Multiple micronutrient deficiencies among patients with intestinal failure during and after transition to enteral nutrition

LLL 44 - Module 3: Micronutrients in Chronic disease

Micronutrients (MN), i.e. trace elements and vitamins, are essential organic molecules, which are required in the diet in relatively small amounts in any form of nutrition (oral, enteral, parenteral). The probability of MN depletion or deficiencies should be considered in all chronic illnesses, especially in those that can interfere with intake, digestion, or intestinal absorption. Low socio-economic status and food deprivation are recognized as the most prevalent reasons for MN deficiencies world-wide. Elderly multimorbid patients with multimodal therapy, as well as patients with long-lasting menu restrictions, are at high risk for both disease related malnutrition as well as multiple MN deficiencies, needing careful specific follow-up. The importance of monitoring MN blood levels along with CRP is essential for optimal care. Drug interactions are also highlighted. In patients with chronic conditions depending on medical nutrition therapy, the provision of adequate dietary reference intakes (DRI) of MN doses and monitoring of their adequacy belongs to standard of care.

LLL 44-4 : Micronutrients in acute disease and critical illness

Micronutrients (MN), i.e. trace elements and vitamins, are essential components of the diet in relatively small amounts in any form of nutrition, with special needs in critically ill patients. Critical illness is characterised by the presence of inflammation and oxidative stress. MNs are tightly involved in antioxidant and immune defences. In addition, some conditions, and treatments result in large losses of biological fluids containing MNs: therefore, acute renal injury requiring renal replacement therapy, acute intestinal failure, and major burns and trauma are at high risk of acute depletion of body stores, and of deficiency. MN requirements are increased above standard DRI. Blood level interpretation is complicated by inflammation: some biomarkers assist the status determination. Due to the acute challenges of critical illness, it of utmost importance to cover the needs to maintain the organism's endogenous immune and antioxidant defences, and capacity to repair tissues. Practical strategies are proposed.

Nutrition support considerations in pediatric small bowel transplantation

Enteral autonomy is the primary goal of intestinal failure therapy. Intestinal transplantation (ITx) is an option when enteral autonomy cannot be achieved and management complications become life-threatening. The purpose of this review is to summarize existing medical literature related to nutrition requirements, nutrition status, and nutrition support after pediatric ITx. Achieving or maintaining adequate growth after intestinal transplant in children can be challenging because of episodes of rejection that require the use of corticosteroids, occurrences of infection that require a reduction or discontinuation of enteral or parenteral support, and fat malabsorption caused by impaired lymphatic circulation. Nutrient requirements should be assessed and modified regularly based on nutrition status, growth, ventilatory status, wound healing, and the presence of complications. Parenteral nutrition (PN) should be initiated as a continuous infusion early postoperatively. Enteral support should be initiated after evidence of graft bowel function and in the absence of clinical complications. Foods high in simple carbohydrates should be limited, as consumption may result in osmotic diarrhea. Short-term use of a fat-free diet followed by a low-fat diet may reduce the risk of the development of chylous ascites. Micronutrient deficiencies and food allergies are common occurrences after pediatric ITx. Enteral/oral vitamin and mineral supplementation may be required after PN is weaned. Nutrition management of children after ITx can be challenging for all members of the healthcare team. Anthropometric parameters and micronutrient status should be monitored regularly so that interventions to promote growth and prevent or reverse nutrient deficiencies can be implemented promptly.

Standardizing vitamin D supplementation to minimize deficiency in children with intestinal failure

BACKGROUND

Vitamin D deficiency is present in 40%-70% of children with intestinal failure (IF), yet there are no published guidelines for repleting and maintaining vitamin D levels in this population. The purpose of this study is to evaluate the efficacy of a standardized vitamin D algorithm in reducing the incidence of deficiency.

METHODS

A retrospective chart review was performed in children with IF who had at least one serum vitamin D (25-hydroxyvitamin D3 ) measurement. Vitamin D levels were compared prealgorithm (2014-2016) and during active-algorithm use (2018-2020). Vitamin D levels were classified as severe deficiency (<12.5 nmol per L), mild deficiency (12.5-39 nmol/L), insufficiency (40-74 nmol/L), optimal (75-224 nmol/L), or toxicity (>225 nmol/L). Descriptive and comparative statistics were calculated using a linear mixed-effects model, with P < 0.05 considered significant.

RESULTS

Twenty-eight children with IF were enrolled, which included 157 vitamin D measurements (58 in the prealgorithm group and 98 in the active-algorithm group). Algorithm compliance was 4% in the prealgorithm group and 61% in the active-algorithm group. Active-algorithm patients had improved vitamin D levels in all categories compared with those of prealgorithm patients (mild deficiency: 8% vs 9%; insufficiency: 41% vs 72%; optimal: 50% vs 19%). Algorithm use was found to have a statistically significant effect on serum vitamin D levels (β = 21.58; 95% confidence interval, 14.11-29.05; P < 0.005).

CONCLUSIONS

Children with IF are at high risk for vitamin D deficiency. Use of a standardized vitamin D supplementation algorithm was associated with increased serum vitamin D levels.

Intravenous iron therapy in pediatrics: who should get it and when is the right time?

Iron-deficiency anemia occurs most commonly in young children due to a low-iron diet and adolescent girls due to menstrual blood loss. However, children with gastrointestinal conditions such as intestinal failure, inflammatory bowel disease, celiac disease, and/or other chronic conditions, including chronic kidney disease and heart failure, also commonly have iron deficiency. Many patients with classic iron-deficiency anemia will improve with oral iron therapy. However, in children who have an incomplete response to oral iron, intravenous iron therapy is increasingly being used. Benefits of intravenous iron therapy include a rapid repletion of iron stores in addition to resolution of anemia, less gastrointestinal side effects, and relief for patients and families struggling with long-term iron supplementation. Indications for first-line therapy with intravenous iron in children with chronic conditions have also increased. Four intravenous iron formulations have approved indications in pediatrics, and many are increasingly used off-label in children as well. Here we discuss the indications and appropriate timing of intravenous iron therapy in children with a wide range of underlying etiologies.

