Abstract
Introduction
Nutrition support teams (NSTs) were developed to standardize nutrition evaluation practices and coordinate transdisciplinary expertise for appropriate administration of inpatient nutritional care. Minimal data are available regarding the current practices, structure, and perceived utility of pediatric NSTs in diverse hospital systems.
Methods
This was a cross‐sectional survey study disseminated electronically to three electronic listservs associated with the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN).
Results
Forty‐seven unique responses were obtained. Sixty‐two percent reported a current NST at their institution. Of those with an NST, 97% reported reviewing parenteral nutrition (PN) orders, 90% recommended nutritional assessment modalities, 86% determined PN appropriateness, and 72% reviewed enteral nutrition orders. More than 50% of respondents strongly agreed that an NST improved patient safety, improved patient nutritional status, improved quality of care, decreased rates of malnutrition, and promoted interdisciplinary care. Among those without an NST, 33% of respondents reported that they were previously unsuccessful at developing an NST at their site. Perceived barriers to NST implementation in more than 50% of respondents were lack of protected time, budget or funding issues, lack of available staff, and lack of interdisciplinary support.
Discussion
This study demonstrates heterogeneity of pediatric NSTs in North America with regard to frequency of services, while showing general consistency in the scope of services provided. It highlights the overall perceived benefit of NSTs. Financial compensation continues to be a barrier to access to NSTs with a notable percentage of NSTs reportedly not billing for services.
Keywords: enteral nutrition, malnutrition, parenteral nutrition, pediatrics
What is Known
Nutrition support teams (NSTs) coordinate transdisciplinary expertise for appropriate administration of nutritional care, including parenteral nutrition (PN) and enteral nutrition (EN).
In the pediatric setting, NST implementation has been shown to increase the use of EN over PN, and was associated with a reduction in overall pediatric intensive care mortality.
What is New
While the current literature and the majority of survey respondents reported looking favorably upon the benefits of NSTs at inpatient pediatric medical facilities, many barriers prevent access.
Financial compensation for NSTs remains heterogeneous among institutions with no standard billing practices.
1. INTRODUCTION
Hospitalized children have complex and diverse nutritional needs. Pediatric malnutrition is prevalent and commonly underdiagnosed in the hospital setting, 1 , 2 , 3 resulting in poorer clinical outcomes. 4 , 5 Reported rates of inpatient pediatric malnutrition are as high as 24.5%. 1 Depending on the etiology, treatment may involve oral, enteral nutrition (EN), or parenteral nutrition (PN). Patients requiring PN are at risk for a range of potentially life‐threatening complications such as electrolyte disturbances, central line‐associated bloodstream infections (CLABSI), thromboses, and micronutrient imbalances.
Nutrition support teams (NSTs) were developed in the 1980s to standardize nutrition evaluation practices and coordinate transdisciplinary expertise for appropriate administration of nutritional care. 6 , 7 Numerous studies have evaluated the efficacy of NST in clinical practice, demonstrating benefits such as improved achievement of prescribed energy requirements, reduction of PN‐related complications, decreased rates of inappropriate PN use, and overall cost savings. 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 Direct, hands‐on management of PN services by a dedicated team has also been associated with significantly fewer metabolic complications (electrolyte and acid/base disturbances). 18 In the pediatric setting, NST implementation has been shown to increase the use of EN over PN, and has been associated with a reduction in overall pediatric intensive care unit (PICU) mortality. 19 Among pediatric patients receiving PN, NST implementation has been associated with more rapid achievement of target caloric goals, 20 decreased length of ICU stay, 21 and lower inpatient CLABSI rates. 22
Although studies appear to show improved outcomes for children receiving care at hospitals with NST implementation, more randomized studies are necessary to confirm their benefit. 6 , 23 Furthermore, barriers such as funding constraints, difficulty demonstrating measurable outcomes, and limited access to nutrition support education have hindered the establishment and sustainability of NST throughout the healthcare system. 24 These barriers were identified as key contributors to declining NST utilization in a 2021 survey by the American Society for Parenteral and Enteral Nutrition (ASPEN) Physician Engagement Committee. 24 While this survey evaluated providers from diverse practice settings, the responsibilities and challenges of NST in pediatric care may differ considerably secondary to the increased vulnerability of pediatric patients and potential long‐term implications of malnutrition during critical periods of growth and development. 25
Although individual institutions have reported outcomes related to pediatric NST, there has been no comprehensive evaluation of their impact across North America. This study aimed to assess the current practices, structure, and perceived utility of pediatric NSTs in diverse hospital systems by surveying healthcare workers associated with the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), across three committee and special interest group (SIG) email listservs. Understanding current models will help to identify effective components of NST programs and inform strategies to enhance their implementation and sustainability.
