Enteral nutrition in short bowel syndrome

Factors associated with accelerated parenteral weaning in children with intestinal failure: A descriptive cohort study

BACKGROUND

The goal of intestinal rehabilitation in children is to wean from parenteral nutrition (PN). The aim of this study was to identify factors associated with accelerated weaning and to evaluate long-term outcomes of children receiving long-term PN.

METHODS

This was a retrospective study of children managed by the Intestinal Rehabilitation Center at Cincinnati Children's Hospital. Medical history data were retrieved. The outcomes of children receiving long-term chronic PN (>2 years) were compared with those of children receiving short-term chronic PN regimen (<2 years).

RESULTS

The cohort consisted of 112 children (58% boys, median [IQR] age of 6.0 [3.7-9.5] years). The group treated with a long-term PN regimen had significantly shorter residual small bowel and large bowel compared with the group treated with a short-term PN regimen (20% vs 60% and 75% vs 100%, respectively; P < 0.05). The lapse of time between PN and enteral feed initiation was longer in the group undergoing long-term PN regimen than in the short-term group (71 vs 32.5 days; P = 0.012). More episodes of central line-associated bloodstream infection (CLABSI) and a higher percentage of feeding aversion was demonstrated in the long-term PN group (2 [1-3] vs 1 [0-2] episodes and 36% vs 0%, respectively).

CONCLUSION

Small bowel, colon length, enteral feed initiation, and frequency of CLABSI are factors associated with duration of PN regimen. A long-term chronic PN regimen is associated with a higher risk of food aversion.

Treatment of Food Aversion and Eating Problems in Children with Short Bowel Syndrome: A Systematic Review

Food Aversion (FA) is a strong refusing behaviour to the oral assumption of food that can affect children with Short Bowel Syndrome (SBS). Management includes behavioural and Messy Play treatments, with few reports on systematic strategies to return the patient to enjoyable eating. We conducted a systematic review to better understand this complex and vital issue. (1) Materials and Methods: We investigated publications using MEDLINE, Embase, and the Web of Science to include articles published up to July 2022. The inclusion criteria were original articles including paediatric patients (aged < 18 years old) affected by SBS and Intestinal Failure (IF) who underwent treatment for FA. (2) Results: A total of 24 patients received treatment—15 (62.5%) patients were male and 9 (37.5%) were female. The age range was from 1 month to 16 years. Treatment of FA was carried out by behavioural therapy in 2 patients and Messy Play Therapy in 12 patients already surgically and pharmacologically managed for SBS. The treatment results showed complete weaning from Parenteral Nutrition in 9/14 cases (64%) using the behavioural treatment and 7/12 cases using Messy Play Therapy. (3) Conclusions: FA is a rare but disabling condition that often affects SBS patients, worsening their overall health and quality of life. This condition should be addressed in an Intestinal Rehabilitation Centre context. Our review sheds light on the literature gap regarding FA, and further studies are required to understand better which treatment options best suit SBS paediatric patients.

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.

Weaning from Parenteral Nutrition

The ultimate goal of treatment of short bowel syndrome/intestinal failure patients is to achieve enteral autonomy by eliminating parenteral nutrition (PN)/intravenous fluids (IV). After optimization of diet, oral hydration and anti-diarrheal medications, attempt should be made to eliminate PN/IV. Weaning from PN/IV should be individualized for each patient. Although teduglutide is the preferred agent for PN/IV volume reduction or successful weaning, optimal patient selection and long-term safety need further evaluation. Following PN/IV elimination, patients need long-term monitoring for nutritional deficiencies. This article will address clinical considerations before, during, and after PN/IV weaning to facilitate safe and successful PN/IV weaning process.

