Abstract Ref Number = APCP95
Nutrition and short bowel syndrome: What’s the best choice
I Gusti Lanang Sidiartha
Department of Pediatric, Faculty of Medicine, Udayana UniversitySanglah General Hospital
Short bowel syndrome (SBS) is an intestinal failure (IF) caused by an inadequate length of intestine due to the intestinal resection. North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) defined of SBS is the need for parenteral nutrition (PN) for > 60 days after intestinal resection or a bowel length of < 25% of expected. The most commonly etiology of SBS in infants is necrotizing enterocolitis and in children is postsurgical complications. The clinical manifestations of SBS are due to the loss of intestinal absorption surface area, the loss of specific sites of absorption, a decrease in production of intestinal hormones, and the loss of the ileocecal valve. In infants and children, SBS caused failure to thrive and malnutrition. Therefore, it is requires a specialized nutrition support. The improvement of survival rate of infants and children with SBS is primarily influenced by the ability to deliver long-term nutritional support.
The initial choice of nutrition support mode for pediatric SBS is PN using the central venous route in order to meet caloric and nutrient requirements. This choice is according to acute phase, which the onset soon after resection, duration for at least 4 weeks and it is characterized by malabsorption, dysmotility, diarrhea, and gastric hypersecretion. Dextrose should be started at 5-7 mg/kg/min and advanced by 1-3 mg/kg/min to an endpoint goal of 12-14 mg/kg/min. Lipids can be started at 1 g/kg/day and advanced by 1 g/kg/day to an endpoint goal of 3 g/kg/day in infants and 1-2 g/kg/day in children. Amino acids can be started liberally at 1.5-2 g/kg/day and advanced to goal by day two or three of PN. Provision of adequate electrolyte, vitamin, and mineral levels is essential for optimal PN support of the infant or child with SBS. Enteral nutrition (EN) can be started to help promote intestinal adaptation and growth if the patient have been stable from a fluid and electrolyte perspective on PN therapy. Intestinal adaptation can begin as soon as 24 to 48 hours post-resection and then this process can take over one year depending on the EN therapy and numerous physiological and metabolic factors. The EN is the best administered using continuous infusion.
Human milk is the best choice for enteral nutrition in infants with SBS because it’s containing growth factors and immunoglobulins that may promote intestinal adaptation. If human milk is unavailable, milk-based formulas can be used. Amino acid-based formulas have been associated with improved outcomes, although there are a little data about whether various macronutrients (long vs. medium vs. short chain fats; intact vs. hydrolyzed vs. amino acid proteins) are associated with better short or long-term outcomes. Dietary fiber supplementation in patients with an intact colon and ileocecal valve is benefit as an additional energy source and helpful in reducing diarrhea, although further study is needed. Micronutrients supplementation is important in patients with SBS because most of them are having vitamin and mineral deficiencies. It is known that micronutrient play important roles in the maintenance of GI structure and function and deficiencies may inhibit intestinal adaptation.