Early enteral feeding in newborn surgical patients

Comparison of human breast milk vs commercial formula-induced early trophic enteral nutrition during postoperative prolonged starvation in an animal model

The present study aimed to characterize the changes in macromolecular composition and structure in ileal tissue induced by postoperative prolonged starvation (PS), human breast milk feeding (HM) and commercial formula feeding (CF) for 48 and 72 h (h). Forty-two Wistar albino rats underwent an ileal transection and primary anastomosis and were then divided into six subgroups. Two groups of seven rats were food-deprived for 48 and 72 h with free access to water only in metabolic cages (48 h PS, 72 h PS). Then, two groups of seven rats received early enteral trophic nutrition (EEN) either using HM, and CF at 48 h post-operation (48 h HM, 48 h CF). The other two groups of seven rats received the same trophic enteral nutrition at 72 h post-operation (72 h HM, 72 h CF). An additional seven rats were fed normal rat chow (control), after which the ileal tissues were harvested and freeze-dried overnight. Then sample spectra were recorded by Fourier transform infrared (FTIR) spectroscopy. PS at 48 and 72 h resulted in an increase in the concentration of lipids and a decrease in the concentration of proteins. CF and HM trophic feeding induced a decrease in membrane fluidity and an increase in lipid order. Ileal tissues showed similar compositional and structural changes in lipids and proteins in the PS and CF groups after 48 and 72 h. A marked decrease in nucleic acid concentration was seen in CF at 48 h compared to HM. The human milk feeding groups did not induce any significant alterations and showed compositional and structural data similar to the controls. In conclusion, EEN application seems to be safer when introduced at 48 h rather than 72 h and time of this nutrition is crucial to maintain ileum structure and therefore immunity and well-being. HM-induced trophic nutrition is seen to protect the ileal tissue from significant alterations within lipid and protein compositions, whereas CF caused notable changes. HM is absolutely the best nutritional source for gut health in this animal model.

Enhanced Recovery After Surgery (ERAS) Society Recommendations for Neonatal Perioperative Care

Importance

Neonates requiring surgery are often cared for in neonatal intensive care units (NICUs). Despite a breadth of surgical pathology, neonates share many perioperative priorities that allow for the development of unit-wide evidence-based Enhanced Recovery After Surgery (ERAS) recommendations.

Observations

The guideline development committee included pediatric surgeons, anesthesiologists, neonatal nurses, and neonatologists in addition to ERAS content and methodology experts. The patient population was defined as neonates (first 28 days of life) undergoing a major noncardiac surgical intervention while admitted to a NICU. After the first round of a modified Delphi technique, 42 topics for potential inclusion were developed. There was consensus to develop a search strategy and working group for 21 topic areas. A total of 5763 abstracts were screened, of which 98 full-text articles, ranging from low to high quality, were included. A total of 16 recommendations in 11 topic areas were developed with a separate working group commissioned for analgesia-related recommendations. Topics included team communication, preoperative fasting, temperature regulation, antibiotic prophylaxis, surgical site skin preparation, perioperative ventilation, fluid management, perioperative glucose control, transfusion thresholds, enteral feeds, and parental care encouragement. Although clinically relevant, there were insufficient data to develop recommendations concerning the use of nasogastric tubes, Foley catheters, and central lines.

Conclusions and Relevance

Despite varied pathology, neonatal perioperative care within NICUs allows for unit-based ERAS recommendations independent of the planned surgical procedure. The 16 recommendations within this ERAS guideline are intended to be implemented within NICUs to benefit all surgical neonates.

When parenteral nutrition is the answer: The case of pediatric intestinal rehabilitation

In pediatric patients with intestinal failure, parenteral nutrition is lifesaving but also has several associated risks. The goals of intestinal rehabilitation include promoting growth, minimizing complications associated with intestinal failure, and reaching enteral autonomy, if possible. Pediatric intestinal rehabilitation programs are interdisciplinary teams that strive to provide optimal care for children dependent on parenteral nutrition. The provision of parenteral nutrition requires close monitoring of patients' growth, nutrition concerns, clinical status, and laboratory parameters. Recent advances in the field of intestinal rehabilitation include new lipid emulsions, considerations regarding enteral feeding, advances in micronutrient provision, and central venous catheter preservation techniques. Challenges in the field remain, including improving overall quality of life with home parenteral nutrition administration and preventing recently recognized complications such as chronic intestinal inflammation.

Pathophysiology and Management of Postoperative Ileus in Adults and Neonates: A Review

Postoperative ileus (POI) is caused by enteric neural dysfunction and inflammatory response to the stress of surgery as well as the effect of anesthetics and opioid pain medications. POI results in prolonged hospital stays, increased medical costs, and diminished enteral nutrition, rendering it a problem worth tackling. Many cellular pathways are implicated in this disease process, creating numerous opportunities for targeted management strategies. There is a gap in the literature in studies exploring neonatal POI pathophysiology and treatment options. It is well known that neonatal immune and enteric nervous systems are immature, and this results in gut physiology which is distinct from adults. Neonates undergoing abdominal surgery face similar surgical stressors and exposure to medications that cause POI in adults. In this review, we aim to summarize the existing adult and neonatal literature on POI pathophysiology and management and explore applications in the neonatal population.

The Safety and Efficacy of Early Enteral Nutrition After Paediatric Enterostomy Closure - The EPOC Study

INTRODUCTION

Keeping children nil by mouth until return of bowel function after intestinal anastomosis surgery is said to reduce complications. Fasting may extend up to five days, risking malnourishment and usage of parenteral nutrition. This study aims to establish the efficacy and safety of early enteral nutrition in children undergoing intestinal stoma closure.

METHODOLOGY

A retrospective cohort study of children aged three months to 16 years who underwent an intestinal stoma closure between 1/1/2019 and 31/12/2021 at two tertiary paediatric hospitals was undertaken. Children fed clear fluids within 24 h (EEN) were compared to those commencing feeds later (LEN). The primary outcome was length of post-operative stay (LOS) and secondary outcomes included: time to feeds; time to stool; and complications.

RESULTS

Of the 129 children that underwent a stoma closure, 69 met inclusion criteria: 35 (51 %) in the LEN group and 34 (49 %) in the EEN group. Children in the EEN group had a significantly shorter LOS (92.6 h vs 121.7 h, p = 0.0045). Early feeding was also associated with a significantly decreased time to free fluids (p < 0.001) and full enteral intake (p = 0.007). There was no significant intergroup difference in complications.

CONCLUSION

Commencing feeding within 24 h of stoma closure is efficacious and safe, with clear reductions in LOS, time to full feeds and time to stool, and no increase in complications. Further research is required to extrapolate these findings to other populations.

LEVEL OF EVIDENCE

III.

Bilateral Exchange: Enteral Nutrition Clinical Decision Making in Pediatric Surgery Patients

INTRODUCTION

Evidence-based medicine guides clinical decision-making; however, promoting enteral nutrition has historically followed a dogmatic approach in which patients graduate from clear liquids to full liquids to a regular diet after return of bowel function. Enhanced recovery after surgery has demonstrated that early enteral nutrition initiation is associated with shorter hospital stays. We aimed to understand postoperative pediatric nutrition practices in Kenya and the United States.

METHODS

We completed a prospective observational study of pediatric surgery fellows during clinical rounds in a pediatric referral center in Kenya (S4A) and one in the United States (Riley). Fellow-patient interactions were observed from postoperative day one to discharge or postoperative day 30, whichever happened first. Patient demographic, operative information, and daily observations including nutritional status were collected via REDCap.

RESULTS

We included 75 patients with 41 (54.7%) from Kenya; patients in Kenya were younger with 40% of patients in Kenya presenting as neonates. Median time to initiation and full enteral nutrition was shorter for the patients at Riley when compared to their counterparts at S4A. In the neonatal subgroup, patients at S4A initiated enteral nutrition sooner, but their hospital length of stays were not significantly different.

