Transcript Nutrition Interventions for Pediatric Patients with Short Bowel

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
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)
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
Etiologies
NEC
Gastroschisis
Intestinal atresia
Volulus
Aganglionosis
Combination
Others
Squires R et al . J. Pediatric. 2012
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
Midgut Volvulus
• 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
Signs & Symptoms: Preresection
• Dependent on the etiology of SBS
• Broad signs and symptoms
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bilious vomiting
abdominal pain
abdominal distention
tachycardia
tachypnea
shock
bloody stools
Complications Post-resection
• Intolerance and malabsoption
▫ Diarrhea
▫ Steatorrhea
• Nutritionl deficiencies
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Weight loss (acute malnutrition)
Growth stunting &  head circumference (chronic)
Dry scaly skin
Brittle hair and nails
Poor wound healing
Absorption Of
Nutrients Along the
GI Tract
Risk for specific nutritional
deficiencies depend on the
anatomy of the small bowel
resection
Pathophysiology: 3 Phases
1. Immediate post-operative phase (1-7 days)
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Loss of communication between stomach and small intestine
Poor absorption Loss of fluid and electrolytes
2. Adaptation
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Intestinal growth and morphological development
EN is initiated critical to adaptation
Can increase absorptive capacity by 4X the initial capacity
3. Intestinal Autonomy
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100% EN is achieved
Labs & Tests
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LFTs
BMP
CBC
Prealbumin & CRP
Tryglycerides
Calcium, phosphorus, magnesium
Fat soluble vitamins (ADEK)
Vitamin B12
Serum zinc levels
Endoscopy & colonoscopy
Treatment Options
• Surgical interventions
▫ Intestinal transplantation
▫ Intestinal lengthening procedures
• Substances indicated to promote adaptation
▫ Growth hormone (GH)
▫ Glutamine
▫ Glucagon-like peptide 2 (GLP-2)
Intestinal Lengthening
Procedures
Bianchi Procedure
STEP Procedure
http://surgery.med.umich.edu/pediatric/chirp/clinical/treatments.shtml
Substances Indicated to Increase
Adaptation
• GH (FDA approved in adults)
▫ Zorbtive® (somatropin rDNA 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
Crucial Component to SBS Management
Role of the RD
• Evaluate nutritional status
• Identify malnutrition and growth failure
• Improve patients nutritional status through
interventions
Goals of the RD
• Goals of the RD
1. To ensure patient is receiving 100% nutritional needs
for proper growth and development
2. Initiate EN as soon as medically appropriate
3. Wean patient from TPN to reduce associated risks
4. End goal 100% EN
ADIME
• Assessment
• Diagnosis
• Interventions
• Monitoring and
• Evalulation
Assessment
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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
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
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.
Interventions
• Parenteral Nutrition
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Cycling
Lipid Reduction Therapy
Omega-3 fatty acids for PN lipids
Ethanol lock therapy
• Enteral Nutrition
▫ Nutrition source
▫ Continuous vs. Bolus
▫ Modulars
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
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
PN-Associated Liver Disease
(PNALD)
• Nutritional interventions to reduce risk of PNALD:
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Wean from TPN (#1)
Cycling TPN
Lipid reduction therapy
Omega-3 fatty acids for PN lipids
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.
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
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
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.
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/am/broviac_placement.shtml
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
Enteral Nutrition
• Introduce EN as soon as possible
• EN provides several beneficial effects on the GI tract
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Fuel for enterocytes
Stimulates hyperplasia
Promotes peristalsis- decreases bacterial overgrowth
Stimulates flow of GI secretions
Initiating EN
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Initiate trophic feeds of one of the following:
1. Mother expressed breast milk (MEBM)
2. Donor expressed breast milk (DEBM)
3. Protein Hydrosylate formulas
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Semi-elemental
Elemental
Formulas
Semi-Elemental
Elemental
Infant
Pediatric
Infant
Pediatric
Alimentum
Peptamen Jr.
Neocate Infant
Neocate Jr.
Pregestimil
Peptamen 1.5
Elecare Infant
Elecare Jr.
Nutramigen
Pediasure
Peptide
Nutramigen
Infant
Vivonex
Continuous vs. Bolus
Continuous
▫ Preferred method in infants
and children with SBS
▫ Causes less stress and demand
on intestinal function
Bolus
▫ More physiological
▫ More often used in older
children
▫ Less tolerated in infants
▫ Provides constant saturation
of intestinal wall may
promote adaptation
▫ Depends on the individual’s
tolerance level
Modulars
• Pectin
• Benefiber
• Beneprotein
• Duocal
• Polycose
• MCT oil
• Human Milk Fortifier
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
Presentation of Patient
• CM
• 13 months old
• Full term, no significant history
• Twin brother
• Diagnosed with SBS at 15 weeks
CM’s Course of Care at SCHC
Oct 10- Nov 21, 2011
Diagnosis of SBS
Age: 3 ¾ mos
CM’s Hospital Course
Oct 10- Nov 21, 2011
Diagnosis of SBS
Age: 3 ¾ mos
•Admitted with abdominal distention
•Diagnosed with midgut volvulus
•160 cm bowel resection
•16 cm remaining with ICV & colon
•Broviac & G-tube placement
•TPN & trophic feeds initiated
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
PES:
GI function
to short bowel
ChiefAltered
Complaint:
Broviacrelated
infection
syndrome
as evidenced
by 16cm
remaining bowel
Medications:
ELT, Gentamycin,
Heparin
and
on TPN/G-tube feeds to meet
Dietdependence
order: (G-tube)
nutritional
needs.
