Nutrition Week (Day 3) Multidisciplinary Feeding Disorders

A recent systematic review/meta-analysis (WG Sharp, VM Volkert, L Scahill, CE McCracken, B McElhanon. J Pediatr 2017; 181: 116-24) by my colleagues at the Marcus Center and Emory indicate that intensive, multidisciplinary treatment for pediatric feeding disorders is a game-changer.

The authors identified 11 studies with 593 patients.

Key finding: After intensive intervention, 71% were successfully weaned off tube feedings at the completion of the intervention and this improved to 80% at last followup. Treatment was also associated with increased oral intake, improved mealtime behaviors, and reduced parenting stress.

Based on the results of their review/meta-analysis, the authors provide a summary of recommendations for “standard of care at intensive day and inpatient programs.”  This lists the professional team which should involve at a minimum: psychology, medicine, nutrition, and speech language/occupational therapy.  Treatment needs active participation of caregivers so that gains will not be lost when intensive treatment is completed. Behavioral intervention is central to success.

In an associated editorial (pg 7-8), the authors (RJ Noel, AH Silverman) explain that the one of the biggest hurdles for intensive treatment is gaining approval from insurance companies. One key point they make: “Their work provides data that will be very useful towards advocacy and improving patient access to such treatment.”

My take: This study provides justification of intensive feeding programs.  That being said, the individuals/programs with the appropriate expertise to achieve these results remain quite limited.

Related blog entries:

A few more slides from my recent PNALD/IFLAD lecture:


The other subjects discussed for PNALD treatment included management of bacterial overgrowth, possible role of STEP surgery, and lipid management strategies.



Nutrition Week (Day 2) SMOFlipid

With newer lipid emulsions, there is the potential to give more lipids and have less liver injury.  A recent report by Diamond et al (JPEN J Parenter Enteral Nutr. 2016 Feb 2. pii: 014860711562692) provides some of the best data for the use of SMOFlipid in infants: Preventing the Progression of Intestinal Failure-Associated Liver Disease in Infants Using a Composite Lipid Emulsion: A Pilot Randomized Controlled Trial of SMOFlipid.

Here’s the abstract: and afterwards some slides from a recent lecture that I gave regarding parenteral nutrition associated liver disease (and intestinal failure associated liver disease):


To examine whether SMOFlipid prevents progression of intestinal failure-associated liver disease (IFALD) in parenteral nutrition (PN)-dependent infants with early IFALD (conjugated bilirubin 17-50 µmol/L, 1-3 mg/dL).


Pilot multicenter blinded randomized controlled trial comparing SMOFlipid with Intralipid. Patients received the trial lipid for up to 12 weeks, unless they achieved full enteral tolerance sooner. The primary clinical outcome was the serum conjugated bilirubin.


Twenty-four infants (mean age, 6 weeks) participated in the trial (13 Intralipid and 11 SMOFlipid). At the time of trial enrollment, patients in both groups were receiving 90% of their calories by PN. Mean duration on trial was 8 weeks and did not differ according to treatment (P = .99). At trial conclusion, patients who received SMOFlipid had a lower conjugated bilirubin than those who received Intralipid (mean difference, -59 µmol/L; P = .03). Patients receiving SMOFlipid were also more likely to have a decrease in serum conjugated bilirubin to 0 µmol/L than those in the Intralipid group over the entire observation period (hazard ratio, 10.6; 95%; P = .03). The time to achievement of full enteral tolerance did not differ statistically (hazard ratio, 1.3; P = .59) between the groups. There was no significant difference in safety outcomes between the groups.


Compared with Intralipid, SMOFlipid reduces the risk of progressive IFALD in children with intestinal failure. This trial was registered at as NCT00793195.

Here are a few more slides from my recent lecture on PNALD/IFALD:




The above slide was borrowed from a talk by Dr. Conrad Cole on short bowel syndrome (available online via the Pediatric Nutritionist blog).



Related blog posts:


Enteral Fish Oil and Intestinal Adaptation in Premature Infants

A provocative article (J Pediatr 2014; 165: 274-9) examines supplementation of enteral fat/fish oil in premature infants as a mechanism to reduce parenteral nutrition associated cholestasis (PNAC).  While the study’s limitations will prevent any dramatic conclusions, the article and associated editorial (pgs 226-27) do make several useful points.

Before discussing the limitations, the design of the study:

Infants were block randomized (block size of 8) into either a control group or treatment group.  While both groups received conventional PN, the treatment group received supplemental enteral fat as microlipid and fish oil after tolerating enteral feeds at 20 mL/kg/d.  Microlipid was started at 1 g/kg/d and advanced up to 2.5 g/kg/d; coinciding with microlipid increases, parenteral intralipid was decreased.  Fish oil was started at 0.2 g every 12 hours and was advanced to a maximum of 0.5 g every 6 hours.  The two fish oil products were Major Fish Oil 500 (Major Pharmaceuticals) and Rugby Sea Omega 50 (Rugby Laboratories).

The limitations include the following:

  • Small cohort of 18 patients in each arm
  • Due to the smell of fish oil, the study could not truly be blinded which introduces potential bias
  • Only 7 of the 36 patients could be considered to have short bowel syndrome as most of the infants had small amounts of intestine resected
  • Advancement of enteral feedings were halted if stoma output reached 20 mL/kg/d.  The editorialists note that 40 mL/kg/d would be more typical.  Thus, in both the treatment group and the control group, there was significant opportunity to reduce PN by more aggressive enteral nutrition advancement.

With these limitations in mind, there authors were able to show that supplemental fat (with fish oil) was associated with less parenteral intravenous lipid, and reduced conjugated bilirubin prior to anastomosis.  However, there was no significant difference in PN duration.  Growth parameters were similar prior to anastomosis, but improved in the treatment group after anastomosis.

In the editorial, it is noted that “enteral feeding with a high-fat diet has been demonstrated to enhance structural features of resection-associated adaptation, the underlying mechanisms for this phenomenon are still presently unknown.”

Take-home message: Enteral fat/fish oil supplementation helped decrease parenteral intravenous lipids in this study.  More broadly, advancing enteral nutrition by accepting higher ostomy outputs is likely the best strategy to avoid PNAC and other PN-associated complications.

Related blog posts: