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Metabolic Bone Disease in Children with Intestinal Failure and Long-Term Parenteral Nutrition: A Systematic Review. Nutrients 2022; 14:nu14050995. [PMID: 35267970 PMCID: PMC8912854 DOI: 10.3390/nu14050995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/20/2022] [Accepted: 02/24/2022] [Indexed: 12/01/2022] Open
Abstract
Metabolic bone disease (MBD) is a possible complication of intestinal failure (IF), with a multi-factorial pathogenesis. The reduction of bone density (BMD) may be radiologically evident before manifestation of clinical signs (bone pain, vertebral compression, and fractures). Diagnosis relies on dual-energy X-ray absorptiometry (DXA). Incidence and evolution of MBD are not homogeneously reported in children. The aim of this systematic review was to define the prevalence of MBD in IF children and to describe risk factors for its development. A comprehensive search of electronic bibliographic databases up to December 2021 was conducted. Randomized controlled trials; observational, cross-sectional, and retrospective studies; and case series published between 1970 and 2021 were included. Twenty observational studies (six case-control) were identified and mostly reported definitions of MBD based on DXA parameters. Although the prevalence and definition of MBD was largely heterogeneous, low BMD was found in up to 45% of IF children and correlated with age, growth failure, and specific IF etiologies. Data demonstrate that long-term follow-up with repeated DXA and calcium balance assessment is warranted in IF children even when PN dependence is resolved. Etiology and outcomes of MBD will be better defined by longitudinal prospective studies focused on prognosis and therapeutic perspectives.
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Wassef J, Lipkin E, Hardigan P, Duro D. Trends in liver profile and nutrition outcomes in children undergoing intestinal rehabilitation using a mixed lipid injectable emulsion. Nutr Clin Pract 2021; 37:1180-1189. [PMID: 34618376 DOI: 10.1002/ncp.10782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Pediatric patients undergoing intestinal rehabilitation (IR) using parenteral nutrition (PN) are at higher risk for intestinal failure-associated liver disease (IFALD). Nutrition support, growth, and liver enzymes must be closely monitored while incorporating hepatoprotective lipid injectable emulsions for optimal patient outcomes. OBJECTIVE Describe trends of liver profile and nutrition outcomes for pediatric patients undergoing IR using SMOFlipid[SO,MCT,OO,FO-ILE]). METHODS After IRB approval, patients undergoing IR using SO,MCT,OO,FO-ILE were observed prospectively from January 1, 2017, through December 1, 2019. The following values were documented monthly: aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (TB), triene/tetraene ratio (TTR), micronutrient and trace element levels, z-scores for growth, and nutrition support regimen. Values were compared. RESULTS The group involved 16 pediatric patients for an average of 16.4 months on SO,MCT,OO,FO-ILE. By the end of the study, mean PN hours per day decreased by 34.7%, P < 0.0001. Mean PN calories per kilogram decreased from 60.4 to 48.3, P = 0.004. SO,MCT,OO,FO-ILE calories met the recommended dietary intake goal of 30% at the average 1.6 g/kg. Growth z-scores increased in those <2 YOA , although the body mass index decreased in our >2 YOA cohort. Total nutrition received from PN decreased to 62%: a 32% change, P = 0.001. There were no statistically significant changes in AST or ALT. TB decreased by 67.08%, P <0.05. No essential fatty acid deficiency was reported (TTR < 0.02). There were no changes in micronutrient and trace element deficiencies. There was zero new incidences of IFALD. CONCLUSIONS SO,MCT,OO,FO-ILE may be used long term in pediatric patients while promoting growth and development.
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Affiliation(s)
- Jessica Wassef
- Salah Foundation Children's Hospital at Broward Health Medical Center, Fort Lauderdale, Florida, USA.,Hackensack Meridian Health at Palisades Medical Center, North Bergen, New Jersey, USA
| | - Elizabeth Lipkin
- Salah Foundation Children's Hospital at Broward Health Medical Center, Fort Lauderdale, Florida, USA
| | - Patrick Hardigan
- Kiran C. Patel College of Allopathic Medicine at Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Debora Duro
- Salah Foundation Children's Hospital at Broward Health Medical Center, Fort Lauderdale, Florida, USA
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Goulet O, Breton A, Coste ME, Dubern B, Ecochard-Dugelay E, Guimber D, Loras-Duclaux I, Abi Nader E, Marinier E, Peretti N, Lambe C. Pediatric Home Parenteral Nutrition in France: A six years national survey. Clin Nutr 2021; 40:5278-5287. [PMID: 34534896 DOI: 10.1016/j.clnu.2021.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/31/2021] [Accepted: 08/05/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Home Parenteral Nutrition (HPN) is the cornerstone management for children suffering from chronic intestinal failure (CIF). In France, HPN is organized from a network of 7 certified centers located in University Hospitals spread across the national territory. This study aims to review the data involving children on HPN over a 6-years period in France to outline the global and continuous improvement in care. PATIENTS AND METHODS This cross-sectional study included all children enrolled in any of the 7 French HPN certified centers from January 1st, 2014 to December 31st, 2019. Data was recorded from annual databases provided by each center regarding: age at inclusion, indication and duration of HPN, type of intravenous lipid emulsion (ILE), outcome [PN weaning off, transfer to adult center, death, intestinal transplantation (ITx)], rate of catheter-related bloodstream infections (CRSBIs) for 1000 days of HPN, Taurolidine lock procedure (TLP) use and prevalence of cholestasis defined as conjugated bilirubin ≥20 μmol/l. RESULTS The number of patients increased by 43.6% from 268 in 2014 to 385 in 2019. According to the year of follow up, the indications for HPN were short bowel syndrome (SBS) (42.3-46.6%), congenital enteropathies (CE) (18.5-22.8%), chronic intestinal pseudo-obstruction syndrome (CIPOS) (13.0-16.3%), long segment Hirschsprung's disease (LSHD) (9.7-13.3%), Crohn's disease (CD) (1.6-2.6%) and other non-primary digestive diseases (NPDD) such as immune deficiency, cancer or metabolic disease (4.0-9.2%). The median age at discharge on HPN decreased from 11.7 months in 2014 to 8.3 months in 2019 (p < .001). By December 31st, 2019, 44.8% of children had left the HPN program after a median duration ranging between 39.9 and 66.4 months. Among these patients, 192 (74.2%) were weaned off PN (94.7% SBS), 41 (15.8%) were transferred to adult centers for CIPOS (42%), SBS (31%) or CE (27%), 21 died (8.1%) - mostly in relation to cancer or immune deficiency - and 5 were transplanted (1.9%): 4 underwent combined liver-intestine transplantation for LSHD (n = 2), SBS, CE and one multivisceral Tx for CIPOS. The use of a composite fish-oil based ILE increased from 67.4% in 2014 to 88.3% in 2019 (p < 0.001). CRBSIs dropped from 1.04 CRSBIs per 1000 days HPN in 2014 to 0.61 in 2019 (p < 0.001) while meantime, the percentage of children receiving TLP increased from 29.4% to 63.0% (p < 0.001). The prevalence of cholestasis (conjugated bilirubin ≥ 20 μmol/l) was low and stable between 4.1 and 5.9% of children during the study period. CONCLUSION In France, the number of children enrolled in a HPN program continuously increased over a 6 years period. SBS is the leading cause of CIF requiring HPN. The rate of CRBSIs dropped dramatically as the use of TLP increased. Mortality rate was low and mainly in relation to the underlying disease (cancer, immune deficiency). Cholestasis and intestinal Tx remained very rare.
