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Wales PW, Hill S, Robinson I, Raphael BP, Matthews C, Cohran V, Carter B, Venick R, Kocoshis S. Long-term teduglutide associated with improved response in pediatric short bowel syndrome-associated intestinal failure. J Pediatr Gastroenterol Nutr 2024; 79:290-300. [PMID: 38873891 DOI: 10.1002/jpn3.12276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 03/20/2024] [Accepted: 05/03/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVES Patients with short bowel syndrome-associated intestinal failure (SBS-IF) require long-term parenteral nutrition and/or intravenous fluids (PN/IV) to maintain fluid or nutritional balance. We report the long-term safety, efficacy, and predictors of response in pediatric patients with SBS-IF receiving teduglutide over 96 weeks. METHODS This was a pooled, post hoc analysis of two open-label, long-term extension (LTE) studies (NCT02949362 and NCT02954458) in children with SBS-IF. Endpoints included treatment-emergent adverse events (TEAEs) and clinical response (≥20% reduction in PN/IV volume from baseline). A multivariable linear regression identified predictors of teduglutide response; the dependent variable was mean change in PN/IV volume at each visit over 96 weeks. RESULTS Overall, 85 patients were analyzed; 78 patients received teduglutide in the parent and/or LTE studies (any teduglutide [TED] group), while seven patients did not receive teduglutide in either the parent or LTE studies. Most TEAEs were moderate or severe in intensity in both groups. By week 96, 82.1% of patients from the any TED group achieved a clinical response, with a mean fluid decrease of 30.1 mL/kg/day and an energy decrease of 21.6 kcal/kg/day. Colon-in-continuity, non-White race, older age at baseline, longer duration of teduglutide exposure, and increasing length of remaining small intestine were significantly associated with a reduction in mean PN/IV volume requirements. CONCLUSIONS In pediatric patients with SBS-IF, teduglutide treatment resulted in long-term reductions in PN/IV requirements. The degree of PN/IV volume reduction depended on the duration of teduglutide exposure, underlying bowel anatomy, and demographics.
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Affiliation(s)
- Paul W Wales
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Susan Hill
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ian Robinson
- Takeda Pharmaceuticals, Inc., Lexington, Massachusetts, USA
| | - Bram P Raphael
- Takeda Pharmaceuticals, Inc., Lexington, Massachusetts, USA
| | | | - Valeria Cohran
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Beth Carter
- Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Robert Venick
- Division of Gastroenterology, Hepatology, and Nutrition, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Samuel Kocoshis
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Fialkowski A, Broyles K, DePaula B, Flores A, Gray M, Graham RJ, Hoch R, Hope KE, McGivney M, McClelland J, Nurko S, Puder M, Stamm D, Duggan CP, Carey A. Achieving Enteral Autonomy in Children with Intestinal Failure Following Inpatient Admission: A Case Series. J Pediatr 2024:114226. [PMID: 39095008 DOI: 10.1016/j.jpeds.2024.114226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 07/05/2024] [Accepted: 07/29/2024] [Indexed: 08/04/2024]
Abstract
We describe cases of intestinal failure wherein inpatient admission was critical toward enteral autonomy. We performed a retrospective chart review of 6 children with long-term parenteral nutrition dependence who were weaned from parenteral nutrition following admission. Admissions included feeding and medication titration, interdisciplinary care, and home parenteral nutrition team consultation.
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Affiliation(s)
| | - Kathryn Broyles
- Division of Gastroenterology, Hepatology and Nutrition; Center for Advanced Intestinal Rehabilitation
| | - Brittany DePaula
- Division of Gastroenterology, Hepatology and Nutrition; Center for Advanced Intestinal Rehabilitation
| | | | - Megan Gray
- Division of Gastroenterology, Hepatology and Nutrition; Center for Advanced Intestinal Rehabilitation,; Department of Surgery and the Vascular Biology Program
| | - Robert J Graham
- Harvard Medical School,; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston MA, USA
| | - Rachel Hoch
- Division of Gastroenterology, Hepatology and Nutrition; Center for Advanced Intestinal Rehabilitation
| | - Kayla E Hope
- Division of Gastroenterology, Hepatology and Nutrition
| | - Megan McGivney
- Center for Advanced Intestinal Rehabilitation,; Department of Surgery and the Vascular Biology Program
| | | | - Samuel Nurko
- Division of Gastroenterology, Hepatology and Nutrition
| | - Mark Puder
- Division of Gastroenterology, Hepatology and Nutrition; Department of Surgery and the Vascular Biology Program,; Harvard Medical School
| | - Danielle Stamm
- Division of Gastroenterology, Hepatology and Nutrition; Center for Advanced Intestinal Rehabilitation
| | - Christopher P Duggan
- Division of Gastroenterology, Hepatology and Nutrition; Center for Advanced Intestinal Rehabilitation,; Harvard Medical School
| | - Alexandra Carey
- Division of Gastroenterology, Hepatology and Nutrition; Center for Advanced Intestinal Rehabilitation,; Harvard Medical School,.
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3
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Sabra HK, Remeih GS, Kereet IM, Hamad M, Ahmed YA, Jahangir K, Bakr MA, Alagelli FA, Sherif H, Elsaid M. Efficacy and safety of glucagon-like peptide 2 in patients with short bowel syndrome: a systematic review and network meta-analysis. J Gastrointest Surg 2024; 28:1194-1205. [PMID: 38663565 DOI: 10.1016/j.gassur.2024.04.009] [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] [Received: 11/23/2023] [Revised: 04/03/2024] [Accepted: 04/12/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Glucagon-like peptide 2 (GLP-2) is a highly conserved enteroendocrine hormone that seems to be a regulator promoting intestinal adaptation. This study aimed to summarize the evidence on the efficacy and safety of exogenous GLP-2 in patients with short bowel syndrome (SBS). METHODS A database search was performed on PubMed, Web of Science Core Collection, Scopus, Ovid, and the Cochrane Central Register of Controlled Trials in November 2022. Clinical trials on the effect of GLP-2 on patients with SBS were included. The Cochrane Risk of Bias 2 and Risk Of Bias In Non-randomized Studies - of Interventions tools for quality assessment of randomized and nonrandomized trials were used. The extracted data were analyzed qualitatively and quantitatively using a network meta-analysis model. RESULTS This study included 23 clinical trials with 843 patients. The patients' ages ranged from 4.0 to 62.4 years. The treatment doses were 0.1, 0.05, and 0.025 mg/kg/day for teduglutide; 5 and 10 mg/week for apraglutide, and 0.1, 1, and 10 mg/day for glepaglutide. The treatment duration ranged from 1 to 32 weeks. Regarding citrulline level, 0.1 mg/kg/day of teduglutide had the highest mean difference (MD; 14.77; 95% CI, 10.20-19.33), followed by 0.05 mg/kg/day (13.04; 95% CI, 9.79-16.2) and 0.025 mg/kg/day (7.84; 95% CI, 2.42-13.26) of teduglutide. In addition, the effect estimate showed significant differences between all teduglutide dose groups and the control group. Different doses of glepaglutide were analyzed to assess the effect on alkaline phosphatase (ALP) levels, in which 0.1 mg/day of glepaglutide showed a significantly higher MD (20.71; 95% CI, 2.62-38.80) than 1 mg/day (the reference) and 10 mg/day (8.45; 95% CI, -10.72 to 27.62) of glepaglutide. However, 0.1 vs 10 mg of glepaglutide has an MD of -14.57 (95% CI, -437.24 to 148.11) for the indirect estimate, whereas 10 mg of glepaglutide has an MD of 8.45 (95% CI, -10.72 to 27.62) for the network estimate. Regarding safety outcomes, there was no significant difference among all teduglutide and apraglutide dose groups compared with the control group. Catheter-related bloodstream infection was the most common adverse event reported with the use of apraglutide, teduglutide, and glepaglutide. CONCLUSION Despite the small number of patients in the included studies and variable follow-up duration, GLP-2 seems to be safe and effective in patients with SBS. GLP-2 showed a positive effect on increasing plasma citrulline level and decreasing ALP level.
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Affiliation(s)
- Hamdy Khaled Sabra
- Faculty of Medicine, Tanta University, Tanta, Egypt; Medical Research Platform, Giza, Egypt
| | - Gehad S Remeih
- Medical Research Platform, Giza, Egypt; Faculty of Pharmacy, Assiut University, Assiut, Egypt
| | - Ibraheem M Kereet
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohammad Hamad
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Yassmien Ali Ahmed
- Medical Research Platform, Giza, Egypt; Faculty of Physical Therapy, October 6 University, October, Egypt
| | - Kainat Jahangir
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Fatma Assad Alagelli
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | - Hadeer Sherif
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, Kasr Al-Ainy University, Cairo, Egypt
| | - Mohamed Elsaid
- Medical Research Platform, Giza, Egypt; Department of Pediatrics, Faculty of Medicine, Delta University for Science and Technology, Dakahlia, Egypt.
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4
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Iyer KR. Indications for Intestinal Transplantation. Gastroenterol Clin North Am 2024; 53:233-244. [PMID: 38719375 DOI: 10.1016/j.gtc.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Outcomes for patients with chronic intestinal failure have improved with organization of experts into multidisciplinary teams delivering care in intestinal rehabilitation programs. There have been improvements in understanding of intestinal failure complications as well as development of newer therapies that have amplified the improvements in survival. In spite of this encouraging trend, patients who fail PN are often referred too late for intestinal transplantation. The author proposes a more rational framework that might allow earlier identification of intestinal failure patients at risk for PN-failure, who could appropriately be considered earlier for intestinal transplantation with improvements in overall outcomes.
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Affiliation(s)
- Kishore R Iyer
- Intestinal Rehabilitation & Transplant Program, Icahn School of Medicine at Mount Sinai and Mount Sinai Hospital, One Gustave Levy Place, Box 1104, New York 10029, USA.
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5
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Im KM, Chung JH. Intestinal Rehabilitation Program for Adult Patients with Intestinal Failure: A 20-Year Analysis of Outcomes in the Single-Center Experience at a Tertiary Hospital. Dig Dis Sci 2024; 69:1770-1777. [PMID: 38446306 PMCID: PMC11098894 DOI: 10.1007/s10620-024-08285-0] [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] [Received: 08/03/2023] [Accepted: 10/29/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND & AIMS The intestinal rehabilitation program (IRP) is a specialized approach to managing patients with intestinal failure (IF). The goal of IRP is to reduce the patient's dependence on parenteral nutrition by optimizing nutrition intake while minimizing the risk of complications and providing individualized medical and surgical treatment. We aimed to provide a thorough overview of our extensive history in adult IRP. METHODS We reviewed the medical records of adults with IF treated at our center's IRP over the past two decades. We collected data on demographic and clinical results, such as the causes of IF, the current status of the remaining bowel, nutritional support, and complications or mortality related to IF or prolonged parenteral nutrition. RESULTS We analyzed a total of 47 adult patients with a median follow-up of 6.7 years. The most common cause of IF was massive bowel resection due to mesenteric vessel thrombosis (38.3%). Twenty-eight patients underwent rehabilitative surgery, including 12 intestinal transplants. The 5-year survival rate was 81.9% with 13 patients who expired due to sepsis, liver failure, or complication after transplantation. Of the remaining 34 patients, 18 were successfully weaned off from parenteral nutrition. CONCLUSION Our results of IRP over two decades suggest that the individualized and multidisciplinary program for adult IF is a promising approach for improving patient outcomes and achieving nutritional autonomy.
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Affiliation(s)
- Kyoung Moo Im
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jae Hee Chung
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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Avitzur Y, Pahl E, Venick R. The Development of the International Intestinal Failure Registry and an Overview of its Results. Eur J Pediatr Surg 2024; 34:172-181. [PMID: 37973155 PMCID: PMC10920018 DOI: 10.1055/a-2212-6874] [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] [Received: 10/25/2023] [Accepted: 11/04/2023] [Indexed: 11/19/2023]
Abstract
Pediatric intestinal failure (IF) is a rare disease that represents an evolving field in pediatric gastroenterology and surgery. With only a limited number of multicenter collaborations, much of the research in pediatric IF is often confined to single-center reports with small sample sizes. This has resulted in challenges in data interpretation and left many knowledge gaps unanswered. Over the past two decades, five large multicenter collaborations, primarily from North America and Europe, have published their findings. Apart from one ongoing European adult and pediatric registry, these relatively large-scale efforts have been concluded.In 2018, the International Intestinal Failure Registry (IIFR) was initiated by the International Intestinal Rehabilitation and Transplant Association to continue these efforts and answer some of the knowledge gaps in pediatric IF. The IIFR goals are to prospectively assess the natural history of children diagnosed with IF and creating a worldwide platform to facilitate benchmarking and evidence-based interventions in pediatric IF. A pilot phase involving 204 enrolled patients was initiated in 2018 to assess the feasibility of an international IF registry and refine the study protocol and data collection forms. Following the successful completion of this phase, the current phase of the IIFR was launched in 2021. As of May 2023, the registry includes 362 prospectively followed children from 26 centers worldwide. This review provides an overview of the development, structure, and challenges of the IIFR, as well as the main findings from both the pilot and current phase.