Elecare 20 @
24ml/hr with 3tsp Benefiber
Nutrition Support:
Recommended
Interventions:
D13P3.2L1 - 500mL
HAL @ 32.2 mL/hr X 18
•Continue
D13P3.2L1 TFV of 550mL/day,
Current Intake:
Lipids
(4/30) M/W/F
495 mL HAL, 35mL IL, 596mL Elecare, 263mL
•Provide
HAL over 16 per home feeding regimen
NS with meds
(tapered)
Anthropometrics:
•9.3mL/hr
1st thand
16th hour, 18.5mL/hr 2nd
•Weight:
9.8 kg (50
%ile)
th hour,th37/hr 3rd-14th hour
and79
15cm
•Length:
(95 %ile)
•Max10-25
GIR=th8.18
•Wt/Lgth:
%ile
•Continue
current G-tube
feeding
•Head circumference:
50 cm
(>95thregimen
%ile)
•Daily
weights,
I/Os, monitor labs
Estimated
Dailystrict
Needs:
• 960 kcal (98 kcal/kg)- RDA
Goals/evaluation:
•16g pro (1.6g/kg)- RDA
•Appropriate
wt gain for age
(11-12g/day)
•980mL fluid (100mL/kg)Holiday-Segar
•Tolerates feeds
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
CM’s Hospital Course
Oct 10- Nov 21, 2011
Diagnosis of SBS
Age: 3 ¾ mos
Altered
GI function150g
related
to SBS
evidenced by need
Wt:Diagnosis:
(5/7) 9.65kg,
wt decreased
(21g/d
X 7 as
days)
fororder:
TPN/G-tube
feedsTFV increased to 550ml/day
TPN
D13P3.2L1,
Monitoring/Evaluation:
EN•Meet
order:100%
Elecare
20 with 3 tsp Benefiber: 20 oz @ 28mL/hr 672mL
needs
Interventions:
(69.6mL/kg),
448 kcal (46.4 kcal/kg), 13.8g pro (1.4g/kg)
•Wt gain 11-12g.day
•Continue
currentElecare
TPN
Intake
(5/7):
712mL
235mL D13P3.2, 19.5mL IL 670 kcal
•Bowel
movements
WNLregimen
20,
5 BM/day
•Continue
current
EN966mL
order, (100mL/kg)
increase per home schedule
(69
kcal/kg),TPN/G-tube
27.8g
Pro,
•Tolerate
feeds
•T/C holding
feeds for
one hour
provide formula
Output
(5/7): 1076mL
(UOP=
4.665and
mL/kg/hr),
BM X2 PO
•Continue
daily weights,
strict
I/Os,
monitor labs
Meds:
Gentamycin,
Ampicillin,
ELT,
Heparin
•RD to follow
May 1,2012
Initial Nutrition
Assessment
Age: 10 ½ mos
May 8, 2012
F/U Nutrition
Assessment
Age: 10 ¾ mos
CM’s Hospital Course
Estimated Daily Needs:
Chief Complaint: Fever with Broviac
•991 kcal (98 kcal/kg), 16.2g pro (1.6g/kg), 1012mL fluid (100mL/kg)
Medications: ELT, Cefotaxime, Vancomycin
Oct
10Nov 21, 2011
Diet
Order:
PES:
Diagnosis
SBS via G-tube, Baby food PO ad lib
Elecare 20 @of
28mL/hr
Altered
to SBS as evidenced by 16cm remaining
Age:GI3function
¾ mosrelated
Nutrition
Support:
D13P3.2 600mL x 19 (60mL/kg/d) @ 31.6mL (8AMsmall bowel and dependence on TPN/G-tube feeds to meet nutritional
5PM) based on 10kg; L1 @5mL/hr x 20 M/W/F
needs.