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Affiliation(s)
- Olivier Goulet
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades University of Paris-UFR Paris Descartes, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children, Paris, France
| | - Anne Breton
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Purpan University Hospital, Certified Center for Home Parenteral Nutrition, Toulouse, France
| | - Marie-Edith Coste
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, La Timone University Hospital, Certified Center for Home Parenteral Nutrition, Marseille, France
| | - Béatrice Dubern
- Division of Pediatric Nutrition and Gastroenterology, Armand Trousseau University Hospital, Certified Center for Home Parenteral Nutrition, Sorbonne University, Paris, France
| | - Emmanuelle Ecochard-Dugelay
- Division of Pediatric Gastroenterology and Nutrition, Robert Debré University Hospital, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children Paris, France
| | - Dominique Guimber
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Jeanne de Flandre University Hospital, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children, Lille, France
| | - Irène Loras-Duclaux
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric University Hospital, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children, Lyon, France
| | - Elie Abi Nader
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades University of Paris-UFR Paris Descartes, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children, Paris, France
| | - Evelyne Marinier
- Division of Pediatric Gastroenterology and Nutrition, Robert Debré University Hospital, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children Paris, France
| | - Noel Peretti
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric University Hospital, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children, Lyon, France
| | - Cecile Lambe
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades University of Paris-UFR Paris Descartes, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children, Paris, France.
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Neelis EG, de Koning BAE, Hulst JM, Papadopoulou R, Kerbiriou C, Rings EHHM, Wijnen RMH, Nichols B, Gerasimidis K. Gut microbiota and its diet-related activity in children with intestinal failure receiving long-term parenteral nutrition. JPEN J Parenter Enteral Nutr 2021; 46:693-708. [PMID: 33982321 PMCID: PMC9255855 DOI: 10.1002/jpen.2188] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background This study characterized gut microbiota and its diet‐related activity in children with intestinal failure (IF) receiving parenteral nutrition (PN) compared with those of healthy controls (HC) and in relation to disease characteristics. Methods The fecal microbiota and short‐chain fatty acids (SCFAs) were measured in 15 IF patients (n = 68) and 25 HC (n = 25). Results Patients with IF had a lower bacterial load (P = .003), diversity (P < .001), evenness (P < .001) and richness (P = 0.006) than HC. Patients with surgical IF had lower diversity (P < .039) than those with functional IF. Propionic acid and butyric acid (p < .001) were lower and d‐lactate and l‐lactate were higher (p < 0.001) in IF patients than in HC. The energy supplied by PN (%PN) was negatively associated with microbiota diversity and SCFA profile. IF patients had more Escherichia‐Shigella (P = .006), Cronobacter (P = .001), and Staphylococcus (Operational Taxonomic Unit 14, P < .001) and less Faecalibacterium (P < 0.001) and Ruminococcus 1 and 2 (P < .001). Duration of PN (P = .005), %PN (P = .005), and fiber intake (P = .011) were predictive of microbiota structure. Higher intake of enteral nutrition was associated with microbiota structure and function closer to those of HC. Conclusions Microbiota composition and its diet‐related function are altered in IF, with depletion of beneficial SCFAs and species and supraphysiological increase of potentially harmful pathobionts. The influence of this compositional and functional microbial dysbiosis on patients’ outcomes and management warrants further exploration.
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Affiliation(s)
- Esther G Neelis
- Department of Pediatric Gastroenterology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Barbara A E de Koning
- Department of Pediatric Gastroenterology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jessie M Hulst
- Department of Pediatric Gastroenterology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rodanthi Papadopoulou
- Human Nutrition, School of Medicine, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Caroline Kerbiriou
- Human Nutrition, School of Medicine, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Edmond H H M Rings
- Department of Pediatric Gastroenterology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pediatric Gastroenterology, Leiden University Medical Center-Willem Alexander Children's Hospital, Leiden, The Netherlands
| | - René M H Wijnen
- Department of Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ben Nichols
- Department of Pediatric Gastroenterology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Konstantinos Gerasimidis
- Department of Pediatric Gastroenterology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
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Abi Nader E, Lambe C, Talbotec C, Acramel A, Pigneur B, Goulet O. Metabolic bone disease in children with intestinal failure is not associated with the level of parenteral nutrition dependency. Clin Nutr 2020; 40:1974-1982. [PMID: 32977995 DOI: 10.1016/j.clnu.2020.09.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND & AIMS Children on long-term home parenteral nutrition (HPN) are at increased risk of suboptimal growth and metabolic bone disease (MBD) i.e. decreased bone mineral density (BMD). The aims of this cross-sectional study were to assess growth and bone health in children on long term HPN and to identify risk factors for MBD. METHODS Children above the age of 5 years, stable on HPN for more than 2 years were included. Medical files were reviewed retrospectively and included demographics, gestational age, birth weight and height, indication for PN, age at PN start, duration of PN, number of weekly PN infusions, weight-for-age and height-for-age (SD), body mass index (BMI, kg/m2) as well as blood and urine analyses at the time of Dual X-ray absorptiometry (DXA) measurements. All BMD values were adjusted to statural age which corresponds to the 50th percentile of height. Growth failure (height-for-age ≤ -2SD) and MBD (at least one BMD measurement ≤ -2SD) were analyzed according to the indication of PN, duration of PN and PN dependency index (PNDI) by comparing means and performing logistic regression analysis. PNDI is the ratio of non-protein energy intake in HPN to resting energy expenditure using Schofield equations. RESULTS Forty children were assessed at 12.4 ± 4.5 years of age. Mean age at PN start was 1.1 ± 3.6 y (median 0.5). The indications for PN were short bowel syndrome (SBS, n = 21), chronic intestinal pseudo-obstruction syndrome (CIPOS, n = 10) and congenital enteropathies (CE, n = 9). The mean number of PN perfusions was 6 ± 1/week. PNDI was 110 ± 30%. The mean serum level of 25-OHD3 was suboptimal at 26.5 ± 9.1 ng/mL (66.2 ± 22.8 nmol/L). The mean concentrations of calcium, phosphorus, and parathyroid hormone (PTH) were in the normal ranges. Eight children (20%) had PTH levels above normal with low 25-OHD3 levels. The mean weight-for-age and height-for-age Z-scores SDS were 0.4 ± 0.9 and -0.5 ± 1.1 respectively. The actual height was lower than genetic target height (p < 0.001). The BMD Z-scores, adjusted to the 50th percentile of height, of the spine, the left femur and the whole body were: -1.1 ± 1.7, -1.2 ± 1.5 and -1.5 ± 1.8 SDS respectively. Children with CE had significantly lower BMD values than those with SBS and CIPOS (p = 0.01). Only two children had bone fractures after a mild trauma (5%). CONCLUSIONS All children on long-term PN, are at risk of low BMD. High dependency on PN (PNDI>120%) and very long-term PN (>10 years) do not appear to increase the risk of growth failure nor MBD. PN-related bone fractures were rare. Close follow-up remains mandatory.
