Intelligence after malnutrition caused by neonatal resection of ileum

Limited ileal resection in infancy: the long-term consequences

BACKGROUND/PURPOSE

The longer-term sequelae of short bowel syndrome in infancy are reasonably well documented, but little is known about the long-term nutritional and metabolic effects of limited (less than 50 cm) ileal resection. This makes it difficult to formulate a rational follow-up policy in such children.

METHODS

All children who underwent limited ileal resection for either necrotizing enterocolitis (NEC) or intussusception at our institution between 1984 and 1992 were invited to attend a detailed clinical, anthropometric, hematologic, and biochemical assessment, together with a biliary and renal ultrasound scan and measurement of bone mineral density.

RESULTS

Twenty-four children (NEC, 17; intussusception, 7) of median age 7.4 years (range, 5.5 to 13.7 years) agreed to participate. Nine previously had undergone an isolated ileal resection, and 15 also had had variable lengths of colon removed. The length of resected ileum ranged from 3 to 44 cm, with a median of 10 cm. Seven control subjects in whom neonatal NEC developed but recovered without surgery were also evaluated. Median height, weight, and body mass index after ileal resection were between the 25th and 50th percentiles; no child was stunted or wasted. After ileal resection, one boy was found to have asymptomatic vitamin B12 deficiency, and three children had low plasma concentrations of vitamin A. Hematologic and biochemical parameters were otherwise normal apart from a few marginally low trace element levels in both subjects and controls. No renal calculi were detected, and bone mineral density measurements were normal in all except one child. Four children had cholelithiasis, all of whom had previously undergone limited ileal resection for NEC (two isolated, two ileocolic). Thus, the prevalence of cholelithasis after limited ileal resection for NEC was 24% at a median age of 7.0 years.

CONCLUSIONS

Growth and nutritional status are well preserved after limited ileal resection in infancy. Limited ileal resection for NEC is associated with a subsequent high prevalence of cholelithiasis and a risk of vitamin B12 deficiency. These findings are important when planning strategies for long-term follow-up.

Neonatal small bowel atresia, stenosis and segmental dilatation

In 8 years, 44 neonates were treated for small bowel atresia, stenosis or segmental dilatation by one surgical team. There was a single lesion in 30 infants and 14 had two or more sites of intestinal obstruction. Associated gastrointestinal abnormalities were found in 23 (52 per cent) patients. Resection of the atresia(s) and primary anastomosis were performed in 34 infants and staged procedures were carried out in ten patients with complicated lesions. Patients undergoing staged procedures had a higher complication rate than those having primary repair (six out of ten and 11 out of 34 respectively). The overall initial survival rate was 93 per cent, rising to 100 per cent in those without associated anomalies or prenatal complications, but more than a quarter (27 per cent) of survivors have long-term disabilities.

Results of surgical treatment of neonatal necrotizing enterocolitis

In 6 years, 74 neonates were treated for necrotizing enterocolitis, 40 (54 per cent) of whom underwent operation. The early postoperative mortality rate was 23 per cent and there was one late death. Of the 30 postoperative survivors, two have short bowel syndrome, two have chronic respiratory disease, two are partially sighted, and five (17 per cent) have severe developmental delay. Only 15 (50 per cent) survivors enjoy good health.

Intellectual ability of adults after lifelong intestinal malabsorption due to coeliac disease

The intellectual impact of lifelong intestinal malabsorption was examined in a consecutive series of 19 adults (mean age, 48 ± 11 years) with untreated coeliac disease. Using a comprehensive test battery no consistent signs of cognitive impairment were found and in the light of recent observations on coeliacs, aspects of nutritional deficiency may prove more pertinent to other forms of cerebral dysfunction.

Follow-up studies of children treated with a long-term intravenous nutrition (IVN) during the neonatal period

The outcome of the 28 children treated with intravenous nutrition (IVN) for more than 4 wk during the neonatal period was investigated. Ten of the 28 children had a normal length of small bowel (group 1) and the other 18 children had a short bowel (group 2). Eight of these 28 children (4 in group 1 and 4 in group 2) died during or after cessation of IVN; three died from complication of IVN and 5 died from their initial disease. On physical examination, delay in catch-up growth was observed in the early postoperative period, particularly in children in group 2, but this diminished with time. Mental and emotional development showed both groups to be within the normal range, except for two children. Intellectual function was also normal in five children over the age of 4 yr who were examined. Hepatic dysfunction was noticed during IVN in 30.0% in group 1 and 66.7% in group 2, indicating that the longer the duration of IVN, the higher the incidence of liver damage. Furthermore, histologic abnormalities in these neonates lasted for a longer time. These results imply that long-term IVN during the neonatal period in surgical patients does not interfere with physical and developmental growth. However, careful and long-term follow-up of liver function after IVN is necessary.

