleName":"","lastName":"Mahfouz","suffix":""},{"id":570762866,"identity":"07004cf0-813f-4a6d-91e9-2b6d6748b6ca","order_by":1,"name":"Ahmed F. Khalil","email":"","orcid":"","institution":"Alexandria University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"F.","lastName":"Khalil","suffix":""},{"id":570762867,"identity":"fda32a9d-f502-4588-80b8-8773b779343c","order_by":2,"name":"Sara Saad","email":"","orcid":"","institution":"Alexandria University","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Saad","suffix":""},{"id":570762868,"identity":"d49959de-3422-4dde-b8b3-d072020a910b","order_by":3,"name":"Marwa Abd Elmaksoud","email":"data:image/png;base64,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","orcid":"","institution":"Alexandria University","correspondingAuthor":true,"prefix":"","firstName":"Marwa","middleName":"Abd","lastName":"Elmaksoud","suffix":""}],"badges":[],"createdAt":"2025-11-20 14:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8165537/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8165537/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":99879287,"identity":"6ac2a168-f490-4689-b4ff-f896e6ceb005","added_by":"auto","created_at":"2026-01-09 10:55:35","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":56833,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-8165537/v1/c6151f84590c051e0d223f06.docx"},{"id":100358769,"identity":"091ea382-3f8f-4935-8b69-332893ebda38","added_by":"auto","created_at":"2026-01-16 07:21:20","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6605,"visible":true,"origin":"","legend":"","description":"","filename":"9e461fb83e0f4d26bc31562f2c65db25.json","url":"https://assets-eu.researchsquare.com/files/rs-8165537/v1/2b73b0366a0736eceee5fc1a.json"},{"id":99879290,"identity":"feff20f4-41c2-42fc-912e-4a0a62f3ab2d","added_by":"auto","created_at":"2026-01-09 10:55:36","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":119416,"visible":true,"origin":"","legend":"","description":"","filename":"9e461fb83e0f4d26bc31562f2c65db251enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8165537/v1/86a8d010378fbc2d14df115f.xml"},{"id":99879289,"identity":"b0dfc399-e7b0-400f-bc91-b9bba2a7dd08","added_by":"auto","created_at":"2026-01-09 10:55:36","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":114036,"visible":true,"origin":"","legend":"","description":"","filename":"9e461fb83e0f4d26bc31562f2c65db251structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8165537/v1/f4eeda3b999134815d979274.xml"},{"id":99879292,"identity":"3e985a26-4ad0-4bc6-a499-bd9c1e04b2e7","added_by":"auto","created_at":"2026-01-09 10:55:38","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":127438,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8165537/v1/2e448da4a5df02cedadd9ee3.html"},{"id":100377085,"identity":"99c2403f-f886-493f-b4d9-fc7959d4fd66","added_by":"auto","created_at":"2026-01-16 08:47:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1475712,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8165537/v1/028d4dd7-b13f-46dc-b393-2a7df547bd62.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Whey-Based Partially Hydrolyzed Formula Versus Polymeric Formula On Undernourished Neurologically Impaired Children: Open-Label Randomized Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNeurological impairment (NI) occurs when there is damage to the nervous system, which can affect the way it processes information and communicates with the rest of the body. This is associated with a wide range of disorders such as cerebral palsy, learning disabilities, and autism.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e The etiology of malnutrition in children with NI is multifactorial including both nutritional and non-nutritional factors. The main nutritional factor is caused by inadequate dietary intake and feeding intolerance as a consequence of a swallowing disorder, GERD, and constipation.\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e The type and severity of underlying NI, ambulatory and cognitive status, as well as the use of anti-epileptic drugs that may affect appetite, are important non-nutritional factors.\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAdequate nutritional support for children with NI may restore linear growth, normalize weight, decrease irritability and spasticity, improve wound healing and peripheral circulation, reduce the frequency of hospitalization, and hence improve overall health and quality of life.\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e For most children with NI over the age of one, a standard formula with fiber is sufficient. However, for those who have symptoms of feeding intolerance, enteral nutrition (EN) using a high-energy whey-based formula may be needed.\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e Whey-based partially hydrolyzed formula (WPHF) contains peptides of varying lengths, including di- and tri-peptides and amino acids. This helps improve absorption and tolerance compared to protein systems composed entirely of free amino acids or intact protein.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e The use of WPHF is associated with enhanced gastric emptying, reduction in vomiting, and aspiration of feeds, resulting in improved feeding tolerance and easier fulfillment of nutritional needs. This may also decrease the feeding time and hence the burden on caregivers.\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e Data concerning the value of using WPHF in children with NI are limited to a few studies that included small groups of children for a short duration.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study aimed primarily to compare the efficacy of WPHF versus PF (standard) on the nutritional status which is reflected by growth parameters and feeding tolerance in undernourished children with NI. The secondary aim was to follow up on the changes in these parameters after using WPHF for 3 and 6 months.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003eThis work was conducted as an open-labelprospective randomized study over 6 months, including children with NI presented to the Clinical Nutrition Clinic at Alexandria University Children\u0026rsquo;s Hospital. This study was approved by the Faculty of Medicine, Alexandria University Research Ethics Committee (protocol ID 0107060) following the Declaration of Helsinki and registered at ClinicalTrial.gov (ID NCT06356103) in April 2024. Written consent was taken from the parents or caregivers of all included children.\u003c/p\u003e\n\u003cp\u003eThe sample size calculation was estimated using G*Power 3.1.9.7 software. The calculation was based on the study by Ibrahim et al.,\u003csup\u003e[9]\u003c/sup\u003e. The estimated minimum sample size at a 5% level of significance to achieve 90% power was 50 children in each group. \u003c/p\u003e\n\u003cp\u003eOne hundred undernourished children with NI aged 2-6 years were included. Inclusion criteria were one or more of the following signs for identification of undernutrition in the studied children: weight for age z score \u0026lt;\u0026ndash;2, triceps skinfold thickness \u0026lt;10th centile for age, mid-upper arm fat or muscle area \u0026lt;10th percentile for age, faltering weight and/or failure to thrive or physical signs of undernutrition such as decubitus skin problems and poor peripheral circulation.\u003csup\u003e[4]\u003c/sup\u003e Children with NI due to metabolic diseases were excluded.