CONCLUSIONS

Studying current nutrition practices may guide early enteral nutrition protocols. Implementing these protocols, particularly in a setting where enteral nutrition alternatives are minimal, may provide evidence of success and overrule dogmatic nutrition advancement. Studying implementation of these protocols in resource-constrained areas, where patient length of stay is often related to socioeconomic factors, may identify additional benefits to patients.

Does Chewing Gum Lead to Earlier Postoperative Gastrointestinal Recovery in Children? A Systematic Review and Meta-analysis

INTRODUCTION

Postoperative ileus is a common occurrence among children undergoing major operations, including gastrointestinal and spinal surgeries. Preliminary evidence in adults suggests that chewing gum plays a role in accelerating the return of postoperative gastrointestinal function. However, evidence is scarce in the paediatric population. The aim of this study was to investigate whether chewing gum has benefits for children.

METHODS

We searched PubMed, Medline, Embase, and Cochrane Trials databases for randomised controlled trials that compare gum chewing with standard care after elective surgery in children from 1st Jan 2005 to 31st July 2021. We assessed the identified trials for quality and performed a systematic review and meta-analysis in accordance with PRISMA and registered in PROSPERO (CRD42022358801). The main outcome measures examined were time to flatus and stool postoperatively, time to tolerate oral intake, and length of hospital stay, which were analysed using fixed effects models. We also examined clinical complication rates and postoperative pain control.

RESULTS

We included six eligible trials, with a total of 357 enrolled patients. The intervention was well tolerated without complications. There was no significant difference in time to flatus (-2.86 h; 95 % CI: -6.2 to 0.47 h, p = 0.09), time to stool (-6.39 h; 95 % CI: -13.9 to 1.2 h, p = 0.1), time to tolerate oral intake (-0.03 days; 95 % CI: -0.15 to 0.1 days, p = 0.68), and length of hospital stay (0.08 days; 95 % CI: -0.07 to 0.22 days, p = 0.29). Postoperative pain control (opioid consumption, pain score, nausea score) was similar in both groups (p > 0.05).

CONCLUSION

Current evidence demonstrates that gum chewing is not associated with earlier postoperative gastrointestinal recovery in children. Future adequately powered and well-designed trials are necessary to evaluate any clinical benefit of chewing gum for children and whether it could result differences in healthcare satisfaction.

LEVEL OF EVIDENCE

I.

Efficacy of Early Enteral Nutrition on Gastrointestinal Surgery Outcomes: A Systematic Review and Meta-Analysis

Congenital anomalies, congenital malformations, or birth defects can be defined as any structural or functional anomalies that develop prenatally and could be identified before, at birth, or later in life. Approximately 6% of babies are born with a congenital anomaly, which results in 2.4 million newborn deaths worldwide. This systematic review and meta-analysis ascertained the quantitative studies published in PubMed, ClinicalKey, Embase, CINAHL, Cochrane Library, and Google Scholar. Two authors independently screened and extracted the data from the primary studies that analyzed the efficacy of early enteral nutrition (EEN) on the postoperative outcome. This systematic review and meta-analysis adopted Cochrane Collaboration guidelines and reported using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. The methodological quality of trials was assessed by Cochrane Collaboration's risk of bias tool. Six trials, representing 488 children, with age ranging from 10 days to 6.5 years, fulfilled the inclusion criteria. EEN has significantly shortened hospital stay, induced early fecal movement, and reduced postoperative wound infections in children with congenital gastrointestinal abnormalities undergoing gastrointestinal anastomosis compared with children who received late enteral nutrition. The review also found that the experimental group who received EEN had no significant impact on the anastomosis leakage, vomiting, and abdominal distension. EEN has some positive effects on postsurgery outcomes among children with congenital gastrointestinal anomalies undergoing gastrointestinal anastomosis.

Early Pre- and Postoperative Enteral Nutrition and Growth in Infants with Symptomatic Congenital Diaphragmatic Hernia

OBJECTIVES

 Nutritional support during the neonatal and postoperative period in congenital diaphragmatic hernia (CDH) is challenging and controversial. We aimed to report on early enteral nutritional support in symptomatic CDH patients during the pre- and postoperative period, including feasibility, associated factors with established full enteral nutrition, and weight at birth, discharge, and 18 months.

METHODS

 We retrospectively collected data on nutrition: type and volume of enteral nutrition and parental support. Enteral feeding was introduced preoperatively from day 1 after birth, increased step-wised (breastmilk preferred), and resumed after CDH repair on the first postoperative day. Baseline data were available from our CDH database.

RESULTS

 From 2011 to 2020, we identified 45 CDH infants. Twenty-two were girls (51.1%), 35 left sided (77.8%), and 40 underwent CDH repair (88.9%). Median (interquartile range) length of stay in the pediatric intensive care unit was 14.6 days (6.0-26.5), and 1-year mortality was 17.8%.Postoperatively, 120 and 160 mL/kg/d of enteral nutrition was achieved after a median of 6.5 (3.6-12.6) and 10.6 (7.6-21.7) days, respectively. In total, 31 (68.9%) needed supplemental parenteral nutrition in a median period of 8 days (5-18), and of those 11 had parenteral nutrition initiated before CDH repair. No complications to enteral feeding were reported.

CONCLUSION

 Early enteral nutrition in CDH infants is feasible and may have the potential to reduce the need for parental nutrition and reduce time to full enteral nutrition in the postoperative period.

Does COVID-19 Infection during Pregnancy Increase the Appearance of Congenital Gastrointestinal Malformations in Neonates?

BACKGROUND

COVID-19 was an infection that was capable of bringing the entire world to a standstill position within a period of days to months. Despite the advancements in the medical sector, the contagion was difficult to control and costed the lives of millions of people worldwide. Many short- and long-term effects are witnessed even to date in people that contracted the disease. Pregnant females had to suffer not only the devastating effects of the virus, but also the psycho-social impact of the lockdown. The impact of COVID-19 infection during pregnancy causing decreased antenatal care or hypoxemic episodes due to severe respiratory distress and whether it could lead to the appearance of congenital gastrointestinal malformation in neonates is still unclear. The aim of our study was to analyze if COVID-19 infection during pregnancy could increase the incidence of gastric malformations in neonates born from these women.

MATERIALS AND METHODS

We sifted the files of all neonates admitted into our hospital between January 2022 and December 2022, and based on inclusion and exclusion criteria, we included the cases having gastrointestinal congenital malformations during the COVID-19 pandemic. We performed a single-center, retrospective, observational descriptive study. We further divided the patients based on the anatomical location of the malformation. We also took down details of the evolution of pregnancy and whether the mother had contracted a SARS-CoV-2 infection during the pregnancy. Details regarding the Apgar score, days of intensive care admission, sex, and nutrition were the key findings studied.

RESULTS

A total of 47 neonates were found to have digestive anomalies, among which, based on the anatomical locations, the number of malformation cases found at the level of the esophagus were 15, while 16 occurred at the level of the pylorus; we found 12 cases of malformation of the duodenum, and four cases had malformation of the rectum. Out of these 47 neonates, 38.3% were females and 61.7% were males. A total of 58% were preemies, among which 9% had intra-uterine growth retardation (IUGR), and 42% were full-term newborns, among which 4% had intra-uterine growth retardation (IUGR). A total of 45% of the births were primiparous pregnancies and 55% were from multiparous females. A total of 14 mothers were found to have tested positive for COVID-19 during the course of pregnancy (p-value = 0.23); many had mild symptoms but were not tested.

