Identifying research priorities for paediatric nutrition for Australia: A Delphi consensus approach

Abstract

Aim

The Australian Academy of Science's Decadal Plan for the science of nutrition emphasised research investment combined with system wide changes to improve the population's nutritional health. This study applied a Delphi consensus process with the aim to develop a definition for ‘paediatric nutrition research’ alongside identifying research themes and specific key priorities.

Methods

Multidisciplinary health professionals with expertise in paediatric nutrition were invited to participate in an on‐line survey. Panellists contributed to refining a new definition of paediatric nutrition research. Consensus was sought on nine priority areas under which more specific topics were listed, with panellists using a 7‐point Likert scale to rate priority statements. Approval was considered where agreement was reached by ≥70% of participants, with a ranked score ≥6.

Results

Participants (n = 104) were invited with n =31 agreeing (response rate: 30%). The majority (n = 28) also completed round 2. The proposed definition of paediatric nutrition research was agreed by 86% of first round respondents. This process generated 7 research themes containing 30 specific topic priorities. The themes were: growth and development; health equity and priority populations; food systems and food access; Aboriginal and Torres Strait Islander Peoples; strengthening prevention and treatment; empowering children, parents, and caregivers to maximise healthy development; and strengthening the workforce.

Conclusions

This study will support the prioritisation of critical nutrition research questions and inform the skills and expertise required within cross‐disciplinary teams needed to tackle the identified priorities. Consultation with Aboriginal and Torres Strait Islander leaders and consumer representatives is required to understand the specific needs of priority communities.

1. INTRODUCTION

The United Nations (UN) Decade of Action on Nutrition 2016–2025 drew attention to worldwide issues relating to malnutrition and the double burden of chronic disease. ¹ In Australia, the Australian Academy of Science's development of a Decadal Plan for the science of nutrition highlighted the need for greater investment in research as well as system wide changes to enhance the nutritional health of all Australians. ² The implementation framework for the Decadal Plan, published in 2024, has been designed to support the nutrition community's commitment to enhancing cross‐disciplinary collaborations for Australia to rise to the challenge of achieving the UN's sustainable development goals. ³ The implementation framework has an underpinning principle to improve collaboration and engagement with culturally and linguistically diverse groups and with Aboriginal and Torres Strait Islander Peoples alongside recognition of their ownership of Indigenous Australian knowledges. ⁴

These overarching framework and guidance documents on food, nutrition and health are inclusive of all Australians without a specific lens on children. Research priorities in Australia have been undertaken by professionals in dietetics who defined priorities which identified the First 1000 days as a key priority area (pre‐conception, pregnancy and infancy). ⁵ However, themes identified by that process did not include and cannot be extrapolated to children and adolescents. Delphi surveys identifying nutrition research gaps for specific paediatric clinical conditions such as cardiology ⁶ and intensive care ⁷ are available, but cross‐disciplinary opinion on priority setting for paediatric nutrition more broadly remains a gap.

In 2021, there were 4.7 million children aged 0–14 years which is projected to increase to 5.3 million in 2046. ⁸ Aboriginal and Torres Strait Islander Peoples comprise 3.8% of the population with one third being children under the age of 15 years (approximately n = 325,800). ⁹ Australia enjoys a multi‐cultural heritage, with 30% (7.7 million) of the population born overseas. ¹⁰

The nature of this diversity brings a rich cultural and social mix alongside a risk that many groups may be under‐served by existing services due to diversity in language, culture and service responsiveness. ¹¹ National surveillance data which monitor overall health indicators report that 22% of children under 5 years and 27% of older children are above a healthy weight, ¹² 3.7% of children 0–4 years live with a disability increasing to 10% in the age group 5–14 years. ¹³ In 2017–18 around 43% of children lived with at least one long‐term health condition. ¹³ Dietary patterns remain to be optimised, for example, only 4.4% of children aged 5–14 years meet the recommended guidelines for vegetable consumption. ¹⁴

