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Bryan NS, Russell SC, Ozler O, Sugiguchi F, Yazigi NA, Khan KM, Ekong UD, Vitola BE, Guerra JF, Kroemer A, Fishbein TM, Matsumoto CS, Ghobrial SS, Kaufman SS. Evaluation of pediatric patients for intestinal transplantation in the modern era. J Pediatr Gastroenterol Nutr 2024; 79:278-289. [PMID: 38828781 DOI: 10.1002/jpn3.12274] [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: 11/16/2023] [Revised: 04/26/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES To review recent evaluations of pediatric patients with intestinal failure (IF) for intestinal transplantation (ITx), waiting list decisions, and outcomes of patients listed and not listed for ITx at our center. METHODS Retrospective chart review of 97 patients evaluated for ITx from January 2014 to December 2021 including data from referring institutions and protocol laboratory testing, body imaging, endoscopy, and liver biopsy in selected cases. Survival analysis used Kaplan-Meier estimates and Cox proportional hazards regression. RESULTS Patients were referred almost entirely from outside institutions, one-third because of intestinal failure-associated liver disease (IFALD), two-thirds because of repeated infective and non-IFALD complications under minimally successful intestinal rehabilitation, and a single patient because of lost central vein access. The majority had short bowel syndrome (SBS). Waiting list placement was offered to 67 (69%) patients, 40 of whom for IFALD. The IFALD group was generally younger and more likely to have SBS, have received more parenteral nutrition, have demonstrated more evidence of chronic inflammation and have inferior kidney function compared to those offered ITx for non-IFALD complications and those not listed. ITx was performed in 53 patients. Superior postevaluation survival was independently associated with higher serum creatinine (hazard ratio [HR] 15.410, p = 014), whereas inferior postevaluation survival was associated with ITx (HR 0.515, p = 0.035) and higher serum fibrinogen (HR 0.994, p = 0.005). CONCLUSIONS Despite recent improvements in IF management, IFALD remains a prominent reason for ITx referral. Complications of IF inherent to ITx candidacy influence postevaluation and post-ITx survival.
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Affiliation(s)
- Nathan S Bryan
- Department of Pediatrics, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Shannon C Russell
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Oguz Ozler
- Department of Pediatrics, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Fumitaka Sugiguchi
- Department of Pediatrics, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Nada A Yazigi
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Khalid M Khan
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Udeme D Ekong
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Bernadette E Vitola
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Juan-Francisco Guerra
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Alexander Kroemer
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Thomas M Fishbein
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Cal S Matsumoto
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Shahira S Ghobrial
- Department of Pharmacy, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Stuart S Kaufman
- Medstar Georgetown Transplant Institute, Medstar Georgetown University Hospital, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
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Spector Cohen I, Belza C, Courtney-Martin G, Srbely V, Wales PW, Muise A, Avitzur Y. Improved long-term outcome of children with congenital diarrhea followed by an intestinal rehabilitation program. J Pediatr Gastroenterol Nutr 2024; 79:269-277. [PMID: 38828718 DOI: 10.1002/jpn3.12275] [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: 08/26/2023] [Revised: 04/28/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Long-term outcomes of congenital diarrheas and enteropathies (CODE) are poorly described. We evaluated the morbidity and mortality of children with CODE followed by an intestinal rehabilitation program (IRP) compared to children with short bowel syndrome (SBS). METHODS Matched case-control study of children with intestinal failure (IF) due to CODE (diagnosed between 2006 and 2020; N = 15) and SBS (N = 42), matched 1:3, based on age at diagnosis and duration of parenteral nutrition (PN). Nutritional status, growth, and IF-related complications were compared. Survival and enteral autonomy were compared to a nonmatched SBS cohort (N = 177). RESULTS Fifteen CODE patients (five males, median age 3.2 years) were followed for a median of 2.9 years. Eleven children were alive at the end of the follow-up, and two achieved enteral autonomy. The CODE group had higher median PN fluid and calorie requirements than their matched SBS controls at the end of the follow-up (83 vs. 45 mL/kg/day, p = 0.01; 54 vs. 30.5 kcal/kg/day, p < 0.01), but had similar rates of growth parameters, intestinal failure associated liver disease, central venous catheter complications and nephrocalcinosis. Kaplan-Meier analyses of 10-year survival and enteral autonomy were significantly lower in CODE patients compared to the nonmatched SBS population (60% vs. 89% and 30% vs. 87%, respectively; log-rank p < 0.008). CONCLUSIONS Despite higher PN needs in CODE, rates of IF complications were similar to matched children with SBS. Enteral autonomy and survival rates were lower in CODE patients. Treatment by IRP can mitigate IF-related complications and improve CODE patient's outcome.
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Affiliation(s)
- Inna Spector Cohen
- Group for Improvement of Intestinal Function and Treatment (GIFT), Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Pediatric Gastroenterology and Nutrition Institute, Ruth Children's Hospital of Haifa, Rambam Medical Center, Haifa, Israel
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), Toronto, Ontario, Canada
| | - Glenda Courtney-Martin
- Group for Improvement of Intestinal Function and Treatment (GIFT), Toronto, Ontario, Canada
| | - Victoria Srbely
- Group for Improvement of Intestinal Function and Treatment (GIFT), Toronto, Ontario, Canada
| | - Paul W Wales
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati, Ohio, USA
- Division of General and Thoracic Surgery, Department of Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Aleixo Muise
- 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 (GIFT), Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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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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Kaenkumchorn TK, Lampone O, Huebner K, Cramer J, Karls C. When parenteral nutrition is the answer: The case of pediatric intestinal rehabilitation. Nutr Clin Pract 2024. [PMID: 38961658 DOI: 10.1002/ncp.11179] [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: 02/19/2024] [Revised: 05/09/2024] [Accepted: 06/03/2024] [Indexed: 07/05/2024] Open
Abstract
In pediatric patients with intestinal failure, parenteral nutrition is lifesaving but also has several associated risks. The goals of intestinal rehabilitation include promoting growth, minimizing complications associated with intestinal failure, and reaching enteral autonomy, if possible. Pediatric intestinal rehabilitation programs are interdisciplinary teams that strive to provide optimal care for children dependent on parenteral nutrition. The provision of parenteral nutrition requires close monitoring of patients' growth, nutrition concerns, clinical status, and laboratory parameters. Recent advances in the field of intestinal rehabilitation include new lipid emulsions, considerations regarding enteral feeding, advances in micronutrient provision, and central venous catheter preservation techniques. Challenges in the field remain, including improving overall quality of life with home parenteral nutrition administration and preventing recently recognized complications such as chronic intestinal inflammation.
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Affiliation(s)
- Tanyaporn K Kaenkumchorn
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Olivia Lampone
- Clinical Nutrition, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Kayla Huebner
- Department of Pharmacy, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Jesse Cramer
- Department of Pharmacy, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Catherine Karls
- Clinical Nutrition, Children's Wisconsin, Milwaukee, Wisconsin, USA
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Boctor DL, Fenton TR, Goulet O, Lambe C. Pediatric Intestinal Failure Associated Eating Disorder: An Overview of the Importance of Oral Feeding in a Population at Risk for Feeding Difficulties. Gastroenterol Clin North Am 2024; 53:309-327. [PMID: 38719381 DOI: 10.1016/j.gtc.2023.12.003] [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
Achieving feeding skills and food acceptance is a multi-layered process. In pediatric intestinal failure (PIF), oral feeding is important for feeding skills development, physiologic adaptation, quality of life and the prevention of eating disorders. In PIF, risk factors for feeding difficulties are common and early data suggests that feeding difficulties are prevalent. There is a unique paradigm for the feeding challenges in PIF. Conventional definitions of eating disorders have limited application in this context. A pediatric intestinal failure associated eating disorder (IFAED) definition that includes feeding/eating skills dysfunction, psychosocial dysfunction, and the influence on weaning nutrition support is proposed.
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Affiliation(s)
- Dana Liza Boctor
- Alberta Children's Hospital, Section of Gastroenterology, Hepatology and Nutrition, University of Calgary, Calgary, 28 Oki Drive NW, Calgary, Alberta T3B-6A8, Canada.
| | - Tanis R Fenton
- Department of Community Health Sciences, Institute of Public Health, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, 3rd Floor, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Olivier Goulet
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Digestive Diseases, Pediatric Intestinal Failure Rehabilitation Center, Hôpital Necker-Enfants Malades, Université Paris Cité, 149 Rue de Sèvres, Paris 75015, France
| | - Cecile Lambe
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Digestive Diseases, Pediatric Intestinal Failure Rehabilitation Center, Hôpital Necker-Enfants Malades, Université Paris Cité, 149 Rue de Sèvres, Paris 75015, France
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Raghu VK, Rumbo C, Horslen SP. From intestinal failure to transplantation: Review on the current need for transplant indications under multidisciplinary transplant programs worldwide. Pediatr Transplant 2024; 28:e14756. [PMID: 38623905 PMCID: PMC11115375 DOI: 10.1111/petr.14756] [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: 08/06/2023] [Revised: 11/24/2023] [Accepted: 04/01/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION Intestinal failure, defined as the loss of gastrointestinal function to the point where nutrition cannot be maintained by enteral intake alone, presents numerous challenges in children, not least the timing of consideration of intestine transplantation. OBJECTIVES To describe the evolution of care of infants and children with intestinal failure including parenteral nutrition, intestine transplantation, and contemporary intestinal failure care. METHODS The review is based on the authors' experience supported by an in-depth review of the published literature. RESULTS The history of parenteral nutrition, including out-patient (home) administration, and intestine transplantation are reviewed along with the complications of intestinal failure that may become indications for consideration of intestine transplantation. Current management strategies for children with intestinal failure are discussed along with changes in need for intestine transplantation, recognizing the difficulty in generalizing recommendations due to the high level of heterogeneity of intestinal pathology and residual bowel anatomy and function. DISCUSSION Advances in the medical and surgical care of children with intestinal failure have resulted in improved transplant-free survival and a significant fall in demand for transplantation. Despite these improvements a number of children continue to fail rehabilitative care and require intestine transplantation as life-saving therapy or when the burden on ongoing parenteral nutrition becomes too great to bear.
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Affiliation(s)
- Vikram K. Raghu
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224
| | - Carolina Rumbo
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Simon P. Horslen
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224
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7
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Andrews A, Fraser-Irwin C, Herbison K, Han DY, Evans HM, Roberts AJ. Ethnicity and socio-economic deprivation in children with intestinal failure in New Zealand: Disparities in incidence, but not in outcomes. J Paediatr Child Health 2024; 60:132-138. [PMID: 38655775 DOI: 10.1111/jpc.16550] [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: 07/15/2023] [Revised: 01/10/2024] [Accepted: 04/14/2024] [Indexed: 04/26/2024]
Abstract
AIMS The New Zealand National Intestinal Failure and Rehabilitation Service (NZ-NIFRS) was established in October 2015 to gather longitudinal data on the aetiology, clinical course and outcomes of children with intestinal failure (IF). One main objective is to achieve health equity for patients with IF in NZ. METHODS Clinical outcomes (enteral autonomy, parenteral nutrition (PN) dependence, death or intestinal transplantation) for IF patients diagnosed from October 2015 to 2018 were analysed; comparisons were made by ethnicity and socio-economic status (SES) using published 'prioritised-ethnicity' health data and the NZ index of deprivation, respectively. The Cox proportional-hazards model was used to assess time to enteral autonomy. RESULTS Of the 208 patients (55.77% male, 43.75% preterm), 170 (81.73%) achieved enteral autonomy and 14 (6.73%) remained PN dependent. Pacific and Māori children accounted for 12.98% and 27.88% of the patient cohort, respectively, compared to 9.46% and 25.65% of the NZ paediatric population. More significantly, IF patients with a high NZ socio-economic deprivation score were overrepresented, with 35.92% in the highest deprivation quintile and 10.19% in the least deprived quintile, compared to 23.53% and 20.31%, respectively, of the NZ paediatric population. There were no significant differences in primary clinical outcomes for any patients based on ethnicity or SES. CONCLUSION While disparities in ethnicity and social deprivation do exist in the incidence of IF in NZ children, clinical outcomes are similar for children regardless of ethnicity or SES. NZ-NIFRS has achieved one of its core objectives: to achieve health equity for all patients with IF nationwide.