CONCLUSIONS

COVID-19 can affect the wellbeing of the pregnant female and their fetus. Larger studies can help gain extensive knowledge as to whether COVID-19 also has the potential to result in congenital gastrointestinal anomalies in children born from COVID-19 positive mothers. In our study, only a few infants born with this pathology were found to be born from COVID-19 positive mothers. Hence, it is difficult to conclude or exclude a direct correlation between the infection and the congenital malformations.

Outcomes of Early Oral Feeding Compared to Delayed Feeding in Children after Elective Distal Bowel Anastomosis

Background

Conventionally, oral feeds after distal bowel anastomosis surgery (ileostomy/colostomy closure) are delayed until after bowel peristalsis is established. The safety of an early feeding regimen is not established in children. This study compared early feeding regimens with delayed feeding in children undergoing elective intestinal anastomosis surgeries.

Materials and Methods

In this retrospective multicentric cohort study, children undergoing elective distal bowel anastomosis surgery were divided into Group A (oral feeds allowed within 6 h) and Group B (delayed feeds). The two groups were compared for the incidence of abdomen distension, vomiting, surgical site infection, duration of analgesia, length of hospital stay, and readmission rate.

Results

During the study, 58 patients were included: Group A (n = 26) and Group B (n = 32). The duration of analgesia (1.9 vs. 4.01 days) and length of hospital stay (3.38 vs. 5.0 days) were significantly less in Group A. Abdominal distension (7.7% vs. 15.6%), vomiting (11.5% vs. 15.6%), surgical site infection rate (3.8% vs. 12.5%), and readmissions (0% vs. 3.1%) were less in Group A, but statistically not significant.

Conclusion

Early feeding after the elective restoration of distal bowel continuity can be safely practiced in the pediatric population. It is associated with a reduced need for analgesia and shorter hospital stay.

Nutritional Management of Intestinal Failure due to Short Bowel Syndrome in Children

BACKGROUND

The most common cause of intestinal failure (IF) in childhood remains short bowel syndrome (SBS), where bowel mass is significantly reduced due to a congenital atresia or resection and parenteral nutrition (PN) needed. Home PN has improved outcome and quality of life, but the long-term therapeutic goal is to achieve enteral autonomy whilst avoiding long term complications. This paper is aimed at discussing nutritional strategies available to clinicians caring for these patients.

METHODS

A literature search was performed from 1992 to 2022 using Pubmed, MEDLINE and Cochrane Database of Systematic Reviews, and recent guidelines were reviewed. In the absence of evidence, recommendations reflect the authors' expert opinion.

RESULTS

Consensus on the best possible way of feeding children with IF-SBS is lacking and practice varies widely between centres. Feeding should commence as soon as possible following surgery. Oral feeding is the preferred route and breast milk (BM) the first milk of choice in infants. Donor BM, standard preterm or term formula are alternatives in the absence of maternal BM. Extensively hydrolysed or amino acid-based feeds are used when these are not tolerated. Solids should be introduced as soon as clinically appropriate. Children are encouraged to eat by mouth and experience different tastes and textures to avoid oral aversion. Aggressive weaning of PN and tube (over-) feeding are now discouraged.

CONCLUSIONS

To date, uniform agreement on the optimal type of feed, timing of food introduction and feeding regime used is lacking and great difference in practice remains. There is need for more research to establish common treatment protocols.

The Development of an Enhanced Recovery Protocol for Kasai Portoenterostomy

Balancing post-operative adequate pain control, respiratory depression, and return of bowel function can be particularly challenging in infants receiving the Kasai procedure (hepatoportoenterostomy). We performed a retrospective chart review of all patients who underwent the Kasai procedure from a single surgeon at Children’s Healthcare of Atlanta from 1 January 2018, to 1 September 2022. 12 patients received the Kasai procedure within the study period. Average weight was 4.47 kg and average age was 7.4 weeks. Most patients received multimodal pain management including dexmedetomidine and/or ketorolac along with intravenous opioids. A balance of colloid and crystalloids were used for all patients; 57% received blood products as well. All patients were extubated in the OR and transferred to the general surgical floor without complications. Return of bowel function occurred in all patients by POD2, and enteral feeds were started by POD3. One patient had a presumed opioid overdose while admitted requiring a rapid response and brief oxygen supplementation. Simultaneously optimizing pain control, respiratory safety, and bowel function is possible in infants receiving the Kasai procedure. Based on our experience and the current pediatric literature, we propose an enhanced recovery protocol to improve patient outcomes in this fragile population. Larger, prospective studies implementing an enhanced recovery protocol in the Kasai population are required for stronger evidence and recommendations.

Systematic Review of Definitions and Outcome Measures for Postoperative Ileus and Return of Bowel Function after Abdominal Surgery in Children

This review aims to objectify which definitions and outcome measures are used for the return of bowel function and postoperative ileus in children. PubMed and Embase were systematically searched from inception to December 17, 2020. Prospective studies conducted in children (aged 0-18 years) undergoing gastrointestinal surgery which reported on definitions and/or outcome measures for post-operative ileus or return of bowel function were evaluated. Definitions and outcome measures were extracted. From 4,027 references, 71 articles were included. From the 17 articles mentioning postoperative ileus, 8 (47%) provided a definition. In total, 34 outcome measures were used and 12 were unique. "Abdominal distension" was the most reported (41%) measure. In 41%, the outcome measures only described the return of gastric motility, while 18% described the return of intestinal motility. The return of bowel function was mentioned in 67 articles, none provided a definition. In total, 133 outcome measures were used and 37 were unique. Time to oral intake was the most reported (14%) measure. In 49%, the outcome measures only described the return of gastric motility, while 10% described the return of intestinal motility. High variation in definitions and outcome measures has limited the generalizability of research into postoperative bowel function in children. Without standardization, it will be impossible to compare research results and evaluate treatments. In children, the return of gastric motility seemingly should get more focus compared to adults. Therefore, we believe that a definition of postoperative ileus with an accompanying core outcome set, developed by a multidisciplinary team, specifically for children is required.

Pathogenesis, diagnosis, dietary management, and prevention of gastrointestinal disorders in the paediatric population

Nutrition has a central role in child growth with long-term effects, and nutrition management in gastrointestinal disorders has great importance for child health and disease outcomes. Breast milk is the first choice for infant nutrition. When it is not available, special milk formulas are adopted in specific conditions, as a medical treatment. Moving from the strong guidelines, recommendations and the new possibilities of special diet treatment, this review will analyse the current diet treatment in different gastrointestinal disorders, including food allergy, cystic fibrosis, inflammatory bowel diseases, short-bowel syndrome, gastroesophageal reflux, and eosinophilic esophagitis. The review also aimed at understanding the role of diet and its effects on these diseases. The growth monitoring can prevent malnutrition and improve disease outcomes, particularly in children, and an appropriate dietary management targeted to specific disorders is the best therapeutic choice alone or in combination with pharmacological therapy.

Systematic review and meta-analysis of safety and efficacy of early enteral nutrition as an isolated component of Enhanced Recovery After Surgery [ERAS] in children after bowel anastomosis surgery

BACKGROUND

Postoperative feeding practices are not uniform in children undergoing bowel anastomosis surgery. Primary aim of this review was to evaluate the safety and efficacy of early enteral nutrition (EEN) as an isolated component of enhanced recovery in children undergoing bowel anastomosis surgery.

METHODS

Medical search engines (PubMed, CENTRAL, Google scholar) were accessed from inception to January 2021. Randomized Controlled Trials (RCT)s, non-randomized controlled trials, observational studies and retrospective studies comparing EEN, initiated within 48 h vs late enteral nutrition (LEN), initiated after 48 h in children ≤ 18 years undergoing bowel anastomosis surgery were included. Primary outcome measure was the incidence of postoperative complications (anastomotic leak, abdominal distension, surgical site infection, wound dehiscence, vomiting and septic complications). Secondary outcome measures were the time to passage of first feces and the length of hospital stay.

