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Exploring the Tall Tales of Nutrition in the ICULori A. Duesing, MSN, RN, CPNP-AC, APNP

Financial Disclosures

▪ None related to this topic

Objectives

▪ Explain the relationship between nutrition and improved outcomes in the critically ill patient

▪ Understand terminology of relevant gastroenterology disease processes

▪ Recognize situations in which nutrition should be utilized in the critically ill patient▪ Recognize situations in which nutrition should be utilized in the critically ill patient

#1 Myth: Starvation or Under-nutrition is Ok!

▪ Nutrition is essential for survival.

▪ Supports anabolism

▪ Ameliorates uncontrolled catabolism

▪ Maintains a competent immune systemMaintains a competent immune system

▪ Bottom line … nutrition if given at the right time by the right route, will improve patient outcomes

Calorie Intake to meet the needs of ICU patients remains unclearMeta analysis including 4 studies showed:• No significant difference in mortality between under- and full fed group• Subgroup analysis showed underfed group significantly lower mortality when fed >33.3% of

standard requirement in comparison to the full-fed group• No difference in mortality between underfed group fed <33.3% of standard caloric

requirements• LOS and LOICUS did not differ

Indirect calorimetry and predictive equations:• 2349 publications retried, with 18 studies included• Predictive equations underestimated and overestimated energy expenditure in

13-90% and 0-88%, respectively• 43% below and 66% above indirect calorimetry values observed

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The latin phrase primum non nocere, translated to “first, do no harm” serves as a reminder to clinicians that good intentions may have harmful consequences. • Use of inaccurate predictive estimates for support of the critically ill• patient combined with aggressive therapy to achieve target nutrition intakes without

consideration of potential consequences of this therapy may have harmful consequences

• Each patient needs to be evaluated closely for signs and symptoms of overfeeding and feeding intolerance

Consensus

▪ Generalized belief that optimal calorie and protein intake are associated with improved patient outcomes

▪ Severity of illness is a variable = less sick patients tolerate EN

▪ Despite these limitations the Society of Critical Care Medicine American Society▪ Despite these limitations, the Society of Critical Care Medicine, American Society of Parenteral and Enteral Nutrition guidelines, and Canadian and European guidelines all recommend

▪ EN be initiated within 48 hours in the critically ill patient who is unable to maintain volitional intake.

▪ There is no known illness or disease that benefits from starvation

“Bowel rest”

▪ Popular in the 1970s for Crohn’s, colitis, acute and chronic pancreatitis, diverticulitis and a number of other GI disorders

▪ Why?

▪ Enteral nutrition (EN) enhances inflammation( )

▪ Removal the stimulus of luminal antigens and bowel function

▪ Contrary:

▪ Starvation does not inhibit bowel function

▪ Starvation decreases splanchnic blood flow resulting in profound structural and functional changes to the GI tract

The splanchnic circulation. Gelman S, Mushlin PS: Catecholamine induced changes in the splanchnic circulation affecting systemic hemodynamics. Anesthesiology 100:434–439, 2004.)

Characteristics of Splanchnic blood flow

▪ Regulates circulating blood volume and systemic blood pressure

▪ In acute hypovolemia, such as hemorrhage, splanchnic circulation is reduced to supply blood and oxygen to vital or essential organs = brain and heart.

▪ A key source of inflammatory mediators▪ A key source of inflammatory mediators

Regulators

Intrinsic

▪ Local metabolic & myogenic control

▪ Blood flow: Vasodilators/vasoconstrictors

Extrinsic

▪ Sympathetic innervations

▪ Increases vascular resistance to decrease blood flow

▪ Local reflexes

▪ Locally produced vasoactive substances

▪ Circulatory vasoactive substances

▪ Systemic hemodynamic changes

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#2 Myth: Parenteral Nutrition is Safe!

▪ If the gut works, use it!

▪ Parenteral nutrition (PN) prevents progressive malnutrition in patients unable to feed enterally

▪ Widely accepted to use the GI tract as a preferred route in delivering nutritional▪ Widely accepted to use the GI tract as a preferred route in delivering nutritional support.

▪ Strongly recommended in critically ill and postoperative patients

▪ Although widely accepted, parenteral nutrition is still used in patients who can be fed enterally

Adverse effects of Parenteral Nutrition▪ Double hit if you are not feeding the gut and using PN

▪ Metabolic, immunologic, endocrine and infective complications associated with high glucose concentration and fat globules via the systemic venous system.

▪ PN bypasses the GI tract and liver

▪ EN stimulates enterohormones which are crucial in regulating gut function and metabolic pathways

▪ EN supplies the portal system supplying the liver with a rich source of nutrients and hormones

▪ Increased risk for GI mucosal atrophy, bacterial overgrowth and translocation, increased intestinal permeability

▪ PN is associated with impaired leukocyte chemotaxis, impaired phagocytosis, impaired bacterial and fungal killing and an attenuated inflammatory response

4696 abstracts with 406 articles included:• PNAC directly correlated with length of PN use• No decrease in the past 4 decades• Multidisciplinary teams to treat PNAC/IFALD show improved outcomes• Discussion regarding Omegavan and SMOF to improve outlines

26 Randomized trials of 2211 patients:• PN + oral and IV dextrose = no difference in mortality• PN alone = risk of mortality doubled

#3 Myth: EN is Contraindicated with Vasopressors!

▪ Hemodynamically unstable and/or require vasopressors = common in the ICU

▪ Vasopressors improve hemodynamics as they shunt blood from the gut to the central circulation

▪ Feeding during these times?▪ Feeding during these times?

▪ No, if limited oxygen delivery to the gut, why would you increase oxygen demand by feeding?

▪ Will cause bowel ischemia NCP• In animal models, mesenteric and renal blood flows improved with low dose

enteral nutrition while receiving low dose vasopressin• As vasopressin therapy increased, the benefit of enteral nutrition on mesenteric

perfusion was not maintained• To promote splanchnic perfusion with use of enteral nutrition, the authors

advocate for enteral nutrition ~6 hours post fluid resuscitation

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In endotoxic and septic shock models, enteral feeding improved• hepatic artery and portal vein blood flow• superior mesenteric artery blood flow• intestinal mucosal microcirculatory flow• hepatic microcirculatory flow• hepatic and intestinal tissue oxygenation, and • hepatic energy stores

Prospective study = 886 ICU mechanically ventilated pts• Optimal nutritional therapy associated with a decrease in 28-day

mortality by 50%• Only reaching energy targets is not associated with a reduction in

mortality.

• Multicenter retrospective study showed lower hospital mortality in patients enterally fed within 48 hours

• EN benefits greater in the sickest receiving multiple vasopressors• Early enteral nutrition vs. late enteral group: 22.5% vs 28.3%; P = 03; and 34.0% vs

44.0%; P < .001, respectively• Early feeding = within 48 hours of the start of mechanical ventilation• Late feeding = Later than 48 hours• Protein/energy needs not reviewed

#4 Myth: Early EN is not Important in Patients Receiving Mechanical Ventilation!

▪ The commencement of enteral nutrition is typically delayed in mechanical ventilated patients

▪ Likely cause? Not a current priority and may be pushed to the back burner

▪ Older guidelines support mechanically ventilated patients go 1 weeks without▪ Older guidelines support mechanically ventilated patients go 1 weeks without nutrition.

▪ Mechanical ventilation is a predictor for failure to provide enteral nutrition

• Early EN within 2 days of admission associated with a significant reduction of ICU and hospital morality

• The implementation of an evidenced-based nutritional management protocol significantly shortened the duration of mechanical ventilation

• EN was associated with reduced risk of death

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#5 Myth: EN is Contraindicated with High Gastric Residual Volume!

▪ Many monitor gastric residual volume (GRV)

▪ Enteral nutrition is stopped with elevated GRVs

▪ High GRVs do not necessarily predict aspiration

▪ Low GRVs do not necessarily predict aspiration will not occur

▪ Interrupting EN with GRV 100-200mls not shown to decrease prevalence of aspiration

Speculation for GRVs

May have arisen from beliefs:

▪ #1 the stomach is a container of finite size

▪ #2 when input exceeds output over time, the stomach will “overflow”

▪ #3 overflow into … the esophagus which equals aspiration

▪ If we have knowledge of gastric contents at any given time through GRV we will predict risk of overflow and ultimately prevent aspiration

Implications to the theory of High GRVs

▪ GRVs accurately reflect the total volume in the stomach

▪ Formula retained in the stomach will alert the clinician to delayed gastric emptying equaling impending intolerance

▪ Stop the feeding to prevent vomiting or aspiration from occurring▪ Stop the feeding to prevent vomiting or aspiration from occurring

Implications of low GRVs

▪ Presumed to indicate low intra-gastric volume

▪ The formula is being emptied appropriately

▪ Risk for aspiration with a low GRV expected to be minimal, so the patient is tolerating enteral feedingstolerating enteral feedings

Flaws to rationale

▪ Total salivary and gastric secretion = output up to 1500mls salivary and 3000mls gastric secretions

▪ Aspiration of oropharyngeal secretions

▪ Some degree of aspiration may occur normally in normal healthy individuals

▪ Patient populations vary with regard to risk for aspiration pneumonia, specifically risk for aspiration of gastric contents.

▪ Must consider the specific patient:

▪ Communicative patients with functional GI tract = no benefit

▪ Uncommunicative patients with potential for impaired GI tracts = might benefit

▪ Patients with inability to handle oral secretions = no benefit

Do residual volumes impede nutritional support?