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Affiliation(s)
- Amy Andrews
- New Zealand National Intestinal Failure & Rehabilitation Service (NZ-NIFRS), Auckland, New Zealand
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand
| | - Cate Fraser-Irwin
- New Zealand National Intestinal Failure & Rehabilitation Service (NZ-NIFRS), Auckland, New Zealand
| | - Kim Herbison
- New Zealand National Intestinal Failure & Rehabilitation Service (NZ-NIFRS), Auckland, New Zealand
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand
| | - Dug Y Han
- Clinical Research Office, Te Toka Tumai - Auckland, Auckland, New Zealand
| | - Helen M Evans
- New Zealand National Intestinal Failure & Rehabilitation Service (NZ-NIFRS), Auckland, New Zealand
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
| | - Amin J Roberts
- New Zealand National Intestinal Failure & Rehabilitation Service (NZ-NIFRS), Auckland, New Zealand
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
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8
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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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10
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Gutierrez SA, Pathak S, Raghu V, Shui A, Huang CY, Rhee S, McKenzie-Sampson S, Lai JC, Wadhwani SI. Neighborhood Income Is Associated with Health Care Use in Pediatric Short Bowel Syndrome. J Pediatr 2024; 265:113819. [PMID: 37940084 PMCID: PMC10847979 DOI: 10.1016/j.jpeds.2023.113819] [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: 07/25/2023] [Revised: 09/27/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE To evaluate associations between neighborhood income and burden of hospitalizations for children with short bowel syndrome (SBS). STUDY DESIGN We used the Pediatric Health Information System (PHIS) database to evaluate associations between neighborhood income and hospital readmissions, readmissions for central line-associated bloodstream infections (CLABSI), and hospital length of stay (LOS) for patients <18 years with SBS hospitalized between January 1, 2006, and October 1, 2015. We analyzed readmissions with recurrent event analysis and analyzed LOS with linear mixed effects modeling. We used a conceptual model to guide our multivariable analyses, adjusting for race, ethnicity, and insurance status. RESULTS We included 4289 children with 16 347 hospitalizations from 43 institutions. Fifty-seven percent of the children were male, 21% were Black, 19% were Hispanic, and 67% had public insurance. In univariable analysis, children from low-income neighborhoods had a 38% increased risk for all-cause hospitalizations (rate ratio [RR] 1.38, 95% CI 1.10-1.72, P = .01), an 83% increased risk for CLABSI hospitalizations (RR 1.83, 95% CI 1.37-2.44, P < .001), and increased hospital LOS (β 0.15, 95% CI 0.01-0.29, P = .04). In multivariable analysis, the association between low-income neighborhoods and elevated risk for CLABSI hospitalizations persisted (RR 1.70, 95% CI 1.23-2.35, P < .01, respectively). CONCLUSIONS Children with SBS from low-income neighborhoods are at increased risk for hospitalizations due to CLABSI. Examination of specific household- and neighborhood-level factors contributing to this disparity may inform equity-based interventions.
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Affiliation(s)
- Susan A Gutierrez
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Sagar Pathak
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Vikram Raghu
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Amy Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Sue Rhee
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Safyer McKenzie-Sampson
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA.
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11
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Patel AD, Casini G, Hagan JL, Debuyserie A, Vogel AM, Gollins L, Hair AB, Fernandes CJ, Premkumar MH. Factors associated with enteral autonomy after reanastomosis in infants with intestinal failure and ostomy: A descriptive cohort study. JPEN J Parenter Enteral Nutr 2024; 48:74-81. [PMID: 37872873 DOI: 10.1002/jpen.2570] [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: 06/24/2023] [Revised: 10/04/2023] [Accepted: 10/18/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND To determine variables associated with outcomes in infants with intestinal failure (IF) and ostomy following reanastomosis (RA). METHODS A single-center, descriptive cohort study of 120 infants with IF and a stoma from January 2011 to December 2020 with subsequent RA during initial hospitalization. The primary outcome was achievement of enteral autonomy (EA) following RA. Other outcomes were duration of hospital stay, and mortality. Penalized logistic regression and linear regression were used for data analysis. RESULTS The median gestational age was 26 weeks, and the median birth weight was 890 g. Three infants died. The median duration between ostomy creation and RA was 80 days (interquartile range; 62.5, 100.5). For each additional day of discontinuity, the odds of EA decreased by 2% (odds ratio [OR] = 0.980; 95% confidence interval [CI]: 0.962, 0.999; P = 0.038), and death increased by 4.2% (OR = 1.042; 95% CI: 1.010, 1.075; P = 0.009). For each additional mL/kg/day of enteral feeds at RA, the odds of EA increased by 7.5% (OR = 1.075; 95% CI: 1.027, 1.126, P = 0.002) and duration of hospital stay decreased by 0.35 days (slope coefficient = -0.351; 95% CI: -0.540, -0.163; P < 0.001). CONCLUSION Shorter duration of intestinal discontinuity and enteral nutrition before RA could positively influence EA and duration of stay in infants with IF and ostomy following RA.
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Affiliation(s)
- Arjun D Patel
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Gina Casini
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph L Hagan
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Anne Debuyserie
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Adam M Vogel
- Departments of Surgery and Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Laura Gollins
- Division of Neonatology, Texas Children's Hospital, Houston, Texas, USA
| | - Amy B Hair
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Muralidhar H Premkumar
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
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12
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Gattini D, Yan H, Belza C, Avitzur Y, Wales PW. Cost-utility analysis of 4% tetrasodium ethylenediaminetetraacetic acid, taurolidine, and heparin lock to prevent central line-associated bloodstream infections in children with intestinal failure. JPEN J Parenter Enteral Nutr 2024; 48:47-56. [PMID: 37465871 DOI: 10.1002/jpen.2551] [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: 11/04/2022] [Revised: 07/17/2023] [Accepted: 07/17/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSI) are a serious complication in children with intestinal failure. This study assessed the incremental costs of 4% tetrasodium ethylenediaminetetraacetic acid (EDTA) compared with taurolidine lock and heparin lock per quality-adjusted life-year (QALY) gained in children with intestinal failure from the healthcare payer and societal perspective. METHODS A Markov cohort model of a 1-year-old child with intestinal failure was simulated until the age of 17 years (time horizon), with a cycle length of 1 month. The health outcome measure was QALYs, with results expressed in terms of incremental costs and QALYs. Model parameters were obtained from published literature and institutional data. Deterministic, probabilistic, and scenario sensitivity analyses were performed. RESULTS 4% Tetrasodium EDTA was dominant (more effective and less expensive) compared with taurolidine and heparin, yielding an additional 0.17 QALYs with savings of CAD$88,277 compared with heparin, and an additional 0.06 QALYs with savings of CAD$52,120 compared with taurolidine lock from the healthcare payer perspective. From the societal perspective, 4% tetrasodium EDTA resulted in savings of CAD$90,696 compared with heparin and savings of CAD$36,973 compared with taurolidine lock. CONCLUSIONS This model-based analysis indicates that 4% tetrasodium EDTA can be considered the optimal strategy compared with taurolidine and heparin in terms of cost-effectiveness. The decision uncertainty can be reduced by conducting further research on the model input parameters. An expected value of perfect information analysis can identify what model input parameters would be most valuable to focus on.
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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, Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Han Yan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, 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, Transplant and Regenerative Medicine Centre, Toronto, Ontario, 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, Transplant and Regenerative Medicine Centre, 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 Toronto, Cincinnati, Ohio, United States
- Cincinnati Center of Excellence for Intestinal Rehabilitation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
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13
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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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14
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Belza C, Courtney-Martin G, Wong-Sterling S, Garofalo E, Silva C, Yanchis D, Avitzur Y, Wales PW. Composite lipid emulsion use and essential fatty acid deficiency in pediatric patients with intestinal failure with high parenteral nutrition dependence: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:930-937. [PMID: 37392380 DOI: 10.1002/jpen.2544] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Reports of essential fatty acid deficiency (EFAD) in patients receiving parenteral nutrition (PN) and a composite lipid (mixed oil intravenous lipid emulsion [MO ILE]) are predominantly when managed by lipid restriction. The objective of this study was to determine the prevalence of EFAD in patients with intestinal failure (IF) who are PN dependent without lipid restriction. METHODS We retrospectively evaluated patients, ages 0-17 years, followed by our intestinal rehabilitation program between November 2020 and June 2021 with PN dependency index (PNDI) of >80% on a MO ILE. Demographic data, PN composition, PN days, growth, and plasma fatty acid profile were collected. A plasma triene-tetraene (T:T) ratio >0.2 indicated EFAD. Summary statistics and Wilcoxon rank sum test evaluated to compare between PNDI category and ILE administration (grams/kilograms/day). P < 0.05 was considered significant. RESULTS Twenty-six patients (median age, 4.1 years [interquartile range (IQR) = 2.4-9.6]) were included. The median duration of PN was 1367 days (IQR = 824-3195). Sixteen patients had a PNDI of 80%-120% (61.5%). Fat intake for the group was 1.7 g/kg/day (IQR = 1.3-2.0). The median T:T ratio was 0.1 (IQR = 0.1-0.2) with no values >0.2. Linoleic and arachidonic acid were low in 85% and 19% of patients, respectively; however, Mead acid was normal in all patients. CONCLUSION This report is the largest to date on the EFA status of patients with IF on PN. These results suggest that, in the absence of lipid restriction, EFAD is not a concern when using MO ILEs in children receiving PN for IF.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Glenda Courtney-Martin
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
| | - Sylvia Wong-Sterling
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Elizabeth Garofalo
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Carina Silva
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Dianna Yanchis
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Paul W Wales
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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15
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Schaefer JT, Schulz-Heise S, Rueckel A, Rauh M, Juengert J, Galiano M, Meier N, Woelfle J, Schiffer M, Hoerning A. Frequency and impact of enteric hyperoxaluria in pediatric short bowel syndrome: a retrospective single centre study. Front Pediatr 2023; 11:1157696. [PMID: 37502194 PMCID: PMC10369460 DOI: 10.3389/fped.2023.1157696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
Objectives The survival of pediatric patients with short bowel syndrome has improved in recent years. Enteric hyperoxaluria as a pathophysiological consequence has been hardly addressed so far. It can be associated with nephrolithiasis, nephrocalcinosis or even renal insufficiency. We assessed the prevalence of hyperoxaluria and its pathogenic consequences in a retrospective single centre study over the last 12 years. Methods We conducted an internal database search for all pediatric patients suffering from short bowel syndrome treated from 2010 to 2022 in the department of pediatric gastroenterology as well as the pediatric nephrology and dialysis unit. Out of 56 patients identified, 26 patients were analysed for etiology of short bowel syndrome, renal excretion of oxalate (24/26), remaining short bowel and large intestinal length as well as further clinical parameters such as eGFR, nephrocalcinosis/urinary stone formation or stool frequency. Results Hyperoxaluria was detected in 14/26 patients (54%). Nephrocalcinosis was present in four patients. Out of these four patients, hyperoxaluria could be proven (21% of all hyperoxaluric patients) in three cases, one hyperoxaluric patient had nephrolithiasis (7%). In one patient hyperoxaluria lead to end stage renal disease. We found that 80% of patients with volvulus developed enteric hyperoxaluria. None of the investigated factors had an effect on oxalate excretion. Conclusion Enteric hyperoxaluria is a relevant pathophysiological finding in patients with short bowel syndrome occurring in about 50% of our cohort with multiple pathogenic complications. Regular screening for hyperoxaluria may be implemented in medical care for patients with short bowel syndrome. If necessary, prophylaxis, e.g., dietary advice or metaphylaxis should be initiated.
