Joanne Olieman

Neonatal short bowel syndrome as a model of intestinal failure: Physiological background for enteral feeding

Intestinal failure (IF) is a well identified clinical condition, which is characterised by the reduction of functional gut capacity below the minimum needed for adequate digestion and absorption of nutrients for normal growth in children. Short bowel syndrome (SBS) is the leading cause of IF in neonates, infants and young children usually as a result of extensive intestinal resection during the neonatal period. Simultaneously maintaining optimal nutritional status and achieving intestinal adaptation is a clinical challenge in short bowel patients. Both growth and development of the child as well as gut adaptation should be considered synergistically as primary outcome parameters. Enteral nutrition (EN) can be introduced orally and/or by tube feeding (TF). Several controversies over nutritional treatment of children with SBS related intestinal failure remain. As reported from different centres around the world, most practices are more experienced based rather than evidence based. This is partly due to the small number of patients with this condition. This review (based on a consensus) discusses the physiological principles and nutritional management, including the type of diet and route of delivery. Perspectives in optimizing intestinal adaptation and reducing the consequences of small intestinal bacterial overgrowth are also discussed.

Enteral Nutrition in Children with Short-Bowel Syndrome: Current Evidence and Recommendations for the Clinician

The optimal enteral feeding regimen in children with short-bowel syndrome (SBS) is debated by clinicians. The purpose of this article is to present an overview of published data on feeding strategies in children with SBS. A structured literature search (years 1966 through 2007) was done to identify human studies in children directly addressing nutrition (or specified nutrients) in relation to SBS. Eight relevant studies retrieved were graded by seven experts according to the Scottish Intercollegiate Guidelines Network criteria. This grading system is based on the study design and methodological quality of individual studies. Recommendations were made based on the outcome according to the Scottish Intercollegiate Guidelines Network if appropriate and on expert opinion otherwise. The most important recommendations are: Enteral nutrition should be initiated as soon as possible after bowel resection to promote intestinal adaptation. Enteral nutrition should be administered in a continuous fashion. Breast milk or standard polymeric formula (depending on the childs age) is recommended as preferred type of nutrition. Bottle-feeding (small volumes) should be started as soon as possible in neonates to stimulate the suck and swallow reflexes. Solid food can be introduced at the age of 4 to 6 months (corrected for gestational age if necessary) to stimulate oral motor activity and to avoid feeding aversion behavior. The team of experts concluded that high-quality research on the preferred types of enteral and oral nutrition in children with SBS is scarce. Multicenter prospective studies on the effects of feeding strategies on bowel adaptation, fecal production, linear growth, and clinical outcome are required to find the optimal feeding regimen in children with SBS.

Interdisciplinary management of infantile short bowel syndrome: resource consumption, growth, and nutrition

BACKGROUND/PURPOSEnTo date, there are hardly any data on the treatment costs of infantile short bowel syndrome (SBS), despite growing interest in evidence-based and cost-effective medicine. Therefore, the aim of the study was to evaluate resource consumption and costs, next to studying nutritional and growth outcomes, in children with SBS who were treated by an interdisciplinary short bowel team.nnnMETHODSnData were collected for 10 children with infantile SBS (<or=1 year of age) born between 2002 and 2007. Data included demographic and medical data of the first admission and data on resource consumption, growth, and type of nutrition for the total follow-up period. Real economic costs were calculated in Euro (euro) and US dollar (

Growth and nutritional aspects of infantile short bowel syndrome for the past 2 decades

).nnnRESULTSnSeven of the 10 patients were discharged with home parenteral nutrition. Total follow-up varied between 9 months and 5.5 years (median, 1.5 years). Six patients could be weaned off parenteral nutrition and 5 patients off enteral tube feeding, resulting in full oral intake. Seven patients had normal growth. Median duration of initial hospital admission was 174 days, and average costs of initial admission amounted to euro166,045 (

Achieving energy goals at day 4 after admission in critically ill children; predictive for outcome?

218,681). Average total costs were euro269,700 (

Impact of infantile short bowel syndrome on long-term health-related quality of life: A cross-sectional study

355,195), reaching to a maximum of euro455,400 (

Promoting intestinal adaptation by nutrition and medication

599,762). These costs mainly comprised hospital admissions (82%), followed by nutrition (12%), surgical interventions (5%), and outpatient visits (1%).nnnCONCLUSIONSnThis study is among the first to describe resource consumption and costs in infants with SBS, examining real economic costs and extending beyond the initial hospitalization. Treatment of SBS requires considerable resource consumption, especially when patients depend on parenteral nutrition. Because the costs mainly comprise those of hospital admissions, early home parenteral nutrition could contribute to costs reduction. Interdisciplinary teams have the potential to facilitate early home parenteral nutrition and thus may reduce health care costs.

