Parenteral nutrition in infants and children

Treatment-related problems in neonates receiving parenteral nutrition: risk factors and implications for practice

OBJECTIVES

Parenteral nutrition (PN) can be associated with several treatment-related problems (TRPs) and complications in neonatal settings. Thus, understanding the extent and type of these problems and related factors is pivotal to prevent negative consequences of these preparations. Thus, the aim of this study is to assess factors affecting TRPs in neonatal patients receiving PN.

METHODS

This was a retrospective chart review of neonates receiving PN in NICU and other wards. We collected their demographics, and laboratory workup. TRPs related to PN preparations as well as their pharmacotherapy were the primary outcomes.

RESULTS

Medical charts of 96 neonate were reviewed. The most encountered TRPs related to patients' pharmacotherapy were the lack of frequent monitoring (34.2%) and low dose (17.5%). For PN-related TPRs, a mismatch between patients' nutritional needs and PN composition was observed in third of the patients. Statistically significant positive correlations between number of medications during hospital stay and number of reported TRPs [(r = 0.275, p < 0.01) and (r = 0.532, p < 0.001)] were observed.

CONCLUSION

In neonates who receive parenteral nutrition (PN), TRPs are often observed. These problems primarily arise from issues in patients' pharmacotherapy, namely monitoring and dosing. Identifying the risk factors for these TRPs emphasizes the full and effective integration of clinical pharmacists into the healthcare team, which can serve as a potential preventive strategy to lower the occurrence of TRPs.

Management of pediatric intestinal failure related to short bowel syndrome

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.

Prediabetes: Adherence to Nutrition Visits Decreases HbA1c in Children and Adolescents

BACKGROUND

Prediabetes, the precursor of type 2 diabetes (T2D), is on the rise in the US, but the determinants of its progression are poorly characterized in youth.

OBJECTIVE

To determine the impact of nutrition visits, as a surrogate marker of lifestyle modification, on the trajectory of prediabetes over a 4-year period.

HYPOTHESIS

Adherence to nutrition visits could reduce BMI and lower HbA1c.

METHODS

A 4-year retrospective study of 108 youth with prediabetes who were recommended to receive medical nutrition therapy every 3 months following their diagnosis. Subjects were divided into 2 groups: the non-adherent group who had ≤1 nutrition visit/year, and the adherent group with ≥2 nutrition visits/year.

RESULTS

There were 46 male subjects, mean age 12.4 ± 3.6y; and 62 female subjects, mean age, 13.3 ± 3.0y, p=0.2. The adherent group (n=44, 41.5%) had higher BMI z-scores, but similar values for HbA1c, metformin use, and racial/ethnic composition compared to the non-adherent group. Overall, 18(17.0%) subjects progressed to T2D in 4y and consisted of 14(22.6%) of the 62 non-adherent subjects and 4(9.1%) of the 44 adherent subjects. The non-adherent subjects progressed to T2D at a mean duration of 25.8 ± 12.6 months while the adherent subjects progressed at a mean duration of 34.9 ± 11.8 months. The hazard ratio of progression from prediabetes to T2D for the non-adherent versus adherent group was 3.88 (95%CI 1.26-11.98, p=0.02). The results remained significant after adjusting for age, sex, race/ethnicity, BMI, and metformin use.

CONCLUSION

Adherence to nutrition visits was associated with a 4-fold reduction in the likelihood to progress from prediabetes to T2D in US youth.

Adverse events and concurrent medications associated with parenteral nutrition use