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Affiliation(s)
- Jan Thomas Schaefer
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, Erlangen, Germany
- Research Center on Rare Kidney Diseases (RECORD), University Hospital Erlangen, Erlangen, Germany
| | - Susanne Schulz-Heise
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Aline Rueckel
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Manfred Rauh
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Joerg Juengert
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Matthias Galiano
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Norbert Meier
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Joachim Woelfle
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Mario Schiffer
- Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - André Hoerning
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-University (FAU) Erlangen-Nürnberg, Erlangen, Germany
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16
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Mutanen A, Engstrand Lilja H, Wester T, Norrby H, Borg H, Persson S, Bjornland K, Brun AC, Telborn L, Stenström P, Pakarinen MP. A nordic multicenter study on contemporary outcomes of pediatric short bowel syndrome in 208 patients. Clin Nutr 2023; 42:1095-1103. [PMID: 37270343 DOI: 10.1016/j.clnu.2023.05.017] [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: 03/14/2023] [Revised: 05/05/2023] [Accepted: 05/21/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND & AIMS Despite advances in the management of short bowel syndrome related intestinal failure (SBS-IF), large-scale contemporary pediatric studies are scarce. The aim of this multicenter study was to assess key outcomes and clinical prognostic factors in a recent Nordic pediatric SBS-IF population. METHODS Patients with SBS-IF treated during 2010-2019, whose parenteral support (PS) started at age <1 year and continued >60 consecutive days were included and retrospectively reviewed. All six participating centers followed multidisciplinary SBS-IF management. Risk factors for PS dependency, intestinal failure associated liver disease (IFALD) and mortality were assessed with Cox regression and Kaplan Meier analyses. IFALD was defined with serum liver biochemistry levels. RESULTS Among 208 patients, SBS-IF resulted from NEC in 49%, gastroschisis w/wo atresia in 14%, small bowel atresia in 12%, volvulus in 11%, and other diagnoses in 14%. Median age-adjusted small bowel length was 43% (IQR 21-80%). After median follow up of 4.4 years (IQR 2.5-6.9), enteral autonomy was reached by 76%, none had undergone intestinal transplantation, and overall survival was 96%. Half of deaths (4/8) were caused by septic complications. Although biochemical cholestasis occurred only in 3% at latest follow-up and none of deaths were directly caused by IFALD, elevated liver biochemistry (HR 0.136; P = 0.017) and shorter remaining small bowel (HR 0.941; P = 0.040) predicted mortality. Shorter remaining small bowel and colon, and presence of end-ostomy were the main predictors of PS dependency, but not IFALD. Patients with NEC reached enteral autonomy more efficiently and had decreased incidence of IFALD compared to other etiologies. CONCLUSIONS Although with current multidisciplinary management, prognosis of pediatric SBS is encouraging, septic complications and IFALD still associated with the remaining low mortality rate.
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Affiliation(s)
- Annika Mutanen
- Department of Pediatric Surgery, The New Children's Hospital, University of Helsinki, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland.
| | - Helene Engstrand Lilja
- Department of Pediatric Surgery, University Children's Hospital, Uppsala University, Uppsala, Sweden
| | - Tomas Wester
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karoliska Institutet, Stockholm, Sweden
| | - Heimir Norrby
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Borg
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Sara Persson
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Kristin Bjornland
- Department of Pediatric Surgery, Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | - Lovisa Telborn
- Department of Pediatric Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Pernilla Stenström
- Department of Pediatric Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, The New Children's Hospital, University of Helsinki, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland; Department of Women's and Children's Health, Karoliska Institutet, Stockholm, Sweden
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17
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Belza C, Wales PW. Intestinal failure among adults and children: Similarities and differences. Nutr Clin Pract 2023; 38 Suppl 1:S98-S113. [PMID: 37115028 DOI: 10.1002/ncp.10987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 04/29/2023] Open
Abstract
Intestinal failure (IF) is a complex medical condition that is caused by a constellation of disorders, resulting in the gut's inability to adequately absorb fluids and nutrients to sustain hydration, growth, and survival, thereby requiring the use of parenteral fluid and/or nutrition. Significant advancements in intestinal rehabilitation have resulted in improved survival rates for individuals with IF. There are distinct differences, however, related to etiology, adaptive potential and complications, and medical and surgical management when comparing children with adults. The purpose of this review is to contrast the similarities and differences between these two distinct groups and provide insight for future directions, as a growing population of pediatric patients will cross into the adult world for IF management.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
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18
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Gigola F, Coletta R, Certini M, Del Riccio M, Forsythe L, Morabito A. Combined procedures for surgical short bowel syndrome: experience from two European centres. ANZ J Surg 2023; 93:1012-1016. [PMID: 36514884 DOI: 10.1111/ans.18184] [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: 04/08/2022] [Revised: 11/14/2022] [Accepted: 11/20/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Autologous gastrointestinal reconstructive surgery (AGIR) has become a key component of intestinal rehabilitation programs. However, the best surgical option for short bowel syndrome (SBS) remains unknown. This paper presents our experience using combined procedures as primary treatment. METHODS We collected data on SBS patients who underwent surgery from 2008 to 2021 in two tertiary European Centres. Combined procedures were defined as more than one technique used on the same patient. Charts were reviewed for demographics, type of procedures, complications, and outcomes. Data are presented as median and IQR. Wilcoxon signed rank was used for all paired analyses. RESULTS Twenty-one children (12 females) underwent combined procedures. Preoperative median small bowel length was 20 cm (IQR: 15-35 cm); after lengthening, it was 35.5 cm (IQR: 30.75-50.50 cm) (P < 0.001). Combined procedures were simultaneous in 15 patients and sequential in 6. At a median of 9.2 years (IQR: 7.55-9.78 years) follow-up, complications were three bowel obstructions after strictures of anastomosis and two wound infections. Two patients achieved enteral autonomy, and others followed a weaning home parenteral nutrition regimen with a median of 4 nights off (IQR: 3-4 nights) starting with a median of 7 nights (IQR: 7-7 nights). CONCLUSIONS Combined AGIR techniques are practical and safe in SBS treatment when tailored to meet patients' needs, combining lengthening, tailoring, and reducing transit time procedures. Therefore, combined AGIR may be considered a resource in intestinal rehabilitation units' armamentarium.
