Reversal of parenteral nutrition-associated liver disease in two infants with short bowel syndrome using parenteral fish oil: implications for future management

Here we report the reversal of cholestasis in 2 infants with intestinal failure and parenteral nutrition-associated liver disease. Treatment involved the substitution of a conventional intravenous fat emulsion with one containing primarily omega-3 fatty acids. Biochemical tests of liver function improved significantly. One child was removed from the liver transplantation list because of improved hepatic function, and the second child had complete resolution of cholestasis while solely on parenteral nutrition. This suggests that fat emulsions made from fish oils may be an effective means of treating and preventing this often-fatal condition. A randomized, controlled trial is necessary to study the efficacy of this new approach to parenteral nutrition-associated liver disease.

Nutritional and other postoperative management of neonates with short bowel syndrome correlates with clinical outcomes

OBJECTIVE

To determine correlates of clinical outcomes in patients with short bowel syndrome (SBS).

METHODS

Retrospective medical record review of neonates treated between 1986 and 1998 who met our criteria for SBS: dependence on parenteral nutrition (PN) for at least 90 days after surgical therapy for congenital or acquired intestinal diseases.

RESULTS

Thirty subjects with complete data were identified; 13 (43%) had necrotizing enterocolitis, and 17 (57%)had intestinal malformations. Mean (SD) residual small bowel length was 83 (67) cm. Enteral feeding with breastmilk (r = -0.821) or an amino acid-based formula (r = -0.793) was associated with a shorter duration of PN, as were longer residual small bowel length (r = -0.475) and percentage of calories received enterally at 6 weeks after surgery(r = -0.527). Shorter time without diverting ileostomy or colostomy (r = 0.400), enteral feeding with a protein hydrolysate formula (r = -0.476), and percentage of calories received enterally at 6 weeks after surgery (r = -0.504) were associated with a lower peak direct bilirubin concentration. Presence of an intact ileocecal valve and frequency of catheter-related infections were not significantly correlated with duration of PN. In multivariate analysis, only residual small bowel length was a significant independent predictor of duration of PN, and only less time with a diverting ostomy was an independent predictor of peak direct bilirubin concentration.

CONCLUSIONS

Although residual small bowel length remains an important predictor of duration of PN use in infants with SBS, other factors, such as use of breast milk or amino acid-based formula, may also play a role in intestinal adaptation. In addition, prompt restoration of intestinal continuity is associated with lowered risk of cholestatic liver disease. Early enteral feeding after surgery is associated both with reduced duration of PN and less cholestasis.

Malnutrition in hospitalized pediatric patients. Current prevalence

OBJECTIVE

To document the current prevalence of protein-energy malnutrition compared with that reported from the same institution in 1976.

DESIGN

All inpatients of this tertiary-care facility were assessed by anthropometric, laboratory, and clinical nutrition assessment methods in a 1-day cross-sectional survey. The comparison study from 1976 was also a 1-day cross-sectional survey.

SETTING

A tertiary-care facility in Boston, Mass.

PATIENTS

The entire inpatient population was assessed on a single weekday in September 1992.

MAIN OUTCOME MEASURES

Prevalence of acute and chronic malnutrition as judged by anthropometric and laboratory data. Data on demographics, admission classification, underlying disease, route of nutrition, and global nutritional status were also assessed.

RESULTS

The prevalence of acute protein-energy malnutrition (weight for height) based on the Waterlow criteria was as follows: severe, 1.3%; moderate, 5.8%; mild, 17.4%; and none, 75.5%. The prevalence of chronic protein-energy malnutrition (height for age) was as follows: severe, 5.1%; moderate, 7.7%; mild, 14.5%; and none, 72.8%. Although the prevalence of acute and chronic protein-energy malnutrition was significantly less in 1992 than in 1976 (P = .03 and P < .001, respectively), the numbers are still alarmingly high. Children younger than 2 years and older than 18 years and those with chronic medical conditions had a higher prevalence of protein-energy malnutrition. Twenty-four percent of patients had a serum albumin level less than 30 g/L, 34.8% had a total lymphocyte count less than 1.5 x 10(9)/L, and 24.9% had a hemoglobin concentration less than 105 g/L. One fourth of all patients were obese (> 120% weight for height), with the greatest prevalence in children aged 2 to 18 years.

CONCLUSIONS

Acute and chronic protein-energy malnutrition remains common in hospitalized pediatric patients in the United States. Important risk factors may be underlying chronic disease, periods of normally rapid growth, and recognized need for nutrition intervention.

Parenteral protein-sparing modified fast in an obese adolescent with Prader-Willi syndrome

A ventilator-dependent, extremely obese adolescent patient with Prader-Willi syndrome was nutritionally managed using a parenteral, protein-sparing modified fast. A solution containing only amino acids, electrolytes, vitamins, and macro- and micro-minerals helped create a ketotic state and facilitate weaning from the ventilator. This case demonstrates an unusual strategy for achieving weight loss and the challenge to provide adequate protein intake while limiting fluid intake.