\u003c/p\u003e\n\u003cp\u003eChildren were randomly assigned to either study group with a 1:1 ratio as per a computer-generated randomization schedule. Group I received 50% of their caloric requirements as isocaloric polymeric formula (standard) and 50% standard nutritional feeding according to ESPGHAN\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e4\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e guidelines. Group 2 received 50% of their caloric requirements as WPHF, and the other 50% as standard nutritional feeding. \u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePre-intervention phase:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAll studied children were evaluated according to ESPGHAN guidelines.\u003csup\u003e[4]\u003c/sup\u003e The following history parameters were recorded at the start of the study including demographic data, family history, medical history, and treatment history. Demographic data included age, sex, residency, and social status. The etiology of NI and the clinical characteristics of the disease were reported including duration, manifestations, expected course, and severity of NI by assessing the degree of intellectual disability by IQ test and the degree of motor impairment by gross motor function classification system (GMFS). History of nutritional intake was taken by a 3-day record of actual food consumption.\u003csup\u003e[10]\u003c/sup\u003e \u003c/p\u003e\n\u003cp\u003eThe physical examination focused on motor and skeletal systems examination (the presence of contractures and scoliosis, which affects positioning during meals). \u003c/p\u003e\n\u003cp\u003eEstimation of caloric needs was performed using dietary reference standards.\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e Nutritional assessments were conducted for all patients by the same observer. The anthropometric measurements were obtained at the start of the study by using standardized techniques and equipment for all studied children, including weight, height/length, body mass index (BMI), head circumference (HC), mid-upper arm circumference (MUAC), and triceps skinfold thickness (TSF). Weight was measured using the double weighing method (weight of the parent subtracted from the combined weight of parent and child) on a digital scale.\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e2\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e Height/length was measured by a stadiometer. In children with joint contractions, spasticity, and/or scoliosis, the length was measured by segmental length measurements using sliding calipers. Then the length was estimated by simple equations such as knee-heel length (L = (2.69 x KH) + 24.2), tibia length (L = (3.26 x TL) + 30.8), and upper arm length (L = (4.35 x UAL) + 21.8).\u003csup\u003e[13]\u003c/sup\u003e BMI was calculated as [weight in kg]/ [height in m]\u003csup\u003e2\u003c/sup\u003e. HC in children younger than 3 years was measured by non-stretchable tape. MUAC was measured by non-stretchable tape at the midpoint between the tip of the shoulder and the tip of the elbow. TSF was measured by a skinfold caliper at the midway between the shoulder and the elbow joints in the vertical direction on the center of the back of the upper arm. The standard deviation (SD) and Z-score (X-m)/SDwere then calculated for all growth parameters.\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e4\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSymptoms of feeding intolerance, such as swallowing difficulties, choking, GERD, constipation, and other conditions associated with the NI, like recurrent chest infections, were identified by careful history taking and review of the previous relevant investigations, if they were performed. Treatment of GERD was initiated in all children if they had suggestive symptoms (excessive vomiting, hematemesis, and refusal of feeding) or a confirmed diagnosis by contrast upper GI study or upper GI endoscopy. Proton pump inhibitors (PPIs) were used to treat suspected or confirmed GERD (Esomeprazole 1-2 mg/kg/day for 4-8 weeks).\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e5\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e Constipation was diagnosed using the Rome IV criteria.\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e6\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e All the children with constipation were treated by the standard protocol as in typically developing children.\u003csup\u003e[4]\u003c/sup\u003e Swallowing difficulties were diagnosed by swallowing specialists and treatment was received according to their recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eNutritional intervention phase\u003c/u\u003e\u003cu\u003e:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eGroup I received 50% of their caloric requirements as isocaloric polymeric formula (standard) and 50% standard nutritional feeding according to ESPGHAN guidelines.\u003csup\u003e[4]\u003c/sup\u003e Group II received 50% of their caloric requirements in the form of WPHF and the other 50 % was given as standard nutritional feeding for 6 months. The WPHF used during the study was Peptamen Junior, 100 kcal/100 ml (Nestl\u0026eacute; Health Science, Vevey, Switzerland). Energy requirements were calculated by the dietary reference intake standard for the BEE method. Energy intake (kcal/day) = BEE \u0026times; 1.1, where BEE is: \u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n\u003cli\u003eMale: 66.5 + (13.75\u0026times; weight in kg) + (5.003\u0026times; height in cm) \u0026ndash; (6.775 \u0026times; age) \u003c/li\u003e\n\u003cli\u003eFemale: 65.1 + (9.56 \u0026times; weight in kg) + (1.850 \u0026times; height in cm) \u0026ndash; (4.676\u0026times; age)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe amount of formula, frequency, duration, and route of feeding were adjusted according to the condition of each child. All the studied children received protein and micronutrient requirements according to the recommended dietary allowance (RDA).\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e7\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e The patients used regular homemade food with the appropriate thickness for each child.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePost interventional phase\u003c/u\u003e\u003cu\u003e:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eGrowth parameters and symptoms of feeding intolerance and recurrent chest infections were reassessed after 3 and 6 months of the nutritional intervention and compared between the two groups. In group II (WPHF), the changes in the aforementioned parameters at 3 months were compared to those at 6 months of using WPHF. Improvement in feeding tolerance was considered when there was an absence or decrease of symptoms and better weight gain.