Download Enteral Nutrition in Short Bowel Syndrome

Pediatric Enteral Nutrition in
Short Bowel Syndrome
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Definition of SBS
BASED ON FUNCTION
 Malabsorptive state occurring as a result of
the loss of a significant portion of the
intestine
 Based on the need for intervention, such as
need for TPN for longer than 1-3 months
FUNCTION MORE IMPORTANT THAN LENGTH
 Amount of resection/remaining bowel
resulting in this degree of malabsorption
varies
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Causes of Short Bowel
Syndrome
436 patients from
13 series (1972-2000)
Necrotizing enterocolitis
29 %
Volvulus
27 %
Atresia
23 %
Gastroschisis
10 %
Aganglionosis
4%
Other
7%
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Factors Contributing to Outcome





Age at time of injury
Amount and site of remaining bowel
Function and motility of residual intestine
Adaptation
Other complicating factors



cholestatic liver disease
infections
further injury to remaining bowel
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Age at Time of Injury
 Intestine will grow as the infant grows
 Potential for growth is greatest in
premature infant
19 to 27 weeks gestation: 115 + 21 cm
 27 to 35 weeks gestation: 172 + 29 cm
 over 35 weeks gestation: 248 + 40 cm
(length of normal jejunum and ileum at autopsy)

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Touloukian. J Ped Surg 1983
Amount and Site of
Remaining Bowel
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Intrinsic factor, pepsin, HCl
CCK, secretin
iron
CCK, secretin,
GIP, VIP
carbohydrates, protein, fats,
vitamins, minerals, trace
elements
water, electrolyte, vitamin B12,
bile salt, fat, fat soluble vitamins
enterglucagon,
GLP-2, peptide YY
water, electrolytes,
SCFA, oxalates
Loss of Any Bowel
 Decreased surface area for absorption
 Shorter transit time
 Hypergastrinemia




decreased pancreatic enzyme activity
precipitation of bile acids
damage to epithelium of proximal small bowel
stimulates intestinal motility
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Loss of Jejunum
 Initial marked decrease in nutrient
absorption
 Generally better tolerated because of
adaptive capacity of ileum
 Decreased CCK and secretin results in
decreased pancreatic enzyme activity
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Loss of Ileum
 Large fluid and electrolyte losses
 Sodium loss can contribute to poor growth
 Zinc depletion can worsen diarrhea
 Loss of ileal brake
 Malabsorption of bile acids impairing fat and
fat soluble vitamin absorption
 Lack of absorption of Vitamin B12
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Loss of Ileocecal Valve
 Promotes small bowel bacterial
overgrowth
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Loss of Colon
 Loss of colonic brake
 Loss of water and electrolyte resorptive
capacity
 Loss of ability to salvage calories from
malabsorbed carbohydrates
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Function and Motility
of Residual Intestine
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Adaptation
 Hyperplasia



increased surface area
Increased crypt cell production
Increased crypt depth
Increased length of villi
 Increased number of transporters per cell
 Increase in enzyme activity
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hyperplasia
Increased surface
area
dilatation
elongation
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Adaptation
Promoted by
Luminal nutrients
Endogenous secretions
Humoral factors
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Post-Operative Management
 Use PN to maintain hydration and
adequate nutrition for growth and
development
 Promote adaptation with the use of
trophic feedings
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Luminal Nutrients-Enteral Nutrition
 Fuel for enterocytes – stimulating
hyperplasia
 Promote peristalsis – decreases overgrowth
 Stimulate flow of gastrointestinal secretions
and secretion of humoral factors
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“The main goal of treatment in SBS is
intestinal adaptation while optimizing
weight gain and linear growth while trying
to maximize enteral nutrition while
minimizing parenteral support.”
“This is as much an art as it is a science”
Quiros-Teijeira et al. J Pediatr 2004
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Type of Feeding
 Breast milk
 Standard formula
 Protein hydrolysate formula
 Amino acid formula
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Breast Milk
 Bolster immune system
 Contain growth factors
 Induce protective colonic flora
 Shorter duration of parenteral nutrition
(Andorsky et al, 2001)
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Standard Formula
 Increased permeability to intact proteins
with mucosal injury
 SBS - dilated intestine, poor motility,
bacterial overgrowth
 Allergic reactions to cow’s milk or soy
protein is common
 Carbohydrate source (lactose)
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Protein Hydrolysate Formula
 Lower antigenicity
 Contain MCT oil – does not require bile
acids or micelles for absorption
 Lower peak bilirubin (Andorsky et al, 2001)
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Amino Acid Based Formula
 Two infants weaned from TPN using a
dilute elemental formula - Christie and Ament
J Pediatr 1975
 Four patients were able to wean from TPN
after change to amino acid based formula
- Bines et al JPGN 1998
 Shorter duration of TPN -Andorsky et al 2001
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EleCare®
 Protein (15% of Kcal)

