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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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2
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Assad M, Jerome M, Olyaei A, Nizich S, Hedges M, Gosselin K, Scottoline B. Dilemmas in establishing preterm enteral feeding: where do we start and how fast do we go? J Perinatol 2023; 43:1194-1199. [PMID: 37169912 DOI: 10.1038/s41372-023-01665-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 03/06/2023] [Accepted: 03/23/2023] [Indexed: 05/13/2023]
Abstract
Beginning and achieving full enteral nutrition is a key step in the care of preterm infants, particularly very low birth weight (VLBW) infants. As is true for many organ system-specific complications of prematurity, the gastrointestinal tract must complete in utero development ex utero while concurrently serving a physiologic role reserved for after completion of full term development. The preterm gut must assume the placental function of the interface between a source of energy, precursors for anabolism, and micronutrients, and the developing infant-through digestion and absorption of milk, instead of directly from the mother via the uteroplacental interface. The benefits of enteral nourishment in preterm infants are counterbalanced by gastrointestinal complications of prematurity: dysmotility leading to difficulty establishing and advancing feeds, and the risk of necrotizing enterocolitis (NEC). Concern for these complications can prolong the need for parenteral nutrition with an associated increase in risk for central line-associated bloodstream infection (CLABSI) and parenteral nutrition (PN)-associated cholestasis or liver disease (PNALD). Thus, a daily issue facing neonatologists caring for preterm infants is how to optimally begin, advance, and reach full enteral nutrition sufficient to satisfy the nutrient, energy, and fluid requirements of VLBW infants while minimizing risk. In this perspective, we provide an overview of the approaches and supporting data for starting and advancing enteral feeds in preterm infants, particularly very low birth weight infants, and we discuss the significant gaps in knowledge that accompany current approaches. This framework recognizes the dilemmas of preterm feeding initiation and advancement and identifies areas of opportunity for further investigation.
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Affiliation(s)
- Maushumi Assad
- Division of Neonatology, Department of Pediatrics, University of Massachusetts T.H.Chan School of Medicine, Worcester, MA, 01655, USA
| | - Maggie Jerome
- Graduate Programs in Human Nutrition, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Amy Olyaei
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Samantha Nizich
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Madeline Hedges
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Kerri Gosselin
- Division of Neonatology, Department of Pediatrics, University of Massachusetts T.H.Chan School of Medicine, Worcester, MA, 01655, USA
| | - Brian Scottoline
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA.
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3
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Sukhotnik I, Levi R, Moran-Lev H. Impact of Dietary Protein on the Management of Pediatric Short Bowel Syndrome. Nutrients 2023; 15:2826. [PMID: 37447153 DOI: 10.3390/nu15132826] [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: 03/27/2023] [Revised: 05/15/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Essential amino acids (AAs) play a key role in stimulating intestinal adaptation after massive small gut resection. The nutritional effect of dietary amino acids during intestinal regrowth has received considerable attention in recent years. This review explores the significance of dietary amino acids in the nutritional management of infants and children with intestinal failure and short bowel syndrome (SBS) as reported in the medical literature over the last three decades. A literature search was conducted using electronic databases. Breast milk emerged as the first-line enteral regimen recommended for infants with SBS. Hydrolyzed formulas (HFs) or amino acid formulas (AAFs) are recommended when breast milk is not available or if the infant cannot tolerate whole protein milk. The superiority of AAFs over HFs has never been demonstrated. Although glutamine (GLN) is the main fuel for enterocytes, GLN supplementation in infants with SBS showed no difference in the child's dependence upon parenteral nutrition (PN). Circulating citrulline is considered a major determinant of survival and nutritional prognosis of SBS patients. Early enteral nutrition and dietary supplementation of AAs following bowel resection in children are essential for the development of intestinal adaptation, thereby eliminating the need for PN.