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Affiliation(s)
- Yaron Avitzur
- Division of Gastroenterology, Hepatology, and Nutrition, Transplant and Regenerative Center, Group for Improvement of Intestinal Function and Treatment, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric Pahl
- Registry Data Analyst and Administrator, International Intestinal Rehabilitation and Transplant Association, The Transplantation Society, Montreal, Quebec, Canada
| | - Robert Venick
- Graduate Research Fellow, Health Informatics, University of Iowa, Iowa City, Iowa, United States
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Mattel Children's Hospital, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, United States
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Sandy NS, Roberts AJ, Wales PW, Toma RK, Belza C, Dogra H, Evans HM, Gattini D, Hind J, Mercer D, Povondra JM, Turner J, Yap J, Wong T, Avitzur Y. Small and large bowel anatomy is associated with enteral autonomy in infants with short bowel syndrome: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024; 48:231-238. [PMID: 38062898 DOI: 10.1002/jpen.2587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Achievement of enteral autonomy (EA) is the ultimate treatment goal in pediatric intestinal failure (IF). We aimed to assess predictors of EA in pediatric short bowel syndrome (SBS) and explore the impact of residual small bowel (SB) and large bowel (LB) length on EA. METHODS A retrospective cohort study was performed on infants aged <12 months (n = 367, six centers) with SBS referred between 2010 and 2015. The cohort was stratified based on the achievement of EA. Statistical testing was completed using t-test, chi-square, Cox proportional hazards regression model, and Kaplan-Meier analysis. RESULTS EA was achieved in 229 patients. In the multivariable analysis, the percentage of residual LB (hazard ratio [HR] = 1.02; 95% CI = 1.01-1.02) and SB (HR = 1.01; 95% CI = 1.01-1.02) length, presence of the ileocecal valve (HR = 2.02; 95% CI=1.41-2.88), and not coming from a high-volume transplantation center (HR = 2.42; 95% CI = 1.68-3.49) were positively associated with EA, whereas a negative association was seen with the presence of stoma at the time when shortest remnant was documented (HR = 0.72; 95% CI = 0.52-1.00). EA achievement was significantly different between the anatomical subgroups (log-rank test P < 0.001) with an EA rate of 80.4% in infants with ≥50% SB and LB (median time 209 days); 62.5% with ≥50% SB and <50% LB (397 days); 58.3% with <50% SB and ≥50% LB (1192 days), and 25.9% with <50% SB and LB. Necrotizing enterocolitis (NEC) was not associated with a better achievement of EA (NEC vs other etiologies: log-rank test P = 0.33). CONCLUSIONS Overall, 62% of infants with IF secondary to SBS achieved EA over a mean time of follow-up of 2.3 years. A colon length of >50% can compensate for the loss of small bowel (<50%) and account for similar EA rates as those in children with residual SB > 50%.
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Affiliation(s)
- Natascha S Sandy
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of São Paulo (USP), São Paulo, Brazil
| | - Amin J Roberts
- Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
- National Intestinal Failure & Rehabilitation Service (NIFRS), Auckland, New Zealand
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ricardo K Toma
- Department of Pediatrics, University of São Paulo (USP), São Paulo, Brazil
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Harween Dogra
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
| | - Helen M Evans
- Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
- National Intestinal Failure & Rehabilitation Service (NIFRS), Auckland, New Zealand
| | - Daniela Gattini
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Hind
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - David Mercer
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jill M Povondra
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Justine Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jason Yap
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Theodoric Wong
- Department of Gastroenterology and Nutrition, Nutrition Support and Intestinal Failure team, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Pardy C, Berkes S, D'Souza R, Fox G, Davidson JR, Yardley IE. Complete Resection of Necrotic Bowel Improves Survival in NEC Without Compromising Enteral Autonomy. J Pediatr Surg 2024; 59:206-210. [PMID: 37957101 DOI: 10.1016/j.jpedsurg.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/09/2023] [Indexed: 11/15/2023]
Abstract
AIMS Controversy persists regarding operative strategy for necrotising enterocolitis (NEC). Some surgeons advocate resecting all necrotic bowel, whilst others defunction with a stoma, leaving diseased bowel in situ to preserve bowel length. We reviewed our institutional experience of both approaches. METHODS Neonates undergoing laparotomy for NEC May 2015-2019 were identified. Data extracted from electronic records included: demographics, neonatal Sequential Organ Failure Assessment (nSOFA) score at surgery, operative findings, and procedure performed. Neonates were assigned to two groups according to operative strategy: complete resection of necrotic bowel (CR) or necrotic bowel left in situ (LIS). Primary outcome was survival, and secondary outcome was enteral autonomy. Outcomes were compared between groups. RESULTS Fifty neonates were identified. Six were excluded: 4 with NEC totalis and 2 with no visible necrosis or histological confirmation of NEC. Of the 44 remaining neonates, 27 were in the CR group and 17 in the LIS group. 32 neonates survived to discharge (73%). On univariate analysis, survival was associated with lower nSOFA score (P = 0.003), complete resection of necrotic bowel (OR 9.0, 95% CI [1.94-41.65]), and being born outside the surgical centre (OR 5.11 [1.23-21.28]). On Cox regression multivariate analysis, complete resection was still strongly associated with survival (OR 4.87 [1.51-15.70]). 28 of the 32 survivors (88%) achieved enteral autonomy. There was no association between operative approach and enteral autonomy (P = 0.373), or time to achieve this. CONCLUSION Complete resection of necrotic bowel during surgery for NEC significantly improves likelihood of surviving without negatively impacting remaining bowel function. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Caroline Pardy
- Evelina London Children's Hospital, London, United Kingdom.
| | | | - Rashmi D'Souza
- Evelina London Children's Hospital, London, United Kingdom
| | - Grenville Fox
- Evelina London Children's Hospital, London, United Kingdom
| | - Joseph R Davidson
- Evelina London Children's Hospital, London, United Kingdom; GOS-UCL Institute of Child Health, London, United Kingdom
| | - Iain E Yardley
- Evelina London Children's Hospital, London, United Kingdom; Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
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Nieminen O, Hukkinen M, Kivisaari R, Mutanen A, Merras-Salmio L, Pakarinen MP. Cutoffs and Characteristics of Abnormal Bowel Dilatation in Pediatric Short Bowel Syndrome. J Pediatr Gastroenterol Nutr 2023; 77:720-725. [PMID: 37679875 DOI: 10.1097/mpg.0000000000003934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES Although excessive intestinal dilatation associates with worsened outcomes in pediatric short bowel syndrome (SBS), little is known about the natural history and definition of pathological dilatation. We addressed fore-, mid-, and hind-gut dilatation in children with SBS, who had not undergone autologous intestinal reconstructive (AIR) surgery, in relation to controls. METHODS SBS children without history of AIR surgery (n = 59) and age-matched controls without any disclosed intestinal pathology (n = 140) were included. Maximum diameter of duodenum, small bowel (SB), and colon were measured in each intestinal contrast series during 2002 to 2020 and expressed as diameter ratio (DR) to L5 vertebrae height. Predictive ability of DR for weaning off parenteral nutrition (PN) was analyzed with Cox proportional hazards regression models using multiple cutoffs. RESULTS Duodenum (DDR), SB (SBDR), and colon (CDR) DR were 53%, 183%, and 23% higher in SBS patients compared to controls ( P < 0.01 for all). The maximal DDR and SBDR measured during follow-up is associated with current PN dependence and young age. DDR correlated with SBDR ( r = 0.586, P < 0.01). Patients with maximal DDR less than 1.5, which was also the 99th percentile for controls, were 2.5-fold more likely to wean off PN ( P = 0.005), whereas SBDR and CDR were not predictive for PN duration. CONCLUSIONS All segments of remaining bowel, especially SB, dilate above normal levels in children with SBS. In SBS children without AIR surgery, PN dependence and young age is associated with duodenal and small intestinal dilatation, while duodenal dilatation also predicted prolonged PN.
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Affiliation(s)
- Oona Nieminen
- From the Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maria Hukkinen
- From the Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Reetta Kivisaari
- the Department of Pediatric Radiology, Medical Imaging Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Annika Mutanen
- From the Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Laura Merras-Salmio
- the Department of Pediatric Gastroenterology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mikko P Pakarinen
- From the Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- the Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
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10
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Gattini D, Belza C, Kraus R, Avitzur Y, Ungar WJ, Wales PW. Cost-utility analysis of teduglutide compared to standard care in weaning parenteral nutrition support in children with short bowel syndrome. Clin Nutr 2023; 42:2363-2371. [PMID: 37862822 DOI: 10.1016/j.clnu.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND & AIMS A growing proportion of children with short bowel syndrome (SBS) remain dependent on long-term parenteral nutrition (PN). Teduglutide offers the potential for more children to decrease PN support and achieve enteral autonomy (EA), but at a significant expense. This study aims to assess the incremental costs of teduglutide plus standard of care compared to standard of care alone in weaning PN support per quality-adjusted life year (QALY) gained in children with SBS. METHODS This is a cost-utility analysis comparing teduglutide with standard of care alone in children with SBS. A microsimulation model of children with SBS on PN aged 1-17 years was constructed over a time horizon of six years, with a cycle length of one month. The study adopted the healthcare system and societal payer perspectives in Ontario, Canada. The health outcome measure was QALYs, with results expressed in terms of incremental costs and QALYs. Scenario analyses were performed to examine the effects of different time horizons, timing of teduglutide initiation, and modeling cost of teduglutide based on pediatric weight-dosing. RESULTS Incremental healthcare system costs for teduglutide compared to standard of care were CAD$441,314 (95% CI, 414,006 to 441,314) and incremental QALYs were 1.80 (95% CI, 1.70 to 1.89) resulting in an incremental cost-effectiveness ratio (ICER) of CAD$285,334 (95% CI, 178,209 to 392,459) per QALY gained. Incremental societal costs were CAD$418,504 (95% CI, 409,487 to 427,522) and incremental societal QALYs were 1.91 (95% CI, 1.85 to 1.98) resulting in an ICER of CAD$261,880 (95% CI, 136,887 to 386,874) per QALY gained. Scenario analysis showed that teduglutide was cost-effective when it was started two years after intestinal resection (ICER CAD$48,741, 95% CI, 17,317 to 80,165) and when its monthly cost was adjusted using weight-based dosing, avoiding wastage of the remaining 5 mg dose vial (Teduglutide dominated over SOC as the less costly and most effective strategy). CONCLUSIONS Although teduglutide was not cost-effective in weaning PN support in children with SBS, starting teduglutide once natural intestinal adaptation is reduced and adjusting its monthly cost to reflect cost by volume as dictated by weight-based dosing rendered the intervention cost-effective relative to standard of care. These results indicate the potential for clinicians to re-assess optimal time for initiation of teduglutide after intestinal resection, drug manufacturers to consider the use of multi-dose or paediatric-dose vials, and the opportunity for decision-makers to re-evaluate teduglutide funding.
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Affiliation(s)
- Daniela Gattini
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Christina Belza
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Raphael Kraus
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Pediatric Rheumatologist, Centre Hospitalier Sainte-Justine (CHUSJ), Montreal, Quebec, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Wendy J Ungar
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences Program, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Paul W Wales
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States; Cincinnati Center of Excellence for Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
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11
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Chatzidaki V, Wood R, Alegakis A, Lawson M, Fagbemi A. Parenteral support and micronutrient deficiencies in children with short bowel syndrome: A comprehensive retrospective study. Clin Nutr ESPEN 2023; 58:270-276. [PMID: 38057017 DOI: 10.1016/j.clnesp.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 10/08/2023] [Accepted: 10/10/2023] [Indexed: 12/08/2023]
Abstract
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.
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Affiliation(s)
- V Chatzidaki
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK.
| | - R Wood
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK
| | - A Alegakis
- Laboratory of Toxicology, University of Crete, Greece
| | - M Lawson
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK
| | - A Fagbemi
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK
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12
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Raghu VK, Leraas HJ, Samoylova M, Park C, Rothenberger SD, Sudan D, Avitzur Y. Predictors of 1-year enteral autonomy in children with intestinal failure: A descriptive retrospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:1047-1055. [PMID: 37573479 PMCID: PMC10843595 DOI: 10.1002/jpen.2557] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/20/2023] [Accepted: 08/02/2023] [Indexed: 08/14/2023]
Abstract
INTRODUCTION The International Intestinal Failure Registry (IIFR) is an international consortium to study intestinal failure (IF) outcomes in a large contemporary pediatric cohort. We aimed to identify predictors of early (1-year) enteral autonomy. METHODS We included IIFR pilot phase patients. IF was defined by a parenteral nutrition need for at least 60 days due to a primary gastrointestinal etiology. The primary outcome was time to enteral autonomy achievement. We built a mixed-effects Weibull accelerated failure time model with random effects by center to analyze variables associated with enteral autonomy achievement with a primary outcome of time ratio (TR). RESULTS We included 189 patients (82% with short bowel syndrome) representing 11 international centers. Cumulative incidence of early enteral autonomy was 51.6%, and death was 6.5%. In multivariable analysis, ostomy presence (TR, 2.63; 95% CI, 1.41-4.90) was associated with increased time to enteral autonomy achievement, and Asian/Indian (TR, 0.28; 95% CI, 0.10-0.81) and Pacific Islander race (TR, 0.34; 95% CI, 0.13-0.90) were associated with decreased time to enteral autonomy achievement. In a second model in the subset with measured percentage of bowel length remaining, ostomy presence (TR, 4.21; 95% CI, 1.90-9.33) was associated with increased time to enteral autonomy achievement, whereas greater percentage of bowel remaining (TR, 0.96; 95% CI, 0.94-0.98) was associated with decreased time to enteral autonomy achievement. CONCLUSIONS Minimizing bowel resection at initial surgery and establishing bowel continuity by ostomy reversal can effectively decrease the time to early enteral autonomy achievement in children with IF.