Amino acid-based medical food and
infant formula

Amino acid profile based on breast milk

“Clinically” hypoallergenic (Sicherer et al,
J Pediatr, 2001)
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per 70 Kcal
Amino Acid Profile per 70 Kcal
Breast Milk and EleCare
EleCare
HM
0.600
0.500
0.400
0.300
0.200
0.100
0.000
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EleCare
 Fat (42% of Kcal)

33% of fat as MCT

30% MCT diet increased (MCT + LCT)
absorption from:
•
•
23 to 58% preserved colon
46 to 58% no colon
(Jeppesen and Mortense Gut, 1998)
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EleCare
 Fat (42% of Kcal)

Provides essential fatty acids
•
•

Linoleic (LA) - 8% of total energy
Linolenic (LNA) - 0.9% of total energy
Dietary Reference Intakes (DRI’s)
•
LA
Infants 0- 6 mos
Infants 7 - 12 mos
Children 1-18 yr
•
8% of Kcal
6% of Kcal
5-10% of Kcal
LNA
Infants 0- 6 mos
Infants 7 - 12 mos
Children 1-18 yr
1% of Kcal
1% of Kcal
0.7-1.2% of Kcal
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EleCare
 Carbohydrate (43% of Kcal)

Corn syrup solids

Osmolality at 20 Kcal/oz = 350 mOsm/kg water

Used in chronic diarrhea due to SBS
(Saavedra, et al, 2000)
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Route of Delivery/Advancing
 Continuous drip

continuous saturation of transporters
 Advance (slowly) as long as


output < 25-50 ml/kg/day
perianal area intact
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Other Strategies to Improve
Feeding Tolerance
 Addition of soluble fibers to the feeding
 Acid blockade
 Zinc
 Sodium chloride
 Loperamide
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Comparisons
of Amino Acid-Based Products
Product
Age
Indication
Fat Blend
Osmolality
(mOsm/kg water)
Infants and
Children
42% of total cal – 33% MCT
350 at 20 cal/fl oz
560 at 30 cal/fl oz
Infant Formula
One+
Junior (unflavored)
EO28 (RTF)
Infants
Children > 1 yr
Children > 1 yr
Children > 1 yr
41% of total cal - 5% MCT
32% of total cal - 35% MCT
46% of total cal - 35% MCT
32% of total cal - 35% MCT
375 at 20cal/fl oz
610 at 30cal/fl oz
607 at 30cal/fl oz
820 at 30cal/fl oz
Vivonex®
Pediatric
Children > 1 yr
25% of total cal - 60% MCT
360 at 24 cal/ fl oz
EleCare®
Neocate®
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Product
Cost per 100 cal
Cost savings per
month compared to
EleCare
EleCare®
$1.60
NA
Neocate® Infant
Formula
$1.90
4 month old- $67
Neocate® 1+
$2.15
15 month old- $214
3 year old- $280
Neocate® Jr.
$1.82
15 month old- $86
3 year old- $112
Pediatric EO28®
$1.67
15 month old- $27
3 year old- $36
Vivonex®
Pediatric
$1.80
15 month old- $78
3 year old- $102
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Summary
 Enteral nutrition is the key to bowel
adaptation
 Breast milk and amino acid formula are
associated with shorter duration of PN
 EleCare is the only infant amino acid
formula with MCT oil.
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