In this study, clinical manifestations of adverse events and frequently used medications in patients receiving parenteral nutrition (PN) in Korea were evaluated using Korea Adverse Event Reporting System (KAERS) database records between 2011 and 2015. Amino acids, fat emulsions, carbohydrates, combinations and solutions for PN were identified as causative agents. Adverse events classified as "certain", "probable" and "possible" based on the WHO-Uppsala Monitoring Centre criteria were analysed. In total, 6439 adverse events from 4260 patients were included for analysis. Mean patient age was 54.4 ± 18.1 years and the mean number of adverse events per patient was 1.5 ± 1.1. Frequent adverse events were gastrointestinal (2159 events, 33.5%), skin/appendage (1344 events, 20.9%), general (846 events, 13.1%) and central/peripheral nervous system (716 events, 11.1%) disorders. Common clinical symptoms were nausea (1248 events, 19.4%), vomiting (558, 8.7%), pruritus (456 events, 7.1%), rash (386 events, 6.0%) and dizziness (329 events, 5.1%). The frequently reported concomitant agents were tramadol (n = 475, 3.1%), fentanyl (n = 405, 2.7%), paracetamol (n = 329, 2.2%), ketorolac (n = 322, 2.1%) and metoclopramide (n = 289 cases, 1.9%). The frequent adverse events remained consistent after accounting for concurrent medications. Our findings from a nationwide reporting system database found that gastrointestinal disorders (nausea and vomiting) were the leading adverse events, requiring further studies on their prevalence, mechanisms and therapeutic options.

Indications and complications of inpatient parenteral nutrition prescribed to children in a large tertiary referral hospital

BACKGROUND

Parenteral Nutrition (PN) is prescribed to children with intestinal failure. Although life saving, complications are common. Recommendations for indications and constituents of PN are made in the 2005 guidelines by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). The aim of this study was to establish if the indications for prescribing PN in a tertiary children's hospital were appropriate, and to identify complications encountered. Data were compared to those published by the National Confidential Enquiry into patient outcome and death (NCEPOD) carried out in the United Kingdom in 2010.

METHODS

Children and newborns receiving inpatient PN over a 6 months period were entered into the study and data was collected prospectively. The appropriate indications for the use of PN were based on the ESPGHAN guidelines. Recorded complications were divided into metabolic, central venous catheter (CVC) related, hepatobiliary and nutritional.

RESULTS

A total of 303 children (67 newborns) were entered into the study. The main indications for the start of PN were critical illness (66/303), surgery (63/303) and bone marrow transplantation (28/303). The ESPGHAN recommendations were followed in 91.7% (278/303) of cases (95.5% of newborns, 90.7% of children). PN was considered inappropriate in 12/303 patients and equivocal in 13. The mean PN duration was 18 days (1-160) and the incidence of complications correlated to the length of PN prescribed. Metabolic, hepatobiliary and CVC related complications affected 74.6, 24.4, 16.4% of newborns and 76.7, 37.7 and 24.6% of children respectively. In relation to the appropriate indications for the start of PN our results mirrored those reported by the NCEPOD audit (92.4% of newborns and 88.6% children). However, the incidence of metabolic disturbances was higher in our cohort (74.6% vs 30.4% in children, 76.7% vs 14.3% in newborns) but CVC related complications lower amongst our newborns (16,4% vs 25%).

CONCLUSIONS

Although the indications for inpatient PN in children is mostly justified, there is still a proportion who is receiving PN unnecessarily. PN related complications remain common. There is a need for better education amongst health professionals prescribing PN and access to nutritional support teams to reduce unwanted side effects.

Intestinal rehabilitation for children with intestinal failure is cost-effective: a simulation study

BACKGROUND

Children with intestinal failure (IF) depend on parenteral nutrition (PN). The goal in the treatment of IF is to wean children off PN through intestinal rehabilitation (IR). Although the healthcare burden of IF is enormous, to our knowledge there has been no previous cost-effectiveness analysis in pediatric IF including IR.

OBJECTIVE

We sought to determine the cost-effectiveness of IR in terms of costs and life-years.

DESIGN

We simulated the treatment of IF in children in a discrete-event model. Data for this model were derived from patient records, the Dutch Registry of Intestinal Failure and Transplantation, the Intestinal Transplant Registry, and the literature. The time horizon of the model was 40 y. Simulated patients were enrolled at a rate of 40 patients/mo for 10 y. Actual costs were calculated for hospital admissions, surgical interventions, endoscopies, PN, and immunosuppressive medication. We evaluated the cost-effectiveness of IR by comparing 1 scenario with IR with 1 scenario without IR. In the scenario with IR, a proportion of patients who represented those with the ability to wean off PN were assigned to IR. In the scenario without IR, all patients progressed to home PN (HPN). In both scenarios, a proportion of patients receiving HPN were eventually eligible for an intestinal transplantation.