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Affiliation(s)
- Vikram K Raghu
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Harold J Leraas
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mariya Samoylova
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christine Park
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Scott D Rothenberger
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Debra Sudan
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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13
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Chiba M, Masumoto K, Kaji T, Matsuura T, Morii M, Fagbemi A, Hill S, Pakarinen MP, Protheroe S, Urs A, Chen ST, Sakui S, Udagawa E, Wada M. Efficacy and Safety of Teduglutide in Infants and Children With Short Bowel Syndrome Dependent on Parenteral Support. J Pediatr Gastroenterol Nutr 2023; 77:339-346. [PMID: 37364133 PMCID: PMC10412081 DOI: 10.1097/mpg.0000000000003867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 06/08/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES Our objective was to evaluate the short- and long-term safety and efficacy of teduglutide treatment in infants and children with short bowel syndrome with intestinal failure (SBS-IF). METHODS Two open-label phase 3 studies and 1 extension study investigated the short- and long-term safety and efficacy of teduglutide (0.05 mg/kg/day) in infants and children with SBS-IF: NCT03571516, 24-week study of infants who were randomized to receive teduglutide or standard of care (SoC); NCT02980666, 24-week study of infants and children who all received teduglutide; and NCT03268811, 24-week extension study of patients who completed NCT02980666 (patients could receive up to 48 weeks of total treatment). RESULTS Twelve infants and 8 children enrolled in the core studies, and 2 infants and 7 children in the extension study. After 24 weeks of treatment, parenteral support (PS) requirements reduced by ≥20% from baseline for 4 infants (57.1%) and 4 children (66.7%) receiving teduglutide and for 2 infants receiving SoC (50.0%). One infant (50.0%) and 4 children (80.0%) receiving teduglutide maintained the ≥20% reduction in PS at 48 weeks of treatment. Two children receiving teduglutide achieved enteral autonomy, after 12 weeks and 28 weeks of treatment, respectively. All adverse events (AEs) were in line with known impacts of SBS-IF and adverse reactions to teduglutide. Only one serious AE (abdominal pain) was considered related to teduglutide. CONCLUSIONS Short- and long-term treatment with teduglutide resulted in clinically meaningful reductions in PS requirements for infants and children with SBS-IF. Teduglutide was well tolerated, and efficacy improved with longer-term treatment.
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Affiliation(s)
- Masahiro Chiba
- From the Division of Pediatric Surgery, Department of Surgery, Showa University, Tokyo, Japan
| | - Kouji Masumoto
- the Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tatsuru Kaji
- the Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Toshiharu Matsuura
- the Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mayako Morii
- the Department of Pediatric Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Andrew Fagbemi
- the Department of Paediatric Gastroenterology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Susan Hill
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, NHS Foundation Trust and UCL Institute of Child Health, London, UK
| | - Mikko P. Pakarinen
- the Pediatric Research Center, Children’s Hospital, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Susan Protheroe
- the Department of Gastroenterology and Nutrition, Birmingham Women and Children’s Hospital, Birmingham, UK
| | - Arun Urs
- the Department of Paediatric Gastroenterology, Sheffield Children’s Hospital, Sheffield, UK
| | - Szu-Ta Chen
- Takeda Development Center Americas, Inc., Boston, MA, USA
| | - Sho Sakui
- Statistical and Quantitative Sciences, Data Sciences Institute, Takeda Pharmaceutical Company Limited, Osaka, Japan
| | - Eri Udagawa
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Motoshi Wada
- the Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- the Division of Pediatric Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Japan
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14
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Lambe C, Talbotec C, Kapel N, Barbot-Trystram L, Brabant S, Nader EA, Pigneur B, Payen E, Goulet O. Long-term treatment with teduglutide: a 48-week open-label single-center clinical trial in children with short bowel syndrome. Am J Clin Nutr 2023; 117:1152-1163. [PMID: 37270289 DOI: 10.1016/j.ajcnut.2023.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Short bowel syndrome (SBS) is the main cause of intestinal failure in children. OBJECTIVES This single-center study evaluated the safety and efficacy of teduglutide in pediatric patients with SBS-associated intestinal failure (SBS-IF). METHODS Children with SBS followed at our center with ≥2 y on parenteral nutrition (PN) and with small bowel length <80 cm who had reached a plateau were consecutively included in the study. At baseline, participants underwent a clinical assessment including a 3-d stool balance analysis, which was repeated at the end of the study. Teduglutide was administered subcutaneously 0.05 mg/kg/d for 48 wk. PN dependence was expressed as the PN dependency index (PNDI), which is the ratio PN non-protein energy intake/REE. Safety endpoints included treatment-emergent adverse events and growth parameters. RESULTS Median age at inclusion was 9.4 y (range: 5-16). The median residual SB length was 26 cm (IQR: 12-40). At baseline, the median PNDI was 94% (IQR: 74-119), (median PN intake: 38.9 calories/kg/d, IQR: 26.1-48.6). At week 24, 24 (96%) children experienced a reduction of >20% of PN requirements with a median PNDI = 50% (IQR: 38-81), (PN intake: 23.5 calories/kg/d IQR: 14.6-26.2), P < 0.01. At week 48, 8 children (32%) were weaned completely off PN. Plasma citrulline increased from 14 μmol/L (IQR: 8-21) at baseline to 29 μmol/L (IQR: 17-54) at week 48 (P < 0.001). Weight, height, and BMI z-scores remained stable. The median total energy absorption rate increased from 59% (IQR: 46-76) at baseline to 73% (IQR: 58-81) at week 48 (P = 0.0222). Fasting and postprandial endogenous GLP-2 concentrations increased at weeks 24 and 48 compared with baseline. Mild abdominal pain at the early phase of treatment, stoma changes, and redness at the injection site were commonly reported. CONCLUSIONS Increased intestinal absorption and PN dependency reduction were observed with teduglutide treatment in children with SBS-IF. TRIAL REGISTRATION ClinicalTrials.gov NCT03562130. https://clinicaltrials.gov/ct2/show/NCT03562130?term=NCT03562130&draw=2&rank=1.
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Affiliation(s)
- Cécile Lambe
- Service de Gastro-entérologie et Nutrition pédiatrique, Université Paris Cité, Hôpital Necker-Enfants Malades, Paris.
| | - Cécile Talbotec
- Service de Gastro-entérologie et Nutrition pédiatrique, Université Paris Cité, Hôpital Necker-Enfants Malades, Paris
| | - Nathalie Kapel
- Laboratoire de Coprologie Fonctionnelle, Université Paris Sorbonne, Hôpital la Pitié-Salpétrière, Paris
| | - Laurence Barbot-Trystram
- Laboratoire de Coprologie Fonctionnelle, Université Paris Sorbonne, Hôpital la Pitié-Salpétrière, Paris
| | - Séverine Brabant
- Laboratoire des Explorations Fonctionnelles, Université Paris Cité, Hôpital Necker-Enfants Malades, Paris
| | - Elie Abi Nader
- Service de Gastro-entérologie et Nutrition pédiatrique, Université Paris Cité, Hôpital Necker-Enfants Malades, Paris
| | - Bénédicte Pigneur
- Service de Gastro-entérologie et Nutrition pédiatrique, Université Paris Cité, Hôpital Necker-Enfants Malades, Paris
| | - Elise Payen
- Service de Gastro-entérologie et Nutrition pédiatrique, Université Paris Cité, Hôpital Necker-Enfants Malades, Paris
| | - Olivier Goulet
- Service de Gastro-entérologie et Nutrition pédiatrique, Université Paris Cité, Hôpital Necker-Enfants Malades, Paris
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15
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Caporilli C, Giannì G, Grassi F, Esposito S. An Overview of Short-Bowel Syndrome in Pediatric Patients: Focus on Clinical Management and Prevention of Complications. Nutrients 2023; 15:nu15102341. [PMID: 37242224 DOI: 10.3390/nu15102341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/26/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Short-bowel syndrome (SBS) in pediatric age is defined as a malabsorptive state, resulting from congenital malformations, significant small intestine surgical resection or disease-associated loss of absorption. SBS is the leading cause of intestinal failure in children and the underlying cause in 50% of patients on home parental nutrition. It is a life-altering and life-threatening disease due to the inability of the residual intestinal function to maintain nutritional homeostasis of protein, fluid, electrolyte or micronutrient without parenteral or enteral supplementation. The use of parenteral nutrition (PN) has improved medical care in SBS, decreasing mortality and improving the overall prognosis. However, the long-term use of PN is associated with the incidence of many complications, including liver disease and catheter-associated malfunction and bloodstream infections (CRBSIs). This manuscript is a narrative review of the current available evidence on the management of SBS in the pediatric population, focusing on prognostic factors and outcome. The literature review showed that in recent years, the standardization of management has demonstrated to improve the quality of life in these complex patients. Moreover, the development of knowledge in clinical practice has led to a reduction in mortality and morbidity. Diagnostic and therapeutic decisions should be made by a multidisciplinary team that includes neonatologists, pediatric surgeons, gastroenterologists, pediatricians, nutritionists and nurses. A significant improvement in prognosis can occur through the careful monitoring of nutritional status, avoiding dependence on PN and favoring an early introduction of enteral nutrition, and through the prevention, diagnosis and aggressive treatment of CRSBIs and SIBO. Multicenter initiatives, such as research consortium or data registries, are mandatory in order to personalize the management of these patients, improve their quality of life and reduce the cost of care.
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Affiliation(s)
- Chiara Caporilli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Giuliana Giannì
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Federica Grassi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
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16
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Speer AL, Fauza DO. Invited Commentary for Disruption of Enterohepatic Circulation of Bile Acids Ameliorates Small Bowel Resection Associated Hepatic Injury. J Pediatr Surg 2023; 58:1079-1080. [PMID: 36935226 DOI: 10.1016/j.jpedsurg.2023.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/10/2023] [Indexed: 02/25/2023]
Affiliation(s)
- Allison L Speer
- McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), Department of Pediatric Surgery, 6431 Fannin St, MSB 5.254, Houston, TX, 77030, USA.
| | - Dario O Fauza
- Boston Children's Hospital, Department of Surgery, 300 Longwood Avenue, Fegan 3, Boston, MA, 02115, USA.
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17
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Smith A, Namjoshi S, Kerner JA, Dunn JCY. Importance of Ileum and Colon in Children with Short Bowel Syndrome. J Pediatr Surg 2023:S0022-3468(23)00089-1. [PMID: 36894441 DOI: 10.1016/j.jpedsurg.2023.01.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/25/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND It is well known that small bowel length is a dominant prognostic indicator in patients with short bowel syndrome (SBS). The relative importance of jejunum, ileum, and colon is less well defined in children with SBS. Here we review the outcome of children with SBS with respect to the type of remnant intestine. METHODS A retrospective review of 51 children with SBS was conducted at a single institution. The duration of parenteral nutrition use was the main outcome variable. The length of the remaining intestine as well as the type of intestine were recorded for each patient. Kaplan-Meier analyses were conducted to compare the subgroups. RESULTS Children with greater than 10% expected small bowel length or more than 30 cm of small bowel achieved enteral autonomy faster than those with less. The presence of ileocecal valve enhanced the ability to wean from parenteral nutrition. The presence of ileum significantly enhanced the ability to wean from parenteral nutrition. Patients with the entire colon also achieved enteral autonomy sooner than those with partial colon. CONCLUSIONS The preservation of ileum and colon is important in patients with SBS. Approaches to preserve or lengthen ileum and colon may be beneficial for these patients. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Asia Smith
- Division of Pediatric Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Shweta Namjoshi
- Division of Gastroenterology, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - John A Kerner
- Division of Gastroenterology, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - James C Y Dunn
- Division of Pediatric Surgery, Department of Surgery, Stanford University, Stanford, CA, USA.
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18
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Factors influencing enteral autonomy after autologous gastrointestinal reconstructive surgery: A two-centre UK perspective. J Pediatr Surg 2023; 58:223-227. [PMID: 36404184 DOI: 10.1016/j.jpedsurg.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 10/11/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS The implementation of multidisciplinary care and improvements in parenteral nutrition (PN) in patients with short bowel syndrome (SBS) have led to better outcomes and higher survivability. Autologous gastrointestinal reconstructive (AGIR) surgery can reduce the duration on PN and lead to earlier enteral autonomy (EA). Our aim was to investigate the effect of SBS aetiology and other predictors on the achievement of enteral autonomy following AGIR surgery. METHODS Retrospective review of all patients undergoing AGIR surgery in two tertiary paediatric surgical units, between 2010 and 2021. Continuous data is presented as median (range). RESULTS Twenty-seven patients underwent 29 AGIR procedures (20 serial transverse enteroplasties (STEP), 9 longitudinal intestinal lengthening and tailoring (LILT)) at an age of 6.6 months (1.5 - 104.5). EA rate was 44% at 13.6 months after surgery (1 - 32.8). AGIR procedures achieved an increase in small bowel length of 70% (pre-operative 46.5 vs 77 cm, p = 0.003). No difference was found between STEP and LILT (p = 0.84). Percentage of expected small bowel length (based on the child's weight) was a strong predictor of EA (bowel length >15% - EA 80% vs bowel length ≤15% - EA 17%, p = 0.008). A diagnosis of gastroschisis showed a negative non-significant correlation with the ability to achieve EA (25% vs 60%, p = 0.12). Overall survival rate was 96%. CONCLUSION AGIR surgery is an important tool in the multidisciplinary management of children with SBS. Percentage of expected small length and aetiology of SBS are likely predictors of achievement of EA in patients undergoing AGIR surgery. LEVEL OF EVIDENCE IV: Retrospective Case-Series.
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Jaksic T. Current short bowel syndrome management: An era of improved outcomes and continued challenges. J Pediatr Surg 2023; 58:789-798. [PMID: 36870826 DOI: 10.1016/j.jpedsurg.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/06/2023] [Indexed: 01/22/2023]
Abstract
Prior to the late 1960s, pediatric short bowel syndrome was a frequently fatal disease. Currently, pediatric interdisciplinary bowel rehabilitation centers report very high survival rates. The mortality trends, up-to-date definitions, incidence, causes, and clinical manifestations of short bowel syndrome are reviewed. Emphasis is placed upon the nutritional, medical, and surgical advances that have contributed to the dramatic improvement in outcomes for pediatric short bowel syndrome patients. Recent findings and remaining challenges are highlighted.
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Affiliation(s)
- Tom Jaksic
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 333 Longwood Avenue, Boston MA, 02115, USA.
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20
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Hair AB, Good M. Dilemmas in feeding infants with intestinal failure: a neonatologist's perspective. J Perinatol 2023; 43:114-119. [PMID: 36127395 DOI: 10.1038/s41372-022-01504-4] [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] [Received: 04/15/2022] [Revised: 08/17/2022] [Accepted: 08/26/2022] [Indexed: 02/07/2023]
Abstract
Intestinal failure in neonatal and pediatric populations can be debilitating for patients and difficult to manage for clinicians. Management strategies include referral to an intestinal rehabilitation center, small volume trophic feeds to stimulate the intestine with cautious advancement of enteral nutrition using a standardized and evidence-based feeding protocol, and supplemental parenteral nutrition to optimize an infant's growth and nutrition. In this review, we discuss the causes of intestinal failure, parenteral nutrition strategies, enteral feeding initiation and advancement protocols, as well as the challenges in feeding an infant with intestinal failure.
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Affiliation(s)
- Amy B Hair
- Division of Neonatology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Misty Good
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
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21
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Cerdó T, García-Santos JA, Rodríguez-Pöhnlein A, García-Ricobaraza M, Nieto-Ruíz A, G. Bermúdez M, Campoy C. Impact of Total Parenteral Nutrition on Gut Microbiota in Pediatric Population Suffering Intestinal Disorders. Nutrients 2022; 14:4691. [PMID: 36364953 PMCID: PMC9658482 DOI: 10.3390/nu14214691] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 08/10/2023] Open
Abstract
Parenteral nutrition (PN) is a life-saving therapy providing nutritional support in patients with digestive tract complications, particularly in preterm neonates due to their gut immaturity during the first postnatal weeks. Despite this, PN can also result in several gastrointestinal complications that are the cause or consequence of gut mucosal atrophy and gut microbiota dysbiosis, which may further aggravate gastrointestinal disorders. Consequently, the use of PN presents many unique challenges, notably in terms of the potential role of the gut microbiota on the functional and clinical outcomes associated with the long-term use of PN. In this review, we synthesize the current evidence on the effects of PN on gut microbiome in infants and children suffering from diverse gastrointestinal diseases, including necrotizing enterocolitis (NEC), short bowel syndrome (SBS) and subsequent intestinal failure, liver disease and inflammatory bowel disease (IBD). Moreover, we discuss the potential use of pre-, pro- and/or synbiotics as promising therapeutic strategies to reduce the risk of severe gastrointestinal disorders and mortality. The findings discussed here highlight the need for more well-designed studies, and harmonize the methods and its interpretation, which are critical to better understand the role of the gut microbiota in PN-related diseases and the development of efficient and personalized approaches based on pro- and/or prebiotics.
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Affiliation(s)
- Tomás Cerdó
- Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Reina Sofia University Hospital, University of Córdoba, 14004 Córdoba, Spain
| | - José Antonio García-Santos
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Anna Rodríguez-Pöhnlein
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - María García-Ricobaraza
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Ana Nieto-Ruíz
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Mercedes G. Bermúdez
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Cristina Campoy
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
- Spanish Network of Biomedical Research in Epidemiology and Public Health (CIBERESP), Granada’s Node, Carlos III Health Institute, Avda. Monforte de Lemos 5, 28028 Madrid, Spain
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22
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Mutanen A, Pöntinen V, Gunnar R, Merras-Salmio L, Pakarinen MP. Efficient achievement of enteral autonomy facilitates resolution of liver injury in necrotizing enterocolitis induced short bowel syndrome. Sci Rep 2022; 12:17516. [PMID: 36266329 PMCID: PMC9584958 DOI: 10.1038/s41598-022-22414-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/14/2022] [Indexed: 01/12/2023] Open
Abstract
Children with short bowel syndrome (SBS) are at high risk for intestinal failure associated liver disease (IFALD). The aim of this retrospective follow-up study was to compare weaning off parenteral nutrition (PN) and IFALD between necrotizing enterocolitis (NEC) and non-NEC induced SBS. Altogether, 77 patients with neonatal SBS treated by our multidisciplinary intestinal failure unit (NEC n = 38, non-NEC SBS n = 39) were included and followed-up at least for 2 years until median age of 10 years (interquartile range, 6.0-16). Occurrence and characteristics of IFALD was assessed with liver biopsies obtained at median age of 3.2 (1.0-6.7) years (n = 62) and serum liver biochemistry. Overall, NEC patients had less end-jejunostomies and autologous intestinal reconstruction surgeries performed compared to non-NEC patients (< 0.05), while remaining small bowel anatomy was comparable between groups. Cumulative weaning off PN was more frequent and duration of PN shorter among NEC patients (P < 0.05). Overall cumulative probability of histological IFALD was lower among NEC patients during whole follow-up period (P = 0.052) and at 10 years (P = 0.024). NEC patients had lower ALT and GGT levels at last follow-up (P < 0.05 for all). In univariate Cox regression analysis, absence of end-jejunostomy, NEC diagnosis, longer remaining small bowel length, multidisciplinary treatment and prematurity were predictive for weaning off PN, while NEC diagnosis and lower birth weight in addition to multidisciplinary care protected from histological IFALD. Neonates with NEC induced SBS reached enteral autonomy earlier than those with non-NEC SBS, which associated with more efficient resolution of histological IFALD among long-term survivors.
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Affiliation(s)
- Annika Mutanen
- grid.7737.40000 0004 0410 2071Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, P.O Box 347, 00029 HUS Helsinki, Finland
| | - Ville Pöntinen
- grid.7737.40000 0004 0410 2071Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, P.O Box 347, 00029 HUS Helsinki, Finland
| | - Riikka Gunnar
- grid.7737.40000 0004 0410 2071Department of Pediatric Gastroenterology, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura Merras-Salmio
- grid.7737.40000 0004 0410 2071Department of Pediatric Gastroenterology, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P. Pakarinen
- grid.7737.40000 0004 0410 2071Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, P.O Box 347, 00029 HUS Helsinki, Finland
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23
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The Variable Response to Teduglutide in Pediatric Short Bowel Syndrome: A Single Country Real-Life Experience. J Pediatr Gastroenterol Nutr 2022; 75:293-298. [PMID: 35730756 DOI: 10.1097/mpg.0000000000003541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The glucagon-like peptide-2 analog Teduglutide has been shown to enhance intestinal absorption and decrease parenteral nutrition (PN) requirements in short bowel syndrome (SBS). As data in children is limited, we evaluated nationwide real-life experience and treatment outcome in children with SBS. METHODS Longitudinal data of children treated with Teduglutide for ≥3 months was collected. Data included demographic and medical background, anthropometrics, laboratory assessments and PN requirements. Treatment response was defined as >20% reduction in PN requirement. RESULTS The study included 13 patients [54% males, median (interquartile range {IQR}) age of 6 (4.7-7) years]. The most common SBS etiology was necrotizing enterocolitis (38%), and median (IQR) small bowel length was 20 (15-40) cm. Teduglutide treatment ranged between 3 and 51 months [median (IQR) of 18 (12-30) months], with 10 patients (77%) treated >1 year. Response to treatment was observed in 8 patients (62%), with a mean [±standard deviation (SD)] treatment duration of 5.9 (±3.2) months. Among responders, 2 patients were weaned off PN and additional 4 decreased PN needs by >40%. There was a median (IQR) reduction in PN volume/kg of 36% (15%-55%) and in PN energy/kg of 27% (6%-58%). Response was not associated with patients' background, and no correlation was found with bowel length or PN dependency at baseline. CONCLUSIONS Real-life response to Teduglutide is highly variable among children with SBS. While most patients did reach 20% reduction in PN, less achieved further significant reduction or enteral autonomy. No predictive factors of response to treatment were identified, and large multicenter studies are needed to elucidate predictive factors and long-term outcome.
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24
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Impact of Pancreatic Enzymes on Enteral Fat and Nitrogen Absorption in Short Bowel Syndrome. J Pediatr Gastroenterol Nutr 2022; 75:36-41. [PMID: 35622082 DOI: 10.1097/mpg.0000000000003465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Patients with short bowel syndrome (SBS) can have a high morbidity rate. To minimize morbidity, enteral autonomy is the primary goal in clinical management of patients with SBS. This is often difficult to achieve because of significant malabsorption. To date, there are limited therapies that improve absorption in patients with SBS. The impact of pancreatic enzyme replacement treatment on enteral absorption has not been studied in this population and was the primary aim of this study. SUBJECTS/METHODS This was an interventional study in 11 subjects (6 pediatric subjects ages 4.0-17.9 years, 5 adult subjects 18-75 years) that compared enteral absorption in each subject before and after pancreatic enzyme medication (Creon). Coefficient of fat absorption (CFA) and coefficient of nitrogen absorption (CNA) were used as markers of enteral absorption of fat and protein, respectively. RESULTS There was no statistically significant mean change in CFA and CNA before and after pancreatic enzyme medication therapy. Six subjects demonstrated an increase in CFA and 8 subjects demonstrated an increase in CNA after the use of pancreatic enzyme medication therapy. CONCLUSIONS There was no statistically significant improvement in enteral fat and protein absorption in the cohort as a whole, though several subjects demonstrated an improvement. These results suggest that some patients with SBS may benefit from treatment with pancreatic enzymes. Further studies are needed to better evaluate the effect of pancreatic enzyme therapy on enteral absorption in subjects with SBS and to characterize factors that may predict a positive response.
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25
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Goldani HA, Ceza MR, Godoy LL, Giesta JM, Beier S, Oliveira JG, Nunes DL, Feldens L, Lucena IR, Taniguchi AN, Hallberg SC, Durant D, Boettcher S, Schneider MA, Mello PP, Riberg MG, Signorini AV, Miller C, Santos BL, Silveira CO, Morais MC, Laggazio TV, Costa CC, Kieling CO. Outcomes of the First 54 Pediatric Patients on Long-Term Home Parenteral Nutrition from a Single Brazilian Center. J Pediatr Gastroenterol Nutr 2022; 75:104-109. [PMID: 35578384 PMCID: PMC9236303 DOI: 10.1097/mpg.0000000000003473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 03/28/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Data on multidisciplinary programs dedicated to home parenteral nutrition (HPN) in Latin America are limited. This study describes the results of the first multidisciplinary pediatric intestinal rehabilitation program for HPN at a public tertiary hospital in Brazil. METHODS We retrospectively reviewed patients aged 0-18 years with intestinal failure (IF) who required parenteral nutrition (PN) for >60 days between January/2014 and December/2020. RESULTS Fifty-four patients were discharged on HPN (15 achieved enteral autonomy, 34 continued on HPN at the end of the study, 1 underwent intestinal transplantation, and 4 died). The median (IQR) age at the study endpoint of patients who achieved enteral autonomy was 14.1 (9.7-19) versus 34.7 (20.4-53.9) months in those who did not achieve enteral autonomy. Overall prevalence of catheter-related thrombosis was 66.7% and catheter-related bloodstream infection rate was 0.39/1000 catheter-days. Intestinal failure-associated liver disease (IFALD) was present in 24% of all patients; none of the patients who achieved enteral autonomy had IFALD. All patients showed significant improvement in anthropometric parameters during the HPN period. The sociodemographic characteristics of the patients' family members were mothers less than 20 years old (7.5%), schooling time more than 10 years (55.5%), and household income between 1 and 3 times the minimum wage (64.8%). The 5-year survival rate for HPN is 90%, and 27.7% of patients achieve enteral autonomy. CONCLUSION The treatment of pediatric patients with IF followed by a multidisciplinary pediatric intestinal rehabilitation program with HPN is feasible and safe in the Brazilian public health system.
