C. E. Paxton

Regionally acquired intestinal failure data suggest an underestimate in national service requirements

Objectives, setting and patients: With complete case referral for prolonged parenteral nutrition (PN) beyond term equivalent, serving a stable population of 1.25 million people, we describe the long-term outcome and survival of patients referred to an intestinal failure (IF) nutrition support team over the first 8 years of existence at a regional paediatric centre, and extrapolate to potential numbers of national home parenteral nutrition (HPN) cases and intestinal transplantation data. Design and outcome measures: Retrospective analysis detailing patient demographics, interventions, use of HPN, occurrence of intestinal failure-associated liver disease (IFALD), and outcomes of enteral adaptation, survival, and referral for and receipt of organ transplantation. Results: 23 patients were referred over 8 years, 20 being PN dependent within the neonatal period. Diagnoses included short bowel syndrome (SBS) (18), neuromuscular abnormalities (4) and congenital enterocyte disorder (1). 12 696 days of PN were delivered with 314 confirmed episodes of sepsis at a median of 12 episodes per patient. 144 central venous catheters (CVCs) were required at a median of four per patient. IFALD occurred in 17 (73%) patients, with 10 (44%) referred for transplant assessment. Thirteen (56%) children received HPN. Overall mortality was 44%. A significant predictor for survival in the SBS group was residual bowel >40 cm (82% vs 28%, p = 0.049). Conclusions: Survival for IF at 56% was lower than reported from non-UK supra-regional centres, and nationally collected data, possibly reflecting pre-selected referral populations. Data from regional centres with complete ascertainment may be important both when counselling parents and when planning regional and national HPN and IF specialist services.

OC-077 Jejunal tube feeding experience in paediatric nutrition support

Introduction There is an emerging group of children in whom poor and worsening upper GI dysmotility limits feed toleration and impacts growth; we wished to evaluate the role of jejunal tube feeding (JTF) in this group. Methods A retrospective cohort study (database/clinical note review) in a tertiary paediatric centre to evaluate use of PEG-J, transgastric gastrojejunostomy (GJ) tubes and surgical roux-en Y jejunostomy (ReYJ), and the impact on growth of JTF in children with worsening GI dysmotility. All children (<18 years) receiving home enteral tube feeding (HETF) during the period 01 January 2002–31 December 2011. Weight at time of commencing JTF and at 6 or 12 months post-start was collected and expressed as SD or Z-score. Change in weight Z-score was calculated using paired t-test. Results A total of 866 children received HETF during the study period, of whom 41(5%) had JTF at home. Median (range) decimal age at start of JTF was 2.7(0.1–16.2) years. 36 of 41 (88%) had an underlying neurodisability; 33 of 41 (80%) were gastrostomy fed prior to commencing JTF. Of the 41 JTF children, 19 (46%) were fed via a GJ tube, 5 (12%) via PEG-J and 17 (42%) had a ReYJ. The majority of JTF related complications occurred with GJ tubes; although usually minor, one death occurred following small bowel intussusception around a GJ tube. Minor JTF complications included burst balloons, holes in the Y-port or tube and fungal infection and resolution required tube changes. Tube migration was a problem with both GJ and PEG-J tubes; ReYJ were associated with the fewest minor complications of stomal infection and leakage. By study end, 21 (51%) continue on JTF, 9 (22%) died (all but 1 due to their underlying condition), 1 (2%) moved out of area, 2 (5%) transitioned to adult services and 8 (20%) returned to gastric feeding. 25 of 41 children had JTF for >6 months and had longitudinal growth data collected; median (range) weight Z-score at the start of JTF was −1.3 (−5.2–2.1) and rose to −1.0 (−3.4–2.3) by 6–12 months, with a significant improvement in mean (95% CI) change in weight Z-score of 0.7 (0.1 to 1.3) (p=0.02). Conclusion There are time consuming practical challenges associated with JTF, some of which are device dependent, and ReY JTF appears best for long-term usage. JTF is an effective intervention to improve growth in children with severe and worsening upper GI dysmotility. Competing interests None declared.

OC-040 Regular nutritional blood test monitoring in children on home enteral tube feeding—is this necessary?

