Medical ProgressEnteral Nutrition in the Management of Pediatric Intestinal Failure
Section snippets
Definitions
IF occurs when there is a reduction of functional intestinal mass necessary for adequate digestion and absorption for nutrient, fluid, and growth requirements, resulting in the need for intensive nutritional support. The American Gastroenterological Association defines IF as the condition that results “from obstruction, dysmotility, surgical resection, congenital defect, or disease-associated loss of absorption and is characterized by the inability to maintain protein-energy, fluid,
Enteral Feeding in IF
Deprivation of enteral calories, often termed “gut rest” in the setting of surgical or other interventions, causes atrophy of the intestinal mucosa, even in the presence of adequate PN support.7, 8, 9 Upon reintroduction of EN, the surgically or functionally shortened intestine must undergo structural and functional adaptations to best absorb luminal nutrients. The histologic hallmark of this compensatory response is intestinal epithelial cell hyperplasia, including increased villus height and
Micronutrient and Vitamin Deficiencies
Nutrients are differentially absorbed in various locations throughout the small intestine, and therefore, the type of bowel resected will predispose to specific micronutrient and vitamin deficiencies (Table II). For example, a patient with duodenal resection is at risk for iron and folate deficiency, whereas a patient with ileal resection is at risk for a deficiency of vitamin B12 and bile acid malabsorption. Bile acid deficiency may in turn predispose to deficiencies of the fat-soluble
Outcomes of IF
An important challenge in the care of patients with IF is the limited longitudinal data available to guide clinical decisions. The Pediatric Intestinal Failure Consortium is a group of 14 pediatric centers with multidisciplinary intestinal rehabilitation programs. A study of 272 infants with IF reported that the cumulative incidence of sustained enteral autonomy at 3 years was 44%; 26% died and 23% underwent intestinal transplantation.44 Notably, 30% of patients who achieved enteral autonomy
Emerging Therapies
Two recent medical therapies have recently emerged for the treatment of IF: GLP-2 and somatropin (human growth hormone). The endogenous peptide GLP-2 is secreted by intestinal L cells and enhances nutrient absorption and increases mucosal surface area, but has a short half-life due to degradation by the enzyme dipeptidyl peptidase IV.49 Teduglutide is a human recombinant GLP-2 analogue engineered with a single amino acid substitution, resulting in a longer half-life, allowing daily subcutaneous
Discussion
The outlook for children with IF has improved dramatically, with survival improving from 54% in one of the earliest published series59 to 73%-100% more recently.44, 60, 61, 62, 63, 64 Multidisciplinary programs now provide comprehensive and longitudinal IF care and improve survival for pediatric patients with IF.65 Current therapeutic goals in these patients include promotion of intestinal adaptation, optimization of quality of life, limiting of PN-associated morbidity, and eventual transition
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Cited by (63)
Special Populations—Surgical Infants
2023, Clinics in PerinatologyNecrotizing Enterocolitis and Short Bowel Syndrome
2023, Avery's Diseases of the NewbornPuberty and growth in patients with pediatric intestinal failure
2022, Journal of Pediatric SurgeryCitation Excerpt :The level of nutritional support at last follow-up was categorized based on degree of PN dependence: EN (full enteral autonomy), mixed (significant enteral tolerance with less than 75% calories from PN), or PN (greater than 75% caloric intake from PN). All patients underwent a standardized protocol for provision and advancement of enteral feeds using guidelines from a multidisciplinary intestinal rehabilitation program [17]. The route of administration of enteral feeds was transitioned from gastric or jejunal formula to oral formula or oral ad lib diet as appropriate.
Trends in Pediatric Intestinal Failure: A Multicenter, Multinational Study
2021, Journal of PediatricsCitation Excerpt :This increasing population of children highlights the need for new strategies that focus on the achievement of enteral autonomy. Besides early provision of enteral nutrition and supportive therapies during the natural bowel adaptation process,32 one of the currently available strategies to promote enteral autonomy is the use of gastrointestinal hormones, such as glucagon-like peptide (GLP-2), to accelerate and induce adaptation.33-36 Subcutaneous administration of the GLP-2 analog teduglutide increases villous height and crypt depth and reduces the need for PN.36-43
Optimizing Duration of Empiric Management of Suspected Central Line-Associated Bloodstream Infections in Pediatric Patients with Intestinal Failure
2020, Journal of PediatricsCitation Excerpt :Other common factors among these 3 patients were the presence of a gastrostomy tube and use of ethanol locks. The majority of enrolled patients had a gastrostomy tube, reflecting the usual practice of providing enteral feedings to prevent intestinal villus atrophy and promote intestinal adaptation.27 Thus, the effect of a gastrostomy tube on the relative risk of CLABSI at or beyond 24 hours was not significant.
Micronutrients in paediatric Intestinal Failure Patients receiving home parenteral nutrition
2020, Clinical NutritionCitation Excerpt :Intestinal failure (IF) is defined as a critical reduction of functional gut mass below the minimum needed for the absorption of nutrients and fluids necessary to maintain health and growth [1,2]. IF can result from anatomical resection of the gut length resulting in short bowel syndrome, neuromuscular diseases causing dysmotility of the gastro-intestinal (GI) tract, or diseases of the intestinal epithelium causing chronic malabsorption [3–5]. The insufficient digestion and absorption in these patients make parenteral nutrition (PN) vital [6,7].
Funded by the National Institutes of Health (K24 HD 058795 [to C.D.] and T32 DK 7477-30 [to K.G.]). C.D. is a site investigator for the NPS-sponsored trial of teduglutide (registered with ClinicalTrials.gov: NCT01952080). The authors declare no conflicts of interest.