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Rundell MR, Bailey RA, Wagner AJ, Warner BB, Miller LE. Long-Term Neurodevelopmental Outcomes in Children with Gastroschisis: A Review of the Literature. Am J Perinatol 2024. [PMID: 38810899 DOI: 10.1055/s-0044-1787173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
This study aimed to investigate and present a review of the literature on long-term neurodevelopmental outcomes in children with gastroschisis. Gastroschisis is the most common abdominal wall defect. Children with gastroschisis are at high risk for premature birth, intestinal failure, sepsis, and repeated anesthesia exposure, which collectively increase the risk for adverse long-term neurodevelopmental outcomes. The existing literature on neurodevelopmental outcomes is limited in number, quality, and generalizability, creating a gap in clinical knowledge and care. Five internet databases were searched by a professional research librarian: Ovid MEDLINE, Scopus, Web of Science, PsycINFO, and Cochrane Library. Included articles were (1) published in English, (2) included postneonatal hospital discharge neurodevelopmental outcomes of children with gastroschisis, and (3) included patients under the age of 18 years. No date parameters were applied. The paucity of literature on long-term neurodevelopmental outcomes in gastroschisis children has left large gaps in the body of knowledge on post-hospital care of such children. In this review, 37 articles were found evaluating neurodevelopmental outcomes in gastroschisis and, while conclusions were contradictory, the literature broadly indicated the potential for neurodevelopmental deficits in the gastroschisis pediatric population. A significant limitation of this review was the heterogeneous samples included in available literature, which confounded the ability to determine cognitive risk of gastroschisis independent of other abdominal wall defects. Findings of this review demonstrate potential risk for neurodevelopmental deficits in the pediatric gastroschisis population exist, yet additional research is needed to definitively predict the significance, type, onset, and trajectory of neurodevelopmental impairment in this population. The significant gaps in long-term outcomes data have elucidated the need for prospective, longitudinal investigation of various cognitive domains in homogenous gastroschisis populations to properly evaluate prevalence of neurodevelopmental deficits and guide recommendations for long-term clinical care. KEY POINTS: · Limited literature exists regarding long-term neurodevelopmental outcomes in gastroschisis.. · There is some evidence to suggest worse cognitive behavioral outcomes in gastroschisis over time.. · Developmental surveillance, screening, and evaluation may be beneficial for gastroschisis patients..
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Affiliation(s)
- Maddie R Rundell
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rachel A Bailey
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Amy J Wagner
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Barbara B Warner
- Department of Pediatrics, Washington University, St. Louis, Missouri
| | - Lauren E Miller
- Division of Neuropsychology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Miller C, Kieling RR, Ziegler B, Giesta JM, Signorini AV, Pires GQ, Feldens L, Ceza MR, Adami MR, Kieling CO, Goldani HAS. Is neurodevelopment impaired in Brazilian children with intestinal failure on prolonged parenteral nutrition? A single center study. Pediatr Surg Int 2024; 40:120. [PMID: 38702423 DOI: 10.1007/s00383-024-05694-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE To assess the neurodevelopment outcomes of children younger than 42 months of age with intestinal failure (IF) using prolonged parenteral nutrition (PN) followed by a Pediatric Multidisciplinary Intestinal Rehabilitation Program from a public tertiary hospital in Brazil. METHODS Bayley III scale was administered in children aged 2 to 42 months with IF and receiving PN for more than 60 days. Composite scores in cognitive, motor, and language domains were analyzed. Developmental delay was defined as a performance 2 standard deviations (SD) below the average at the 3 domains. Association between Bayley III composite scores and clinical variables related to IF were tested. RESULTS Twenty-four children with median (IQR) age of 17.5 months (9-28.5) were studied, 58.3% were male. Developmental delay was found in 34%, 33% and 27% of the patients in cognitive, motor, and language domains, respectively. There was no significant association between the Bayley-III composite scores and length of hospitalization, prematurity, and number of surgical procedures with anesthesia. CONCLUSION The study demonstrated impairments in the cognitive, motor and language domains in approximately one-third of young patients with IF on prolonged PN.
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Affiliation(s)
- Cristina Miller
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
| | | | - Bruna Ziegler
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | - Giovana Q Pires
- Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Letícia Feldens
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marília R Ceza
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marina R Adami
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carlos O Kieling
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Helena A S Goldani
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Belza C, Wales PW. Intestinal failure among adults and children: Similarities and differences. Nutr Clin Pract 2023; 38 Suppl 1:S98-S113. [PMID: 37115028 DOI: 10.1002/ncp.10987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 04/29/2023] Open
Abstract
Intestinal failure (IF) is a complex medical condition that is caused by a constellation of disorders, resulting in the gut's inability to adequately absorb fluids and nutrients to sustain hydration, growth, and survival, thereby requiring the use of parenteral fluid and/or nutrition. Significant advancements in intestinal rehabilitation have resulted in improved survival rates for individuals with IF. There are distinct differences, however, related to etiology, adaptive potential and complications, and medical and surgical management when comparing children with adults. The purpose of this review is to contrast the similarities and differences between these two distinct groups and provide insight for future directions, as a growing population of pediatric patients will cross into the adult world for IF management.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
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Predictors of Social-Emotional Development and Adaptive Functioning in School-Age Children with Intestinal Failure. J Clin Psychol Med Settings 2022:10.1007/s10880-022-09919-z. [PMID: 36371790 DOI: 10.1007/s10880-022-09919-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Despite a focus on neurocognition in pediatric intestinal failure (IF) to date, we examined social-emotional and adaptive functioning. METHODS Children (N = 63) in our IF rehabilitation program underwent neuropsychological assessments including caregiver- and teacher-reported questionnaires. Results were compared to norms using z-tests. Caregiver and teacher reports were compared using t tests. Medical and demographic factors were examined in an exploratory manner using correlation and targeted regression analyses, adjusting for gestational age and full-scale IQ. RESULTS Caregiver and teacher reports indicated poorer executive, internalizing, behavioral, and adaptive functioning compared to norms. Teachers reported more executive dysfunctions than caregivers. Necrotizing enterocolitis diagnosis predicted internalizing emotional problems. Immigrant status predicted poorer social and practical adaptive functioning. Living with biological parents predicted fewer externalizing emotional and behavioral problems. CONCLUSIONS The group displayed social-emotional and adaptive functioning concerns. Identifying medical and demographic risks can allow for screening and intervention.
