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Lara-Pompa NE, Macdonald S, Fawbert K, Shaw V, Wells JC, Fewtrell M, Hill S. Measuring body composition in pediatric patients with complex diagnoses: Acceptability, practicality, and validation of different techniques. Nutr Clin Pract 2024; 39:673-684. [PMID: 38142311 DOI: 10.1002/ncp.11098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 10/17/2023] [Accepted: 11/05/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Body composition could help identify malnutrition in pediatric patients, but there is uncertainty over which techniques are most suitable and prevailing opinion that measurements are difficult to obtain in practice. This study examined the acceptability, practicality, reliability, and validity of different anthropometric and body composition measurements in patients with complex diagnoses in a tertiary pediatric hospital. METHODS A total of 152 children aged 5-18 years had weight, height, body mass index (BMI), mid-upper arm circumference (MUAC), 4-site skinfold thicknesses (SFT), bioelectrical impedance analysis (BIA), and dual-energy x-ray absorptiometry (DXA) assessed on admission and discharge. Acceptability was assessed in a continuous scale, practicality with number/percentage of successful measurements, reliability with intraclass correlation coefficients and coefficients of repeatability, and validity between "simpler" techniques and DXA with Bland-Altman analysis of agreement and Cohen kappa. RESULTS Techniques were overall acceptable. Measurements were successful in >50%, with patient refusal uncommon. Coefficients of repeatability were good (0.3 cm MUAC and height, 0.2 kg weight, and 1.0 mm SFTs). All techniques significantly overestimated DXA fat mass, but BMI and triceps SFT better identified abnormal fat mass (κ = 0.46 and 0.49). BIA fat-free mass was not significantly different from DXA, with substantial agreement between techniques (κ = 0.65). CONCLUSION Body composition by a range of techniques is acceptable, practical, and reliable in a diverse group of children with complex diagnoses. BIA seems a good alternative to DXA for assessing fat-free mass, triceps SFT, and BMI for fat mass but should be used with care as it could overestimate total fat mass in individuals.
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Affiliation(s)
- Nara E Lara-Pompa
- Childhood Nutrition Research Centre, UCL Great Ormond St Institute of Child Health, London, UK
- Clinical Nutrition, Hospital Infantil Teletón de Oncología, Santiago de Querétaro, México
| | - Sarah Macdonald
- Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Katherine Fawbert
- Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Vanessa Shaw
- Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jonathan C Wells
- Childhood Nutrition Research Centre, UCL Great Ormond St Institute of Child Health, London, UK
| | - Mary Fewtrell
- Childhood Nutrition Research Centre, UCL Great Ormond St Institute of Child Health, London, UK
| | - Susan Hill
- Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Yanchis D, So S, Patterson C, Belza C, Garofalo E, Wong-Sterling S, Silva C, Avitzur Y, Wales PW, Hulst JM, Kong D, Xu L, Li Y, Courtney-Martin G. Body Composition and Physical Activity in Pediatric Intestinal Failure On and Off Parenteral Nutrition. J Pediatr Gastroenterol Nutr 2023; 77:558-564. [PMID: 37434279 DOI: 10.1097/mpg.0000000000003884] [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: 07/13/2023]
Abstract
OBJECTIVES Data on the relationship between body composition (BC) and physical activity (PA) in children with intestinal failure (IF) are lacking. The objectives were to collect data on PA and BC in children with IF, both parenterally and enterally fed, and to assess the relationship between PA and BC. METHODS Cross-sectional study in children 5-18 years with IF including those receiving parenteral nutrition (PN) and those fully enterally fed. PA levels were measured using accelerometry. BC was measured by dual-energy X-ray absorptiometry. Data were compared to age- and sex-matched population norms using t tests. Regression analysis assessed the relationship between BC and PA. RESULTS Fifty-eight children with IF (38 males), mean (SD) age of 10.0 (3.5) years, 20 dependent on PN were included. Patients with IF had significantly fewer steps per day ( P ≤ 0.001) compared with literature controls, with a mean (SD) of 7,972 (3,008) and 11,749 (1,106), respectively. There were no significant differences between patients receiving PN and those enterally fed, but both groups were significantly less active than literature controls ( P < 0.001). Patients with IF had higher fat mass and lower fat-free mass compared to literature controls ( P = 0.008). PA had a significant effect on BC ( r2 = 0.32, P < 0.001). CONCLUSIONS Children with IF, those receiving PN and those fully enterally fed, are at risk of decreased PA and altered BC. PA should be part of ongoing rehabilitation and management to optimize outcomes.
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Affiliation(s)
- Dianna Yanchis
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephanie So
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
- the Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Catherine Patterson
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
- the Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Christina Belza
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Elizabeth Garofalo
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Sylvia Wong-Sterling
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Carina Silva
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Yaron Avitzur
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
- the Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Paul W Wales
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jessie M Hulst
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
- the Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- the Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Dehan Kong
- the Department of Statistical Sciences, University of Toronto, Toronto, ON, Canada
| | - Libai Xu
- the Department of Statistical Sciences, University of Toronto, Toronto, ON, Canada
| | - Yuxuan Li
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Glenda Courtney-Martin
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
- the Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
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3
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Yanchis D, So S, Patterson C, Belza C, Garofalo E, Wong-Sterling S, Silva C, Avitzur Y, Wales PW, Hulst JM, Kong D, Xuyx L, Courtney-Martin G. Assessment of body composition in pediatric intestinal failure: A comparison study. JPEN J Parenter Enteral Nutr 2023; 47:920-929. [PMID: 37355855 DOI: 10.1002/jpen.2540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/12/2023] [Accepted: 06/21/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND The objective of the study was to compare bioelectrical impedance analysis (BIA) and skinfolds with dual energy x-ray absorptiometry (DXA) in the assessment of body composition of children with intestinal failure. DXA is the reference method for body composition assessment in clinical settings. METHODS Children aged 1-18 years with intestinal failure whohave DXA as part of routine clinical monitoring were eligible. BIA measured total body water on the same day as DXA. Skinfold measurements were taken at four sites: triceps, biceps, subscapular, and suprailiac. Percentage of fat mass (%FM) and fat-free mass (%FFM) were derived from resistance and reactance measured by BIA by using age-specific equations. Percentage of FM was calculated from skinfold measures by using age-specific equations. Data on patient characteristics, intestinal failure-related factors, and feeding method were collected. Paired t test examined differences in %FM and %FFM and Bland-Altman analysis determined the agreement between BIA, skinfolds, and DXA. Marginal linear model assessed the effect of age, sex, and feeding method on the difference in body composition obtained between DXA and BIA and between DXA and skinfolds. RESULTS Sixty-eight children with intestinal failure, mean age 8.9 ± 4.2 years, were studied. There was no difference between %FFM and %FM obtained by DXA and BIA (P = 0.26), with a mean bias (95% CI) of -0.69 (-1.9 to 0.5) for %FFM. Sex and age were individually and jointly associated with the bias observed between DXA and BIA (P < 0.05). Skinfold and DXA measurements were significantly different (P < 0.05). CONCLUSIONS BIA is an acceptable clinical tool for assessing body composition in pediatric intestinal failure.