It is acknowledged that Aboriginal and Torres Strait Islander Peoples experience of social and emotional wellbeing varies between groups and within individuals. ¹⁵ The concept of social and emotional wellbeing recognises that a person's wellbeing is influenced by the social determinants of health via inequity of policies, institutional racism, the effects of colonisation and other past events. These factors have led to health inequities for Aboriginal and Torres Strait Islander Peoples, with those living in remote areas facing higher rates of disease burden and lower life expectancy compared with those in non‐remote areas. ¹⁶ Key social determinants in Australia influencing these issues include disparities in educational and employment opportunities, limitations in access to health services and housing, and the lower availability and higher cost of fresh fruit and vegetables. ¹⁷ Local areas and specific communities may experience unique challenges and different outcomes to others and may have different needs and priorities. Within any geographical area there may be areas of relative advantage or disadvantage. Household food insecurity remains an ongoing issue in Australia with one in three households experiencing moderate to severe food insecurity. ¹⁸ Food insecurity is known to profoundly impact on adults’ health and children's development and cognitive potential. ¹⁹ , ²⁰

There is no doubt that multi‐sectoral actions and cross disciplinary working is needed to overcome all the challenges that Australian children need to optimise their nutritional health and reduce their risk of developing diet‐related non‐communicable diseases in later life. In the nutrition field, there is a broad spectrum and diversity in practice areas, ranging from individual focused clinical interventions and programs through to population level health promotion and prevention strategies. It is anticipated that all aspects of practice can gain benefits from having a priority document that has broad consensus and reflects the scope of research within paediatric nutrition. Identified priority actions from a consensus process can be used as reference documents for advocacy and policy development, provide support for funding applications as well as identifying the range of skills and expertise required within cross‐disciplinary teams who are needed to address the complex and inter‐related issues that can impact any child's growth and development. Therefore, this research aimed to co‐create a definition of ‘paediatric nutrition research’ and then identify and rank priority areas and themes for interdisciplinary paediatric nutrition research for the next decade for Australia.

2. METHODS

Ethical approval was gained from Children's Health Queensland and Health Service Human Ethics Committee (HREC‐21/QCHQ/R8164) for this multi‐round Delphi study, which was not prospectively registered. The Delphi technique is a well‐established method for obtaining consensus on a given topic. ²¹ Consensus is obtained through a series of questionnaires delivered on multiple occasions to collect data from an expert panel of participants. ²²

This Delphi process was led by a steering group of three academics and two paediatric dietitian specialists who sought guidance from the host organisations’ Indigenous Health Nurse Navigator to ensure that the wording of the finalised Delphi statements was consistent with the Lowitja Institute ²³ and other relevant national guidelines regarding research autonomy for Aboriginal and Torres Strait Islander Peoples. Subject matter experts (panel members) were identified and recruited from research institutes with active researchers in paediatrics, tertiary and quaternary paediatric hospitals across all States and Territories, community health services, government, non‐government organisations and advocacy networks at a state and national level and research grant recipients from nationally competitive schemes. Inclusion criteria used to define ‘paediatric expert’ were a minimum of 10 years paediatric experience if they were dietitians; a minimum of Level C with publications in the field of paediatric nutrition/dietetics if the potential Delphi panel member was employed in a research or educational establishment; or a leadership role where the potential panel member represented a peak body, society or professional organisation or non‐governmental organisation. Contributions from diverse professional groups were sought, including hospital based medical clinicians, nursing, allied health and professional organisations representing Aboriginal and Torres Strait Islander People. A maximum of three rounds of responses to obtain consensus was determined a priori.

All identified panel experts were invited to contribute via direct email from the research team; they were permitted to redirect the invitation to another relevant expert from their organisation if they were not able to participate themselves. Panellists were not de‐identified to the research team. Adjustments to improve accessibility for those with impairment were not made. Participants were required to read an information statement and consent to participate. Then, the Delphi survey was distributed through the online platform Qualtrics. No incentives for participation were provided to participants.