Introduction The use of home enteral tube feeding (HETF) in children with chronic illness is increasing. 6-monthly nutritional blood test monitoring (NBTM) while on HETF is recommended by BAPEN for adults; there is minimal evidence to inform guidelines regarding the biochemical monitoring of children on long-term HETF. Aim To provide evidence for or against the practice of 6-monthly NBTM in children receiving HETF. Methods We performed a retrospective review of all children age <18 years, who were started on HETF from 01 January 2005 to 30 June 2010 by the nutrition support team (NST) in the Royal Hospital for Sick Children, Edinburgh. Patients who received <2 months of HETF, or failed to receive more than one set of NBTM within the 1st year of starting HETF were excluded. Comparison of baseline NBTM results with results at 6–12 months after the start of HETF were made. Our NBTM profile includes full blood count, renal profile, bone profile, liver function tests, folate, ferritin, vitamin B12, fat-soluble vitamins and trace elements (Se, Cu, Zn). Results 42 children were included in the study; none developed refeeding syndrome. 37 (88%) had NBTM performed within 6 months of commencing HETF, 19 (45%) at 6 months after commencing HETF, and 21 (50%) at 1 year after commencing HETF. Significant abnormal parameters identified prior to commencing HETF included low Hb levels (32%), low ferritin levels (31%) and low folate levels (25%). Small groups of between 8% and 10% had low levels of trace elements (Se and Cu) and vitamin D levels. At 6 months and 1 year after start of HETF, there was a small increase of children with low Hb levels (40%) but an improvement in those with low ferritin (14%) and low folate levels (6%). 4% of the study had low vitamin D, and/or trace element (Zn, Cu, Se) levels. There were no toxic levels of vitamins or trace elements within 12 months of start of HETF. Trend comparison was performed in 25 children who had NBTM both before and within a year of commencing HETF. None of the children developed toxic levels of trace elements, one child developed high trace element levels (Se) and another continued to have high Se levels after starting HETF. None of the children developed toxic or high levels of fat soluble vitamins. There were no worryingly low micronutrient levels in any of the 25 children after the start of HETF. Conclusion Children on HETF in our study maintain and had improvement of their micronutrient status after start of HETF. Six monthly blood test monitoring may only be necessary in special circumstances (refeeding syndrome, frankly deficient or toxic micronutrient levels at start of HETF) and may not significantly enhance the overall nutritional monitoring and management of all children on HETF. Competing interests None declared.

PMO-071 Eleven year regional UK cohort study reveals distinctly different temporal trends between neonatal and paediatric home enteral tube feeding

Introduction Home enteral tube feeding (HETF) is increasingly being used to provide nutrition support (NS) for children to promote growth and development. It is unclear if there are differences in the extent of use and temporal usage trends between neonatal and paediatric clinical practice. Aims To determine: Absolute numbers of children and neonates discharged on HETF from the regional (SE Scotland) tertiary paediatric and neonatal units, the temporal trends in both paediatric and neonatal HETF over an extended period, and the comparison of these trends. The numbers of neonates transferred on enteral tube feeding (ETF) from the regional neonatal to the regional paediatric unit over the last 2 years of the time period and their outcome in terms of need for HETF. Methods A retrospective cohort study (database and clinical note review) to compare numbers of children within the population of 838 573 in Lothian discharged on HETF from the single SE Scottish regional neonatal unit and the single SE Scottish regional paediatric unit, and their inter-relationships. All children and neonates discharged on HETF over the study period 1 July 2000–30 June 2011 were included. The fate of neonatal transfers requiring ETF to the paediatric centre was studied over the period of 1 July 2009–30 June 2011. Results 485 Lothian children were discharged on HETF from the regional paediatric hospital (paediatric HETF) compared with 114 from the neonatal unit (neonatal HETF) over the same time period. Over the study period a rise in numbers requiring paediatric HETF was observed (average of 34 per year in 2000–2005 increasing to 55 per year in 2006–2011), however there was a decreasing number requiring neonatal HETF (average of 16 per year in 2000–2005 decreasing to 8 per year in 2006–2011). HETF was primarily used short term in the neonatal group for immaturity alone. During the 2-year period of the study 7/2009–6/2011, 20 neonates were transferred to the regional paediatric unit on ETF; 11 (55%) were subsequently discharged on HETF from the paediatric unit, but these neonatal transfers only accounted for 10% of the total of 103 paediatric HETF discharges. Conclusion These novel data firstly demonstrate that the incidence of HETF usage on discharge from a UK paediatric regional centre continues to increase while that from the neonatal unit serving the same region is falling, and secondly that sick neonates transferred on ETF make up only a small number of incident paediatric HETF cases. Competing interests None declared.