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Affiliation(s)
- Dianna Yanchis
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephanie So
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Patterson
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Christina Belza
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth Garofalo
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sylvia Wong-Sterling
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carina Silva
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jessie M Hulst
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Dehan Kong
- Department of Statistical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Libai Xuyx
- Department of Statistical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Glenda Courtney-Martin
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
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Norsa L, Goulet O, Alberti D, DeKooning B, Domellöf M, Haiden N, Hill S, Indrio F, Kӧglmeier J, Lapillonne A, Luque V, Moltu SJ, Saenz De Pipaon M, Savino F, Verduci E, Bronsky J. Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 2: Long-Term Follow-Up on Home Parenteral Nutrition. J Pediatr Gastroenterol Nutr 2023; 77:298-314. [PMID: 37256821 DOI: 10.1097/mpg.0000000000003850] [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: 06/02/2023]
Abstract
Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The preferred treatment for IF is parenteral nutrition which may be required until adulthood. The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their expertise. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. This second part of the position paper is dedicated to the long-term management of children with SBS-IF. The paper mainly focuses on how to achieve intestinal rehabilitation, treatment of complications, and on possible surgical and medical management to increase intestinal absorption.
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Affiliation(s)
- Lorenzo Norsa
- From the Department of Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Olivier Goulet
- the Department of Pediatric Gastroenterology-Hepatology-Nutrition, APHP Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Daniele Alberti
- the Department of Pediatric Surgery, ASST Spedali Civili, Brescia, Italy
- the Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Barbara DeKooning
- From the Department of Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Magnus Domellöf
- the Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Nadja Haiden
- the Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Susan Hill
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Flavia Indrio
- the Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Jutta Kӧglmeier
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Alexandre Lapillonne
- the Neonatal Intensive Care Unit, APHP Necker-Enfants Malades Hospital, Paris Cité University, Paris, France
- the CNRC, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Veronica Luque
- Serra Hunter, Universitat Rovira I Virgili, IISPV, Tarragona, Spain
| | - Sissel J Moltu
- the Department of Neonatology, Oslo University Hospital, Oslo, Norway
| | - Miguel Saenz De Pipaon
- the Department of Neonatology, Instituto de Investigación Sanitaria del Hospital Universitario La Paz - IdiPAZ, Hospital Universitario La Paz - Universidad Autónoma de Madrid, Madrid, Spain
| | - Francesco Savino
- the Dipartimento di Patologia e cura del bambino "Regina Margherita", A.U.O. Città delle Salute e della Scienza di Torino, Torino, Italy
| | - Elvira Verduci
- the Department of Pediatrics, Ospedale dei Bambini Vittore Buzzi University of Milan, Milan, Italy
| | - Jiri Bronsky
- the Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
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Wang P, Sun H, Maitiabula G, Zhang L, Yang J, Zhang Y, Gao X, Li J, Xue B, Li CJ, Wang X. Total parenteral nutrition impairs glucose metabolism by modifying the gut microbiome. Nat Metab 2023; 5:331-348. [PMID: 36782071 DOI: 10.1038/s42255-023-00744-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/12/2023] [Indexed: 02/15/2023]
Abstract
Total parenteral nutrition (TPN) can lead to complications, such as glucose metabolism disorders. While TPN is associated with impairments in intestinal function, the gut barrier and mucosal immunity, the relationship between the gut microbiome and TPN-related glucose metabolism disorders remains to be explored. In a cohort of 256 participants with type 2 intestinal failure, we show that parenteral nutrition providing >80% of total energy induces insulin resistance and a higher risk of complications. Using various male mouse models, we demonstrate that changes in Lactobacillaceae and indole-3-acetic acid (IAA) levels underlie these complications. Lactobacillaceae and IAA levels decrease in TPN-treated mice and participants, while their abundances in the latter are negatively correlated with insulin resistance and serum lipopolysaccharide levels. Furthermore, IAA activates the aryl hydrocarbon receptor and increases glucagon-like peptide-1 secretion through upregulation of Gcg expression and increased stem cell differentiation towards L cells. Finally, liraglutide, a glucagon-like peptide-1 receptor agonist, completely prevents TPN-induced glucose metabolism disorders in mice. Thus, TPN induces glucose metabolism disorders by altering the gut microbiota and its metabolites.
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Affiliation(s)
- Peng Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Haifeng Sun
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Gulisudumu Maitiabula
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Li Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jianbo Yang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yupeng Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xuejin Gao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Bin Xue
- MOE Key Laboratory of Model Animal for Disease Study, Model Animal Research Center of the Medical School of Nanjing University, Nanjing, China.
- Core Laboratory, Sir Run Run Hospital, Nanjing Medical University, Nanjing, China.
| | - Chao-Jun Li
- State Key Laboratory of Reproductive Medicine and China International Joint Research Center on Environment and Human Health, Center for Global Health, School of Public Health, Gusu School, Nanjing Medical University, Nanjing, China.
| | - Xinying Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
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Muscle Strength, Agility, and Body Composition in Children With Intestinal Failure on Parenteral Nutrition. J Pediatr Gastroenterol Nutr 2022; 75:438-443. [PMID: 35830733 DOI: 10.1097/mpg.0000000000003553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES With increasing number of children with intestinal failure (IF) on long-term parenteral nutrition (PN), this study assesses the impact of IF on muscle strength, speed, and agility and body composition (BC), identifying clinical factors that may predict impairment. METHODS Cross-sectional study in children 5-18 years with IF on PN. Assessments included Bruininks-Oseretsky Test of Motor Proficiency-2 strength and agility subtest (BOT-2), and grip strength. BC data from dual-energy x-ray absorptiometry (DXA) measurements and clinical variables were collected by chart abstraction. Data were compared to age and sex matched controls and population norms. RESULTS Twenty-one children with IF (14 males), median age 8.33 (IQR: 6.96-11.04) years and 33 controls (20 males), 8.25 (6.67-10.79) years were included. Strength and agility ( P < 0.001) and grip strength ( P = 0.001) differed between groups. Nine of 21 (43%) of children with IF scored >1 standard deviation (SD) below mean on BOT-2 and 13 of 21 (62%) had grip strength >1 SD below mean. DXA measurements showed 10 of 18 (56%) of children had lower fat-free mass (FFM)% and higher fat mass (FM)% than reference norms. Decreased FFM% was associated with lower BOT-2 scores ( r = 0.479; P = 0.044) and grip strength scores >1 SD below mean ( P = 0.047). Additional clinical factors significantly impacting strength and agility included prematurity, height, hospitalizations, sepsis, and small bowel length. CONCLUSIONS Children with IF are at risk of decreased muscle strength and agility, along with altered BC. Ongoing medical, nutritional, and rehabilitation intervention is vital to optimize outcomes.