Data collection commenced in May 2022 (Round 1) and the final round of responses was obtained during August 2022 (Round 2). Participants were sent one prompting email to respond to the request to complete the survey; each round was sent after 2 weeks of the initial invitation, with the email including the survey link and a reminder of the closing date of the survey. Panellists were able to withdraw their results up until the time of data analysis. Study authors did not participate in the consensus gathering process. There were no deviations from the initial protocol.

A proposed definition of paediatric research was drawn from the existing definition of research in nutrition and dietetics, ⁵ with the author team discussion resulting in a draft definition being presented to the survey participants. Research themes were based on combining several documents that had proposed areas of paediatric need for research, including nutrition for children in critical care, ⁷ National Action Plan 2020–2030, ²⁴ Closing the Gap, ²⁵ and current national research agendas as set out by the National Health and Medical Research Council, ²⁶ Australian Research Council, ²⁷ and the National Eating Disorder research strategy. ²⁸

The definition of paediatric nutrition research offered to participants in round 1 was as follows: “Within an interprofessional research framework, paediatric nutrition research integrates a range of systems (e.g., parent and child physiological systems, disease/disability, health service food, social, economic, political and environmental) that can improve the health of all children and young people”.

Next, research areas pertinent to paediatrics were collated and constructed into nine overarching research themes by the authorship team through a process of discussion. These nine themes considered in Round 1 were: (i) growth and development, (ii) health equity and priority populations, (iii) food systems and food access, (iv) Aboriginal and Torres Strait Islander communities’ health, (v) informatics and evidence‐based practice, (vi) achieving the balance between prevention and treatment, (vii) empowering children, parents and caregivers to maximise healthy development, (viii) mental health, and (ix) strengthening the workforce.

Participants were asked to comment on the proposed definition of ‘paediatric research’. Then they were asked to read and rate their agreement with each priority topic listed within the 9 themes using a 7‐point sliding Likert scale (1 = strongly disagree, 7 = strongly agree). Free text comment boxes allowed participants to record any research themes or priority areas for research in addition to the 58 topic areas listed in Round 1. Open text comments received in Round 1 from participants regarding the proposed research definition was incorporated into a revised version. The questionnaire was not pilot tested as participants were able to add commentary to each section. Round 1 survey results were collated and compiled to form the basis for the Round 2 survey questions that were distributed to only the participants who completed the Round 1 survey, as per the Delphi process.

Priorities that were rated highly (≥6) by participants in Rounds 1 and 2 by ≥70% of participants ⁵ were accepted as agreed priorities. All priorities that did not receive (≥70% agreement) by the end of Round 2 were removed. As the a priori agreement was met after Round 2, no further rounds were undertaken. The ACCORD (ACcurate COnsensus Reporting Document) methodology and reporting guidelines were applied to ensure appropriate data were both collected and reported. ²⁹

3. RESULTS

One hundred and four multidisciplinary health professionals were identified as potential panel experts and invited to participate via email, with 31 agreeing to do so (response rate: 30%) and 28 completed the second panel polling process. Most of the discipline classified as ‘allied health’ had qualifications in dietetics (invited 55/104, with 21 ‘dietitians’ actively participating in both Round 1 and Round 2).

See Figure 1 for participant flow and discipline participation. The mean years of experience for Round 1 participants was 19 years 8 months, and in Round 2 was 19 years 5 months.

FIGURE 1.

Participant flow and participating disciplines through the Delphi process. *Of the n = 64 allied health experts invited, n = 55 identified as having dietetic qualifications and n = 4 as nutritionists. **Other professional category identifiers were Researcher/Academic, Behaviour, Nutrition, and Public Health.