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.

Efficacy and safety of intravenous iron sucrose in children younger than 2 years with intestinal failure

Iron-deficiency anemia (IDA) is highly prevalent in children with intestinal failure (IF) and oral iron supplementation is often ineffective in this patient population. Even though various intravenous (IV) iron formulations are available, there is a dearth of data on the use of newer parenteral iron products such as IV iron sucrose, especially in infants and young children (<2 years of age) with IF. To determine safety and efficacy, we performed a retrospective chart review on infants and children younger than 2 years with IF who received IV iron sucrose for IDA between October 2019 and August 2021. The review revealed that 10 events of IV iron sucrose replacement were administered to five children aged 4-22 months with IF and IDA. We observed a mean increase in hemoglobin of 1.9 ± 0.6 g/dl, and peak hemoglobin levels were seen at 4.3 ± 0.8 weeks after the IV iron sucrose dose. The infusions were well tolerated, and no short-term adverse reactions or laboratory abnormalities were observed. Based on these observations, the use of IV iron sucrose appears to be safe and effective in infants and young children with IF and could be considered in the management of IDA in this patient population.

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.

Inflammation and micronutrient deficiency as major risk factors for anemia in children with intestinal failure: A longitudinal cohort study

BACKGROUND

Most data on anemia in children with intestinal failure (IF) have been obtained from studies in which the data were collected at a single point in time. We aimed to identify the frequency of anemia and factors associated with hemoglobin levels in children with IF during their course of home parenteral nutrition.

METHODS

We performed a longitudinal cohort study of patients with IF followed up at a pediatric intestinal rehabilitation center. Outcome variables were hemoglobin levels and prevalence of anemia during the follow-up period. The exposure variables were age, duration of parenteral nutrition, chronic disease, and serum concentrations of C-reactive protein, iron, copper, selenium, vitamins A, D, B₁₂ , and folic acid.

RESULTS

Twenty-five children with a median time of receiving parenteral nutrition of 40.7 months were included. A median (and interquartile range) of 40.7 (25.2-58) hemoglobin measurements were performed per patient. Mean (SD) hemoglobin was 10.7 (1.8) g/dL at baseline and 11.6 (0.9) g/dL in the last observation (paired t test, P = 0.07); 32% of patients had mean hemoglobin values below the lower limit for age. In a multivariable predictive model, having C-reactive protein >1 mg/dL was associated with a decrease of 0.57 g/dL in hemoglobin (95% CI, -0.90 to -0.24, P = 0.01), and an increase of 1 mg/L in vitamin A concentration was associated with the increase of 0.93 g/dL in Hb level (95% CI, 0.24-1.61; P = 0.008).

CONCLUSION

Anemia affects almost one-third of children with IF and its frequency decreases during the follow-up period. Hemoglobin levels are associated with inflammatory response and serum micronutrient concentrations.

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.

Complementary food introduction practices in infants with intestinal failure

BACKGROUND

Oral intake in infants with intestinal failure (IF) may be limited due to intolerance or feeding difficulties. Guidelines for the introduction of semisolid or solid complementary foods (CFs) to infants with IF do not exist. CF intake and caloric contribution from CF is difficult to assess due to malabsorption and incomplete recording. The aim of this study was to identify institutional approaches to introducing CF to infants with IF.

METHODS

The American Society for Parenteral and Enteral Nutriton (ASPEN) Pediatric Intestinal Failure Section Registered Dietitian/Nutritionist (RDN) working group designed a 10-question online cloud-based survey to assess group member practice related to the introduction of CF to infants with IF.

RESULTS

Twenty-six surveys were completed. Thirteen (50%) RDNs recommend introduction of CF between 4 and 6 months of age. Nineteen (76%) recommend adding pureed foods to gastrostomy tube feedings. Seventeen (65%) follow standard infant feeding practice guidelines with half citing the American Academy of Pediatrics. Approximately half (44%) recommend introducing vegetables first and the majority (80%) recommend delaying the introduction of fruits. The vast majority (92%) recommend specific foods to minimize stool output including green beans, bananas, infant cereals, and meats/protein.

CONCLUSION

Institutional practices related to the introduction of CF to infants with IF vary. Similarities with first food choice and foods to avoid were observed. Evidenced-based practice guidelines for the introduction of CF to infants with IF need to be established to determine best practices for reducing stool output, encouraging weaning from parenteral nutrition, and achieving enteral autonomy.

Selenium Deficiency Leads to Inflammation, Autophagy, Endoplasmic Reticulum Stress, Apoptosis and Contraction Abnormalities via Affecting Intestinal Flora in Intestinal Smooth Muscle of Mice

Selenium (Se) is a micronutrient that plays a predominant role in various physiological processes in humans and animals. Long-term lack of Se will lead to many metabolic diseases. Studies have found that chronic Se deficiency can cause chronic diarrhea. The gut flora is closely related to the health of the body. Changes in environmental factors can cause changes in the intestinal flora. Our study found that Se deficiency can disrupt intestinal flora. Through 16s high-throughput sequencing analysis of small intestinal contents of mice, we found that compared with CSe group, the abundance of Lactobacillus, Bifidobacterium, and Ileibacterium in the low selenium group was significantly increased, while Romboutsia abundance was significantly decreased. Histological analysis showed that compared with CSe group, the small intestine tissues of the LSe group had obvious pathological changes. We examined mRNA expression levels in the small intestine associated with inflammation, autophagy, endoplasmic reticulum stress, apoptosis, tight junctions, and smooth muscle contraction. The mRNA levels of NF-κB, IκB, p38, IL-1β, TNF-α, Beclin, ATG7, ATG5, LC3α, BaK, Pum, Caspase-3, RIP1, RIPK3, PERK, IRE1, elF2α, GRP78, CHOP2, ZO-1, ZO-2, Occludin, E-cadherin, CaM, MLC, MLCK, Rho, and RhoA in the LSe group were significantly increased. The mRNA levels of IL-10, p62 BcL-2 and BcL-w were significantly decreased in the LSe group compared with the CSe group. These results suggest that changes in the abundance of Lactobacillus, bifidobacterium, ileum, and Romboutsia may be associated with cellular inflammation, autophagy, endoplasmic reticulum stress, apoptosis, tight junction, and abnormal smooth muscle contraction. Intestinal flora may play an important role in chronic diarrhea caused by selenium deficiency.