Short bowel syndrome in infants: the critical role of luminal nutrients in a management program

Short bowel syndrome develops when the remnant mass of functioning enterocytes following massive resections cannot support growth or maintain fluid–electrolyte balance and requires parenteral nutrition. Resection itself stimulates the intestine’s inherent ability to adapt morphologically and functionally. The capacity to change is very much related to the high turnover rate of enterocytes and is mediated by several signals; these signals are mediated in large part by enteral nutrition. Early initiation of enteral feeding, close clinical monitoring, and ongoing assessment of intestinal adaptation are key to the prevention of irreversible intestinal failure. The length of the functional small bowel remnant is the most important variable affecting outcome. The major objective of intestinal rehabilitation programs is to achieve early oral nutritional autonomy while maintaining normal growth and nutrition status and minimizing total parenteral nutrition related comorbidities such as chronic progressive liver disease. Remarkable progress has been made in terms of survivability and quality of life, especially in the context of coordinated multidisciplinary programs, but much work remains to be done.

Peptide YY induces intestinal proliferation in peptide YY knockout mice with total enteral nutrition after massive small bowel resection

OBJECTIVE

In previous research, peptide YY (PYY) administered in supraphysiological doses did not induce significant proliferative effects in rats that were allowed to feed ad libitum after massive small bowel resection (SBR). The main reason may well have been the interference of endogenous PYY released from L cells in the distal bowel in response to the presence of augmented unabsorbed intraluminal nutrients. The purpose of the present study was to explore the effect of PYY on intestinal proliferation with total enteral nutrition (TEN) in a SBR model of PYY knockout (Pyy(-/-)) mice, which do not produce endogenous PYY.

MATERIALS AND METHODS

Pyy(-/-) mice were assigned into 3 experimental groups: sham mice (sham group) underwent bowel transection and reanastomosis, and received TEN; SBR mice (SBR group) underwent a 50% small bowel resection, and received TEN; and SBR-PYY mice (SBR-PYY group) underwent a 50% small bowel resection, received TEN, and were treated with PYY1-36 subcutaneously from day 2 postoperatively. Parameters of enterocyte proliferation and apoptosis were determined on day 8 following operation.

RESULTS

SBR-PYY mice demonstrated a significant increase in (vs SBR) bowel and mucosal weights, mucosal DNA and protein, villus height, and crypt depth in jejunum and ileum. SBR-PYY mice also showed an increased crypt cell proliferation index in jejunum and ileum and decreased villus cell apoptotic index in ileum compared with SBR animals.

CONCLUSIONS

In an SBR model of Pyy(-/-) mice, PYY induces proliferation of residual intestine with TEN.

Role of the colon in short bowel syndrome and intestinal transplantation

Colon is a crucial partner for small intestinal adaptation and function in patients who underwent extensive small intestinal resection or transplantation. This short review deals with the different properties and roles of the colon in these settings, involving fluid and electrolytes absorption, absorption of medium-chain triglycerides, and production of short-chain fatty acids for malabsorbed energy salvage. The colon may adapt after small intestinal resection, whereas it hosts the most important part of the intestinal microbiota, which plays a crucial role in intestinal function and health. Also, colon may be responsible for D-lactic acidosis as well, as it can be injured by noninfectious colitis. Finally, the relevance of a simultaneous colon grafting is discussed as it is occasionally considered in specific patients requiring intestinal transplantation.

Pediatric enteral nutrition

Common to all pediatric patients receiving enteral nutrition is the inability to consume calories orally. This is often secondary to issues of inadequate weight gain, inadequate growth, prolonged feeding times, weight loss, a decrease in weight/age or weight/height ratios, or a persistent triceps skinfold thickness <5% for age. Enteral nutrition requires enteral access. In the neonatal period the nasoenteric route is usually used. In pediatric patients requiring long-term enteral access, surgically, endoscopically, or radiologically placed percutaneous feeding tubes are common. Jejunal feeding tubes are used in pediatric patients with gastric feeding intolerance or persistent gastroesophageal reflux. Low-profile enteral access devices are preferred by most pediatric patients because of their cosmetic appearance. For most children, a standard pediatric polypeptide enteral formula is well tolerated. There are specialized pediatric enteral formulas available for patients with decreased intestinal length, altered intestinal absorptive capacity, or altered pancreatic function. Weaning patients from tube feeding to oral nutrition is the ultimate nutrition goal. A multidisciplinary approach to patients with short bowel syndrome will maximize the use of enteral nutrition while preserving parenteral nutrition for patients with true enteral nutrition therapy failure.

Arguments for a lower carbohydrate-higher fat diet in patients with a short small bowel

Short small bowel patients suffer from malabsorption due to a strongly reduced small bowel surface. These patients usually get a high caloric high carbohydrate-low fat diet at oral or enteral feeding. At several points our studies demonstrate that the effect of this formula is doubtful. In these patients the intestinal flora has strongly been changed and even become characteristic due to abundant presence of lactobacilli (up to nearly 100%). In many patients with a high carbohydrate-low fat diet these bacteria both produce massive amounts of d-lactic acid and gaseous CO2, and they destroy the primary bile acids that are necessary for uptake of lipids. Thus, they cause (i) an increased risk of D-lactic acidosis and D-lactic acid-associated encephalopathy, (ii) flatulence, abdominal pain and non-infectious diarrhoea, and (iii) low uptake of fat and lipophilic vitamins. It is argued that by gradually converting the diet to a low carbohydrate-high fat diet growth of the characteristic lactobacilli can be strongly reduced and so also the mentioned inconveniences.

The effects of long-term total parenteral nutrition on gut mucosal immunity in children with short bowel syndrome: a systematic review

BACKGROUND: Short bowel syndrome (SBS) is defined as the malabsorptive state that often follows massive resection of the small intestine. Most cases originate in the newborn period and result from congenital anomalies. It is associated with a high morbidity, is potentially lethal and often requires months, sometimes years, in the hospital and home on total parenteral nutrition (TPN). Long-term survival without parenteral nutrition depends upon establishing enteral nutrition and the process of intestinal adaptation through which the remaining small bowel gradually increases its absorptive capacity. The purpose of this article is to perform a descriptive systematic review of the published articles on the effects of TPN on the intestinal immune system investigating whether long-term TPN induces bacterial translocation, decreases secretory immunoglobulin A (S-IgA), impairs intestinal immunity, and changes mucosal architecture in children with SBS. METHODS: The databases of OVID, such as MEDLINE and CINAHL, Cochran Library, and Evidence-Based Medicine were searched for articles published from 1990 to 2001. Search terms were total parenteral nutrition, children, bacterial translocation, small bowel syndrome, short gut syndrome, intestinal immunity, gut permeability, sepsis, hyperglycemia, immunonutrition, glutamine, enteral tube feeding, and systematic reviews. The goal was to include all clinical studies conducted in children directly addressing the effects of TPN on gut immunity. RESULTS: A total of 13 studies were identified. These 13 studies included a total of 414 infants and children between the ages approximately 4 months to 17 years old, and 16 healthy adults as controls; and they varied in design and were conducted in several disciplines. The results were integrated into common themes. Five themes were identified: 1) sepsis, 2) impaired immune functions: In vitro studies, 3) mortality, 4) villous atrophy, 5) duration of dependency on TPN after bowel resection. CONCLUSION: Based on this exhaustive literature review, there is no direct evidence suggesting that TPN promotes bacterial overgrowth, impairs neutrophil functions, inhibits blood's bactericidal effect, causes villous atrophy, or causes to death in human model.The hypothesis relating negative effects of TPN on gut immunity remains attractive, but unproven. Enteral nutrition is cheaper, but no safer than TPN. Based on the current evidence, TPN seems to be safe and a life saving solution.

New and emerging therapies for short bowel syndrome in children

This review provides an overview of traditional as well as emerging therapies useful in the management of pediatric short bowel syndrome. Pediatric short bowel syndrome is relatively uncommon; however, when it does occur, it presents a unique challenge to medical care providers. The use of parenteral and enteral nutrition to maximize growth and enhance intestinal adaptation so as to increase absorptive surface area has been the primary focus of therapy. In recent years, the advent of pharmacologic advances, including the use of antibacterial drugs, anti-motility drugs and hormonal therapies, has had a significant impact on this condition. At times, surgery may be indicated for dealing with complications, or providing alternative therapy such as transplantation. With ongoing research, it is likely that improved pharmacologic therapy will be available for enhanced intestinal adaptation, control of gut motility, treatment of small bowel bacterial overgrowth, and treatment of rejection following small intestinal transplantation.