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Affiliation(s)
- Francesca Gigola
- Department of Neurosciences, Psychology Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Riccardo Coletta
- Department of Neurosciences, Psychology Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- School of Health and Society, University of Salford, Salford, UK
| | - Martina Certini
- Department of Neurosciences, Psychology Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Marco Del Riccio
- Department of Health Sciences, University of Florence, Postgraduate School in Hygiene and Preventive Medicine, Florence, Italy
| | - Lynette Forsythe
- Department of Dietetics and Nutrition, Royal Manchester Children's Hospital, Manchester, UK
| | - Antonino Morabito
- Department of Neurosciences, Psychology Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- School of Health and Society, University of Salford, Salford, UK
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Demirok A, Nagelkerke SCJ, Benninga MA, Köglmeier J, Mutanen A, Arnell H, Felcht J, Guimber D, Wahlstedt C, Avitzur Y, Lambe C, Tabbers MM. Development of a core outcome set for pediatric chronic intestinal failure. JPEN J Parenter Enteral Nutr 2023; 47:364-371. [PMID: 36546585 DOI: 10.1002/jpen.2468] [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: 10/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND In research on pediatric chronic intestinal failure, heterogeneity in reported definitions and outcomes exists. This leads to a risk of reporting bias and impossibility of evidence synthesis. Also, reported outcomes should be relevant to both healthcare providers and patients and their parents. Therefore, the aim of this study is to create a core outcome set (COS) to be used in studies on pediatric chronic intestinal failure. METHODS Candidate outcomes were selected from a recent systematic review. A three-round Delphi study among key stakeholders and a consensus meeting with an expert panel were undertaken to achieve consensus on the COS. RESULTS Seventy-two stakeholders (79%) completed all three rounds of the Delphi process. Ninety-eight outcomes were assessed, and five new outcomes were added after the first round. Ten outcomes were included in the final COS: weaning from parenteral nutrition, growth, mortality, central line-related infection, central line longevity, sepsis not related to central line infection, central line-related thrombosis, intestinal failure-associated liver disease, (serious) adverse events, and health-related quality of life. CONCLUSION This pediatric chronic intestinal failure COS consists of 10 outcomes important for all key stakeholders. Usage of this set in future research should minimize outcome heterogeneity and enhance the value of evidence synthesis. This will lead to better management in this field of rare gastrointestinal conditions.
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Affiliation(s)
- Aysenur Demirok
- Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center University of Amsterdam, Amsterdam, the Netherlands
| | - Sjoerd C J Nagelkerke
- Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center University of Amsterdam, Amsterdam, the Netherlands
| | - Marc A Benninga
- Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center University of Amsterdam, Amsterdam, the Netherlands
| | - Jutta Köglmeier
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Annika Mutanen
- Department of Pediatric Surgery, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Henrik Arnell
- Pediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital and Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Judith Felcht
- Pediatric Surgery, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Dominique Guimber
- Pediatric Gastroenterology, Hepatology and Nutrition, Jeanne de Flandre Hospital, Lille University Hospital, Lille, France
| | - Christina Wahlstedt
- Pediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital and Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cécile Lambe
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, Hôpital Necker-Enfants Malades, Université Paris Cité, Paris, France
| | - Merit M Tabbers
- Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center University of Amsterdam, Amsterdam, the Netherlands
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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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Eshel Fuhrer A, Sukhotnik S, Moran-Lev H, Kremer K, Ben-Shahar Y, Sukhotnik I. Motility disorders in children with intestinal failure: a national tertiary referral center experience. Pediatr Surg Int 2022; 38:1737-1743. [PMID: 36114865 DOI: 10.1007/s00383-022-05223-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Intestinal dysmotility (ID) problems are common in patients with pediatric-onset intestinal failure (IF) and short bowel syndrome (SBS), leading to significant morbidity and delays in the advancement of enteral nutrition (EN). We aimed to investigate the clinical features and complications of ID in children with IF and SBS. METHODS Retrospective chart review of all children with IF and/or SBS who required parenteral nutrition (PN) > 6 weeks or small-intestinal resection ≥ 50%. Patients were divided into SBS and non-SBS groups. SBS group was divided into two subgroups: with and without ID. Patients with ID were identified (clinically, radiologically and functionally) and analyzed with regard to demographics, intestinal anatomy, complications and outcomes (short and long term). RESULTS A total of 42 children with IF were treated in our institution during 2003-2022. In non-SBS group (n = 10), ID was the most common cause of IF (80%). SBS-group included 32 children; 18 children (56%) developed ID. The clinical profile of SBS-ID patients (vs SBS) was: female gender (56%), remaining small bowel length ≤ 55 cm, estimated residual small bowel ≤ 28% (p = 0.045) and absence of ICV (56%). Common symptoms of the SBS-ID group were: food intolerance (61%), abdominal distension (50%), vomiting (44%), malabsorption and severe constipation. Complications included FTT (67%) (p = 0.003), bacterial overgrowth with subsequent bloodstream infection (33%) (p = 0.75), and lactic acidosis (11%). Lengthening procedure (STEP) was performed in 11 SBS-ID patients (61%) (p = 0.002). In all patients, STEP operation "rescued" their dysfunctional intestine. Eight of these patients (73%) were weaned from TPN. Survival rate was 100%; however, one SBS-ID patient is a candidate for combined intestinal and liver transplantation. CONCLUSIONS ID is the most common complication of SBS and is the most common cause of IF in non-SBS patients. ID has a high morbidity rate and various clinical manifestations. Successful treatment of these infants may be achieved with the use of tapering enteroplasty.