Pathophysiology and therapeutic management of anemia in gastrointestinal disorders

INTRODUCTION

Anemia is a common complication of gastrointestinal (GI) disorders, with a prevalence up to 60% in celiac disease (CeD) and inflammatory bowel disease (IBD). Iron deficiency anemia (IDA) is the most prevalent form of anemia in these conditions, but chronic inflammation and vitamin B12 deficiency represent other common contributing mechanisms, especially in IBD.

AREAS COVERED

We discuss the pathogenesis of anemia in various medical GI disorders, the sometime problematic distinction between IDA, anemia of inflammation (AI) and the association of the two, and therapeutic and preventive measures that can be useful for the management of anemia in GI disorders. Unfortunately, with the exception of IDA and AI in IBD, large RCT concerning the treatment of anemia in GI disorders are lacking.

EXPERT OPINION

Anemia management strategies in GI disorders are outlined, with a focus on the main prevention, diagnostic, and therapeutic measures. Specific problems and situations such as the role of gluten-free diet for IDA treatment in CeD, the choice between oral and parenteral supplementation of iron or vitamin B12 in carential anemias, the use of endoscopic procedures to stop bleeding in intestinal angiodysplasia and preventive/treatment strategies for NSAID-associated GI bleeding are discussed.

Nutritional Management of Short Bowel Syndrome

Short bowel syndrome (SBS) of infancy is a cause of prolonged morbidity with intolerance to enteral feeding, specialized nutritional needs, and partial/total dependence on parenteral nutrition. These infants can benefit from individualized nutritional strategies to support and enhance the process of intestinal adaptation. Early introduction of enteral feeds during the period of intestinal adaptation is crucial, even though the enteral feedings may need to be supplemented with an effective, safe, and nutritionally adequate parenteral nutritional regimen. Newer generation intravenous lipid emulsions can be effective in preventing and treating intestinal failure-associated liver disease. Prevention of infection(s), pharmaceutical interventions to enhance bowel motility and prevent/mitigate bacteria overgrowth, and specialized multidisciplinary care to minimize the injury to other organs such as the liver, kidneys, and the brain can assist in nutritional rehabilitation and lower the morbidity in SBS.

Management of pediatric intestinal failure related to short bowel syndrome

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.

Anaemia in Children Receiving Home Parenteral Nutrition: A Common Problem?

OBJECTIVES

Children receiving home parenteral nutrition (HPN) are at risk of iron deficiency anaemia. Our aim was to determine the incidence of iron deficiency anaemia in paediatric HPN and efficacy of each therapeutic approach.

METHODS

Retrospective data collection from children receiving HPN at a tertiary referral centre over a 12-month period (2015). Full blood count, and whenever available, ferritin and C-reactive protein were collected at least 3 times for each patient. Liver function tests were checked at the beginning and end of the study and number of blood transfusions/iron infusions recorded.

RESULTS

Forty-one HPN patients (61% girls; 51% motility disorder, 29% enteropathy, 20% short bowel syndrome) were identified. Eighty-three percent of children were anaemic at the beginning of the study with the number decreasing to 73% by the end. Iron deficiency anaemia was most commonly seen and treated with blood transfusion in 46% of cases and iron infusions in 29%. There was no statistical difference in the level of haemoglobin improvement between the 2 treatments (50% vs 33%, P  = 0.657) nor a significant difference in haemoglobin (g/L) level achieved. The results for both were, however, more favourable in the infusion group. Patients receiving transfusions had a significantly higher incidence of abnormal liver function compared with those who hadinfusions (93% vs 37%, P = 0.009).

CONCLUSIONS

Iron deficiency anaemia is common in children receiving HPN. A large proportion of patients still receive blood transfusions as first-line therapy but intravenous iron can be a suitable alternative. Treatment guidelines are required.

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.

Outcomes and Perioperative Nutritional Management in a Porcine Model of Short Bowel Syndrome

INTRODUCTION

Short bowel syndrome (SBS) results from significant intestinal loss and is characterized by insufficient absorption of nutrients and fluids. Preclinical large animal SBS models typically require parenteral nutrition (PN) support and may not be appropriate for studying interventions to improve intestinal absorption or adaptation. Here, we describe the development of a porcine SBS model that does not require PN support.

METHODS

Eight male Yorkshire piglets underwent either a 75% or 90% jejunoileal resection (n = 5) or no resection (n = 3). Continuous enteral nutrition (EN) was provided via a gastrostomy tube. The final SBS model consisted of a 75% resection and nutrition provided via combination EN (60%) and per oral pig chow (40%). Body weight and concentration of fat-soluble vitamins were assessed on postoperative days (POD) 7, 14, and 21. For assessing fat malabsorption, the coefficient of fat absorption (CFA) was calculated following a 72-h stool collection.

RESULTS

Resected animals had decreased weight gain compared to unresected controls (POD21 + 8.3% versus +28.8%, P = 0.048). Vitamin D concentration was significantly lower in resected animals compared to controls on POD 7, POD 14, and POD 21. Serum vitamin E concentration was also lower on POD 21. Resected animals developed fat malabsorption with lower CFA (76.5% versus 95.3%, P = 0.014).

CONCLUSIONS

We describe the development of a porcine SBS model that does not require PN support. Piglets in this model gain less weight, demonstrate fat malabsorption, and develop fat-soluble vitamin deficiencies. This model will benefit investigations of intestinal absorption or adaptation while potentially decreasing costs and confounding complications related to PN administration.