RESULTS

IR prolonged survival; the mean number of life-years per patient was 19.4 in the scenario with IR compared with 18.2 in the scenario without IR. Average total costs per patient were €819,292 in the scenario with IR compared with €1,176,830 in the scenario without IR (equivalent to 1,129,230 US$ and 1,622,025 US$, respectively, in January 2014); costs mainly included hospital admissions and PN.

CONCLUSIONS

On the basis of our simulations, we concluded that IR improved the survival of children with IF and was associated with cost savings. Therefore, we consider IR to be a cost-effective treatment for children with IF.

Poor Prognostic Factors in Patients with Parenteral Nutrition-Dependent Pediatric Intestinal Failure

PURPOSE

Parenteral nutrition (PN) not only provides nutritional support but also plays a crucial role in the treatment of children with intestinal failure. The aim of this study was to evaluate the clinical significance and clinical outcomes of long-term PN.

METHODS

Retrospective cohort study was conducted using the medical records of patients treated at Seoul National University Children's Hospital. This study included 19 patients who received PN for over six months. Most patients received home PN.

RESULTS

The indications for PN included short bowel syndrome, chronic intestinal pseudo-obstruction, and intractable diarrhea of infancy. The median age of PN initiation was 1.3 years, and the median treatment duration was 2.9 years. Two patients were weaned from PN; 14 continued to receive PN with enteral feedings; and 3 patients died. The overall survival rates at 2 and 5 years were 93.3% and 84.0%, respectively. The incidence of catheter-related bloodstream infections was 2.7/1,000 catheter-days and was associated with younger age at PN initiation and lower initial height Z-score. Six patients developed catheter-related central vein thrombosis, with an incidence of 0.25/1,000 catheter-days. Eleven patients experienced PN-associated liver disease (PNALD), and one patient underwent multi-visceral transplant. The patients with PNALD exhibited lower final heights and body weight Z-scores. All patients experienced micronutrient deficiencies transiently while receiving PN.

CONCLUSION

PN is an important and safe treatment for pediatric intestinal failure. PNALD was linked to final anthropometric poor outcomes. Micronutrient deficiencies were common. Anthropometric measurements and micronutrient levels must be monitored for successful PN completion.

Review of macronutrients in parenteral nutrition for neonatal intensive care population

Parenteral nutrition (PN) has become essential in the management of sick and growing newborn populations in the NICU. In the past few decades, PN has become fundamental in the nutritional management of the very low birth weight infant (<1,500 g).1 Although the components in PN are commonly determined and ordered by the physician or neonatal nurse practitioner provider, the NICU nurse is responsible for confirming the components in the daily PN prior to infusion and is responsible for maintaining the infusion of PN. Nurses should understand the nutritional components of PN as well as the indications, side effects, and infusion limitations of each component. The purpose of this article is to review the macronutrients in PN, including carbohydrates, protein, and fat. A subsequent article will review the micronutrients in PN, including electrolytes, minerals, and vitamins.

Multiple micronutrient deficiencies among patients with intestinal failure during and after transition to enteral nutrition

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.

Developing and implementing all-in-one standard paediatric parenteral nutrition

Parenteral nutrition (PN) is a feeding mode suitable for children that do not achieve requirements via the enteral route. For this intervention to be successful, healthcare professionals require: knowledge on nutrient requirements; access to an aseptic compounding facility; and a system that ensures adequate and safe delivery of PN. Previously, it was thought that individualised PN was the "gold standard" for delivering nutrients to children; however, studies have highlighted concerns regarding inadequate delivery of nutrients, prescribing and compounding errors. We, therefore, set out to develop and implement all-in-one (AIO) paediatric PN solutions. Through a systematic approach, four AIO PN solutions were developed: birth-two months of age (Ped 1); two months-10 kg (Ped 2); 11-15 kg (Ped 3); and 16-30 kg (Ped 4). We implemented them with the help of a teaching pack, over a one month time period, and reviewed usage at six months. At that time, five children initially received standard PN without electrolyte changes; but after a few days, electrolytes needed amendments, and three required individualised PN. A change to AIO PN is feasible and safe; however, some may require electrolyte changes, and there will always be those that will require individualised PN.