RESULTS

Twelve hundred and eighty-six children from 10 studies were included in this review. No difference was seen between the EEN and LEN groups in the incidence of anastomotic leak (1.69% vs 4.13%; p = 0.06), abdominal distention (13.87% vs 12.31%; p = 0.57), wound dehiscence (3.07% vs 2.69%; p = 0.69) or vomiting (8.11% vs 8.67%; p = 0.98). The incidence of surgical site infections (7.51% vs 11.72%; p = 0.04), septic complications (14.02% vs 26.22%; p = 0.02) as well as pooled overall complications (8.11% vs 11.27%; RR 0.71; 95% CI = 0.56 to 0.89; p = 0.003; I² = 33%) were significantly lower in the EEN group. The time to passage of first feces (MD - 17.23 h; 95% CI -23.13 to -11.34; p < 0.00001; I² = 49%) and the length of hospital stay (MD -2.95 days; 95% CI -3.73 to -2.17; p < 0.00001; I² = 93%) were significantly less in the EEN group.

CONCLUSION

EEN is safe and effective in children following bowel anastomosis surgery and is associated with a lower overall incidence of complications as compared to LEN. EEN also promotes early bowel recovery and hospital discharge. However, further well designed RCTs are required to validate these findings.

LEVEL OF EVIDENCE

V.

Uncomplicated gastroschisis care in the US and Kenya: Treatment at two tertiary care centers

BACKGROUND

Gastroschisis is a common birth defect with < 5% mortality in high income countries, but mortality in sub Saharan Africa remains high. We sought to compare gastroschisis management strategies and patient outcomes at tertiary pediatric referral centers in the United States and Kenya.

METHODS

This retrospective chart review examined uncomplicated gastroschisis patients treated at Riley Hospital for Children in Indianapolis, USA (n = 110), and Shoe4Africa Children's Hospital in Eldoret, Kenya (n = 75), from 2010 to 2018. Analyzed were completed using Chi square, Fisher's exact, and independent samples t tests and medians tests at the 95% significance level.

RESULTS

Survival in the American cohort was double that of the Kenyan cohort (99.1% vs 45.3%, p< 0.001). Sterile bag use for bowel containment was lower in Kenya (81.3% vs 98.1%, p< 0.001), but silo use was comparable at both institutions (p = 0.811). Kenyan patients had earlier median enteral feeding initiation (4vs 10 days, p< 0.001) and accelerated achievement of full enteral feeding (10vs 23 days, p< 0.001), but none received TPN. Despite earlier feeding, Kenyan patients displayed a higher prevalence of wound infections (70.8% vs 17.1%, p< 0.001) and sepsis (43.9% vs 4.8%, p< 0.001). In Kenya, survivors and non survivors displayed no difference in sterile bag use, hemodynamic stability, all cause infection rates, or antibiotic free hospital days. Defect closure (p< 0.001) and enteral feeding initiation (p< 0.001) were most predictive of survival.

CONCLUSION

Improving immediate response strategies for gastroschisis in Kenya could improve survival and decrease infection rates. Care strategies in the US can center on earlier enteral feeding initiation to reduce time to full feeding.

LEVEL OF EVIDENCE

Level III.

Trans-anastomotic tube feeding in the management of congenital duodenal obstruction: a systematic review and meta-analysis

BACKGROUND

Feed intolerance is a common problem in neonates with congenital duodenal obstruction (CDO). Some surgeons insert trans-anastomotic tubes (TAT) to facilitate feed tolerance. We conducted a systematic review to evaluate the efficacy and safety of TATs in CDO.

METHODS

Medline, EmBase, CINAHL, and Cochrane Library were searched till July 2020. Risk of bias was assessed using ROBINS-I tool. Meta-analysis was conducted using Random Effects Model.

RESULTS

No randomized controlled trials addressing the question were identified. In the 6 included observational studies, 96 infants underwent intraoperative TAT placement and 117 did not. Four studies reported benefits of TAT such as early attainment of full feeds and decreased need for parenteral nutrition. Two studies reported better outcomes in the no-TAT group. Accidental removal of TAT without clinical harm was reported in three studies [5/37 (14%), 4/17 (23%), and 2/4 (50%)]. Overall meta-analysis found no differences between the groups on any outcome. However, sensitivity analysis after excluding two studies with high risk of bias found that TAT tubes are associated with shorter duration of PN and shorter time to full enteral feeds. GRADE of evidence was very low for all outcomes.

CONCLUSIONS

Evidence is limited regarding the efficacy and safety of intraoperative TAT placement in neonates with CDO. Well-designed RCTs are needed to address the issue definitively.

Early enteral feeding versus traditional feeding in neonatal congenital gastrointestinal malformation undergoing intestinal anastomosis: A randomized multicenter controlled trial of an enhanced recovery after surgery (ERAS) component

PURPOSE

the aim of this clinical trial was to evaluate the safety and efficacy of early enteral feeding (EEN) following intestinal anastomosis in neonates with congenital gastrointestinal malformation.

METHODS

a multicenter, prospective, randomized controlled trial (registered under chictr.org.cn Identifier no.ChiCTR-INR-17014179) was conducted between 2018 and 2019. Four centers in China analyzed 156 newborns of congenital gastrointestinal malformation undergoing intestinal anastomosis to EEN group (n = 78) or control (C) group (n = 78). The primary outcomes of this study were length of postoperative stay (LOPS) and time to full feeds. Secondary outcomes included morbidity of complications, parenteral nutrition (PN) duration, feeding intolerance, 30 day mortality rate and 30 day readmission rate.

RESULTS

the mean time to full feeds and LOPS in the EEN group were 15.0 (9.8-22.8) days and 17.6 (12.0-29.8) days, while that were 18.0 (12.0-24.0) days and 20.0 (15.0-30.3) days in C groups respectively. There was no significant difference between two groups(P >0.05). No significant intergroup difference was found with respect to postoperative morbidity, PN duration or feeding intolerance(P >0.05).

CONCLUSIONS

early enteral feeding following intestinal anastomosis in neonates with congenital gastrointestinal malformation is safe. Post-operative outcomes demonstrated a trend toward improvement.

LEVEL OF EVIDENCE

Level Ⅰ.

Early enteral feeding after intestinal anastomosis in children: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Delayed enteral feeding (DEF) contributes to postoperative complications among children undergoing intestinal surgery. Various recent studies indicate the benefits of early enteral nutrition after intestinal surgery in adults. This systematic review and meta-analysis evaluates whether early enteral feeding (EEF) is beneficial in children who underwent intestinal anastomosis.

METHODS

MEDLINE, PubMed, the Cochrane Library, and Web of Science databases were searched for RCTs that addressed the effect of EEF in children (younger than 18 years old) undergoing intestinal anastomosis. EEF was defined as starting enteral feeding before the 3rd postoperative day. Studies were selected based on predetermined inclusion and exclusion criteria. A meta-analysis was performed using RevMan 5.3 to estimate odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs).

RESULTS

Four RCT studies met the inclusion criteria, comprising 97 cases with EEF and 89 cases with DEF. Enteral feeding started significantly earlier in the EEF group compared to the DEF group (MD = - 2.80; 95% CI - 3.11 to - 2.49; p < 0.00001). Postoperative anastomotic leak rate was unchanged between EEF and DEF groups (OR = 0.86; 95% CI 0.17-4.46; p = 0.86). The EEF group had a shorter length of hospital stay (MD = - 3.38; 95% CI - 4.29 to - 2.48; p < 0.00001), earlier time to bowel movement return (MD = - 0.57; 95% CI - 0.79 to - 0.35; p < 0.00001), lower incidence of surgical infection (OR = 0.27; 95% CI 0.08-0.90; p = 0.03), and faster tolerance of full enteral feeding (MD = - 2.00; 95% CI - 3.01 to - 2.79; p < 0.00001). Incidence of fever (OR = 0.37; 95% CI 0.10-1.31; p = 0.12), emesis, and abdominal distention (OR = 0.63; 95% CI 0.13-3.16; p = 0.58) were not different between the two groups.

CONCLUSIONS

Early enteral feeding after intestinal anastomosis in children does not increase the risk of postoperative anastomotic leak, fever, emesis, and abdominal distention. However, early enteral feeding is beneficial as it promotes the return of bowel function, reduces the length of hospital stay and the incidence of surgical infection in comparison to delayed enteral feeding.

Consensus Guidelines for Perioperative Care in Neonatal Intestinal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations

Background

Enhanced Recovery After Surgery (ERAS^®) Society guidelines integrate evidence-based practices into multimodal care pathways that have improved outcomes in multiple adult surgical specialties. There are currently no pediatric ERAS^® Society guidelines. We created an ERAS^® guideline designed to enhance quality of care in neonatal intestinal resection surgery.

Methods

A multidisciplinary guideline generation group defined the scope, population, and guideline topics. Systematic reviews were supplemented by targeted searching and expert identification to identify 3514 publications that were screened to develop and support recommendations. Final recommendations were determined through consensus and were assessed for evidence quality and recommendation strength. Parental input was attained throughout the process.

Results

Final recommendations ranged from communication strategies to antibiotic use. Topics with poor-quality and conflicting evidence were eliminated. Several recommendations were combined. The quality of supporting evidence was variable. Seventeen final recommendations are included in the proposed guideline.

Discussion

We have developed a comprehensive, evidence-based ERAS guideline for neonates undergoing intestinal resection surgery. This guideline, and its creation process, provides a foundation for future ERAS guideline development and can ultimately lead to improved perioperative care across a variety of pediatric surgical specialties.

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05530-1) contains supplementary material, which is available to authorized users.

Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection

Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.

An overview of the current management of short-bowel syndrome in pediatric patients

Short-bowel syndrome (SBS) is defined as a state of malabsorption after resection or loss of a major portion of the bowel due to congenital or acquired factors. This article presents an overview on the recent management of pediatric SBS. The pediatric SBS population is very heterogeneous. The incidence of SBS is estimated to be 24.5 per 100,000 live births. The nutritional, medical, and surgical therapies available require a comprehensive evaluation. Thus, multidisciplinary intestinal rehabilitation programs (IRPs) are necessary for the management of these complex patients. The key points of focus in IRP management are hepato-protective strategies to minimize intestinal failure-associated liver disease; the aggressive prevention of catheter-related bloodstream infections; strategic nutritional supply to optimize the absorption of enteral calories; and the management and prevention of small bowel bacterial overgrowth, nephrocalcinosis, and metabolic bone disease. As the survival rate of children with SBS currently exceeds 90%, the application of small bowel transplantation has been evolving. The introduction of innovative treatments, such as combined therapy of intestinotrophic hormones, including glucagon-like peptide-2, may lead to further improvements in patients' quality of life.

Clinical Manifestation of Gastroesophageal Reflux among Children with Chronic Constipation

BACKGROUND Functional gastrointestinal system diseases (FGIDs) are a group of childhood disorders, our knowledge of which is relatively limited. More importantly, the different subgroups among such a disease group are closely interrelated, and their natural courses and interrelations have yet to be fully clarified. Functional constipation and gastroesophageal reflux disease (GERD) are most frequently seen among this group. However, evidence as to whether any relationship exists between them is limited. In this study, we tried to examine the existence or absence of this relationship. METHODS First, patients with functional constipation were identified based on ROME III criteria, which included 205 patients. All patients were classified into two groups of 185 and 20 patients based on their ability to respond to the questions. Then age, sex, duration of constipation, treatment, and symptoms associated with reflux were examined based on the GERD questionnaire (in case group 185) and I-GERD (in case group 20). Score > 11 in the GERD questionnaire and score > 15 in the I-GERD questionnaire were considered as reflux disease. The variables that were evaluated using Chi-square and Fisher exact tests using SPSS software version 19 included age, sex, the onset of constipation, constipation duration, duration of treatment of constipation, ROME III criteria, and symptoms associated with reflux. RESULTS In the current study 205 subjects were included (girls = 49.8%, boys = 50.2%). The mean age of the children was 5.51 ± 3.15 years. Among the Rome III criteria, the most frequent were retentive posturing, painful defecation, history of large stool defecation, defecation less than 2 times per week, stool accumulation in the rectum, and fecal incontinency more than once a week, respectively. The lowest symptom among people with chronic constipation was fecal incontinency. Also, 46.8% of all patients in the study had a positive familial history. In general, there were 29 patients (14.1%) with reflux out of the 205 patients with functional constipation. In the present study, no significant relationship was found between Rome III criteria and reflux. CONCLUSION The frequency of GERD among cases with constipation was 14.1%. There was no significant relationship between Rome III criteria and reflux.

Impact of Nutrition Support Team on Postoperative Nutritional Status and Outcome of Patients with Congenital Gastrointestinal Anomalies

BACKGROUND The aim of this study was to evaluate postoperative nutritional status in patients who underwent operations due to congenital gastrointestinal anomalies in surgical neonatal intensive care units (NICUs) and to investigate the role of nutrition support teams (NSTs) on the outcome. METHODS A retrospective clinical study was carried out at two NICUs in Dr. Sheikh Pediatric Hospital, Mashhad, Iran. One of the NICUs was supported by NST and the other was not. A total of 120 patients were included through a non-random simple sampling. Different variables such as age, sex, prematurity, type of anomaly, birth weight, use of vasoactive drugs, weight gain in NICU, length of NICU stay, postoperative enteral nutrition initiation, duration of mechanical ventilation, mortality rate, maximum of blood sugar, the amount of calorie delivered to the calorie requirement ratio, and distribution of energy from enteral or parenteral roots were compared between the patients of two NICUs. RESULTS Median weight gain and the amount of calorie delivered during NICU stay in subjects of NSTsupported NICU was significantly more than other NICU. There was no significant difference in the length of NICU stay, enteral nutrition initiation after the operation, ventilation days, and percent of mortality between the two groups. The percentage of enteral feeding was also increased by about 2.8%, which was not significant. CONCLUSION NST could increase post-operative weight gain and calorie delivery in patients as well as providing an increase in enteral feeding rather than parenteral.

Early enteral feeding after pediatric abdominal surgery: A systematic review of the literature

INTRODUCTION

Traditionally enteral nutrition has been delayed following abdominal surgery in children, to prevent complications. However, recent evidence in the adult literature refutes the supposed benefits of fasting and suggests decreased complications with early enteral nutrition (EEN). This review aimed to compile the evidence for EEN in children in this setting.

METHODS

Databases Pubmed, EmBase, Medline and reference lists were searched for articles containing relevant search terms according to PRISMA guidelines. First and second authors reviewed abstracts. Studies containing patients less than 18 years undergoing abdominal surgery, with feeding initiated earlier than standard practice, were included. Studies including pyloromyotomy were excluded. Primary outcome was length of stay (LOS). Secondary outcomes included time to full enteral nutrition, time to stool and postoperative complications.

RESULTS

Fourteen articles met inclusion criteria - five on neonatal abdominal surgery, three on gastrostomy formation and six on intestinal anastomoses. There were three randomized control trials (RCTs), five cohort studies, four historical control trials, one nonrandomized trial and one case series. Nine studies showed a decreased LOS with EEN. Most studies which reported time to full enteral nutrition showed improvement with EEN; however, time to stool was similar in most studies. Postoperative complications were either decreased or not statistically different in EEN groups in all studies.

CONCLUSION

Studies to date in a limited number of procedures suggest EEN appears safe and effective in children undergoing abdominal surgery. Although robust evidence is lacking, there are clear benefits in LOS and time to full feeds, and no increase in complications.