▪ GRVs may lead to clogging of feeding tubes = acid mixed with intact proteins in the tube clotting the formula

▪ Low GRVs may give clinicians false sense of security

▪ Institutional threshold values of GRVs guide the clinician to withhold nutrition▪ Institutional threshold values of GRVs guide the clinician to withhold nutrition

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• Randomized ICU ventilated patients

• #1 GRV >200ml

• #2 GRV >400mls• Aspiration prevalence was similar between groups

Tests to evaluate for aspiration

▪ Videofluorographic swallow study = “gold standard” modified barium swallow test looking at 3 phases of swallowing (oral, pharyngeal and esophageal phases)

▪ Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

▪ Scintigraphy▪ Scintigraphy

McClave, et al recommends:

• High-risk patient populations should be identified by their disease process, not solely by GRV

• Trauma, head injury, sedated, altered mental status

• Pertinent physical findings suggesting ileus

• Abdominal distention, nausea, vomiting, or overt aspiration or regurgitationg p g g

• Clinicians should not depend on GRVs to distinguish high risk from low risk

• Obvious trend of increasing GRVs should prompt a clinical pathway or algorithm

• Rather than automatic cessation of enteral feeding, consider:

• Prokinetic agent, depending on age

• Reducing sedation

• Sepsis

• Elevate head of bed

#6 Myth: Post-pyloric Feeding Reduces the Risk of Aspiration!

▪ Many clinicians believe critically ill patients should receive post-pyloric feedings.

▪ Undoubtedly, some ICU patients would not tolerate early gastric feeding due to delayed gastric emptying

▪ Underlying co-morbidities

▪ Medications

▪ Electrolyte disturbances, hyperglycemia

▪ Surgery

▪ Shock

▪ No consensus for routine use of post-pyloric feeding and associated decrease aspiration risk

Meta-analysis. • Unable to demonstrate a clinical benefit from post-pyloric versus gastric tube feeding in a

mixed group of critically ill patients, including medical, neurosurgical, and trauma ICU patients.

• The incidences of pneumonia, ICU LOS, and mortality were similar between groups.

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Now what, gastric feeding has failed?

▪ Gastric feeding intolerance

▪ Abdominal distension

▪ regurgitation

Timed trial of prokinetics▪ Timed trial of prokinetics

▪ Then, place post-pyloric feeding tube

▪ Known gastric dysmotility and ECMO = post-pyloric feeding

#7 Myth: EN is Contraindicated in Patients Without Bowel Sounds and/or a Postoperative Ileus!

▪ 1905, first clinician to suggest the relationship between bowel sounds and bowel function

▪ Part of the standard physical exam

▪ After abdominal surgery the auscultation of bowel sounds leads to feeding▪ After abdominal surgery, the auscultation of bowel sounds leads to feeding

• Bowel sounds require the swallowing of air and gastric emptying• Small bowel myoelectric activity returned immediately after surgery.• On average, took 2.4 days for the return of auscultated bowel sounds

#8 Myth: EN is Contraindicated Following GI Surgery!

▪ The period of post-operative ileus is believed to last for 3-5 days

▪ Treated with nasogastric tube to low intermittent suction, intravenous fluids, parenteral nutrition

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• Systematic review and meta-analysis of randomised controlled trials comparing any type of enteral feeding started within 24 hours after surgery with nil by mouth management in elective gastrointestinal surgery

• 837 patients, 11 studies• No clear advantage to keeping patients nil by mouth after elective gastrointestinal

resection

Enteral feeding post surgery

▪ Aggressive enteral nutrition does not come without risk

▪ Gastrointestinal intolerance:

▪ Abdominal distention

H t i▪ Hypotension

▪ Shock

▪ Small bowel ischemia or necrosis

▪ High mortality rate

• Before and after episodes of hypotension, the benefits of enteral nutrition warrant a fairly aggressive approach

• The risk:benefit ratio rises steeply during the period of hypotension• Feeds may be continued during this period, as long as there is close clinical monitoring

and a high index of suspicion is maintained for any signs of GI intolerance and the possibility of early mucosal ischemic injury

#9 Myth: EN is Contraindicated in Patients with an Open Abdomen!

▪ NPO or PN

▪ Assumption that enteral nutrition be held due to bowel wall edema and bowel dysfunction

Retrospective review = 78 patients

Early enteral nutrition in the open abdomen was associated with (1)earlier primary abdominal closure(2)lower fistula rate(3)lower hospital charges by $50,000

Retrospective study of 37 pts with ACS:

Enteral feeding was never started in 12 patients; 4 died within 48 hours of admission 7 required vasoactive agents until their death and 1 developed anadmission, 7 required vasoactive agents until their death, and 1 developed an enterocutaneous fistula requiring parenteral nutrition. Enteral feeding was initiated in the remaining 25 patients: 13 had feeds started within 24 hours of abdominal closure; 5 were fed with open abdomens; and 7 had a delay because of vasopressors (n = 2), multiple trips to the operating room (n = 2), paralytics (n = 2), and increased intra-abdominal pressures (n = 1). Once advanced, enteral feeding was tolerated in 23 (92%) of the 25 patients with attainment of goal feeds in a mean of 3.1 +/- 1 days.

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#10 Myth: EN is Contraindicated in Patients with Pancreatitis!

▪ In 1991, it was believed in acute severe pancreatitis, total parenteral nutrition be initiated to allow rest of the pancreas and provide nutrient deficits and energy caused by the inflammatory process.

What is pancreatitis?▪ Acute pancreatitis is sudden inflammation of the pancreas that may be mild or life threatening but usually subsides.

▪ Gallstones and alcohol abuse are the main causes of acute pancreatitis

▪ Heredity

▪ Medication

▪ Virus

▪ Cystic fibrosis diagnosis with increased risk▪ Cystic fibrosis diagnosis with increased risk

▪ Severe abdominal pain is the predominant symptom

▪ Whether mild or severe, acute pancreatitis usually requires hospitalization

▪ Gallstones and constant, heavy alcohol abuse account for almost 80% of hospital admissions for acute pancreatitis

▪ Women, ~1½ times that of men caused by gallstones

▪ Normally, the pancreas secretes pancreatic fluid through the pancreatic duct to the duodenum

▪ This pancreatic fluid contains inactive digestive enzymes and inhibitors that inactivate any enzymes that become

activated on the way to the duodenum

▪ Blockage of the pancreatic duct by a gallstone stuck in the sphincter of Oddi stops the flow of pancreatic fluid.

▪ Causing activated enzymes to accumulate in the pancreas, overwhelm the inhibitors, which begin to digest the cells of

the pancreas, causing severe inflammation

N t iti l t h ld b i d ti th ti i t ti th t• Nutritional support should be viewed as an active therapeutic intervention that improves the outcome of patients with acute pancreatitis

• Enteral nutrition should begin within 24 h after admission following the initial period of volume resuscitation and control of nausea and pain

• Patients with mild acute pancreatitis should be started on a low-fat oral diet • In patients with severe acute pancreatitis, enteral nutrition may be provided by

the gastric or jejunal route

Six randomized controlled studies with 263 participants• Enteral nutrition was associated with a significantly lower incidence of infections

(relative risk 0.45; 95% confidence interval 0.26 to 0.78, P = 0.004)• Reduced surgical interventions to control pancreatitis (0.48, 0.22 to 1.0, P =

0.05) Reduced length of hospital stay (mean reduction 2.9 days, 1.6 days to 4.3 days, P < 0.001).

• There were no significant differences in mortality (relative risk 0.66, 0.32 to 1.37, P = 0.3) or non-infectious complications (0.61, 0.31 to 1.22, P = 0.16) between the two groups of patients.

Conclusions Enteral nutrition should be the preferred route of nutritional support in patients with acute pancreatitis.

#11 Patients Must be Fed Semi-recumbent at 45 Degrees!

▪ In 1999, Drakulovic, et al in their randomized controlled study found:

▪ 39 intubated patients in semi-recumbent

▪ 47 intubated patients in supine

▪ Risk for pneumonia was highest in EN fed patients in supineRisk for pneumonia was highest in EN fed patients in supine

▪ Standard nursing care of the intubated patient for the head of bed to be elevated 45 degrees – especially if receiving enteral nutrition

▪ Centers for Disease Controls and Prevention, the Agency of Healthcare Research and Quality and the Institute for Healthcare Improvement all suggest elevating the head of bed to reduce reflux and pneumonia

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Semirecumbent versus supine or near supine

▪ Van Nieuwenhoven, et al (2006) randomized 112 intubated patients = 45 degrees was not achieved 85% of the time

▪ The non-supine patients were repositioned more frequently than supine

▪ No difference in ventilator associated pneumonia

▪ Grap, et al (2005) reported a mean backrest elevation of 21.7 degrees without association to pneumonia

▪ Rose et al (2010) of 2112 backrest elevation measurements in 371 patients in 32 ICUs▪ Rose, et al (2010) of 2112 backrest elevation measurements in 371 patients in 32 ICUs.