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Affiliation(s)
- Elie Abi Nader
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, National Reference Center for Rare Digestive Diseases, Necker Enfants Malades University Hospital, 75015, Paris, France; Université de Paris, Faculty of Medicine, 75006, Paris, France.
| | - Cécile Lambe
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, National Reference Center for Rare Digestive Diseases, Necker Enfants Malades University Hospital, 75015, Paris, France
| | - Cécile Talbotec
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, National Reference Center for Rare Digestive Diseases, Necker Enfants Malades University Hospital, 75015, Paris, France
| | - Alexandre Acramel
- Department of Pharmacy, Necker Enfants Malades University Hospital, 75015, Paris, France
| | - Bénédicte Pigneur
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, National Reference Center for Rare Digestive Diseases, Necker Enfants Malades University Hospital, 75015, Paris, France; Université de Paris, Faculty of Medicine, 75006, Paris, France
| | - Olivier Goulet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, National Reference Center for Rare Digestive Diseases, Necker Enfants Malades University Hospital, 75015, Paris, France; Université de Paris, Faculty of Medicine, 75006, Paris, France
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Abstract
OBJECTIVES Little is known about school-age functioning in children with intestinal failure (IF). This study examines neurocognitive outcomes of children with IF at ages 4 to 8 years treated at a single centre, along with relevant medical and demographic variables. METHODS Between 2012 and 2016, neurocognitive assessments were administered to 28 children receiving treatment in our IF rehabilitation program, and included measures of intelligence, academics, learning/memory, language, visual-motor integration, and fine-motor dexterity. DSM-IV/V criteria were used to diagnose Learning Disability, Intellectual Disability, and/or Attention Deficit/Hyperactivity Disorder. RESULTS Intellectual functioning ranged from extremely low to superior (Full Scale IQ range 53-123, mean = 89). Forty-six percentage received a cognitive/learning DSM diagnosis. Total number of first-year septic episodes correlated with poorer outcomes on the most cognitive measures. Adjusting for gestational age (61% were born <37 weeks), number of first-year septic episodes negatively predicted working memory, visual-motor integration, and visual memory scores. Additional factors correlating with poorer outcomes on ≥2 cognitive measures included length of first-year admissions, necrotizing enterocolitis diagnosis, and first-year sustained conjugated hyperbilirubinemia. Having ≥2 first-year septic episodes increased the likelihood of poorer outcome. Having a sibling was a significant positive predictor of working memory, processing speed, reading, and verbal learning skills. CONCLUSIONS Our data provides preliminary evidence that children with IF are at risk of neurocognitive problems at early school age. Managing septic events during the first year is one strategy that may help reduce long-term neurocognitive risks in this population.
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Goulet O, Abi Nader E, Pigneur B, Lambe C. Short Bowel Syndrome as the Leading Cause of Intestinal Failure in Early Life: Some Insights into the Management. Pediatr Gastroenterol Hepatol Nutr 2019; 22:303-329. [PMID: 31338307 PMCID: PMC6629594 DOI: 10.5223/pghn.2019.22.4.303] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/11/2019] [Indexed: 12/13/2022] Open
Abstract
Intestinal failure (IF) is the critical reduction of the gut mass or its function below the minimum needed to absorb nutrients and fluids required for adequate growth in children. Severe IF requires parenteral nutrition (PN). Pediatric IF is most commonly due to congenital or neonatal intestinal diseases or malformations divided into 3 groups: 1) reduced intestinal length and consequently reduced absorptive surface, such as in short bowel syndrome (SBS) or extensive aganglionosis; 2) abnormal development of the intestinal mucosa such as congenital diseases of enterocyte development; 3) extensive motility dysfunction such as chronic intestinal pseudo-obstruction syndromes. The leading cause of IF in childhood is the SBS. In clinical practice the degree of IF may be indirectly measured by the level of PN required for normal or catch up growth. Other indicators such as serum citrulline have not proven to be highly reliable prognostic factors in children. The last decades have allowed the development of highly sophisticated nutrient solutions consisting of optimal combinations of macronutrients and micronutrients as well as guidelines, promoting PN as a safe and efficient feeding technique. However, IF that requires long-term PN may be associated with various complications including infections, growth failure, metabolic disorders, and bone disease. IF Associated Liver Disease may be a limiting factor. However, changes in the global management of IF pediatric patients, especially since the setup of intestinal rehabilitation centres did change the prognosis thus limiting "nutritional failure" which is considered as a major indication for intestinal transplantation (ITx) or combined liver-ITx.
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Affiliation(s)
- Olivier Goulet
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Digestive Diseases, Pediatric Intestinal Failure Rehabilitation Center, Hôpital Necker-Enfants Malades, University Sorbonne-Paris-Cité Paris Descartes Medical School, Paris, France
| | - Elie Abi Nader
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Digestive Diseases, Pediatric Intestinal Failure Rehabilitation Center, Hôpital Necker-Enfants Malades, University Sorbonne-Paris-Cité Paris Descartes Medical School, Paris, France
| | - Bénédicte Pigneur
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Digestive Diseases, Pediatric Intestinal Failure Rehabilitation Center, Hôpital Necker-Enfants Malades, University Sorbonne-Paris-Cité Paris Descartes Medical School, Paris, France
| | - Cécile Lambe
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Digestive Diseases, Pediatric Intestinal Failure Rehabilitation Center, Hôpital Necker-Enfants Malades, University Sorbonne-Paris-Cité Paris Descartes Medical School, Paris, France
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Hartman C, Shamir R, Simchowitz V, Lohner S, Cai W, Decsi T, Braegger C, Bronsky J, Cai W, Campoy C, Carnielli V, Darmaun D, Decsi T, Domellöf M, Embleton N, Fewtrell M, Fidler Mis N, Franz A, Goulet O, Hartman C, Hill S, Hojsak I, Iacobelli S, Jochum F, Joosten K, Kolaček S, Koletzko B, Ksiazyk J, Lapillonne A, Lohner S, Mesotten D, Mihályi K, Mihatsch WA, Mimouni F, Mølgaard C, Moltu SJ, Nomayo A, Picaud JC, Prell C, Puntis J, Riskin A, Saenz De Pipaon M, Senterre T, Shamir R, Simchowitz V, Szitanyi P, Tabbers MM, Van Den Akker CH, Van Goudoever JB, Van Kempen A, Verbruggen S, Wu J, Yan W. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Complications. Clin Nutr 2018; 37:2418-2429. [DOI: 10.1016/j.clnu.2018.06.956] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 12/30/2022]
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Hukkinen M, Merras-Salmio L, Pakarinen MP. Health-related quality of life and neurodevelopmental outcomes among children with intestinal failure. Semin Pediatr Surg 2018; 27:273-279. [PMID: 30342603 DOI: 10.1053/j.sempedsurg.2018.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Treatment results of pediatric intestinal failure have improved markedly during the last decades. With improved survival the attention is turning to other essential outcomes including quality of life and neurodevelopment. So far, relatively few studies with limited number of patients and variable methodology have addressed these issues. Based on these studies using generic health related quality of life tools, children with intestinal failure demonstrate decreased physical health, while PN-dependence is also associated with compromised emotional functioning. Impairments of social functioning are frequently observed among older children and parents. Few recent studies on neurodevelopment imply significant impairments in motor and mental skills among children with intestinal failure despite small sample sizes and limited follow-up times. Development of a disease-specific survey designed for the pediatric intestinal failure population could better reveal the health issues with greatest impact on quality of life. Robust studies with appropriate methodology on neurodevelopment in pediatric intestinal failure with extended follow-up times are urgently needed. Quality of life and neurodevelopment requires greater attention from medical professionals managing children with intestinal failure.
