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Nutrition Interventions for Pediatric Patients with Short Bowel Syndrome

Nutrition Interventions for Pediatric Patients with Short Bowel Syndrome. Jackie Costantino Sodexo Dietetic Intern. Austin Rath. “I just want to eat everything.” . Outline. Discussion of SBS and current treatments Medical Nutrition Therapy Case Study Patient Questions.

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Nutrition Interventions for Pediatric Patients with Short Bowel Syndrome

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  1. Nutrition Interventions for Pediatric Patients with Short Bowel Syndrome Jackie Costantino Sodexo Dietetic Intern

  2. Austin Rath “I just want to eat everything.”

  3. Outline • Discussion of SBS and current treatments • Medical Nutrition Therapy • Case Study Patient • Questions

  4. What is Short Syndrome? Bowel

  5. What is SBS? • Significant loss of bowel length leading to malabsorption of fluid and nutrients • 7 out of 1,000 live births for neonates with birth weights <1500g • Risk  with  birth weight &gestational age • Outcome based on many variables: length, anatomy of bowel resection, functional mass • May be accompanied by intestinal failure (IF)

  6. SBS Associated Intestinal Failure • Definition in the pediatric population: • Insufficient intestinal mass to… • Absorb and digest fluid and nutrients • Maintain fluid, protein-energy and micronutrient balance for normal growth and development • Acute IF: Dependent on PN for 4-6 weeks • Chronic IF: Dependent on PN >90 days

  7. Etiologies Squires R et al . J. Pediatric. 2012

  8. Gastroschisis • Congenital defect when an infant's intestines protrude from the body through one side of the umbilical cord http://www.cdc.gov/ncbddd/ birthdefects/Gastroschisis-graphic.html

  9. MidgutVolvulus • Involves the entire midgut twisting around the super mesenteric artery (SMA), cutting off the blood supply • Midgut includes: • Distal duodenum • Ileum • Colon • Transverse colon http://emedicine.medscape.com/article/411249-overview

  10. Signs & Symptoms: Pre-resection • Dependent on the etiology of SBS • Broad signs and symptoms • bilious vomiting • abdominal pain • abdominal distention • tachycardia • tachypnea • shock • bloody stools

  11. Complications Post-resection • Intolerance and malabsoption • Diarrhea • Steatorrhea • Nutritionl deficiencies • Weight loss (acute malnutrition) • Growth stunting &  head circumference (chronic) • Dry scaly skin • Brittle hair and nails • Poor wound healing

  12. Absorption Of Nutrients Along the GI Tract Risk for specific nutritional deficiencies depend on the anatomy of the small bowel resection

  13. Pathophysiology: 3 Phases • Immediate post-operative phase (1-7 days) • Loss of communication between stomach and small intestine • Poor absorption Loss of fluid and electrolytes • Adaptation • Intestinal growth and morphological development • EN is initiated critical to adaptation • Can increase absorptive capacity by 4X the initial capacity • Intestinal Autonomy • 100% EN is achieved

  14. Labs & Tests • LFTs • BMP • CBC • Prealbumin & CRP • Tryglycerides • Calcium, phosphorus, magnesium • Fat soluble vitamins (ADEK) • Vitamin B12 • Serum zinc levels • Endoscopy & colonoscopy

  15. Treatment Options • Surgical interventions • Intestinal transplantation • Intestinal lengthening procedures • Substances indicated to promote adaptation • Growth hormone (GH) • Glutamine • Glucagon-like peptide 2 (GLP-2)

  16. Intestinal Lengthening Procedures Bianchi Procedure STEP Procedure http://surgery.med.umich.edu/pediatric/chirp/clinical/treatments.shtml

  17. Substances Indicated to Increase Adaptation • GH (FDA approved in adults) • Zorbtive® (somatropinrDNA origin for injection) • 191 amino acid peptide hormone • GH + glutamine may stimulate intestinal growth • GLP-2 (not FDA approved) • Gattex® (teduglutide) • 33 amino acid peptide and growth hormone • Adult studies show  dependence on TPN