2. METHODS
This was a cross‐sectional survey designed to evaluate NST prevalence, structure, case volume, and provider attitudes regarding the benefits, utility, and barriers to NST implementation for pediatric patients.
2.1. Ethics statement
The study was reviewed and approved by an Institutional Review Board (IRB‐80584) at Stanford University. A waiver of consent was utilized.
2.2. Questionnaire design
The questionnaire assessed participants' work setting (size and type of hospital) as well as whether programs had an active NST, previously had an active NST, or no NST.
Participants who indicated there was an NST or a previous NST were asked questions about the duration, team composition structure, weekly logistical operations (e.g., frequency with which patients are seen), and perceived benefits of NST existence. For perceived benefits, participants were shown a list of potential benefits and asked to select which benefits were provided by their NST.
Participants who indicated that there was no NST present were asked questions about the architecture of care for patients receiving PN as well as potential barriers and potential benefits of an NST team. The questionnaire was piloted by group authors for clarity and flow prior to distribution. The questionnaire is included in Supplementary Materials.
2.3. Questionnaire distribution
Along with a description of the study purpose, a survey link was disseminated electronically to members of the NASPGHAN Nutrition Committee, NASPGHAN Council for Pediatric Nutrition Professionals (CPNP), and NASPGHAN Intestinal Rehabilitation (IR) SIG. The survey was open for response collection from August 25, 2025 to September 30, 2025, with one additional reminder email to complete the survey. The questionnaire included a combination of categorical and qualitative responses and was implemented using REDCap.
2.4. Statistical analysis
We summarized continuous variables with means/standard deviation or median (interquartile range) depending on underlying distribution. Categorical variables were tabulated as proportions. This was primarily a descriptive study with no formal statistical testing. Data cleaning and analysis were performed with R version 4.5.2.
3. RESULTS
3.1. Demographics
Survey responses were obtained from 47 distinct individuals (Table 1). Most respondents (n = 28, 59.6%) were non‐trainee physicians, with dietitians (n = 17, 36%) as the next largest group. All geographic regions of the United States were represented (Table 1), and two respondents were from Canada. All respondents were employed at academic pediatric hospitals, with 79% working in a free‐standing children's hospital and 19% working on a pediatric floor within a larger adult hospital. Most respondents (n = 32, 68%) were employed at medium‐sized hospitals (100–499 beds). Twenty‐nine (62%) respondents indicated the presence of an NST at their facility. Most respondents (n = 24, 51.1%) were from the NASPGHAN IR SIG, with representation from the NASPGHAN Nutrition Committee (n = 13, 27.7%) and CPNP (n = 16, 34%).
Table 1.
Survey respondent demographics (n = 47).
| Characteristic | n (%) |
|---|---|
| Occupation | |
| Medical doctor (non‐trainee) | 28 (60%) |
| Dietitian | 17 (36%) |
| Advanced practice provider | 1 (2.1%) |
| Pharmacist | 1 (2.1%) |
| Geographic region | |
| Midwest US | 15 (32%) |
| Northeast US | 10 (21%) |
| Southeast US | 9 (19%) |
| West US | 8 (17%) |
| Southwest US | 3 (6.4%) |
| Canada | 2 (4.3%) |
| Hospital type | |
| Academic | 47 (100%) |
| Children's hospital status | |
| Free‐standing children's hospital | 37 (79%) |
| Pediatric wing in larger adult hospital | 9 (19%) |
| Other | 1 (2.1%) |
| Hospital size | |
| Large (>500 beds) | 14 (30%) |
| Medium (100–499 beds) | 32 (68%) |
| Small (<100 beds) | 1 (2.1%) |
| NASPGHAN membershipa | |
| Nutrition committee | 13 (27.7%) |
| CPNP | 16 (34%) |
| Intestinal rehabilitation SIG | 24 (51.1%) |
| Presence of inpatient NST | |
| Yes | 29 (62%) |
| No | 18 (38%) |
Abbreviations: CPNP, Council for Pediatric Nutrition Professionals; NASPGHAN, North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition; NST, nutrition support team; SIG, special interest group; US, United States.
Respondents could be members of more than one committee.
3.2. Characteristics and clinical practices of institutions with NSTs
Among respondents who indicated the presence of an inpatient NST, 76% of respondents reported caring for all pediatric units and teams in the inpatient setting (Table 2). Around a third of sites also provided nutrition support for the neonatal intensive care (NICU), cardiac intensive care (CICU), PICU, surgical teams, general pediatrics teams, and subspecialty services. In terms of pediatric populations cared for by NST, 93% of respondents reported that they helped manage long‐term (>30 days) PN patients, 88% managed IR patients, 86% managed short‐term (<30 days) PN patients, and 76% managed home PN patients. Over 50% of respondents also reported that their NST helped with the management of EN patients and complex nutritional problems.