▪ 45 degrees = recorded in 5.3% of instances

▪ 30-45 degrees = recorded 22.3% of instances

▪ Nursing a patient semirecumbent at 45 degrees is not feasiable

▪ Attempts may not reduce ventilator associated pneumonia

▪ 45 degree positioning = patient slides down, sacral pressure, uncomfortable for patient

▪ Supine at 0 degrees probably increases the risk of pneumonia; however, no strong evidence that elevation of the head of the bed to 10-30 degrees will increase the risk for pneumonia

Conclusion

▪ Myths delay and limit optimal enteral nutrition

▪ Few exceptions prohibit enteral nutrition = GI bleed requiring endoscopy, surgical problem that must be repaired or planned extubation where oral feeding is likely to be resumed

▪ Early EN is feasible and improves outcomes of critically ill patients

▪ Patients who are about to die or are deceased

References▪ Artinian, V., Krayem, H., & DiGiovine, B. (2006). Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients. Chest, 129(4), 960-967.▪ Barr, J., Hecht, M., Flavin, K.E., Khorana, A., & Gould, M.K. (2004). Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol. Chest,

125(4), 1446-1457.▪ Choi, E.Y., Park, D-A., Park, J. (2015). Calorie intake of enteral nutrition and clinical outcomes in acutely critically ill patients: a meta-analysis of randomized controlled trials. Journal of Parenteral and

Enteral Nutrition, ahead of print.▪ Collier, B., Guillamondegui, O., Cotton, B., Donahue, R., Conrad, A., Groh, K., Richman, J., Vogel, T., Miller, R. & Diaz, J. (2007). Feeding the open abdomen. JPEN, 31(5), 410-415.▪ Cothren, C.C., Moore, E.E., Ciesla, D.J., Johnson, J.L., Moore, J.B., Haenel, J.B., Burch, J.M. (2004). Postinjury abdominal compartment syndrome does not preclude early enteral feeding after definitive

closure. Am J. Surg, 188(6), 653-658.▪ Dickerson, R.N. (2011). Optimal caloric intake for critically ill patients: first do no harm. Nutrition in Clinical Practice, 26(1), 48-54.▪ Drakulovic, M.B., Torres, A., Bauer, T.T., Nicolas, J.M., Nogue, S., Ferrer, M. (1999). Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized

trial. The Lancet, 354, 1851-1858.▪ Grap, M.J., Monro, C.L., Hummel, R.S., et al (2005). Effect of backrest elevation on the development of ventilator-associated pneumonia. Am J Critical Care, 14, 396-402.▪ Heyland, D.K., MacDonald, S., Keefe, L. & Drover, J.W. (1998). Total parenteral nutrition in the critically ill patient: a meta-analysis. JAMA, 16(280), 2013-2019.▪ Khalid I Doshi P & DiGlovine B (2010) Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation Nutrition in Critical Care 19(3) 261-268▪ Khalid, I., Doshi, P., & DiGlovine, B. (2010). Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Nutrition in Critical Care, 19(3), 261-268.▪ Lauriti, G., Zani, A., Aufieri, R., Cananzi, M., Chiesa, P.L., Eaton, S., & Pierro, A. (2014). Incidence, prevention, and treatment of parenteral nutrition-associated cholestasis and intestinal failure-

associated liver disease in infants and children: a systematic review. JPEN, 38(1), 70-85.▪ Lewis, S.J., Egger, M., Sylvester, P.A., Thomas, S. (2001). Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials.▪ Marik, P.E. (2014). Enteral nutrition in the critically ill: myths and misconceptions. Critical Care Medicine 42 (4), 962-969.▪ Marik, P.E. (2009). What is the best way to feed patients with pancreatitis? Crit Care, 15(2), 131-138.▪ Marik, P.E., Zaloga, G.P. (2004). Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. (2004), BMJ, 328, 1407. ▪ Marik, P.E. & Zaloga, G.P. (2003). Gastric versus post-pyloric feeding: a systematic review. Critical Care, 7(3), 46-51.▪ McClave, S.A. & Chang, W.K. (2003). Feeding the hypotensive patient: does enteral feeding precipitate or protect against ischemic bowel? Nutrition Clinical Practice, 18(4), 279-284.▪ McClave, S.A., Lukan, J.K., Stefater, J.A., Lowen, C.C., Looney, S.W., Matheson, P.J., Gleeson, & K., Spain, D.A. (2005). Poor validity of residual volumes as a marker for risk of aspiration in critically ill

patients. Critical Care Medicine, 33(2), 324-330.▪ McClave, S.A., & Snider, H.L. (2002). Clinical use of gastric residual volumes as a monitor for patients on enteral tube feeding. JPEN, 26(6), 43-48▪ Mushlin, G.S. (2004). Catecholamine induced changes in the splanchnic circulation affecting systemic hemodynamics. Anesthesiology 100, 434-439.▪ Parks, D.A., Jacobson, E.D. (1985). Physiology of the splanchnic circulation, JAMA, 145 (7), 1278-1281.▪ Rose, L., Baldwin, I., Crawford, T., et al. (2010). Semirecumbent positioning in ventilator-dependent patients: a multicenter, observational study. Am J Critical Care 19, 100-108.▪ Tatucu-Babet, O.A., BNutDiet, Ridley, E.J., Tierney, A.C. (2015). The prevalence of underprescription or overprescription of energy needs in critically ill mechanically ventilated adults as determined by

indirect calorimetry: a systematic literature review. Journal of Parenteral and Enteral Nutrition, ahead of print.▪ Taylor, S.J., Manara, A.R., & Brown, J. (2010). Treating delayed gastric emptying in critical illness: metoclopramide, erythromycin, and bedside (Cortrak) nasointestinal tube placement. JPEN, 34(3),

289-294.▪ Van Nieuwenhoven, C.A., Vandenbroucke-Grauls, C., van Tiel, F.H. (2012). Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Critical

Care Medicine, 34, 396-402.▪ Waldhausen, J.H.T., Shaffrey, M.E., Skenderis, S., Jones R.S., & Schrimer, B.D. (1990). Gastrointestinal myoelectric and clinical patterns of recovery after laparotomy. Annals of Surgery, 211(6), 777-

785.▪ Weijs, P.J.M., Stapel, S.N., deGroot, S.D.W., Driessen, R.H., deJong, E., Girbes, A.R.J., Strack van Schijndel, R.J.M., & Beishuizen, A. Optimal protein and energy nutrition decreases mortality in

mechanically ventilated, critically ill patients: a prospective observational cohort study. JPEN, 36(1) 60-68.▪ Yang,S., Wu, X., Yu, W., & Li, J. (2014). Early enteral nutrition in critically ill patients with hemodynamic instability: an evidence-based review and practical advice. Nutrition in Clinical Practice, 29(1), 90-

96.▪ Zaloga, G.P., Roberts, P.R., & Marik, P. (2003). Feeding the hemodynamically unstable patient: a critical evaluation of the evidence. Nutrition Clinical Practice, 18(4), 285-93.

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Failure to thrive

© Children’s Specialty Group. All rights reserved.

Lori A. Duesing, MSN, RN, CPNP-AC, APNPDivision of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin

Disclosures

I h l t fi i l


I have no relevant financial relationships to disclose

Objectives

• To define FTT and determine which children will benefit from nutritional intervention

• To describe the common interventions used in the management of FTT and feeding disorders


management of FTT and feeding disorders

• To describe FTT and feeding disorder scenarios where a primary care provider should seek help from specialists

Definitions


1. Weight < 75% of median weight for chronological age (Gomez criterion)

2. Weight < 80% of median weight for length (Waterlowcriterion)

3. Body mass index for chronological age < 5th centile


y g g4. Weight for chronological age < 5th centile5. Length for chronological age < 5th centile6. Weight deceleration crossing more than two major

centile lines from birth until weight within the given age group

7. Conditional weight gain = lowest 5%, adjusted for regression towards the mean from birth until weight within the given age group

Olsen EM, et al. Arch Dis Child. 2007. © Children’s Specialty Group. All rights reserved.

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• Is 3% of the population below the 3rd

percentile?– WHO growth charts for children under 24 months– Observations falling ≥ 3 SD and ≤ 3 SD of the

sample median were excluded


sample median were excluded

• Is weight alone enough?– Proportionately small children are often not

failing to thrive– Weight-for-length or BMI < 3rd percentile may be

a better marker of FTT


• What is stable growth during infancy?– 6-39% of full-term infants cross two weight

percentiles between birth and 2 years


• Growth curves are averages which are mathematically smoothed out

Mei Z, et al. Pediatrics. 2004 Mei Z, et al. Clin Pediatr. 2011

Which growth charts and for what ages?