Shwachman's syndrome. A review of 21 cases

21 patients (10 male, 11 female) aged between 11 months and 29 years with Shwachman's syndrome are reviewed. All patients had exocrine pancreatic insufficiency. Haematological features included neutropenia in 19 (95%), anaemia in 10 (50%), and thrombocytopenia in 14 (70%); one patient developed erythroleukaemia. Severe infections occurred in 17 (85%) from which 3 (15%) died. Only one child exceeded the 3rd centile for height, and growth retardation was particularly evident in the older patients. All had skeletal abnormalities or delayed skeletal maturation, or both. Metaphyseal dyschondroplasia affected 13 of the older patients and was associated with skeletal deformities. Eight of 9 children under 2 1/2 years had rib abnormalities. Respiratory function tests in children under 2 years demonstrated reduced thoracic gas volume and chest wall compliance. Older patients had reduced forced expiratory volume and forced vital capacity. Neurological assessment showed developmental retardation or reduced IQ assessments, or both, in 85% of patients studied. Other neurological abnormalities included hypotonia, deafness, and retinitis pigmentosa. Neonatal problems had been present in 16 (80%) of the patients and 5 were of low birthweights. Hepatomegaly with biochemical evidence of liver involvement occurred in the younger patients and resolved with age. Other associated features included dental abnormalities, renal dysfunction, an icthyotic maculopapular rash in 13 (65%), delayed puberty, diabetes mellitus, and various dysmorphic features. These findings stress the diverse manifestations of the syndrome and extend knowledge on a number of aspects. Sibship segregation ratios support an autosomal mode of inheritance and an hypothesis for the pathophysiological basis of this syndrome is advanced.

The effect of treatment on mental and psychomotor development of marasmic infants according to age of admission

The mental and psychomotor development of severely malnourished infants were examined during nutritional and psychological treatment. There was a significant difference between younger and older infants in their response to the treatment. The older infants had a remarkable reduction of their psychomotor development at admission and showed a considerable recovery throughout treatment. The younger infants became more affected during hospitalisation. The bodyweight deficit had mostly recovered by the end of the treatment.

Psychomotor development during treatment of severely marasmic infants

Previous studies of amlnourished infants have shown that their psychomotor development improves parallel to their nutritional rehabilitation. The present study showed that our patients recovered weight-for-age faster than height-for-age, becoming 42% obese at the end of the treatment. The psychomotor development was also significantly improved, but mainly in social, language and fine coordination areas. The gross motor behaviour did not show any improvement during 5 months of treatment. These results are interpreted in terms of the syndrome of dissociation of maturation.

A clinical study of young infants after small intestinal resection

We prospectively studied 15 infants who, before 3 months of age, underwent resection of the small intestine-proximal in 3 infants, mid in 6, and distal in 6. Two died before one year of age. Many required prolonged parenteral nutrition, but by one year, 12 of the 13 survivors were on oral feedings only, and seven were above the third percentile for height and weight. Developmental delay occurred in the early postoperative period but diminished with time. There was compensatory adaptation of the remaining gut, shown by improving fat and B12 absorption and duodenal bile-salt concentrations. Bacterial contamination complicating end-to-side anastomoses occurred in two cases (P), gastric hyperacidity in four of 12 (1P, 3M), and hyperoxaluria in eight of 14 (1P, 5M, 2D). Studies of immune competence revealed normal cellular immune function (11/11), transient hypogammaglobulinemia (3/14), hypocomplementemia (1/12), and serum autoantibodies (3/10). Thus, massive resection of the small intestine did not preclude spontaneous improvement in absorptive function, growth, and development.

The treatment of intractable diarrhea by the method of "Baustein" principle using a casein hydrolisate

Ten infants with intractable diarrhea, celiac disease and small bowel resection were treated with a special dietetic regimen called "Baustein" principle. The three major food constituents were added to the formula stepwise: first glucose and maltodextrin followed by protein and vegetable oil or MCT oil. The protein source was a newly developed casein hydrolisate also containing minerals, trace elements and vitamins.

Growth and fat absorption after resection of ileum in childhood

Twelve children who have survived resection of more than 45 cm of ileum (eight during the neonatal period and four later in childhood) have been reassessed at periods ranging from 3 to 16 years. No child had persistent diarrhea for longer than one year after a resection, and only two children had a restricted fat intake for more than two years. These two children showed no advantage in growth compared with the ten who had normal diet within two years of the resection. The weights of individual children are appropriate for their heights. Their heights tend to be less than those of their siblings, but only two are less than the third percentile compared to height expected in relation to that of parents. The older children still have marked steatorrhea but no diarrhea, and serum levels of vitamins A, D, and E are normal. These observations suggest that two years after extensive resection ileum some children may tolerate a normal diet and grow well despite persisting defects in absorption. Infants with more extensive resections are now surviving and may require special diets and vitamin supplements for longer periods of time.