Fat soluble vitamin status in children on home parenteral nutrition in a tertiary paediatric intestinal rehabilitation unit

BACKGROUNDS & AIMS

Children with intestinal failure on home parenteral nutrition are at risk of fat malabsorption and fat soluble vitamin deficiency. Fish oil containing mixed lipid emulsions (SMOFlipid®) with higher vitamin E content, have a theoretical risk of exceeding current recommendations for vitamin E dosing and, may influence other fat soluble vitamin status in these children. The aim of this study was to assess for fat soluble vitamin status in children on long-term home parental nutrition receiving a mixed lipid emulsion (SMOFlipid®) compared with those receiving traditional soy or soy/olive oil based (non- SMOFlipid®) lipid emulsions and whether this is influenced by the underlying cause of intestinal failure.

METHODS

Retrospective longitudinal study in a tertiary referral paediatric hospital of children on home parental nutrition during the period January 2000 to June 2019. Data was retrieved using medical and pharmacy records, laboratory database, and summarised using inferential statistics.

RESULTS

111 patients (n = 58 female) received home parental nutrition in 121 discrete episodes (range 45-5329 days). N = 61 (55%) were diagnosed with anatomical short bowel syndrome, of which necrotising enterocolitis was the most common cause (n = 14). SMOFlipid® was used exclusively in n = 79 patients, non-SMOFlipid® exclusively in n = 19, and n = 13 changed from non-SMOFlipid® to SMOFlipid® during the study period. The median vitamin E level and vitamin E:lipid ratio were significantly higher for patients on SMOFlipid® compared to non-SMOFlipid® (27.9 vs 18.3 μmol/L respectively, p < 0.001; 7.10 vs 4.00 μmol/mmol; p < 0.001). Median vitamin A level was comparable (1.19 vs 1.12 μmol/L, p = 0.241), while median vitamin D level was significantly lower in the non-SMOFlipid® group consistent with mild deficiency (63.7 vs 43.0 nmol/L, p < 0.001).

CONCLUSION

The use of SMOFlipid® correlated with higher Vitamin E level in paediatric home parental nutrition patients. Lower vitamin D level appears to correlate with the use of non-SMOFlipid®. A larger prospective cohort is required to delineate any clinical significance from these findings.

ASPEN definitions in pediatric intestinal failure

Pediatric intestinal failure (PIF) is a relatively rare disease entity which requires focused interdisciplinary care and specialized nutrition management. There has long been a lack of consensus in the definition of key terms related to PIF due to its rarity and plethora of small studies rather than large trials. As such, the American Society for Parenteral and Enteral Nutrition (ASPEN) Pediatric Intestinal Failure Section, composed of clinicians from a variety of disciplines caring for children with intestinal failure, is uniquely poised to provide insight into this definition void. This document is the product of an effort by the Section to create evidence-based consensus definitions, with the goal of allowing for appropriate comparisons between clinical studies and measurement of longterm patient outcomes. This manuscript was approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.

Chronic intestinal failure and short bowel syndrome in Crohn’s disease

Chronic intestinal failure (CIF) is a rare but feared complication of Crohn’s disease. Depending on the remaining length of the small intestine, the affected intestinal segment, and the residual bowel function, CIF can result in a wide spectrum of symptoms, from single micronutrient malabsorption to complete intestinal failure. Management of CIF has improved significantly in recent years. Advances in home-based parenteral nutrition, in particular, have translated into increased survival and improved quality of life. Nevertheless, 60% of patients are permanently reliant on parenteral nutrition. Encouraging results with new drugs such as teduglutide have added a new dimension to CIF therapy. The outcomes of patients with CIF could be greatly improved by more effective prevention, understanding, and treatment. In complex cases, the care of patients with CIF requires a multidisciplinary approach involving not only physicians but also dietitians and nurses to provide optimal intestinal rehabilitation, nutritional support, and an improved quality of life. Here, we summarize current literature on CIF and short bowel syndrome, encompassing epidemiology, pathophysiology, and advances in surgical and medical management, and elucidate advances in the understanding and therapy of CIF-related complications such as catheter-related bloodstream infections and intestinal failure-associated liver disease.

Vitamin D status in children with intestinal failure who have achieved enteral autonomy

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.

Caregiver Decision-making in Pediatric Intestinal Failure: A Qualitative Study Focused on Iron Deficiency Anemia

BACKGROUND

Caregivers of children with intestinal failure (IF) face difficult decisions without a clear best alternative. Providers assist in decision-making but often lack knowledge of caregiver perspectives. Using decision-making around anemia treatment as a focal point, we explored how caregivers of children with IF prefer to make decisions. Our goal was to offer insight to guide providers as they assist in decision-making.

METHODS

We conducted 12 half-hour semistructured interviews with parents of children with IF. Interview questions addressed general decision-making and specifics of iron supplementation, including key factors and stakeholders in decision-making. Interviews were transcribed verbatim. Two investigators coded the transcripts and inductively derived themes.

RESULTS

Four themes were identified regarding decision-making. They involved the search for reliable, accurate, and positive information; the role of caretakers on the medical team; the relationships between caretakers and the medical team; and effective communication. Themes around anemia treatment included: identification of anemia by bloodwork; proactive supplementation; individualized regimens; prioritizing safety and convenience.

CONCLUSIONS

Understanding caregiver perspectives regarding anemia treatment in pediatric IF identifies opportunities for systematic quality improvement.

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

PURPOSE

Vitamins and trace elements are essential nutrients for growth and intestinal adaptation in children with short bowel syndrome (SBS). This study aimed to assess micronutrients' status during and after weaning off PN in pediatric SBS.

METHODS

This retrospective study evaluated the follow-up of 31 children with SBS between Jan 2010 and Sep 2019. Clinical data were reviewed from the patients' electric medical record. Serum electrolytes, trace elements, vitamin B12, vitamin D, and folate concentrations were collected before and after enteral autonomy.