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStatistical analysis of the data\u003c/u\u003e\u003cu\u003e \u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eData was fed to the computer and analyzed using the IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp) Qualitative data were described using numbers and percentages. The Shapiro-Wilk test was used to verify the normality of the distribution. Quantitative data were described using range (minimum and maximum), mean, standard deviation, median, and interquartile range (IQR). Chi-square test for categorical variables, to compare between different groups. Monte Carlo correction for chi-square when more than 20% of the cells have an expected count of less than 5. Student The student t-test for normally distributed quantitative variables, to compare between two studied groups. Mann-Whitney test for abnormally distributed quantitative variables, to compare between two studied groups. Cochran\u0026apos;s test is used for a non-parametric test for binary response variables, and Post Hoc Test (Dunn\u0026apos;s) for pairwise comparisons. The Friedman test is used for abnormally distributed quantitative variables, to compare between more than two periods or stages, and Post Hoc Test (Dunn\u0026apos;s) for pairwise comparisons. The significance of the obtained results was judged at the 5% level. \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDemographic data and clinical characteristics of the disease showed male predominance in both studied groups. The mean age was 3.5 \u0026plusmn;1.1 years in group I versus a mean age of 3.8 \u0026plusmn;1.3 years in group II. The demographic data and clinical characteristics of the disease were matched in both groups at the start of the study (Table 1). Tube feeding was used in 14% of group I versus 18% of group II.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (1):\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Demographic data and clinical characteristics of both groups\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup I\u0026nbsp;\u003cbr\u003e\u0026nbsp;(n = 50)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup II\u0026nbsp;\u003cbr\u003e\u0026nbsp;(n = 50)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest of Significant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale gender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e26 (52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e27 (54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e=\u003cbr\u003e\u0026nbsp;0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.841\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e3.5 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e3.8 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003et=1.144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRural residency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e39 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e37 (74%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e=0.219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.640\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCauses of NI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"11\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e=6.353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"11\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.853\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003ePost-HIE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e19 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e19 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eGenetic syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e10 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e9 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eStructural brain deformity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e10 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e6 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eDemyelinating disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003ePost-meningitic CP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eNeuro-degenerative disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eNeuro-metabolic disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003ePost-TORCH infections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003ePost intracranial hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003ePost kernicterus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of disease\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u0026lt;1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e=0.925\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003csup\u003eMC\u003c/sup\u003ep=\u003cbr\u003e\u0026nbsp;0.657\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e1-3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e24 (48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e21 (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u0026gt;3 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e24 (48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e28 (56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExpected course of disease\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eStationary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e34 (68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e37 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e=0.440\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.803\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eRegressive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e10 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e8 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eProgressive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e6 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e5 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeizures present\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e33 (66%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e25 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e=2.627\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIQ test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eModerate \u0026nbsp;(42 \u0026ndash; 55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e5 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e6 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e=5.424\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eSevere \u0026nbsp;(25 \u0026ndash; 41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e5 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eProfound \u0026nbsp;(\u0026lt;25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e45 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e39 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGMFS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eGrade III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 66px;\"\u003e\n \u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e=3.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.162\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eGrade IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e9 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e15 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eGrade V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e41 (82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e34 (68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeeding route\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eOral feeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e43(86.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e41(82.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003ec\u003csup\u003e2\u003c/sup\u003e=0.298\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.585\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eTube feeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e7(14.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e9(18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnergy need \u0026nbsp;(kcal/day) \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e686.3 \u0026plusmn;62.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e687.4 \u0026plusmn;60.