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Chen CB, Chugh S, Fujiki M, Radhakrishnan K. Overview of Physical, Neurocognitive, and Psychosocial Outcomes in Pediatric Intestinal Failure and Transplantation. Curr Gastroenterol Rep 2022; 24:145-155. [PMID: 36040624 DOI: 10.1007/s11894-022-00848-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Intestinal failure and transplantation may significantly impact physical, neurocognitive, and psychosocial development in pediatric patients. Currently, there is a paucity of literature on the effects of intestinal failure and transplantation on these aspects of development. This article will review the current literature and discuss the short and long-term impacts as well as interventions to improve clinical outcomes in children with intestinal failure or those undergoing transplantation. RECENT FINDINGS Psychological disorders, neurodevelopmental delay, and social maladaptation are frequently encountered in this patient population. While the main focus is often on medical management, equal emphasis should be placed on other aspects of development such as increasing social support and improving school performance. The transition to adulthood also presents many obstacles for patients and healthcare providers should anticipate challenges such as childbirth, employment, and raising a family. The pre-operative, perioperative, and post-operative periods all represent opportunities for medical intervention. Frequent monitoring of physical, psychosocial, and neurocognitive status helps to improve clinical outcomes and long-term quality of life. Future research should emphasize continued development of multidisciplinary programs and specialized services to help address the physical and psychosocial needs of children with intestinal failure as well as transplant recipients.
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Affiliation(s)
- Charles B Chen
- Department of Child Health, University of Missouri School of Medicine, 400 N. Keene St, 65201, Columbia, MO, USA.
| | - Shreeya Chugh
- Department of Child Health, University of Missouri School of Medicine, 400 N. Keene St, 65201, Columbia, MO, USA
| | - Masato Fujiki
- Center for Gut Rehabilitation and Transplantation, Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, 44195, Cleveland, OH, USA
| | - Kadakkal Radhakrishnan
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, 9500 Euclid Ave, 44195, Cleveland, OH, USA
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Abstract
Intestinal failure (IF) secondary to short bowel syndrome is a challenging and complex medical condition with significant risk for surgical and medical complications. Significant advancements in the care of this patient population have led to improved survival rates. Due to their intensive medical needs children with IF are at risk for long-term complications that require comprehensive management and close monitoring. The purpose of this paper is to review the available literature emphasizing the surgical aspects of care for children with IF secondary to short bowel syndrome. A key priority in the surgical care of this patient population includes strategies to preserve available bowel and maximize its function. Utilization of novel surgical techniques and autologous bowel reconstruction can have a significant impact on children with IF secondary to short bowel syndrome related to the function of their bowel and ability to achieve enteral autonomy. It is also important to understand the potential long-term complications to ensure strategies are put in place to mitigate risk with early detection to improve long-term outcomes.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, Cincinatti Children's Hospital Medical Center, University of Cincinnati, Cincinnatii, USA; Cincinnati Children's Intestinal Rehabilitation Program, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 2023, Cincinnati, Ohio 45229, USA.
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Roorda D, Königs M, Eeftinck Schattenkerk L, van der Steeg L, van Heurn E, Oosterlaan J. Neurodevelopmental outcome of patients with congenital gastrointestinal malformations: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2021; 106:635-642. [PMID: 34112720 PMCID: PMC8543204 DOI: 10.1136/archdischild-2021-322158] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/12/2021] [Indexed: 12/29/2022]
Abstract
AIM Children with congenital gastrointestinal malformations may be at risk of neurodevelopmental impairment due to challenges to the developing brain, including perioperative haemodynamic changes, exposure to anaesthetics and postoperative inflammatory influences. This study aggregates existing evidence on neurodevelopmental outcome in these patients using meta-analysis. METHOD PubMed, Embase and Web of Science were searched for peer-reviewed articles published until October 2019. Out of the 5316 unique articles that were identified, 47 studies met the inclusion criteria and were included. Standardised mean differences (Cohen's d) between cognitive, motor and language outcome of patients with congenital gastrointestinal malformations and normative data (39 studies) or the studies' control group (8 studies) were aggregated across studies using random-effects meta-analysis. The value of (clinical) moderators was studied using meta-regression and diagnostic subgroups were compared. RESULTS The 47 included studies encompassed 62 cohorts, representing 2312 patients. Children with congenital gastrointestinal malformations had small-sized cognitive impairment (d=-0.435, p<0.001; 95% CI -0.567 to -0.302), medium-sized motor impairment (d=-0.610, p<0.001; 95% CI -0.769 to -0.451) and medium-sized language impairment (d=-0.670, p<0.001; 95% CI -0.914 to -0.425). Patients with short bowel syndrome had worse motor outcome. Neurodevelopmental outcome was related to the number of surgeries and length of total hospital stay, while no relations were observed with gestational age, birth weight, age and sex. INTERPRETATION This study shows that children with congenital gastrointestinal malformations exhibit impairments in neurodevelopmental outcome, highlighting the need for routine screening of neurodevelopment during follow-up.