RESULTS

Thirty-one SBS cases were reviewed (median onset age 11 days after birth, 51.6% boys, mean PN duration 4 months, and mean residual small intestine length 58.2 cm). Median duration of follow-up was 10 months (interquartile range [IQR]: 4, 19). The common micronutrient deficiencies were zinc (51.6%), copper (38.7%), vitamin D (32.3%), and phosphorus (25.8%) after the transition to EN. The proportion of patients deficient in vitamin D decreased dramatically from 93.5% to 32.3% (P < 0.001), and serum concentrations of vitamin D increased significantly (27.4 ± 12.3 vs. 60.3 ± 32.9 nmol/l, P = 0.03) after achieving full enteral feeding more than 1 month. Additionally, serum magnesium levels significantly increased (0.76 ± 0.17 vs. 0.88 ± 0.14 mmol/l, P = 0.03). Hemoglobin levels elevated significantly after weaning off PN (104.3 ± 10.7 vs. 117.8 ± 13.7 g/l, P = 0.03).

CONCLUSIONS

Micronutrient deficiencies remain a common problem in pediatric SBS through intestinal rehabilitation. Therefore, we strongly recommend supplementation of more vitamin D and trace elements (zinc, copper, and phosphorus) under regular monitoring during long-term intestinal rehabilitation.

Microsimulation Model to Compare Enteral and Parenteral Iron Supplementation in Children With Intestinal Failure

BACKGROUND

Children with chronic intestinal failure have a high prevalence of anemia, commonly from iron deficiency, leading to frequent blood transfusions. No current guideline exists for iron supplementation in these children. In this analysis, we evaluate the effectiveness and the cost-effectiveness of using parenteral, enteral, and no iron supplementation to reduce blood transfusions.

METHODS

We created a microsimulation model of pediatric intestinal failure over a 1-year time horizon. Model outcomes included cost (US dollars), blood transfusions received, and hemoglobin trend. Strategies tested included no supplementation, daily enteral supplementation, and monthly parenteral supplementation. We estimated parameters for the model using an institutional cohort of 55 patients. Model parameters updated each 1-month cycle using 2 regressions. A multivariate mixed-effects linear regression estimated hemoglobin values at the next month based on data from the prior month. A mixed-effects logistic regression on hemoglobin predicted the probability of receiving a blood transfusion in a given month.

RESULTS

Compared with no supplementation, both enteral and parenteral iron supplementation reduced blood transfusions required per patient by 0.3 and 0.5 transfusions per year, respectively. Enteral iron cost $34 per avoided blood transfusion. Parenteral iron cost an additional $6600 per avoided blood transfusion compared with enteral iron.

CONCLUSIONS

We found both parenteral and enteral iron to be effective at reducing blood transfusions. The cost of enteral iron makes it the desired choice in patients who can tolerate it. Future work should aim to identify which subpopulations of patients may benefit most from one strategy over the other.

Intestinal Failure: A Description of the Problem and Recent Therapeutic Advances

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.

Micronutrients in paediatric Intestinal Failure Patients receiving home parenteral nutrition

BACKGROUND & AIMS

Children with intestinal failure (IF) receive parental nutrition to ensure adequate growth and development. The aim of this study was to assess micronutrient status in paediatric IF patients receiving home parenteral nutrition (HPN) in comparison to a group of healthy children.

METHODS

An observational cross-sectional study was performed at Oslo University Hospital and at the Department of Nutrition, University of Oslo from January to September 2017. All children with IF, aged two to 18 years, were invited to participate. A reference group of healthy children was recruited through social media advertisement. Dietary intake was assessed by a four-day food record, and enteral and parenteral provision was recorded. Blood samples were analysed for vitamins, minerals and haematology to assess iron status. Two spot urine samples from each subject were analysed for iodine concentration (UIC) and creatinine.

RESULTS

Nineteen children with IF and 50 healthy children were included. The mean age of the participants was 10.0 years. IF-patients received a median of 76% of their estimated energy requirements from parenteral nutrition (PN). Recommended intake (RI) for iodine from the diet was reached by 16% of IF patients and 28% of healthy children. In the IF group there was a significant positive correlation between UIC and the percentage of iodine intake from oral diet and enteral nutrition support (r = 0.57, p = 0.03). Although the IF patients had a median parenteral iodine supply of more than twice the ESPGHAN recommendation, the median UIC was 89 μg/L indicating insufficient iodine status. This may suggest that the ESPGHAN recommendation for iodine in paediatric parenteral nutrition is too low. The healthy children had sufficient iodine status according to the median UIC (133 μg/L). IF patients had significantly lower total provision of iron compared to the healthy children, 4,9 vs 8,4 mg/day (p = 0.01) with 21% of IF patients and 28% of healthy children reaching RI for iron. The prevalence of anaemia was higher in IF patients than in the healthy children (40 vs.10%, p = 0.016).

CONCLUSION

The study indicates an insufficient iodine and iron status among paediatric IF patients. Iodine status was associated with enteral provision and patients had insufficient status even if they received the ESPGHAN recommendation of iodine.

TRIAL IDENTIFICATION NUMBER

Clinical Trials AEV2017/1. 2016/391/REK sør-øst B.

The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients

Parenteral nutrition (PN) is a complex and specialized form of nutrition support that has revolutionized the care for both pediatric and adult patients with acute and chronic intestinal failure (IF). This has led to the development of multidisciplinary teams focused on the management of patients receiving PN: nutrition support teams (NSTs). In this review we aim to discuss the historical aspects of IF management and NST development, and the practice, composition, and effectiveness of multidisciplinary care by NSTs in patients with IF. We also discuss the experience of two IF centers as an example of contemporary NSTs at work. An NST usually consists of at least a physician, nurse, dietitian, and pharmacist. Multidisciplinary care by an NST leads to fewer complications including infection and electrolyte disturbances, and better survival for patients receiving short- and long-term PN. Furthermore, it leads to a decrease in inappropriate prescriptions of short-term PN leading to significant cost reduction. Complex care for patients receiving PN necessitates close collaboration between team members and NSTs from other centers to optimize safety and effectiveness of PN use.