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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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Vlug LE, Neelis EG, Wells JCK, Fewtrell MS, Kastelijn WLM, Olieman JF, Vermeulen MJ, Roelants JA, Rizopoulos D, Wijnen RMH, Rings EHHM, de Koning BAE, Hulst JM. Anthropometrics and fat mass, but not fat-free mass, are compromised in infants requiring parenteral nutrition after neonatal intestinal surgery. Am J Clin Nutr 2021; 115:503-513. [PMID: 34637493 PMCID: PMC8827070 DOI: 10.1093/ajcn/nqab345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/08/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Children with intestinal failure (IF) receiving long-term parenteral nutrition (PN) have altered body composition (BC), but data on BC changes from start of PN onwards are lacking. OBJECTIVES We aimed to assess growth and BC in infants after neonatal intestinal surgery necessitating PN and at risk of IF, and to explore associations with clinical parameters. METHODS A prospective cohort study in infants after intestinal surgery. IF was defined as PN dependency for >60 d. SD scores (SDS) for anthropometry were calculated until 6-mo corrected age. In a subgroup, fat mass (FM) and fat-free mass (FFM) were measured with air-displacement plethysmography at 2- and 6-mo corrected age. SDS for length-adjusted FM index and FFM index were calculated. Associations between cumulative amount of PN and BC parameters were analyzed with linear mixed-effect models. RESULTS Ninety-five neonates were included (54% male, 35% born <32 wk) and 39 infants (41%) had IF. Studied infants had compromised anthropometric parameters during follow-up. At 6-mo corrected age, they remained smaller (median weight-for-age SDS -0.9 [IQR -1.5, 0.1], P < 0.001) than the normal population. In 57 infants, 93 BC measurements were performed. FM index SDS was lower than in healthy infants at 2- and 6-mo corrected age (-0.9 [-1.6, -0.3], P < 0.001 and -0.7 [-1.3, 0.1], P = 0.001, respectively), but FFM index SDS did not differ. A higher cumulative amount of PN predicted a higher FM index in female infants but lower FM index in male infants. CONCLUSIONS In this cohort of infants receiving PN after intestinal surgery, compromised anthropometrics, decreased FM, and adequate FFM were observed during the first 6 mo. Male and female infants seemed to respond differently to PN when it comes to FM index. Continuing growth monitoring after the age of 6 mo is strongly recommended, and further research should explore the benefit of incorporating ongoing BC monitoring during follow-up.
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Affiliation(s)
- Lotte E Vlug
- Department of Pediatrics, Division of Gastroenterology, Erasmus MC University Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Esther G Neelis
- Department of Pediatrics, Division of Gastroenterology, Erasmus MC University Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jonathan C K Wells
- Childhood Nutrition Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom,Population, Policy, and Practice Programme, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Mary S Fewtrell
- Childhood Nutrition Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom,Population, Policy, and Practice Programme, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Wendy L M Kastelijn
- Department of Internal Medicine, Division of Dietetics, Erasmus MC University Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Joanne F Olieman
- Department of Internal Medicine, Division of Dietetics, Erasmus MC University Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marijn J Vermeulen
- Department of Neonatology, Erasmus MC University Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jorine A Roelants
- Department of Neonatology, Erasmus MC University Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dimitris Rizopoulos
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - René M H Wijnen
- Department of Pediatric Surgery, Erasmus MC University Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Edmond H H M Rings
- Department of Pediatrics, Division of Gastroenterology, Erasmus MC University Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands,Department of Pediatrics, Division of Gastroenterology, Leiden University Medical Center Willem Alexander Children's Hospital, Leiden, The Netherlands
| | | | - Jessie M Hulst
- Department of Pediatrics, Division of Gastroenterology, Erasmus MC University Medical Center Sophia Children's Hospital, Rotterdam, The Netherlands,Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
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Yanchis D, Belza C, Harrison D, Wong-Sterling S, Kean P, So S, Patterson C, Wales PW, Avitzur Y, Courtney-Martin G. Normal anthropometry does not equal normal body composition in pediatric intestinal failure. JPEN J Parenter Enteral Nutr 2021; 46:207-214. [PMID: 34510469 DOI: 10.1002/jpen.2265] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/24/2021] [Accepted: 09/08/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Published reports on abnormal body composition in pediatric patients with intestinal failure have been in patients with poor growth. The goal of the current study is to report the body composition of normally growing patients with intestinal failure. METHODS Children 8-18 years old with a dual-energy x-ray absorptiometry (DXA) between January 1, 2013, and July 15, 2018, were included in the study. Data were retrospectively collected from the medical charts and included demographics, residual bowel anatomy, nutrition support, height, and weight. DXA data, including total body less head bone mineral density (BMD), fat mass (FM), and fat-free mass (FFM), were collected and compared with published literature controls matched for age and sex. RESULTS Thirty-four children met inclusion criteria. Mean age at the time of DXA was 9.6 ± 1.8 years. Weight- and height-for-age z-scores were -0.4 ± 0.9 and -0.5 ± 1.0, respectively. Mean BMD z-score was -1.0 ± 1.3. Twenty-six percent of patients (n = 9) had reduced BMD. Patients with intestinal failure had higher FM (P = .02) and lower FFM (P = .02) compared with controls. CONCLUSIONS These data show that, despite reference range z-scores for height and weight, children with intestinal failure are at risk for abnormal body composition. Body composition should be routinely measured in children with intestinal failure to direct nutrition interventions.
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Affiliation(s)
- Dianna Yanchis
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Christina Belza
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Debra Harrison
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Sylvia Wong-Sterling
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Penni Kean
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephanie So
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, ON, Canada
| | - Catherine Patterson
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, ON, Canada
| | - Paul W Wales
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Yaron Avitzur
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Glenda Courtney-Martin
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Faculty of Kinesiology, University of Toronto, Toronto, ON, Canada.,Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
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10
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Pybus R, Puntis JW. Parenteral nutrition. Arch Dis Child 2021; 106:921-922. [PMID: 33087385 DOI: 10.1136/archdischild-2020-319647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Rachel Pybus
- Paediatric Gastroenterology, Leeds Children's Hospital, Leeds, UK
| | - John W Puntis
- Paediatric Gastroenterology, The General Infirmary at Leeds, Leeds, UK
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11
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Chiplunker AJ, Chen L, Levin MS, Warner BW, Davidson NO, Rubin DC. Increased Adiposity and Reduced Lean Body Mass in Patients with Short Bowel Syndrome. Dig Dis Sci 2020; 65:3271-3279. [PMID: 31907775 PMCID: PMC7924810 DOI: 10.1007/s10620-019-06032-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 12/24/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Few studies have examined the metabolic consequences of short bowel syndrome (SBS) and its effects on body composition in adults. We hypothesized that body composition of SBS patients is altered compared to a normal age-, race-, and sex-matched population, regardless of parenteral nutrition (PN) dependence. AIM To compare the body composition of adult patients with SBS to age-, sex-, and race-matched healthy controls. METHODS Twenty patients with SBS underwent body composition analysis using the GE Lunar iDXA scanner. Patients were age-, sex-, and race-matched to controls from the National Health and Nutrition Examination Survey (1999-2004). Mean differences in body mass index, fat-free mass, fat mass, percent body fat, visceral adipose tissue mass and volume, and bone mineral density were measured. Statistical analysis was performed using SAS 9.4 software. RESULTS Fifty-five percent of subjects had a history of PN use, and 30% were current PN users. Mean percent body fat for SBS patients was 35.1% compared to 30.9% for healthy controls (p = 0.043). Fat-free mass was reduced in SBS (p = 0.007). Patients with reduced bone mass had a trend toward significantly more years of PN exposure compared to those with normal bone mass (p = 0.094), and a trend toward older age (p = 0.075). CONCLUSIONS SBS is associated with increased percent body fat and reduced fat-free mass, suggesting that improved dietary and therapeutic interventions are needed to restore normal metabolic indices and avoid risk of metabolic syndrome in SBS patients.