Mo1989 Serum D-Lactate: A Novel Biomarker for Severe Small Bowel Bacterial Overgrowth in Children With Intestinal Failure

was to evaluate the clinical outcomes, particularly with regards to IBD, in children presenting with abdominal pain who have findings of thickened bowel wall on CT scan. METHODS: A retrospective analysis of pediatric patients at two large military medical centers with CT findings of thickened bowel wall was performed between January 2007 and April 2011. Patients with no known underlying disease, presenting with abdominal pain in the outpatient setting were included. Endoscopic findings and their clinical variables, as well as follow up assessments in those who did not undergo endoscopy, were evaluated. RESULTS: 56 patients (mean age 13.7 years) presenting with abdominal pain in the outpatient setting who had thickened bowel wall findings on CT scan were identified. 27% had isolated TI thickening, 23% had both TI and colonic thickening, while 29% had colonic involvement only. Of the 56 patients, 20 (36%) underwent endoscopic evaluation. 11 of those 20 (55%) were ultimately diagnosed with IBD based on histology and their clinical picture. The lab variables that most strongly predicted IBD in these patients included ESR>22 (100% had IBD), CRP>1.5 (100%), albumin 320 (82%), and hemoglobin (hgb)<12 (62%). Of the remaining patients who did not undergo endoscopy, 25% had appendicitis, 27% had infectious gastroenteritis and 22% were diagnosed with functional pain. Additional follow up of these patients for an average of 22 months beyond the original CT scan revealed no new diagnoses of IBD. CONCLUSIONS: The presence of thickened bowel wall on CT scans is a non-specific finding in children. Ultimately, 20% of our patients were diagnosed with IBD, suggesting that urgent subspecialty evaluation may not always be warranted. However, laboratory screening with ESR, CRP, albumin, platelets, and hgb, utilizing the cutoff values described, would have accurately separated most of our patients with IBD. The use of these screening tests on patients noted to have bowel wall thickening may help distinguish which patients require additional evaluation and endoscopy.

Does jejunal feeding promote growth in children with worsening upper GI dysmotility

Background and aim Promotion of optimal growth and development in children with underlying chronic disease is a goal of nutrition support teams (NST). NST are faced with a challenging group of children (usually with profound underlying neurodisability) in whom worsening upper GI dysmotility limits feed toleration and impacts growth. Jejunal feeding is increasingly used in this group when changes in feed type, method of feed delivery and maximal medical management of reflux have all failed to promote growth. We aimed to evaluate the effect of jejunal feeding on subsequent growth in children with severe GI dysmotility. Methods A retrospective cohort study (database/clinical note review) in a tertiary paediatric centre to investigate the impact on growth of jejunal feeding (>6 months) in children with worsening GI dysmotility. All children (<18 years) receiving home enteral tube feeding (HETF) during the period 01.01.02-30.09.11 were included. Data on weight at time of commencing jejunal feeding and at 6 or 12 months (whichever duration was exceeded) post establishment was collected and expressed as standard deviation or Z-score. Change in Z-score was calculated using paired t-test. Results A total of 866 children received HETF during the study period, of whom 38 (4%) were jejunally fed. Growth data was collected on 25 (56% female) children fed via a transgastric gastrojejunostomy (GJ) tube, PEG-J or a surgical roux-en Y jejunostomy >6 months. Median (range) decimal age at commencement of jejunal feeding was 2.6 (0.1-16.2) years. The median (range) weight Z-score at the start of jejunal feeding was –1.3 (−5.2 to 2.1) and rose to –1.0 (−3.4-2.3) by 6-12 months post-start. A significant improvement in mean (95% CI) change in weight Z-score of 0.7 (0.1-1.3) (p=0.02) was found. As the majority of children were non-ambulatory (and knee heights are not routinely recorded), there was minimal height (and thus BMI) data recorded. Children received a range of jejunal feed types - 42% whole protein, 41% hydrolysed and 17% elemental feeds. Conclusions Jejunal feeding is an effective intervention to improve growth during the management of children with severe and worsening upper GI dysmotility on HETF.