Nutritional Feeding Strategies in Pediatric Intestinal Failure

Intestinal failure is defined as a critical reduction of the gut mass or function, below the minimum needed to absorb nutrients and fluids. The ultimate goal in intestinal failure is to promote bowel adaptation and reach enteral autonomy while a healthy growth and development is maintained. The condition is heterogeneous and complex. Therefore, recommendations for the type and duration of parenteral, enteral, and oral nutrition are variable, with the child's age as an additional key factor. The aim of this review is to provide an overview of nutritional feeding strategies in this heterogeneous population. Different perspectives on nutritional management, nutrition and adaptation, and microbiome and nutrition will be discussed.

Etiology and Medical Management of Pediatric Intestinal Failure

Pediatric intestinal failure occurs when gut function is insufficient to meet the growing child's hydration and nutrition needs. After massive bowel resection, the remnant bowel adapts to lost absorptive and digestive capacity through incompletely defined mechanisms newly targeted for pharmacologic augmentation. Management seeks to achieve enteral autonomy and mitigate the development of comorbid disease. Care has improved, most notably related to reductions in blood stream infection and liver disease. The future likely holds expansion of pharmacologic adaptation augmentation, refinement of intestinal tissue engineering techniques, and the development of a learning health network for efficient multicenter study and care improvement.

Copper Deficiency in Children With Intestinal Failure: Risk Factors and Influence on Hematological Cytopenias

BACKGROUND

We investigated to what extent serum copper influences hemoglobin (Hb), neutrophil, and platelet counts and the factors associated with serum copper in children with intestinal failure (IF) who have their micronutrient status monitored according to a standard protocol.

METHODS

Children with IF admitted to a pediatric intestinal rehabilitation program and receiving home parenteral nutrition (PN) were followed up prospectively. Patients received vitamins and multi-trace elements (TEs) as part of the PN. Copper, iron, zinc, vitamin A, and cobalamin serum levels were routinely monitored at 3-month intervals or monthly when a deficiency was detected. Complete blood counts were performed biweekly. Repeated-measures analyses were used to estimate the effect of explanatory variables on the outcomes.

RESULTS

Thirteen children with a median time receiving PN of 16.6 months were included. An average of 7 copper measurements per patient were performed; 53.8% of patients had a low serum level at least twice during the follow-up. Eight patients with cholestasis had TEs of PN discontinued. In the multivariable analysis, copper was not associated with Hb levels; an increase of 10 µg/dL in serum copper resulted in an increase of 240/mm³ (95% confidence interval [CI], 18.0-30.1) neutrophils and of 8429/mm³ (95% CI, 466-1219) platelets (P < .001). Time of PN without copper, direct bilirubin levels, and ostomy were associated with lower serum copper.

CONCLUSION

The increase in serum copper was associated with significant increases in neutrophil and platelet counts. Time without copper in PN, cholestasis, and having an ostomy negatively influenced copper status.

Zinc Deficiency and Long-Term Outcome in Cases After Isolated Intestinal Transplantation in Taiwan

OBJECTIVES

The small intestine is the primary site for absorption of dietary zinc. Intestinal transplant recipients are at high risk for zinc deficiency because of the long process of posttransplant adaptation. We initiated an intestinal transplant program in Taiwan in 2007. In this study, we aimed to retrospectively investigate the incidence of zinc deficiency in recipients after intestinal transplantation.

METHODS

Twenty-one isolated intestinal transplants were performed in 20 patients with 1 retransplantation. The level of serum zinc was monitored periodically, and zinc supplements were administered when zinc level was below 700 ng/mL. Twelve patients with graft above 1-year survival and with available related data were enrolled for the analysis of zinc deficiency. The levels of serum zinc were tracked, and the protocol of zinc supplementation is discussed herein.

RESULTS

The survival rates of 20 transplant recipients for 1 year, 3 years, and 5 years were 85%, 75%, and 65%, respectively. In the 12 grafts that survived longer than 1 year, we found that zinc deficiency was highest during the third (41.7%) to sixth (50%) month after transplantation. Sustained supplementation of zinc was required for over 70% of patients throughout the 3-year period to maintain their zinc level around the lower normal limit.

CONCLUSION

The outcome of isolated small bowel transplantation is promising. Periodical monitoring and sufficient dosing of zinc supplements should be considered into the posttransplant protocol to prevent zinc deficiency after intestinal transplantation.

Growth, Body Composition, and Micronutrient Abnormalities During and After Weaning Off Home Parenteral Nutrition

OBJECTIVES

The aim of the study is to assess growth, body composition, and micronutrient abnormalities in children with intestinal failure (IF) over time, both during and after weaning off parenteral nutrition (PN).

METHODS

Retrospective study in children on home PN between 2001 and 2015. Weight-for-age (WFA) and height-for-age (HFA) SD scores (SDS) were calculated, as well as fat mass (FM) and fat-free mass (FFM) SDS obtained by dual energy x-ray absorptiometry. The course of growth parameters and body composition was analyzed with linear-mixed models. All micronutrient measurements during the study period were obtained.

RESULTS

Fifty-two patients were included with a median follow-up of 3.4 years. Seventy-one percent weaned off after a median PN duration of 0.9 years. One year after the start of PN, 28 patients were still PN-dependent with median WFA-SDS of -0.66 and median HFA-SDS of -0.96, both significantly lower than zero. Catch-up growth was achieved during PN, but HFA-SDS decreased after weaning (P = 0.0001). At a median age of 6.2 years, median %FM SDS was 0.30 and FFM SDS was -1.21, the latter significantly lower than zero. Frequent micronutrient abnormalities during PN were vitamin A (90%), zinc (87%), and iron (76%) and after weaning vitamin A (94%), E (61%), and 25-OH vitamin D (59%).