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Affiliation(s)
- Adeeti J. Chiplunker
- Department of Medicine, Division of Gastroenterology, Washington University in St. Louis School of Medicine
| | - Ling Chen
- Division of Biostatistics, Washington University in St. Louis School of Medicine
| | - Marc S. Levin
- Department of Medicine, Division of Gastroenterology, Washington University in St. Louis School of Medicine.,VA St. Louis Health Care System, Washington University in St. Louis School of Medicine
| | - Brad W. Warner
- Division of Pediatric Surgery St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine
| | - Nicholas O. Davidson
- Department of Medicine, Division of Gastroenterology, Washington University in St. Louis School of Medicine.,Department of Developmental Biology; Washington University in St. Louis School of Medicine
| | - Deborah C. Rubin
- Department of Medicine, Division of Gastroenterology, Washington University in St. Louis School of Medicine.,Department of Developmental Biology; Washington University in St. Louis School of Medicine
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12
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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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13
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Kvammen JA, Thomassen RA, Kjeserud CN, Sæland C, Godang K, Bollerslev J, Thorsby PM, Juliusson PB, Bentsen BS, Henriksen C. Bone mineral density and vitamin D in paediatric intestinal failure patients receiving home parenteral nutrition. Clin Nutr ESPEN 2020; 39:234-241. [PMID: 32859323 DOI: 10.1016/j.clnesp.2020.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/06/2020] [Accepted: 06/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Patients with intestinal failure (IF) are dependent on long-term home parenteral nutrition (HPN) to ensure growth and development. The primary aim of the present study was to assess bone mineral density (BMD) and vitamin D status in paediatric IF patients on HPN and a group of healthy children aged 2-18 years. Secondary aims were to assess growth, body composition, nutrient provision and physical activity. METHODS An observational cross-sectional study was performed at Oslo University Hospital and at the Department of Nutrition, University of Oslo, from January to September 2017. Dual energy x-ray absorptiometry (DXA; Lunar Prodigy in IF patients and Lunar iDXA in healthy subjects) was performed to assess BMD and body composition. BMD z-score (BMDz) was calculated for total body and lumbar spine L2-L4 based on the integrated reference population in the software. Weight and height were measured for growth assessment. Nutrient provision was assessed by a 4-day food record. Blood samples were analysed for 25-hydroxy-vitamin D (25(OH)D) and 1,25-dihydroxyvitamin D (1,25(OH)2D). Physical activity was reported by a questionnaire. RESULTS Nineteen IF patients and 50 healthy children were included. The mean age of participants was 10.0 years. The aetiology of IF patients was paediatric intestinal pseudo-obstruction (58%), short bowel syndrome (26%), and intestinal enteropathy (16%). Lower median BMDz for total body (-0.4 vs 1.1, P < 0.001) and lumbar spine L2-L4 (-0.9 vs 0.2, P = 0.01) were found in the IF group compared with the healthy children. Vitamin D provision was significantly higher in IF patients (17 μg/d vs 5.3 μg/d, P < 0.001). Both groups were sufficient in 25(OH)D (IF patients 71 nmol/L vs healthy 81 nmol/L). Nevertheless, IF patients had significantly lower 1,25(OH)2D than healthy children (71 pmol/L vs 138 pmol/L, P < 0.001). The IF group was significantly shorter (height for age z-score -1,5 vs 0,1, P = 0.001) and lighter (weight for age z-score -1,0 vs 0,1, P = 0.009) compared with the healthy subjects. BMIz did not differ; however, body fat percentage was significantly higher in IF patients compared with healthy children (34% vs 25%, P = 0.02). A lower frequency of physical activity was found in the IF group compared with the healthy group (P = 0.001). CONCLUSIONS Paediatric IF patients on HPN had lower BMD, impaired growth, and higher body fat percentage in comparison with the healthy children. Despite a higher total supply of vitamin D in the IF group, the levels of 25(OH)D did not differ. Nevertheless, a significantly lower level of 1,25(OH)2D was found in IF patients. The results raise questions regarding differences between oral and parenteral vitamin D provision and whether intestinal function is important for the metabolism of vitamin D. TRIAL IDENTIFICATION NUMBER Clinical Trials AEV2017/1. 2016/391/REK sør-øst B REVISION NUMBER: CLNESP-D-20-00022.
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Affiliation(s)
- Janne Anita Kvammen
- University of Oslo, Department of Nutrition, Institute of Basic Medical Sciences, Faculty of Medicine, Oslo, Norway; Oslo University Hospital, Department of Paediatric Medicine, Oslo, Norway.
| | - Rut Anne Thomassen
- Oslo University Hospital, Department of Paediatric Medicine, Oslo, Norway
| | | | - Camilla Sæland
- University of Oslo, Department of Nutrition, Institute of Basic Medical Sciences, Faculty of Medicine, Oslo, Norway; Oslo University Hospital, Department of Paediatric Medicine, Oslo, Norway
| | - Kristin Godang
- Oslo University Hospital, Department of Specialized Endocrinology, Oslo, Norway
| | - Jens Bollerslev
- Oslo University Hospital, Department of Specialized Endocrinology, Oslo, Norway; University of Oslo, Faculty of Medicine, Oslo, Norway
| | - Per Medbøe Thorsby
- Oslo University Hospital, Hormone Laboratory, Department of Medical Biochemistry, Oslo, Norway
| | - Petur Benedikt Juliusson
- University of Bergen, Department of Clinical Science, Bergen, Norway; Norwegian Institute of Public Health, Department of Health Registries, Bergen, Norway
| | | | - Christine Henriksen
- University of Oslo, Department of Nutrition, Institute of Basic Medical Sciences, Faculty of Medicine, Oslo, Norway
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14
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Watrobska-Swietlikowska D, MacLoughlin R. The effect of UV-protected ethylene vinyl acetate (EVA) bags on the physicochemical stability of pediatric parenteral nutrition admixtures. ACTA ACUST UNITED AC 2019; 27:255-264. [PMID: 31102140 PMCID: PMC6593020 DOI: 10.1007/s40199-019-00270-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 04/30/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The safe administration of parenteral admixtures should be considered under the headings of physical and chemical stability. Vitamins are considered to be most susceptible to chemical degradation. OBJECTIVES To evaluate the protective effect of UV-protected monolayer ethylene vinyl acetate (EVA) bags in comparison with that of EVA bags without UV protection, on the physicochemical characteristics and stability of the light sensitive vitamins in pediatric parenteral admixtures stored under various temperature and light conditions. METHODS Four different parenteral pediatric admixtures (with trace elements and vitamins) in two types of ethylenovinylacetate (EVA) monolayer containers (with - yellow one and without - transparent one UV protection) were assessed. The physicochemical analyses such as visual inspection, pH and potential zeta measurements, lipid globules size distribution and vitamins concentration were performed at 0 h, 24 h, 8 days and 8 days+24 h after the preparation of the TPN admixtures. In order to quantify ascorbic acid, thiamine and pyridoxine levels, HPLC was used. RESULTS No differences (p < 0.05) in physicochemical stability of TPN admixtures were noted between two types of EVA bags, with the compositions assessed; stored 8 days (4 °C ± 2) without light plus 24 h at room temperature and light exposure. However significant differences were noticed in ascorbic acid, thiamine and pyridoxine content after 8 days+24 h in comparison with t = 0. This was noted for both for UV-protected bags and bags without UV-protection, Nevertheless, amounts were still within the pharmacopeial range. CONCLUSIONS Both EVA bags under test (with and without UV-protection) ensure physicochemical stability up 8 days at 4 °C ± 2 °C without light exposure and then 24 h at room temperature with light exposure for the total pediatric parenteral admixtures, intended for home parenteral nutrition. Graphical abstract Scheme of physicochemical analysis of parenteral admixtures.