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Affiliation(s)
- Igor Sukhotnik
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
| | - Reut Levi
- Department of Pediatric Gastroenterology, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
| | - Hadar Moran-Lev
- Department of Pediatric Gastroenterology, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
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4
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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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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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6
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Wang J, Xu H, Wang J, Xiao D. Evaluation of postoperative feeding strategies in children with intestinal atresia: A single-center retrospective study. Front Pediatr 2022; 10:953852. [PMID: 36186653 PMCID: PMC9515948 DOI: 10.3389/fped.2022.953852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/15/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Postoperative enteral nutrition has a significant influence on the prognosis of patients with congenital intestinal atresia. Currently, there is no precise guidance on enteral nutrition management. This study aimed to compare the outcomes of different feeding strategies based on the initial volume and daily advancement in postoperative patients with congenital intestinal atresia. METHODS This study was a retrospective study collected from October 2019 to July 2021 in Shenzhen Children's Hospital. According to the initial volume and daily advancement, the patients were divided into high-dose group and low-dose group. General basic information such as age, sex, and lesion type was gathered. The postoperative outcome included the levels of hemoglobin (HGB), albumin (ALB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), direct bilirubin (DB), length of stay, length of total PN, time to reach 100% enteral nutrition (EN) (120 kcal·kg-1·d-1), infection incidence and intestinal failure associated liver disease (IFALD) incidence (DB>2 mg·dL-1). RESULTS In total, 32 patients with congenital intestinal atresia were identified. There was no significant difference between the high-dose group and the low-dose group in the baseline characteristic. The length of time to reach 100% (p = 0.001) enteral nutrition and postoperative hospital stay (p = 0.092) were shorter in the high-dose group. In the high-dose group, patients at discharge were with not only lower levels of DB (p = 0.009), AST (p = 0.109) and ALT (p = 0.045) but also higher level of ALB (p = 0.459) and hemoglobin (p = 0.354). The incidence of IFALD was significantly lower in the high-dose group (p = 0.032). There was no significant difference in the overall incidence of postoperative complications. CONCLUSIONS Within the limitations, the findings of this study suggest that High-dose feeding (initial volume>15 ml·kg-1·d-1, daily advancement>10 ml·kg-1·d-1) is beneficial for the prognosis of patients diagnosed with congenital intestinal atresia treated by intestinal.
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Affiliation(s)
- Jiepin Wang
- Department of General Surgery, Shenzhen Children's Hospital, Shenzhen, China.,Medical College, Shantou University, Shantou, China
| | - Haozhong Xu
- Department of General Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Junxiang Wang
- Department of General Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Dong Xiao
- Department of General Surgery, Shenzhen Children's Hospital, Shenzhen, China
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7
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Moschino L, Duci M, Fascetti Leon F, Bonadies L, Priante E, Baraldi E, Verlato G. Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection. Nutrients 2021; 13:nu13020340. [PMID: 33498880 PMCID: PMC7910892 DOI: 10.3390/nu13020340] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.
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MESH Headings
- Enterocolitis, Necrotizing/complications
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/prevention & control
- Enterocolitis, Necrotizing/surgery
- Failure to Thrive/prevention & control
- Humans
- Infant
- Infant Nutritional Physiological Phenomena
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/prevention & control
- Infant, Premature, Diseases/surgery
- Intestines/surgery
- Short Bowel Syndrome/etiology
- Short Bowel Syndrome/prevention & control
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Affiliation(s)
- Laura Moschino
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Elena Priante
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Giovanna Verlato
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
- Correspondence: ; Tel.: +39-0498211428
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8
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Channabasappa N, Girouard S, Nguyen V, Piper H. Enteral Nutrition in Pediatric Short-Bowel Syndrome. Nutr Clin Pract 2020; 35:848-854. [PMID: 32815247 DOI: 10.1002/ncp.10565] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pediatric intestinal failure (IF) is the critical reduction of intestinal mass or function below the amount necessary for normal growth in children. Short-bowel syndrome (SBS) is the most common cause of IF in infants and children and is caused by intestinal resection. Enteral autonomy and freedom from parenteral nutrition is the mainstay of nutrition management in SBS. The goal is to achieve intestinal adaptation while maintaining proper growth and development. Treatment is variable, and there remains a paucity of evidence to draw well-informed conclusions for the care of individuals in this complex population. Physiological principles of enteral nutrition and practical recommendations for advancing the diet of patients with pediatric SBS are presented. Emerging trends in nutrition management, such as the growing interest in blending diets and the impact on SBS, are reviewed. Finally, the influence of the microbiome on enteral tolerance and small bowel bacterial overgrowth are considered.
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Affiliation(s)
- Nandini Channabasappa
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sara Girouard
- Department of Clinical Nutrition, Children's Health of Dallas, Dallas, Texas, USA
| | - Van Nguyen
- Department of Gastroenterology, Children's Health of Dallas, Dallas, Texas, USA
| | - Hannah Piper
- Division of Pediatric Surgery, Unversity of British Columbia, Vancouver, British Columbia, Canada
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9
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Mezoff EA, Minneci PC, Dienhart MC. Intestinal Failure: A Description of the Problem and Recent Therapeutic Advances. Clin Perinatol 2020; 47:323-340. [PMID: 32439114 DOI: 10.1016/j.clp.2020.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Pediatric intestinal failure occurs when gut function is insufficient to meet the nutrient and hydration needs of the growing child. The commonest cause is short bowel syndrome with maldigestion and malabsorption following massive bowel loss. The remnant bowel adapts during the process of intestinal rehabilitation. Management promotes the achievement of enteral autonomy while mitigating the risk of comorbid disease. The future of care is likely to see expansion of pharmacologic methods for augmenting bowel adaptation, tissue engineering techniques enabling immune suppression-free autologous bowel transplant, and the development of electronic health record tools for efficient, collaborative study and care improvement.