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Affiliation(s)
- Maria Hukkinen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, P.O. Box 281, 00029 HUS Helsinki, Finland; Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, Finland
| | - Laura Merras-Salmio
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, P.O. Box 281, 00029 HUS Helsinki, Finland; Section of Pediatric Gastroenterology, Children's Hospital, Helsinki University Hospital, Finland
| | - Mikko P Pakarinen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, P.O. Box 281, 00029 HUS Helsinki, Finland; Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, Finland.
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Abi Nader E, Lambe C, Talbotec C, Pigneur B, Lacaille F, Garnier-Lengliné H, Petit LM, Poisson C, Rocha A, Corriol O, Aigrain Y, Chardot C, Ruemmele FM, Colomb-Jung V, Goulet O. Outcome of home parenteral nutrition in 251 children over a 14-y period: report of a single center. Am J Clin Nutr 2016; 103:1327-36. [PMID: 27030532 DOI: 10.3945/ajcn.115.121756] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 03/01/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Parenteral nutrition (PN) is the main treatment for intestinal failure. OBJECTIVE We aimed to review the indications for home parenteral nutrition (HPN) in children and describe the outcome over a 14-y period from a single center. DESIGN We conducted a retrospective study that included all children who were referred to our institution and discharged while receiving HPN between 1 January 2000 and 31 December 2013. The indications for HPN were divided into primary digestive diseases (PDDs) and primary nondigestive diseases (PNDDs). We compared our results to a previous study that was performed in our unit from 1980 to 2000 and included 302 patients. RESULTS A total of 251 patients were included: 217 (86%) had a PDD. The mean ± SD age at HPN onset was 0.7 ± 0.3 y, with a mean duration of 1.9 ± 0.4 y. The indications for HPN were short bowel syndrome (SBS) (59%), PNDD (14%), congenital enteropathies (10%), chronic intestinal pseudo-obstruction syndromes (9%), inflammatory bowel diseases (5%), and other digestive diseases (3%). By 31 December 2013, 52% of children were weaned off of HPN, 9% of the PDD subgroup had intestinal transplantation, and 10% died mostly because of immune deficiency. The major complications of HPN were catheter-related bloodstream infections (CRBSIs) (1.7/1000 d of PN) and intestinal failure-associated liver disease (IFALD) (51 children; 20% of cohort). An increased rate of CRBSIs was observed compared with our previous study, but we saw a decreasing trend since 2012. No noteworthy deceleration of growth was observed in SBS children 6 mo after weaning off HPN. CONCLUSIONS SBS was the major indication for HPN in our cohort. IFALD and CRBSIs were potentially life-threatening problems. Nevertheless, complication rates were low, and deaths resulted mostly from the underlying disease.
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Affiliation(s)
- Elie Abi Nader
- Departments of Pediatric Gastroenterology, Hepatology and Nutrition, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Cécile Lambe
- Departments of Pediatric Gastroenterology, Hepatology and Nutrition
| | - Cécile Talbotec
- Departments of Pediatric Gastroenterology, Hepatology and Nutrition
| | | | | | | | | | | | - Amélia Rocha
- Departments of Pediatric Gastroenterology, Hepatology and Nutrition
| | - Odile Corriol
- Pharmacy, and Paris Descartes University, Paris, France; and
| | - Yves Aigrain
- Pediatric Surgery and Transplantation, Necker Enfants Malades University Hospital, Certified Center for Home Parenteral Nutrition, National Reference Center for Rare Digestive Diseases in Children, APHP, Paris, France; Paris Descartes University, Paris, France; and
| | - Christophe Chardot
- Pediatric Surgery and Transplantation, Necker Enfants Malades University Hospital, Certified Center for Home Parenteral Nutrition, National Reference Center for Rare Digestive Diseases in Children, APHP, Paris, France; Paris Descartes University, Paris, France; and
| | - Frank M Ruemmele
- Departments of Pediatric Gastroenterology, Hepatology and Nutrition, Paris Descartes University, Paris, France; and
| | | | - Olivier Goulet
- Departments of Pediatric Gastroenterology, Hepatology and Nutrition, Paris Descartes University, Paris, France; and
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11
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Ubesie AC, Kocoshis SA, Mezoff AG, Henderson CJ, Helmrath MA, Cole CR. Multiple micronutrient deficiencies among patients with intestinal failure during and after transition to enteral nutrition. J Pediatr 2013; 163:1692-6. [PMID: 23978355 PMCID: PMC3842410 DOI: 10.1016/j.jpeds.2013.07.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/20/2013] [Accepted: 07/09/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the prevalence of deficiencies of specific micronutrients (iron, zinc, magnesium, phosphorus, selenium, copper, folate, and vitamins A, D, E, and B12) in children with intestinal failure (IF), and to identify risk factors associated with developing these deficiencies. STUDY DESIGN This study was a retrospective review of prospectively collected data from 178 children with IF managed by the Intestinal Care Center of Cincinnati Children's Hospital Medical Center between August 1, 2007, and July 31, 2012. Transition to full enteral nutrition (FEN) was defined as the period during which the patient received between 20% and 100% of estimated required nutrition enterally. FEN was defined as the patient's ability to tolerate 100% estimated required nutrition enterally for >2 weeks. RESULTS Necrotizing enterocolitis was the most common cause of IF (27.5%). Iron was the most common micronutrient deficiency identified both during (83.9%) and after (61%) successful transition to FEN, with a significant reduction in the percentage of patients with iron deficiency between these 2 periods (P = .003). Predictors of micronutrient deficiency after successful transition to FEN included birth weight (P = .03), weight percentile (P = .02), height percentile (P = .04), and duration of parenteral nutrition (PN) (P = .013). After multivariate adjustments, only duration of PN remained statistically significant (P = .03). CONCLUSION Micronutrient deficiencies persist in patients with IF during and after transition to FEN. These data support the need for routine monitoring and supplementation of these patients, especially those on prolonged PN.
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Affiliation(s)
- Agozie C Ubesie
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria.
| | - Samuel A Kocoshis
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children’s Hospital Medical Center,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Adam G Mezoff
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children’s Hospital Medical Center,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Carol J Henderson
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael A Helmrath
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children’s Hospital Medical Center,Division of Pediatric and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Conrad R Cole
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children’s Hospital Medical Center,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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12
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Abstract
Short-term bowel adaptation has been documented, but data on long-term effects are scarce. The aim of the present study was to evaluate the long-term consequences of infantile short bowel syndrome (SBS). A cross-sectional assessment (2005–7) of growth, nutritional status, defecation pattern and health status in individuals with a history of infantile SBS, born between 1975 and 2002, were performed. Data were compared with reference values of healthy controls and presented as means and standard deviations or median and ranges. A total of forty subjects (sixteen male and twenty-four female; mean age 14·8 (sd 6·8) years) had received parenteral nutrition during a median of 110 (range 43–2345) d, following small bowel resection. The mean standard deviation scores (SDS) for weight for height and target height (TH) of the children were normal; mean SDS for height for age was − 0·9 (sd 1·3). The median BMI adults was 19·9 (range 17–26) kg/m2; mean SDS for height for age was − 1·0 (range − 2·5 to 1·5). Height in general was significantly shorter than TH, and 53 % of children and 78 % of adults were below TH range. Most subjects had normal body fat percentage (%BF). SDS for total body bone mineral density were generally normal. The SDS for bone mineral content (BMC) of the children were − 1·0 (sd 1·1). Mean energy intake was 91 % of the estimated average requirements. The frequencies of defecation and bowel complaints of the subjects were significantly higher than in healthy controls. In conclusion, infantile SBS results in shorter stature than was expected from their calculated TH. BMC was lower than reference values, but the subjects had normal weight for height and %BF.