Table 2.
| Characteristic | n (%) |
|---|---|
| Team composition | |
| Dietitian | 29 (100%) |
| Medical doctor (non‐trainee) | 27 (93.1%) |
| Pharmacist | 19 (65.5%) |
| Medical trainees | 11 (37.9%) |
| Clinical nurse specialist or RN | 10 (34.5%) |
| Advanced practice provider | 9 (31%) |
| Social worker | 8 (27.6%) |
| Surgeon | 7 (24.1%) |
| Case manager | 5 (17.2%) |
| Feeding therapist | 3 (10.3%) |
| Physical therapist | 1 (3.4%) |
| Rounding format | |
| Bedside | 21 (72.4%) |
| Video conference | 4 (13.8%) |
| In‐person conference (table rounds) | 10 (34.5%) |
| Hybrid (in‐person and video) | 10 (34.5%) |
| Rounding approach | |
| With primary team | 12 (41.4%) |
| With primary team dietitian | 9 (31%) |
| Independently | 10 (34.5%) |
| Patient and family participation | |
| Yes | 13 (44.8%) |
| No | 10 (34.5%) |
| Not sure | 6 (20.7%) |
| Years established | |
| Less than 5 years | 4 (13.8%) |
| 5–10 years | 6 (20.7%) |
| 10–20 years | 7 (24.1%) |
| More than 20 years | 8 (27.6%) |
| Not sure | 4 (13.8%) |
| Protected time | |
| Yes | 18 (62.1%) |
| No | 6 (20.7%) |
| Not sure | 5 (17.2%) |
Abbreviations: NST, nutrition support team; RN, registered nurse.
Percentages calculated among sites with NST.
Respondents could select more than one response.
There were a variety of specific nutritional support services provided by NSTs (Table S1). Ninety‐seven percent of respondents reported reviewing PN orders, 93% assessed laboratory values, 90% recommended nutritional assessment modalities, 86% determined PN appropriateness, 83% provided comprehensive nutritional assessments, and 72% reviewed EN orders. Less than half of the respondents reported assessing feeding tube placement appropriateness, evaluating central lines and care, or assessing oral feeding skills. Approximately one‐third of NST rounded daily, one‐third rounded once weekly, and one‐third rounded less frequently. Seventeen percent of respondents estimated that their NST consulted on more than 40 patients weekly, 14% consulted on 20–30 patients weekly, 17% consulted on 10–20 patients weekly, and 31% consulted on less than 10 patients weekly.
Respondents were asked to provide information about metrics tracked by their NST, as well as methods of communication and billing (Table S2). More than 30% of respondents reported that their NST routinely tracked avoidance of PN use if not necessary, days of PN, and CLABSI rates. Twenty‐eight percent tracked malnutrition rates (z score trends), 17% tracked length of stay, and 10% tracked length of intensive care (ICU) stay and PN bag waste. Most respondents reported that their NST communicated their consultation with a note and direct communication with the primary team. Approximately one‐fourth of teams either communicated their nutritional recommendations with a pended electronic medical order or through a signed electronic medical order. About 59% of NST services were billed by the medical doctor, 21% were billed by the dietitian, and 7% were billed by the pharmacist or advanced practice provider (APP). Seventeen percent of respondents reported that their NST was not billing for services.
Respondents provided information about perceived benefits of their current inpatient NST (Figure 1). More than 50% of respondents strongly agreed that the team improved patient safety, improved patient nutritional status, improved quality of care, decreased rates of malnutrition, and promoted interdisciplinary care.
Figure 1.
Perceived benefits among providers with presence of NST. ICU, intensive care unit; NST, nutrition support team.
3.3. Institutional absence of NST
Survey information was also collected from respondents who did not have a current inpatient NST at their institution. When asked which providers within their institution were responsible for managing inpatient PN, 78% reported dietitians, 72% reported pharmacists, 56% reported medical doctors, 50% reported APPs, 39% reported medical trainees, and 22% reported surgeons (Figure S1). Primary PN management for IR patients was performed by the gastroenterology primary service in 50% of respondents. Six percent of respondents did not care for IR patients. When surveyed on whether respondents felt that the development of NST at their institution would be helpful, two‐thirds reported yes. More than 50% of respondents strongly agreed that NST would improve patient safety, improve patient nutritional status, and improve quality of care (Figure 2).
Figure 2.
Perceived potential benefits among providers with absence of NST. ICU, intensive care unit; NST, nutrition support team.