• 0-2 years: use WHO growth standards

• 2 years +: use CDC growth charts


2 years +: use CDC growth charts

• Danish birth cohort– Significant undernutrition

• 3% under the age of 1– Poor concurrence among all seven criteria


– None of the FTT children met all the criteria– Most met only one criterion – Most single criteria

• Not accurate enough

Olsen et al. Arch Dis Child 2007

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• Genetic short stature– Short parents– Low percentiles but do not cross

percentiles


percentiles

• To the average of the parents’ heights– Add 2.5” if male– Subtract 2.5” if female


• This is the median height expected for that child – 8.5 cm on either side of the median will

give 2 SD on either side

• Ex-premature infant– Normal birth weight if corrected for

gestation– Low percentiles if uncorrected but may


Low percentiles if uncorrected, but may show catch-up growth

• Preemies under 32 weeks gestation– May never catch up if growth during first

months of life was poor

• Constitutional delay– Initial drop in percentiles, then follow their

own line– Family history +


Family history +– Bone age assessment

• Catch-down growth– Above-expected birth weight– Initial fall in percentiles, then follow

percentiles


percentiles– This is important in LGA babies

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• Weight-for-length < 2nd percentile (WHO growth chart) or BMI < 3rd percentile (CDC growth chart)

• Poor or no weight gain – Over a period of time that varies according to the age of

the child


• Significant downtrend in weight percentiles– 30% of full-term infants cross one percentile and 23% cross

two percentiles between birth and 2 years

• These should be done along with– Assessment of parental size / growth– Correction for prematurity (where applicable)


• Inadequate intake of calories• Loss of calories

– Vomiting– Maldigestion

M l b ti


– Malabsorption• Increased caloric need

– Cardiorespiratory disease– Liver disease– Renal disease– Chronic infections

• Inability to utilize calories consumed– Chromosomal disorders– Endocrine disorders

Metabolic disorders


– Metabolic disorders

• Failure of food intake underlies most cases of FTT– lack of available food– lack of knowledge about infant feeding

maternal depression


– maternal depression– specific dietary beliefs

• Parent-child interaction– parent not offering food– child refusing to take food

• Specific organic issues in the infant

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• Pregnancy and labor • Birth weight• Early neonatal history


• Early neonatal history• Feeding issues in the first year of life

• The most common definition of SGA is 2SD below the mean for gestational age (≤ 2SD)

• ~90% of SGA infants exhibit spontaneous catch-up growth


p g

• Appropriate weight gain (“Goldilocks” amounts) is associated with the best neurological outcomes– ↑↑ weight gain (> 5000 gm in the first 16 weeks of

life) is associated with ↓ cognition and ↑BMI at age 7 years

Karlberg et al. Pediatr Res 1995Pylipow et al. J Pediatr 2009

• If a child is ≤ 2SD below the mean for gestational age, then child is SGA

Female 2SD below mean Male

Gest age grams pounds‐ounces Gest age grams pounds‐ounces

23 427 15.1 oz 23 474 1 lb 0.7 oz

24 471 1 lb 0.6 oz 24 497 1 lb 1.5 oz

25 496 1lb 1.5 oz 25 545 1lb 3.2 oz

26 536 1 lb 2.9 oz 26 598 1 lb 5.1 oz


27 598 1 lb 5.1 oz 27 661 1 lb 8.3 oz

28 652 1 lb 7 oz 28 732 1 lb 9.8 oz

29 747 1 lb 10.3 oz 29 841 1 lb 13.6 oz

30 884 1 lb 15.2 oz 30 913 2 lb 0.2 oz

31 1006 2 lb 3.5 oz 31 1083 2 lb 6.2 oz

32 1130 2 lb 7.9 oz 32 1211 2 lb 10.7 oz

33 1304 2 lb 14 oz 33 1376 3 lb 0.5 oz

34 1480 3 lb 4.2 oz 34 1560 3 lb 7.0 oz

35 1540 3 lb 6.3 oz 35 1663 3 lb 10.6 oz

36 1647 3 lb 10.1 oz 36 1802 3 lb 15.6 oz

37 1844 4 lb 1 oz 37 2022 4 lb 7.31 oz

38 2160 4 lb 12.2 oz 38 2265 4 lb 15.9 oz

39 2364 5 lb 3.4 oz 39 2480 5 lb 7.4 oz

40 2531 5 lb 9.3 oz 40 2596 5 lb 11.6 oz

41 2592 5 lb 11.4 oz 41 2655 5 lb 13.7 oz

Adapted from Olsen et al. Pediatrics 2010.

• Immunizations• Development• Medical or surgical illnesses


• Frequent infections

• Plot previous points


3/6/2015

6

• Feeding behavior and environment• Allergies to foods• Assessment of intake


Assessment of intake– Qualitative vs quantitative– 24-hour food recall– 3-day diet record

• Who feeds the child?• Where and when does the child eat?• Are there distractions?


• Is there any force feeding?• Is there any grazing?

• Perception of growth failure as a problem


• Vital for accurate assessment of growth• Length

– Length board until age 2• Weight


• Weight– < 24 months

• Nude or in clean, dry diaper– 24+ months

• Light clothing

• Thorough physical exam

© Children’s Specialty Group. All rights reserved. © Children’s Specialty Group. All rights reserved.

3/6/2015

7

• Z-scores allow more precision in describing anthropometric status


z‐score = – 3.5

z‐score = – 2.1

• Causes – Genetics 50%– Constitutional/nutritional 35%– Chronic illness >10%


– Endocrine < 5%• Children with growth hormone

deficiency are not usually malnourished

• In malnutrition, serum IGF-1 will be low

• Low weight, low height → Malnutrition• Normal weight, low height → Endocrine• Normal weight, low height,

dysmorphism → Endocrine and


Genetics

• SGA patients without catch-up growth by the age of 3 years can be referred to an endocrinologist for possible growth hormone treatment


• Laboratory tests do not help in the evaluation of FTT– 1.4 – 3.2 % laboratory tests were helpful in

making a diagnosis


making a diagnosis– All positive results suspected clinically

Berwick et al. Arch Dis Child 1982Sills RH. Am J Dis Child 1978 Larson‐Nath C. 2015

• Do not perform lab tests unless– Child is not responding to standard interventions– Child has other symptoms or signs of disease


• Common labs– CBC, ESR– Metabolic panel, electrolytes– Anti-TTG IgA, serum IgA level– Fecal elastase– Urinalysis

3/6/2015

8


• Have parents describe typical day• Look for red flags

• Excessive juice intakeE i ilk i t k


• Excessive milk intake• ‘Grazing’

• 15 calories per ounce, no protein

• Has been shown to be


contributing factor to FTT

Smith MM, et al. Pediatrics. 1994

• Excessive milk consumption can cause iron deficiency anemia and constipation

• If milk intake excessive, cut back to promote increase in solid food intake


increase in solid food intake

• Whole milk - until age of 2

• Recommended milk intake– 2-3 years: 16-20 ounces– 4-12 years: 24-32 ounces

Children < 1 year• Adding powdered formula to expressed

breast milk• Increasing calories in formula


Children > 1 year• 30 calorie per ounce beverages

– Ready-to-feed: Pediasure, Nutren Jr– Mix powder with milk: Carnation Instant Breakfast

w/ whole milk– Milk with heavy cream : 7 oz of whole milk with 1

oz of heavy cream

• Use the family’s usual foods– Add fat to the child’s foods– Suggest fats that are appropriate to the

food being served


food being served

• Do not commence junk food

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• Meals/snacks – At table or in high chair

• Structured meals and snacks N th 20 30 i t t t/d i k


– No more than 20-30 minutes to eat/drink– Feed every 3 hours

• Only water between meals and snacks

• Ask parents to look for a complete Pediatric multivitamin (not a gummy!)

• Most complete multivitamins½ t bl t f 2 & 3 ld


– ½ tablet for 2 & 3-year-olds– Full tablet for 4+ years


• Establish Meal Time Routine– Meals and snacks offered every 3 hourly– Limit all feedings to maximum of 30 minutes


g– All meals and should be offered in a high

chair/at the table– Minimize distractions– Avoid force feeding– Eliminate grazing between meals and snacks– Water between meals and snacks

• Decrease or eliminate juice• High-calorie diet

– Use the family’s regular meals but add fats only to foods presented to the patient


only to foods presented to the patient

– Do not switch child over to junk food

– High-Calorie Beverages

• In moderate or severe failure to thrive• Unmotivated families

– risk of child worsening if something is not


done• Balance between high-calorie

beverage and solid food• Wean off high-calorie beverage at the

first possible opportunity

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• Investigate and appropriately treat causes of vomiting and diarrhea


• Investigate for malabsorption if child is consuming sufficient calories

• Referral to appropriate subspecialists

• Eliminate juice• Eliminate grazing

M i ll t t ll lid d


• Maximally concentrate all solids and liquids

• Consider tube-feeding early• Referral to appropriate subspecialists

Feeding Disorders


Feeding Disorders

Normal Feeding Milestones

• Rapid acquisition of feeding skills during 1st year of life– no plateau

• Consistent increase in variety and


Consistent increase in variety and volume consumed during 1st year of life

• Should transition through purees, finger foods and early table foods by 1st

birthday

Normal Feeding Milestones

• Demonstrate basic chewing skills by age1 – continued refinement throughout early

childhood


• Age and development should always guide feeding expectations

• Feeding a child should not be stressful

In any child with a feeding disorder

• Is it organic in origin? Is it a lack of skill?

• Is it a behavioral issue?


In general, the younger the child the less likely that it is a behavioral issue

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Any child with a feeding disorder

• Establish Meal Time Routine– Meals and snacks offered every 3 hourly– All meals and should be offered in a high

chair/at the table


chair/at the table– Minimize distractions– Avoid force feeding– Grazing in between meal and snack times

should be eliminated

Consider hunger manipulation

• This should only be done when it is fairly certain it is behavioral

• Should not be done in malnourished children


children• Should be done correctly up to ½ - 1

whole day • Should be abandoned if it does not

work

Candidates for the Feeding Team

• Have enough neurological abilities to PO feed

• Highly motivated families


g y

• Behavioral feeding problems

• Chronically G-tube-fed children who have the ability to eat by mouth

• Making a diagnosis of FTT requires a combination of objective and subjective information

• Once a diagnosis of FTT is made, further information is required to guide


information is required to guide management

• Most children with FTT do not require laboratory studies

• Most children with FTT and Feeding Disorders can be managed through a series of simple interventions

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The New Opportunities for Verification ofThe New Opportunities for Verification of Enteral Tube Location (NOVEL) Project Update

Lori A. Duesing, MSN, RN, CPNP-AC, APNPDivision of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin

Objectives:

▪ Discuss NG/OG/post-pyloric tube placement verification in pediatrics

▪ Discuss the NOVEL project mission

▪ Discuss research findings

▪ Discuss future direction

Background

▪ In 2012, a safety alert was distributed by the Child Health Patient Safety Organization recommending the immediate discontinuation of the auscultation method for NG tube placement verification

▪ 1.3-2.4% of NG tube in over 2,000 insertion were located outside of the t i t ti l t tgastrointestinal tract.