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Affiliation(s)
- Daniëlle Roorda
- Department of Pediatric Surgery, Amsterdam Reproduction and Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Free University Amsterdam, Amsterdam, The Netherlands
- Department of Pediatrics, Emma Neuroscience Group, Amsterdam Reproduction & Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marsh Königs
- Department of Pediatrics, Emma Neuroscience Group, Amsterdam Reproduction & Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurens Eeftinck Schattenkerk
- Department of Pediatric Surgery, Amsterdam Reproduction and Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Free University Amsterdam, Amsterdam, The Netherlands
| | - Lideke van der Steeg
- Department of Pediatric Surgery, Amsterdam Reproduction and Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Free University Amsterdam, Amsterdam, The Netherlands
- Pediatric Surgery, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Ernest van Heurn
- Department of Pediatric Surgery, Amsterdam Reproduction and Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Free University Amsterdam, Amsterdam, The Netherlands
| | - Jaap Oosterlaan
- Department of Pediatrics, Emma Neuroscience Group, Amsterdam Reproduction & Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Lepus CA, Samela K, Emerick KM, Mokha JS. Vitamin D status in children with intestinal failure who have achieved enteral autonomy. Nutr Clin Pract 2021; 36:1284-1289. [PMID: 34161622 DOI: 10.1002/ncp.10685] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Vitamin D deficiency is highly prevalent in children with intestinal failure (IF) who receive parenteral nutrition (PN), but data on vitamin D status after achieving enteral autonomy (EA) are limited. We aimed to evaluate the prevalence of vitamin D deficiency in this population while exploring clinical variables that may be associated with its development. METHODS A retrospective review was performed on 29 children with IF who had achieved EA. Deficiency was defined as a mean serum 25-hydroxyvitamin D <30 ng/ml. DATA RESULTS Sixty-six percent of children had at least one deficient level during the study period, with 38% being deficient based on the mean vitamin D levels. Eighty-four percent had radiologic evidence of osteopenia. Compared with the sufficient group (n=18), the deficient group (n=11) received higher daily mean vitamin D doses (2246 vs 920 IU; P=.02), had shorter remnant small-bowel length (53.8 vs 82.1 cm; P=.03), and were PN dependent for a longer duration (1.3 vs 0.58 years; P=.01). Univariate analyses revealed longer remnant gut length (odds ratio [OR] = 1.03; P=.04) and shorter duration of PN (OR = 0.26; P=.04) to be significantly associated with sufficient vitamin D status. CONCLUSION Vitamin D deficiency and osteopenia are highly prevalent in pediatric patients with a history of IF who have achieved EA, despite enteral supplementation with higher than standard doses. Shorter remnant small-bowel length and longer duration of PN were associated with vitamin D deficiency. These findings emphasize the importance of prolonged surveillance and highlight the need for alternate dosing regimens.
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Affiliation(s)
- Chelsea A Lepus
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Kate Samela
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Karan M Emerick
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Jasmeet S Mokha
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, Connecticut, USA
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Bell M, Cole CR, Hansen NI, Duncan AF, Hintz SR, Adams-Chapman I. Neurodevelopmental and Growth Outcomes of Extremely Preterm Infants with Short Bowel Syndrome. J Pediatr 2021; 230:76-83.e5. [PMID: 33246015 PMCID: PMC8861973 DOI: 10.1016/j.jpeds.2020.11.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To determine if preterm infants with surgical necrotizing enterocolitis (sNEC) or spontaneous intestinal perforation (SIP) with short bowel syndrome (SBS) have worse neurodevelopmental and growth outcomes than those with sNEC/SIP without SBS, and those with no necrotizing enterocolitis, SIP, or SBS. STUDY DESIGN We undertook a retrospective analysis of prospectively collected data from infants born between 22 and 26 weeks of gestation in the National Institute of Child Health and Human Development Neonatal Research Network centers from January 1, 2008, to December 31, 2016. Survivors were assessed at 18-26 months corrected age by standardized neurologic examination and Bayley Scales of Infant and Toddler Development, Third Edition. The primary outcome was moderate-severe neurodevelopmental impairment. Growth was assessed using World Health Organization z-score standards. Adjusted relative risks were estimated using modified Poisson regression models. RESULTS Mortality was 32%, 45%, and 21% in the 3 groups, respectively. Eighty-nine percent of survivors were seen at 18-26 months corrected age. Moderate-severe neurodevelopmental impairment was present in 77% of children with SBS compared with 62% with sNEC/SIP without SBS (adjusted relative risk, 1.22; 95% CI, 1.02-1.45; P = .03) and 44% with no necrotizing enterocolitis, SIP, or SBS (adjusted relative risk, 1.60; 95% CI, 1.37-1.88; P < .001). Children with SBS had lowcognitive, language, and motor scores than children with sNEC/SIP without SBS. At follow-up, length and head circumference z-scores remained more than 1 SD below the mean for children with SBS. CONCLUSIONS Preterm infants with sNEC/SIP and SBS had increased risk of adverse neurodevelopmental outcomes at 18-26 months corrected age and impaired growth compared with peers with sNEC/SIP without SBS or without any of these conditions.
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Affiliation(s)
- Mercedes Bell
- The Permanente Medical Group, Kaiser Oakland Medical Center, Oakland, CA
| | - Conrad R. Cole
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Nellie I. Hansen
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Andrea F. Duncan
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA
| | - Susan R. Hintz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Ira Adams-Chapman
- Emory University School of Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, GA
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Huisenga D, La Bastide‐Van Gemert S, Van Bergen A, Sweeney J, Hadders‐Algra M. Developmental outcomes after early surgery for complex congenital heart disease: a systematic review and meta-analysis. Dev Med Child Neurol 2021; 63:29-46. [PMID: 32149404 PMCID: PMC7754445 DOI: 10.1111/dmcn.14512] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 01/25/2023]
Abstract
AIM (1) To systematically review the literature on developmental outcomes from infancy to adolescence of children with complex congenital heart disease (CHD) who underwent early surgery; (2) to run a meta-regression analysis on the Bayley Scales of Infant Development, Second Edition Mental Developmental Index and Psychomotor Developmental Index (PDI) of infants up to 24 months and IQs of preschool-aged children to adolescents; (3) to assess associations between perioperative risk factors and outcomes. METHOD We searched pertinent literature (January 1990 to January 2019) in PubMed, Embase, CINAHL, and PsycINFO. Selection criteria included infants with complex CHD who had primary surgery within the first 9 weeks of life. Methodological quality, including risk of bias and internal validity, were assessed. RESULTS In total, 185 papers met the inclusion criteria; the 100 with high to moderate methodological quality were analysed in detail. Substantial heterogeneity in the group with CHD and in methodology existed. The outcome of infants with single-ventricle CHD was inferior to those with two-ventricle CHD (respectively: average scores for PDI 77 and 88; intelligence scores 92 and 98). Perioperative risk factors were inconsistently associated with developmental outcomes. INTERPRETATION The literature on children undergoing surgery in early infancy suggests that infants with a single ventricle are at highest risk of adverse developmental outcomes.
