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Adler A, Radhakrishnan K, Yeaney N. Implementation of standardized feeding pathways for infants with gastroschisis to improve patient outcomes: A quality improvement project in a level IV surgical NICU. Nutr Clin Pract 2024. [PMID: 39319372 DOI: 10.1002/ncp.11216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 08/23/2024] [Accepted: 08/31/2024] [Indexed: 09/26/2024] Open
Abstract
Gastroschisis is a leading cause of pediatric intestinal failure. Feeding guidelines may lead to improved patient outcomes including decreased time to reach full feeds, a reduction in the duration of parenteral nutrition, and reduced length of stay. However, there is limited evidence on what the ideal feeding guidelines are for this complex gastrointestinal diagnosis. In this quality improvement project, after completing a literature review, we created three pathways based on the complexity of the gastroschisis. We reviewed historical data without a defined feeding pathway/guideline to our newly created pathways in the intervention group. The study included 35 patients with varying degrees of gastroschisis complexity, consisting of 9 current patients (October 2021-December 2022) who were provided with defined feeding pathways and 26 historical patients before the protocol was implemented (January 2015-August 2021). There were no significant differences in the number of days required for full feeds between the two groups. However, the mean duration of parenteral nutrition was 18.9 days (95% CI, -31.8 to -7.0) shorter in the intervention group. Although not statistically significant, the patients in the intervention group had a mean length of stay that was 13.1 days (95% CI, -50.0 to 25.4) shorter than the historical group. The creation of standardized feeding guidelines for the gastroschisis population resulted in a statistically nonsignificant decrease in time to reach full enteral feeds, a statistically significant reduced duration of parenteral nutrition, and a statistically nonsignifiant decreased length of stay.
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Affiliation(s)
- Andrea Adler
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Kadakkal Radhakrishnan
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Natalie Yeaney
- Division of Neonatology and Neonatal Director Fetal Care Center, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
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Pilkington M, Nelson G, Pentz B, Marchand T, Lloyd E, Chiu PPL, de Beer D, de Silva N, Else S, Fecteau A, Giuliani S, Hannam S, Howlett A, Lee KS, Levin D, O'Rourke L, Stephen L, Wilson L, Brindle ME. Enhanced Recovery After Surgery (ERAS) Society Recommendations for Neonatal Perioperative Care. JAMA Surg 2024; 159:1071-1078. [PMID: 39083294 DOI: 10.1001/jamasurg.2024.2044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2024]
Abstract
Importance Neonates requiring surgery are often cared for in neonatal intensive care units (NICUs). Despite a breadth of surgical pathology, neonates share many perioperative priorities that allow for the development of unit-wide evidence-based Enhanced Recovery After Surgery (ERAS) recommendations. Observations The guideline development committee included pediatric surgeons, anesthesiologists, neonatal nurses, and neonatologists in addition to ERAS content and methodology experts. The patient population was defined as neonates (first 28 days of life) undergoing a major noncardiac surgical intervention while admitted to a NICU. After the first round of a modified Delphi technique, 42 topics for potential inclusion were developed. There was consensus to develop a search strategy and working group for 21 topic areas. A total of 5763 abstracts were screened, of which 98 full-text articles, ranging from low to high quality, were included. A total of 16 recommendations in 11 topic areas were developed with a separate working group commissioned for analgesia-related recommendations. Topics included team communication, preoperative fasting, temperature regulation, antibiotic prophylaxis, surgical site skin preparation, perioperative ventilation, fluid management, perioperative glucose control, transfusion thresholds, enteral feeds, and parental care encouragement. Although clinically relevant, there were insufficient data to develop recommendations concerning the use of nasogastric tubes, Foley catheters, and central lines. Conclusions and Relevance Despite varied pathology, neonatal perioperative care within NICUs allows for unit-based ERAS recommendations independent of the planned surgical procedure. The 16 recommendations within this ERAS guideline are intended to be implemented within NICUs to benefit all surgical neonates.
