Micronutrient Monitoring in Intestinal Failure

J Pediatr 2013; 163: 1692-6.  This retrospective study of prospectively collected data from 178 children provides data with regard to micronutrient deficiency among intestinal failure patients transitioning to enteral feeds. Figures 1 and 2 along with Table 2 provide the prevalence of micronutrient deficiency while receiving supplemental parenteral nutrition (PN) and while on full enteral nutrition (FEN).  Iron deficiency was most common in both situations with prevalence of 84% and 61% respectively. With the exception of folate (0%), all of the vitamins and micronutrients had fairly high rates of deficiency.  While on FEN,  deficiencies were  the following:

  • Vitamin A        19%
  • Vitamin B12    6.5%
  • Vitamin D        30%
  • Vitamin E          6%
  • Copper            8%
  • Iron                61%
  • Selenium         4%
  • Zinc               23%

The study does not indicate that the deficiency values were adjusted based on CRP values.  Instead, “low serum levels were used to define deficiencies.”  This is likely to lead to numerous errors.  Nevertheless, it is clear that these deficiencies are common.  Another finding of the study was that normal anthropometrics did not reduce the frequency of these deficiencies.  In their patient population, 57 of 136 (42%) with sufficient height and weight data had a height-for-age z-scores of <-2 by the time of FEN; where as 52 of 139 patients (37%) had weight-for-age z-scores of <-2.

A recent post on The Pediatric Nutritionist blog provides a suggested approach to the monitoring of vitamins and micronutrients based on the need for parenteral nutrition and on the need to consider inflammatory markers in the interpretation of these lab values: The Importance of Nutrition Lab Monitoring Protocols Featuring 

Bottomline: Vitamin and micronutrient deficiencies are common among intestinal failure patients.  In addition, a large percentage of these kids are not large at all.

Related blog post:

What happens to micronutrient levels in the hospital setting 

What helps kids poop?

While there are a number of answers to the above title, the answer that I’m looking for is physical activity (JPGN 2013; 57: 768-74).

With regard to the referenced study, a large prospective birth-cohort study (n=347 participants) in Rotterdam showed that preschool children with increased physical activity had about 1/3rd less frequency of functional constipation in the fourth year of life.  Activity measurements at the age of 2 years were accomplished by wearing ActiGraph accelerometers during 1 weekday and 1 weekend day.  Additionally, children who had physical activity of 60 min/day at age 4 had about 1/2 the likelihood of having functional constipation.  There are several limitations to the study; reduced activity and constipation could both be present in some individuals as a consequence of personality or psychologic attributes rather than physical activity having a causal relationship in causing constipation.

Bottomline: Another good reason to encourage physical activity –it might help with regular bowel habits.

Also, on a separate note, a recent blog post by Kipp Ellsworth is a useful reference for lab monitoring (micronutrients and vitamins) in children with short bowel syndrome:

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