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13
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David AI, Chida VV, Lee ADW, Fiuza FSOR, Calil DM, Mantovani DDC, Maranhão ER, Campi GB, Llanos JC, Ferraz Neto BH. Multivisceral transplantation in pigs: a model for research and training. EINSTEIN-SAO PAULO 2011; 9:372-6. [PMID: 26761108 DOI: 10.1590/s1679-45082011ao1956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Accepted: 08/01/2011] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To present a model for research and training in multivisceral transplantation in pigs. METHODS Eight Large White pigs (four donors and four recipients) were operated. The multivisceral transplant with stomach, duodenum, pancreas, liver and intestine was performed similarly to transplantation in humans with a few differences, described below. Anastomoses were performed as follows: end-to-end from the supra-hepatic vena cava of the graft to the recipient juxta diaphragmatic vena cava; end-to-end from the infra-hepatic vena cava of the graft to the inferior (suprarenal) vena cava of the recipient; and end-to-side patch of the aorta of the graft to the infrarenal aorta of the recipient plus digestive reconstruction. RESULTS The performance of the multivisceral transplantion was possible in all four animals. Reperfusions of the multivisceral graft led to a severe ischemia-reperfusion syndrome, despite flushing of the graft. The animals presented with hypotension and the need for high doses of vasoactive drugs, and all of them were sacrificed after discontinuing these drugs. CONCLUSION Some alternatives to minimize the ischemia-reperfusion syndrome, such as the use of another vasoactive drug, use of a third pig merely for blood transfusion, presence of an anesthesia team in the operating room, and reduction of the graft, will be the next steps to enable experimental studies.
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Affiliation(s)
- André Ibrahim David
- Hospital das Clínicas, Faculdade de Medicina, Department of Transplants, Universidade de São Paulo - USP, Sao Paulo, SP, BR
| | - Valéria Vieira Chida
- Centro de Experimentação e Treinamento (CETEC), Instituto Israelita de Ensino e Pesquisa Albert Einstein - IIEPAE, Sao Paulo, SP, BR
| | - Andre Dong Won Lee
- Hospital das Clínicas, Faculdade de Medicina, Department of Transplants, Universidade de São Paulo - USP, Sao Paulo, SP, BR
| | | | | | | | | | - Gabriel Beligni Campi
- Faculdade de Ciências Médicas da Santa Casa de São Paulo - FCMSCSP, Sao Paulo, SP, BR
| | - Juan Carlos Llanos
- Universidade Estadual "Júlio de Mesquita Filho" - UNESP, Botucatu, SP, BR
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Yang CFJ, Duro D, Zurakowski D, Lee M, Jaksic T, Duggan C. High prevalence of multiple micronutrient deficiencies in children with intestinal failure: a longitudinal study. J Pediatr 2011; 159:39-44.e1. [PMID: 21324480 PMCID: PMC3112274 DOI: 10.1016/j.jpeds.2010.12.049] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 12/08/2010] [Accepted: 12/30/2010] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine the prevalence of micronutrient deficiencies in children with intestinal failure as they transitioned from parenteral nutrition (PN) to enteral nutrition (EN). STUDY DESIGN We reviewed medical records of all patients with severe intestinal failure treated from 1999 to 2008 at a multidisciplinary intestinal rehabilitation program who had undergone micronutrient biochemical monitoring. RESULTS The cohort of 30 children (mean age, 5 years; range, 2 to 9 years; 18 boys) had median PN duration of 23 weeks (IQR, 13 to 34 weeks). Median transition from PN to full EN lasted 12 weeks (IQR, 8 to 20 weeks); during this transition, 33% of patients had at least one vitamin deficiency and 77% at least one mineral deficiency. After transition to 100% EN, 70% had at least one vitamin deficiency and 77% had at least one mineral deficiency, with the most common deficiencies being vitamin D (68%), zinc (67%), and iron deficiency (37%). After transition to 100% EN, multivariate analysis identified regular use of a multivitamin supplement (P=.004) and intact ileocecal valve (P=.02) as protective against the development of vitamin deficiencies, independent of bowel length, gestational age, and days on PN. CONCLUSIONS Children with intestinal failure exhibit a high prevalence of micronutrient deficiencies during intestinal rehabilitation. Regular monitoring and aggressive supplementation in children with intestinal failure is warranted.
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Affiliation(s)
- Chi-fu Jeffrey Yang
- Harvard Medical School, Boston, MA, USA,Center for Advanced Intestinal Rehabilitation (CAIR), Children's Hospital, Boston, MA
| | - Debora Duro
- Division of Gastroenterology and Nutrition, Children's Hospital, Boston, Harvard Medical School, Boston, MA, 02115, USA,Center for Advanced Intestinal Rehabilitation (CAIR), Children's Hospital, Boston, MA
| | - David Zurakowski
- Department of Surgery, Children's Hospital, Boston, Harvard Medical School, Boston, MA, 02115, USA
| | - Michele Lee
- Harvard University, Cambridge, MA, 02138, USA
| | - Tom Jaksic
- Department of Surgery, Children's Hospital, Boston, Harvard Medical School, Boston, MA, 02115, USA,Center for Advanced Intestinal Rehabilitation (CAIR), Children's Hospital, Boston, MA
| | - Christopher Duggan
- Division of Gastroenterology and Nutrition, Children's Hospital, Boston, Harvard Medical School, Boston, MA, 02115, USA,Center for Advanced Intestinal Rehabilitation (CAIR), Children's Hospital, Boston, MA
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15
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Miyasaka EA, Brown PI, Kadoura S, Harris MB, Teitelbaum DH. The adolescent child with short bowel syndrome: new onset of failure to thrive and need for increased nutritional supplementation. J Pediatr Surg 2010; 45:1280-6. [PMID: 20620332 DOI: 10.1016/j.jpedsurg.2010.02.100] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Accepted: 02/23/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Proper nutrition for children with short bowel syndrome (SBS) is challenging. An underappreciated SBS cohort is the group of adolescents in which nutritional demand is markedly increased. We identified several children that previously had weaned off parenteral nutrition but needed re-initiation of parenteral nutrition or increased enteral nutritional supplementation (NS) during adolescence. This study aims to identify characteristics of adolescent SBS patients to better understand their nutritional status. METHODS A single institution, retrospective review of SBS patients over 10 years was done. Patients were analyzed for NS need, remaining bowel length, height, weight, and essential nutrient levels. RESULTS Sixteen adolescent SBS patients were identified for analysis. Of these, ten did not require increased NS upon reaching adolescence (group A), and six required increased NS during adolescence (group B). Group B patients required a mean increase in NS of 29.6 kcal/kg per day. Group B patients had significantly shorter remaining bowel length. NS resulted in minimal height increase, but more substantial gains in weight and pubertal development. CONCLUSIONS Adolescents with SBS may require NS beyond what can be provided enterally. These patients are at risk for nutritional deficiencies, and an aggressive approach to monitoring and supplementing these deficiencies is warranted, especially during this critical period of growth.