LEVEL OF EVIDENCE

IV.

Role of Nutrition in Prevention of Neonatal Spontaneous Intestinal Perforation and Its Complications: A Systematic Review

Background: Spontaneous intestinal perforation (SIP) is a devastating complication of prematurity, and extremely low birthweight (ELBW < 1000 g) infants born prior to 28 weeks are at highest risk. The role of nutrition and feeding practices in prevention and complications of SIP is unclear. The purpose of this review is to compile evidence to support early nutrition initiation in infants at risk for and after surgery for SIP. Methods: A search of PubMed, EMBASE and Medline was performed using relevant search terms according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Abstracts and full texts were reviewed by co-first authors. Studies with infants diagnosed with SIP that included information on nutrition/feeding practices prior to SIP and post-operatively were included. Primary outcome was time to first feed. Secondary outcomes were incidence of SIP, time to full enteral feeds, duration of parenteral nutrition, length of stay, neurodevelopmental outcomes and mortality. Results: Nineteen articles met inclusion criteria—nine studies included feeding/nutrition data prior to SIP and ten studies included data on post-operative nutrition. Two case series, one cohort study and sixteen historical control studies were included. Three studies showed reduced incidence of SIP with initiation of enteral nutrition in the first three days of life. Two studies showed reduced mortality and neurodevelopmental impairment in infants with early feeding. Conclusions: Available data suggest that early enteral nutrition in ELBW infants reduces incidence of SIP without increased mortality.

Small Proportion of Low-Birth-Weight Infants With Ostomy and Intestinal Failure Due to Short-Bowel Syndrome Achieve Enteral Autonomy Prior to Reanastomosis

BACKGROUND

It is challenging to provide optimum nutrition in low-birth-weight (LBW) infants with short-bowel syndrome (SBS) and ostomy. This study aims to evaluate the clinical course of LBW infants with SBS and ostomy in response to enteral feeds, recognize characteristics associated with achievement of enteral autonomy prior to reanastomosis, and evaluate associated short-term outcomes.

METHODS

A retrospective analysis of 52 LBW neonates with intestinal failure (IF) caused by SBS and ostomy treated in a neonatal intensive care unit from 2012 to 2018 was performed. Clinical characteristics and short-term outcomes were studied in relation to the location of the ostomy and the success with enteral feeding achieved prior to reanastomosis.

RESULTS

Of the 52 infants with SBS, jejunostomy, ileostomy, and colostomy were present in 9, 40, and 3 infants, respectively. Fourteen (26.92%) infants achieved enteral autonomy transiently, and 7 (13.46%) sustained until reanastomosis. All 9 infants with jejunostomy were parenteral nutrition dependent, compared with 22 with ileostomy and none with colostomy (P = 0.002). Infants who achieved enteral autonomy showed lower incidence of cholestasis (P = 0.038) and better growth velocity (P = 0.02) prior to reanastomosis.

CONCLUSIONS

A minority of LBW infants with SBS and ostomy achieved enteral autonomy prior to reanastomosis. Distal ostomy (ileostomy and colostomy), reduced cholestasis, and better growth were associated with achievement of enteral autonomy. Our report highlights the challenges in establishing enteral autonomy in LBW infants with IF and ostomy, and the feasibility of that approach in a minority of patients, with tangible benefits.

Nutritional Feeding Strategies in Pediatric Intestinal Failure

Intestinal failure is defined as a critical reduction of the gut mass or function, below the minimum needed to absorb nutrients and fluids. The ultimate goal in intestinal failure is to promote bowel adaptation and reach enteral autonomy while a healthy growth and development is maintained. The condition is heterogeneous and complex. Therefore, recommendations for the type and duration of parenteral, enteral, and oral nutrition are variable, with the child's age as an additional key factor. The aim of this review is to provide an overview of nutritional feeding strategies in this heterogeneous population. Different perspectives on nutritional management, nutrition and adaptation, and microbiome and nutrition will be discussed.

Transanastomotic tubes reduce the cost of nutritional support in neonates with congenital duodenal obstruction

PURPOSE

To determine the impact of intra-operative Trans-anastomotic Tube (TAT) placement on the cost of post-operative nutrition in infants with congenital duodenal obstruction (CDO).

METHODS

A retrospective analysis of patients undergoing corrective surgery for CDO, with birth-weight over 1.5 kg over a 10-year period. Data are presented as median (inter-quartile range) and analysed with Mann-Whitney U test and Fisher's exact test as appropriate.

RESULTS

59 patients were included. There was no difference between TAT and non-TAT groups for baseline characteristics, age at operation and abnormality. In the TAT group there was a significant reduction in the duration of post-operative parenteral nutrition (PN) [6 (0-11) vs 12 (8-19) days, p = 0.006], the cost of PN [£750 (0-1375) vs £1500 (1000-2375), p = 0.006] and the total cost of nutrition [£765.26 (38.36-1404) vs £1387.52 (1008.23-2363.08), p = 0.015], thereby demonstrating a median cost saving of £622.26 per patient. 14% experienced TAT displacement but no other TAT complications were encountered.

CONCLUSION

The use of a TAT is a safe and effective way to reduce the duration of PN required in patients with CDO. This infers a significant cost saving per patient, a factor that cannot be overlooked in this period of austerity.

Early oral feeding versus traditional feeding after transanal endorectal pull-through procedure in Hirschsprung's disease

Our study questioned whether the outcome of postoperative early oral feeding is different from traditional postoperative feeding in children with Hirschsprung's disease who underwent transanal endorectal pull-through.This was an observational and comparative study. Patients were allocated into 2 groups. Age, gender, fever, surgery-related infectious, abdominal distension, bowel obstruction, need for reoperation, peritonitis, anastomosis leak, and abscess formation were assessed. IV fluids and antibiotics usage were recorded. A Chi-square test, independent sample unpaired Student t test and Mann-Whitney test were used. P-value < .05 was considered statistically significant.Infections occurred in no patient in group 1 and 1 patient in group 2. Stenosis occurred in 3 patients in group 1 and 2 patients in group 2. Abdominal distension occurred in 4 patients in group 1 and 3 patients in group 2. Fever occurred in 2 patients in group 1 and 1 patient in group 2 within the first 24 hours and it occurred in 13 and 17 patients, respectively, within 48 hours. All patients of group 1 (n = 15) were treated with antibiotics and intravenous fluid administration; 1 patient for 24 hours, 12 patients for 48 hours, and 1 for 72 hours, respectively. All patients of group 2 (n = 18) were treated with antibiotics and intravenous fluid administration for 5 days. We noted a significant difference regarding the duration of antibiotic treatment and intravenous fluid administration after 72 hours.This study showed that there was no difference between the outcomes of early and traditional postoperative feeding. Due to a significant difference in the antibiotics and IV fluid administration intervals between these 2 groups which cause a prolonged hospital stay and higher costs, it seems that early postoperative feeding is superior to traditional strategy.

A comparison of lipid minimization strategies in children with intestinal failure

PURPOSE

The purpose of this study was to compare outcomes of lipid minimization with either Intralipid (IL) or Omegaven® in children with intestinal failure (IF) who developed intestinal failure-associated liver disease (IFALD) while receiving parenteral nutrition (PN).

METHODS

A retrospective review of children with IF requiring PN who developed IFALD (direct bilirubin >2 mg/dL) while receiving IL (2009-2016) was performed. Clinical characteristics, nutritional, and laboratory values were compared between children treated with reduced IL or Omegaven®.