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003et=-0.103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.918\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFiber needs (gm/day)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e21.5\u0026plusmn;2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e22.0\u0026plusmn;3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003et=-0.897\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.372\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e NI: neurological impairment; post-HIE: post-hypoxic ischemic encephalopathy; GMFS= gross motor function classification system; c\u003csup\u003e2\u003c/sup\u003e: \u0026nbsp;Chi-square test; t: Student t-test; MC: Monte Carlo; p: p-value for comparing between the two studied groups\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the start of the study, the nutritional assessment showed that all growth parameters were matching in group I and group II (Weight Z-score; -4.08 in group I vs -3.95 in group II) and (Length Z-score; -2.19 in group I vs -2.58 in group II). After nutritional intervention, children in group II showed improvement in all growth parameters compared to children in group I after the initial 3 months of intervention. The weight (p=0.005), BMI (p\u0026lt;0.001), MUAC (p\u0026lt;0.001), and TSF (p\u0026lt;0.001) showed statistically significant and continuous improvement as early as the first 3 months. (Table 2)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (2): \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Growth parameters in both groups before and after nutritional intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"616\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 171px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrowth parameters \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup I\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup II\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eZ score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-4.08 (-4.45 \u0026ndash; -3.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-3.95 (-4.21 - -2.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=1209.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.777\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-3.92 (-4.58 \u0026ndash; -3.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-3.27 (-3.64 - -2.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=840.0\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.005\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-4.13 (-4.81 \u0026ndash; -3.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.52 (-3.39 \u0026ndash; -1.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=466.50\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eZ-Score \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-2.19 (-3.72 - -1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.58 (-3.64 \u0026ndash; -1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=1100.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.302\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-2.26 (-3.36 - -1.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.32 (-3.59 \u0026ndash; -1.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=1132.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-2.21 (-2.67 \u0026ndash; -1.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.38 (-3.53 \u0026ndash; -1.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=1158.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.526\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eZ-Score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-3.97 (-4.85 \u0026ndash; -3.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-3.47 (-5.69 - -3.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=1030.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.129\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-3.91 (-4.90 \u0026ndash; -3.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.50 (-3.75 - -1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=607.50\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-3.86 (-4.93 \u0026ndash; -3.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-1.19 (-2.28 \u0026ndash; -0.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=250.50\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHC\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Z-Score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-3.12 (-5.58 \u0026ndash; -1.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-3.14 (-5.22 \u0026ndash; -1.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=145.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.688\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-4.08 (-5.67 - -1.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.93 (-5.13 \u0026ndash; -1.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=91.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.472\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-4.20 (-5.8 - -1.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.93 (-5.28 \u0026ndash; -1.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=94.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.553\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMUAC \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eZ-Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-3.56 (-4.18 --3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-3.05 (-3.93 \u0026ndash; -2.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=770.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-3.77 (-4.30 \u0026ndash; -3.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.77 (-3.64 \u0026ndash; -2.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=631.0\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-3.76 (-4.34 \u0026ndash; -3.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.34 (-3.20 \u0026ndash; -1.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=453.0\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTSF \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eZ-Score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-4.25 (-4.45 \u0026ndash; -3.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-3.42 (-4.48 \u0026ndash; -3.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=1028.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.127\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-4.13 (-4.39 \u0026ndash; -3.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.93 (-3.45 \u0026ndash; -2.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=650.0\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-4.13 (-4.47 \u0026ndash; -3.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-2.36 (-3.33 \u0026ndash; -1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003eU=358.5\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e BMI: body mass index; HC: head circumference; MUAC: mid-upper arm circumference; TSF: triceps skinfold thickness; SD: U: Mann Whitney test; c\u003csup\u003e2\u003c/sup\u003e: \u0026nbsp;Chi square test; FE: Fisher Exact test; p: p value for comparing between the two studied groups; *: Statistically significant at p \u0026le; 0.05.\u003c/p\u003e\n\u003cp\u003eAt the start of the study, there was no significant difference between both groups in the symptoms of feeding intolerance and chest infections. After nutritional intervention, there was a statistically significant and continuous improvement in feeding tolerance (improved choking, GERD and constipation) and chest infections in group II compared to group I as early as the first 3 months. (Table 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (3) Symptoms of feeding intolerance and chest infections in both groups before and after nutritional intervention.