Parenterale Ernährung

Während eine kurzfristige parenterale Ernährung bei verschiedensten Indikationen in der Kinderchirurgie, der Kinderonkologie und der Kindergastroenterologie i. Allg. gut vertragen wird und vereinfacht durchzuführen ist, empfiehlt es sich aufgrund unterschiedlicher Prognosen bei der Indikationsstellung für eine längerfristige parenterale Ernährung zu berücksichtigen, ob es sich bei dem Kind um ein Früh- oder Neugeborenes handelt oder ob ein Kind jenseits der Altersgrenze von 4 Wochen ernährt werden muss.

Parenteral trace elements in children: clinical aspects and dosage recommendations

PURPOSE OF REVIEW

Since the 1970s, it has been known that the supplementation of trace elements with parenteral nutrition is required in order to avoid the clinical manifestations of their deficiencies. However, the correct level of requirements of these trace elements, particularly in paediatrics, has provided some debate. The recent developments might help revise some of the current recommendations, particularly in short-term parenteral nutrition provision.

RECENT FINDINGS

Parenterally fed preterm neonates require routine addition of zinc. Provision of chromium and manganese in parenteral nutrition should be limited, particularly for short-term patients. Newer parenteral iron preparations provide the opportunity for a safer and larger dose of administration.

SUMMARY

Clinicians should prescribe according to the individual requirements and revise the routine practice of providing 'all in one' parenteral trace elements preparations, as these products do not reflect or allow tailored provision in paediatrics and may increase the risk of toxicity.

Poor post-operative growth in infants with two-ventricle physiology

BACKGROUND

Adequate nutritional support is essential for normal infant growth and development. Infants with congenital cardiac disease are known to be at risk for growth failure. We sought to describe perioperative growth in infants undergoing surgical repair of two-ventricle congenital cardiac disease and assess for predictors of their pattern of growth.Materials and methodsFull-term infants who underwent surgical repair of two-ventricle congenital cardiac disease at a single institution were enrolled in a retrospective cohort study performed following a larger prospective study. Infants with facial, gastrointestinal, or neurologic anomalies, trisomy chromosomal abnormality, birth weight less than 2500 grams, or those transferred to another institution before discharge home were excluded. The primary outcome was change in weight-for-age z score from surgery to discharge. Our secondary outcome variable was post-operative hospital length of stay.

RESULTS

A total of 76 infants met the inclusion criteria. Medain age at surgery was 5 days with a range from 1 to 44. The median weight-for-age z score at surgery was -0.2 with a range from -2.9 to 2.8 and by discharge had dropped to -1.2 with a range from -3.4 to 1.8. The median change in weight-for-age z score from surgery to discharge was -1.0 with a range from -2.3 to 0.2. Delayed post-operative nutrition (p < 0.001) and reintubation following initial post-operative extubation (p = 0.001) were associated with decrease in weight-for-age z score.

CONCLUSIONS

Infants undergoing repair of two-ventricle congenital cardiac disease had poor growth in the post-operative period. This may be mitigated by early initiation of post-operative nutrition.

Surgery and transplantation - Guidelines on Parenteral Nutrition, Chapter 18

In surgery, indications for artificial nutrition comprise prevention and treatment of catabolism and malnutrition. Thus in general, food intake should not be interrupted postoperatively and the re-establishing of oral (e.g. after anastomosis of the colon and rectum, kidney transplantation) or enteral food intake (e.g. after an anastomosis in the upper gastrointestinal tract, liver transplantation) is recommended within 24 h post surgery. To avoid increased mortality an indication for an immediate postoperatively artificial nutrition (enteral or parenteral nutrition (PN)) also exists in patients with no signs of malnutrition, but who will not receive oral food intake for more than 7 days perioperatively or whose oral food intake does not meet their needs (e.g. less than 60–80%) for more than 14 days. In cases of absolute contraindication for enteral nutrition, there is an indication for total PN (TPN) such as in chronic intestinal obstruction with a relevant passage obstruction e.g. a peritoneal carcinoma. If energy and nutrient requirements cannot be met by oral and enteral intake alone, a combination of enteral and parenteral nutrition is indicated. Delaying surgery for a systematic nutrition therapy (enteral and parenteral) is only indicated if severe malnutrition is present. Preoperative nutrition therapy should preferably be conducted prior to hospital admission to lower the risk of nosocomial infections. The recommendations of early postoperative re-establishing oral feeding, generally apply also to paediatric patients. Standardised operative procedures should be established in order to guarantee an effective nutrition therapy.