With regards to the development of a consensus definition, panellists contributed comments to further refine the proposed definition, and the final agreed definition in round two with 85% agreement was as follows:

“Within an interprofessional research framework, paediatric nutrition research integrates a range of human and environmental systems (e.g., educational, physiological, family, cultural, social, psychological, health services, food and commercial, economic, and political) that can improve the health of all infants, children, and young people.”

There were 9 broad research themes with 58 research topic priorities presented to those who consented to participate in the Round 1 panel. As panellists had the opportunity in both rounds to add free text and add additional research themes or topics, some re‐wording of topics occurred to ensure that panellists suggestions were included and reduce duplication of concepts, in particular the more inclusive term ‘infants, children and young people’ instead of the word ‘children’ resulted in some modification of topics. To create the survey for Round 2, 58 priority topics from Round 1 were re‐presented as there were some minor changes to wording to some agreed statements, plus an additional 11 new topics identified by respondents in free text responses in Round 1. The Indigenous Health Nurse Navigator further assisted in the precise wording of each theme and topic to ensure culturally appropriate wording. Following the second‐round panel, 30 priority research topics across seven themes reached consensus, see Figure 2.

FIGURE 2.

Consensus priorities for Australian research in paediatric nutrition. *Topics presented in Round 2 only.

The two themes (Mental Health and Informatics and evidence‐based practice) and research topics not reaching consensus are presented in Figure S1.

Within the theme Growth and development, there were five priority actions, with the top‐ranking action for research that enhanced our understanding of the social and physical environments (family, school and community).

The theme Health equity and priority populations included four priorities: economic determinants of health, health access, experiences, and outcomes to inform policy design. In the theme Food systems and food access, research that supported equitable access to healthy foods, were the three priority topics were selected by Delphi participants.

The theme relating specifically to Aboriginal and Torres Strait Islander People involves five statements for research topics to be prioritised. These covered nutrition and health equity and improving outcomes, through to using innovative and culturally responsible ways of gathering nutrition data within Aboriginal and Torres Strait Islander children and their carers.

In the theme Strengthening prevention and treatment, three priorities were identified including translational research on the effectiveness of nutrition‐related approaches. Five priorities were selected in the theme Empowering children, parents, and caregivers to maximise healthy development. These priorities utilised a range of strategies including understanding, supporting, and using user‐centred design and delivery within relevant populations.

In the final theme of Strengthening the workforce, there were five priority actions identified, including the development of inter‐professional infant, child, and young person nutrition research and evaluation capacity of the workforce.

4. DISCUSSION

For the first time, this research provides an agreed definition of what paediatric nutrition research entails, reflecting the broad basis and scope of practice of those working with children and young people. As such, it provides information on which to formulate education of nutrition professionals who seek to specialise in paediatric care but also highlights the need for collaboration across a range of other disciplines to ensure that the necessary skills are available to a team to grapple with the challenges that some of the research action areas present.

This research advances our understanding of priority areas of research that need to be supported to deliver improved nutritional care and health outcomes for Australian children. In a resource‐constrained environment, a consensus prioritisation of key questions pertinent to improving the nutritional health of Australian children can be used to inform advocacy work, to provide the evidence for funding applications to address these agreed areas and the need to bring cross‐disciplinary teams together to solve these complex problems. This work also provides a framework from which advice to Government and funding bodies can be given in the knowledge that it is broadly supported by the nutrition community and reflects contemporary issues by addressing uncertainties and nutrition practices associated with improved child and family outcomes.