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"629\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptoms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup I\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup II\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSwallowing difficulties\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e45 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e43 (86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.379\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.538\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e45 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e43 (86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.379\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.538\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e45 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e43 (86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.379\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.538\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChoking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e36 (72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e27 (54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e3.475\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e36 (72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e15 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e17.647\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e34 (68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e11 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e21.374\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGERD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e19 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e17 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.677\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e18 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e9 (18%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e4.110\u003c/span\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e0.043\u003c/span\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e18 (36.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e2 (4%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e16.450\u003c/span\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDysphagia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e17 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e15 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.184\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.668\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e17 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e14 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.421\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.517\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e17 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e14 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.421\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.517\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConstipation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e46 (92%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e48 (96%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.709\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003csup\u003eFE\u003c/sup\u003ep=\u003cbr\u003e\u0026nbsp;0.678\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e42 (84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e22 (44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e17.361\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e36 (72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e11 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e25.090\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChest infections\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e24 (48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e21 (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.364\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.546\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e23 (46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e8 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e10.519\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e17 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\n \u003cp\u003e5 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e8.392\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.004\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e GERD: gastro-esophageal reflux disease; c\u003csup\u003e2\u003c/sup\u003e: \u0026nbsp;Chi square test; FE: Fisher Exact test; p: p value for comparing between the two studied groups; *: Statistically significant at p \u0026le; 0.05\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn group II, the improvement in\u0026nbsp;most of the anthropometric measurements namely: weight, BMI, MUAC and TSF, GERD and constipation after 6 months of nutritional intervention was statistically significant when compared to the improvement achieved at the initial 3 months. After 6 months of using WPHF, the percentage of children with choking and/or recurrent chest infections had dropped markedly when compared to the initial 3 months (Table 4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (4):\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Growth parameters, symptoms of feeding intolerance, and chest infections in group II (WPHF) after 3 and 6 months of nutritional intervention\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 3 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost 6 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight \u0026nbsp; \u0026nbsp; Z-Score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-3.95\u003c/p\u003e\n \u003cp\u003e(-4.60 \u0026ndash; -2.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-3.27\u0026nbsp;\u003cbr\u003e\u0026nbsp;(-3.64 - -2.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-2.52\u003cbr\u003e\u0026nbsp; (-3.39 \u0026ndash; -1.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003eFr=64.432\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 340px;\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e=0.002\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e3\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength \u0026nbsp; \u0026nbsp; Z-Score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-2.58\u003c/p\u003e\n \u003cp\u003e(-3.64 \u0026ndash; -1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-2.32\u003cbr\u003e\u0026nbsp; (-3.59 \u0026ndash; -1.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-2.38\u003cbr\u003e\u0026nbsp; (-3.53 \u0026ndash; -1.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003eFr=3.283\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.194\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI \u0026nbsp; \u0026nbsp; Z-Score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-3.47\u003cbr\u003e\u0026nbsp;(-4.56 \u0026ndash; -2.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-2.50\u0026nbsp;\u003cbr\u003e\u0026nbsp;(-3.75 - -1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-1.19\u0026nbsp;\u003cbr\u003e\u0026nbsp;(-2.28 \u0026ndash; -0.