Current Intake:
(5/13) 408.8 HAL, 672mL Elecare 20 ( I/O)= 1542.8/663
Recommended Interventions:
Anthropometrics:
•Continue current TPN withthlipids M/W/F
•Weight: 10.115 kg (50-75 %ile Wt/age)
•Continue current EN regimen
(5/1) 9.8kg, (4/7) 9.65kg
•T/C increasing Elecare 20 kcal/oz
to 30mL/hr if BM WNL
•Length/Height: 70 cm (~5th%ile Ht/age)
•Monitor daily weights, labs,
I/Os
and BM
May 8, 2012
1,2012
•(4/26) 73.5, (5/1)May
79cm
inconsistency
•Please re-check
length
(inconsistency)
F/U Nutrition
•Wt/Ht: >95th%ile Initial Nutrition
Assessment
•Head circumference: 49
cm (>95th%ile HC/age) Assessment
Age: 10 ¾ mos
Age: 10 ½ mos
May 13, 2012
Readmitted
w/Central Line
Infection
Age: 11 mos
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
Dec 5, 2011 – June 21, 2012
GI Outpatient Visits
Age: 5 ¾ mos- 12 mos
May 8, 2012
F/U Nutrition
Assessment
Age: 10 ¾ mos
May 13, 2012
Readmitted
w/Central Line
Infection
Age: 11 mos
GI Outpatient Visits
• Mom has gradually increased G-tube feeds 2mL/hr every
week as tolerated
• (start rate) 2mL/hr (current rate) 34mL/hr
• Gradually weaned from TPN
• Feeds held 2-3 times per day to allow PO
• Baby foods slowly introduced
• Benefiber consistently in feeds secondary to loose stools
Update on CM
• Current EN:
▫ Elecare Jr. 37 kcal/oz @ 34mL/hr with Benefiber
• Current PN:
▫ 30g Dextrose per day (No amino acids or lipids)
• Plan:
▫ To gradually concentrate Elecare Jr. by 2 kcal per week
as tolerated to goal concentration of 30 kcal/oz
▫ To continue to wean TPN
CM’s Weight Progression
Weight (kg)
10
8
6
4
2
0
Date
CM’s Progression from PN to EN
Date
Age (mo) EN Regimen
% Kcal
from EN
PN Regimen
% Kcal
from PN
% Kcal
TOTAL
Oct 2011
4¼
None
0
D17 P3 L2.99
100
100
Nov 2011
5
2mL/hr
6
D16 P3 L2.5
94
100
Jan2012
7¼
10mL/hr
27
*Lipids 3d/wk
73
April 2012
9
24ml/hr
50
D13 P3.2 L1
50
June 2012
12
34mL/hr
61
D13 P3.2
39
June 2012
12 ¼
34mL/hr
*Elecare Jr. 22
73
50g D, 14g AA
27
Present
13 ¾
90
30g D
10
34mL/hr
*Elcare Jr. 27
Lipids
100
reduced
100
Lipids 100
D/C’d
100
AAs D/C’d
100
Critical Comments
• Anthropometrics- inconsistent height
• Estimated kcal needs
• Medications: ELT & heparin
• Laboratory values: suggestive of anemia
Key Points
 Goal #1- Meet 100% needs for proper growth and
development
 Goal #2- Start EN as soon as medically appropriate
 Goal #3- Reduce risk of PNALD and line infections
▫ Wean TPN as EN increases
▫ Reduce lipids to 1g/kg/day 3X/week when cholestasis
is present
Austin’s Cupcake Fund
References
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Cole CR. Pathophysiology and Medical Management of Intestinal Failure in Childhood. Cincinnati Children’s
Hospital Medical Center 2012.
Beattie LM, Barclay AR, Wilson DC. Short bowel syndrome and intestinal failure in infants and children. Paediatrics
and Child Health 2010; 20:10.
Teitlbaun H. “Pediatric Intestinal Failure: Approaches to Optimize Care.” PASPEN (Philadelphia Area Society for
Parental and Enteral Nutrition) Spring Conference 2012.
Gastroschisis [CHOP]. Philadelphia: The Children’s Hospital of Philadelphia; c1996-2012 [updated 2012 Feb; cited
2012 June 10]. Available from http://www.chop.edu/service/fetal-diagnosis-and-treatment/fetaldiagnoses/gastroschisis.html.
Intestinal Malrotation and Volvulus [Cincinnati Children’s]. Cincinnati: Cincinnati Children’s Hospital Medical
Center; c1999-2012 (updated 2012 Aug; cited 2012 June]. Available from:
http://www.cincinnatichildrens.org/health/i/intestinal-malrotation
Bunting KD, Mills J, Phillips S, Ramsey E, Rich S, Trout S. Pediatric Nutrition Reference Guide. 9 th ed. Houston: Texas
Children’s Hospital; 2010.
Pediatric Nutrition Care Manual. Short Bowel Syndrome. Available from:
http://nutritioncaremanual.org/topic.cfm?ncm_heading=Nutrition%20Care&ncm_toc_id=144771
McMellen M, Wakeman D, Longshore S, et al. “Growth Factors: Possible Roles for clinical Management of the Short
Bowel Syndrome.” Semin Pediatr Surg 2010; 19 (1): 35-43.
Tee C, Wallis K, Gabe S, et al. Emerging treatment options for short bowel syndrome: potential role of teduglutide.
Clinical and Experimental Gastroenterology 2011:4 189-196.
Omegaven
• Diamond et al.’s retrospective cohort study
• 12 pediatric SBS patients with advanced PNALD
• All being considered for liver transplant
• Treatment: 1g/kg Intralipid, 1g/kg Omegaven
(total lipids=2g/kg)
• Intralipid decreased or d/c’d if PNALD worsening
Results
• 9 out of 12 completely resolved hyperbilirubinemia
within a median of 24 weeks
• Out of those 9 patients:
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4 achieved resolution with combination of Intralipid
and Omegaven
5 achieved resolution after Intralipids discontinued
All 12 patients were no longer considered for liver
transplant