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Affiliation(s)
- Darlene Huisenga
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
| | - Sacha La Bastide‐Van Gemert
- University of GroningenUniversity Medical Center GroningenDepartment of EpidemiologyGroningenthe Netherlands
| | - Andrew Van Bergen
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,Advocate Children’s Heart Institute Division of Pediatric Cardiac Critical CareAdvocate Children’s HospitalOak LawnILUSA
| | - Jane Sweeney
- Pediatric Science Doctoral ProgramRocky Mountain University of Health ProfessionsProvoUTUSA
| | - Mijna Hadders‐Algra
- University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
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Mezoff EA, Minneci PC, Dienhart MC. Intestinal Failure: A Description of the Problem and Recent Therapeutic Advances. Clin Perinatol 2020; 47:323-340. [PMID: 32439114 DOI: 10.1016/j.clp.2020.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Pediatric intestinal failure occurs when gut function is insufficient to meet the nutrient and hydration needs of the growing child. The commonest cause is short bowel syndrome with maldigestion and malabsorption following massive bowel loss. The remnant bowel adapts during the process of intestinal rehabilitation. Management promotes the achievement of enteral autonomy while mitigating the risk of comorbid disease. The future of care is likely to see expansion of pharmacologic methods for augmenting bowel adaptation, tissue engineering techniques enabling immune suppression-free autologous bowel transplant, and the development of electronic health record tools for efficient, collaborative study and care improvement.
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Affiliation(s)
- Ethan A Mezoff
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University College of Medicine, Center for Intestinal Rehabilitation and Nutrition Support, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Peter C Minneci
- Department of Surgery, The Ohio State University College of Medicine, Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Molly C Dienhart
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University College of Medicine, Center for Intestinal Rehabilitation and Nutrition Support, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
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Ohtaka-Maruyama C. Subplate Neurons as an Organizer of Mammalian Neocortical Development. Front Neuroanat 2020; 14:8. [PMID: 32265668 PMCID: PMC7103628 DOI: 10.3389/fnana.2020.00008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/20/2020] [Indexed: 12/30/2022] Open
Abstract
Subplate neurons (SpNs) are one of the earliest born and matured neurons in the developing cerebral cortex and play an important role in the early development of the neocortex. It has been known that SpNs have an essential role in thalamocortical axon (TCA) pathfinding and the establishment of the first neural circuit from the thalamus towards cortical layer IV. In addition to this function, it has recently been revealed in mouse corticogenesis that SpNs play an important role in the regulation of radial neuronal migration during the mid-embryonic stage. Moreover, accumulating studies throw light on the possible roles of SpNs in adult brain functions and also their involvement in psychiatric or other neurological disorders. As SpNs are unique to mammals, they may have contributed to the evolution of the mammalian neocortex by efficiently organizing cortical formation during the limited embryonic period of corticogenesis. By increasing our knowledge of the functions of SpNs, we will clarify how SpNs act as an organizer of mammalian neocortical formation.
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Affiliation(s)
- Chiaki Ohtaka-Maruyama
- Neural Network Project, Department of Brain Development and Neural Regeneration, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
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Molina TL, Stoll B, Mohammad M, Mohila CA, Call L, Cui L, Guthrie G, Kunichoff D, Lin S, Welch-Jernigan R, Nielsen J, Premkumar M, Robinson J, Smith V, Teets H, Obelitz-Ryom K, Hagan J, Cruz S, Lau P, Puyau M, Shypailo R, Manjarin R, Butte N, Fang Z, Olutoye O, Thymann T, Sangild P, Burrin D. New generation lipid emulsions increase brain DHA and improve body composition, but not short-term neurodevelopment in parenterally-fed preterm piglets. Brain Behav Immun 2020; 85:46-56. [PMID: 31026499 PMCID: PMC6813879 DOI: 10.1016/j.bbi.2019.04.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 12/16/2022] Open
Abstract
New generation, multicomponent parenteral lipid emulsions provide key fatty acids for brain growth and development, such as docosahexaenoic acid (DHA) and arachidonic acid (AA), yet the content may be suboptimal for preterm infants. Our aim was to test whether DHA and AA-enriched lipid emulsions would increase activity, growth, and neurodevelopment in preterm piglets and limit brain inflammation. Cesarean-delivered preterm pigs were given three weeks of either enteral preterm infant formula (ENT) or TPN with one of three parenteral lipid emulsions: Intralipid (IL), SMOFlipid (SMOF) or an experimental emulsion (EXP). Activity was continuously monitored and weekly blood sampling and behavioral field testing performed. At termination of the study, whole body and tissue metrics were collected. Neuronal density was assessed in sections of hippocampus (HC), thalamus, and cortex. Frontal cortex (FC) and HC tissue were assayed for fatty acid profiles and expression of genes of neuronal growth and inflammation. After 3 weeks of treatment, brain DHA content in SMOF, EXP and ENT pigs was higher (P < 0.01) in FC but not HC vs. IL pigs. There were no differences in brain weight or neuron density among treatment groups. Inflammatory cytokine TNFα and IL-1β expression in brain regions were increased in IL pigs (P < 0.05) compared to other groups. Overall growth velocity was similar among groups, but IL pigs had higher percent body fat and increased insulin resistance compared to other treatments (P < 0.05). ENT pigs spent more time in higher physical activity levels compared to all TPN groups, but there were no differences in exploratory behavior among groups. We conclude that a soybean oil emulsion increased select brain inflammatory cytokines and multicomponent lipid emulsions enriched with DHA and AA in parenteral lipids results in increased cortical DHA and improved body composition without affecting short term neurodevelopmental outcomes.