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Affiliation(s)
- Eiichi A Miyasaka
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI 48109-0245, USA
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16
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Olieman JF, Poley MJ, Gischler SJ, Penning C, Escher JC, van den Hoonaard TL, van Goudoever JB, Bax NMA, Tibboel D, IJsselstijn H. Interdisciplinary management of infantile short bowel syndrome: resource consumption, growth, and nutrition. J Pediatr Surg 2010; 45:490-8. [PMID: 20223310 DOI: 10.1016/j.jpedsurg.2009.08.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 07/30/2009] [Accepted: 08/02/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE To date, there are hardly any data on the treatment costs of infantile short bowel syndrome (SBS), despite growing interest in evidence-based and cost-effective medicine. Therefore, the aim of the study was to evaluate resource consumption and costs, next to studying nutritional and growth outcomes, in children with SBS who were treated by an interdisciplinary short bowel team. METHODS Data were collected for 10 children with infantile SBS (<or=1 year of age) born between 2002 and 2007. Data included demographic and medical data of the first admission and data on resource consumption, growth, and type of nutrition for the total follow-up period. Real economic costs were calculated in Euro (euro) and US dollar ($). RESULTS Seven of the 10 patients were discharged with home parenteral nutrition. Total follow-up varied between 9 months and 5.5 years (median, 1.5 years). Six patients could be weaned off parenteral nutrition and 5 patients off enteral tube feeding, resulting in full oral intake. Seven patients had normal growth. Median duration of initial hospital admission was 174 days, and average costs of initial admission amounted to euro166,045 ($218,681). Average total costs were euro269,700 ($355,195), reaching to a maximum of euro455,400 ($599,762). These costs mainly comprised hospital admissions (82%), followed by nutrition (12%), surgical interventions (5%), and outpatient visits (1%). CONCLUSIONS This study is among the first to describe resource consumption and costs in infants with SBS, examining real economic costs and extending beyond the initial hospitalization. Treatment of SBS requires considerable resource consumption, especially when patients depend on parenteral nutrition. Because the costs mainly comprise those of hospital admissions, early home parenteral nutrition could contribute to costs reduction. Interdisciplinary teams have the potential to facilitate early home parenteral nutrition and thus may reduce health care costs.
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Affiliation(s)
- Joanne F Olieman
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Erasmus MC, Rotterdam, The Netherlands.
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17
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Abstract
The management of the child with intestinal failure is complex, and it is developing into a multispecialty field of its own led by expert teams of both transplant and nontransplant surgeons, gastroenterologists, and dieticians. Patients are at risk for medical, surgical, and nutritional complications that should be anticipated so that they can be prevented or managed appropriately. Catheter associated infections and intestinal failure associated liver diseases are important complications that impact the likelihood of bowel adaptation and long-term survival. The clinical assessment of a pediatric intestinal failure patient should include evaluation of the child within the context of recognized prognostic factors.
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Affiliation(s)
- Jason S Soden
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Colorado Denver School of Medicine and The Children's Hospital, Aurora, Colorado 80045, USA.
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18
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Wu J, Tang Q, Feng Y, Huang J, Tao Y, Wang Y, Cai W, Shi C. Nutrition assessment in children with short bowel syndrome weaned off parenteral nutrition: a long-term follow-up study. J Pediatr Surg 2007; 42:1372-6. [PMID: 17706499 DOI: 10.1016/j.jpedsurg.2007.03.036] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of the study was to assess long-term growth and nutrition status of children with neonatal short bowel syndrome (SBS) after weaning off parenteral nutrition (PN). METHODS Eight children with neonatal SBS weaned from PN therapy for more than 2 years were studied. Medical records were reviewed; anthropometric measurements and blood test (hemoglobin, albumin and prealbumin, immunoglobulin, electrolytes, trace elements, and fat-soluble vitamins) were assayed during follow-up. RESULTS Anthropometric measurements, weight for age, and height for age were normal in all children; one child was found to be overweight according to weight for height z score. No children were found to have anemia, although one presented with macrocytosis and another had microcytosis. Low serum concentrations of zinc in 3 cases and iron in 1 case were detected. Immunoglobulin levels of all children were within the reference value. Low plasma levels of vitamin A in 2 cases, vitamin E in 4 cases, and beta-carotene in 2 cases were found; one of them had obviously low levels of the 3 fat-soluble vitamins. CONCLUSION Children with SBS are still at risk for different nutrient malabsorption even after weaning off PN for a long time. Therefore, they need long-term, regular monitoring and intensive nutritional care to prevent various nutrient deficiencies.
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Affiliation(s)
- Jiang Wu
- Department of Pediatric Surgery, Clinical Nutrition Center, Xin Hua Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai 200092, China
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Duggan C, Piper H, Javid PJ, Valim C, Collier S, Kim HB, Jaksic T. Growth and nutritional status in infants with short-bowel syndrome after the serial transverse enteroplasty procedure. Clin Gastroenterol Hepatol 2006; 4:1237-41. [PMID: 16904948 DOI: 10.1016/j.cgh.2006.06.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The aim of this study was to describe the long-term nutritional outcomes of 4 patients with short bowel syndrome (SBS) who underwent a newly described bowel-lengthening procedure, the serial transverse enteroplasty (STEP) procedure. METHODS We performed a retrospective review of the medical records of 4 children who underwent STEP at 1 center. The primary outcome measure was the percentage of total dietary energy received by the enteral route before and after STEP. Other outcome measures were weight and height Z scores and body composition, as measured by arm anthropometric values. RESULTS Four children with SBS were identified, all of whom had been dependent on parenteral nutrition since birth. The mean preoperative follow-up period was 234 days (range, 63-502 days), and the mean postoperative follow-up period was 362 days (range, 252-493 days). By using model-based mean estimates, the mean enteral nutrition intake was 48% preoperatively vs 62% postoperatively (P = .02). The model mean weight for age Z score increased by .7 SDs postoperatively (P = .01), and the model mean weight for height increased by .6 SDs (P < .0001). The percent standard mid-upper-arm circumference increased by 13.1% postoperatively (P = .03), and the percent standard triceps skinfold increased by 24.5% postoperatively (P < .0001). CONCLUSIONS The STEP procedure was associated with improved growth and body composition among 4 children with SBS in the face of a decreasing need for parenteral nutrition. Among patients with refractory SBS and dilated small intestine, the STEP procedure is associated with improved clinical and nutritional outcomes in the first year after surgery.
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Affiliation(s)
- Christopher Duggan
- Division of Gastroenterology and Nutrition, Children's Hospital, Boston, Massachusetts 02115, USA.