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Affiliation(s)
- Mercedes Pilkington
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Gregg Nelson
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brandon Pentz
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Tyara Marchand
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Erin Lloyd
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Priscilla P L Chiu
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David de Beer
- Department of Anaesthetics, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Nicole de Silva
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Scott Else
- Department of Anesthesia, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Annie Fecteau
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stefano Giuliani
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Cancer Section, Developmental Biology and Cancer Programme, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Simon Hannam
- Department of Neonatology, Heart and Lung Directorate, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Alexandra Howlett
- Department of Pediatrics, Division of Neonatology, University of Calgary, Calgary, Alberta, Canada
| | - Kyong-Soon Lee
- Department of Pediatrics, Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Levin
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lorna O'Rourke
- Department of Neonatology, Heart and Lung Directorate, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Lori Stephen
- Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Lauren Wilson
- Department of Anesthesia, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Mary E Brindle
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of Pediatric Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Al Qurashi M, Mohammad H, Aga SS, Mustafa A, Alallah J, Al Hindi M, Al Harbi M, Hasosah M. Acquired Zinc Deficiency in Preterm Infant Post-Surgery for Necrotizing Enterocolitis (NEC) on Prolonged Total Parenteral Nutrition (TPN). Pediatr Rep 2024; 16:551-557. [PMID: 39051233 PMCID: PMC11270164 DOI: 10.3390/pediatric16030046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/20/2024] [Accepted: 06/20/2024] [Indexed: 07/27/2024] Open
Abstract
Zinc (Zn) is a vital trace element that plays a pivotal role in protein synthesis, cellular growth, and differentiation and is involved as a cofactor of metalloenzymes, performing a wide variety of metabolic, immune, and synthesis roles. Zn is required at all stages of an infant's and child's development, and severe Zn deficiency has been reported to lead to slower physical, cognitive, and sexual growth. Preterm neonates are at a higher risk of developing zinc deficiency for a variety of reasons, including low Zn intake from enteral feeds containing breast milk, relative malabsorption due to immaturity of the gastrointestinal tract with limited absorptive capacity, increased urinary loss of zinc, and increased demand during the early developmental stages. Moreover, premature infants are at risk of gastrointestinal diseases like necrotizing enterocolitis (NEC), which can limit absorption capacity and potentially lead to malabsorption. TPN is frequently used in preterm infants to provide them with sufficient nutrients and calories. However, it has its own complications, including cholestasis, especially if used for prolonged periods. In this case report, we are presenting the case of a male preterm infant who was delivered by caesarean section at 26 weeks' gestation. The baby developed an intestinal perforation due to NEC, for which he underwent surgery for resection of the necrotic bowel and the creation of a high ileal stoma and was put on prolonged total parenteral nutrition (TPN), which led to the development of zinc deficiency.
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Affiliation(s)
- Mansour Al Qurashi
- Department of Pediatrics, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, Jeddah 21423, Saudi Arabia; (M.A.Q.); (H.M.); (A.M.); (J.A.); (M.A.H.); (M.A.H.); (M.H.)
- King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah 21423, Saudi Arabia
| | - Hadeel Mohammad
- Department of Pediatrics, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, Jeddah 21423, Saudi Arabia; (M.A.Q.); (H.M.); (A.M.); (J.A.); (M.A.H.); (M.A.H.); (M.H.)
- King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah 21423, Saudi Arabia
| | - Syed Sameer Aga
- King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah 21423, Saudi Arabia
- Basic Medical Sciences, College of Medicine, King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, Jeddah 21423, Saudi Arabia
| | - Ahmed Mustafa
- Department of Pediatrics, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, Jeddah 21423, Saudi Arabia; (M.A.Q.); (H.M.); (A.M.); (J.A.); (M.A.H.); (M.A.H.); (M.H.)
- King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah 21423, Saudi Arabia
| | - Jubara Alallah
- Department of Pediatrics, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, Jeddah 21423, Saudi Arabia; (M.A.Q.); (H.M.); (A.M.); (J.A.); (M.A.H.); (M.A.H.); (M.H.)