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003eFr=69.160\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 340px;\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e3\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHC \u0026nbsp; \u0026nbsp; Z-Score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-3.14\u0026nbsp;\u003cbr\u003e\u0026nbsp;(-5.22 \u0026ndash; -1.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-2.93\u0026nbsp;\u003cbr\u003e\u0026nbsp;(-5.13 \u0026ndash; -1.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-2.93\u0026nbsp;\u003cbr\u003e\u0026nbsp;(-5.28 \u0026ndash; -1.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003eFr=1.088\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.580\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMUAC \u0026nbsp; \u0026nbsp; Z-Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-3.05\u0026nbsp;\u003cbr\u003e\u0026nbsp;(-3.93 \u0026ndash; -2.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-2.77\u0026nbsp;\u003cbr\u003e\u0026nbsp;(-3.64 \u0026ndash; -2.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-2.34\u0026nbsp;\u003cbr\u003e\u0026nbsp;(-3.20 \u0026ndash; -1.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003eFr=68.677\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 340px;\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e=0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e3\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTSF \u0026nbsp; \u0026nbsp; Z-Score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-3.42\u0026nbsp;\u003cbr\u003e\u0026nbsp;(-4.48 \u0026ndash; -3.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-2.93\u0026nbsp;\u003cbr\u003e\u0026nbsp;(-3.45 \u0026ndash; -2.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e-2.36\u003cbr\u003e\u0026nbsp; (-3.33 \u0026ndash; -1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003eFr=80.708\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 340px;\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e, p\u003csub\u003e3\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSwallowing difficulties\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e43 (86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e43 (86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e43 (86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003eQ = 0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChoking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e27 (54%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e15 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e11 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003eQ = 23.111\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 340px;\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e=0.001\u003csup\u003e*\u003c/sup\u003e,p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e ,p\u003csub\u003e3\u003c/sub\u003e=0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGERD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e17 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e9 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003eQ = 19.882\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 340px;\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e=0.017\u003csup\u003e*\u003c/sup\u003e,p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e ,p\u003csub\u003e3\u003c/sub\u003e=0.038\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDysphagia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e15 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e14 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e14 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003eQ = 0.667\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.717\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConstipation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e48 (96%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e22 (44%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e11 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003eQ = 58.541\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 340px;\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e ,p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e ,p\u003csub\u003e3\u003c/sub\u003e=0.027\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChest infections\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e21 (42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e8 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e5 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003eQ = 27.125\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 340px;\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e,p\u003csub\u003e2\u003c/sub\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e,p\u003csub\u003e3\u003c/sub\u003e=0.358\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e BMI: body mass index; HC: head circumference; GERD; gastro-esophageal reflux disease; MUAC: mid-upper arm circumference; TSF: triceps skinfold thickness; Fr: Friedman test, significant between periods was done using Post Hoc Test (Dunn\u0026apos;s); Q: Cochran\u0026apos;s test, significant between periods was done using Post Hoc Test (Dunn\u0026apos;s); p: p value for comparing between the three studied periods; p\u003csub\u003e1\u003c/sub\u003e: p value for comparing between Pre and after 3 Months; p\u003csub\u003e2\u003c/sub\u003e: p value for comparing between Pre and after 6 Months; p\u003csub\u003e3\u003c/sub\u003e: p value for comparing between 3 and 6 Months; P*= significant between periods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study showed that undernourished children with NI receiving WPHF showed significant improvement in most of the anthropometric parameters during the study course. They also had better feeding tolerance with significant improvement in GERD, choking, and constipation. They experienced fewer chest infections due to improved nutrition and better feeding tolerance. We reported a direct relation between the duration of use of WPHF and the magnitude of improvement of all the aforementioned parameters.\u003c/p\u003e\n\u003cp\u003e In children with NI, growth and anthropometric measurements reflect the child\u0026apos;s nutritional status.\u003csup\u003e[18]\u003c/sup\u003e Studies investigating the efficacy of WPHF on the growth parameters in undernourished children with NI are very limited. In the present study, all the growth parameters, especially the weight improved significantly in children who received WPHF compared to the children on PF. Our results are in line with the study by Minor et al.,\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e7\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e who reported that all children with developmental delay and poor weight gain achieved an increase in weight after switching to whey-based formula. Nutritional assessment in children with NI should not be based solely on weight and height measurements. Routine assessment of MUAC which reflects lean body mass and TSF which reflects reserve fat are recommended.