▪ 20% of those tubes led to pulmonary complications

▪ Abdominal film is current gold standard

Background continued

▪ In addition to this alert, the American Association of Critical Care Nurses (AACN) issued a practice alert3 and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) implemented practice recommendations4 to address the risks and potential complications associated with misplaced NG tubes.

▪ National Association Childrens Hospitals (N.A.C.H.), ECRI Institute. Blind Pediatric NG Tube Placements - Continue to Cause Harm. Child Health, Patient Safety Organization. Overland Park, KS: Child Health Patient Safety Organization, Inc.; 2012, August.

▪ Sorokin R, Gottlieb JE. Enhancing Patient Safety During Feeding-Tube Insertion: A Review of More than 2000 Insertions. JPEN J Parenter Enteral Nutr. 2006;30(5):440 - 445.

▪ American Association of Critical Care Nurses (AACN). AACN Practice Alert: Verification of Feeding Tube Placement (blindly inserted): American Association of Critical Care Nurses; 2010.

▪ Bankhead R, Boullata J, Brantley S, et al. A.S.P.E.N Enteral Nutrition Practice Recommendations. JPEN J Parenter Enteral Nutr. 2009;33(2):122 - 167.

Background continued

▪ Common in hospital and home settings

▪ Used for enteral nutrition, fluids and medication administration

▪ Broad discrepancies regarding verification of placement = lack of literature

▪ Pediatrics more complex than adults: size of patient in relationship to size of tube, goal to minimize exposure to radiation

▪ X-ray is the gold standard, followed by pH

▪ NG tube misplacement can cause serious neurological harm or death

▪ Nurses are primary health care providers who insert NG tubes in the hospital and home settings

A mother’s story: (get out the Kleenex)▪ M y n a m e i s D e a h n a V i s s c h e r a n d I l o s t m y s o n t o a n a v o i d a b l e m e d i c a l e r r o r. O n A p r i l 8 , 2 0 0 8

I g a v e b i r t h t o G r a n t L a r s V i s s c h e r. H e w a s b o r n w i t h a h e a r t d e f e c t t h a t r e q u i r e d s u r g e r y. H e f l e w t h r o u g h t h e r e c o v e r y o f h i s s u r g e r y w i t h a m a z i n g p r o g r e s s . A t 1 1 d a y s o l d , a n d w i t h i n a c o u p l e o f d a y s o f b e i n g r e l e a s e d f r o m t h e h o s p i t a l , h e d i e d b e c a u s e a n u r s e m a d e a m i s t a k e p l a c i n g h i s f e e d i n g t u b e . I n s t e a d o f g o i n g i n t o h i s s t o m a c h i t w e n t i n t o h i s l u n g s . A l l d a y w e w a t c h e d h i m s u f f e r a n d t h e n d i e t h a t n i g h t b e f o r e o u r e y e s . I t i s a g u t w r e n c h i n g p a i n t h a t I w i s h o n n o o n e .

▪ T h e d a y h i s f e e d i n g t u b e w a s m i s p l a c e d w a s a d a y I w i l l n e v e r f o r g e t . I t w a s a d a y t h a t q u e s t i o n s I a s k e d w o u l d f o r e s h a d o w t h e e v e n t s t h a t l e d t o h i s d e a t h . I n t h e m o r n i n g t h e n u r s e c a m e i n a n d w a s n o t c o m f o r t a b l e w i t h h i s c u r r e n t f e e d i n g t u b e p l a c e m e n t a n d w a n t e d t o p u t i n a n e w o n e . A s s h e w a s p l a c i n g h i s n e w f e e d i n g t u b e I a s k e d h e r h o w s h e w o u l d k n o w i t w a s i n t h e r i g h t p l a c e . T h e n u r s e t h e n s h o w e d m e t h a t s h e w o u l d p u t i n a b u r s t o f a i r i n t h e t u b e a n d l i s t e n t h r o u g h a s t e t h o s c o p e t o h e a r t h e b u b b l e i n h i s a b d o m e n I a s k e d t h e t h e t u b e a n d l i s t e n t h r o u g h a s t e t h o s c o p e t o h e a r t h e b u b b l e i n h i s a b d o m e n . I a s k e d t h e n u r s e h o w s h e c o u l d b e s u r e t h a t s o u n d w a s a c c u r a t e l y i n h i s a b d o m e n ? S h e t h e n s h o w e d m e h o w f l u i d w a s r e m o v e d f r o m t h e t u b e t o s h o w t h a t i t w a s i n h i s s t o m a c h . I t h e n a s k e d h e r h o w s h e k n e w t h a t w a s s t o m a c h f l u i d a n d n o t f l u i d f r o m e l s e w h e r e i n h i s b o d y ? S h e d i d n ’ t h a v e a n a n s w e r f o r t h a t . I n s t e a d s h e t o l d m e t h a t I w o u l d p r o b a b l y n e e d t o l e a r n h o w t o p l a c e h i s f e e d i n g t u b e i n h i m a s h e m a y g o h o m e w i t h i t a n d i f i t c a m e o u t a t h o m e I ’ d h a v e t o r e p l a c e i t . S h e t o l d m e t h a t i f t h a t w a s t h e c a s e t h e y w o u l d t e a c h m e h o w t o d o w h a t s h e d i d . I d i d n o t k n o w t h e n t h a t m y q u e s t i o n s w o u l d c o m e t o h a u n t m e , a s t h e v e r y t h i n g s t h a t I w a s s h o w n t o a b s o l v e m y f e a r s w e r e p r o v e n f a l s e . H e d i e d t h a t n i g h t b e c a u s e t h e p l a c e m e n t w a s n o t c o r r e c t d e s p i t e t h e t e s t s t h e n u r s e d i d t o v e r i f y p l a c e m e n t .

▪ G r a n t o n l y l i v e d 1 1 d a y s . I m o u r n m y l o s s d a i l y. M o s t l y, I m o u r n f o r t h e t i m e I d i d n o t g e t t o s p e n d w i t h h i m . S i n c e G r a n t ’ s d e a t h I h a v e b e c o m e d e t e r m i n e d t o f i n d a b e t t e r a n d s a f e r m e t h o d f o r f e e d i n g t u b e p l a c e m e n t s s o t h a t n o o t h e r p a r e n t o r p e r s o n w i l l h a v e t o e x p e r i e n c e t h e l o s s t h a t I h a v e . I k n o w t h e r e h a s t o b e a b e t t e r w a y a n d I k n o w w e w i l l f i n d i t .

* * P e r m i s s i o n f r o m D e a h n a t o s h a r e ( 9 / 1 1 / 1 4 )

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Ponder these questions

▪ How many of you have known of or been associated with an adverse outcome?

▪ Do you think NG tube misplacements is under-reported?

▪ What role does quality and safety have in relationship to placement?

▪ Should we be concerned just from this one story?

American Society for Parenteral and Enteral Nutrition (ASPEN)

▪ A literature review revealed very few pediatric studies to guide our practice

▪ ASPEN formed a task force to address this issue

▪ Invited participation from stakeholder organizations

N d th j t NOVEL (th N O t iti f V ifi ti f E t l T b▪ Named the project NOVEL (the New Opportunities for Verification of Enteral Tube Location)

Why ASPEN?

ASPEN Strategic Goals and the Novel Project

▪ Foster the discovery of new knowledge and its application to the field of nutritional science (NS) therapy

▪ Education healthcare professionals to provide optimal care

▪ Advocate on behalf of the field of NS to improve clinician experience and patient▪ Advocate on behalf of the field of NS to improve clinician experience and patient outcomes

▪ Position ASPEN a the leading organization in NS therapy

NOVEL Project

▪ Mission:

▪ Determine best practices in NG tube placement verification in pediatric patients

▪ Work with biomedical engineers and industry to develop non-radiologic methods to verify and re verify NG tube placementto verify and re-verify NG tube placement

▪ Disseminate knowledge to professionals to improve clinical practice

Study

▪ Email blasts were sent to members of ASPEN, AACN, SPN and Patient Safety Officers explaining the NOVEL project with directions for IRB and data collection

▪ 140+ individuals/hospitals requested the protocol and 8 withdrew▪ 140+ individuals/hospitals requested the protocol and 8 withdrew

▪ Final count = 63 participating institutions

▪ 2 conference calls were held in December 2013 to explain the data collection process to local investigators

▪ Hospitals sent in IRB approval letters and data collection forms

▪ Data were collected between January – April 2014

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Data Collection Tool

▪ Respondents were asked to fill out:

▪ Name of hospital (coded)

▪ Project coordinators credentials

▪ Census on the day of collectionCensus on the day of collection

▪ Number of critical care beds

▪ Number of NICU beds

▪ Verification method for checking placement

▪ Ranked in order 1, 2, 3

Example of toolPatient Number(1,2,3,4)

Patient Weight in kg Patient age (See below) Patient Location(PICU, NICU, med/surg floor)

Size of tube in Fr. Location of tube(NG,OG, postpyloric)