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Affiliation(s)
| | - Ronan MacLoughlin
- Aerogen, IDA Business Park, Dangan, Galway, Ireland.,School of Pharmacy, Royal College of Surgeons, Dublin, Ireland.,School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin 2, Dublin, Ireland
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15
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Zemrani B, Bines JE. Monitoring of long-term parenteral nutrition in children with intestinal failure. JGH OPEN 2019; 3:163-172. [PMID: 31061893 PMCID: PMC6487815 DOI: 10.1002/jgh3.12123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/02/2018] [Accepted: 11/03/2018] [Indexed: 12/19/2022]
Abstract
Pediatric intestinal failure (IF) is a rare and complex condition associated with significant morbidity and mortality. It is defined as the reduction of gut mass or function below the minimal needed for absorption of nutrients and fluid to sustain life and growth. Since the advent of specialized multidisciplinary intestinal rehabilitation centers, IF management has considerably evolved in the last years, but serious complications of long-term parenteral nutrition (PN) can occur. Main complications include intestinal failure-associated liver disease, growth failure, body composition imbalance, central venous access complications, micronutrient deficiencies and toxicities, metabolic bone disease, small intestinal bacterial overgrowth, and renal disease. With improvement in survival rates of patients over the last 20 years, emphasis should be on limiting IF-related comorbidities and improving quality of life. Close monitoring is pivotal to ensuring quality of care of these patients. The care of children with chronic IF should involve a comprehensive monitoring plan with flexibility for individualization according to specific patient needs. Monitoring of children on long-term PN varies significantly across units and is mainly based on experience, although few guidelines exist. This narrative review summarizes the current knowledge and practices related to monitoring of children with IF. The authors also share their 20-year experience at the Royal Children's Hospital in Melbourne Australia on this topic.
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Affiliation(s)
- Boutaina Zemrani
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition The Royal Children's Hospital Melbourne Victoria Australia
| | - Julie E Bines
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition The Royal Children's Hospital Melbourne Victoria Australia.,Murdoch Children's Research Institute Melbourne Victoria Australia
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16
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Neelis E, Kouwenhoven S, Olieman J, Tabbers M, Jonkers C, Wells J, Fewtrell M, Wijnen R, Rings E, de Koning B, Hulst J. Body Composition Using Air Displacement Plethysmography in Children With Intestinal Failure Receiving Long-Term Home Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2019; 44:318-326. [PMID: 30900272 DOI: 10.1002/jpen.1527] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 02/17/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Children with intestinal failure (IF) are at risk of growth failure, but little information about body composition is available. Our aim was to assess body composition using air displacement plethysmography (ADP) and relate it to clinical and growth parameters. METHODS In this prospective descriptive observational 2-center cohort study, children aged 2-18 years receiving home parenteral nutrition (PN) for ≥6 months underwent ADP measurement. Fat mass index (FMI) and fat-free mass index (FFMI) standard deviation scores (SDSs) were calculated to normalize for small body size. RESULTS Twenty-one out of 22 children, median age 7.4 years, underwent successful ADP measurement after a median PN duration of 5.5 years. They were significantly lighter (median weight for age SDS -0.71, P = 0.004) and shorter (median height for age SDS -1.55, P < 0.001) than the normal population mean; 52% were growing below target height range. They had low FFMI (median SDS -1.53, P < 0.001) and high FMI (median SDS 0.80, P = 0.002). Weight for height and body mass index (BMI) were significantly associated with FFMI and BMI with FMI, but children with the same weight and height showed different body composition. In 13 patients with 1-year follow-up, growth and body composition did not change significantly. CONCLUSION Children with IF receiving long-term PN show lower FFM and higher FM than healthy children. Additionally, children with similar routine growth parameters showed different body composition. Further studies should evaluate the effect of a patient-tailored approach including physical activity and nutrition advice based on body composition.
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Affiliation(s)
- Esther Neelis
- Department of Pediatric Gastroenterology, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Stefanie Kouwenhoven
- Department of Pediatrics, Amsterdam UMC, Vrije Universiteit Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands
| | - Joanne Olieman
- Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Dietetics, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Merit Tabbers
- Department of Pediatric Gastroenterology, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands
| | - Cora Jonkers
- Department of Dietetics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jonathan Wells
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Mary Fewtrell
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - René Wijnen
- Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Edmond 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
| | - Barbara de Koning
- Department of Pediatric Gastroenterology, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Jessie Hulst
- Department of Pediatric Gastroenterology, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
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17
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Messova A, Dziubak R, Köglmeier J. Renal Function in Children on Long Term Home Parenteral Nutrition. Front Pediatr 2019; 7:137. [PMID: 31058118 PMCID: PMC6477075 DOI: 10.3389/fped.2019.00137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/25/2019] [Indexed: 11/13/2022] Open
Abstract
Objectives: To assess renal function in pediatric intestinal failure (IF) patients on long term home parenteral nutrition (HPN). Methods: Children who received HPN for a minimum of 3 years between 2007 and 2017 were identified from the IF clinic of a large tertiary referral center. Estimated glomerular filtration rate (eGFR) was calculated using the Schwartz formula at discharge on HPN, after 6 months, 1, 2, and 3 years. Results: Twenty five patients (40% male) fulfilled the inclusion criteria. The indications for HPN were due to an underlying motility disorder in 56% (14/25), enteropathy in 24% (6/25), and short bowel syndrome in 20% (5/25). At the start of HPN 80% (20/25) had a normal eGFR. Four children (17%) had an abnormal eGFR. In the group of patients with normal eGFR at the start of HPN 30% (6/20) had at least one episode of decreased eGFR in the following 3 years, however there was no significant decline in eGFR at the end of the 3 year study period. Overall there was no statistically significant deterioration of eGFR in the study population (p = 0.7898). Conclusion: In our cohort of children on long term HPN no significant decline of eGFR could be demonstrated within 3 years of starting PN.