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Affiliation(s)
- Ethan A Mezoff
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University College of Medicine, Center for Intestinal Rehabilitation and Nutrition Support, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Peter C Minneci
- Department of Surgery, The Ohio State University College of Medicine, Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Molly C Dienhart
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University College of Medicine, Center for Intestinal Rehabilitation and Nutrition Support, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
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10
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Cost-effectiveness Analysis of Feeding Guidelines for Infants Following Intestinal Surgery. J Pediatr Gastroenterol Nutr 2020; 70:657-663. [PMID: 31977952 DOI: 10.1097/mpg.0000000000002642] [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
OBJECTIVE The aim of the study was to determine the cost-effectiveness of postoperative feeding guidelines to reduce complications in infants with intestinal surgery compared to standard feeding practices. METHODS Using outcomes from a cohort study, Markov models from health care and societal perspectives simulated costs per hospitalization among infants fed via guidelines versus standard practice. Short-term outcomes included intestinal failure-associated liver disease, necrotizing enterocolitis after feeding, sepsis, and mortality. Effectiveness was measured as length of stay. The incremental cost-effectiveness ratios (ICER) compared cost over length of stay. Univariate and multivariate probabilistic sensitivity analyses with 10,000 Monte Carlo Simulations were performed. A second decision tree model captured the cost per quality-adjusted life years (QALYs) using utilities associated with long-term outcomes (liver cirrhosis and transplantation). RESULTS In the hospital perspective, standard feeding had a cost of $31,258,902 and 8296 hospital days, and the feeding guidelines had a cost of $29,295,553 and 8096 hospital days. The ICER was $-9832 per hospital stay with guideline use. More than 90% of the ICERs were in the dominant quadrant. Results were similar for the societal perspective. Long-term costs and utilities in the guideline group were $2830 and 0.91, respectively, versus $4030 and 0.90, resulting in an ICER of $-91,756/QALY. CONCLUSION In our models, feeding guideline use resulted in cost savings and reduction in hospital stay in the short-term and cost savings and an increase in QALYs in the long-term. Using a systematic approach to feed surgical infants appears to reduce costly complications, but further data from a larger cohort are needed.
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11
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Shakeel F, Newkirk M, Sellers A, Shores DR. Postoperative Feeding Guidelines Improve Outcomes in Surgical Infants. JPEN J Parenter Enteral Nutr 2019; 44:1047-1056. [PMID: 31705574 DOI: 10.1002/jpen.1726] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/01/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Early introduction of enteral nutrition (EN) in postoperative infants improves intestinal adaptation, reducing the risk of intestinal failure-associated liver disease (IFALD). Our objective was to determine whether guideline use reduces feeding variability and improves outcomes in the neonatal intensive care unit (NICU). METHODS In a cohort study, surgical infants at risk for IFALD were evaluated pre and post implementation of feeding guidelines at 2 NICUs. A total of 167 guideline infants (2013-2018) were compared with 242 historical controls (2007-2013). Adherence was measured with timing and volume of initial postoperative feed. Primary outcomes were IFALD incidence and time to reach 50% and 100% of energy from EN. Secondary outcomes were parenteral nutrition (PN) days, postoperative necrotizing enterocolitis (NEC), central line-associated bloodstream infection (CLABSI), and length of stay (LOS). RESULTS Moderate IFALD decreased from 32% to 20% (P = .005) in the guideline group. Time to achieve 50% and 100% energy from EN was decreased from medians of 8 to 5 and 28 to 21 days, respectively (P < .001). There was an overall decrease in PN use from 41 to 29 days (P = .002), CLABSI incidence from 25% to 5% (P < .001), and LOS from 70 to 53 days (P = .030). Once stratified by diagnosis, infants with NEC showed greatest improvement and reduction in IFALD from 67% to 42% (P = .045). With no difference in postoperative NEC (P = .464). CONCLUSION Early standardized postoperative EN guidelines in intestinal-surgery infants was associated with improved outcomes, including faster achievement of feeding goals and reduced IFALD severity, especially in infants with NEC.