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Affiliation(s)
- Tiffany L. Molina
- Baylor College of Medicine, Department of Pediatrics, Section of Neonatology, 6621 Fannin St. MS W6104. Houston, TX 77030
| | - Barbara Stoll
- USDA-ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St. Houston, TX 77030
| | - Mahmoud Mohammad
- USDA-ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St. Houston, TX 77030
| | - Carrie A. Mohila
- Baylor College of Medicine, Department of Pathology & Immunology, Texas Children’s Hospital, Department of Pathology, 6621 Fannin St. Suite AB1195 Houston, TX 77030
| | - Lee Call
- USDA-ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St. Houston, TX 77030
| | - Liwei Cui
- USDA-ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St. Houston, TX 77030
| | - Gregory Guthrie
- USDA-ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St. Houston, TX 77030
| | - Dennis Kunichoff
- USDA-ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St. Houston, TX 77030
| | - Sen Lin
- Institute of Animal Nutrition, Sichuan Agricultural University, Chengdu, Sichuan 611130, People’s Republic of China
| | | | - Jon Nielsen
- Dept of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, DK
| | - Muralidhar Premkumar
- Baylor College of Medicine, Department of Pediatrics, Section of Neonatology, 6621 Fannin St. MS W6104. Houston, TX 77030
| | - Jason Robinson
- USDA-ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St. Houston, TX 77030
| | - Victoria Smith
- Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
| | - Haley Teets
- Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
| | - Karina Obelitz-Ryom
- Comparative Pediatrics and Nutrition, University of Copenhagen, 68 Dyrlægevej, DK-1870 Frederiskberg C., Copenhagen, Denmark
| | - Joseph Hagan
- Baylor College of Medicine, Department of Pediatrics, Section of Neonatology, 6621 Fannin St. MS W6104. Houston, TX 77030
| | - Stephanie Cruz
- Baylor College of Medicine, Department of Pediatric Surgery, 6701 Fannin St. Houston, TX 77030
| | - Patricio Lau
- Baylor College of Medicine, Department of Pediatric Surgery, 6701 Fannin St. Houston, TX 77030
| | - Maurice Puyau
- USDA-ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St. Houston, TX 77030
| | - Roman Shypailo
- USDA-ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St. Houston, TX 77030
| | - Rodrigo Manjarin
- Department of Animal Science, California Polytechnic State University, San Luis Obispo, California
| | - Nancy Butte
- USDA-ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St. Houston, TX 77030
| | - Zhengfeng Fang
- Institute of Animal Nutrition, Sichuan Agricultural University, Chengdu, Sichuan 611130, People’s Republic of China
| | - Oluyinka Olutoye
- Baylor College of Medicine, Department of Pediatric Surgery, 6701 Fannin St. Houston, TX 77030
| | - Thomas Thymann
- Comparative Pediatrics and Nutrition, University of Copenhagen, 68 Dyrlægevej, DK-1870 Frederiskberg C., Copenhagen, Denmark
| | - Per Sangild
- Comparative Pediatrics and Nutrition, University of Copenhagen, 68 Dyrlægevej, DK-1870 Frederiskberg C., Copenhagen, Denmark
| | - Douglas Burrin
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates St., Houston, TX 77030, United States.
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Abstract
OBJECTIVES Little is known about school-age functioning in children with intestinal failure (IF). This study examines neurocognitive outcomes of children with IF at ages 4 to 8 years treated at a single centre, along with relevant medical and demographic variables. METHODS Between 2012 and 2016, neurocognitive assessments were administered to 28 children receiving treatment in our IF rehabilitation program, and included measures of intelligence, academics, learning/memory, language, visual-motor integration, and fine-motor dexterity. DSM-IV/V criteria were used to diagnose Learning Disability, Intellectual Disability, and/or Attention Deficit/Hyperactivity Disorder. RESULTS Intellectual functioning ranged from extremely low to superior (Full Scale IQ range 53-123, mean = 89). Forty-six percentage received a cognitive/learning DSM diagnosis. Total number of first-year septic episodes correlated with poorer outcomes on the most cognitive measures. Adjusting for gestational age (61% were born <37 weeks), number of first-year septic episodes negatively predicted working memory, visual-motor integration, and visual memory scores. Additional factors correlating with poorer outcomes on ≥2 cognitive measures included length of first-year admissions, necrotizing enterocolitis diagnosis, and first-year sustained conjugated hyperbilirubinemia. Having ≥2 first-year septic episodes increased the likelihood of poorer outcome. Having a sibling was a significant positive predictor of working memory, processing speed, reading, and verbal learning skills. CONCLUSIONS Our data provides preliminary evidence that children with IF are at risk of neurocognitive problems at early school age. Managing septic events during the first year is one strategy that may help reduce long-term neurocognitive risks in this population.
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Neonatal Intestinal Failure Is Independently Associated With Impaired Cognitive Development Later in Childhood. J Pediatr Gastroenterol Nutr 2020; 70:64-71. [PMID: 31651669 DOI: 10.1097/mpg.0000000000002529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The impact of pediatric intestinal failure (IF) on neurodevelopment beyond infancy has not been systematically studied. Our aim was to evaluate cognitive and motor impairment and to identify risk factors for adverse outcomes among children with IF. METHODS We conducted a cross-sectional single-center study at the Helsinki University Children's Hospital. Patients with IF with >60 days of parental nutrition (PN) dependency aged between 3 and 16 years (n = 40) were invited to participate. The cognitive and motor skills were evaluated using validated tests: Wechsler Preschool and Primary Scale of Intelligence, 3rd edition, Wechsler Intelligence Scale for Children, 4th edition, and Movement Assessment Battery for Children, 2nd edition. RESULTS All the patients attending the study tests (n = 30, males = 24) were included. Their median age, gestational age, and birth weight was 7.5 (range 3-16) years, 35 (interquartile range [IQR] 28-38) weeks and 2238 (IQR 1040-3288) grams, respectively. Median duration of PN was 13 (IQR 5-37) months and 9 patients were currently on PN. Median intelligence quotient was 78 (IQR 65-91) and 10 (35%) patients had an intelligence quotient under 70 (-2 standard deviation). Significant motor impairment was detected in 10 patients (36%) and milder difficulties in 8 (28%). Adverse cognitive outcome was associated with neonatal short bowel syndrome, number of interventions under general anesthesia, and length of inpatient status, whereas adverse motor outcome was associated with prematurity. CONCLUSION Clinically significant cognitive and motor impairments are alarmingly common among neonatal patients with IF. We recommend early neurodevelopmental follow-up for all children with IF.
