This retrospective study (n=263) examined the rate of venous thromboembolism (VTE) in pediatric patients who required parenteral nutrition for at least 90 consecutive days.
The cumulative incidence of VTE was 28.1%, with a rate of 0.32 VTEs per 1000 catheter-days
The number of catheters and early gestational age were noted to be independent risk factors for VTE
No patients had progression of thrombus while receiving therapeutic anticoagulation
Of those with acute DVTs (n=47), 24 (51%)resolved on repeat imaging, 14 (30%)were stable, and and 9 (19%) had decreased
4.4% (2 of 45) had a major bleed while on anticoagulation
The authors note that the true rate of VTE is likely even higher because only 42% categorized as not having a VTE had undergone dedicated venous imaging.
My take: A lot of patients with intestinal failure develop VTE. Given the risks of treatment, the role of prophylactic anticoagulation remains unclear. This is where a prospective study would be helpful.
This was a cross-sectional study of caregivers of children (n=34) with intestinal failure receiving long-term parenteral nutrition. 97% of caregivers were the child’s mother and median duration of providing care among respondents was 3.4 years.
Caregivers reported a median of 29.2 hours per week (IQR, 20.8-45.7 hours per week) of direct medical care. 6.1 hours was spent on providing PN and care of the central venous catheter. 6.3 hours was spent on enteral nutrition and enteral tube care.
In the associated editorial (pgs 10-12 by S Mauskar, JG Berry. Open Access! “Failing to Support Families’ Burden of Care for Children with Intestinal Failure“), the authors note that in the U.S. there has been a growing population of children at home with greater medical complexity and reliance on medical technology and that the need for home nursing support “greatly exceeds the supply, leaving many families on their own to care for their children.”
They also note that the medical literature (over the last 25 years) on caregiver burden for children notes it is associated with “marital discord, loss of employment, and financial struggle…In the U.S. a substantial portion of children with medical complexity assisted with technology live in single-parent households, in poverty, and are exposed to adverse childhood events…very vulnerable to the effects of high caregiving burden.”
My take: This study shows that while we have an effective treatment for intestinal failure, the burden of this treatment is very high even with care coordination and social worker help. Understanding this burden could help medical providers be more empathetic for the family who is struggling with home medical care (eg. child with recurrent admissions for central line infections).
The authors have devised a SQUIRT score for short bowel syndrome. The higher score indicates better enteral tolerance with a highest score of 13 and a lowest score is 3. It is a composite score based on composition, frequency and volume/blowouts. The authors define a blow-out to be a stool loose enough and large enough for the child to require a change of clothes.
How to Score:
Consistency (choose best stool of the day) Playdough, Formed 5 Peanut Butter, Pasty 4 Pudding, Seedy 3 Pea Soup, Loose 2 Water 1
Occurrences (over 24 hours) 1 to 3 4 4 to 6 3 7 to 9 2 Greater Than 10 1 Ostomy Present 0
Volume With Ostomy Without Ostomy (mL/kg) (# of blowouts)
< 10 mL/kg 8 0 =4
10 -14 mL/kg 7 15-19 mL/kg 6 1 =3
20-24 mL/kg 5 2 =2 25-29 mL/kg 4
30-34 mL/kg 3
35 mL/kg 2
>35 mL/kg 1 >3 =1
The authors state that this scoring system has been used in their institution. “This tool can provide objective information to guide clinical decision making. Even patients with ostomies, for whom we can measure stool volume, benefit from SQUIRT scores because including the variable of stool consistency provides a more nuanced assessment than relying on volume.”
My take:This type of scoring system would be useful, primarily in patients in which the volume of stool is difficult to measure. It would benefit from trials to validate its utility.
Methods: Retrospective study. Among 180 patients, 35 required long-term parenteral nutrition (SBS-IF group) and 145 acquired full oral feeding within 6 months (oral feeding group) over mean f/u of 7.9 years.
Both bowel matting (OR, 14.2, P = .039) and secondarily diagnosed atresia or stenosis (OR, 17.78, P = .001) were independent postnatal predictors of SBS-IF.
An initial residual small bowel length of more than 50 cm was the best predictive cut-off for nutritional autonomy, with a sensitivity of 67% and a specificity of 100%
My take: This study identifies bowel matting and atresia/stenosis as additional factors in predicting nutritional autonomy.
Lately, there have been a lot of articles on neurocognitive function. The latest (A Gold et al. JPGN 2020; 70: 225-31) describes the myriad of problems facing children with intestinal failure (IF). The authors literally used 12 different measures of neurocognitive and academic measures –though not all 28 subjects had each of these measures (Table 2).
The authors specifically excluded 5 children with severe neurodevelopmental problems that precluded participation in standardized assessment and 10 children who were transplant recipients.
Also, when judging the results, it is important to keep in mind that their cohort had a good maternal education level; 68% were college graduates.