  18. Medical Nutrition Therapy Crucial Component to SBS Management

  19. Role of the RD • Evaluate nutritional status • Identify malnutrition and growth failure • Improve patients nutritional status through interventions

  20. Goals of the RD • Goals of the RD • To ensure patient is receiving 100% nutritional needs for proper growth and development • Initiate EN as soon as medically appropriate • Wean patient from TPN to reduce associated risks • End goal 100% EN

  21. ADIME • Assessment • Diagnosis • Interventions • Monitoring and • Evalulation

  22. Assessment • Patient’s history • Anthropometrics • “Ins and Outs” • Stool characteristics • Feeding access points • Food history • Estimated needs • Physical observations • Medications and supplements • Laboratory and diagnostic tests

  23. Assessment • Estimated Needs • Pediatric Nutrition Care Manual: • Calories: Estimated Energy Requirement (EER)  1.2 • Protein: DRI  1.3 • Pediatric Reference Guide of Texas Children’s Hospital: • Calorie needs: DRI x 1.0-1.5

  24. Diagnosis • Common problems for SBS: • Increased nutrient needs (NI-5.1) • Altered gastrointestinal function (NC-1.4) • Impaired nutrient utilization (NC 2.1) • Example PES statement SBS: • Altered gastrointestinal function related to short bowel syndrome (___cm remaining), as evidenced by inability to tolerate full enteral feeds and need for parenteral nutrition support.

  25. Interventions • Parenteral Nutrition • Cycling • Lipid Reduction Therapy • Omega-3 fatty acids for PN lipids • Ethanol lock therapy • Enteral Nutrition • Nutrition source • Continuous vs. Bolus • Modulars

  26. Total Parenteral Nutrition (TPN) • Essential when intestinal failure (IF) is present • Necessary for proper growth and development, but NOT ideal route for nutrition! • Associated with 2 main causes of death among SBS • PN-associated liver disease (PNALD) • Central line infections

  27. PN-Association Liver Disease (PNALD) • Most prevalent and severe complication of long term PN • 27% in children and 85% in neonates • Risk of death  8 fold when cholestasis is present

  28. PN-Associated Liver Disease (PNALD) • Nutritional interventions to reduce risk of PNALD: • Wean from TPN (#1) • Cycling TPN • Lipid reduction therapy • Omega-3 fatty acids for PN lipids

  29. Lipid Reduction Therapy Reducing lipids to 1g/kg/day 3 times per week has shown to improve bilirubin levels and resolve cholestasis in SBS patients without causing EFAD.

  30. Lipid Reduction Therapy • Prospective study at the University of Michigan • 2005-2007 • 31 NICU patients on PN with direct bili of 2.5 mg/dL • Treatment group: 1g/kg/day 2 times per week • Control group: 3/kg/day daily • EFAD monitored monthly

  31. Results • Treatment group: bili levels • Control group: slight bili levels • Treatment group developed mild EFAD, but resolved when lipids increased to 1g/kg/d 3days/week • No difference in growth

  32. Omega-3 Fatty Acids • Use of omega-3 fatty acids as an alternative to standard lipid emulsions may  risk for PNALD • Theory: omega-3 fatty acids have less pro-inflammatory effects and potential anti-inflammatory properties • Omegaven® is the only current lipid emulsion made from 100% fish oil Diamond et al. Changing the Paradigm: Omegaven for the Treatment of Liver Failure in Pediatric Short Bowel Syndrome.