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Affiliation(s)
- Helena A.S. Goldani
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul
| | - Marilia R. Ceza
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Liege L. Godoy
- Pediatric Nursing Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Juliana M. Giesta
- Nutrition Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Simone Beier
- Social Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Juliana G. Oliveira
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Daltro L. Nunes
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Leticia Feldens
- Pediatric Surgery Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Iara R.S. Lucena
- Radiology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Silvia C. Hallberg
- Psychology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Daiane Durant
- Pediatric Nursing Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Simone Boettcher
- Pediatric Nursing Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Marcia A. Schneider
- Nutrology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Patricia P. Mello
- Nutrology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Mariana G.L. Riberg
- Pharmacy Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Alana V. Signorini
- Speech and Language Therapy Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Cristina Miller
- Physiotherapy Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Berenice L. Santos
- Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul
| | - Claudete O. Silveira
- Administrative Department, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Maira C.M. Morais
- Administrative Department, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Terezinha V. Laggazio
- Administrative Department, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Carla C. Costa
- Social Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Carlos O. Kieling
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
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26
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Pediatric intestinal transplantation. Semin Pediatr Surg 2022; 31:151181. [PMID: 35725057 DOI: 10.1016/j.sempedsurg.2022.151181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Advancements in donor management, organ preservation and operative techniques, as well as immunosuppressive therapies, have provided children with intestinal failure and its complications a chance not only for enteral autonomy but also long-term survival through intestinal transplantation (ITx). First described in the 1960's, experience has grown in managing these complex patients both pre- and post-transplant. The goals of this review are to provide a brief history of intestinal transplantation and intestinal rehabilitation in pediatric patients, followed by focused discussions of the indications for ITx, induction and maintenance immunosuppression therapies, common post-operative complications, and outcomes/quality of life post-transplant.
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27
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Lezo A, Diamanti A, Marinier EM, Tabbers M, Guz-Mark A, Gandullia P, Spagnuolo MI, Protheroe S, Peretti N, Merras-Salmio L, Hulst JM, Kolaček S, Ee LC, Lawrence J, Hind J, D’Antiga L, Verlato G, Pukite I, Di Leo G, Vanuytsel T, Doitchinova-Simeonova MK, Ellegard L, Masconale L, Maíz-Jiménez M, Cooper SC, Brillanti G, Nardi E, Sasdelli AS, Lal S, Pironi L. Chronic Intestinal Failure in Children: An International Multicenter Cross-Sectional Survey. Nutrients 2022; 14:nu14091889. [PMID: 35565856 PMCID: PMC9103944 DOI: 10.3390/nu14091889] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/13/2022] [Accepted: 04/26/2022] [Indexed: 02/02/2023] Open
Abstract
Background: The European Society for Clinical Nutrition and Metabolism database for chronic intestinal failure (CIF) was analyzed to investigate factors associated with nutritional status and the intravenous supplementation (IVS) dependency in children. Methods: Data collected: demographics, CIF mechanism, home parenteral nutrition program, z-scores of weight-for-age (WFA), length or height-for-age (LFA/HFA), and body mass index-for-age (BMI-FA). IVS dependency was calculated as the ratio of daily total IVS energy over estimated resting energy expenditure (%IVSE/REE). Results: Five hundred and fifty-eight patients were included, 57.2% of whom were male. CIF mechanisms at age 1−4 and 14−18 years, respectively: SBS 63.3%, 37.9%; dysmotility or mucosal disease: 36.7%, 62.1%. One-third had WFA and/or LFA/HFA z-scores < −2. One-third had %IVSE/REE > 125%. Multivariate analysis showed that mechanism of CIF was associated with WFA and/or LFA/HFA z-scores (negatively with mucosal disease) and %IVSE/REE (higher for dysmotility and lower in SBS with colon in continuity), while z-scores were negatively associated with %IVSE/REE. Conclusions: The main mechanism of CIF at young age was short bowel syndrome (SBS), whereas most patients facing adulthood had intestinal dysmotility or mucosal disease. One-third were underweight or stunted and had high IVS dependency. Considering that IVS dependency was associated with both CIF mechanisms and nutritional status, IVS dependency is suggested as a potential marker for CIF severity in children.
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Affiliation(s)
- Antonella Lezo
- Department of Clinical Nutrition, OIRM-S, Anna Hospital, Città della Salute e della Scienza, 10126 Turin, Italy;
| | | | - Evelyne M. Marinier
- Service des Maladies Digestives et Respiratoires de l’Enfant, Centre de Référence des Maladies Digestives Rares, Hôpital R Debré, 75019 Paris, France;
| | - Merit Tabbers
- Emma Children’s Hospital/Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands;
| | - Anat Guz-Mark
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children’s Medical Center of Israel, Petach Tikva 4920235, Israel;
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Paolo Gandullia
- Pediatric Gastroenterology and Endoscopy, IRCCS G, Gaslini Institute, 16147 Genoa, Italy;
| | - Maria I. Spagnuolo
- Section of Paediatrics, Department of Translational Medical Science, University of Naples Federico II, 80138 Naples, Italy;
| | - Sue Protheroe
- Department of Gastroenterology and Nutrition, Birmingham Children’s Hospital NHS Trust, Birmingham B4 6NH, UK;
| | - Noel Peretti
- Paediatric Hospital “Femme Mère Enfant de Lyon”, 69677 Lyon, France;
| | - Laura Merras-Salmio
- Pediatric Gastroenterology Unit, Helsinki University Hospital, Children’s Hospital Helsinki, 00290 Helsinki, Finland;
| | - Jessie M. Hulst
- Erasmus Medical Center, Sophia Children’s Hospital, 3015 CN Rotterdam, The Netherlands;
| | - Sanja Kolaček
- Children’s Hospital Zagreb, Zagreb Medical University, 10000 Zagreb, Croatia;
| | - Looi C. Ee
- Queensland Children’s Hospital, Brisbane, QLD 4101, Australia;
| | | | - Jonathan Hind
- Paediatric Liver, GI and Nutrition Centre, King’s College Hospital, London SE5 9RS, UK;
| | - Lorenzo D’Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, “Papa Giovanni XXIII” Hospital, 24127 Bergamo, Italy;
| | - Giovanna Verlato
- Paediatric Nutrition Service-Neonatal Intensive Care Unit, University Hospital of Padova, 35128 Padova, Italy;
| | - Ieva Pukite
- University Children Hospital, LV-1004 Riga, Latvia;
| | - Grazia Di Leo
- Pediatric Department, University of Trieste, IRCCS Burlo Garofolo, 34137 Trieste, Italy;
| | - Tim Vanuytsel
- University Hospital Leuven, Leuven Intestinal Failure and Transplantation (LIFT), 3000 Leuven, Belgium;
| | | | - Lars Ellegard
- Sahlgrenska University Hospital, Institute of Medicine, Departement of Internal Medicine and Clinical Nutrition, University of Gothenburg, 41390 Gothenburg, Sweden;
| | | | - María Maíz-Jiménez
- Department of Endocrinology and Nutrition, Hospital 12 de Octubre, 28041 Madrid, Spain;
| | - Sheldon C. Cooper
- University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK;
| | - Giorgia Brillanti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy;
| | - Elena Nardi
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, 40138 Bologna, Italy;
| | - Anna S. Sasdelli
- Clinical Nutrition and Metabolism Unit, Center for Chronic Intestinal Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bolohna, Italy;
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford M6 8HD, UK;
| | - Loris Pironi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy;
- Clinical Nutrition and Metabolism Unit, Center for Chronic Intestinal Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bolohna, Italy;
- Correspondence:
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Sieverding L, Michel J, Urla C, Sturm E, Winkler F, Hofbeck M, Fuchs J, Hilberath J, Warmann SW. Spectrum of Interventional Procedures During Hybrid Central Line Placement in Pediatric Intestinal Rehabilitation Patients With End-Stage Vascular Access. Front Nutr 2022; 9:863063. [PMID: 35419386 PMCID: PMC8995563 DOI: 10.3389/fnut.2022.863063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/07/2022] [Indexed: 12/01/2022] Open
Abstract
Background Loss of available central vein access sites for parenteral nutrition delivery represents one of the main indications for intestinal transplantation in children with intestinal failure. Placement of central venous catheters can be challenging in advanced loss of patent venous pathways. We recently described the hybrid technique (interventional plus surgical approach) of central line placement in children. The aim of this study was to describe and analyze the interventions used during the hybrid procedures regarding feasibility, safety and outcome. Methods We retrospectively analyzed the course of all children in our intestinal rehabilitation program undergoing hybrid central line placement. We evaluated patients' conditions, interventional techniques and surgical peculiarities as well as outcome. Results 203 children were treated in our intestinal rehabilitation program between 2010 and 2021. Due to loss of venous access, hybrid technique was performed in 53 children during 76 interventions. In 40 cases the same vessel was reused via Seldinger technique. Among the 30 ultrasound-guided new vessel punctures, 12 were performed by puncture of collateral vessels. Extended interventions due to thoracic central venous obstruction and/or thrombosis requiring additional access via a femoral vein for rehabilitation of the vascular system was performed during 29 procedures including catheter extraction (1), angioplasties (18), stent placement (1), revascularization (5) and thrombectomy (4). Placement of a central line was not possible in 6 children which eventually underwent extended thoracic/vascular surgery: in three children the previously placed catheter could not be removed, in one child, placement of a thrombectomy-catheter was not possible because of inferior vena cava occlusion, and in two children, revascularization failed. Intestinal transplantation was considered in one patient because of impending loss of vascular access. Two self-limiting minor extravasations and one intervention-associated pericardial effusion occurred. Conclusions Hybrid interventions for central venous catheter placement and vascular rehabilitation enable a high success rate in children with intestinal failure and end-stage vascular access, circumventing the need for intestinal transplantation or advanced surgery. The relevant procedures are complex and require a foresighted and individualized approach with a wide range of interventional techniques. If performed with expertise, this combined interventional/surgical approach is feasible and safe.
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Affiliation(s)
- Ludger Sieverding
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Christian Urla
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Ekkehard Sturm
- Department of Pediatric Gastroenterology and Hepatology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Franziska Winkler
- Department of Pediatric Gastroenterology and Hepatology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Johannes Hilberath
- Department of Pediatric Gastroenterology and Hepatology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Steven Walter Warmann
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, University of Tübingen, Tübingen, Germany
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Vinit N, Talbotec C, De Tristan MA, Salomon LJ, Giuseppi A, Rousseau V, Beaudoin S, Lambe C, Ville Y, Sarnacki S, Goulet O, Chardot C, Lapillonne A, Khen-Dunlop N. Predicting Factors of Protracted Intestinal Failure in Children with Gastroschisis. J Pediatr 2022; 243:122-129.e2. [PMID: 34748742 DOI: 10.1016/j.jpeds.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To identify prenatal and neonatal predictors of short bowel syndrome-related intestinal failure (SBS-IF) in gastroschisis. STUDY DESIGN This retrospective study included all patients with gastroschisis born between 2000 and 2017 who were enrolled in our home parenteral nutrition program, and all patients with gastroschisis born in our institution who survived 2 weeks, during the same time period. Prenatal ultrasound features, neonatal status, anatomic features, oral feeding, and parenteral nutrition dependency were analyzed. RESULTS Among 180 patients, 35 required long-term parenteral nutrition (SBS-IF group) and 145 acquired full oral feeding within 6 months (oral feeding group). The mean follow-up was 7.9 years (IQR, 1.6-17.5 years) and 5.0 years (IQR, 0.1-18.2 years), respectively. Both bowel matting (OR, 14.23; 1.07-16.7; P = .039) and secondarily diagnosed atresia or stenosis (OR, 17.78; 3.13-100.98; P = .001) were independent postnatal predictors of SBS-IF. Eighteen children (51% of the SBS-IF group) were still dependent on artificial nutrition at the last follow-up. patients with SBS-IF who achieved full oral feeding had a median residual small-bowel length of 74 cm (IQR, 51-160 cm) vs 44 cm (IQR, 10-105 cm) for those still dependent on artificial nutrition (P = .02). An initial residual small bowel length of more than 50 cm was the best predictive cut-off for nutritional autonomy, with a sensitivity of 67% and a specificity of 100%. CONCLUSIONS Bowel matting, complex gastroschisis, and secondary intestinal obstruction were associated with SBS-IF in gastroschisis. For patients with SBS-IF, a small bowel length of more than 50 cm was predictive of secondary nutritional autonomy.