Enteral and parenteral nutrition in the care of patients with short-bowel syndrome

Short-bowel syndrome is a challenging entity for the gastroenterologist, requiring integration of medical, nutritional, surgical and psychological therapies. Treatment must be based on the patient's age, remaining gastrointestinal anatomy, baseline nutritional status and underlying general health as well as the numerous complications which may arise. This chapter reviews physiological alterations that occur with short-bowel syndrome and how therapies can be tailored to most adequately meet the needs of these patients. Emphasis on early stages of therapy to enhance intestinal adaptation is focused on as management during this time has a significant impact on the long-term outcome of these patients.

Mortality and economics in short bowel syndrome

The incidence of patients with short-bowel syndrome (SBS) has increased over the years due to progress of intensive care medicine and parenteral nutrition techniques. These techniques have significantly improved the prognosis of neonates, children and adults who have lost major parts of their intestinal tract. Long-term survival is possible and does not depend primarily on the length of the remaining bowel but on complications such as parenteral nutrition-associated cholestasis, recurrent septicaemia, central venous catheter infections, and the motility of the remaining intestine. Thus, the overall related mortality in infants with SBS ranges from 15 to 25%, and in adults from 15 to 47%, depending on the age of the patients, the underlying disease, and the duration on total parenteral nutrition. Home parenteral nutrition (HPN) significantly decreases the complication rate and improves the psychological situation of the patient. Additionally, HPN reduces in-hospital cost significantly. Nevertheless, the annual costs/patient are between $100000 and $150000. The mortality rate of SBS patients on HPN is about 30% after 5 years, which is still lower than the 5-year survival rate of intestinal grafts, and it is about equal to patients' survival after intestinal transplantation. However, the overall costs of a successful intestinal transplantation are already lower after 2 years when compared with the cost of a prolonged HPN programme.

Low-fat diet impairs postresection intestinal adaptation in a rat model of short bowel syndrome

BACKGROUND

Low-fat diets (LFD) are utilized frequently in patients with short bowel syndrome (SBS). The purpose of this study was to investigate the effects of LFD on intestinal adaptation, enterocyte proliferation, and enterocyte cell death in a rat model of SBS.

METHODS

Adult male Sprague-Dawley rats were divided into 3 experimental groups: Sham-NC rats underwent bowel transection and reanastomosis and were fed normal chow (NC), SBS-NC rats underwent 75% small bowel resection and were fed NC, and SBS-rats were fed a low-fat diet (SBS-LFD). Parameters of intestinal adaptation, enterocyte proliferation, and enterocyte apoptosis were determined on day 14 after operation.

RESULTS

SBS-NC rats showed a significant increase (v Sham-NC) in jejunal and ileal bowel and mucosal weight, mucosal DNA and protein, villus height, and crypt depth. A significant 67% increase in crypt cell proliferation rate and 265% increase in villus enterocyte apoptosis was seen in the ileum of SBS-NC rats compared with control animals (P <.05). SBS-LFD animals showed lower ileal mucosal weight (29%; P <.05), jejunal crypt depth (20%; P <.05), and ileal villus height (21%; P <.05). A significant decrease in villus apoptosis in jejunum (74%; P <.05) and ileum (67%; P <.05) and a decrease in cell proliferation in ileum (35%; P <.05) was seen also after exposure to LFD compared with SBS-NC.

CONCLUSIONS

In a rat model of SBS, early LFD appears to inhibit parameters of intestinal adaptation. A possible mechanisms for this effect may be decreased cell proliferation. Decreased enterocyte loss via apoptosis, found in this study, may reflect a reduced number of enterocyte.