  33. Central Line Infections • 10-35% mortality associated with line infections • More common in children •  risk for sepsis • Can cause loss of central venous access for PNrisk for malnutrition http://surgery.med.umcommon in children ich.edu/pediatric/clinical/patient_content/a-m/broviac_placement.shtml

  34. Central Line Infections • Ethanol lock therapy • Dramatically reduces rate of a blood stream infections • Can be initiated in patients when weight is >5kg and TPN cycling is achieved (at 22 hours) • Most effect when given daily for at least 2 hours • NOT compatible with heparin • NOT compatible with polyurethane catheters

  35. Enteral Nutrition • Introduce EN as soon as possible • EN provides several beneficial effects on the GI tract • Fuel for enterocytes • Stimulates hyperplasia • Promotes peristalsis- decreases bacterial overgrowth • Stimulates flow of GI secretions

  36. Initiating EN • Initiate trophic feeds of one of the following: • Mother expressed breast milk (MEBM) • Donor expressed breast milk (DEBM) • Protein Hydrosylate formulas • Semi-elemental • Elemental

  37. Formulas

  38. Continuous vs. Bolus Continuous • Preferred method in infants and children with SBS • Causes less stress and demand on intestinal function • Provides constant saturation of intestinal wall may promote adaptation Bolus • More physiological • More often used in older children • Less tolerated in infants • Depends on the individual’s tolerance level

  39. Modulars • Pectin • Benefiber • Beneprotein • Duocal • Polycose • MCT oil • Human Milk Fortifier

  40. Monitoring and Evaluation Trend anthropometrics Monitor labs closely vitamin/mineral deficiencies for decreased liver function Monitor I/Os Adjust feeding regimen accordingly to meet 100% needs    

  41. Case Study

  42. Presentation of Patient • CM • 13 months old • Full term, no significant history • Twin brother • Diagnosed with SBS at 15 weeks

  43. CM’sCourse of Care at SCHC Oct 10- Nov 21, 2011 Diagnosis of SBS Age: 3 ¾ mos

  44. CM’s Hospital Course Oct 10- Nov 21, 2011 Diagnosis of SBS Age: 3 ¾ mos • Admitted with abdominal distention • Diagnosed with midgutvolvulus • 160 cm bowel resection • 16 cm remaining with ICV & colon • Broviac & G-tube placement • TPN & trophic feeds initiated

  45. CM’s Hospital Course • PES: Altered GI function related to short bowel syndrome as evidenced by 16cm remaining bowel and dependence on TPN/G-tube feeds to meet nutritional needs. • Recommended Interventions: • Continue D13P3.2L1 TFV of 550mL/day, • Lipids M/W/F • Provide HAL over 16 per home feeding regimen (tapered) • 9.3mL/hr 1st and 16th hour, 18.5mL/hr 2nd and 15th hour, 37/hr 3rd-14th hour • Max GIR= 8.18 • Continue current G-tube feeding regimen • Daily weights, strict I/Os, monitor labs • Goals/evaluation: • Appropriate wt gain for age (11-12g/day) • Tolerates feeds • Chief Complaint: Broviac infection • Medications:ELT, Gentamycin, Heparin • Diet order: (G-tube) • Elecare20 @ 24ml/hr with 3tsp Benefiber • Nutrition Support: • D13P3.2L1- 500mL HAL @ 32.2 mL/hr X 18 • Current Intake: • (4/30) 495 mL HAL, 35mL IL, 596mL Elecare, 263mL NS with meds • Anthropometrics: • Weight: 9.8 kg (50th%ile) • Length: 79 cm (95th%ile) • Wt/Lgth: 10-25th%ile • Head circumference: 50 cm (>95th%ile) • Estimated Daily Needs: • 960 kcal (98 kcal/kg)- RDA • 16g pro (1.6g/kg)- RDA • 980mL fluid (100mL/kg)- Holiday-Segar Oct 10- Nov 21, 2011 Diagnosis of SBS Age: 3 ¾ mos May 1,2012 Initial Nutrition Assessment Age: 10 ½ mos

  46. CM’s Hospital Course Oct 10- Nov 21, 2011 Diagnosis of SBS Age: 3 ¾ mos May 1,2012 Initial Nutrition Assessment Age: 10 ½ mos May 8, 2012 F/U Nutrition Assessment Age: 10 ¾ mos