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Affiliation(s)
- Nicolas Vinit
- Department of Pediatric Surgery and Transplantation, Necker-Enfants Malades Hospital, APHP, Paris, France.
| | - Cécile Talbotec
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Necker-Enfants Malades Hospital, APHP, Paris, France
| | | | - Laurent J Salomon
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France; Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Agnès Giuseppi
- Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Véronique Rousseau
- Department of Pediatric Surgery and Transplantation, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Sylvie Beaudoin
- Department of Pediatric Surgery and Transplantation, Necker-Enfants Malades Hospital, APHP, Paris, France; Paris Descartes School of Medicine, Paris Center University, Paris, France
| | - Cécile Lambe
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Yves Ville
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France; Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Sabine Sarnacki
- Department of Pediatric Surgery and Transplantation, Necker-Enfants Malades Hospital, APHP, Paris, France; Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Olivier Goulet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Necker-Enfants Malades Hospital, APHP, Paris, France; Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Christophe Chardot
- Department of Pediatric Surgery and Transplantation, Necker-Enfants Malades Hospital, APHP, Paris, France; Paris Descartes School of Medicine, Paris Center University, Paris, France
| | - Alexandre Lapillonne
- Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, APHP, Paris, France; Paris Descartes School of Medicine, Paris Center University, Paris, France
| | - Naziha Khen-Dunlop
- Department of Pediatric Surgery and Transplantation, Necker-Enfants Malades Hospital, APHP, Paris, France; Paris Descartes School of Medicine, Paris Center University, Paris, France
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Characteristics and outcomes of a multi-institution cohort of infants with necrotizing enterocolitis totalis. J Perinatol 2022; 42:440-445. [PMID: 34455416 PMCID: PMC8397862 DOI: 10.1038/s41372-021-01191-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To characterize the presentation, management and outcomes of infants with necrotizing enterocolitis totalis (tNEC) vs surgical non-totalis NEC (sNEC). STUDY DESIGN This retrospective study identified infants undergoing surgery for NEC through The Children's Hospitals Neonatal Database. Demographic, surgical and mortality characteristics were compared. RESULTS Of 1059 infants, 161 (15.2%) had tNEC. Perinatal characteristics did not differ. tNEC infants were older and were less likely to have pneumoperitoneum at referral (5.6% vs 13.1%, p < 0.001) or intestinal perforation at surgery (38.5% vs 66.7%, p < 0.001). Infants with tNEC were more acidotic preoperatively (7.1, [IQR 7, 7.3] vs 7.3, [IQR 7.2, 7.4], p < 0.001). Mortality was 96.9% for tNEC and 26.5% for sNEC (p < 0.001). tNEC cases varied by center, accounting for 0-43% of all surgical NEC cases. CONCLUSIONS Mortality is high for tNEC infants, who present at older age, with greater illness severity but are less likely to have intestinal perforation than sNEC infants.
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Peters FB, Bone JN, Van Oerle R, Albersheim S, Casey L, Piper H. The Importance of the ileocecal valve and colon in achieving intestinal independence in infants with short bowel syndrome. J Pediatr Surg 2022; 57:117-121. [PMID: 34696920 DOI: 10.1016/j.jpedsurg.2021.09.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/08/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE Infants with short bowel syndrome (SBS) wean from parenteral nutrition (PN) support at variable rates. Small bowel length is a predictor, but the importance of the ileocecal valve (ICV) and colon are unclear. We aim to determine if the ICV and/or colon predict enteral autonomy. METHODS Infants from a single intestinal rehabilitation program were retrospectively reviewed. Etiology of SBS, intestinal anatomy, and duration of nutritional support were collected for three years. The primary outcome was time to full enteral nutrition. ANCOVA and Cox proportional hazards model were used, with p < 0.05 significant. RESULTS 55 infants with SBS were included. After accounting for the effect of small bowel, PN duration was shorter for infants with the ICV compared to those without (mean 218 vs. 538 days, p = 0.003), and had a more significant effect on infants with ≤50% of small bowel. Increased small bowel length was a positive predictor of weaning. Patients with ≤50% of colon spent less time on PN with the ICV, compared to without (mean 220 vs 715 days, p = 0.009). CONCLUSIONS Preservation of the ICV was associated with shorter duration of PN support, while colon was not. Small bowel length is a positive predictor of enteral autonomy. LEVEL OF EVIDENCE Level III retrospective comparative study TYPE OF STUDY: Retrospective review.
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Affiliation(s)
- Francesca Bell Peters
- Faculty of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC V6T1Z3, Canada.
| | - Jeffrey N Bone
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Rhonda Van Oerle
- Division of Neonatology, University of British Columbia/BC Women's Hospital and Health Center, Vancouver, BC, Canada
| | - Susan Albersheim
- Division of Neonatology, University of British Columbia/BC Women's Hospital and Health Center, Vancouver, BC, Canada
| | - Linda Casey
- Department of Pediatrics, University of British Columbia/BC Children's Hospital, Vancouver, BC, Canada
| | - Hannah Piper
- Division of Pediatric Surgery, University of British Columbia/BC Children's Hospital, Vancouver, BC, Canada.
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Jiang W, Chen G, Wang Y, Zhong W, Zhou C, Zhang J, Lv X, Du C, Zhu Z, Geng Q, Tang W. Multi-Center Analysis of Predictive Factors of Enteral Autonomy and Risk Factors of Complications of Pediatric Intestinal Failure in China. Front Pediatr 2022; 10:813865. [PMID: 35186808 PMCID: PMC8848277 DOI: 10.3389/fped.2022.813865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/10/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The aim of this study was to identify predictors for enteral autonomy and intestinal failure (IF)-related complications and evaluate the outcomes of a multi-center pediatric cohort in China. METHODS The medical records of pediatric patients with IF treated at four medical centers in China from January 1, 2012 to November 31, 2020 were retrospectively reviewed. Enteral autonomy was defined as sustained growth and cessation of parenteral nutrition for >90 days. Multivariate logistic regression analysis was used to identify factors predictive of enteral autonomy and the risk factors of complications, such as IF-associated liver disease (IFALD) and catheter-related bloodstream infection (CRBSI). RESULTS The study cohort of 92 pediatric patients with IF included 71 (77%) who underwent surgery and 21 (23%) who received non-surgical treatment. Eventually, 63 (68.5%) patients achieved enteral autonomy by the end of the follow-up period. Multivariate logistic regression analysis indicated that longer duration of parenteral nutrition (PN), sepsis, and non-breastfeeding were risk factors for enteral autonomy. When considering the detailed intraoperative data, the presence of an ileocecal valve (ICV) and greater residual small bowel (RSB) length were reaffirmed as predictors of achieving enteral autonomy. Medium/long-chain (MCT/LCT) lipids or sepsis were identified as negative predictors for IFALD. Univariate analysis revealed that the use of MCT/LCT lipids was associated with a greater likelihood of CRBSI. CONCLUSION In this cohort, enteral autonomy was achieved at a percentage of 68.5%, and the risk factors for not achieving enteral autonomy were a longer duration of PN, sepsis, and non-breastfeeding. The presence of an ICV and a greater RSB length were important predictors of achieving enteral autonomy.
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Affiliation(s)
- Weiwei Jiang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Guanglin Chen
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ying Wang
- Division of Pediatric Gastroenterology and Nutrition, Shanghai Jiaotong University School of Medicine Xinhua Hospital, Shanghai, China
| | - Wei Zhong
- Department of Neonatal Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Chonggao Zhou
- Department of Neonatal Surgery, Hunan Children's Hospital, Changsha, China
| | - Jie Zhang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaofeng Lv
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Chunxia Du
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Zhongxian Zhu
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Qiming Geng
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Weibing Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
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Gattini D, Roberts AJ, Wales PW, Beath SV, Evans HM, Hind J, Mercer D, Wong T, Yap J, Belza C, Huysentruyt K, Avitzur Y. Trends in Pediatric Intestinal Failure: A Multicenter, Multinational Study. J Pediatr 2021; 237:16-23.e4. [PMID: 34153281 DOI: 10.1016/j.jpeds.2021.06.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To assess the natural history and outcomes of children with intestinal failure in a large, multicenter, geographically diverse contemporary cohort (2010-2015) from 6 pediatric intestinal failure programs. STUDY DESIGN Retrospective analysis of a multicenter intestinal failure cohort (n = 443). Competing-risk analysis was used to obtain cumulative incidence rates for the primary outcome (enteral autonomy, transplantation, or death). The χ2 test and Cox proportional hazard regression were used for bivariate and multivariable analyses. RESULTS The study cohort comprised 443 patients (61.2% male). Primary etiologies included short bowel syndrome (SBS), 84.9%; dysmotility disorder, 7.2%; and mucosal enteropathy, 7.9%. Cumulative incidences for enteral autonomy, transplantation, and death at 6 years of follow-up were 53.0%, 16.7%, and 10.5%, respectively. Enteral autonomy was associated with SBS, ≥50% of small bowel length, presence of an ileocecal valve (ICV), absence of portal hypertension, and follow-up in a non-high-volume transplantation center. The composite outcome of transplantation/death was associated with persistent advanced cholestasis and hypoalbuminemia; age <1 year at diagnosis, ICV, and intact colon were protective. CONCLUSIONS The rates of death and transplantation in children with intestinal failure have decreased; however, the number of children achieving enteral autonomy has not changed significantly, and a larger proportion of patients remain parenteral nutrition dependent. New strategies to achieve enteral autonomy are needed to improve patient outcomes.
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Affiliation(s)
- Daniela Gattini
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Amin J Roberts
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sue V Beath
- Department of Gastroenterology and Nutrition, Nutrition Support and Intestinal Failure team, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Helen M Evans
- Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
| | - Jonathan Hind
- Paediatric Liver, GI, and Nutrition Centre, King's College Hospital, London, United Kingdom
| | - David Mercer
- Organ Transplant Center, University of Nebraska Medical Center, Omaha, NE
| | - Theodoric Wong
- Department of Gastroenterology and Nutrition, Nutrition Support and Intestinal Failure team, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Jason Yap
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada
| | - Koen Huysentruyt
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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Mussolino AFJ, Tannuri ACA, Gonçalves JDO, Serafini S, Tannuri U. Adaptation Processes of the Remaining Jejunum or Ileum after Extensive Intestinal Resection. J INVEST SURG 2021; 35:793-800. [PMID: 34583613 DOI: 10.1080/08941939.2021.1963355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To compare the adaptation processes of the remaining jejunum or ileum after extensive intestinal resection in a growing animal model. MATERIALS AND METHODS Forty 21-day old rats were divided into four groups: JG: remaining jejunum group - ileal enterectomy; IG: ileum remaining group - jejunum enterectomy; SHAM: sham-operated group - open-and-close laparotomy; and NO: non-operated animals. RESULTS After 3 weeks, JG and IG animals had decreased weights comparing to SHAM and NO animals (p = 0.017 and p = 0.005, respectively). The histomorphometric analysis showed that in JG animals the villi were higher than in SHAM, NO, and IG animals (p = 0.007, p = 0.008, and p = 0.01), the depth of crypts in JG and IG animals was greater than in NO and SHAM animals (p = 0.03, p = 0.002, and p = 0.003 respectively), and muscle layer thickness of the jejunum of JG animals had values greater than SHAM and NO animals (p = 0.01 and p = 0.02, respectively). The Ki-67 expression in the ileum was higher in comparison with the jejunum (p = 0.014). The pro-apoptotic gene (Bax) expression was decreased in JG animals compared to IG, SHAM, and NO animals (p = 0.013, p = 0.024, and p = 0.021). The anti-apoptotic gene (Bcl-XL) expression was decreased in JG animals in comparison to IG and NO animals (p = 0.002 and p = 0.046) although it was increased in the colon of IG animals in comparison to JG, SHAM, and NO animals (p = 0.002, p = 0.001, and p = 0.001, respectively). The Bax/Bcl-XL ratio was higher in JG than in IG animals (p = 0.011). CONCLUSION Adaptive responses seemed to be more effective in the ileum than in the jejunum.
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Affiliation(s)
- Affonso Flávio Jorge Mussolino
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Josiane de Oliveira Gonçalves
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Suellen Serafini
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Uenis Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
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Kinstlinger N, Fink A, Gordon S, Levin TL, Friedmann P, Nafday S, Statter M, Borenstein SH. Is necrotizing enterocolitis the same disease in term and preterm infants? J Pediatr Surg 2021; 56:1370-1374. [PMID: 33526254 DOI: 10.1016/j.jpedsurg.2021.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/06/2020] [Accepted: 01/11/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Necrotizing enterocolitis predominantly affects preterm (PT) infants. The paucity of data regarding the clinical course in term infants makes it difficult to predict outcomes and counsel families. To identify predisposing factors and gain a better understanding of the clinical course of NEC in term infants, we reviewed our experience with term infants and compared it to outcomes in PT infants. METHODS We performed a 10 year retrospective review of all infants admitted to our NICU with Bell stage 2 NEC or greater. Infants < 37 weeks gestation were considered PT. Term and PT infant comorbidities, outcomes and intraoperative findings were compared. RESULTS Fifteen (12%) of 125 infants were term. Compared to PT infants, term infants were more likely to have congenital heart disease (33% term vs. 10% PT, p = 0.02) and develop NEC sooner (4 days in term vs. 17 days in PT, p < 0.001) but were less likely to require operative intervention (20% term vs. 38% PT; p = 0.17). There was no significant difference in Bell stage, survival and development of intestinal failure. NEC totalis occurred exclusively in PT infants. CONCLUSIONS NEC in term infants has unique clinical features that distinguishes it from NEC in PT infants.