\u003csup\u003e[4]\u003c/sup\u003e In the current work, assessment of BMI, MUAC, and TSF were performed before and after nutritional intervention. All of these parameters showed significant improvement in children who received WPHF. The study by Minor et al.,\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e7\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e was conducted on a small group of children (13 cases) only focused on weight and height assessment and did not investigate the effect of WPHF on body fat reserve or lean body mass. There is a lack of data about the value of the long-term use of WPHF in the nutritional rehabilitation of undernourished children with NI. The current study highlighted that there is a direct relation between the duration of use of WPHF and the magnitude of improvement in all growth parameters. Therefore, the use of WPHF for more prolonged periods may be a valid recommendation. \u003c/p\u003e\n\u003cp\u003eWe reported a considerable improvement in choking and GERD in children who received WPHF compared to children on PF. Similar findings were observed by Minor et al.,\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e7\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e who reported that 92% of children with NI had improvement in GERD symptoms, specifically vomiting. In a 24-hour pH probe study, Khoshoo et al.,\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e9\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e reported a significant reduction in the episodes and duration of GERD in 14 children with NI who consumed a whey-based formula compared to the standard casein-based formula (p\u0026lt;0.05). Improvement of GERD in children with NI consuming WPHF was even more noticeable when the use of WPHF was extended to 6 months. The role of WPHF in alleviating the symptoms of GERD may be explained by the enhanced gastric emptying time. This explanation can be supported by the finding of study by Brun et al.,\u003csup\u003e[20]\u003c/sup\u003e . The median gastric half-emptying time was faster with a whey formula than with the casein formula. Based on the above, WPHF may be considered as an additional tool in the management of GERD in children with NI, especially when pharmacotherapeutic interventions alone fail to alleviate the symptoms or when a surgical alternative may not be desirable or feasible.\u003c/p\u003e\n\u003cp\u003eThe delay in colonic transit time which is more frequent in children with NI, may explain the frequent prevalence of constipation in those children.\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e2\u003c/sup\u003e\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e The current work showed a significant and rapid improvement in constipation in children with NI who used WPHF compared to children who used PF along the study course. Also, there was a remarkable decrease in the use of laxatives. The rate of improvement increased with the prolongation of the use of WPHF to 6 months. Pediatric studies performed by Minor et al.,\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e7\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e and Mundi et al.,\u003csup\u003e[8]\u003c/sup\u003e reported that the majority of children with NI showed significant improvement in constipation within the first few weeks after the transition to whey-based formula. The mechanism of constipation relief in children with NI using WPHF is not completely understood, but it may be related to its easier digestion and absorption when compared to PF due to the higher contents of medium‐chain triglycerides (MCTs) and hydrolyzed proteins.\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e8\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e Further studies may be needed to confirm these possible mechanisms and to assess the need and dosage of laxatives in children with NI using WPHF.\u003c/p\u003e\n\u003cp\u003eChildren with NI are more susceptible to recurrent chest infections due to increased secretions, poor cough, GERD, choking, decreased mobility, skeletal deformities, and malnutrition. In the current study, there was a significant reduction in chest infections and hospitalizations in children who received WPHF. The observed improvement in this group increased when the WPHF was used for a more prolonged period (6 months). The reduction in chest infections may be explained by the improvement in gastric emptying time with WPHF, which results in a decrease in GERD and choking. Improved nutritional status after diet modification and increased caregiver\u0026apos;s awareness of the importance of physiotherapy during the study are also important contributing factors in the reduction of chest infections. No studies have assessed this point in children with NI. Huang et al.,\u003csup\u003e[22]\u003c/sup\u003e used a peptide-based formula in mechanically ventilated well-developed children with pneumonia and reported significant improvement in mechanical ventilation and hospital stay in the group who received the peptide-based formula. Still, more studies are needed in children with NI to explore the value of WPHF in the reduction of chest infections.\u003c/p\u003e\n\u003cp\u003eAmong the strengths of this work is its prospective design. All the possible growth parameters were evaluated and monitored before starting the intervention and at least twice during the study period which allowed a complete and comprehensive assessment of nutritional status. Assessment and treatment of causes of feeding intolerance in the recruited children is an additional strength of this study. \u003c/p\u003e\n\u003cp\u003eOne of the limitations of our study was the lack of use of laboratory or imaging techniques to assess nutritional status. Additionally, the open-label nature of the study is considered as another limitation to the current trial. \u003c/p\u003e\n\u003cp\u003eFuture studies that include more prolonged periods of nutritional support and more advanced markers of nutritional assessment may be more confirmatory. To demonstrate the efficacy of WPHF, we recruited undernourished children, but given the efficacy proven by our work, we recommend the inclusion of WPHF in the nutritional rehabilitation of children with NI as a part of their initial therapeutic management before they develop undernutrition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIn conclusion\u003c/strong\u003e. Compared to PF , WPHF is linked to improved nutritional status and most growth parameters in undernourished children with NI. Additionally, WPHF lessens the incidence of related chest infections while improving feeding intolerance symptoms such as GERD, choking, and constipation in comparison to the other group with PF. Many of these benefits were noticed within the first three months of WPHF feeding; however, using it for an extra three months was linked to even more notable improvements. \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBEE =Basal energy expenditure.\u003c/p\u003e\n\u003cp\u003eCP= Cerebral palsy.\u003c/p\u003e\n\u003cp\u003eESPGHAN= European Society for Pediatric Gastroenterology, Hepatology and Nutrition.\u003c/p\u003e\n\u003cp\u003eGERD= Gastroesophageal reflux disease.\u003c/p\u003e\n\u003cp\u003eGI= Gastrointestinal\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGMFS= Gross motor function classification system.\u003c/p\u003e\n\u003cp\u003eHC= Head circumference.\u003c/p\u003e\n\u003cp\u003eKH=\u0026nbsp;Knee-heel length.\u003c/p\u003e\n\u003cp\u003eL= Length.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMCTs= Medium‐chain triglycerides.\u003c/p\u003e\n\u003cp\u003eMUAC= Mid-upper arm circumference.\u003c/p\u003e\n\u003cp\u003eNI= Neurological impairment.\u003c/p\u003e\n\u003cp\u003eP*= Significant between periods.\u003c/p\u003e\n\u003cp\u003ePPIs= Proton pump inhibitors.\u003c/p\u003e\n\u003cp\u003eRDA= Recommended dietary allowance.\u003c/p\u003e\n\u003cp\u003eSD= Standard deviation.\u003c/p\u003e\n\u003cp\u003eTL= Tibia length\u003c/p\u003e\n\u003cp\u003eTSF= Triceps skinfold thickness.\u003c/p\u003e\n\u003cp\u003eUAL= Upper arm length.