CONCLUSIONS

Children with IF demonstrate abnormal growth and body composition and frequent micronutrient abnormalities. Longitudinal evaluation showed that catch-up growth occurs during PN, but height SDS decreases after weaning. This underlines the need for close monitoring, also after reaching enteral autonomy.

Insights into medical management of pediatric intestinal failure

Medical management of children with Intestinal failure continues to evolve. The development of specialized teams focused on the management of these children has made the most significant impact in improving outcomes. Medical management strategies are centered on the provision of adequate fluid electrolytes and calories to allow for appropriate growth and neurological development. Enteral therapy and drugs are required to enhance bowel adaptation while parenteral nutrition is the main source of nutrients, electrolytes and fluid. Modification in parenteral nutrition with the availability of lipid alternatives are contributing to decreasing incidence of Intestinal failure associated liver disease. Utilization of patient centered central line care bundles has also significantly contributed to the decrease in morbidity and mortality. This review provides insight into the current medical therapy available for managing intestinal failure in children.

Health-related quality of life and neurodevelopmental outcomes among children with intestinal failure

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.

Children With Intestinal Failure Undergoing Intestinal Rehabilitation Are at Risk for Essential Fatty Acid Deficiency

BACKGROUND

Essential fatty acid (EFA) status may be compromised during the intestinal failure (IF) rehabilitation. Parenteral lipid restriction is used to treat intestinal failure associated liver disease (IFALD), while the enteral fatty acid (FA) absorption remains limited. We analyzed the FA status among pediatric IF and intestinal insufficiency patients.

METHODS

We evaluated 49 patients aged 0-18 years attending our nationwide IF referral center. Their serum FA fractions were determined and examined against previous nutrition, parenteral lipid emulsion, and intestinal anatomy data. The patients were divided into 3 subgroups according to their dependence on parenteral nutrition (PN): full enteral (EN) (n = 33), supplemental PN (n = 14) or predominantly PN (n = 20). Trien:tetraen ratio (TTR) ≥0.2 was considered diagnostic for essential fatty acid deficiency (EFAD) and increased risk was suspected if TTR exceeded 0.1.

RESULTS

We identified 8 (16%) patients with elevated TTR ≥0.1; in 3 of them the ratio exceeded 0.2. Five of these children belonged to supplemental PN group. This group carried the highest incidence of elevated TTR (P = 0.0016), with median TTR at 0.06 (interquartile range 0.03-0.09) and two-thirds of the analyzed TTR ≥0.5. Increased EFAD risk was associated with young age (P = 0.0291), current PN with low parenteral lipid content (P = 0.0003), and short remaining small bowel (P = 0.0013).

CONCLUSIONS

IF children with supplemental PN carry the highest overall risk for EFAD. Young age, current PN, and short remaining small bowel also increase the risk for EFAD.

Laboratory Monitoring of Children on Home Parenteral Nutrition: A Prospective Study

BACKGROUND

The primary hypothesis of this article is that a team approach in creating a protocolized laboratory monitoring schedule for home parenteral nutrition (PN) patients improves patient safety by decreasing the occurrence of nutrition deficiencies and is cost-effective.

METHODS

In this prospective cohort study of home PN patients, each patient followed an established protocol of laboratory monitoring and weekly review by an interdisciplinary team of dietitians, nurses, and physicians. Data collected included anthropometric measurements, laboratory results, deviations from laboratory protocols, laboratory charges, PN shortage information, and means of ameliorating such shortages. Cost-effectiveness analysis was only performed for nonmicronutrient laboratory tests.

RESULTS

Fifteen children (male, n = 6) with a median age of 59 months (range, 19-216) were included in this study. Primary diagnoses included short bowel syndrome (47%) and intestinal pseudo-obstruction (40%). Patients received PN mixtures from 6 different infusion companies and experienced 60 different shortages in the PN formulation requiring adjustments or substitutions (mean, 4 shortages per patient). All patients had appropriate growth and complete micronutrient monitoring. No patient experienced any clinical symptoms due to shortages. The median number of laboratory draws/patient per month was 2.9 preprotocol compared with 1.14 postprotocol (P = .003). The median per patient per month charges were $2014 (interquartile range [IQR], 1471-2780) preprotocol compared with $792 (IQR, 435-1140) postprotocol (P = .002).

CONCLUSIONS

A structured team approach to laboratory monitoring of home PN patients can simplify PN management, significantly decrease monthly laboratory costs, and lead to fewer laboratory draws while improving micronutrient monitoring and preventing deficiencies.

Is Serum Methylmalonic Acid a Reliable Biomarker of Vitamin B12 Status in Children with Short Bowel Syndrome: A Case Series

We describe 3 patients with short bowel syndrome who had persistently elevated serum methylmalonic acid (MMA) levels while being treated for vitamin B12 deficiency. Following treatment for presumed small bowel bacterial overgrowth, MMA levels normalized. Among patients with short bowel syndrome, MMA levels may have limited specificity for vitamin B12 deficiency.

Survey of Nutrition Management Practices in Centers for Pediatric Intestinal Rehabilitation

BACKGROUND

Nutrition management of pediatric intestinal failure (IF) requires interdisciplinary coordination of parenteral nutrition (PN) and enteral nutrition (EN) support. Nutrition strategies used by specialists in pediatric intestinal rehabilitation to promote gut adaptation and manage complications have not been previously summarized.

METHODS

A practice survey was distributed to members of the dietitian subgroup of the American Society for Parenteral and Enteral Nutrition Pediatric Intestinal Failure Section. The survey included 24 open-ended questions related to PN and enteral feeding strategies, nutrition management of PN-associated liver disease, and laboratory monitoring.