Thirty‐three percent of respondents reported that they were previously unsuccessful at developing an NST at their site. Perceived barriers to NST implementation in more than 50% of respondents were lack of protected time, budget or funding issues, lack of available staff, and lack of interdisciplinary support (Figure S2).
4. DISCUSSION
This study characterizes the current landscape of NSTs in pediatric inpatient hospitals across North America. Survey results demonstrated general consistency in the scope of services provided, with greater variability in the frequency of services. Most NSTs reported managing short‐ and long‐term PN, IR patients, and EN across pediatric inpatient units. The frequency of NST engagement varied widely, ranging from daily participation in patient care to weekly or less frequent consultation. Billing practices differed across institutions, with just over half of NST reporting billing through a physician provider. A subset of teams reported no billing for services, raising concerns regarding the sustainability of nutrition support programs in those settings. Although the majority of NST reported having protected time, the extent of this protected time was not assessed in the current survey.
Despite reported variability in services, respondents consistently perceived NST as adding value to patient care, citing improvements in patient safety, quality of care, and clinical outcomes. NST were also viewed as facilitating interdisciplinary collaboration within institutions, a cornerstone of high‐quality patient care. Importantly, respondents from centers without NST largely agreed that establishing such teams would be beneficial and would enhance patient care delivery. This perceived positive benefit is in line with current literature. 26
Notably, only 62% of respondents reported the presence of an NST at their current institution. Among respondents at institutions without an NST, many described unsuccessful attempts to establish one in the past. Prior studies have identified financial limitations, insufficient outcomes data, and limited access to nutrition support education as key barriers to widespread implementation of NST. 24 Less than a third of respondents reported regular tracking of key quality metrics, such as unnecessary PN use or malnutrition rates. This lack of consistent evaluation likely limits the availability of objective clinical outcomes data. Future research, including randomized controlled trials (RCTs), should focus on generating robust clinical and financial outcome data from institutions with established NSTs. Further demonstration of measurable benefits through randomized studies may help address existing barriers and support broader adoption. Additionally, comparative evaluation of different NST structures and care models may clarify which specific components are most effective in improving patient outcomes and are financially sustainable, given that respondents from institutions with NST did not unanimously strongly agree or agree to perceived benefits.
Several limitations of this study should be acknowledged. Participation was voluntary, introducing the possibility of selection bias, as respondents may have had a greater interest in NST. This might occur in larger, academic institutions. The sample size was modest and largely limited to academic hospitals, with no representation from other healthcare settings such as community hospitals. To preserve confidentiality, it was not possible to determine whether multiple respondents represented the same institution. Nevertheless, these findings highlight the need for further investigation into the impact, optimal structure, and implementation strategies of NST to support high‐quality nutrition care across healthcare systems.
5. CONCLUSION
Complex nutritional needs are common among hospitalized pediatric patients. While the literature supports the value of NST in quality of care, their use remains inconsistent. There are no current standardized guidelines for the use of NST, especially with regard to the types of patients who would benefit, how frequently NST should provide consultation, and how services should be rendered and billed. Our study provides evidence that NST are viewed favorably by most healthcare workers, though barriers to access remain. Future research should focus on more diverse medical facilities and a larger cohort of respondents. Nutrition medicine would benefit from practice guidelines related to NST and policy support for billing based on advanced nutritional expertise.
CONFLICT OF INTEREST STATEMENT
Arun Ajmera serves as a consultant for Kate Farms and Nutricia. Mary Abigail S. Garcia serves as a consultant for Alcresta. Alexandra Carey receives salary support from SterileCare and Alcresta. Tanyaporn K. Kaenkumchorn is a consultant for Kids Eat in Color. The remaining authors declare no conflicts of interest.
Supporting information
Supplemental Figure 1: Inpatient PN Management Responsibilities in Absence of NST.
Supplemental Figure 2: Perceived Barriers to Implementation Among Providers with Absence of NST.
Supplemental Table 1: NST Scope of Practice and Activities (n=29)*# *Percentages calculated among sites with NST #Respondents could select more than one response.
Supplemental Table 2: Current NST Tracking, Communication, and Billing Practices (n=29)*# *Percentages calculated among sites with NST #Respondents could select more than one response.
Suporting file 1.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Figure 1: Inpatient PN Management Responsibilities in Absence of NST.
Supplemental Figure 2: Perceived Barriers to Implementation Among Providers with Absence of NST.
Supplemental Table 1: NST Scope of Practice and Activities (n=29)*# *Percentages calculated among sites with NST #Respondents could select more than one response.
Supplemental Table 2: Current NST Tracking, Communication, and Billing Practices (n=29)*# *Percentages calculated among sites with NST #Respondents could select more than one response.
Suporting file 1.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.