\u003c/p\u003e\n\u003cp\u003eWPHF = Whey-based partially hydrolyzed formula.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;PF = Polymeric formula\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e The authors thank the staff members of the Pediatric Neurology and Gastroenterology Clinic for their collaboration during data collection. The authors would also like to thank the children who participated in this work and their parents.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e No potential conflict of interest was reported by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u0026nbsp; Ethical approval for the study was obtained from the local Faculty of Medicine Ethics Committee\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from the patient\u0026rsquo;s parents before study participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026apos;N/A\u0026apos;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e All data used are included in this article. Further data that support the findings of this study are available from the corresponding author upon reasonable request by mail.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability:\u0026nbsp;\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026apos;N/A\u0026apos;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThis study adheres to CONSORT 2010 guidelines\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions: \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study\u0026apos;s conception and design. Material preparation, data collection and analysis were performed by Sara Saad. The first draft of the manuscript was written by Aml Mahfouz, Sara Saad, and Ahmed Foad. \u0026nbsp;All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eQueensland Government. My child has neurological impairment: Information for Queensland families of young children. 2014. Available from: file:///C:/Users/Rada/Downloads/my-child-has-neurological-impairment.pdf. [Accessed in: Feb, 2024].\u003c/li\u003e\n\u003cli\u003eSullivan PB, McIntyre E. Gastrointestinal problems in disabled children. Curr. Paediatr. 2005; 15(4):347-353.\u003c/li\u003e\n\u003cli\u003ePenagini F, Mameli C, Fabiano V, Brunetti D, Dilillo D, Zuccotti GV. Dietary Intakes and Nutritional Issues in Neurologically Impaired Children. Nutrients 2015; 7(11):9400-9415.\u003c/li\u003e\n\u003cli\u003eRomano C, van Wynckel M, Hulst J, Broekaert I, Bronsky J, Dall\u0026apos;Oglio L, et al. 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Available from: https://theromefoundation.org/rome-iv/rome-iv-criteria/. [Accessed in: Feb, 2024].\u003c/li\u003e\n\u003cli\u003eNational Institute of Health (NIH). Nutrient Recommendations: Dietary Reference Intakes (DRI). Available from: https://ods.od.nih.gov/HealthInformation/nutrientrecommendations.aspx. [Accessed in: Fec, 2024].\u003c/li\u003e\n\u003cli\u003eS\u0026aacute;nchez-Lastres J, Eir\u0026iacute;s-Pu\u0026ntilde;al J, Otero-Cepeda JL, Pav\u0026oacute;n-Belinch\u0026oacute;n P, Castro-Gago M. Nutritional status of mentally retarded children in north-west Spain. I. Anthropometric indicators. Acta Paediatr. 2003; 92(6):747-753.\u003c/li\u003e\n\u003cli\u003eKhoshoo V, Zembo M, King A, Dhar M, Reifen R, Pencharz P. Incidence of gastroesophageal reflux with whey- and casein-based formulas in infants and in children with severe neurological impairment. J. Pediatr. Gastroenterol. Nutr. 1996; 22(1):48-55.\u003c/li\u003e\n\u003cli\u003eBrun AC, St\u0026oslash;rdal K, Johannesdottir GB, Bentsen BS, Medhus AW. The effect of protein composition in liquid meals on gastric emptying rate in children with cerebral palsy. Clin. Nutr. 2012; 31(1):108-112.\u003c/li\u003e\n\u003cli\u003ePark ES, Park CI, Cho SR, Na SI, Cho YS. Colonic transit time and constipation in children with spastic cerebral palsy. Arch. Phys. Med. Rehabil. 2004; 85(3):453-456.\u003c/li\u003e\n\u003cli\u003eHuang XJ, Guo FF, Li F, Zhao JC, Fan YZ, Wang N, et al. Nutritional support in children with pneumonia on mechanical ventilation by short-peptide enteral nutrition formula. Zhongguo Dang Dai Er Ke Za Zhi 2020; 22(11):1209-1214.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Neurological Impairment, Children, Feeding tolerance, Partially Hydrolyzed Formula, Anthropometric measurements","lastPublishedDoi":"10.21203/rs.3.rs-8165537/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8165537/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Undernutrition is common in neurologically impaired children. It increases the burden of comorbidities and affects the quality of life of these children. This study aimed to compare the efficacy of whey-based partially hydrolyzed formula (WPHF) versus isocaloric polymeric formula on the nutritional status of undernourished children with neurological impairment (NI). The secondary aim was to follow up on the changes in these parameters after using WPHF for 3 and 6 months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e In this 6-month prospective, open-label, randomized study, children with NI aged 2–6 years were assigned to two groups. Group I received 50% of their caloric needs as an isocaloric polymeric formula and 50% of their standard nutritional feeding, as per ESPGHAN guidelines. Group II received 50% of their caloric needs as WPHF, with the remaining 50% from standard feeding. Anthropometric measurements, feeding intolerance symptoms, and chest infection frequency were assessed at baseline, 3 months, and 6 months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 100 children (50 per group) were included, with cerebral palsy being the most common cause of NI. After 3 months, Group II showed significant improvement in anthropometric measures and fewer symptoms of feeding intolerance. These benefits were further enhanced after 6 months of continued WPHF use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e In undernourished children with NI, WPHF significantly improves nutritional status, growth parameters, and feeding tolerance compared to the standard polymeric formula. Notable improvements were observed within 3 months and increased with prolonged intervention.\u003c/p\u003e\n\u003cp\u003eThis study was registered at ClinicalTrial.gov (ID: NCT06356103) on 16th March 2024. “Retrospectively\u003cu\u003eregistered. https://register.clinicaltrials.gov/prs/app/template/EditRecord.vm?epmode=View\u0026amp;listmode=Edit\u0026amp;uid=U00076LH\u0026amp;ts=62\u0026amp;sid=S000EAYY\u0026amp;cx=-bryze2\u003c/u\u003e\u003c/p\u003e","manuscriptTitle":"Whey-Based Partially Hydrolyzed Formula Versus Polymeric Formula On Undernourished Neurologically Impaired Children: Open-Label Randomized Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-09 10:55:24","doi":"10.21203/rs.3.rs-8165537/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-01-07T09:47:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-05T10:58:57+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-15T05:51:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-12T17:34:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-11-28T19:40:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"229f3a7a-6458-48f2-b666-90203b579b08","owner":[],"postedDate":"January 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-09T10:55:24+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-09 10:55:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8165537","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8165537","identity":"rs-8165537","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}