RESULTS

16 children were reviewed (8 treated with IL and 8 treated with Omegaven® at a median dose of 1g/kg/d). Both groups had similar demographics, small bowel length, and parenteral nutritional intake during the study (82.9±27.1 kcal/kg/d vs. 75.9±16.5 kcal/kg/d, p=0.54). The mean direct bilirubin (DBili) prior to initiating treatment was 7.8±4.3 mg/dL and 7.5±3.5 mg/dL (p=0.87) in the IL and Omegaven® groups, respectively. The IL group took a median of 113 days to achieve a DBili <0.5 mg/dL compared to 124 days in the Omegaven® group (p=0.49). There were no differences in markers of liver function or growth trajectories among groups.

CONCLUSIONS

Lipid minimization with either IL or Omegaven® has similar success in achieving a normal DBili in children with IF and IFALD without major differences in nutritional status or growth.

TYPE OF STUDY

Treatment Study LEVEL OF EVIDENCE: III.

Reinfusion of Succus Entericus Into the Mucous Fistula Decreases Dependence on Parenteral Nutrition in Neonates

Background. Neonates who undergo surgery and have an ostomy with a creation of a mucous fistula are at nutritional risk, especially if the ostomy placement is proximal and the remaining bowel is not being used. Total parenteral nutrition (TPN) is used to maintain the neonatal nutritional status, but long-term use is associated with increased morbidities. The concept of reinfusing succus entericus into the mucous fistula to decrease the neonate’s dependence on TPN has been limited to case reports. Methods. This is a retrospective cohort study documenting the effectiveness of reinfusing succus entericus into the mucous fistula for neonates admitted to the neonatal intensive care unit (NICU). The authors’ primary hypothesis was that neonates who had succus entericus reinfused into the mucous fistula had decreased dependence on TPN. Results. Of the premature infants receiving mucous fistula feedings, 65% had TPN discontinued, whereas 67% of the term infants had TPN discontinued. The type of ostomy affected the neonate’s ability to be weaned off TPN. In all, 80% of the neonates with ileostomies were able to have TPN discontinued as compared with only 38% of the neonates with jejunostomies. Conclusions. The reinfusion of succus entericus into the mucous fistula decreases the neonate’s dependence on TPN and may prevent the progression of TPN-related morbidities from long-term use. Reinfusion of succus entericus into the mucous fistula may be a beneficial practice for neonates with ostomy placements.

Surgical fasting guidelines in children: Are we putting them into practice?

BACKGROUND

Patients are traditionally kept fasting (NPO) from midnight prior to surgery, to prevent aspiration during anesthesia. NPO time is continued postoperatively, out of concern for ileus. Prolonged periods of NPO place the pediatric population at risk for under-nutrition. Published guidelines for preoperative NPO times have been shown to be safe. The aim of this study was to investigate current pre- and postoperative feeding practices of children at a pediatric tertiary care hospital.

METHODS

Medical charts were used to extract data prospectively from 53 patients undergoing general, neurosurgical, or urological procedures. Date and time of NPO periods were recorded as well as the physician's postoperative diet orders and diet progression. Surgical procedures were classified as complex or noncomplex by the surgeons. Data were summarized and compared to published recommendations.

RESULTS

Preoperative NPO times were greater than recommended in 70% of patients studied (n=37). Median time spent NPO preoperatively was not significantly different between complex (11.5h) and noncomplex groups (10.8h). Postoperative NPO time was significantly greater for complex procedures than for noncomplex. Most patients received some postoperative NPO time, even when it was not included in the physician diet order.

CONCLUSION

Observed preoperative NPO time exceeded current recommendations in this study.

Intestinal failure-associated liver disease: a position paper of the ESPGHAN Working Group of Intestinal Failure and Intestinal Transplantation

Intestinal failure-associated liver disease is the most prevalent complication affecting children with intestinal failure receiving long-term parenteral nutrition. This paper reviews the definition, diagnostic criteria, pathogenesis, and risk factors. The authors discuss the role of enteral nutrition, parenteral nutrition, and its components, especially lipid emulsions. The authors also discuss the surgical treatment, including intestinal transplantation, its indications, technique, and results, and emphasise the importance of specialised intestinal failure centres.

Factors responsible for the prolonged stay of surgical neonates in intensive care units

OBJECTIVES

The length of hospital stay (HS) for patients is a major concern due to its social, economic and administrative implications; this is particularly important for neonates admitted to intensive care units (ICUs). This study aimed to determine the factors responsible for prolonged HS in surgical neonates.

METHODS

This retrospective study was conducted at Sultan Qaboos University Hospital, in Muscat, Oman. The medical records of 95 neonates admitted to the neonatal ICU who underwent general surgical procedures between July 2009 and June 2013 were reviewed. Mann-Whitney U and Pearson's Chi-squared tests were used for non-parametric numerical and categorical variables, respectively. A multiple regression analysis was performed to find a relationship between the variables and to detect the most important factor responsible for prolonged HS. A P value of <0.05 was considered statistically significant.

RESULTS

Gestational age, birth weight, number of days on a ventilator and postoperative morbidity were associated with prolonged HS. Furthermore, the age of neonates at first full enteral feed was associated with increased HS using both independent and multiple regression analyses.

CONCLUSION

Prolonged HS can occur as a result of many factors. In this study, a number of factors were identified, including low gestational age, low birth weight, increased number of days on a ventilator and postoperative morbidity. Additionally, neonate age at first full enteral feeds also correlated with increased HS. Further research on this topic is suggested to explore this correlation in more detail and to inform future practices.

Early Oral Feeding in Pediatric Intestinal Anastomosis

A prospective nonrandomized study of 31 children aged <16 years over a period of 14 months was conducted to evaluate the effects of early oral feeding (EOF) in children with intestinal anastomosis. Patients undergoing elective or emergency intestinal anastomosis below the ligament of Trietz with no contamination were included while contaminated cases and neonatal atresias were excluded. First feed was the direct oral feed started within 24 h, usually the morning after surgery. Liquid feeds were started initially and increased at 4 hourly increments to appropriate feed for age. Time to full feeds was recorded. Patients were monitored for vomiting, abdominal distension, and signs of leak. Time to first stool and length of hospital stay were recorded. Median age of patient was 12 months. Mean time to first feed was 16 h, and mean time to full feeds was 36 h. Four of the 31 patients had delayed tolerance to feed, either due to vomiting or distension, which was transient and resolved spontaneously in three patients and due to prolonged ileus in the fourth patient. None of the patients had leaks. Most of the patients were discharged by postoperative day 3 (83 %). Early enteral feeding in pediatric intestinal anastomosis can be safely started without looking for traditional markers of return of bowel activity. It lowers hospital stay with no adverse effects. Generalization of this concept to selected emergency and neonatal surgeries can be considered, but needs further randomized control trial to validate.

Efficacy and safety of a parenteral amino acid solution containing alanyl-glutamine versus standard solution in infants: a first-in-man randomized double-blind trial

BACKGROUND & AIMS

Efforts are directed at reaching the optimal composition of pediatric amino acids (AA) infusions. The goal was to demonstrate the safety and efficacy of a newly developed parenteral AA solution containing alanyl-glutamine (GLN-AA) compared to Standard-AA.

METHODS

This is a randomized (2:1), double-blind, multicentre clinical pilot trial. Infants after surgical interventions were allocated to receive GLN-AA or Standard-AA over a minimum of 5 days to maximum of 10 days. AA profiles in blood samples obtained at baseline, day 7, and end of treatment were compared to normal ranges. Data regarding safety, and efficacy were also collected.

RESULTS

Infants were comparable for (safety population) gestational age at birth (36 vs 38 weeks), birth weight (2460 vs 2955 g), and day of life during start intervention (1 vs 2 days). Plasma AA profiles in infants treated with GLN-AA (n = 13) were closer the normal ranges than those in infants treated with Standard-AA (n = 6). There were no clinical or statistical differences in adverse events, safety and efficacy parameters between both groups.