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Affiliation(s)
- Noah Kinstlinger
- Division of Pediatric Surgery, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA
| | - Adam Fink
- Division of Pediatric Radiology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA
| | - Sharon Gordon
- Division of Pediatric Radiology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA
| | - Terry L Levin
- Division of Pediatric Radiology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA
| | - Patricia Friedmann
- Department of Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, 10467 USA
| | - Suhas Nafday
- Division of Neonatology, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA
| | - Mindy Statter
- Division of Pediatric Surgery, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA; Department of Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, 10467 USA
| | - Steven H Borenstein
- Division of Pediatric Surgery, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY, 10467 USA; Department of Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, 10467 USA.
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Modi BP, Galloway DP, Gura K, Nucci A, Plogsted S, Tucker A, Wales PW. ASPEN definitions in pediatric intestinal failure. JPEN J Parenter Enteral Nutr 2021; 46:42-59. [PMID: 34287974 DOI: 10.1002/jpen.2232] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David P Galloway
- Division of Gastroenterology, Hepatology and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kathleen Gura
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anita Nucci
- Department of Nutrition, Georgia State University, Atlanta, Georgia, USA
| | | | - Alyssa Tucker
- Department of Clinical Nutrition, Children's National Medical Center, Washington, District of Columbia, USA
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment, Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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Proli F, Faragalli A, Talbotec C, Bucci A, Zemrani B, Chardot C, Abi Nader E, Goulet O, Lambe C. Variation of plasma citrulline as a predictive factor for weaning off long-term parenteral nutrition in children with neonatal short bowel syndrome. Clin Nutr 2021; 40:4941-4947. [PMID: 34358840 DOI: 10.1016/j.clnu.2021.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/11/2021] [Accepted: 07/13/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND & AIMS Long-term parenteral nutrition (PN) is the mainstay of the therapeutic strategy in intestinal failure (IF) due to neonatal short bowel syndrome (SBS). Our aim was to identify prognostic factors for PN weaning and to assess if measuring plasma citrulline concentrations over time could account for the intestinal adaptation in progress. METHODS This retrospective study included children with neonatal SBS with surgical measurement of the residual bowel length and repeated plasma citrulline assessments during a 4-year follow-up. The degree of IF was assessed by the PN dependency index (PN caloric intake/Resting energy expenditure). The analysis was carried out according to SBS anatomical groups: end-jejunostomy (type 1), jejuno-colic (type 2) and jejuno-ileal anastomosis (type 3). RESULTS Fifty-five patients (8 type 1, 27 type 2, 20 type 3) were included. None of the patients with SBS type 1, 11 (41%) with type 2 and 11 (55%) with type 3 were weaned off during the follow-up period. Plasma citrulline levels significantly increased with time in patients who were finally weaned off PN; conversely, the levels did not consistently increase in patients who were still on PN at the end of the study period. There was an inverse relationship between plasma citrulline levels and the PN dependency index. The increasing citrulline levels had a positive effect on the probability of weaning, 2.7 times higher for each point increase in citrulline. No significant effect of age and residual bowel length at baseline was found. CONCLUSION The increased plasma citrulline level over time in addition to the SBS anatomical type is a reliable marker for subsequent PN weaning. The prediction of PN weaning assessed solely by the residual bowel length or a single measurement of citrulline is insufficient and should also take into account the anatomical type of SBS and repeated measurements of plasma citrulline levels.
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Affiliation(s)
- Francesco Proli
- Division of Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Intestinal Diseases, Intestinal Rehabilitation Center, Certified Center for Home Parenteral Nutrition, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France; Department of Pediatrics, Department of Woman, Child Health and Public Health, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.
| | - Andrea Faragalli
- Centre of Epidemiology, Biostatistics and Medical Information Technology, Università Pol. Delle Marche, Ancona, Italy
| | - Cécile Talbotec
- Division of Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Intestinal Diseases, Intestinal Rehabilitation Center, Certified Center for Home Parenteral Nutrition, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France
| | - Andrea Bucci
- Department of Economics, University G. D'Annunzio of Chieti-Pescara, Pescara, Italy
| | - Boutaina Zemrani
- Division of Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Intestinal Diseases, Intestinal Rehabilitation Center, Certified Center for Home Parenteral Nutrition, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France
| | - Christophe Chardot
- Pediatric Surgery, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France
| | - Elie Abi Nader
- Division of Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Intestinal Diseases, Intestinal Rehabilitation Center, Certified Center for Home Parenteral Nutrition, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France
| | - Olivier Goulet
- Division of Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Intestinal Diseases, Intestinal Rehabilitation Center, Certified Center for Home Parenteral Nutrition, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France
| | - Cécile Lambe
- Division of Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Intestinal Diseases, Intestinal Rehabilitation Center, Certified Center for Home Parenteral Nutrition, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France
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38
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Neam VC, Faino A, O'Hara M, Wendel D, Horslen SP, Javid PJ. Prospective evaluation of the family's health-related quality of life in pediatric intestinal failure. JPEN J Parenter Enteral Nutr 2021; 46:652-659. [PMID: 34170551 DOI: 10.1002/jpen.2212] [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: 11/11/2022]
Abstract
BACKGROUND Due to altered nutrition regimens and complex medical needs, pediatric intestinal failure (IF) may have a powerful impact on health-related quality of life (HRQOL). Studies have shown that children with IF experience lower HRQOL. Data on the HRQOL of families of children with IF are lacking. METHODS We performed a prospective analysis of the HRQOL of families of children with IF in a regional intestinal rehabilitation program from 2011 to 2018. The Pediatric Quality of Life Family Impact Module (FIM) was administered annually to parents. FIM scores were regressed on risk factors using linear mixed-effect models that accounted for repeated surveys within families. RESULTS A total of 117 families completed 272 surveys. FIM scores increased with patient age across nearly all survey dimensions. Total FIM scores were lower when compared to families of healthy children (median differences = -5, P = .01) and similar to families of chronically ill children. While IF families reported major deficits in the Communication (-11, P < .001) and Worry (-17, P < .001) dimensions, they also reported higher Family Relationship scores (+7, P < .01). On multivariable regression, presence of a major comorbidity and four or more hospital admissions in the prior year were associated with lower family HRQOL (P < .05). Parenteral nutrition dependence was independently associated with lower scores in the Communication (-7, P = .03) and Daily Activities (-10, P = .02) dimensions. CONCLUSION Families of children with IF experience a decreased HRQOL that may improve with patient age. Intestinal rehabilitation programs should address the HRQOL of families in addition to patients.
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Affiliation(s)
| | - Anna Faino
- Seattle Children's Research Institute, Seattle, Washington, USA
| | | | - Danielle Wendel
- Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
| | - Simon P Horslen
- Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
| | - Patrick J Javid
- Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
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39
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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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40
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Martos Rodríguez M, Guillén G, López-Fernández S, Martín Gimenez M, Ruiz CW, Ribes C, López M, Molino JA. Anastomosis near to the ileocecal valve in neonates with focal intestinal perforation, is it safe. J Matern Fetal Neonatal Med 2021; 35:7011-7014. [PMID: 34096446 DOI: 10.1080/14767058.2021.1934444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Anastomosis near the ileocecal valve (ICV) are controversial due to the increased pressure on the suture; in this situation, the valve could be removed at a first stage or at the moment of stoma closure. However, preservation of the ICV has proved important benefits in the long term. The aim of this study is to evaluate its feasibility in neonates with focal intestinal perforation (FIP). METHODS Retrospective study (2010-2019) of neonates with FIP who underwent intestinal resection and primary anastomosis. Patients were divided into group A (anastomosis less than 5 cm from ICV) and group B (more than 5 cm). RESULTS Forty patients were treated. Patients ostomized or with resection of ICV were excluded. Finally, 24 patients (birth weight 1043 ± 594 g (520-3000), age 8.8 ± 7.8 days (2-39)) were included for analysis. Patent ductus arteriosus was present in 75%. There were 6 patients in group A (25%) and 18 in group B (75%). Groups were comparable in terms of gestational age, birth weight, and age at the time of surgery (p > .05). There were no cases of dehiscence nor stenosis of the anastomosis. There were no differences in reoperation rate, infectious complications, time to enteral feeding, days of parenteral nutrition, hospital stay nor survival (p > .05). CONCLUSION Ileo-ileal anastomosis closer to the ileocecal junction, in neonates with focal intestinal perforation, is an effective and safe option which also allows the preservation of the ICV avoiding the complications derived from its absence in a group of patients with high morbidity.
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Affiliation(s)
| | - Gabriela Guillén
- Neonatal Surgery Unit, Pediatric Surgery Division, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Sergio López-Fernández
- Neonatal Surgery Unit, Pediatric Surgery Division, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - César W Ruiz
- Neonatology Division, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Cármen Ribes
- Neonatology Division, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Manuel López
- Pediatric Surgery Division, Vall d'Hebron University Hospital, Barcelona, Spain
| | - José Andrés Molino
- Neonatal Surgery Unit, Pediatric Surgery Division, Vall d'Hebron University Hospital, Barcelona, Spain
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41
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Fatemizadeh R, Gollins L, Hagan J, Debuyserie A, King K, Vogel AM, Van Buren KL, Hair AB, Premkumar MH. In neonatal-onset surgical short bowel syndrome survival is high, and enteral autonomy is related to residual bowel length. JPEN J Parenter Enteral Nutr 2021; 46:339-347. [PMID: 33881791 DOI: 10.1002/jpen.2124] [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: 12/26/2022]
Abstract
BACKGROUND In an era of improved management and treatment options, this study aims to describe the long-term outcomes and factors predictive of outcomes of neonatal-onset intestinal failure (IF) due to surgical short bowel syndrome (SBS). METHODS Retrospective, single-center cohort study of infants born between January 2011 and December 2018 with inclusion criteria: <44 weeks postmenstrual age at SBS diagnosis, <28 days on admission, parenteral nutrition dependence >60 days, and documented intestinal resection. Primary outcomes included survival and achievement of enteral autonomy (EA). Data analysis utilized Fisher.s exact test, Kruskal-Wallis test, survival analysis methods, Cox proportional hazards regression, linear regression and logistic regression. RESULTS Ninety-five patients (males 56%) were studied with median follow-up of 38 months (IQR 19, 59). Survival at last follow-up was 96%, and EA was achieved in 85%. Forty-eight patients had documented residual bowel length (RBL) with median length of 49 cm (IQR 36, 80). Survival in patients with RBL of <30cm (n = 8), 30-59cm (n = 19), and >60cm (n = 21) was 100%, 95%, and 95% respectively. Shorter RBL was associated with longer time to achieve EA (p = 0.007), but not with survival (p = 0.81). Delay in achieving EA was associated with absence of ileocecal valve (p = 0.002) and bloodstream infections (p < 0.001). Peak conjugated bilirubin correlated with increased mortality (p = 0.002). CONCLUSION Overall high rate of survival and achievement of EA was found in neonatal onset IF due to SBS. EA but not survival was correlated with RBL. Ileocecal valve, bloodstream infections, and conjugated bilirubin levels were the other predictive factors of outcomes.
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Affiliation(s)
- Roxana Fatemizadeh
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Laura Gollins
- Clinical Nutrition Services, Texas Children's Hospital, Houston, Texas, USA
| | - Joseph Hagan
- Section of Neonatal-Perinatal Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Anne Debuyserie
- Section of Neonatal-Perinatal Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kristi King
- Clinical Nutrition Services, Texas Children's Hospital, Houston, Texas, USA
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kristin L Van Buren
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Amy B Hair
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Muralidhar H Premkumar
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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42
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Wendel D, Cole CR, Cohran VC. Approach to Intestinal Failure in Children. Curr Gastroenterol Rep 2021; 23:8. [PMID: 33860385 DOI: 10.1007/s11894-021-00807-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Pediatric intestinal failure is a complex condition requiring specialized care to prevent potential complications. In this article, we review the available evidence supporting recent advances in care for children with intestinal failure. RECENT FINDINGS Multidisciplinary intestinal rehabilitation teams utilize medical and surgical management techniques to help patients achieve enteral autonomy (EA) while preventing and treating the complications associated with intestinal failure. Recent advances in lipid management strategies, minimization of intestinal failure associated liver disease, prevention of central line-associated blood stream infections, and loss of access, as well as development of promising new hormone analogue therapy have allowed promotion of intestinal adaptation. These advances have decreased the need for intestinal transplant. There have been recent advances in the care of children with intestinal failure decreasing morbidity, mortality, and need for intestinal transplantation. The most promising new therapies involve replacement of enteroendocrine hormones.