  47. CM’s Hospital Course • Monitoring/Evaluation: • Meet 100% needs • Wt gain 11-12g.day • Bowel movements WNL  5 BM/day • Tolerate TPN/G-tube feeds • Diagnosis: Altered GI function related to SBS as evidenced by need for TPN/G-tube feeds • Interventions: • Continue current TPN regimen • Continue current EN order, increase per home schedule • T/C holding feeds for one hour and provide formula PO • Continue daily weights, strict I/Os, monitor labs • RD to follow • Wt:(5/7)9.65kg, wt decreased 150g (21g/d X 7 days) • TPN order: D13P3.2L1, TFV increased to 550ml/day • EN order: Elecare 20 with 3 tsp Benefiber: 20 oz @ 28mL/hr 672mL (69.6mL/kg), 448 kcal (46.4 kcal/kg), 13.8g pro (1.4g/kg) • Intake(5/7): 712mL Elecare 20, 235mL D13P3.2, 19.5mL IL 670 kcal (69 kcal/kg), 27.8g Pro, 966mL (100mL/kg) • Output(5/7): 1076mL (UOP= 4.665 mL/kg/hr), BM X2 • Meds:Gentamycin, Ampicillin, ELT, Heparin Oct 10- Nov 21, 2011 Diagnosis of SBS Age: 3 ¾ mos May 1,2012 Initial Nutrition Assessment Age: 10 ½ mos May 8, 2012 F/U Nutrition Assessment Age: 10 ¾ mos

  48. CM’s Hospital Course • Estimated Daily Needs: • 991 kcal (98 kcal/kg), 16.2g pro (1.6g/kg), 1012mL fluid (100mL/kg) • PES: • Altered GI function related to SBS as evidenced by 16cm remaining small bowel and dependence on TPN/G-tube feeds to meet nutritional needs. • Recommended Interventions: • Continue current TPN with lipids M/W/F • Continue current EN regimen • T/C increasing Elecare 20 kcal/oz to 30mL/hr if BM WNL • Monitor daily weights, labs, I/Os and BM • Please re-check length (inconsistency) • Chief Complaint: Fever withBroviac • Medications:ELT, Cefotaxime, Vancomycin • Diet Order: • Elecare20 @ 28mL/hr via G-tube, Baby food PO ad lib • Nutrition Support: D13P3.2 600mL x 19 (60mL/kg/d) @ 31.6mL (8AM-5PM) based on 10kg; L1 @5mL/hr x 20 M/W/F • Current Intake: • (5/13) 408.8 HAL, 672mL Elecare 20 ( I/O)= 1542.8/663 • Anthropometrics: • Weight: 10.115 kg (50-75th%ileWt/age) • (5/1) 9.8kg, (4/7) 9.65kg • Length/Height: 70 cm (~5th%ile Ht/age) • (4/26) 73.5, (5/1) 79cm inconsistency • Wt/Ht: >95th%ile • Head circumference: 49 cm (>95th%ile HC/age) Oct 10- Nov 21, 2011 Diagnosis of SBS Age: 3 ¾ mos May 1,2012 Initial Nutrition Assessment Age: 10 ½ mos May 8, 2012 F/U Nutrition Assessment Age: 10 ¾ mos May 13, 2012 Readmitted w/Central Line Infection Age: 11 mos

  49. CM’s Hospital Course Oct 10- Nov 21, 2011 Diagnosis of SBS Age: 3 ¾ mos Dec 5, 2011 – June 21, 2012 GI Outpatient Visits Age: 5 ¾ mos- 12 mos May 1,2012 Initial Nutrition Assessment Age: 10 ½ mos May 8, 2012 F/U Nutrition Assessment Age: 10 ¾ mos May 13, 2012 Readmitted w/Central Line Infection Age: 11 mos

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