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Affiliation(s)
- Audelia Eshel Fuhrer
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Stephanie Sukhotnik
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Hadar Moran-Lev
- Department of Pediatric Gastroenterology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Department of Pediatrics, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Keren Kremer
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yoav Ben-Shahar
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Igor Sukhotnik
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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22
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Predictors of Social-Emotional Development and Adaptive Functioning in School-Age Children with Intestinal Failure. J Clin Psychol Med Settings 2022:10.1007/s10880-022-09919-z. [PMID: 36371790 DOI: 10.1007/s10880-022-09919-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Despite a focus on neurocognition in pediatric intestinal failure (IF) to date, we examined social-emotional and adaptive functioning. METHODS Children (N = 63) in our IF rehabilitation program underwent neuropsychological assessments including caregiver- and teacher-reported questionnaires. Results were compared to norms using z-tests. Caregiver and teacher reports were compared using t tests. Medical and demographic factors were examined in an exploratory manner using correlation and targeted regression analyses, adjusting for gestational age and full-scale IQ. RESULTS Caregiver and teacher reports indicated poorer executive, internalizing, behavioral, and adaptive functioning compared to norms. Teachers reported more executive dysfunctions than caregivers. Necrotizing enterocolitis diagnosis predicted internalizing emotional problems. Immigrant status predicted poorer social and practical adaptive functioning. Living with biological parents predicted fewer externalizing emotional and behavioral problems. CONCLUSIONS The group displayed social-emotional and adaptive functioning concerns. Identifying medical and demographic risks can allow for screening and intervention.
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23
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Muscle Strength, Agility, and Body Composition in Children With Intestinal Failure on Parenteral Nutrition. J Pediatr Gastroenterol Nutr 2022; 75:438-443. [PMID: 35830733 DOI: 10.1097/mpg.0000000000003553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES With increasing number of children with intestinal failure (IF) on long-term parenteral nutrition (PN), this study assesses the impact of IF on muscle strength, speed, and agility and body composition (BC), identifying clinical factors that may predict impairment. METHODS Cross-sectional study in children 5-18 years with IF on PN. Assessments included Bruininks-Oseretsky Test of Motor Proficiency-2 strength and agility subtest (BOT-2), and grip strength. BC data from dual-energy x-ray absorptiometry (DXA) measurements and clinical variables were collected by chart abstraction. Data were compared to age and sex matched controls and population norms. RESULTS Twenty-one children with IF (14 males), median age 8.33 (IQR: 6.96-11.04) years and 33 controls (20 males), 8.25 (6.67-10.79) years were included. Strength and agility ( P < 0.001) and grip strength ( P = 0.001) differed between groups. Nine of 21 (43%) of children with IF scored >1 standard deviation (SD) below mean on BOT-2 and 13 of 21 (62%) had grip strength >1 SD below mean. DXA measurements showed 10 of 18 (56%) of children had lower fat-free mass (FFM)% and higher fat mass (FM)% than reference norms. Decreased FFM% was associated with lower BOT-2 scores ( r = 0.479; P = 0.044) and grip strength scores >1 SD below mean ( P = 0.047). Additional clinical factors significantly impacting strength and agility included prematurity, height, hospitalizations, sepsis, and small bowel length. CONCLUSIONS Children with IF are at risk of decreased muscle strength and agility, along with altered BC. Ongoing medical, nutritional, and rehabilitation intervention is vital to optimize outcomes.
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24
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Wendel D, Javid PJ. Medical and Surgical Aspects of Intestinal Failure in the Child. Surg Clin North Am 2022; 102:861-872. [DOI: 10.1016/j.suc.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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25
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Chen CB, Chugh S, Fujiki M, Radhakrishnan K. Overview of Physical, Neurocognitive, and Psychosocial Outcomes in Pediatric Intestinal Failure and Transplantation. Curr Gastroenterol Rep 2022; 24:145-155. [PMID: 36040624 DOI: 10.1007/s11894-022-00848-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Intestinal failure and transplantation may significantly impact physical, neurocognitive, and psychosocial development in pediatric patients. Currently, there is a paucity of literature on the effects of intestinal failure and transplantation on these aspects of development. This article will review the current literature and discuss the short and long-term impacts as well as interventions to improve clinical outcomes in children with intestinal failure or those undergoing transplantation. RECENT FINDINGS Psychological disorders, neurodevelopmental delay, and social maladaptation are frequently encountered in this patient population. While the main focus is often on medical management, equal emphasis should be placed on other aspects of development such as increasing social support and improving school performance. The transition to adulthood also presents many obstacles for patients and healthcare providers should anticipate challenges such as childbirth, employment, and raising a family. The pre-operative, perioperative, and post-operative periods all represent opportunities for medical intervention. Frequent monitoring of physical, psychosocial, and neurocognitive status helps to improve clinical outcomes and long-term quality of life. Future research should emphasize continued development of multidisciplinary programs and specialized services to help address the physical and psychosocial needs of children with intestinal failure as well as transplant recipients.
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Affiliation(s)
- Charles B Chen
- Department of Child Health, University of Missouri School of Medicine, 400 N. Keene St, 65201, Columbia, MO, USA.