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16
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So S, Patterson C, Gold A, Rogers A, Belza C, de Silva N, Avitzur Y, Wales PW. Neurodevelopmental outcomes of infants with intestinal failure at 12 and 26 months corrected age. Early Hum Dev 2019; 130:38-43. [PMID: 30660017 DOI: 10.1016/j.earlhumdev.2018.12.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 12/28/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Survival rates of infants with intestinal failure (IF) are increasing, yet multiple medical factors may impact development. AIMS This study examines neurodevelopmental outcomes at 12-15 and 26-32 months corrected age in a cohort of children with IF. STUDY DESIGN Prospective single centre neurodevelopmental assessments of children admitted to an intestinal rehabilitation program between 2011 and 2013. Outcome measures include: Mullen Scales of Early Learning (12 and 26 months), and Vineland-II Adaptive Behaviour Scales - Caregiver Report (26 months). Standard scores were correlated with medical and demographic factors. RESULTS Thirty-one children (17 males), median gestational age 34 weeks (IQR 30-36) with birth weight (BW) 2.12 kg (IQR 1.24-2.52). Ten (32.2%) were dependent on parental nutrition (PN) at the second assessment. At 12 months, 11/30 (36.7%) scored below average (>1SD below mean) on the early learning composite and 24/30 (80%) were below average on the gross motor subscale. Comparatively, at 26 months, mean early learning scores were significantly lower with >50% scoring below average. Mean gross motor scores remained low, and 14/27 (51.9%) were below average on the Vineland-II motor domain. At 12 months, factors significantly associated with lower scores are primarily related to prematurity. At 26 months, the impact of IF-related variables such as bowel length and PN days are more apparent. CONCLUSION Children with IF are at risk of developmental delay in multiple domains. While gross motor skills appear to be most significantly affected, cognitive deficits become more apparent at 26 months, highlighting the importance of early developmental follow up.
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Affiliation(s)
- Stephanie So
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Catherine Patterson
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anna Gold
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alaine Rogers
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christina Belza
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicole de Silva
- Department of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
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17
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Motor Proficiency and Generalized Self-Efficacy Toward Physical Activity in Children With Intestinal Failure. J Pediatr Gastroenterol Nutr 2019; 68:7-12. [PMID: 30052565 DOI: 10.1097/mpg.0000000000002107] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Survival rates of children with intestinal failure have increased; however, associated co-morbidities may affect long-term motor developmental outcomes. This study evaluates motor proficiency and generalized self-efficacy toward physical activity (PA) in children ages 6 to 12 years with intestinal failure. METHODS This is an observational, cross-sectional study of children followed in a multidisciplinary intestinal rehabilitation program. Motor proficiency was assessed using the Bruininks-Oseretsky Test of Motor Proficiency-2 Short Form (BOT-2 SF) and the Scales of Independent Behavior (parent-proxy report). Children completed the Children's Self-Perceptions of Adequacy in and Predilection for Physical Activity (CSAPPA) and a PA questionnaire. Relevant demographic and medical variables were correlated with assessment results. RESULTS Participants include 30 children (18 males), median age 7 years (interquartile range [IQR] 6-9) with gestational age 35 weeks (IQR 32-39) and birth weight 2.13 kg (IQR 1.68-2.77). Thirteen (43%) were dependent on parenteral nutrition. Fifteen (50%) scored below average on the BOT-2 SF. Lower BOT-2 SF scores were significantly associated with lower CSAPPA scores (r = 0.480, P = 0.01), with a common barrier to PA being the presence of a central line or enterostomy tube. Gestational age, height z scores, length of hospital admissions, and number of septic events were all significantly correlated with lower scores in motor proficiency. Number of septic events and total parenteral nutrition days were significant predictors of lower BOT-2 SF scores, when adjusting for birth weight. CONCLUSIONS Multiple medical variables related to intestinal failure may affect motor proficiency and PA self-efficacy. Developmental follow-up is important to optimize motor skill development and promote PA participation.
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18
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Neelis E, de Koning B, van Winckel M, Tabbers M, Hill S, Hulst J. Wide variation in organisation and clinical practice of paediatric intestinal failure teams: an international survey. Clin Nutr 2018; 37:2271-2279. [DOI: 10.1016/j.clnu.2017.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/09/2017] [Accepted: 11/12/2017] [Indexed: 10/18/2022]
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19
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Attitudes Surrounding the Management of Neonates with Severe Necrotizing Enterocolitis. J Pediatr 2018; 199:186-193.e3. [PMID: 29754868 PMCID: PMC6063789 DOI: 10.1016/j.jpeds.2018.03.074] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/13/2018] [Accepted: 03/29/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To assess providers' recommendations as to comfort care versus medical and surgical management in clinical scenarios of newborns with severe bowel loss and to assess how a variety of factors influence providers' decision making. STUDY DESIGN We conducted a survey of pediatric surgeons and neonatologists via the American Pediatric Surgical Association and American Academy of Pediatrics Section of Neonatal-Perinatal Medicine. We examined how respondents' recommendations were affected by a variety of patient and provider factors. RESULTS There were 288 neonatologists and 316 pediatric surgeons who responded. Irrespective of remaining bowel length, comfort care was recommended by 73% of providers for a premature infant with necrotizing enterocolitis and 54% for a full-term infant with midgut volvulus. The presence of comorbidities and earlier gestational age increased the proportion of providers recommending comfort care. Neonatologists were more likely to recommend comfort care than surgeons across all scenarios (OR, 1.45-2.00; P < .05), and this difference was more pronounced with infants born closer to term. In making these recommendations, neonatologists placed more importance on neurodevelopmental outcomes (P < .001), and surgeons emphasized experience with long-term quality of life (P < .001). CONCLUSION Despite a contemporary survival of >90% in infants with intestinal failure, a majority of providers still recommend comfort care in infants with massive bowel loss. Significant differences were identified in clinical decision making between surgeons and neonatologists. These data reinforce the need for targeted education on long-term outcomes in intestinal failure to neonatal and surgical providers.
