Micronutrient deficiencies in pediatric short bowel syndrome: a 10-year review from an intestinal rehabilitation center in China

Vitamin and trace element status and growth in children with short bowel syndrome being weaned off parenteral nutrition

OBJECTIVES

Children with short bowel syndrome (SBS) are at increased risk of micronutrient deficiencies. We aimed to study weaning off parenteral nutrition (PN) as a risk factor for vitamin and trace element deficiencies and growth deficit.

METHODS

Children born between 2010 and 2019, treated for SBS in Helsinki University Hospital, were followed for their nutrition, growth, and vitamin and trace element biochemical status. Information on these as well as patient characteristics and intestinal anatomy were collected from electronic patient records.

RESULTS

A total of 59 patients with SBS were identified. The weaning period was found to be a risk factor for micronutrient deficiencies and growth. Most frequent deficiencies were detected for vitamin K as suggested by prothrombin time (PT) (91% of patients), vitamin D (70%), and vitamin A (67%). Other deficiencies were less common with 44% for vitamin B12, 25% for selenium, 19% for copper, 24% for zinc, and 11% for vitamin E. For all the studied micronutrients, 3 months before to 1 month postweaning had the highest rate of micronutrient deficiencies, except for vitamin B12, for which the highest proportion of deficiencies presented at 1-6 months postweaning.

CONCLUSIONS

The weaning period from PN is a risk for micronutrient deficiencies. Regular monitoring and sufficient supplementation are essential for preventing malnutrition.

Nutritional management after necrotizing enterocolitis and focal intestinal perforation in preterm infants

Nutritional management of preterm infants recovering from necrotizing enterocolitis (NEC) or focal intestinal perforation (FIP) is challenging, especially in infants managed surgically. The logistics of how, when, and what to feed are unclear and current nutritional practices are primarily based on physiological principles and consensus opinion in individual units, rather than high-quality evidence. The aim of this narrative review is to summarize the literature on nutritional management after NEC or FIP in preterm infants: when to restart enteral nutrition, type of enteral nutrition to use, and how to advance nutrition. We also discuss treatment of micronutrient deficiencies, cholestasis, replacement of stoma losses, and optimal time of stoma closure. In conclusion, there are in sufficient high-quality studies available to provide evidence-based recommendations on the best nutritional practice after NEC or FIP in preterm infants. A local or national consensus based early nutrition guideline agreed upon by a multidisciplinary team including pediatric surgeons, pediatricians/neonatologists, nurses, and nutritionists is recommended. Further studies are urgently needed. IMPACT: There is no good quality evidence or nutritional standard across neonatal units treating infants after medical or surgical NEC or FIP. With this review we hope to start providing some consistency across patients and between providers treating patients with NEC and FIP. Mother's own milk is recommended when restarting enteral nutrition after NEC or FIP. In the absence of high-quality evidence, a consensus based early nutrition guideline agreed upon by a multidisciplinary team is recommended. Nutritional research projects are urgently needed in NEC and FIP patients.

Parenteral support and micronutrient deficiencies in children with short bowel syndrome: A comprehensive retrospective study

BACKGROUND & AIMS

Short bowel syndrome (SBS) is the leading cause of chronic intestinal failure. The duration of parenteral support (PS) and the long-term micronutrient needs in children with SBS vary, based on their clinical and anatomical characteristics. Our study aimed to review the clinical course and identify high risk patient groups for prolonged PS and long-term micronutrient supplementation.

METHODS

A retrospective review was conducted on electronic medical records of children with SBS and chronic intestinal failure who were enrolled in the multidisciplinary intestinal rehabilitation program at Manchester Children's Hospital, UK. Children were included in the review if they required PN for more than 60 days out of 74 consecutive days and had at least 3 years of follow-up. Statistical analysis was performed using IBM SPSS Statistics 24.0.

RESULTS

40 children with SBS achieved enteral autonomy (EA) and 14 remained dependent on PS after 36 months of follow up. Necrotizing enterocolitis was the most common cause for intestinal resection (38.9%) followed by gastroschisis (22.2%), malrotation with volvulus (20.4%), segmental volvulus (9.3%) and long segment Hirschsprung disease (1.9%). Those who achieved EA had significantly longer intestinal length 27.5% (15.0-39.3) than those who remained on PS 6.0% (1.5-12.5) (p < 0.001). Type I SBS was only found in the PS cohort. Median PN dependence was 10.82 months [IQR 5.73-20.78]. Congenital diagnosis was associated with longer PN dependence (21.0 ± 20.0) than acquired (8.7 ± 7.8 months), (p = 0.02). The need for micronutrient supplementation was assessed after the transition to EA; 87.5% children had at least one micronutrient depletion, most commonly Vitamin D (64.1%), followed by iron (48.7%), Vitamin B12 (34.2%), and vitamin E (28.6%). Iron deficiency and vitamin A depletion were correlated with longer PS after multivariate analysis (OR: 1.103, 1.006-1.210, p = 0.037 and OR: 1.048, 0.998-1.102, p = 0.062 respectively).