The priorities identified in this Delphi study incorporated prevention and public health approaches and are therefore quite different to those specifically identified in highly specialist clinical areas. For example, the Delphi undertaken in the United Kingdom for paediatric intensive care identified priority areas including determining energy requirements of ventilated neonates, evidence for nutritional supplementation of probiotics to manage and prevent sepsis, extending the understanding of post‐intensive care syndrome on nutrition and growth, and evidence for parenteral nutrition commencement. ⁷

It is worthy to note that two themes were not supported as priority areas by this consensus process. These were Mental health and Informatics and evidence‐based practice. This may reflect the research interests or practice areas as participants self‐selected their involvement in this process. As with much research conducted during the COVID‐19 pandemic, engaging with participants proved challenging, resulting in a lower than ideal response rate overall but a high engagement with the Delphi process from senior researchers and academics and less community engagement than was ideal. It may also reflect the timing of the data collection process and the fact it was undertaken during the COVID‐19 pandemic before the extent of the mental health impacts on young people were evident, especially the increase in mental health concerns such as depression, anxiety, disordered eating and high body weight. ³⁰ , ³¹ , ³² , ³³

A limitation is the pre‐determined survey content. Despite being sourced from a variety of existing documents and sources plus the opportunity for respondents to recommend additional priority areas, the approach may not capture the full scope of nutrition research priorities for infants and children. We endeavoured to apply ‘a prevention to treatment’ lens to the themes to incorporate the broad range of practice that nutrition professional is engaged with across Australia. We further recognise as a limitation of this process the very limited input by Aboriginal and Torres Strait Islander Elders and members of those communities and the need for different engagement methods and wider consultation is acknowledged.

Strengths were that the survey was extended beyond nutritionists and dietitians to include health professionals with expertise in paediatrics. This was important since research should be collaborative, with grant funding success in national rounds needing to be multidisciplinary. However, panellists with dietetic qualifications made up 100% of Round 2 panellists in the ‘allied health’ category which would without doubt influence priority areas identified and reflect the dietetic disciplines appreciation of the need to target resources towards areas of need including Aboriginal and Torres Strait Islander peoples.

The knowledge obtained within this Delphi study will support the prioritisation of important nutrition research questions and inform the development of successful research collaborations and funding applications. Further consultation with Aboriginal and Torres Strait Islander leaders and collaboration with consumer representatives is recommended to ensure that the priorities identified are broadly supported. The results will be shared with the Australian Academy of Science national committee for nutrition to provide evidence for advocacy efforts to improve funding and opportunities for research into food and nutrition to benefit all Australia's children.

AUTHOR CONTRIBUTIONS

Conceptualisation: HT, DG, AD, KB; Data collection and analysis AD; HT and JP drafted the manuscript, all authors contributed to, and approved the final version. We appreciate the expertise of Vena Beetson, Indigenous Health Nurse Navigator, Children's Health Queensland who contributed to the positioning of statements relating to Aboriginal and Torres Strait Islander Peoples.

FUNDING INFORMATION

Funding to support AD was provided by a Health Services Research Grant, the Children's Hospital Foundation.

CONFLICT OF INTEREST STATEMENT

Prof. Judi Porter and Prof. Helen Truby are Editorial Board members of Nutrition & Dietetics. They were excluded from the peer‐review process and all decision making regarding this article. This manuscript has been managed throughout the review process by the Journal's Editor. The Journal operates a blinded peer review process and the peer reviewers for this manuscript were unaware of the authors of the manuscript. This process prevents authors who also hold an editorial role to influence the editorial decisions made. Prof Danielle Gallegos was supported by funding from the Queensland Children's Hospital Foundation via a philanthropic donation from Woolworths staff and customers. Other authors declare no conflicts of interest. All authors are in agreement with the manuscript and declare that the content has not been published elsewhere.

ETHICS STATEMENT

Ethical approval was gained from Children's Health Queensland and Health Service Human Ethics Committee (HREC‐21/QCHQ/R8164) for this multi‐round Delphi study.

Supporting information

FIGURE S1. Priority areas and topics that did not receive >70% consensus and were removed from the final results.

Doolan A, Bell K, Gallegos D, Porter J, Truby H. Identifying research priorities for paediatric nutrition for Australia: A Delphi consensus approach. Nutrition & Dietetics. 2025;82(3):319‐326. doi: 10.1111/1747-0080.70017

DATA AVAILABILITY STATEMENT

Research data are not shared.