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20
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Abstract
Pediatric intestinal failure is a complex and devastating condition defined as the inability of the intestine to absorb an adequate amount of fluid and nutrients to sustain life. The primary goal of intestinal failure treatment is to achieve enteral autonomy with a customized treatment plan. Although recent improvements in intestinal failure patient care have led to significant improvements in the morbidity and mortality rate, children with intestinal failure are at risk for multiple complications such as intestinal failure associated liver disease, recurrent septic episodes, central line complications, metabolic bone disease, impaired kidney function, and failure to thrive. In this article, we review the current literature on the etiology and factors affecting prognosis of pediatric IF.
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Affiliation(s)
- Annika Mutanen
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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21
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Hukkinen M, Merras-Salmio L, Pakarinen MP. Health-related quality of life and neurodevelopmental outcomes among children with intestinal failure. Semin Pediatr Surg 2018; 27:273-279. [PMID: 30342603 DOI: 10.1053/j.sempedsurg.2018.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Treatment results of pediatric intestinal failure have improved markedly during the last decades. With improved survival the attention is turning to other essential outcomes including quality of life and neurodevelopment. So far, relatively few studies with limited number of patients and variable methodology have addressed these issues. Based on these studies using generic health related quality of life tools, children with intestinal failure demonstrate decreased physical health, while PN-dependence is also associated with compromised emotional functioning. Impairments of social functioning are frequently observed among older children and parents. Few recent studies on neurodevelopment imply significant impairments in motor and mental skills among children with intestinal failure despite small sample sizes and limited follow-up times. Development of a disease-specific survey designed for the pediatric intestinal failure population could better reveal the health issues with greatest impact on quality of life. Robust studies with appropriate methodology on neurodevelopment in pediatric intestinal failure with extended follow-up times are urgently needed. Quality of life and neurodevelopment requires greater attention from medical professionals managing children with intestinal failure.
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Affiliation(s)
- Maria Hukkinen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, P.O. Box 281, 00029 HUS Helsinki, Finland; Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, Finland
| | - Laura Merras-Salmio
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, P.O. Box 281, 00029 HUS Helsinki, Finland; Section of Pediatric Gastroenterology, Children's Hospital, Helsinki University Hospital, Finland
| | - Mikko P Pakarinen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, P.O. Box 281, 00029 HUS Helsinki, Finland; Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, Finland.
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22
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Martin C, Patel M, Williams S, Arora H, Brawner K, Sims B. Human breast milk-derived exosomes attenuate cell death in intestinal epithelial cells. Innate Immun 2018; 24:278-284. [PMID: 29991305 PMCID: PMC6830917 DOI: 10.1177/1753425918785715] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Human breast milk has been shown to reduce the incidence of necrotizing enterocolitis (NEC). Breast milk has many components (immunoglobulins, proteins, fat, and, of recent interest, exosomes), but the specific component that affords protection against NEC is not known. Exosomes are small-nanometer vesicles that are rich in protein, lipid, and microRNA. Here, we hypothesized that human breast milk-derived exosomes can protect intestinal epithelial cells (IECs) from cell death. Human breast milk was collected, separated using ultracentrifugation, and quantified using NanoSight tracking analysis. Purified exosomes were added to IECs that had been treated with varying concentrations of H2O2. Cells were then incubated overnight with the human breast milk-derived exosomes and assessed for cell viability. Western blot analysis showed that both clathrin and CD81 were present in the purified sample. Oxidative stress using H2O2 caused a 50% decrease in cell viability and human breast milk-derived exosomes had a protective effect in IECs. In the presence of H2O2, exosomes had a statistically significant protective effect. The protection seen by human breast milk-derived exosomes was not attenuated by cycloheximide. Thus, human breast milk-derived exosomes allow IECs to be protected from oxidative stress, but the mechanism is still not clear. Exosomes derived from human breast milk are an attractive treatment concept for children with intestinal injury.
