It is always nice to see how other centers manage clinical problems. In a recent review (J Pediatr 2014; 165: 1065-90) from Boston Children’s, the authors provide details on how they use enteral nutrition in pediatric intestinal failure (IF) patients. Prior to reviewing their approach, the authors provide a few definitions:
- “IF occurs when there is a reduction of functional intestinal mass necessary for adequate digestion and absorption for nutrient, fluid, and growth requirements, resulting in the need for intensive nutritional support.”
- “IF resulting from extensive intestinal resection is termed SBS” (short bowel syndrome)
The authors also discuss intestinal adaptation and factors that predispose to improvement. Enteral nutrition (EN) stimulates adaptation and ‘gut rest’ results in atrophy of intestinal mucosa.
- “Prompt initiation of enteral feeding after bowel resection has been shown to decrease the duration of hospitalization”
- “The optimal choice for EN in infants with IF seems to be human milk…If human milk is unavailable, amino acid-based formulas have been associated with improved outcomes.”
- If intact colon with ileocecal valve, supplementation with dietary fiber (e.g.. green beans) at 2 g/kg/d may be helpful.
- In this population, there is a high prevalence of micronutrient deficiencies while on partial PN support, TPN (depending on availability of components), and when on exclusive enteral feedings.
- “We commonly employ an approach that uses … continuous feeding at night and bolus feeding during the day.
- Outcomes of IF are reviewed (noted in previous blog entry –see below). Citrulline can be useful predictor of enteral autonomy.
Feeding Advancement Principles -Figure 1:
When feeds are held, usually held for 8 hours and then restarted at 75% of previous rate
- If <10 mL/kg/d or < 10 stools/d —->advance rate by 10-20 mL/kg/d
- If 10-20 mL/kg/d or 10-12 stools/d —>no change
- If >20 mL/kg/d or >12 stools/d —->reduce or hold feeds
- If 2 mL/kg/h —> advance rate by 10-20 mL/kg/d
- If 2-3 mL/kg/h –>no change
- If >3 mL/kg/h –>reduce or hold feeds
Also suggested to reduce or holding feeds when/if:
- signs of dehydration
- stool reducing substances >1%
- gastric aspirates > four times previous hour’s infusion rate
- When developmentally appropriate, offer one hour’s worth of continuous feeds BID-TID after 5 days of continuous feeds. Hold tube feeds during oral feeds.
- More than an hour’s worth of oral feeds once infant has reached full volume of feeds by continuous route and gaining weight.
Take-home message: Outcomes of IF have improved. This review provides one approach towards optimizing enteral nutrition.
Related blog posts:
- IFfy outcome | gutsandgrowth
- Green beans for short gut syndrome | gutsandgrowth
- Four advances for intestinal failure | gutsandgrowth
- Micronutrient Monitoring in Intestinal Failure | gutsandgrowth