- King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah 21423, Saudi Arabia
| | - Mohammed Al Hindi
- Department of Pediatrics, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, Jeddah 21423, Saudi Arabia; (M.A.Q.); (H.M.); (A.M.); (J.A.); (M.A.H.); (M.A.H.); (M.H.)
- King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah 21423, Saudi Arabia
| | - Mohammed Al Harbi
- Department of Pediatrics, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, Jeddah 21423, Saudi Arabia; (M.A.Q.); (H.M.); (A.M.); (J.A.); (M.A.H.); (M.A.H.); (M.H.)
- King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah 21423, Saudi Arabia
| | - Mohammed Hasosah
- Department of Pediatrics, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, Jeddah 21423, Saudi Arabia; (M.A.Q.); (H.M.); (A.M.); (J.A.); (M.A.H.); (M.A.H.); (M.H.)
- King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah 21423, Saudi Arabia
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Itriago E, Trahan KF, Massieu LA, Garg PM, Premkumar MH. Current Practices, Challenges, and Recommendations in Enteral Nutrition After Necrotizing Enterocolitis. Clin Perinatol 2023; 50:683-698. [PMID: 37536772 DOI: 10.1016/j.clp.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Necrotizing enterocolitis (NEC) is a neonatal disease with high mortality and morbidity. There is a lack of evidence-based recommendations on nutritional rehabilitation following NEC, and much of the current practice is guided by institutional policies and expert opinions. After a diagnosis of NEC, infants are exposed to an extended period of bowel rest and a prolonged course of antibiotics. Recognizing the patient characteristics that predict nutritional tolerance, early initiation of enteral nutrition, minimizing periods of bowel rest and antibiotic exposure, and standardization of dietary practices are the mainstay of post-NEC nutrition.
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Affiliation(s)
- Elena Itriago
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Kimberly Fernandez Trahan
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Leonor Adriana Massieu
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Parvesh M Garg
- Wake Forest School of Medicine, Brenner Children's Hospital, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Muralidhar H Premkumar
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
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5
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Riddle S, Karpen H. Special Populations-Surgical Infants. Clin Perinatol 2023; 50:715-728. [PMID: 37536774 DOI: 10.1016/j.clp.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Congenital gastrointestinal disorders and other surgical diagnoses share many common problems: increased nutritional requirements to prevent catabolism, enhance wound healing, and provide optimal growth; impaired motility and altered intestinal flora leading to feeding intolerance requiring long-term parenteral nutrition; gastroesophageal reflux and poor feeding mechanics requiring tube feedings and support; growth failure; poor barrier function and risk of infection; and other long-term sequelae. Consequently, the surgical "at-risk" infant requires specialized nutritional support to meet their increased requirements to ensure adequate growth and meet the increased demands from critical illness.
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Affiliation(s)
- Stefanie Riddle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| | - Heidi Karpen
- Emory University School of Medicine/Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, ECC Room 324, Atlanta, GA 30322, USA
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6
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Aurora M, Keyes ML, Acosta JG, Swartz K, Lombay J, Ciaramitaro J, Rudnick A, Kelleher C, Hally S, Gee M, Madhavan V, Roumiantsev S, Cummings BM, Nelson BD, Lerou PH, Matute JD. Standardizing the Evaluation and Management of Necrotizing Enterocolitis in a Level IV NICU. Pediatrics 2022; 150:189570. [PMID: 36164852 PMCID: PMC10026590 DOI: 10.1542/peds.2022-056616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outcomes. This quality improvement project aimed to decrease variation in the evaluation and management of NEC in a Level IV NICU. METHODS A multidisciplinary team investigated institutional variation in NEC management and developed a standardized guideline and electronic medical record tools to assist in evaluation and management. Retrospective baseline data were collected for 2 years previously and prospectively for 3.5 years after interventions. Outcomes included the ratio of observed-to-expected days of antibiotics and nil per os (NPO) on the basis of the novel guidelines and the percentage of cases treated with piperacillin/tazobactam. Balancing measures were death, surgery, and antifungal use. RESULTS Over 5.5 years, there were 124 evaluations for NEC. Special cause variation was noted in the observed-to-expected antibiotic and NPO days ratios, decreasing from 1.94 to 1.18 and 1.69 to 1.14, respectively. Piperacillin/tazobactam utilization increased from 30% to 91%. There were no increases in antifungal use, surgery, or death. CONCLUSIONS Variation in evaluation and management of NEC decreased after initiation of a guideline and supporting electronic medical record tools, with fewer antibiotic and NPO days without an increase in morbidity or mortality. A quality improvement approach can benefit patients and decrease variability, even in diseases with limited evidence-based standards.