Participating Institutions▪ Children's of Mississippi, Jackson, MS▪ N.C. Children's Hospital at UNC Health Care, Chapel Hill, NC▪ Children’s Hospital & Medical Center, Omaha, NE▪ Virtua Health, Mount Holly, NJ▪ Children's Hospital at Montefiore, Bronx, NY▪ Cohen Children's Medical Center, New Hyde Park, NY▪ St Mary's Hospital for Children, Bayside, NY▪ Stony Brook University, Stony Brook, NY▪ MetroHealth Medical Center, Cleveland, OH▪ Akron Children's Hospital, Akron, OH▪ Akron Children's Hospital, Akron General Medical Center (NICU), Akron, OH▪ Akron Children's Hospital, Summa Akron City Hospital (NICU), Akron, OH▪ Akron Children’s Hospital, St. Elizabeth's Hospital (NICU), Youngstown, OH▪ Mahoning Valley Special Care Nursery at Beeghly in Boardman, Boardman, OH

▪ Banner Thunderbird Medical Center, Glendale, AZ▪ Banner Estrella Medical Center, Phoenix, AZ▪ Banner Del E Webb Medical Center, Sun City West, AZ▪ Children's Central, Madera, CA▪ Rady Children's Hospital, San Diego, CA▪ California Pacific Medical Center, San Francisco, CA▪ Lucile Packard Children's Hospital, Palo Alto, CA▪ Children's Hospital Oakland, Oakland, CA▪ Children's Hospital Colorado, Aurora, CO▪ Connecticut Children's Medical Center, Hartford, CT▪ Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE▪ UF Health Shands Children's Hospital, Gainesville, FL▪ Children's Healthcare of Atlanta at Scottish Rite, Atlanta, GA▪ Children's Healthcare of Atlanta at Egleston, Atlanta, GA

ChildS D M i IAg y y g y

▪ Dayton Children's, Dayton, OH▪ The Children's Hospital at OU Medical Center, Oklahoma City, OK▪ Children's Hospital of Pittsburgh, Pittsburgh, PA▪ The Children's Hospital of Philadelphia, Philadelphia, PA▪ Sanford USD Medical Center, Sioux Falls, SD▪ Monroe Carell Jr. Children's Hospital at Vanderbilt University Medical Center, Nashville, TN▪ East Tennessee Children's Hospital, Knoxville, TN▪ Cook Children's Medical Center, Fort Worth, TX▪ Dell Children's Medical Center, Austin, TX▪ Children’s Medical Center, Dallas, TX▪ Seattle Children's Hospital, Seattle, WA▪ University of Wisconsin Hospitals and Clinics, Madison, WI▪ Children's Hospital of Wisconsin, Milwaukee, WI▪ Brenner Children's Hospital, Winston-Salem, NC▪ Alaska Native Medical Center, Anchorage, AK▪ Phoenix Children's Hospital, Phoenix, AZ

▪ ChildServe, Des Moines, IA▪ Mercy Children's Hospital and Clinics, Des Moines, IA▪ Rehabilitation Institute of Chicago, Chicago, IL▪ University of Chicago Comer Children's Hospital, Chicago, IL▪ Rockford Memorial Hospital, Rockford, IL▪ Riley Hospital for Children at Indiana University Health, Indianapolis, IN▪ The Center for Women and Infants at University of Louisville Hospital, Louisville, KY▪ Our Lady of the Lake Children's Hospital, Baton Rouge, LA▪ Mount Washington Pediatric Hospital, Baltimore, MD▪ Mercy Medical Center, Baltimore, MD▪ Sparrow Hospital Children's Center, Lansing, MI▪ Children's Mercy Hospital, Kansas City, MO▪ Truman Medical Center, Kansas City, MO▪ Boone Hospital Center, Columbia, MO

▪ 63 Participating Sites

▪ Total census = 8333

▪ 39 pediatric facilities

▪ 8 adult with newborn

16 d lt ith di t i d b▪ 16 adults with pediatrics and newborn

▪ Percentage of patients with tube at time of collection = 23.94%

▪Total number of NICU beds = 2791

▪Total number of PICU beds = 1438

▪Location of patients with tubes

NICU 1219▪NICU = 1219

▪PICU = 359

▪Med/Surg beds = 421

▪Unknown = 5

▪Mean age = 14.33 months

▪Mean tube size = 6.5 French

▪Mean weight = 6.83kg

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▪ Prevalence of NG tubes, n=1995

▪NG = ~66% n=1316

▪OG = ~21% n=414

▪ Post pyloric = ~13% n=261

▪ 4 unknown

▪ Of the 63 sites:

▪ All listed a primary method of checking tube placement verification

▪ 55 sites listed a secondary method of checking

▪ 39 sites listed a tertiary method of checking

Verification of Placement

▪METHOD 1

▪Aspiration 21/63 = 33%

▪Auscultation 18/63 = 29%▪Auscultation 18/63 = 29%

▪Measurement 8/63 = 13%

▪pH 10/63 = 16%

▪X-ray 6/63 = 1%


▪METHOD 2

▪Aspiration 5/63 = .08%

▪Auscultation 20/63 = 0 32%▪Auscultation 20/63 = 0.32%

▪Measurement 4/63 = .06%

▪pH 5/63 = .08%

▪X-ray 19/63 = 30%


▪METHOD 3▪Aspiration 12/63 = 19%▪Auscultation 3/63 = 0.4%▪Measurement 9/63 = 14%▪pH 1/63 = 0.1%▪X-ray 13/63 = 21%▪ Some left blank, one indicated fluoroscopy

Verification by Type of Institution

▪ Pediatric Hospitals

▪ Method 1 – aspiration

▪ Method 2 – X-ray

▪ Method 3 – measurement

Adult hospitals with a NICU▪ Adult hospitals with a NICU

▪ Method 1 – auscultation



▪ Adult/Pediatric/Neonatal Hospital

▪ Method 1 – aspiration


▪ Method 3 – X-ray

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What does this mean?

▪ This data validates what is in the literature = limited

▪ Despite current recommendations, there is clearly inconsistencies across the country

▪ Research is needed▪ Research is needed

▪ Barriers to implementing current recommendations

▪ EBP studies for best practice

▪ Size/weight of patient affecting verification

▪ Negative effects of repeated X-ray exposure

Forward thinking for NOVEL

▪ Establish best practice

▪ Evidence based practice studies to evaluate the guidelines

▪ Potential for Enteral Access Safety Teams

▪ Dissemination of studies surrounding NG tube safety

From a nurse“…I placed the NG like I had done hundreds of times in the past, with no complications and checked placement with air bolus and started the feed. The patient ended up coding on the floor and being sent to our PICU where she was intubated and started on ECMO. The moment that the patient went into respiratory distress, my whole life changed. I had not missed a day of work in seven years and went to my nurse manager and told her I needed to leave and could no longer be a nurse, and that I would not be back to work…”from invited commentary in NCP June,2014

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Short bowel syndrome Short bowel syndrome ––A nutrition perspectiveA nutrition perspectivep pp p

Lori A. Duesing, MSN, RN, CPNPLori A. Duesing, MSN, RN, CPNP--AC, AC, APNPAPNP

Division of Gastroenterology and NutritionDivision of Gastroenterology and NutritionMedical College of WisconsinMedical College of Wisconsin

Milwaukee, WIMilwaukee, WI

ObjectivesObjectives

To review theTo review the definitiondefinition and and common etiologiescommon etiologiesof short bowel syndrome of short bowel syndrome

To discuss the To discuss the pathophysiologypathophysiology of short bowel of short bowel syndrome and thesyndrome and the physiology of adaptationphysiology of adaptationsyndrome and the syndrome and the physiology of adaptationphysiology of adaptation

To review the To review the clinical managementclinical management of short of short bowel syndromebowel syndrome

To discuss the To discuss the complicationscomplications of short bowel of short bowel syndromesyndrome

DefinitionDefinition

ShortShort--bowel syndrome (SBS) is bowel syndrome (SBS) is defined functionally and is defined functionally and is

considered to exist when the considered to exist when the patient has malabsorption in thepatient has malabsorption in thepatient has malabsorption in the patient has malabsorption in the

presence of a shortened small presence of a shortened small intestineintestine

Major features of SBSMajor features of SBS

dehydration secondary to diarrheadehydration secondary to diarrhea

malabsorption of macromalabsorption of macro and micronutrientsand micronutrients malabsorption of macromalabsorption of macro-- and micronutrientsand micronutrients

malnutritionmalnutrition

failure to thrivefailure to thrive

Neonates

Normal anatomy

Abnormal anatomy

NEC

Midgut volvulus

Multiple atresias

Gastroschisis

Etiology of SBSEtiology of SBS

Older children and

adults

Gastroschisis

Hirschsprung disease

Crohn’s diseaseMalrotation with volvulus TumorsRadiation enteritis

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Length needed for TPNLength needed for TPN--free survivalfree survival

In infants with ‘‘normal’’ birth weight at least 15 cm of jejunum or ileum and the ileocecal valve

or 40 cm of small bowel without the ileocecal valve

Gestational age is imperative when reporting residual g p p gbowel length 28-week-old neonate has approximately 200 cm of bowel,

and this increases to 300 cm at term

The anticipated increase in bowel length is greatest in premature infants - an important prognostic factor in SBS patients

Adapted Nonadapted p-value Small bowel length < 15 cm

7% 38% <0.05

Patients with IC valve

68% 23% <0.001

Colonic i

32% 77% <0.001 resection>50% of colonic length resected

29% 70% <0.05

Primary anastomosis

48% 15% <0.01

QuirosQuiros--Tejeira et al. J Peds 2005; 145: 157Tejeira et al. J Peds 2005; 145: 157--6363

The percent of daily energy intake through the The percent of daily energy intake through the enteral route at 12 weeksenteral route at 12 weeks Infants getting 75% of their calories enterally by 12 Infants getting 75% of their calories enterally by 12

weeks the likelihood of weaning off TPN is 90%weeks the likelihood of weaning off TPN is 90%weeks, the likelihood of weaning off TPN is 90% weeks, the likelihood of weaning off TPN is 90%

Those getting 50% enterally at 12 weeks, the Those getting 50% enterally at 12 weeks, the likelihood of weaning is 75%likelihood of weaning is 75%

those getting only 25% enterally, the likelihood of those getting only 25% enterally, the likelihood of weaning is only 50%weaning is only 50%

Sondheimer et al. J Pediatr 132:80-84, 1998

JejunoJejuno--ileal length in premiesileal length in premies

19 19 –– 27 weeks27 weeks 114.8 +/114.8 +/-- 21 cm21 cm

27 27 –– 35 weeks35 weeks 172.1 +/172.1 +/-- 29 cm29 cm

> 35 weeks> 35 weeks 248.0 +/248.0 +/-- 40 cm40 cm

Touloukian RJ, Smith GJ: Normal intestinal length in preterm infants. J Pediatr Surg 18:720-723, 1983

Physiology and Physiology and pathophysiologypathophysiologyp p y gyp p y gy

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JejunumJejunum

Long villiLong villi Large absorptive surfaceLarge absorptive surface

High concentration of High concentration of enzymes and carrier proteinsenzymes and carrier proteins Top site for nutrientTop site for nutrientTop site for nutrient Top site for nutrient

absorptionabsorption Large tight junctionsLarge tight junctions

Relatively porousRelatively porous Large influx of water and Large influx of water and

electrolytes into the electrolytes into the lumen from the lumen from the vasculaturevasculature

IleumIleum Short villiShort villi

Smaller absorptive surfaceSmaller absorptive surface AbsorptionAbsorption

Less important for Less important for nutrient absorptionnutrient absorption

Important for bile saltImportant for bile salt Important for bile salt Important for bile salt and vitamin Band vitamin B12absorptionabsorption

Small tight junctionsSmall tight junctions Conserves water and Conserves water and

electrolyteselectrolytes

Effect of resectionsEffect of resections

Normal physiology

Duodenum Jejunum Ileum

Concentrated Concentrated nutrients nutrients delivereddelivered

a large influx of a large influx of fluid and electrolytes fluid and electrolytes

into the lumen into the lumen

Absorption of Absorption of majority of fluid and majority of fluid and

electrolytes electrolytes


Ileal resectionDuodenum Jejunum Ileum






Fluid and electrolyte disturbances


Jejunal resectionDuodenum Jejunum Ileum






Less fluid and electrolyte disturbances

The ileocecal valveThe ileocecal valve

Serves as a barrier for reflux of colonic bacteria Serves as a barrier for reflux of colonic bacteria from the colon into the small intestinefrom the colon into the small intestineResection may result in bacterial overgrowth Resection may result in bacterial overgrowth

in the small intestinein the small intestine It also regulates the exit of fluid and nutrients It also regulates the exit of fluid and nutrients

from the small intestinefrom the small intestineRapid transit of nutrients into the colon may Rapid transit of nutrients into the colon may

worsen malabsorption and increase sensitivity worsen malabsorption and increase sensitivity to osmotic loadsto osmotic loads

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The colonThe colon

The adult colon receives and absorbs 1The adult colon receives and absorbs 1--2 liters 2 liters of fluid from the small bowelof fluid from the small bowel

ResectionResection Dehydration and electrolyte problemsDehydration and electrolyte problems Loss of energy via SCFALoss of energy via SCFA

Right colon absorbs the majority of water and Right colon absorbs the majority of water and electrolyteselectrolytes If the right colon is removed, gradual improvement If the right colon is removed, gradual improvement

in sodium and water absorption occurs in the left in sodium and water absorption occurs in the left coloncolon

AdaptationAdaptation

AdaptationAdaptation

Compensatory response that follows an abrupt decrease in mucosal surface area after an extensive small bowel resection

Incl des anatomic and f nctional changes that Includes anatomic and functional changes that increase the gut’s digestive and absorptive capacity

Begins within 48 hours of surgery but may require up to 5 years for completion

AdaptationAdaptationStructural alterationsStructural alterations

The remnant small bowel increases in length and caliber, with hyperplasia / hypertrophy of each intestinal layeres ye

The magnitude of the response is greater after resection of the proximal small bowel compared with a distal resection


The patient’s age at the time of resection affects the extent of bowel lengtheningthe extent of bowel lengthening Neonates are more likely than adults to achieve

independence from TPN after extensive resection


The adapting intestine develops an increased caliber and hypertrophy of the longitudinal and circular smooth muscle layers

The increased intestinal caliber increases the absorptive surface area

may result in ineffective peristalsis

This dysmotility leads to stasis, bacterial overgrowth, sepsis, and malabsorption

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Epithelial hyperplasia is the fundamental change Increases villus height

I d h Increases crypt depth

The number of villi is also increased

The sodium-glucose co-transporter increases its activity up to 2.5-fold

Di h id d di id l h

AdaptationAdaptationFunctional alterationsFunctional alterations

Disaccharidases and dipeptidases along the brush border of the adapting small bowel show increased activity when measured per villus

Intestinal epithelium performs an important barrier function to infection

Septic episodes in SBS may be secondary to a breach of this barrier with translocation of

AdaptationAdaptationIntestinal permeabilityIntestinal permeability

breach of this barrier with translocation of bacteria

Bacterial overgrowth secondary to gut dysmotility is common in patients with SBS and can lead to bacterial translocation

Mechanisms of adaptationMechanisms of adaptationIntestinal epithelium in resected bowel

E iProduction of

Exposure to pancreatic and biliary secretions

Exposure to nutrientsProduction of trophic factors

Disaccharides >> monosaccharidesHydrolyzed protein >> Intact proteinLong chain fats >> medium chain fats

Mechanisms of adaptationMechanisms of adaptationIntestinal epithelium in resected bowel

EProduction of trophic

Trophic hormonesTrophic hormones EnteroglucagonEnteroglucagon GastrinGastrin SecretinSecretin CholecystokininCholecystokinin Epidermal growth factorEpidermal growth factor InsulinInsulin--like growth factor Ilike growth factor I

P id YYP id YY Exposure

to nutrients

Production of trophic factors

Peptide YYPeptide YY GlucagonGlucagon--like peptide 2 (GLP like peptide 2 (GLP -- 2)2)

Trophic substancesTrophic substances ProstaglandinsProstaglandins PolyaminesPolyamines

NutrientsNutrients Long Long -- chain fatschain fats Omega Omega –– 3 fatty acids3 fatty acids Short Short -- chain fatty acidschain fatty acids FiberFiber ? Glutamine? Glutamine

‘Pharmacological’ manipulation‘Pharmacological’ manipulation

GlutamineGlutamine MCTMCT LCTLCT Soluble fiberSoluble fiber

-- UnclearUnclear-- Works with an intact colonWorks with an intact colon-- UnclearUnclear-- UnclearUnclear

Pancreatic enzymesPancreatic enzymes Bile acidsBile acids Growth hormoneGrowth hormone GLPGLP--22

-- Do not workDo not work-- UnclearUnclear

-- PromisingPromising-- PromisingPromising

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How to feed?How to feed?When to feed?When to feed?Wh t t f d?Wh t t f d?What to feed?What to feed?

MalabsorptionMalabsorption The major consequence of resection of the small intestine is The major consequence of resection of the small intestine is

malabsorptionmalabsorption Due to reduction of the absorptive surface area with loss of Due to reduction of the absorptive surface area with loss of

digestive enzymes and transport carrier proteinsdigestive enzymes and transport carrier proteins Carbohydrates Carbohydrates

PProduce tremendous osmotic diarrhea following resection roduce tremendous osmotic diarrhea following resection of the ileum as reabsorption of water is impairedof the ileum as reabsorption of water is impairedof the ileum as reabsorption of water is impairedof the ileum as reabsorption of water is impaired

ProteinsProteins Larger molecules which are ingested in smaller quantities, Larger molecules which are ingested in smaller quantities,

produce fewer symptoms when produce fewer symptoms when malabsorbedmalabsorbed FatsFats

Large molecules, whose malabsorption creates little additional fluid Large molecules, whose malabsorption creates little additional fluid loss from the small intestineloss from the small intestine

Fat Fat soluablesoluable vitamins vitamins may also be may also be malabsorbedmalabsorbed in large quantities in large quantities Following extensive Following extensive ilealileal resection, bile salt depletion may occurresection, bile salt depletion may occur

Motility changesMotility changes

Motility abnormalities following intestinal Motility abnormalities following intestinal resectionresection Intestinal transit time may increase as the intestine Intestinal transit time may increase as the intestine

adapts in an attempt to increase nutrient contactadapts in an attempt to increase nutrient contactadapts in an attempt to increase nutrient contact adapts in an attempt to increase nutrient contact time with the smalltime with the small--bowel mucosabowel mucosa

Mucosal surface area will likewise increase as the Mucosal surface area will likewise increase as the small intestine dilates small intestine dilates

Unfortunately, both of these changes result in Unfortunately, both of these changes result in increased bacterial content in the small bowelincreased bacterial content in the small bowel