RESULTS

Dietitians from 14 centers completed the survey. Management components for patients at risk for cholestasis were consistent and included fat minimization, trace element modification, avoiding PN overfeeding, and providing EN. Parenteral amino acid solutions designed for infants/young children are used in patients <1 or 2 years of age. Trace minerals are dosed individually in 10 of 14 centers. Eleven centers prescribe a continuous infusion of breast milk or elemental formula 1-2 weeks after resection while 3 centers determine the formula type by the extent of resection. Most (86%) centers do not have a protocol for initiating oral/motor therapy. Laboratory panel composition varied widely by center. The selection and frequency of use depended on clinical variables, including cholestatic status, exclusive vs partial PN dependence, postrepletion verification vs routine monitoring, intestinal anatomy, and acuity of care.

CONCLUSION

EN and PN management strategies are relatively consistent among U.S. centers. Collaborative initiatives are necessary to define better practices and establish laboratory monitoring guidelines.

Long-term outcomes of pediatric intestinal failure

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.

Enteral nutrition in pediatric intestinal failure: does initial feeding impact on intestinal adaptation?

Primary IF can be due to impaired gut length or impaired gut function; short bowel syndrome (SBS) is the leading cause of IF. In IF patients complete enteral starvation should be avoided whenever possible and enteral/oral nutrition (EN/ON) should be employed at the maximum tolerated amount in each phase of the clinical evolution of IF. Intraluminal nutrients have stimulatory effects on epithelial cells and on trophism that enhance intestinal adaptation. Areas covered: Evidence for nutritional interventions in pediatric IF is limited and of poor quality. Clinical practice in SBS feeding are more 'experience-based' rather than 'evidence-based' and this dearth of clinical evidence is partly due to the rarity of this condition. This review updates knowledge concerning the impact of the initial diet with EN/ON in neonatal onset SBS in the process of bowel adaption. Expert commentary: Human milk resulted the preferred starting diet and it is generally combined with amino-acids (AAs) in Northern America and with hydrolyzed proteins (HFs) in Europe; polymeric diet is rarely employed. HFs were not more effective than AAs in promoting intestinal adaptation.

Redefining short bowel syndrome in the 21st century

In 1968, Wilmore and Dudrick reported an infant sustained by parenteral nutrition (PN) providing a potential for survival for children with significant intestinal resections. Increasing usage of TPN over time led to some patients developing Intestinal Failure Associated Liver Disease (IFALD), a leading cause of death and indication for liver/intestinal transplant. Over time, multidisciplinary teams called Intestinal Rehabilitation Programs (IRPs) began providing meticulous and innovative management. Usage of alternative lipid emulsions and lipid minimization strategies have resulted in the decline of IFALD and an increase in long-term and transplant-free survival, even in the setting of ultrashort bowel (< 20 cm). Autologous bowel reconstructive surgeries, such as the serial tapering enteroplasty procedure, have increased the likelihood of achieving enteral autonomy. Since 2007, the number of pediatric intestinal transplants performed has sharply declined and likely attributed to the newer innovations healthcare. Recent data support the need for changes in the listing criteria for intestinal transplantation given the overall improvement in outcomes. Over the last 50 y, the diagnosis of short bowel syndrome has changed from a death sentence to one of hope with a vast improvement of quality of life and survival.

When Is Parenteral Nutrition Appropriate?

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.

Anemia and iron deficiency in gastrointestinal and liver conditions

Iron deficiency anemia (IDA) is associated with a number of pathological gastrointestinal conditions other than inflammatory bowel disease, and also with liver disorders. Different factors such as chronic bleeding, malabsorption and inflammation may contribute to IDA. Although patients with symptoms of anemia are frequently referred to gastroenterologists, the approach to diagnosis and selection of treatment as well as follow-up measures is not standardized and suboptimal. Iron deficiency, even without anemia, can substantially impact physical and cognitive function and reduce quality of life. Therefore, regular iron status assessment and awareness of the clinical consequences of impaired iron status are critical. While the range of options for treatment of IDA is increasing due to the availability of effective and well-tolerated parenteral iron preparations, a comprehensive overview of IDA and its therapy in patients with gastrointestinal conditions is currently lacking. Furthermore, definitions and assessment of iron status lack harmonization and there is a paucity of expert guidelines on this topic. This review summarizes current thinking concerning IDA as a common co-morbidity in specific gastrointestinal and liver disorders, and thus encourages a more unified treatment approach to anemia and iron deficiency, while offering gastroenterologists guidance on treatment options for IDA in everyday clinical practice.

Poor Prognostic Factors in Patients with Parenteral Nutrition-Dependent Pediatric Intestinal Failure

PURPOSE

Parenteral nutrition (PN) not only provides nutritional support but also plays a crucial role in the treatment of children with intestinal failure. The aim of this study was to evaluate the clinical significance and clinical outcomes of long-term PN.

METHODS

Retrospective cohort study was conducted using the medical records of patients treated at Seoul National University Children's Hospital. This study included 19 patients who received PN for over six months. Most patients received home PN.

RESULTS

The indications for PN included short bowel syndrome, chronic intestinal pseudo-obstruction, and intractable diarrhea of infancy. The median age of PN initiation was 1.3 years, and the median treatment duration was 2.9 years. Two patients were weaned from PN; 14 continued to receive PN with enteral feedings; and 3 patients died. The overall survival rates at 2 and 5 years were 93.3% and 84.0%, respectively. The incidence of catheter-related bloodstream infections was 2.7/1,000 catheter-days and was associated with younger age at PN initiation and lower initial height Z-score. Six patients developed catheter-related central vein thrombosis, with an incidence of 0.25/1,000 catheter-days. Eleven patients experienced PN-associated liver disease (PNALD), and one patient underwent multi-visceral transplant. The patients with PNALD exhibited lower final heights and body weight Z-scores. All patients experienced micronutrient deficiencies transiently while receiving PN.

CONCLUSION

PN is an important and safe treatment for pediatric intestinal failure. PNALD was linked to final anthropometric poor outcomes. Micronutrient deficiencies were common. Anthropometric measurements and micronutrient levels must be monitored for successful PN completion.