CONCLUSION

This first-in-man study shows that GLN-AA is safe in infants after surgical interventions, and is well tolerated. Compared to reference values, GLN-AA better reflects the amino acid requirements of the infant.

Medical update and potential advances in the treatment of pediatric intestinal failure

Short bowel syndrome (SBS) and intestinal failure are chronic malabsorption disorders with considerable nutritional and growth consequences in children. Intestinal failure occurs when the functional gastrointestinal mass is reduced even if there is normal anatomical gastrointestinal length. A number of management strategies are often utilized to achieve successful intestinal rehabilitation and maintain adequate nutrition to avoid intestinal transplant. These strategies include minimizing the effect of parenteral associated liver disease, limiting catheter complications, and treating bacterial overgrowth in the remaining small intestine. In addition, there continues to be significant research interest in enhancing intestinal adaptation with targeted therapies. The purpose of this review is to discuss current perspectives and to highlight recent medical advances in novel investigational therapies.

The current state of evidence-based pediatric surgery

BACKGROUND

The efficiency of medical care in the United States has become intensely scrutinized with expectations from patients, families, payors, lawmakers, and, currently, the President. The most effective vehicle to bring more efficient care is the employment of evidence-based medicine whenever possible. Evidence-based medicine is dependent on best evidence, and best evidence is generated from prospective trials. To evaluate current state of evidence based practice in pediatric surgery we reviewed the literature for trials conducted in our field the past 10 years.

METHODS

All randomized controlled trials from January 1999 through December 2009 published in the English literature were identified through a literature search using PubMed (www.pubmed.com). We included only those in pediatric general surgery excluding transplant, oncology, and the other nongeneral subspecialties.

RESULTS

The search criteria produced 56 manuscripts, of which 51 described appropriate randomization techniques. A definitive trial design with a sample size calculation was utilized in only 19 studies (34%). A statistically significant difference between treatment arms was identified in 29 of the 56 (52%) trials. There were 26 different journals of publication, with the Journal of Pediatric Surgery being most common (20) followed by Pediatric Surgery International (7). The combined total publications from January 1999 through December 2009 for the 26 journals these randomized trials represent 0.04% of all publications. Appendicitis was the most common condition that was studied (n = 10) followed by pyloric stenosis (n = 4). Trials originated in 19 different countries led by the United States (28%), United Kingdom (14%), and Turkey (12%). There was a generally progressive increase in published trials from 1999 to 2009, however, the percentage of prospective articles published in pediatric surgery was similar to a previous review published in 1999.

CONCLUSIONS

The current state of evidence-based surgery in pediatric surgery has remained stable in the first decade of the 21st century. Randomized controlled trials represent less than 0.05% of all publications involving pediatric surgery. Some of the hurdles to evidence based surgery are identified and reviewed.

Feeding after percutaneous endoscopic gastrostomy in children: early feeding trial

BACKGROUND

Percutaneous endoscopic placement of a gastrostomy tube is a common procedure to provide feeding access in children. The practice has been to withhold the initial feeding for a prescribed length of time because of safety concerns. The shortest reported time to feeding in pediatric patients is 6 hours.

PATIENTS AND METHODS

A prospective randomized trial was devised to compare the tolerance of feedings at 3 and 6 hours after percutaneous endoscopic gastrostomy placement. The change in abdominal girth before and 1 hour after the initial feeding, any vomiting, and the gastric residual volume before the next feeding were recorded. The length of stay was also documented.

RESULTS

Forty successive patients who met the entry criteria were enrolled, with 20 in each group. There were no statistical differences between the groups for age or sex distribution. There were no significant differences in the recorded episodes of emesis from either group (median value 0 in both groups, P = 0.82). The changes in abdominal girths were also similar and statistically not significantly different (median values 0 for 3 hours vs 0.5 cm for 6 hours, P = 0.29). Gastric residual volumes were low overall and not different depending on the time that feedings were started (median value 0 in both groups, P = 0.47). The length of stay was statistically the same between the 3- and 6-hour feeding groups (median values 30.7 hours for 3 hours vs 30.0 hours for 6 hours, P = 0.92).

CONCLUSIONS

Feedings after percutaneous endoscopic gastrostomy placement can be started as soon as 3 hours after the procedure is completed with no increase in complications.

Normograde, minimally invasive technique for oesophagostomy in cats

A percutaneous technique to place oesophageal feeding tubes in cats is described. Nineteen traumatised cats underwent different surgical procedures for facial and/or oral trauma and subsequent oesophagostomy. The tube placement was easy to perform, requiring a 14G over-the-needle vascular catheter, a curved forceps and a 1.2mm feeding tube. During insertion, the tube was directed aborally (normograde direction) to its definitive position in a one-step procedure. The tube was removed when the patient started to eat voluntarily. A major limit of this technique was represented by the small diameter of the feeding tube, requiring the use of a liquid diet. However, considering the absence of complications, the rapidity of the procedure and its cost efficacy, it was considered as an effective alternative to more complicated and invasive techniques, in particular if a short period of starvation is predictable.

Neonatal outcome of gastroschisis is mainly influenced by nutritional management

OBJECTIVE

The aim of the study was to evaluate early minimal enteral feeding (MEF) and gradual enteral nutrition increment on neonatal outcome of gastroschisis.

PATIENTS AND METHODS

An intervention group was prospectively assessed and compared with an observational historical control group. The prospective study relied on a new protocol of enteral nutrition. According to the new protocol, MEF was initiated 5 days after bowel reintegration and milk amounts were increased 12 mL/kg/day. In the control group, enteral nutrition was delayed until resolution of postoperative ileus, and increment of feeding was not systematized.

RESULTS

Twenty-two patients were included in the MEF group and compared with 51 control patients. Infants in the control group had lower gestational age (36 vs 35 gestational weeks [GW], P=0.03) and birth weight (2465 vs 2200 g, P=0.05). Time to first enteral nutrition (5 vs 11.5 days, P=0.0005) was significantly shorter in the MEF group. All patients in this group were fully enteral fed at day 60, though 30.4% of patients in the control group still needed parenteral nutrition at day 60 (P=0.004). Incidence of nosocomial infection was reduced (9% of patients vs 40%, P=0.016) and hospital stay tended to be shorter in the MEF group (40 vs 54.5 days, P=0.08). In the univariate analysis, factors influencing the length of parenteral nutrition during the 2 periods were the severity of perivisceritis and new nutritional protocol. In the multivariate analysis, only nutritional protocol was significantly associated with the length of parenteral nutrition (P=0.038).

CONCLUSIONS

Early MEF and controlled increase of nutritional elements after bowel reintegration significantly improved outcome of gastroschisis in newborns.

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

PURPOSE

The 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.

METHODS

Children 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.

RESULTS

Twenty-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).

CONCLUSIONS

Improved 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.

A case of fetal midgut volvulus and jejunal atresia: nutritional support and maintenance of mucosal function and integrity

Fetal midgut volvulus is a quite rare disease. Here, we report a case of a preterm newborn with fetal peritonitis, jejunal atresia with volvulus of post-atresic small bowel since about 30 cm from ileo-cecal valve (ICV) followed by a not-used microileus and microcolon. The surgical intervention consisted in the resection of volvulated necrotic small bowel followed by primary anastomosis. After surgery, total parenteral nutrition (TPN) has been started since 16(th) of post-operative days when enteral feeding (EN) was administered with a lactose-free formula containing hydrolyzed protein and medium-chain triglycerides (Pregestimil). Re-establishing intestinal continuity was preferred rather than stoma that would have required TPN. In fact, re-operation could have led to a shorter residual small bowel (RSB), since the anastomosis was at 15 cm from ICV. Our study provides evidence that not only the type of procedure (enteral versus parenteral) of nutritional support, but also the type of milk may modify the outcome. Early EN should be encouraged in newborn abdominal surgical patients because it is associated with reduced complications.