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20
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Abstract
PURPOSE OF REVIEW This review summarizes recent knowledge and clinical practice for pediatric patients suffering extensive intestinal resection causing short bowel syndrome. This condition requires the use of parenteral nutrition, as long as intestinal failure persists, and may be, in some selected cases, an indication for intestinal transplantation. RECENT FINDINGS Biological evaluation of intestinal failure is becoming possible with the use of plasma citrulline as a marker of intestinal mass. Few epidemiological data are available; some indicate an increased incidence of short bowel syndrome-related gastroschisis and persistent high incidence of necrotizing enterocolitis. Morbidity and mortality data in pediatric patients with short bowel syndrome are limited, while long-term outcome is better documented from recently reported cohorts. Non-transplant surgery is one of the best options for patients with unadapted short bowel syndrome. Isolated liver transplantation may be avoided. The use of trophic factors for enhancing mucosal hyperplasia still remains disappointing. SUMMARY The management should include therapies adapted to each stage of intestinal failure, based on a multidisciplinary approach in centers involving pediatric surgery, pediatric gastroenterology, parenteral nutrition expertise, home-parenteral nutrition program, and liver-intestinal transplantation experience. If managed appropriately, the prognosis of short bowel syndrome is excellent, with limited indications for intestinal and/or liver transplantation. Timing for patient referral in specialized centers remains an issue.
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Affiliation(s)
- Olivier Goulet
- Integrated Program of Intestinal Failure, Home Parenteral Nutrition, and Intestinal Transplantation, National Reference Center for Rare Digestive Diseases, Necker Hospital for Sick Children, University of Paris, France.
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Goulet O, Ruemmele F. Causes and management of intestinal failure in children. Gastroenterology 2006; 130:S16-28. [PMID: 16473066 DOI: 10.1053/j.gastro.2005.12.002] [Citation(s) in RCA: 241] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2004] [Accepted: 06/06/2005] [Indexed: 12/28/2022]
Abstract
Intestinal failure is a condition requiring the use of parenteral nutrition as long as it persists. Causes of severe protracted intestinal failure include short bowel syndrome, congenital diseases of enterocyte development, and severe motility disorders (total or subtotal aganglionosis or chronic intestinal pseudo-obstruction syndrome). Intestinal failure may be irreversible in some patients, thus requiring permanent parenteral nutrition. Liver disease may develop with subsequent end-stage liver cirrhosis in patients with intestinal failure as a consequence of both underlying digestive disease and unadapted parenteral nutrition. Death will occur if combined liver-intestine transplantation is not performed. Catheter-related sepsis and/or extensive vascular thrombosis may impede the continuation of a safe and efficient parenteral nutrition and may also require intestinal transplantation in some selected cases. Thus management of patients with intestinal failure requires an early recognition of the condition and the analysis of its risk of irreversibility. Timing of referral for intestinal transplantation remains a crucial issue. As a consequence, management should include therapies adapted to each stage of intestinal failure based on a multidisciplinary approach in centers involving pediatric gastroenterology, parenteral nutrition expertise, home parenteral nutrition program, pediatric surgery, and liver intestinal transplantation program.
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Affiliation(s)
- Olivier Goulet
- Integrated Program of Intestinal Failure, Home Parenteral Nutrition and Intestinal Transplantation, National Reference Center for Rare Digestive Disease, Hôpital Necker-Enfants Malades, Université Reni Descartes, Paris, France.
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González HF, Pérez NB, Malpeli A, Martínez MI, Del Buono B, Viteri FE. Nutrition and immunological status in long-term follow up of children with short bowel syndrome. JPEN J Parenter Enteral Nutr 2005; 29:186-91. [PMID: 15837778 DOI: 10.1177/0148607105029003186] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about the long-term evolution, nutrition status, growth, and eventual deficiencies of patients with short bowel syndrome (SBS) adapted to oral feeding after parenteral nutrition (PN). Because there are not absolute criteria for weaning from parenteral or enteral nutrition to oral feeding, new nutrient deficiencies may develop. Subtle nutrition deficits could induce subclinical immune deficiencies; therefore, we studied long-term growth, nutrition status, and the state of the immune system in 10 patients with SBS after weaning PN for at least 2 years. METHODS Ten children with SBS (3-12 years old; mean, 7.4 years) who had not received PN for at least 2 years were studied. Anthropometric measurements, hemoglobin values, and indicators of iron, zinc, copper, folate and vitamin B(12) nutrition status were evaluated, along with immunoglobulins, lymphocyte subpopulations, and polymorphonuclear candidicidal activity. RESULTS Weight-for-height was normal in 8 children; height-for-age was low in 5 children whose SBS was established early in life. Fat body mass was also low in 5 subjects. Four children presented macrocytosis, 2 with anemia. Low serum levels of vitamin B(12) (1 child), folates (4 children), and ferritin (2 children) were observed. Diminished candidicidal activity (4 children) was the only remarkable immunological abnormality. CONCLUSION Many biologic and growth deficiencies are frequently seen in patients with SBS, even in children adapted to enteral feeding. This finding and the existence of previously unreported decreased candidicidal activity in some patients with SBS deserve long-term clinical and biologic follow up.
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Affiliation(s)
- Horacio F González
- Instituto de Desarrollo e Investigaciones Pediátricas, Hospital de Niños Sor María Ludovica, Calle 16 No 1069 1900, La Plata, Argentina.
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Nagy ES, Paris MCJ, Taylor RG, Fuller PJ, Sourial M, Justice F, Bines JE. Colostrum protein concentrate enhances intestinal adaptation after massive small bowel resection in juvenile pigs. J Pediatr Gastroenterol Nutr 2004; 39:487-92. [PMID: 15572887 DOI: 10.1097/00005176-200411000-00008] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Short bowel syndrome (SBS) usually results from the surgical removal of a large segment of small intestine. Patient outcome depends on the extent of intestinal resection and adaptation of the remaining intestine. We evaluated the impact of colostrum protein concentrate (CPC) on intestinal adaptation after massive small bowel resection in a porcine model of infant SBS. METHODS Four-week-old piglets underwent an approximate 75% small bowel resection (R, n = 23) or a control transection operation (C, n = 14). Postoperatively, animals from both groups received either pig chow (R = 6, C = 5), polymeric infant formula (R = 6, C = 3) or polymeric infant formula supplemented with CPC (R = 11, C = 6) for 8 weeks until sacrifice. Clinical outcome measures included weight gain and stool consistency. Morphologic measures were intestinal villus height and crypt depth. Functional outcome measure was mucosal disaccharidase activity. RESULTS Resected animals fed polymeric infant formula alone had reduced weight gain compared with controls fed the same diet (P < 0.005). Despite massive small bowel resection, animals fed pig chow or polymeric infant formula supplemented with CPC grew at an equivalent rate to controls fed polymeric infant formula alone. Resected animals supplemented with CPC had increased villus length and crypt depth in the jejunum (P < 0.001) and ileum (P < 0.001) compared with resected animals fed either pig chow or polymeric infant formula alone. CONCLUSION In an animal model of SBS, CPC supplementation of polymeric infant formula resulted in normal weight gain and features of enhanced morphologic adaptation.