Neonatology/Paediatrics - Guidelines on Parenteral Nutrition, Chapter 13

There are special challenges in implementing parenteral nutrition (PN) in paediatric patients, which arises from the wide range of patients, ranging from extremely premature infants up to teenagers weighing up to and over 100 kg, and their varying substrate requirements. Age and maturity-related changes of the metabolism and fluid and nutrient requirements must be taken into consideration along with the clinical situation during which PN is applied. The indication, the procedure as well as the intake of fluid and substrates are very different to that known in PN-practice in adult patients, e.g. the fluid, nutrient and energy needs of premature infants and newborns per kg body weight are markedly higher than of older paediatric and adult patients. Premature infants <35 weeks of pregnancy and most sick term infants usually require full or partial PN. In neonates the actual amount of PN administered must be calculated (not estimated). Enteral nutrition should be gradually introduced and should replace PN as quickly as possible in order to minimise any side-effects from exposure to PN. Inadequate substrate intake in early infancy can cause long-term detrimental effects in terms of metabolic programming of the risk of illness in later life. If energy and nutrient demands in children and adolescents cannot be met through enteral nutrition, partial or total PN should be considered within 7 days or less depending on the nutritional state and clinical conditions.

Enhancing parenteral nutrition therapy for the neonate

The neonate receiving parenteral nutrition (PN) therapy requires a physiologically appropriate solution in quantity and quality given according to a timely, cost-effective strategy. Maintaining tissue integrity, metabolism, and growth in a neonate is challenging. To support infant growth and influence subsequent development requires critical timing for nutrition assessment and intervention. Providing amino acids to neonates has been shown to improve nitrogen balance, glucose metabolism, and amino acid profiles. In contrast, supplying the lipid emulsions (currently available in the United States) to provide essential fatty acids is not the optimal composition to help attenuate inflammation. Recent investigations with an omega-3 fish oil IV emulsion are promising, but there is need for further research and development. Complications from PN, however, remain problematic and include infection, hepatic dysfunction, and cholestasis. These complications in the neonate can affect morbidity and mortality, thus emphasizing the preference to provide early enteral feedings, as well as medication therapy to improve liver health and outcome. Potential strategies aimed at enhancing PN therapy in the neonate are highlighted in this review, and a summary of guidelines for practical management is included.

Feeding problems in the late preterm infant

Much of the neonatal nutrition literature has focused on the management of very low birth weight infants, a group of infants usually less than 33 weeks gestation. Much less attention has been paid to nutritional management issues in preterm infants at higher gestations. This article reviews nutritional issues that exist from the 239th day (34 0/7 weeks gestation) and ending on the 259th day (36 6/7 weeks gestation) since the first day of the mother's last normal menstrual period.

Parenteral lipid emulsions in paediatrics

PURPOSE OF REVIEW

Lipid emulsions are crucial for providing essential fatty acids and energy in infants and children requiring parenteral nutrition. There is ongoing debate about the optimal composition of lipid emulsions and the optimal timing for introducing lipids to the parenteral nutrition of premature infants in order to enhance the benefits and to minimize the risk of complications.

RECENT FINDINGS

Several studies have investigated the effects of early compared with late administration of lipid emulsions. A meta-analysis demonstrated that early introduction of lipid emulsions does not improve short-term growth or prevent morbidity and mortality in preterm infants. On the other hand, early introduction of lipid emulsions was not shown to increase the risk of complications. A number of studies have investigated the effects of different fatty acid compositions in lipid emulsions on peroxidation. In-vitro findings suggest that lipid peroxidation is related to the polyunsaturated fatty acid content and inversely related to the alpha-tocopherol/polyunsaturated fatty acid ratio of the fat emulsion. The composition of lipid emulsions has also been shown to influence fatty acid metabolism. A mixture of medium-chain and long-chain triglycerides seems to enhance the incorporation of essential fatty acids and long-chain polyunsaturated fatty acids into circulating lipids when compared with an emulsion containing only long-chain triglycerides.

SUMMARY

Although the composition of lipid emulsions has been demonstrated to influence peroxidation and fatty acid metabolism, outcome studies are needed to confirm advantageous effects.

Short bowel syndrome and intestinal transplantation in children

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.

Causes and management of intestinal failure in children

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.

Glucagon-like peptide-2 acutely increases proximal small intestinal blood flow in TPN-fed neonatal piglets

Glucagon-like peptide-2 (GLP-2) is a gut hormone that is secreted in response to enteral feeding and stimulates small intestinal mucosal growth. We have previously shown that GLP-2 infusion acutely increases portal venous blood flow in TPN-fed piglets. The aim of this study was to localize the vasoactive effect of GLP-2 within the gastrointestinal tissues and other visceral organs in TPN-fed piglets. Tissue blood flow rates were quantified using fluorescent microsphere deposition in anesthetized TPN-fed piglets given intravenous infusion of GLP-2 at either 500 pmol·kg−1·h−1 (low GLP-2, n = 7 pigs) or 2,000 pmol·kg−1·h−1 (high GLP-2, n = 8 pigs) for 2 h. Compared with baseline, the low and the high GLP-2 treatment significantly increased the blood flow rate in the duodenum (+77%) and jejunum (+40% and 80%), respectively, but blood flow to the distal small intestine and colon (−15%) was unchanged or slightly decreased. Baseline mucosal blood flow was five-fold higher than serosal blood flow; however, high GLP-2 treatment increased serosal (+140%) to a larger degree than mucosal blood flow (+73%). The high GLP-2 dose increased pancreatic flow (+34%) but decreased blood flow in the kidneys (−14%) and stomach (−12%), whereas the spleen and brain were unaffected. These findings suggest that the acute GLP-2-mediated stimulation of portal blood flow in TPN-fed piglets occurs principally via increased blood flow through the superior mesenteric artery to the proximal small intestine, a tissue region where the GLP-2R mRNA abundance and trophic GLP-2 effects are greatest.

A multiagent strategy to decrease regimen-related toxicity in children undergoing allogeneic hematopoietic stem cell transplantation

Regimen-related toxicity (RRT) is a frequent cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). In this pilot study, we examined the feasibility and potential efficacy of administering a fixed combination of agents as a novel approach to reducing RRT in children undergoing HSCT. Thirty-seven patients were treated with ursodeoxycholic acid, folinic acid, vitamin E, and parenteral nutrition titrated to measured energy expenditure in the peritransplantation period. Outcomes were compared with those in historical controls (n = 131). Compliance with oral ursodeoxycholic acid and vitamin E of at least 90% was achieved in a mean of 86% (95% confidence interval, 75%-97%) of patients. In the study group, we observed (1) reduced prevalence and severity of mucositis (P = .008 and.004, respectively); (2) less severe hepatic toxicity (P = .007); and (3) shorter time to engraftment (P = .02) compared with the control group. These benefits appeared most pronounced among high-risk patients. The administration of this regimen, including oral medications, is feasible during the peritransplantation period, and it is well tolerated. The decreased RRT observed in comparison to historical controls suggests that combination approaches deserve exploration as a means of reducing the morbidity of HSCT.

Pediatric Parenteral Nutrition

Pediatric and adult parenteral nutrition have more similarities than differences. The differences between the two practices become apparent in the time frame for starting support, a few pediatric-specific products, and growth monitoring. The biggest challenge facing the practitioner is to familiarize him- or herself with the wide range of requirements for macro- and micronutrients.

Irreversible intestinal failure

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.