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Pediatric Enteral Nutrition in

Short Bowel Syndrome

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Definition of SBS

Malabsorptive state occurring as a result of the loss of a significant portion of the intestine

Based on the need for intervention, such as need for TPN for longer than 1-3 months

Amount of resection/remaining bowel resulting in this degree of malabsorption varies

BASED ON FUNCTION

FUNCTION MORE IMPORTANT THAN LENGTH

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Causes of Short Bowel Syndrome

Necrotizing enterocolitisVolvulusAtresiaGastroschisisAganglionosisOther

436 patients from 13 series (1972-2000)

29 %

27 %

23 %

10 %

4 %

7 %

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Factors Contributing to Outcome

Age at time of injury Amount and site of remaining bowel Function and motility of residual intestine Adaptation Other complicating factors

cholestatic liver disease infections further injury to remaining bowel

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Age at Time of Injury

Intestine will grow as the infant grows Potential for growth is greatest in

premature infant 19 to 27 weeks gestation: 115 + 21 cm 27 to 35 weeks gestation: 172 + 29 cm over 35 weeks gestation: 248 + 40 cm

(length of normal jejunum and ileum at autopsy)

Touloukian. J Ped Surg 1983

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Amount and Site ofRemaining Bowel

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Intrinsic factor, pepsin, HCl

CCK, secretin

iron

carbohydrates, protein, fats,vitamins, minerals, trace elements

CCK, secretin,GIP, VIP

water, electrolyte, vitamin B12,bile salt, fat, fat soluble vitamins

enterglucagon,GLP-2, peptide YY

water, electrolytes, SCFA, oxalates

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Loss of Any Bowel

Decreased surface area for absorption

Shorter transit time

Hypergastrinemia decreased pancreatic enzyme activity precipitation of bile acids damage to epithelium of proximal small bowel stimulates intestinal motility

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Loss of Jejunum

Initial marked decrease in nutrient absorption

Generally better tolerated because of adaptive capacity of ileum

Decreased CCK and secretin results in decreased pancreatic enzyme activity

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Loss of Ileum

Large fluid and electrolyte losses

Sodium loss can contribute to poor growth

Zinc depletion can worsen diarrhea

Loss of ileal brake

Malabsorption of bile acids impairing fat and fat soluble vitamin absorption

Lack of absorption of Vitamin B12

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Loss of Ileocecal Valve

Promotes small bowel bacterial overgrowth

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Loss of Colon

Loss of colonic brake

Loss of water and electrolyte resorptive

capacity

Loss of ability to salvage calories from

malabsorbed carbohydrates

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Function and Motility of Residual Intestine

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Adaptation

Hyperplasia increased surface area Increased crypt cell production Increased crypt depth Increased length of villi

Increased number of transporters per cell

Increase in enzyme activity

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hyperplasia

dilatation elongation

Increased surfacearea

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Promoted by

Luminal nutrients

Endogenous secretions

Humoral factors

Adaptation

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Post-Operative Management

Use PN to maintain hydration and adequate nutrition for growth and development

Promote adaptation with the use of trophic feedings

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Luminal Nutrients-Enteral Nutrition

Fuel for enterocytes – stimulating hyperplasia

Promote peristalsis – decreases overgrowth

Stimulate flow of gastrointestinal secretions and secretion of humoral factors

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“The main goal of treatment in SBS is intestinal adaptation while optimizing weight gain and linear growth while trying to maximize enteral nutrition while minimizing parenteral support.”

“This is as much an art as it is a science”

Quiros-Teijeira et al. J Pediatr 2004

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Type of Feeding

Breast milk

Standard formula

Protein hydrolysate formula

Amino acid formula

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Breast Milk

Bolster immune system

Contain growth factors

Induce protective colonic flora

Shorter duration of parenteral nutrition (Andorsky et al, 2001)

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Standard Formula

Increased permeability to intact proteins with mucosal injury

SBS - dilated intestine, poor motility, bacterial overgrowth

Allergic reactions to cow’s milk or soy protein is common

Carbohydrate source (lactose)

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Protein Hydrolysate Formula

Lower antigenicity

Contain MCT oil – does not require bile acids or micelles for absorption

Lower peak bilirubin (Andorsky et al, 2001)

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Amino Acid Based Formula

Two infants weaned from TPN using a dilute elemental formula - Christie and Ament J Pediatr 1975

Four patients were able to wean from TPN after change to amino acid based formula - Bines et al JPGN 1998

Shorter duration of TPN -Andorsky et al 2001

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EleCare®

Protein (15% of Kcal) Amino acid-based medical food and

infant formula

Amino acid profile based on breast milk

“Clinically” hypoallergenic (Sicherer et al, J Pediatr, 2001)

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Amino Acid Profile per 70 Kcal Breast Milk and EleCare

0.000

0.100

0.200

0.300

0.400

0.500

0.600

per

70

Kca

l

EleCare HM

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EleCare

Fat (42% of Kcal) 33% of fat as MCT

30% MCT diet increased (MCT + LCT) absorption from:

• 23 to 58% preserved colon• 46 to 58% no colon

(Jeppesen and Mortense Gut, 1998)

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EleCare

Fat (42% of Kcal) Provides essential fatty acids

• Linoleic (LA) - 8% of total energy• Linolenic (LNA) - 0.9% of total energy

Dietary Reference Intakes (DRI’s) • LA

Infants 0- 6 mos 8% of KcalInfants 7 - 12 mos 6% of KcalChildren 1-18 yr 5-10% of Kcal

• LNA Infants 0- 6 mos 1% of KcalInfants 7 - 12 mos 1% of KcalChildren 1-18 yr 0.7-1.2% of

Kcal

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EleCare

Carbohydrate (43% of Kcal)

Corn syrup solids

Osmolality at 20 Kcal/oz = 350 mOsm/kg water

Used in chronic diarrhea due to SBS (Saavedra, et al, 2000)

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Route of Delivery/Advancing

Continuous drip continuous saturation of transporters

Advance (slowly) as long as output < 25-50 ml/kg/day perianal area intact

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Other Strategies to Improve Feeding Tolerance

Addition of soluble fibers to the feeding

Acid blockade

Zinc

Sodium chloride

Loperamide

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Comparisonsof Amino Acid-Based Products

Osmolality(mOsm/kg water)

Fat BlendAge Indication

Product

360 at 24 cal/ fl oz25% of total cal - 60% MCTChildren > 1 yrVivonex®

Pediatric

375 at 20cal/fl oz

610 at 30cal/fl oz

607 at 30cal/fl oz

820 at 30cal/fl oz

41% of total cal - 5% MCT

32% of total cal - 35% MCT

46% of total cal - 35% MCT

32% of total cal - 35% MCT

Infants

Children > 1 yr

Children > 1 yr

Children > 1 yr

Neocate®

Infant Formula

One+

Junior (unflavored)

EO28 (RTF)

350 at 20 cal/fl oz

560 at 30 cal/fl oz

42% of total cal – 33% MCTInfants and Children

EleCare®

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Product Cost per 100 cal Cost savings per month compared to

EleCareEleCare® $1.60 NA

Neocate® Infant Formula

$1.90 4 month old- $67

Neocate® 1+ $2.15 15 month old- $214

3 year old- $280

Neocate® Jr. $1.82 15 month old- $86

3 year old- $112

Pediatric EO28® $1.67 15 month old- $27

3 year old- $36

Vivonex® Pediatric

$1.80 15 month old- $78

3 year old- $102

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Summary

Enteral nutrition is the key to bowel adaptation

Breast milk and amino acid formula are associated with shorter duration of PN

EleCare is the only infant amino acid formula with MCT oil.