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Affiliation(s)
- Eva S Nagy
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Parkville, Victoria, Australia
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25
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Miranda-Sanchez S, Ruiz JC, Talbotec C, Corriol O, Goulet O, Colomb V. Pathologie osseuse associée à la nutrition parentérale chez l'enfant. NUTR CLIN METAB 2004. [DOI: 10.1016/j.nupar.2004.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Intestinal failure (IF) can be defined as the reduction of functional gut mass below the minimal amount necessary for digestion and absorption adequate to satisfy the nutrient and fluid requirements for maintenance in adults or growth in children. In developed countries, IF mainly includes individuals with the congenital or early onset of conditions requiring protracted or indefinite parenteral nutrition (PN). Short bowel syndrome was the first commonly recognized cause of protracted IF. The normal physiologic process of intestinal adaptation after extensive resection usually allows for recovery of sufficient intestinal function within weeks to months. During this time, patients can be sustained on parenteral nutrition. Only a few children have permanent intestinal insufficiency and life-long dependency on PN. Non-transplant surgery including small bowel tapering and lengthening may allow weaning from PN in some cases. Hormonal therapy with recombinant human growth hormone has produced poor results while therapy with glucagon-like peptide-2 holds promise. Congenital diseases of enterocyte development such as microvillus inclusion disease or intestinal epithelial dysplasia cause permanent IF for which no curative medical treatment is currently available. Severe and extensive motility disorders such as total or subtotal intestinal aganglionosis (long segment Hirschsprung disease) or chronic intestinal pseudo-obstruction syndrome may also cause permanent IF. PN and home-PN remain are the mainstays of therapy regardless of the cause of IF. Some patients develop complications while receiving long-term PN for IF especially catheter related complications (thrombosis, sepsis) and liver disease. These patients may be candidates for intestinal transplantation. This review discusses the causes of irreversible IF and emphasizes the specific medico-surgical strategies for prevention and treatment of these conditions at several stages of IF.
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Affiliation(s)
- Olivier Goulet
- Département de Gastroentérologie, Hépatologie et Nutrition Pédiatriques, Hôpital Necker- Infants Malades and INSERM, Faculté de Necker, Paris, France.
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Bines JE, Taylor RG, Justice F, Paris MCJ, Sourial M, Nagy E, Emselle S, Catto-Smith AG, Fuller PJ. Influence of diet complexity on intestinal adaptation following massive small bowel resection in a preclinical model. J Gastroenterol Hepatol 2002; 17:1170-9. [PMID: 12453276 DOI: 10.1046/j.1440-1746.2002.02872.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
AIMS To investigate the effect of dietary complexity on intestinal adaptation using a preclinical model. METHODS Four-week-old piglets underwent a 75% proximal small bowel resection or transection operation (control). Post-operatively, animals received either pig chow (n = 15), polymeric formula (n = 9), polymeric formula plus fiber (n = 6), or elemental formula (n = 7). RESULTS The weight gain of all groups was reduced compared with controls that were fed the same diet. Animals that had a resection, which were fed elemental formula, had significantly reduced weight gain compared with the other groups (4.7 4.2 vs 30.7 7.1 kg chow and 11.5 1.3 kg polymeric formula). Villus height was increased in the jejunum, ileum and terminal ileum of resected animals compared with controls in animals fed with pig chow, polymeric formula and elemental formula. The animals that had a resection had a significant reduction in the transepithelial conductance (10.4 5.5 vs 25.4 6.5 mS/cm2) and 51Chromium-EDTA flux (2.8 1.9 vs 4.8 4.9 microL/h per cm2) compared with the controls. CONCLUSIONS A complex diet was found to be superior to an elemental diet in terms of the morphological and functional features of adaptation following massive small bowel resection.
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Affiliation(s)
- Julie E Bines
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Parkville, Victoria, Australia.
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28
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Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2002. [PMID: 11841046 DOI: 10.1177/0148607102026001011] [Citation(s) in RCA: 365] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
Technical developments in feeding, together with the growth of support structures in the community has lead to a steady increase in the number of children receiving home enteral tube feeding and home parenteral nutrition. In many cases the adverse nutritional consequences of disease can be ameliorated or prevented, and long term parenteral nutrition represents a life saving intervention. Careful follow up of children receiving home nutritional therapy is necessary to establish the ratio of risks to benefits. A considerable burden is sometimes placed on family or other carers who therefore require adequate training and ongoing support. The respective responsibilities of different agencies relating to funding and support tasks require more clear definition.
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Affiliation(s)
- J W Puntis
- Neonatal Unit, Clarendon Wing, The General Infirmary at Leeds, Belmont Grove, Leeds LS2 9NS, UK.
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30
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Gottrand F, Sfeir R, Guimber D, Michaud L, Bonnevalle M, Turck D. Prise en charge à long terme du grêle court : spécificités de l'enfant. NUTR CLIN METAB 2000. [DOI: 10.1016/s0985-0562(00)80010-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ball PA. Use of computers in long-term/home parenteral nutrition--a missed opportunity? Curr Opin Clin Nutr Metab Care 2000; 3:231-5. [PMID: 10871241 DOI: 10.1097/00075197-200005000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Desk-top microcomputers and total parenteral nutrition grew up together, and in their early days there was considerable progress in both camps. Since that time, the power of computing devices has increased dramatically, as has their ability to share information both between individual systems and worldwide through facilities such as the Internet and e-mail. Although there are some signs of continuing progress, to date there appears to be little evidence in peer-reviewed journals that this increased power is being utilized or that the vision of the pioneers in this area has been realized.
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Affiliation(s)
- P A Ball
- University of Otago, School of Pharmacy, Dunedin, New Zealand.
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32
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Abstract
Home artificial nutrition is a mature technology that has been with us for over a quarter of a century. Its use appears to be more widespread in the USA than in other western countries. Issues of outcome, ethics, and quality of life are increasingly important. Complications continue to be reported, some newly recognized and some that we must continually relearn.
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Affiliation(s)
- T O Lipman
- Department of Veterans Affairs Medical Center, Washington DC 20422, USA.
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Miles MS, Holditch-Davis D, Burchinal P, Nelson D. Distress and growth outcomes in mothers of medically fragile infants. Nurs Res 1999; 48:129-40. [PMID: 10337844 DOI: 10.1097/00006199-199905000-00003] [Citation(s) in RCA: 122] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND With recent advances in medical and nursing care, many high-risk infants are surviving the neonatal period with severe, life-threatening chronic illnesses, resulting in extended hospitalizations and/or frequent rehospitalizations and long periods of dependence on technology for survival. OBJECTIVE To describe the factors predicting maternal adjustment in mothers caring for medically fragile infants. METHOD Subjects were mothers (n = 67) whose infants had a serious life-threatening illness requiring hospitalization and technology for survival. Data for this longitudinal study were collected at enrollment and hospital discharge, and at 6, 12, and 16 months after birth. Distress was measured as depressive symptoms using the Center for Epidemiologic Studies Depression Scale, and growth was assessed using a personal developmental impact rating scale. Data about personal characteristics, parental role attainment, infant-illness characteristics, and maternal illness distress were collected. RESULTS Mothers of medically fragile infants experience distress and growth as a result of their child's illness. Mean scores on the depression scale at both time points were moderately high and a high percentage of mothers scored at risk for depressive symptoms. Maternal developmental impact ratings at 6 months were neutral to slightly negative and at 16 months were between neutral and positive. While the mean depressive symptom scores and maternal developmental ratings were lower at the later time points, these differences were not significant. Maternal depressive symptoms and developmental impact ratings were moderately but negatively correlated at 6 and 16 months, indicating that higher depressive symptoms were related to more negative developmental impact ratings. Distress was influenced by maternal characteristics, hospital environmental stress, and worry about the child's health. Growth was influenced by characteristics of the child's illness, hospital environmental stress, concern about the child's health, and level of maternal role attainment. CONCLUSIONS Nurses should consider personal characteristics and level of parental role attainment as well as characteristics of the child and illness-related distress in their approaches to intervention with mothers of critically ill infants.
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Affiliation(s)
- M S Miles
- Department of Children's Health, University of North Carolina at Chapel Hill, 27599-7460, USA.
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