CONCLUSION

In our cohort, small bowel length was the main predictor for EA. Children on longer PS, had more often a congenital cause of resection and were at risk for micronutrient deficiencies in EA.

Current Practices, Challenges, and Recommendations in Enteral Nutrition After Necrotizing Enterocolitis

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.

Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 2: Long-Term Follow-Up on Home Parenteral Nutrition

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The preferred treatment for IF is parenteral nutrition which may be required until adulthood. The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their expertise. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. This second part of the position paper is dedicated to the long-term management of children with SBS-IF. The paper mainly focuses on how to achieve intestinal rehabilitation, treatment of complications, and on possible surgical and medical management to increase intestinal absorption.

Assessing the Correlation between Blood Trace Element Concentrations, Picky Eating Habits, and Intelligence Quotient in School-Aged Children

INTRODUCTION

Inadequate levels of iron, zinc, and copper have been linked to growth impairment and cognitive and motor development deficits. The objective of this study is to examine the deficiencies of trace elements and their correlation with selective eating patterns and the intelligence quotient (IQ) of children.

METHODS AND PATIENTS

The cross-sectional analysis involved 430 children aged between 7 and 10 years. Blood samples were analyzed using Inductively Coupled Plasma Mass Spectrometry (ICP-MS) to measure the trace elements levels. Children's IQs were assessed using Raven's Standard Progressive Matrices.

RESULTS

Among the sample group, 20.3% exhibited iron deficiency, 42.5% had zinc deficiency, and 14% had insufficient copper levels. Single trace element deficiency was observed in 56.9% of the children, while 66.7% showed coexisting deficiencies of iron and zinc. Children with lower development levels exhibited significantly lower serum zinc levels compared to those with higher development levels (76.78 ± 10.67 vs. 81.14 ± 10.19 μg/dL). The analysis reveals that picky eaters had lower serum iron levels (76.59 ± 10.42 μg/dL) and higher serum copper levels (123.74 ± 13.45 μg/dL).

CONCLUSION

A strong association was observed between zinc deficiency, picky eating habits, and lower developmental stages. The findings underscore the importance of monitoring nutritional status in children, given the significant implications for their cognitive development.

Vitamin B12 deficiency presenting as intestinal pseudo-obstruction in short bowel syndrome: A case report

Bowel obstruction and nutrient deficiencies are commonly encountered complications seen during follow-up of patients with short bowel syndrome. It is rare to see vitamin B₁₂ deficiency among micronutrient deficits. The onset of B₁₂ deficiency can be insidious, with autonomic features preceding other symptoms. In this study, we report a case in which vitamin B₁₂ deficiency presented with intestinal dysmotility mimicking mechanical bowel obstruction.

The Outcomes of Treatment in Infants with Short Bowel Syndrome

Objective We reviewed 50 infant cases with short bowel syndrome (SBS) to examine the treatment outcome of SBS management in a tertiary hospital in Vietnam.

Material and Methods A case series was performed at the National Children's Hospital, Hanoi, Vietnam. A total of 50 cases with SBS were reviewed. Clinical and laboratory characteristics before and after treatment were collected.

Results The most common cause of SBS was necrotizing enterocolitis. Common clinical symptoms included watery stools, dehydration, and malnutrition. After treatment, the patient's weight, albumin, and prothrombin improved markedly. There are 72% of children with good or fair treatment results. The rate of sepsis was high (18%). There was one case with complications of catheter infection and one case of liver failure. Three children died during treatment, one died from septic shock and multiple organ failure, and two died from respiratory failure.

Conclusion This study showed promising treatment outcomes in pediatrics.

SARS-CoV-2 Antibody Prevalence in Adult Patients with Short Bowel Syndrome - A German Multicenter Cross-Sectional Study

BACKGROUND

Not all patients suffer from a severe course of SARS-CoV-2 infection, demanding a definition of groups at risk. Short bowel syndrome (SBS) has been assumed to be a risk factor, due to the complexity of disease, the need for interdisciplinary care and frequent contact with caretakers. We aimed to establish data on the course of infection and prevalence of SARS-CoV-2 seropositivity in SBS patients in Germany.