Health-related quality of life, anxiety, depression and distress of mothers and fathers of children on Home parenteral nutrition

PURPOSEnThe aim of this retrospective study is to describe characteristics of the first year of infantile short bowel syndrome (SBS), with regard to nutritional correlates and growth. Differences in outcome between decade 1980 (1980 to 1990) and decade 1990 (1990 to 2000) were studied.nnnMETHODSnChildren with infantile SBS, who had been admitted in their first year of life between January 1975 and January 2002, were included. Patient characteristics, duration of parenteral nutrition (PN), type of enteral nutrition, and every quarterly term weight and height for age were collected. Data of decade 1980 and decade 1990 were compared, using appropriate statistical analysis.nnnRESULTSnTwenty-eight patients were identified for decade 1980 vs 62 patients in decade 1990. Length of stay was significantly shorter in decade 1990 (116 vs 182 days; P = .018). Residual bowel length was not significantly longer in the latter decade (74 cm vs 60 cm; not significant [ns]). Mean weight for age (SD score [SDS]) in the first year of SBS in decade 1980 was significantly lower than in decade 1990 (0.9 SDS; P = .035).nnnCONCLUSIONSnImproved care of patients with SBS and the slightly longer residual bowel length (ns) in decade 1990 resulted in shorter length of stay, shorter duration of PN, and significantly higher SDS for weight for age compared with decade 1980.

Fish oil in long-term parenteral nutrition in children: Omega-3 fatty acids have beneficial effects on liver

BACKGROUND & AIMSnAdequate nutritional intake is essential during pediatric intensive care admission. We investigated whether achievement of energy intake goals at day 4 after admission and route of nutrition were associated with improved outcome.nnnMETHODSnObservational study using prospectively acquired data. Patients receiving enteral and/or parenteral nutrition were included. The energy intake target range at day 4 after admission was 90-110% of resting energy expenditure +10%. Acute malnutrition was defined as weight-for-age <-2 SD. Clinical outcome measures were length of stay, days on ventilator, duration of antibiotics and number of new infections. Data as median (min-max).nnnRESULTSnOf 325 subjects (age 0.14 (0.0-18.0) year), 19% were acutely malnourished upon admission. Median 86% of energy goals were administered via the enteral route. With enteral energy intake, 7% of patients were fed within the target range, 50% were fed below and 43% were fed above the target range. In a subgroup (n = 223) the acutely malnourished proportion at discharge (26%) was not significantly different from that upon admission (22%). Whether the energy intake was below, within or above the target range did not affect changes in clinical outcome, nor did the route of nutrition.nnnCONCLUSIONSnAcute malnutrition was highly prevalent upon admission and at discharge. With our nutritional protocol we achieved high rates of (enteral) energy intake. A high percentage of our population received enteral energy above the target energy range. However, there was no association between the amount of energy intake or route of nutrition and clinical outcome.

Nutritional assessment as standard of care on a pediatric intensive care unit; does it work?

BACKGROUND/PURPOSEnStudies on the long-term effects of short bowel syndrome (SBS) on the quality of life are scarce. Therefore, we determined health-related quality of life (HRQoL) in children and adolescents with a history of infantile SBS compared with that of same-aged controls drawn from the general population.nnnMETHODSnCross-sectional assessment (2005-2007) of HRQoL in children with a history of infantile SBS treated in their first year of life, born between 1987 and 2002, using generic HRQoL measures was performed. Children aged 5 to 18 years and their parents filled out the Pediatric Quality of Life Inventory. Differences in scores between subjects and controls were analyzed using independent sample t tests.nnnRESULTSnThirty-one children with a history of SBS (19 girls and 12 boys; mean age, 11.8 ± 4.2 years) participated, giving an overall response rate of 70%. The children and their parents reported significantly lower HRQoL than 275 healthy age-matched children and their parents (P < .05).nnnCONCLUSIONSnChildren with a history of infantile SBS have a lower HRQoL than healthy age-matched controls. This difference lasts beyond childhood and way beyond the period of intestinal rehabilitation early in life. These findings highlight the need for targeted interventions to address these dimensions of impaired HRQoL.