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Affiliation(s)
- Danielle Wendel
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA.
| | - Conrad R Cole
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Valeria C Cohran
- Division of Gastroenterology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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43
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Torres C, Badalyan V, Mohan P. Twelve-year outcomes of intestinal failure-associated liver disease in children with short-bowel syndrome: 97% transplant-free survival and 81% enteral autonomy. JPEN J Parenter Enteral Nutr 2021; 46:197-206. [PMID: 33794031 DOI: 10.1002/jpen.2112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 01/28/2023]
Abstract
Our aim was to analyze the outcomes in children with short-bowel syndrome (SBS), parenteral nutrition dependence (PND), and intestinal failure-associated liver disease (IFALD) treated in our Intestinal Rehabilitation Program (IRP) during 2007-2018. We retrospectively reviewed charts of 135 patients with SBS-PND at the time of enrollment in IRP; of these, 89 (66%) had IFALD, defined as conjugated bilirubin (CB) of ≥2 mg/dl at enrollment and/or abnormal liver biopsy showing stage 2-4 fibrosis. Outcomes included resolution of CB, enteral autonomy, laboratory parameters (platelets, aspartate aminotransferase to platelet ratio index), growth trends, transplant rates, and mortality. Of the 89 patients, 74 had elevated CB at enrollment; the other 15 had normalized CB but had fibrosis on liver biopsy. Thirty-eight patients had liver biopsies: 36 (95%) had fibrosis, including 21/36 with bridging fibrosis/cirrhosis. The median proportion of residual small bowel was 23% (interquartile range, 13%-38%) of the expected length for age and median, daily energy requirement by PN was 100%. Two received a transplant, three died (one posttransplant), and the remaining 85 survived; 69 (81%) achieved enteral autonomy. Seventy-three (99%) of the 74 patients with hyperbilirubinemia normalized their CB with medical treatment. In a subset of eight of 89 patients with initial platelet count of <100,000/μl(median 50,500/μl) and median CB of 21 mg/dl, seven achieved CB normalization and had improved platelet count. Overall survival was 97% (censored 96.3%). We demonstrate high transplant-free survival and enteral autonomy rates among children with SBS-IFALD relying on low-dose soybean lipid emulsion.
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Affiliation(s)
- Clarivet Torres
- Intestinal Rehabilitation Program, Division of Gastroenterology, Hepatology, and Nutrition, Children's National Hospital, Washington, DC, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Vahe Badalyan
- Intestinal Rehabilitation Program, Division of Gastroenterology, Hepatology, and Nutrition, Children's National Hospital, Washington, DC, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Parvathi Mohan
- Intestinal Rehabilitation Program, Division of Gastroenterology, Hepatology, and Nutrition, Children's National Hospital, Washington, DC, USA.,George Washington University School of Medicine, Washington, DC, USA
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44
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Moschino L, Duci M, Fascetti Leon F, Bonadies L, Priante E, Baraldi E, Verlato G. Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection. Nutrients 2021; 13:nu13020340. [PMID: 33498880 PMCID: PMC7910892 DOI: 10.3390/nu13020340] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.
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MESH Headings
- Enterocolitis, Necrotizing/complications
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/prevention & control
- Enterocolitis, Necrotizing/surgery
- Failure to Thrive/prevention & control
- Humans
- Infant
- Infant Nutritional Physiological Phenomena
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/prevention & control
- Infant, Premature, Diseases/surgery
- Intestines/surgery
- Short Bowel Syndrome/etiology
- Short Bowel Syndrome/prevention & control
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Affiliation(s)
- Laura Moschino
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Elena Priante
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Giovanna Verlato
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
- Correspondence: ; Tel.: +39-0498211428
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45
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Muto M, Kaji T, Onishi S, Yano K, Yamada W, Ieiri S. An overview of the current management of short-bowel syndrome in pediatric patients. Surg Today 2021; 52:12-21. [PMID: 33464414 DOI: 10.1007/s00595-020-02207-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/29/2020] [Indexed: 12/13/2022]
Abstract
Short-bowel syndrome (SBS) is defined as a state of malabsorption after resection or loss of a major portion of the bowel due to congenital or acquired factors. This article presents an overview on the recent management of pediatric SBS. The pediatric SBS population is very heterogeneous. The incidence of SBS is estimated to be 24.5 per 100,000 live births. The nutritional, medical, and surgical therapies available require a comprehensive evaluation. Thus, multidisciplinary intestinal rehabilitation programs (IRPs) are necessary for the management of these complex patients. The key points of focus in IRP management are hepato-protective strategies to minimize intestinal failure-associated liver disease; the aggressive prevention of catheter-related bloodstream infections; strategic nutritional supply to optimize the absorption of enteral calories; and the management and prevention of small bowel bacterial overgrowth, nephrocalcinosis, and metabolic bone disease. As the survival rate of children with SBS currently exceeds 90%, the application of small bowel transplantation has been evolving. The introduction of innovative treatments, such as combined therapy of intestinotrophic hormones, including glucagon-like peptide-2, may lead to further improvements in patients' quality of life.
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Affiliation(s)
- Mitsuru Muto
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Tatsuru Kaji
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Keisuke Yano
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Waka Yamada
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.
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46
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Höllwarth ME, Solari V. Nutritional and pharmacological strategy in children with short bowel syndrome. Pediatr Surg Int 2021; 37:1-15. [PMID: 33392698 DOI: 10.1007/s00383-020-04781-2] [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] [Accepted: 11/06/2020] [Indexed: 12/11/2022]
Abstract
Short bowel syndrome in neonates is a severe and life-threatening disease after a major loss of small bowel with or without large bowel. Intestinal adaptation, by which the organism tries to restore digestive and absorptive capacities, is entirely dependent on stimulation of the active enterocytes by enteral nutrition. This review summarizes recent knowledge about the pathophysiologic consequences after the loss of different intestinal parts and outlines the options for enteral nutrition and pharmacological therapies to support the adaptation process.
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Affiliation(s)
- Michael E Höllwarth
- Univ. Clinic of Pediatric and Adolescent Surgery, Medical University, Graz, Austria.
| | - Valeria Solari
- Department of Pediatric Surgery, Klinik Donaustadt, 1220, Vienna, Austria
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47
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McNelis K, Goddard G, Jenkins T, Poindexter A, Wessel J, Helmrath M, Poindexter B. Delay in achieving enteral autonomy and growth outcomes in very low birth weight infants with surgical necrotizing enterocolitis. J Perinatol 2021; 41:150-156. [PMID: 33268832 PMCID: PMC7710157 DOI: 10.1038/s41372-020-00880-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/26/2020] [Accepted: 11/13/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To understand the nutritional intake and growth outcomes of very low birth weight infants with surgical necrotizing enterocolitis (NEC). STUDY DESIGN In a retrospective cohort study, linear mixed models were used to compare growth outcomes from birth to 24 months corrected age for very low birth weight (VLBW) infants with surgical NEC to those with spontaneous intestinal perforation (SIP). Kaplan-Meier curves were developed to demonstrate the duration of parenteral nutrition (PN) use. RESULT Height differed by surgical NEC and SIP over time (interaction p = 0.03). Surviving infants with surgical NEC had lower head circumference z-scores at 24 months. Of infants surviving surgical NEC, 71% received PN for >60 days after diagnosis. CONCLUSION The majority of infants with surgical NEC have a delay in achieving enteral autonomy. There was a difference in linear catch-up growth over time between infants with SIP and surgical NEC at 24 months.
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Affiliation(s)
- Kera McNelis
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,University of Cincinnati, College of Medicine, Cincinnati, OH, USA.
| | - Gillian Goddard
- grid.239573.90000 0000 9025 8099Division of Pediatric and General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,grid.239424.a0000 0001 2183 6745Department of Surgery, Boston Medical Center, Boston, MA USA
| | - Todd Jenkins
- grid.239573.90000 0000 9025 8099Division of Pediatric and General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Anne Poindexter
- grid.24827.3b0000 0001 2179 9593University of Cincinnati, College of Medicine, Cincinnati, OH USA ,grid.239573.90000 0000 9025 8099Division of Pediatric and General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Jacqueline Wessel
- grid.239573.90000 0000 9025 8099Division of Pediatric and General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Michael Helmrath
- grid.24827.3b0000 0001 2179 9593University of Cincinnati, College of Medicine, Cincinnati, OH USA ,grid.239573.90000 0000 9025 8099Division of Pediatric and General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Brenda Poindexter
- grid.239573.90000 0000 9025 8099Division of Neonatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,grid.189967.80000 0001 0941 6502Department of Pediatrics, Emory University, Atlanta, GA USA
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48
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Raghu VK, Rudolph JA, Smith KJ. Cost-effectiveness of teduglutide in pediatric patients with short bowel syndrome: Markov modeling using traditional cost-effectiveness criteria. Am J Clin Nutr 2020; 113:172-178. [PMID: 33021637 PMCID: PMC9630124 DOI: 10.1093/ajcn/nqaa278] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Teduglutide use in pediatric patients with short bowel syndrome can aid in the achievement of enteral autonomy, but with a price of >$400,000 per y. OBJECTIVE The current study evaluated the cost-effectiveness of using teduglutide in conjunction with offering intestinal transplantation in US pediatric patients with short bowel syndrome. DESIGN A Markov model was used to evaluate the costs (in US dollars) and effectiveness [in quality-adjusted life years (QALYs)] of using teduglutide compared with offering intestinal transplantation. Parameters were estimated from published data where available. The primary effect modeled was the probability of weaning from parenteral nutrition while on teduglutide. Sensitivity analyses were performed on all model parameters. RESULTS Compared with offering only intestinal transplantation, adding teduglutide cost ${\$}$124,353/QALY gained. Reducing the cost of the medication by 16% allowed the cost to reach the typical benchmark of ${\$}$100,000/QALY gained. Probabilistic sensitivity analysis favored transplantation without offering teduglutide in 68% of iterations at a ${\$}$100,000/QALY threshold. Never using teduglutide created an opportunity cost of over ${\$}$100,000 per patient. CONCLUSIONS At its current price, teduglutide does not provide a cost-effective addition to transplantation in the treatment of pediatric short bowel syndrome. Further work should look to identify cost-reducing strategies, including alternative dosing regimens.
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Affiliation(s)
| | - Jeffrey A Rudolph
- Departments of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kenneth J Smith
- Departments of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Abstract
OBJECTIVES Caring for a child on home parenteral nutrition (HPN) is stressful, and its emotional impact not fully appreciated. This study explored the emotional wellbeing and coping styles of parents and children on HPN. METHODS Questionnaire data were collected for parents of children (0-18 years) on HPN. Children 8 years and older completed the revised children's anxiety and depression scale. Parents completed the Hospital Anxiety and Depression Scale, Paediatric Inventory for Parents (PIP) and brief COPE. RESULTS A total of 14 children were included, 20 parents (13 females) and 4 children completed the survey. Parents had mean PIP difficulty and frequency score of 117.9 and 124, respectively, higher compared to parents of children with other chronic illness. PIP scores were significantly higher where children were also enterally tube fed (P < 0.05). Thirty-five per cent parents scored above clinical threshold on anxiety subscale of Hospital Anxiety and Depression Scale and 30% in borderline range. On depression subscale 15% scored above clinical threshold range and 15% in borderline range. Mean anxiety and depression scores in parents of children with short bowel syndrome (11.8, 7.8) were significantly higher than those with neuromuscular disease (5.8, 1.6) P < 0.05. Coping styles differed according to health condition and whether child was enterally fed. CONCLUSIONS There is a significant emotional impact of caring for a child on HPN, assessment and treatment of anxiety, depression, and stress should be a routine part of care. Individual needs of the child and parent need to be taken into account in providing the most appropriate psychological support.
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Choudhury RA, Yoeli D, Hoeltzel G, Moore HB, Prins K, Kovler M, Goldstein SD, Holland-Cunz SG, Adams M, Roach J, Nydam TL, Vuille-Dit-Bille RN. STEP improves long-term survival for pediatric short bowel syndrome patients: A Markov decision analysis. J Pediatr Surg 2020; 55:1802-1808. [PMID: 32345501 DOI: 10.1016/j.jpedsurg.2020.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 01/31/2020] [Accepted: 03/22/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Increasingly, for pediatric patients with short bowel syndrome (SBS), intestinal lengthening procedures such as serial transverse enteroplasty (STEP) are being offered with the hope of improving patients' chances for achieving enteral autonomy. However, it remains unclear to what extent STEP reduces the long-term need for intestinal transplant or improves survival. METHODS Based on existing literature, a decision analytic Markov state transition model was created to simulate the life of 1,000 pediatric SBS patients. Two simulations were modeled: 1) No STEP: patients were listed for transplant once medical management failed and 2) STEP: patients underwent STEP therapy and subsequent transplant listing if enteral autonomy was not achieved. Sensitivity analysis of small bowel length and anatomy was completed. Base case patients were defined as neonates with a small bowel length of 30cm. RESULTS For base case patients with an ostomy and a NEC SBS etiology, STEP was associated with increased rates of enteral autonomy after 10 years for patients with an ICV (53.9% [STEP] vs. 51.1% [No STEP]) and without an ICV (43.4% [STEP] vs. 36.3% [No STEP]). Transplantation rates were also reduced following STEP therapy for both ICV (17.5% [STEP] vs. 18.2% [No STEP]) and non-ICV patients (20.2% [STEP] vs. 22.1% [No STEP]). 10-year survival was the highest in the (+) STEP and (+) ICV group (85.4%) and lowest in the (-) STEP and (-) ICV group (83.3%). CONCLUSIONS For SBS patients, according to our model, STEP increases rates of enteral autonomy, reduces need for intestinal transplantation, and improves long-term survival. TYPE OF STUDY Economic/Decision Analysis or Modeling Studies LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
- Rashikh A Choudhury
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO.
| | - Dor Yoeli
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Gerard Hoeltzel
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Hunter B Moore
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Kas Prins
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Mark Kovler
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Seth D Goldstein
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Stephan G Holland-Cunz
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Megan Adams
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Jonathan Roach
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Trevor L Nydam
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Raphael N Vuille-Dit-Bille
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
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