METHODS

From January 2021 until January 2022 a total of 119 patients from three different tertiary care centers with SBS were included. All patients received an antibody test against the nucleocapsid (N) antigen and were asked to fill out a questionnaire, which included frequency of contact with medical personnel, risk behavior and worries.

RESULTS

67% of SBS patients received parenteral nutrition with a median of 6 days per week. The seroprevalence of SARS-CoV-2 antibodies was 7.6% (n=9). Seven patients with positive antibodies had COVID-19 with a mild course. None of the patients were hospitalized or needed further treatment. There was no difference in willingness to take risks in SARS-CoV-2 antibody positive and negative patients (p=0.61). Patients were predominantly worried about the economy (61%) and transmitting COVID-19 (52%), less frequent (26%) about receiving insufficient medical treatment.

CONCLUSION

These are the first clinical results concerning SARS-CoV-2 seropositivity and COVID-19 disease in patients with SBS. The seropositivity is comparable to national data, which we attribute to increased risk awareness and avoidance. Further studies are warranted to investigate effects of COVID-19 infection in SBS patients.

CLINICAL RELEVANCY STATEMENT

Patients with short bowel syndrome are proposed to be a group at high-risk for a severe course of COVID-19. This multicenter cross-sectional study analyzes the prevalence of antibodies against the nucleocapsid (N) antigen in patients with short bowel syndrome, their risk behavior and frequency of contact with medical personnel. The overall SARS-CoV-2 seropositivity in short bowel syndrome patient was comparable to national data, possibly attributed to increased risk awareness and avoidance. This article is protected by copyright. All rights reserved.

Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes

Necrotizing enterocolitis (NEC) is the main gastrointestinal emergency of preterm infants for whom bowel rest and parenteral nutrition (PN) is essential. Despite the improvements in neonatal care, the incidence of NEC remains high (11% in preterm newborns with a birth weight <1500 g) and up to 20−50% of cases still require surgery. In this narrative review, we report how to optimize PN in severe NEC requiring surgery. PN should begin as soon as possible in the acute phase: close fluid monitoring is advocated to maintain volemia, however fluid overload and electrolytes abnormalities should be prevented. Macronutrients intake (protein, glucose, and lipids) should be adequately guaranteed and is essential in each phase of the disease. Composite lipid emulsion should be the first choice to reduce the risk of parenteral nutrition associated liver disease (PNALD). Vitamin and trace elements deficiency or overload are frequent in long-term PN, therefore careful monitoring should be planned starting from the recovery phase to adjust their parenteral intake. Neonatologists must be aware of the role of nutrition especially in patients requiring long-term PN to sustain growth, limiting possible adverse effects and long-term deficiencies.

Current Surgical Concepts and Indications in the Management of the Short Bowel State: A Call for the Use of Multidisciplinary Intestinal Rehabilitation Programs

The mainstay of management for short bowel syndrome (SBS) is to promote access to the best quality of care provided by the intestinal rehabilitation program (IRP) in specialized centres. When treating SBS patients, the main goal is to minimize disease-associated complications, as well as achieve enteral autonomy. Surgical strategies should be selected cautiously upon the actual state of the bowel with respect to what it is clinically relevant for that specific patient. To this aim, a personalized and multidisciplinary approach for such a complex syndrome is needed.

Serum Trace Element Levels and Their Correlation with Picky Eating Behavior, Development, and Physical Activity in Early Childhood

Trace elements are vital components for healthy growth, development, and physical activity. The aim of this study was to investigate the relationship between trace element (iron, zinc, copper) deficiencies and picky eating behavior, development level, and physical activity level. This cross-sectional study involved 203 children aged 4-7 years; picky eating behavior, development level, and physical activity level were assessed through questionnaires. Zinc deficiency has the highest prevalence (37.4%); 67.5% of the children were assessed as picky eaters. Children with picky eating behaviors, poor development level, or poor physical activity level have significantly lower zinc levels, and higher prevalence of zinc deficiency. Pearson's correlation coefficient indicated a positive correlation between serum zinc level and development scores (r = 0.221, p = 0.002) and physical activity scores (r = 0.469, p < 0.001). In multivariate analysis, zinc deficiency independently related to picky eating (OR = 2.124, p = 0.037, CI = 1.042-4.312), developmental level (OR = 0.893, p = 0.022, CI = 0.810-0.984), and physical activity level (OR = 0.785, p < 0.001, CI = 0.700-0.879). In conclusion, the prevalence of zinc deficiency in children aged 4-7 was high, especially in picky eaters. Zinc deficiency was significantly associated with low development and poor physical activity in early childhood.