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Affiliation(s)
- Colin Martin
- 1 Department of Surgery/Division of Pediatric Surgery, University of Alabama School of Medicine, USA
| | - Mikita Patel
- 1 Department of Surgery/Division of Pediatric Surgery, University of Alabama School of Medicine, USA
| | - Sparkle Williams
- 2 Department of Pediatrics/Division of Neonatology and Center of Glial Biology in Medicine, University of Alabama School of Medicine, USA
| | - Hamish Arora
- 2 Department of Pediatrics/Division of Neonatology and Center of Glial Biology in Medicine, University of Alabama School of Medicine, USA
| | | | - Brian Sims
- 2 Department of Pediatrics/Division of Neonatology and Center of Glial Biology in Medicine, University of Alabama School of Medicine, USA
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23
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Lansing M, Sauvé Y, Dimopoulos I, Field CJ, Suh M, Wizzard P, Goruk S, Lim D, Muto M, Wales P, Turner J. Parenteral Lipid Dose Restriction With Soy Oil, Not Fish Oil, Preserves Retinal Function in Neonatal Piglets. JPEN J Parenter Enteral Nutr 2018. [DOI: 10.1002/jpen.1145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Marihan Lansing
- Department of Pediatrics; University of Alberta; Edmonton Canada
| | - Yves Sauvé
- Department of Ophthalmology and Visual Sciences; University of Alberta; Edmonton Canada
| | - Ioannis Dimopoulos
- Department of Ophthalmology and Visual Sciences; University of Alberta; Edmonton Canada
| | - Catherine J. Field
- Department of Agricultural Food and Nutritional Science; University of Alberta; Edmonton Canada
| | - Miyoung Suh
- Department of Human Nutritional Sciences; University of Manitoba; Winnipeg Canada
| | - Pamela Wizzard
- Department of Pediatrics; University of Alberta; Edmonton Canada
| | - Susan Goruk
- Department of Agricultural Food and Nutritional Science; University of Alberta; Edmonton Canada
| | - David Lim
- Department of Surgery; University of Alberta; Edmonton Canada
| | - Mitsuru Muto
- Department of Pediatric Surgery; Kagoshima University; Sakuragaoka Kagoshima Japan
| | - Paul Wales
- Department of Pediatrics; University of Alberta; Edmonton Canada
- Research Institute, Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
- Departments of Pediatrics and Nutritional Sciences; Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
- Division of General Surgery; Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
- Group for Improvement of Intestinal Function and Treatment; Hospital for Sick Children; Toronto Ontario Canada
| | - Justine Turner
- Department of Pediatrics; University of Alberta; Edmonton Canada
- Department of Agricultural Food and Nutritional Science; University of Alberta; Edmonton Canada
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24
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Growth Trajectory in Children With Short Bowel Syndrome During the First 2 Years of Life. J Pediatr Gastroenterol Nutr 2018; 66:484-488. [PMID: 28953527 DOI: 10.1097/mpg.0000000000001762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Infants with short bowel syndrome (SBS) require diligent nutritional support for adequate growth. Enteral independence is a primary goal, but must be balanced with ensuring sufficient nutrition. We aimed to describe growth trajectory in infants with SBS as function of nutritional intake during first 2 years of life. METHODS Infants with SBS were reviewed (2008-2016). z Scores for weight, height, and head circumference (HC) were recorded at birth, 3, 6, 12, 18, and 24 months. Nutritional intake, serum liver enzyme, and bilirubin levels were assessed at all time points. Pearson correlation coefficients were used to measure association with P < 0.05 considered significant. RESULTS Forty-one infants were included, with median gestational age of 34 weeks (interquartile range [IQR] 29-36 weeks). Median small bowel length was 36 cm (IQR 26-52 cm) and median % expected small bowel length was 28% (IQR 20%-42%). Mean z scores for weight and length were >0 at birth, but <0 from 3 months to 2 years. HC remained <0 throughout the study. Mean z scores at 2 years for weight, length, HC, and weight-for-length were -0.90 (SD 1.1), -1.33 (SD 1.4), -0.67 (SD 1.2), and -0.12 (SD 1.2), respectively. Percentage calories from PN was positively correlated with weight in the first 3 months of life (P = 0.01). CONCLUSIONS Babies with SBS are high risk for poor growth during the first 2 years of life. Although weaning PN is important for these patients, doing so too quickly in infancy may contribute to compromised growth. The long-term impact on overall development is not known.
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25
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Robinson JR, Kennedy C, van Arendonk KJ, Green A, Martin CR, Blakely ML. Neurodevelopmental considerations in surgical necrotizing enterocolitis. Semin Pediatr Surg 2018; 27:52-56. [PMID: 29275818 DOI: 10.1053/j.sempedsurg.2017.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The majority of surviving infants with surgical necrotizing enterocolitis (NEC) will have some degree of neurodevelopmental impairment. The impact of specific medial and surgical treatments for infants with severe NEC remains largely unknown but is being actively investigated. It is incumbent upon all providers caring for these infants to continue to focus on long term neurodevelopmental outcomes and to develop more widespread methods of neurodevelopmental assessment.
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Affiliation(s)
- Jamie R Robinson
- Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Doctors Office Tower, Suite 7100, Nashville, Tennessee 37232
| | | | - Kyle J van Arendonk
- Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Doctors Office Tower, Suite 7100, Nashville, Tennessee 37232
| | - Alyssa Green
- Meharry Medical College School of Medicine, Nashville, Tennessee
| | - Camilia R Martin
- Department of Neonatology and Division of Translational Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Children's Way, Doctors Office Tower, Suite 7100, Nashville, Tennessee 37232.
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26
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Abstract
Management of pediatric intestinal failure has evolved in recent decades, with improved survival since the advent of specialized multidisciplinary intestinal failure centers. Though sepsis and intestinal failure associated liver disease still contribute to mortality, we now have growing data on the long-term outcomes for this population. While intestinal adaptation and parenteral nutrition weaning is most rapid during the first year on parenteral support, achievement of enteral autonomy is possible even after many years as energy and protein requirements decline dramatically with age. Intestinal transplant is an option for patients experiencing complications of long-term parenteral nutrition who are expected to have permanent intestinal failure, but outcomes are hindered by immunosuppression-related complications. Much of the available data comes from single center retrospective reports, with variable inclusion criteria, intestinal failure definitions, and follow-up durations; this limits the ability to analyze outcomes and identify best practices. As most children now survive long-term, the focus of management has shifted to the avoidance and management of comorbidities, support of normal growth and development, and optimization of quality of life for these medically and surgically complex patients.
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Affiliation(s)
- Brenna S Fullerton
- Department of Surgery, Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Fegan 3, Boston, MA 02115
| | - Charles R Hong
- Department of Surgery, Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Fegan 3, Boston, MA 02115
| | - Tom Jaksic
- Department of Surgery, Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Fegan 3, Boston, MA 02115.
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27
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Affiliation(s)
- Christopher P Duggan
- From the Center for Advanced Intestinal Rehabilitation (C.P.D., T.J.), Division of Gastroenterology, Hepatology, and Nutrition (C.P.D.), and the Department of Surgery (T.J.), Boston Children's Hospital and Harvard Medical School, Boston
| | - Tom Jaksic
- From the Center for Advanced Intestinal Rehabilitation (C.P.D., T.J.), Division of Gastroenterology, Hepatology, and Nutrition (C.P.D.), and the Department of Surgery (T.J.), Boston Children's Hospital and Harvard Medical School, Boston
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