| | - Shreeya Chugh
- Department of Child Health, University of Missouri School of Medicine, 400 N. Keene St, 65201, Columbia, MO, USA
| | - Masato Fujiki
- Center for Gut Rehabilitation and Transplantation, Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, 44195, Cleveland, OH, USA
| | - Kadakkal Radhakrishnan
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic Foundation, 9500 Euclid Ave, 44195, Cleveland, OH, USA
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26
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Gigola F, Cianci MC, Cirocchi R, Ranucci MC, Del Riccio M, Coletta R, Morabito A. Use of Teduglutide in Children With Intestinal Failure: A Systematic Review. Front Nutr 2022; 9:866518. [PMID: 35774551 PMCID: PMC9237607 DOI: 10.3389/fnut.2022.866518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/11/2022] [Indexed: 12/19/2022] Open
Abstract
Background and Objectives Short-bowel syndrome (SBS) results from the loss of a significant portion of the small intestine leading to a state of malabsorption. After an intestinal loss, there is a process of adaptation involving the Glucagon-Like Peptide-2 (GLP-2), an enteroendocrine peptide also involved in nutrient absorption. Teduglutide is a recombinant analog of GLP-2 approved in 2016 to treat selected SBS pediatric patients who are dependent on parenteral support. The present systematic review aims to evaluate the efficacy of Teduglutide in pediatric patients with SBS in reducing the need for parenteral nutrition (PN). Materials and Methods We performed a literature search on MEDLINE and Embase to include articles up to November 2021. We included articles that involved using Teduglutide in the SBS pediatric population to define its efficacy in reducing the need for PN. The key words used were GLP-2, teduglutide, child. Results Fourteen studies completely fulfilled the inclusion criteria. Two hundred 23 patients were treated with Teduglutide, and the median duration of treatment was 45 weeks (IQR: 36–52.5 weeks). One-hundred and fifty-two patients were treated with 0.05 mg/Kg/d of subcutaneous Teduglutide, 38 received 0.025 mg/Kg/d and 8 received either 0.125 mg/Kg/d or 0.20 mg/Kg/d. A total of 36 patients achieved enteral autonomy (EA) after a median of 24 weeks of treatment (IQR: 24–48 weeks) and 149 patients showed a reduction in PN needs in terms of volume, calories, or hours per day. Eleven studies reported complications: gastrointestinal were the most common, with 89 cases reported in treated patients and 11 in non-treated patients. Conclusion Teduglutide appears safe and effective in reducing PN requirements and improving EA in the pediatric population. However, more studies are needed to understand its efficacy in the long term and after discontinuation and possible complications. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022301593].
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Affiliation(s)
- Francesca Gigola
- Department of Pediatric Surgery, Meyer Children’s Hospital Academic Centre, Florence, Italy
| | - Maria Chiara Cianci
- Department of Pediatric Surgery, Meyer Children’s Hospital Academic Centre, Florence, Italy
| | - Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Maria Chiara Ranucci
- Department of Digestive and Emergency Surgery, Santa Maria di Terni Hospital, University of Perugia, Perugia, Italy
| | - Marco Del Riccio
- Postgraduate School of Hygiene and Preventive Medicine, Florence, Italy
| | - Riccardo Coletta
- Department of Pediatric Surgery, Meyer Children’s Hospital Academic Centre, Florence, Italy
- School of Health and Society, University of Salford, Salford, United Kingdom
- *Correspondence: Riccardo Coletta,
| | - Antonino Morabito
- Department of Pediatric Surgery, Meyer Children’s Hospital Academic Centre, Florence, Italy
- Meyer Children’s Hospital, Department of Neurofarba, University of Florence, Florence, Italy
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27
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Abstract
Intestinal failure (IF) secondary to short bowel syndrome is a challenging and complex medical condition with significant risk for surgical and medical complications. Significant advancements in the care of this patient population have led to improved survival rates. Due to their intensive medical needs children with IF are at risk for long-term complications that require comprehensive management and close monitoring. The purpose of this paper is to review the available literature emphasizing the surgical aspects of care for children with IF secondary to short bowel syndrome. A key priority in the surgical care of this patient population includes strategies to preserve available bowel and maximize its function. Utilization of novel surgical techniques and autologous bowel reconstruction can have a significant impact on children with IF secondary to short bowel syndrome related to the function of their bowel and ability to achieve enteral autonomy. It is also important to understand the potential long-term complications to ensure strategies are put in place to mitigate risk with early detection to improve long-term outcomes.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, Cincinatti Children's Hospital Medical Center, University of Cincinnati, Cincinnatii, USA; Cincinnati Children's Intestinal Rehabilitation Program, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 2023, Cincinnati, Ohio 45229, USA.
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28
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Difficult Vascular Access in Children with Short Bowel Syndrome: What to Do Next? CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9050688. [PMID: 35626867 PMCID: PMC9139311 DOI: 10.3390/children9050688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/27/2022] [Accepted: 05/05/2022] [Indexed: 12/19/2022]
Abstract
Short Bowel Syndrome and intestinal failure are chronic and severe conditions that may require life-long parenteral nutrition in children. Survival of these children rely on the correct functioning of central venous catheters; therefore, careful management, prevention, and treatment of complications is of paramount importance. Despite a growing awareness of preserving the vascular real estate, a certain number of patients still experience a progressive and life-threatening exhaustion of vascular access. We searched the literature to highlight the current management of children with vascular exhaustion, specifically focusing on vascular access salvage strategies and last-resource alternative routes to central veins. Given the paucity of data, results are reported in the form of a narrative review.
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29
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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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30
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Gondolesi GE, Ortega M, Martinez MI, Rumbo C, Solar H. Autologous gastrointestinal reconstruction surgery for short bowel syndrome: the cornerstone for intestinal rehabilitation. Curr Opin Organ Transplant 2022; 27:148-153. [PMID: 35153280 DOI: 10.1097/mot.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Intestinal failure (IF) evolved from being the last recognized organ failure, to become one of the most progressive fields in terms of therapeutic alternatives and results. Short bowel syndrome (SBS) is the main cause of IF in adults and children. The use of surgery allowed patients with unfavorable anatomy type and length to be wean off parenteral nutrition. We aim to evaluate its current impact on intestinal rehabilitation. RECENT FINDINGS Autologous gastro-intestinal reconstructive surgery (AGIRS), including bowel lengthening contributes by converting patient's anatomy to a more favorable one, improving quality of life, and modifying the natural history of the disease, allowing to recover intestinal autonomy in approximately 70% of the adults and 50% of the children's with SBS-IF. The current use of postsurgical medical rehabilitation strategies including the use of enterohormones complement the path to sufficiency, increasing the chances of success in both age group of patients. SUMMARY The development of AGIRS has changed the outcome of SBS-IF patients, becoming the main surgical procedure prescribed in multidisciplinary units, allowing to enhance the number of patients achieving intestinal autonomy throughout rehabilitation, leaving transplantation as the last surgical alternative.
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Affiliation(s)
- Gabriel E Gondolesi
- Servicio de Cirugía General
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Mariana Ortega
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Maria I Martinez
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Carolina Rumbo
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Héctor Solar
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
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