Nutritional Management of Infants with Short Bowel Syndrome

https://doi.org/10.1053/j.semperi.2007.02.009Get rights and content

The prevalence of short bowel syndrome appears to be increasing because of more aggressive surgical and medical approaches to the management of neonatal intraabdominal catastrophies. Hence, a large cohort of neonates with intestinal failure occupies neonatal intensive care units, requiring chronic total parenteral nutrition (TPN) in hopes that the residual bowel will adapt, thereby permitting weaning of TPN. Alternatively, when there is no hope for adaptation, these infants are maintained on TPN in hopes that they will grow to a size and state of general health satisfactory for either isolated intestinal transplant when liver function is preserved or combined liver–intestinal transplantation when the liver is irreparably damaged. Thus, it is imperative to provide enough parenteral nutrition to facilitate growth while minimizing TPN constituents predisposing to liver damage. Liver disease associated with intestinal failure (IFALD) seems to occur due to a variety of host factors combined with deleterious components of TPN. Host factors include an immature bile secretory mechanism, bile stasis due to fasting, and repeated septic episodes resulting in endotoxemia. Many constituents of TPN are associated with liver damage. Excessive glucose may result in fatty liver and/or hepatic fibrosis, excessive protein may lead to reduced bile flow, and phytosterols present in intravenous lipid may produce direct oxidant damage to the liver or may impede cholesterol synthesis and subsequent bile acid synthesis. Parenteral strategies employed to minimize TPN damage include reducing glucose infusion rates, reducing parenteral protein load, and reducing parenteral lipid load. Furthermore, preliminary studies suggest that fish oil-based lipid solutions may have a salutary effect on IFALD. Ultimately, provision of enteral nutrition is imperative for preventing or reversing IFALD as well as facilitating bowel adaptation. While studies of trophic hormones are ongoing, the most reliable current method to facilitate adaptation is to provide enteral nutrition. Continuous enteral feeding remains the mainstay of enteral nutrition support.

Section snippets

Parenteral Nutrition

Parenteral nutrition (PN) is essential for survival of infants and children with SBS, but it also may contribute to the mortality of this condition. Unfortunately, long-term PN is associated with the development of intestinal failure-associated liver disease (IFALD) in 40% to 60% of infants who require PN therapy for intestinal failure.22 It has also been termed TPN-associated cholestasis, but IFALD may be the better term as the liver injury may progress to end-stage liver disease. Liver injury

Summary

The management of infantile SBS and intestinal failure is challenging and requires vigorous attention to detail. The task of caring for children with these disorders is labor intensive for dieticians, nurses, physicians, and families. Ultimately, while some management principles are evidence-based, others involve understanding of individual patient variations and the “art” rather than the science of medicine. Much more research is required, and many resources are needed to better standardize

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