Importance of enteral nutritionImportance of enteral nutrition

Atrophy has been observed in the small intestine deprived of nutrient contact either by bypassing the small intestine surgically or by using parenteral nutritionparenteral nutrition

Intravenous feeding following small-bowel resection results in slight mucosal atrophy, whereas enteral nutrition stimulates mucosal hyperplasia

Enteral nutritionEnteral nutrition

Enteral nutrition is also important for stimulating regeneration of the mucosa The combination of parenteral and enteral nutrition is

superior to parenteral nutrition in stimulating intestinal i i f i i h d di hregeneration in a group of patients with protracted diarrhea

of infancy

A more rapid resolution of malabsorption and diarrhea following enteral nutrition alone versus parenteral nutrition in the same disorder has also been observed

Enteral nutrition is also important in maintaining mucosal mass in SBS

Managing a patient with SBSManaging a patient with SBSInitial managementInitial management

The immediate postoperative period is characterized by a transient ileus, and all n trients m st be given parenterally to stabilizenutrients must be given parenterally to stabilize fluid and electrolyte imbalances

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Patients then develop large-volume fluid and electrolyte secretions once the ileus resolves, and gastric fluid and ostomy losses may be high Because these losses vary significantly with time, placing the

patient on a standard parenteral nutrition solution is optimal fl d l h b l d b d h


Excessive fluid losses can then be replaced based on the electrolyte content of these secretions as determined in the laboratory

These secretions can be replaced every few hours using a separate fluid and electrolyte solution

Losses tend to be high in sodium and solutions with at least 80 - 100 mEq/L of sodium are needed to maintain fluid and electrolyte homeostasis

The first stage of therapy is the time to replete any nutritional deficiency states that may have


any nutritional deficiency states that may have existed at the time of resection

When fluid and electrolyte losses have decreased, a continuous enteral infusion is initiated

Elemental diets are s ally sed

Managing a patient with SBSManaging a patient with SBSFurther managementFurther management

Elemental diets are usually used Some people use a lower concentration of formula

and advance the concentration prior to advancing the rate (this prevents overloading the patient)

Others start at optimal concentrations and advance the rate as tolerated

Continuous enteral infusion is gradually advanced based on the absence of the following: A marked increase in stool loss by more than 50%

Stool losses greater than 40 to 50 mL/kg/day or ostomy


output strongly positive for reducing substances

In patients with an intact colon, a decrease in stool pH below 5.5 is frequently indicative of carbohydrate malabsorption

Further advancement of enteral feedings is likely to result in a significant increase in osmotic diarrhea in such patients

The use of continuous enteral infusion is advantageous Feedings are frequently better tolerated Emesis is reduced Carrier proteins are continuously saturated and intestinal

function is optimized


function is optimized The increased enteral calories try to increase the functional

workload of the small intestine, resulting in additional stimulation of intestinal adaptation

Administration of extra calories through the enteral route reduces the need for parenteral nutrition and its complications

The appropriate solids to give initially to patients with short-bowel syndrome are a matter of controversy

Tradition has suggested high-carbohydrate diets


Tradition has suggested high carbohydrate diets

These are hyperosmolar and may increase fluid losses

Meat may be the best initial solid Feeding fats or proteins results in less fluid loss

Fat is also a good trophic agent to the small intestine

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Enteral formulasEnteral formulas Patients with SBS are given elemental diets

These are diets that contain amino acids rather than peptides However, most protein is absorbed in the form of di- and

tripeptides, so the concept of an elemental diet is extended in pediatrics to partially elemental formulas - extensive protein hydrolysateshydrolysates

Carbohydrates are usually present from one or more sources, including partially hydrolyzed starch and disaccharides such as sucrose

A mixture of medium- and long-chain fats is included Adult elemental formulas are usually inappropriate in pediatrics

deficient in vitamins, minerals, and essential fatty acids tend to be high in carbohydrate content

Alimentum and Pregestimil relatively high in fat content, reducing the osmotic load in the

small intestine Both contain substantial amounts of long-chain fats, important

for their trophic effect

Enteral formulasEnteral formulas

p In older infants and toddlers, fiber-supplemented complex formulas

may be instituted as they produce a firmer stool fiber, through its effect on SCFA production, may play a role in

adaptation Newer ‘amino-acid’ formulas do not confer any absorption

advantage

As parenteral nutrition is decreased and enteral nutrition is increased, intermittent parenteral nutrition can be used.

The patient is given the parenteral portion of his nutrition over an 8 to 16 hour period each day

Managing a patient with SBSManaging a patient with SBSLongLong--term managementterm management

nutrition over an 8- to 16-hour period each day In small infants, parenteral nutrition may be required

for the greater part of the 24-hour day, but soon the interval “off ” parenteral nutrition can gradually be increased as the patient’s tolerance of enteral calories increases

Caloric changes are gradually increased, based on the child’s growth needs, to ensure that the child parallels the 50th percentile for both height and weight

Excessive caloric administration is often a problem at


pthis stage of management as the child is incapable of regulating his/her own nutrient intake

Careful monitoring of the child’s growth to make certain that the patient’s weight gain is appropriate for length

Fluid losses are often substantial during early stages of short-bowel syndrome management The enteral diets may be diluted with oral electrolyte solution

and the rate of administration increased accordingly to l h l d i lif i ll


replace these losses and simplify patient management as well as improve absorption

In the absence of small bowel bacterial overgrowth, the antimotility agents, such as loperamide, may occasionally be useful in slowing intestinal transit and increasing fluid and nutrient retention

Early in the course of therapy, preparations for home parenteral nutrition should be made

Home parenteral nutrition d h f l


reduces the cost of long-term management

decreases family stresses and nosocomial infections

It has now become the standard of care in patients with short-bowel syndrome

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Colon presentColon present Colon absentColon absent

CarbohydrateCarbohydrate 5050--60% of calories60% of calories

Complex carbohydratesComplex carbohydrates

5050--60% of calories60% of calories

Complex carbohydratesComplex carbohydrates

FatFat 2020--30% of calories30% of calories

Adequate essential fatsAdequate essential fats

MCT / LCTMCT / LCT


Adequate essential fatsAdequate essential fats

LCTLCT

ProteinProtein 2020--30% of calories30% of calories

High biologic valueHigh biologic value


High biologic valueHigh biologic value

FiberFiber Net secretorsNet secretors

SolubleSoluble

Net secretorsNet secretors

SolubleSoluble

OxalateOxalate RestrictRestrict __

FluidsFluids ORS and /or hypotonicORS and /or hypotonic ORSORS

Chronic complicationsChronic complications

Chronic complicationsChronic complicationsBacterial overgrowthBacterial overgrowth

One of the least-recognized complications

Also one of the most treatable

Overgrowth is considered to occur when b i l i i h ll i ibacterial content increases in the small intestine above normal levels

Usually caused by facultative organisms and a variety of anaerobic bacteria

Treatment Broad-spectrum antibiotics Initially given intermittently, usually the first 5 days

of each month

Chronic complicationsChronic complicationsBacterial overgrowthBacterial overgrowth

Oral metronidazole, either alone or in combination with bactrim is frequently effective

Several other combinations are also helpful Refractory patients may require continuous

antibiotic therapy, with periodic rotation of antibiotics

Excessive fluid secretion frequently occurs in SBS Often due to excessive carbohydrate administration This complication occurs more frequently with bolus than

with continuous enteral feeding

Somatostatin analogs have been used usually with

Chronic complicationsChronic complicationsWatery diarrheaWatery diarrhea

Somatostatin analogs have been used - usually with transient results

Cholestyramine (bile acid binder) is sometimes helpful in short-bowel syndrome with watery diarrhea

Cholestyramine may worsen diarrhea in massive ileal resections

Once patients are free of parenteral nutrition, they are subject to nutritional deficiency states.

Usually, macronutrients can be absorbed in adequate quantities

Trace minerals and vitamins, are often less well

Chronic complicationsChronic complicationsNutritional deficienciesNutritional deficiencies

Trace minerals and vitamins, are often less well absorbed Malabsorption of fat-soluble vitamins, especially A, D, and E,

is common Iron and zinc deficiency is common Selenium absorption may also be impaired Low serum levels of calcium and magnesium are also

frequently observed

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Occasionally, the supplemental parenteral vitamins, minerals, micronutrients, and even fluid may be required even if the patient is able to absorb enough calories and protein to meet

Chronic complicationsChronic complicationsNutritional deficienciesNutritional deficiencies

to absorb enough calories and protein to meet growth needs.

Following ileal resection, patients should be monitored carefully for vitamin B12 deficiency

Parenteral nutrition liver diseaseParenteral nutrition liver disease The major cause of death in children with SBS Common in children receiving long-term parenteral

nutrition The incidence increases in inverse proportion to age;

therefore, it is more common in small infants Many mechanisms have been postulated Prevention (?)

aggressive use of enteral feedings – at least 20 - 30% of the total daily caloric intake through the enteral route

Prevention / treatment of bacterial overgrowth Reduction in catheter-related sepsis Omegaven

Surgical techniques in SBSSurgical techniques in SBS

Surgical techniques in SBSSurgical techniques in SBSTapering enteroplasty


Intestinal plication


Creation of intestinal valves

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Bianchi procedure


STEP procedure

Attempt to wean off PN

Unable to tolerate Participation in

Successful Unsuccessful or incomplete

Monitor for complications

Tolerating home PN

home PN

Appropriate nontransplant surgery

candidate

investigational studies

Successful Unsuccessful or incomplete

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