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Affiliation(s)
- Megan Aurora
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors contributed equally to this work
| | - Madeline L Keyes
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- Harvard Neonatal-Perinatal Medicine Fellowship Program, Boston, Massachusetts
- These authors contributed equally to this work
| | | | | | - Jesiel Lombay
- Divisions of aNewborn Medicine
- Departments of Pediatrics
| | | | | | | | | | - Michael Gee
- Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | - Paul H Lerou
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors co-supervised this work
| | - Juan D Matute
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors co-supervised this work
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7
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Aroonsaeng D, Losty PD, Thanachatchairattana P. Postoperative feeding in neonatal duodenal obstruction. BMC Pediatr 2022; 22:467. [PMID: 35922792 PMCID: PMC9347087 DOI: 10.1186/s12887-022-03524-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/28/2022] [Indexed: 11/19/2022] Open
Abstract
Background Findings from manometry studies and contrast imaging reveal functioning gastric physiology in newborns with duodenal atresia and stenosis. Stomach reservoir function should therefore be valuable in aiding the postoperative phase of gastric feeding. The aim of this study was therefore to compare the feasibility of initiating oral or large volume(s) gavage feeds vs small volume bolus feeds following operation for congenital duodenal anomalies. Methods Single-center electronic medical records of all babies with duodenal atresia and stenosis admitted to a university surgical center during January 1997–September 2021 were analyzed. A fast-fed group (FF) included newborns fed with oral or gavage feeds advanced at a rate of at least 2.5 ml/kg and then progressed more than once a day vs slow-fed group (SF) fed with gavage feeds at incremental rate less than 2.5 ml/kg/day for each time period of oral tolerance or by drip feeds. Total feed volume was limited to 120–150 ml/kg/day in the respective study cohort populations. Results Fifty-one eligible patients were recruited in the study - twenty-six in FF group and twenty-five in SF group. Statistically significant differences were observed in the (i) date of first oral feeds (POD 7.7 ± 3.2 vs 16.1 ± 7.7: p < 0.001), and (ii) first full feeds (POD 12.5 ± 5.3 vs 18.8 ± 9.7: p < 0.01) in FF vs SF study groups. Conclusion Initial feeding schedules with oral or incremental gavage-fed rates of at least 2.5 ml/kg in stepwise increments and multi-steps per day is wholly feasible in the postoperative feeding regimens of neonates with congenital duodenal disorders. Significant health benefits are thus achievable in these infants allowing an earlier time to acquiring full enteral feeding and their hospital discharge.
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Affiliation(s)
- Dolrudee Aroonsaeng
- Division Of Pediatric Surgery, Department Of Surgery, Faculty Of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Pediatric Surgery Unit, Department of Surgery, Khon Kaen University, Khon Kaen, Thailand
| | - Paul D Losty
- Division Of Pediatric Surgery, Department Of Surgery, Faculty Of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Institute Of Life Course And Medical Sciences, University Of Liverpool, Liverpool, UK
| | - Pornsri Thanachatchairattana
- Division Of Pediatric Surgery, Department Of Surgery, Faculty Of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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Di Dato F, Iorio R, Spagnuolo MI. IFALD in children: What's new? A narrative review. Front Nutr 2022; 9:928371. [PMID: 35958249 PMCID: PMC9358220 DOI: 10.3389/fnut.2022.928371] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022] Open
Abstract
Intestinal failure-associated liver disease (IFALD) is a progressive liver disease complicating intestinal failure (IF). It is a preventable and reversible condition, but at the same time, a potential cause of liver cirrhosis and an indication to combined or non-combined liver and small bowel transplantation. The diagnostic criteria are not yet standardized, so that its prevalence varies widely in the literature. Pathophysiology seems to be multifactorial, related to different aspects of intestinal failure and not only to the long-term parenteral nutrition treatment. The survival rates of children with IF have increased, so that the main problems today are preventing complications and ensuring a good quality of life. IFALD is one of the most important factors that limit long-term survival of patients with IF. For this reason, more and more interest is developing around it and the number of published articles is increasing rapidly. The purpose of this narrative review was to focus on the main aspects of the etiology, pathophysiology, management, prevention, and treatment of IFALD, based on what has been published mainly in the last 10 years. Controversies and current research gaps will be highlighted with the aim to pave the way for new project and high-quality clinical trials.
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Affiliation(s)
| | | | - Maria Immacolata Spagnuolo
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
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Keefe G, Culbreath K, Edwards EM, Morrow KA, Soll RF, Modi BP, Horbar JD, Jaksic T. Current outcomes of infants with esophageal atresia and tracheoesophageal fistula: A multicenter analysis. J Pediatr Surg 2022; 57:970-974. [PMID: 35300859 DOI: 10.1016/j.jpedsurg.2022.01.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aims to quantify mortality rates and hospital lengths of stay (LOS) in neonates with esophageal atresia and tracheoesophageal fistula (EA/TEF), and to characterize the effects of birth weight (BW) and associated congenital anomalies upon these. METHODS Data regarding patients with EA/TEF were prospectively collected (2013-2019) at 298 North American centers. The primary outcome was mortality and secondary outcome was LOS. Risk factors affecting mortality and LOS were assessed. RESULTS EA/TEF was diagnosed in 3290 infants with a median BW of 2476 g (IQR 1897,2970). In-hospital mortality was 12.7%. Mortality was inversely correlated with BW. After adjustment, the risk of mortality decreased by approximately 11% with every 100 g increase in BW. A significant congenital anomaly other than EA/TEF was diagnosed in 37.9% of patients. Risk of mortality increased in patients with associated congenital anomalies, most notably in those with a severe cardiac anomaly. Lower BW was associated with an increased mean LOS among survivors. Similar to mortality risk, additional anomalies were associated with prolonged LOS. CONCLUSIONS This study demonstrates an in-hospital mortality of over 10%. Both increased mortality and prolonged LOS are highly associated with lower birth weight and the presence of concomitant congenital anomalies.
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Affiliation(s)
- Gregory Keefe
- Boston Children's Hospital, Department of Surgery, Boston, MA, United States of America
| | - Katherine Culbreath
- Boston Children's Hospital, Department of Surgery, Boston, MA, United States of America
| | - Erika M Edwards
- Vermont Oxford Network, Burlington, VT, United States of America
| | - Kate A Morrow
- Vermont Oxford Network, Burlington, VT, United States of America
| | - Roger F Soll
- Vermont Oxford Network, Burlington, VT, United States of America
| | - Biren P Modi
- Boston Children's Hospital, Department of Surgery, Boston, MA, United States of America
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, VT, United States of America
| | - Tom Jaksic
- Boston Children's Hospital, Department of Surgery, Boston, MA, United States of America.