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Affiliation(s)
- Assylzhan Messova
- Unit of Nutrition and Intestinal Failure Rehabilitation, Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Robert Dziubak
- Unit of Nutrition and Intestinal Failure Rehabilitation, Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Jutta Köglmeier
- Unit of Nutrition and Intestinal Failure Rehabilitation, Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, London, United Kingdom
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18
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ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Organisational aspects. Clin Nutr 2018; 37:2392-2400. [DOI: 10.1016/j.clnu.2018.06.953] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/18/2022]
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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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Growth, Body Composition, and Micronutrient Abnormalities During and After Weaning Off Home Parenteral Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:e95-e100. [PMID: 30028828 DOI: 10.1097/mpg.0000000000002090] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The aim of the study is to assess growth, body composition, and micronutrient abnormalities in children with intestinal failure (IF) over time, both during and after weaning off parenteral nutrition (PN). METHODS Retrospective study in children on home PN between 2001 and 2015. Weight-for-age (WFA) and height-for-age (HFA) SD scores (SDS) were calculated, as well as fat mass (FM) and fat-free mass (FFM) SDS obtained by dual energy x-ray absorptiometry. The course of growth parameters and body composition was analyzed with linear-mixed models. All micronutrient measurements during the study period were obtained. RESULTS Fifty-two patients were included with a median follow-up of 3.4 years. Seventy-one percent weaned off after a median PN duration of 0.9 years. One year after the start of PN, 28 patients were still PN-dependent with median WFA-SDS of -0.66 and median HFA-SDS of -0.96, both significantly lower than zero. Catch-up growth was achieved during PN, but HFA-SDS decreased after weaning (P = 0.0001). At a median age of 6.2 years, median %FM SDS was 0.30 and FFM SDS was -1.21, the latter significantly lower than zero. Frequent micronutrient abnormalities during PN were vitamin A (90%), zinc (87%), and iron (76%) and after weaning vitamin A (94%), E (61%), and 25-OH vitamin D (59%). CONCLUSIONS Children with IF demonstrate abnormal growth and body composition and frequent micronutrient abnormalities. Longitudinal evaluation showed that catch-up growth occurs during PN, but height SDS decreases after weaning. This underlines the need for close monitoring, also after reaching enteral autonomy.
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Engelstad HJ, Barron L, Moen J, Wylie TN, Wylie K, Rubin DC, Davidson N, Cade WT, Warner BB, Warner BW. Remnant Small Bowel Length in Pediatric Short Bowel Syndrome and the Correlation with Intestinal Dysbiosis and Linear Growth. J Am Coll Surg 2018; 227:439-449. [PMID: 30077861 PMCID: PMC6162148 DOI: 10.1016/j.jamcollsurg.2018.07.657] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pediatric short bowel syndrome (SBS) is a malabsorptive state placing patients at risk for malnutrition, dehydration, and bacterial overgrowth. These patients are often dependent on parenteral nutrition (PN) while intestinal adaptation is underway. The aim of this study was to characterize the effect of remnant small bowel length on the gut microbiome. Further, we sought to examine the contribution of clinical and nutritional variables to the gut microbiota and anthropometric growth. STUDY DESIGN Clinical data, anthropometrics, and fecal samples were collected from 14 SBS patients and 10 age- and sex-matched controls. Fecal bacterial DNA composition was analyzed using 16s ribosomal RNA gene sequencing. Statistical analysis was completed using the Mann-Whitney or Fisher's exact tests when applicable and linear mixed effect modeling. RESULTS Distinct microbiota changes were found among those with the least remaining small bowel (<35 cm) compared with those with longer remaining bowel and controls. Those with <35 cm small bowel displayed an increased relative abundance of Proteobacteria, while those with longer remaining small bowel had a higher proportion of Firmicutes. Further, patients with less remaining bowel required more PN (p < 0.01), with a tendency to be shorter in height (p = 0.05) and with a higher BMI (p = 0.05). CONCLUSIONS Remnant small bowel length appears to be a predictor of stunting with diminished linear growth, parenteral nutrition dependency, and a greater relative abundance of Proteobacteria in the gut. These findings suggest an integrated adaptive response predicted by remnant intestinal length. Further research is necessary to examine the effects of intestinal dysbiosis on clinical outcomes.
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Affiliation(s)
- Holly J Engelstad
- Department of Pediatrics, Washington University, School of Medicine, St Louis, MO
| | - Lauren Barron
- Department of Surgery, Washington University, School of Medicine, St Louis, MO
| | - Joseph Moen
- Department of Biostatistics, Washington University, School of Medicine, St Louis, MO
| | - Todd N Wylie
- Department of Pediatrics, Washington University, School of Medicine, St Louis, MO
| | - Kristine Wylie
- Department of Pediatrics, Washington University, School of Medicine, St Louis, MO
| | - Deborah C Rubin
- Department of Medicine, Washington University, School of Medicine, St Louis, MO
| | - Nicholas Davidson
- Department of Medicine, Washington University, School of Medicine, St Louis, MO
| | - W Todd Cade
- Department of Medicine, Washington University, School of Medicine, St Louis, MO; Program in Physical Therapy, Washington University, School of Medicine, St Louis, MO
| | - Barbara B Warner
- Department of Pediatrics, Washington University, School of Medicine, St Louis, MO
| | - Brad W Warner
- Department of Surgery, Washington University, School of Medicine, St Louis, MO.
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Hill S, Ksiazyk J, Prell C, Tabbers M. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Home parenteral nutrition. Clin Nutr 2018; 37:2401-2408. [PMID: 30098848 DOI: 10.1016/j.clnu.2018.06.954] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Susan Hill
- Great Ormond Street Hospital for Children, London WC1N 3JH, UK; Institute of Child Health, London WC1N 1EH, UK.
| | - Janusz Ksiazyk
- The Children's Memorial Health Institute, Warsaw, Poland
| | - Christine Prell
- Dr. von Hauner Children's Hospital, Medical Center of the University of Munich, Munich, Germany
| | - Merit Tabbers
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Barron L, Courtney C, Bao J, Onufer E, Panni RZ, Aladegbami B, Warner BW. Intestinal resection-associated metabolic syndrome. J Pediatr Surg 2018; 53:1142-1147. [PMID: 29588076 PMCID: PMC5994370 DOI: 10.1016/j.jpedsurg.2018.02.077] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 02/27/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Short bowel syndrome occurs following massive small bowel resection (SBR) and is one of the most lethal diseases of childhood. We have previously demonstrated hepatic steatosis, altered gut microbiome, and increased fat deposition in our murine model of SBR. These novel findings prompted us to investigate potential alterations in glucose metabolism and systemic inflammation following intestinal resection. METHODS Male C57BL6 mice underwent 50% proximal SBR or sham operation. Body weight and composition were measured. Fasting blood glucose (FBG), glucose, and insulin tolerance testing were performed. Small bowel, pancreas, and serum were collected at sacrifice and analyzed. RESULTS SBR mice gained less weight than shams after 10weeks. Despite this, FBG in resected mice was significantly higher than sham animals. After SBR, mice demonstrated perturbed body composition, higher blood glucose, increased pancreatic islet area, and increased systemic inflammation compared with sham mice. Despite these changes, we found no alteration in insulin tolerance after resection. CONCLUSIONS After massive SBR, we present evidence for abnormal body composition, glucose metabolism, and systemic inflammation. These findings, coupled with resection-associated hepatic steatosis, suggest that massive SBR (independent of parenteral nutrition) results in metabolic consequences not previously described and provides further evidence to support the presence of a novel resection-associated metabolic syndrome.
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Affiliation(s)
- Lauren Barron
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; St. Louis Children's Hospital, St. Louis, MO, USA
| | - Cathleen Courtney
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; St. Louis Children's Hospital, St. Louis, MO, USA
| | - James Bao
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; St. Louis Children's Hospital, St. Louis, MO, USA
| | - Emily Onufer
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; St. Louis Children's Hospital, St. Louis, MO, USA
| | - Roheena Z Panni
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; St. Louis Children's Hospital, St. Louis, MO, USA
| | - Bola Aladegbami
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; St. Louis Children's Hospital, St. Louis, MO, USA
| | - Brad W Warner
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA; St. Louis Children's Hospital, St. Louis, MO, USA.