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Affiliation(s)
- Fauzia Shakeel
- Department of Maternal Fetal and Neonatal Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Melanie Newkirk
- Department of Nutritional Services, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Austin Sellers
- Department of Clinical and Translational Research Organization, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Darla R Shores
- Division of Gastroenterology, Hepatology and Nutrition, Johns Hopkins Children's Center, Baltimore, Maryland, USA
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12
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Bapat R, Gulati IK, Jadcherla S. Impact of SIMPLE Feeding Quality Improvement Strategies on Aerodigestive Milestones and Feeding Outcomes in BPD Infants. Hosp Pediatr 2019; 9:859-866. [PMID: 31658999 DOI: 10.1542/hpeds.2018-0243] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Delays with enteral and oral feeding milestones among premature infants with bronchopulmonary dysplasia (BPD) can be due to provider variation or infant-dependent factors. Our objectives with this study were to compare aerodigestive milestones and length of stay in BPD infants after implementing a quality improvement program to improve feeding outcomes. METHODS Using the Institute for Healthcare Improvement model for quality improvement, we implemented the simplified, individualized, milestone-targeted, pragmatic, longitudinal, and educational (SIMPLE) feeding strategy to enhance feeding and aerodigestive milestones among BPD infants. The key interventions addressed were as follows: (1) enteral feed initiation and advancement protocol; (2) oral feeding progression guidelines, optimization of respiratory support, feeding readiness scores, nonnutritive breastfeeding, and cue-based feeding; (3) active multidisciplinary collaboration; and (4) family-centered care. Comparisons were made between baseline (January 2009 to March 2010) and SIMPLE feeding strategy (May 2010 to December 2013) groups. Both groups included infants between 23 0/7 and 32 6/7 weeks' birth gestation, and ≤34 weeks' postmenstrual age at admission and discharge. RESULTS The baseline group and SIMPLE feeding group included 92 patients and 187 patients, respectively. Full enteral feeding, first oral feeding, full oral feeding, and length of stay milestones were (all P < .05) achieved sooner in the SIMPLE feeding group. Although the overall prevalence of BPD in the 2 groups is similar, the incidence of moderate BPD has decreased (P < .05) and severe BPD has increased (P < .05) in the SIMPLE feeding group. CONCLUSIONS SIMPLE feeding strategy advances postnatal maturation and acquisition of feeding milestones irrespective of the severity of BPD and impacts the length of stay, thereby lowering resource use.
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Affiliation(s)
- Roopali Bapat
- Nationwide Children's Hospital, Columbus, Ohio; and
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Ish K Gulati
- Nationwide Children's Hospital, Columbus, Ohio; and
- Innovative Feeding Disorders Program, The Research Institute at Nationwide Children's Hospital
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Sudarshan Jadcherla
- Nationwide Children's Hospital, Columbus, Ohio; and
- Innovative Feeding Disorders Program, The Research Institute at Nationwide Children's Hospital
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
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Belza C, Wales JC, Courtney-Martin G, de Silva N, Avitzur Y, Wales PW. An Observational Study of Smoflipid vs Intralipid on the Evolution of Intestinal Failure-Associated Liver Disease in Infants With Intestinal Failure. JPEN J Parenter Enteral Nutr 2019; 44:688-696. [PMID: 31448447 DOI: 10.1002/jpen.1692] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/23/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND SMOFlipid has a more diverse lipid profile than traditional Intralipid and has become the standard lipid for patients in our intestinal rehabilitation program. Our objective was to compare outcomes in neonates with intestinal failure (IF) who received SMOFlipid against those receiving Intralipid. METHODS This was a retrospective cohort study of infants with IF with a minimum follow-up of 12 months in 2008-2016. Patients were stratified into 2 groups: group 1 received SMOFlipid; group 2 was a historical cohort who received Intralipid. The primary outcome was liver function evaluated using conjugated bilirubin (CB) levels. Statistical analysis included the Mann-Whitney U and χ2 tests, with an α value < 0.05 considered significant. Approval was obtained from our institutional review board. RESULTS Thirty-seven patients were evaluated (17 = SMOFlipid, 20 = Intralipid). SMOFlipid patients were less likely to reach CB of 34 (24% vs 55%, P = 0.05), 50 µmol/L (11.8% vs 45%; P = 0.028), and did not require Omegaven (0% vs 30%; P = 0.014). CB level at 3 months after initiation of parenteral nutrition (PN) was lower in patients receiving SMOFlipid (0 vs 36 µmol/L; P = 0.01). Weight z-scores were improved for patients receiving SMOFlipid at 3 months (-0.932 vs -2.092; P = 0.028) and 6 months (-0.633 vs -1.614; P = 0.018). There were no differences in PN-supported patients or demographics between the groups. CONCLUSION Use of SMOFlipid resulted in decreased development of IF-associated liver disease in patients with IF when assessed using biochemical tests.