13 of 28 (46%) received a diagnosis of cognitive/learning DSM diagnosis
29% met diagnostic criteria for a learning disability, 7% for ADHD, and 11% for intellectual disability; comparison Canadian prevalence rates are 4%, 5%, and 1% respectively
The number of first-year septic episodes was associated with poorer outcomes; ≥2 or more episodes increased the likelihood.
Sustained cholestasis was associated with poor outcomes
The average level of intellectual functioning in their sample of 28 children was within 1 standard deviation of the population mean
There are a lot of risk factors for neurodevelopment impairment in these children with IF: prematurity, nutritional status/specific nutrient deficiencies, cholestasis, need for anesthesia/surgeries
My take: More than half of children with IF had neurodevelopemental impairment. In this cohort, recurrent sepsis in the first year of life and sustained cholestasis were associated risk factors.
Both SMOFlipid and Omegaven help prevent and/or treat parenteral nutrition associated cholestasis.
SMOFlipid is much less expensive (see slide below) -50 gm of SMOFlipid ~$5 compared to 10 gm of Omegaven at $35, thus omegaven costs more than 30 times SMOFlipid.
Though SMOFlipid is not FDA approved in children, it is being used widely and allows for increased calories compared to lipid minimization with intralipid and could improve neurocognitive outcomes.
SMOF dosing (listed below) with goal of 3 g/kg in preterm infants.
Resolution of cholestasis does not mean reversal of cirrhosis. Thus, lipid emulsion intervention at earlier stage may be important.
Bram Raphael Getting In Line: Towards a Clinical Practice Guideline For CVC Salvage
Several infections are very difficult to clear, especially yeast, enterococcus, and pseudomonas
Salvaging central lines may obviate the need for multi-visceral transplant which carries a 5-year ~50% mortality rate
Cefepime provides good gram-negative coverage; consider meropenem in those with septic shock
Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
A recent study (C Belza et al. JPEN 2019; https://doi.org/10.1002/jpen.1692) showed that SMOFlipid reduced the frequency of cholestasis in intestinal failure patients. Thanks to Kipp Ellsworth for reference.
This was a retrospective cohort study of infants with IF with a minimum follow‐up of 12 months in 2008–2016. Patients were stratified into 2 groups: group 1 received SMOFlipid; group 2 was a historical cohort who received Intralipid. The primary outcome was liver function evaluated using conjugated bilirubin (CB) levels…
Thirty‐seven patients were evaluated (17 = SMOFlipid, 20 = Intralipid). SMOFlipid patients were less likely to reach CB of 34 (24% vs 55%, P = 0.05), 50 µmol/L (11.8% vs 45%; P = 0.028), and did not require Omegaven (0% vs 30%; P = 0.014). CB level at 3 months after initiation of parenteral nutrition (PN) was lower in patients receiving SMOFlipid (0 vs 36 µmol/L; P = 0.01). Weight z‐scores were improved for patients receiving SMOFlipid at 3 months (−0.932 vs −2.092; P = 0.028) and 6 months (−0.633 vs −1.614; P = 0.018).
I did not make it to this year’s meeting but did get a chance to catch up on a lot information via the PG 2018 Syllabus and based on information posted online.
Here are a couple of highlights for me:
My favorite slide from postgraduate course -Dr. Robert Kramer
Slides regarding the topic of Treat-toTarget Dr. Eric Benchimol:
Slides regarding GI symptoms and autism from Dr. Kara Margolis:
Slide regarding the frequency of bariatric surgery: Dr. Rohit Kohli:
Slides regarding intestinal failure population from Dr. Conrad Cole:
From Dr. Miranda van Tilburg regarding psychological therapies for functional GI disorders:
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
Increasingly, kidney problems are recognized in children with intestinal failure/short bowel syndrome who receive long-term parenteral nutrition. A recent study (H Billing et al JPGN 2018; 66: 751-54) highlights the experience with this issue at a pediatric intestinal rehabilitation center in Germany.
Among 50 patients with a median age of 4.2 years, 76% had proteinuria
30% had chronic kidney disease –indicated by reduced creatinine clearance of <90 min (1.73 squared)/min
Hypercalciuria was identified in 30 patients (60%)
Nephrocalcinosis was identified in 9 patients (18%)
The authors note that end-stage renal failure has not been reported in association with intestinal failure, though proteinuria is associated as a risk factor.
My take: This observational study shows a high frequency of kidney issues in children with intestinal failure. With improvements in survival, chronic kidney disease could become a more significant clinical issue.
Tweet below indicates need for careful nutrition input when children are placed on unusual diets, including the ketogenic diet.
In this study, there were no social or demographic factors which were identified which were associated with increased hospitalization
Having a colon and an ileocecal valve lowered the risk of hospitalization
The use of SBBO treatment was associated with increased hospitalization though this may have been a marker of more severe disease
Vascular catheter infections were reduced compared to study at same institution previously but remained an important risk factor for hospitalization
My take: this study illustrates the challenges in reducing hospitalization. While the authors did not identify social/demographic factors, my experience is that there are some families who are much more capable than others in taking care of children with complex problems. If all children had the best parents, that would truly allow the hospitalization rate to be reduced much lower.