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Neelis E, Rijnen N, Sluimer J, Olieman J, Rizopoulos D, Wijnen R, Rings E, de Koning B, Hulst J. Bone health of children with intestinal failure measured by dual energy X-ray absorptiometry and digital X-ray radiogrammetry. Clin Nutr 2018; 37:687-694. [DOI: 10.1016/j.clnu.2017.02.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/19/2017] [Accepted: 02/16/2017] [Indexed: 12/12/2022]
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Growth Trajectory in Children With Short Bowel Syndrome During the First 2 Years of Life. J Pediatr Gastroenterol Nutr 2018; 66:484-488. [PMID: 28953527 DOI: 10.1097/mpg.0000000000001762] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Infants with short bowel syndrome (SBS) require diligent nutritional support for adequate growth. Enteral independence is a primary goal, but must be balanced with ensuring sufficient nutrition. We aimed to describe growth trajectory in infants with SBS as function of nutritional intake during first 2 years of life. METHODS Infants with SBS were reviewed (2008-2016). z Scores for weight, height, and head circumference (HC) were recorded at birth, 3, 6, 12, 18, and 24 months. Nutritional intake, serum liver enzyme, and bilirubin levels were assessed at all time points. Pearson correlation coefficients were used to measure association with P < 0.05 considered significant. RESULTS Forty-one infants were included, with median gestational age of 34 weeks (interquartile range [IQR] 29-36 weeks). Median small bowel length was 36 cm (IQR 26-52 cm) and median % expected small bowel length was 28% (IQR 20%-42%). Mean z scores for weight and length were >0 at birth, but <0 from 3 months to 2 years. HC remained <0 throughout the study. Mean z scores at 2 years for weight, length, HC, and weight-for-length were -0.90 (SD 1.1), -1.33 (SD 1.4), -0.67 (SD 1.2), and -0.12 (SD 1.2), respectively. Percentage calories from PN was positively correlated with weight in the first 3 months of life (P = 0.01). CONCLUSIONS Babies with SBS are high risk for poor growth during the first 2 years of life. Although weaning PN is important for these patients, doing so too quickly in infancy may contribute to compromised growth. The long-term impact on overall development is not known.
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Poinsot P, Geoffroy P, Braillon P, Denis A, Loras-Duclaux I, Marotte S, Boutroy S, Bacchetta J, Touzet S, Lachaux A, Peretti N. Longitudinal Bone Mineralization Assessment in Children Treated With Long-Term Parenteral Nutrition for Severe Intestinal Failure. JPEN J Parenter Enteral Nutr 2017; 42:613-622. [PMID: 28355492 DOI: 10.1177/0148607117701399] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 03/01/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Metabolic bone disease is common in children receiving home parenteral nutrition (HPN) for intestinal failure (IF). Long-term evolution of bone mass in pediatric IF is poorly documented. The aims of this study were (1) to determine the prevalence of low bone mass (LBM) in children receiving HPN for IF, (2) to evaluate the evolution of total bone mineral content (TBMC) during HPN with dual-energy x-ray absorptiometry (DXA), and (3) to identify related factors. METHODS All children referred in our HPN center from 2004 to 2014 were eligible. Inclusion criteria were HPN dependence due to noninflammatory IF, at least 2 TBMC assessments, and HPN duration of at least 2 years at last DXA. TBMC was expressed in z score for ideal weight for height (WFH). LBM was defined by a TBMC WFH z score ≤-2 standard deviations (SD). RESULTS A total of 175 DXAs for 31 children were performed, mean of 5.6 ± 2.9 assessments per child. The median time between first and last DXA recorded was 6.2 years (0.7-16.6). At the first DXA, 14 children (45%) had a LBM. TBMC increased by +0.1 ± 0.04 SD per year of HPN (P = .012). The risk of LBM decreased with an odds ratio of 0.9 per year of HPN (95% confidence interval, 0.92-0.99; P = .018). Lean mass z score and calcium parenteral intakes were related to the TBMC improvement. CONCLUSION LBM is common in pediatric IF, but bone status could improve during HPN in these children.
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Affiliation(s)
- Pierre Poinsot
- Hepatology, Gastroenterology and Pediatric Nutrition Unit, Femme Mere Enfant Hospital, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Perrine Geoffroy
- Hepatology, Gastroenterology and Pediatric Nutrition Unit, Femme Mere Enfant Hospital, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Pierre Braillon
- Radiology Department, Hopital Femme Mere Enfant, Hospices Civils de Lyon, Lyon, France
| | - Angelique Denis
- Medical Information and Research Analysis Department, Hospices Civils de Lyon, Lyon, France
| | - Irene Loras-Duclaux
- Hepatology, Gastroenterology and Pediatric Nutrition Unit, Femme Mere Enfant Hospital, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Stéphanie Marotte
- Hepatology, Gastroenterology and Pediatric Nutrition Unit, Femme Mere Enfant Hospital, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Stéphanie Boutroy
- INSERM U1033, Lyos, Pathophysiology, Hospices Civils de Lyon, Lyon, France
| | - Justine Bacchetta
- INSERM U1033, Lyos, Pathophysiology, Hospices Civils de Lyon, Lyon, France.,Pediatric Nephrology, Rheumatology, Dermatology Unit, Femme Mere Enfant Hospital, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Sandrine Touzet
- Medical Information and Research Analysis Department, Hospices Civils de Lyon, Lyon, France
| | - Alain Lachaux
- Hepatology, Gastroenterology and Pediatric Nutrition Unit, Femme Mere Enfant Hospital, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Noel Peretti
- Hepatology, Gastroenterology and Pediatric Nutrition Unit, Femme Mere Enfant Hospital, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France.,INSERM U1060, CarMeN laboratory, Hospices Civils de Lyon, F-69003 Lyon, France
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Doulgeraki AE, Athanasopoulou HI, Katsalouli MS, Petrocheilou GM, Paspati IN, Monopolis IK. Body composition of patients with Duchenne muscular dystrophy: the Greek experience. Acta Neurol Belg 2016; 116:565-572. [PMID: 26680652 DOI: 10.1007/s13760-015-0582-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 12/01/2015] [Indexed: 11/28/2022]
Abstract
Greece ranks among the first countries suffering from the obesity epidemic globally. The aim of the study was to evaluate body composition in Greek patients with Duchenne muscular dystrophy (DMD). We hypothesized that able-bodied patients would not differ from controls, in terms of adiposity, based on clinical observations during everyday practice. STUDY DESIGN Cross-sectional study of steroid-dependent DMD subjects, who underwent dual-energy X-ray absorptiometry and laboratory metabolic bone profile evaluation. Forty-two patients and thirty-one controls were studied. Overall, DMD subjects were shorter (height Z-score = -1.4, p = 0.01). Their bone mineral density (BMD) was low (lumbar spine BMD Z-score = -1.2, p < 0.01, subcranial total body BMD Z-score = -1.8, p < 0.01). Lean tissue mass (LTM) was also decreased (LTM Z-score = -2.2, p < 0.01). The above findings were more pronounced in adolescence. Regarding adiposity, increased fat mass (FM) was found only in pubertal DMD patients (FM Z-score = 1.4, p < 0.01), whereas prepubertal, able-bodied patients did not differ from controls, thus confirming the initial hypothesis. Finally, 65 % of DMD subjects had increased bone resorption markers and 57 % had suboptimal vitamin D levels. The importance of using native population as controls for body composition analysis is highlighted. In Greece, abnormal body composition in DMD patients is more striking when loss of ambulation occurs and not during the prepubertal period, due to the concurrent presence of obesity in the pediatric population. Thus, adolescents with this neuromuscular disorder should be targeted toward prompt lifestyle interventions.