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Affiliation(s)
- Christina Belza
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada.,Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Canada
| | - John C Wales
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada
| | - Glenda Courtney-Martin
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada.,Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Canada
| | - Nicole de Silva
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada
| | - Yaron Avitzur
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada.,Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada.,Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada
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Shores DR, Alaish SM, Aucott SW, Bullard JE, Haney C, Tymann H, Nonyane BAS, Schwarz KB. Postoperative Enteral Nutrition Guidelines Reduce the Risk of Intestinal Failure-Associated Liver Disease in Surgical Infants. J Pediatr 2018; 195:140-147.e1. [PMID: 29402454 PMCID: PMC5869117 DOI: 10.1016/j.jpeds.2017.11.058] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 11/14/2017] [Accepted: 11/30/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the effectiveness of postoperative feeding guidelines in reducing the incidence and severity of intestinal failure-associated liver disease (IFALD) among infants. STUDY DESIGN Two cohorts of infants <6 months old undergoing intestinal surgery were compared: preguideline (retrospective data from 2007 to 2013; n = 83) and postguideline (prospective data from 2013 to 2016; n = 81). The guidelines included greater initial enteral nutrition volumes of 20 mL/kg/d and daily feeding advancement if tolerated. The primary outcomes were incidence of IFALD (peak direct bilirubin [DB] >2 mg/dL) and severity (DB >5 mg/dL for moderate-severe). Multiple logistic regression was used to determine the odds of developing IFALD. Other outcomes were time to reach 50% and 100% goal calories from enteral nutrition and the incidence of necrotizing enterocolitis after feeding. RESULTS The incidence of IFALD decreased from 71% to 51% (P = .031), and median peak DB decreased from 5.7 to 2.4 mg/dL (P = .001). After adjusting for diagnosis and prematurity, the odds of developing IFALD of any severity were reduced by 60% (OR 0.40, 95% CI 0.20-0.85), and the odds of developing moderate-to-severe IFALD were reduced by 72% (OR 0.28, 95% CI 0.13-0.58) with guideline use. Time to reach 50% enteral nutrition decreased from a median of 10 to 6 days (P = .020) and time to reach 100% enteral nutrition decreased from 35 to 21 days (P = .035) with guideline use. The incidence of necrotizing enterocolitis after initiating enteral nutrition did not change (5% vs 9%, P = .346). CONCLUSIONS Implementation of feeding guidelines reduced time to reach feeding goals, significantly reducing IFALD incidence and severity.
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Affiliation(s)
- Darla R Shores
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD.
| | - Samuel M Alaish
- Department of General Pediatric Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Susan W Aucott
- Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Janine E Bullard
- Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Courtney Haney
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Heidi Tymann
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Bareng A S Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kathleen B Schwarz
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
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Affiliation(s)
- Christopher P Duggan
- From the Center for Advanced Intestinal Rehabilitation (C.P.D., T.J.), Division of Gastroenterology, Hepatology, and Nutrition (C.P.D.), and the Department of Surgery (T.J.), Boston Children's Hospital and Harvard Medical School, Boston
| | - Tom Jaksic
- From the Center for Advanced Intestinal Rehabilitation (C.P.D., T.J.), Division of Gastroenterology, Hepatology, and Nutrition (C.P.D.), and the Department of Surgery (T.J.), Boston Children's Hospital and Harvard Medical School, Boston
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Abstract
Intestinal failure is a recognized complication of surgically-managed necrotizing enterocolitis (NEC). Functional adaptation of remaining bowel means that many children are eventually able to achieve enteral autonomy. Integrated multidisciplinary care in the early post-operative phase is key to long-term success. The objective of this review is to outline a clinical approach to management of intestinal and nutritional complications experienced by children following intestinal resection for NEC.
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Affiliation(s)
- Kelsey D J Jones
- Department of Paediatric Gastroenterology and Nutrition, Oxford Childrens' Hospital, Oxford University Hospitals NHS Foundation Trust, United Kingdom
| | - Lucy J Howarth
- Department of Paediatric Gastroenterology and Nutrition, Oxford Childrens' Hospital, Oxford University Hospitals NHS Foundation Trust, United Kingdom
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