Article Text
Abstract
Background Short bowel syndrome (SBS) is the leading cause of paediatric intestinal failure (IF). Long-term parenteral nutrition (PN) is required for maintaining biochemical stability and growth during the time bridge for achieving enteral autonomy (EA). Factors as the primary cause of intestinal resection and the length and part of the remaining bowel segment influence the time required for reversing intestinal failure but can also indicate those children at risk of nutritional deficiencies after reaching EA.
Methods Review of the medical notes of 40 patients with EA (24M, 16F, mean age 8.7 (2–16.2) yrs) and 14 patients dependent on PN (7M, 7F, mean age 9.5 (4.4–16) yrs), who had intestinal resection and required PN for more than 60 days.
The children with antenatal intestinal diagnosis were compared with those with postnatal diagnosis. They have been further divided according to the remaining segment of the small bowel (SB) to two groups: Group A: 10–25%% of remaining SB and full of the colon or ≥25% of SB with full or part of colon, Group B<10% with full or part or no colon, 10–25% with part or no colon (table 1).
The groups were compared for the time of PN requirement, the need for supplementation after reaching EA and the development of small intestine bacterial overgrowth (SIBO) using appropriate statistical methods.
Results ♣ Necrotizing enterocolitis was the leading cause for intestinal resection (38.9%) followed by gastroschisis (22.2%), malrotation with volvulus (20.4%), segmental volvulus (9.3%) and long segment Hirschsprung disease (1.9%). There was no difference in the prevalence of antenatal and postnatal causes between the groups of EA and PN.
♣ Children with shorter intestinal length (group B) were more likely to remain on PN compared to those with longer segments (group A) (RR 2.38, 95%CI 1.34–4.2, p=0.008) (figure I).
♣ Patients with an antenatal diagnosis remained longer on PN compared to those with a postnatal diagnosis (655.9±268d vs250.9±115d respectively, t2.68, p=0.005), which was confirmed after stratified analysis of the children with longer intestine (group A in the EA vs group A in the PN group) (558.9±307d vs 185.2±63.6d, t=2.57, p=0.008).
♣ SIBO was more common in the group with antenatal vs postnatal diagnosis (RR1.77 95%CI 0.85–3.72, p=0.09), despite that the two groups didn’t differ in the presence of ICV (OR 0.77, 95%CI 0.21–2.79, p=0.47).
♣ B12 supplementation was required significantly more frequently in the group with antenatal diagnosis vs with postnatal (RR 9.71, 95%CI 1.34–67.4, p<0.001)
♣ Vitamin D supplementation was required more frequently in the group with antenatal diagnosis vs with postnatal (RR1.64, 95%0.95–2.85, p=0.05). Supplementation of vitamin A and E and iron didn’t differ among the groups.
Conclusion Intestinal length was the predictor for enteral autonomy in our cohort. The children with an antenatal diagnosis required PN for longer and were at risk for developing vitamin D and B12 deficiency and SIBO, despite bowel lengthening procedures. This patient group, therefore, needs closer monitoring and supplementation by the IF multidisciplinary teams.