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10
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Khalaf RT, Ford SL. Intestinal failure-associated liver disease in the neonatal ICU: what we know and where we're going. Curr Opin Pediatr 2022; 34:184-190. [PMID: 35051980 DOI: 10.1097/mop.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Parenteral nutrition is an integral part of the care of infants in the neonatal ICU. However, prolonged use of parenteral nutrition can be associated with adverse outcomes, most notably parenteral nutrition-associated liver disease, now known as intestinal failure-associated liver disease (IFALD). This review highlights pertinent developments in the epidemiology of IFALD as it pertains to neonates and showcases recent advances in the pathophysiology, treatment, and outcomes of neonates with IFALD. RECENT FINDINGS The role of intravenous lipid emulsions in the pathogenesis, prevention, and treatment of IFALD remains a target for investigative studies. Recent data continues to support the use of fish-oil based intravenous lipids, but its use is limited due to concerns for essential fatty acid deficiency. Use of soy-based lipids and mixed lipids is not wrought with such concerns as these are often used at greater doses but their use is limited due to higher proinflammatory fatty acid content, increased phytosterols and decreased antioxidants, risk factors for the development of IFALD. SUMMARY Hepatic complications may limit the use of parenteral nutrition in the neonatal ICU. However, the pathophysiology of IFALD is continuing to be further elucidated and novel targets are being developed for the treatment of IFALD. As noninvasive disease monitoring strategies continue to be developed, early enteral nutrition ameliorates the risk of IFALD and should be considered when possible.
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Affiliation(s)
- Racha T Khalaf
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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11
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Bobo KS, Cober MP, Eiland LS, Heigham M, King M, Johnson PN, Miller JL, Sierra CM. Key articles and guidelines for the pediatric clinical pharmacist from 2019 and 2020. Am J Health Syst Pharm 2021; 79:364-384. [PMID: 34864839 DOI: 10.1093/ajhp/zxab426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To summarize recently published research reports and practice guidelines deemed to be significantly impactful for pediatric pharmacy practice. SUMMARY Our author group was composed of 8 board-certified pediatric pharmacists. Eight major themes were identified: critical care, hematology/oncology, medication safety, general pediatrics, infectious diseases, neurology/psychiatry, gastrointestinal/nutrition, and neonatology. The author group was assigned a specific theme(s) based on their practice expertise and were asked to identify articles using MEDLINE and/or searches of relevant journal articles pertaining to each theme that were published from January 2019 through December 2020 that they felt were "significant" for pediatric pharmacy practice. A final list of compiled articles was distributed to the authors, and an article was considered significant if it received a vote from 5 of the 8 authors. Thirty-two articles, including 16 clinical practice guidelines or position statements and 16 review or primary literature articles, were included in this review. For each of these articles, a narrative regarding its implications for pediatric pharmacy practice is provided. CONCLUSION Given the heterogeneity of pediatric patients, it is difficult for pediatric pharmacists to stay up to date with the most recent literature, especially in practice areas outside their main expertise. Over the last few years, there has been a significant number of publications impacting the practice of pediatric pharmacists. This review of articles that have significantly affected pediatric pharmacy practice may be helpful in staying up to date on key articles in the literature.
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Affiliation(s)
- Kelly S Bobo
- Le Bonheur Children's Hospital, Memphis, TN, USA
| | - M Petrea Cober
- Akron Children's Hospital, Akron, OH, and Northeast Ohio Medical University, Rootstown, OH, USA
| | - Lea S Eiland
- Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | | | - Morgan King
- Cleveland Clinic Fairview Hospital, Cleveland, OH, USA
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Jamie L Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Moschino L, Duci M, Fascetti Leon F, Bonadies L, Priante E, Baraldi E, Verlato G. Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection. Nutrients 2021; 13:nu13020340. [PMID: 33498880 PMCID: PMC7910892 DOI: 10.3390/nu13020340] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.
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MESH Headings
- Enterocolitis, Necrotizing/complications
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/prevention & control
- Enterocolitis, Necrotizing/surgery
- Failure to Thrive/prevention & control
- Humans
- Infant
- Infant Nutritional Physiological Phenomena
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/prevention & control
- Infant, Premature, Diseases/surgery
- Intestines/surgery
- Short Bowel Syndrome/etiology
- Short Bowel Syndrome/prevention & control
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Affiliation(s)
- Laura Moschino
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Elena Priante
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Giovanna Verlato
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
- Correspondence: ; Tel.: +39-0498211428
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