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Affiliation(s)
- Artemis E Doulgeraki
- Department of Bone and Mineral Metabolism, Institute of Child Health, "Agia Sophia" Children's Hospital, 115 27, Goudi, Athens, Greece.
| | - Helen I Athanasopoulou
- Department of Bone and Mineral Metabolism, Institute of Child Health, "Agia Sophia" Children's Hospital, 115 27, Goudi, Athens, Greece
| | | | - Glykeria M Petrocheilou
- Department of Bone and Mineral Metabolism, Institute of Child Health, "Agia Sophia" Children's Hospital, 115 27, Goudi, Athens, Greece
| | - Ioanna N Paspati
- Department of Orthopedics, "Penteli" Children's Hospital, Athens, Greece
| | - Ioannis K Monopolis
- Department of Statistics, Institute of Child Health, "Agia Sophia" Children's Hospital, Athens, Greece
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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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Impact of Surgery for Neonatal Gastrointestinal Diseases on Weight and Fat Mass. J Pediatr 2015; 167:568-71. [PMID: 26148657 DOI: 10.1016/j.jpeds.2015.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/20/2015] [Accepted: 06/04/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare growth, fat mass (FM), and fat-free mass in surgical infants vs matched controls at similar postconceptional age (PCA). STUDY DESIGN Anthropometric and body composition measurements by air-displacement plethysmography (PeaPod-Infant Body Composition System; LMI, Concord, California) were performed at the same PCA in 21 infants who received gastrointestinal surgery and in 21 controls matched for gestational age, birth weight, and sex. RESULTS Despite similar anthropometry at birth, postsurgical infants were shorter (50.4 [4.7] cm vs 53.2 [4.1] cm, P = .001), lighter (3516 [743] g vs 3946 [874] g, P < .001), and had lower FM content (%FM 14.8 [4.7]% vs 20.2 [5.8]%, P < .0001) than their peers at similar PCA (43 [4] weeks). All surgical infants but 1 (20/21) received parenteral nutrition (PN). Mean PN duration was 40 (30) days. Five infants in the control group received PN because of prematurity for 15 (9-30) days. Nine infants in the surgical group and 1 in the control group had PN-associated cholestasis. CONCLUSIONS Neonates having surgery for gastrointestinal diseases were shorter, had lower weight, and lower FM content than their peers, despite receiving more PN. Body composition evaluation and monitoring may help optimize growth in these newborns.
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Hukkinen M, Merras-Salmio L, Sipponen T, Mutanen A, Rintala RJ, Mäkisalo H, Pakarinen MP. Surgical rehabilitation of short and dysmotile intestine in children and adults. Scand J Gastroenterol 2015; 50:153-61. [PMID: 25421304 DOI: 10.3109/00365521.2014.962607] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIMS This is a descriptive study aiming to compare outcomes of intestinal rehabilitation surgery among pediatric and adult intestinal failure (IF) patients with either primary intestinal motility disorders or short bowel syndrome (SBS) treated by our nationwide program. METHODS Medical records of IF patients (n = 31, 71% children) having undergone autologous intestinal reconstructions (AIR) (n = 25), intestinal transplantation (ITx) (n = 5), or being listed for ITx (n = 2) between 1994 and 2014 were reviewed. RESULTS At surgery, median age was 3.4 (interquartile range, 1.0-22.1) in SBS (n = 22) and 16.5 (3.2-26.7) years in dysmotility patients (n = 9) who received median 60% and 83% of energy requirement parenterally, respectively. Median small bowel length was shorter in SBS than dysmotility patients (34 versus 157 cm, p < 0.001). Following AIR, none of the dysmotility patients achieved permanent intestinal autonomy, whereas 68% of SBS patients weaned off parenteral nutrition (PN) (p = 0.022) and none required listing for ITx. Five dysmotility patients who underwent ITx achieved intestinal autonomy. Regarding both AIR and ITx procedures, no significant difference in PN weaning was observed between the two subgroups. At last follow-up, 3.3 (0.6-8.0) years postoperatively, median plasma bilirubin was 6 (4-16) µmol/l, while liver biopsy showed fibrosis (Metavir stage 1-2) in 50% and cholestasis in 8%. Proportion of PN energy requirement had reduced significantly (p = 0.043) among PN-dependent SBS (n = 7) but not among dysmotility patients (n = 5). Overall survival was 90%. CONCLUSION AIR surgery was beneficial among selected SBS patients, whereas in intestinal dysmotility disorders, permanent PN weaning was only achieved by ITx.
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Affiliation(s)
- Maria Hukkinen
- Pediatric Liver and Gut Research Group, University of Helsinki , Helsinki , Finland
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Abstract
OBJECTIVES The aim of the study was to examine the agreement of multifrequency bioelectric impedance analysis (BIA) and anthropometry with reference methods for body composition assessment in children with intestinal failure (IF). METHODS We conducted a prospective pilot study in children 14 years or younger with IF resulting from either short bowel syndrome or motility disorders. Bland-Altman analysis was used to examine the agreement between BIA and deuterium dilution in measuring total body water (TBW) and lean body mass (LBM), and between BIA and dual-energy x-ray absorptiometry (DXA) techniques in measuring LBM and fat mass (FM). FM and percent body fat (%BF) measurements by BIA and anthropometry were also compared in relation to those measured by deuterium dilution. RESULTS Fifteen children with IF, median (interquartile range) age 7.2 (5.0, 10.0) years, and 10 (67%) boys, were studied. BIA and deuterium dilution were in good agreement with a mean bias (limits of agreement) of 0.9 (-3.2 to 5.0) for TBW (L) and 0.1 (-5.4 to 5.6) for LBM (kg) measurements. The mean bias (limits) for FM (kg) and %BF measurements were 0.4 (-3.8 to 4.6) kg and 1.7 (-16.9 to 20.3)%, respectively. The limits of agreement were within 1 standard deviation of the mean bias in 12 of 14 (86%) subjects for TBW and LBM, and in 11 of 14 (79%) for FM and %BF measurements. Mean bias (limits) for LBM (kg) and FM (kg) between BIA and DXA were 1.6 (-3.0 to 6.3) kg and -0.1 (-3.2 to 3.1) kg, respectively. Mean bias (limits) for FM (kg) and %BF between anthropometry and deuterium dilution were 0.2 (-4.2 to 4.6) and -0.2 (-19.5 to 19.1), respectively. The limits of agreement were within 1 standard deviation of the mean bias in 10 of 14 (71%) subjects. CONCLUSIONS In children with IF, TBW and LBM measurements by multifrequency BIA method were in agreement with isotope dilution and DXA methods, with small mean bias and clinically acceptable limits of agreement. In comparison with deuterium dilution, BIA was comparable to anthropometry for FM and %BF assessments with small mean bias, but the limits of agreement were large. BIA is a reliable method for TBW and LBM assessments in population studies; however, its reliability in individual patients, especially for FM assessments, cannot be guaranteed.
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