Pediatric Nutrition in Practice

184 Goulet^

Ta b l e 1. Which type of diet should be used

Breast milk

• Contains lactose, growth factors, nucleotides, long-chain
  fatty acids, glutamine and other amino acids that promote
  intestinal adaptation


• Promotes microbiota rich in lactobacilli and bifidobacteria


• In infants with SBS, it reduces the duration of PN


• Should be used as much as possible in neonatal SBS

Enteral formulas
Carbohydrates
Oligo- and polysaccharides

• Poorly tolerated by patients with limited mucosal
  absorptive surface area


• Broken down in small intestinal lumen into osmotically
  active organic acids


• Should not exceed 40% of calories, and be lactose free
  for patients with intractable diarrhea of infancy
  Fiber supplementation


• Helpful in older children with SBS with intact colon


• Promotes colonic bacterial production of short-chain
  fatty acids
  Lipids
  Long-chain triglycerides


• Poorly digested in case of small intestinal bacterial
  overgrowth because of bile acid changes


• Poorly absorbed in patients with severe malabsorption


• Have trophic effects on small intestinal mucosa


• Supplementation with n–3 or n–6 polyunsaturated
  fatty acids may enhance mucosal growth
  MCT


• Rapidly hydrolyzed by pancreatic lipase


• Do not provide essential fatty acids


• Less dependent on an extensive absorptive surface for
  adequate absorption


• Water soluble, and absorbed intact directly into the
  portal circulation


• As part of lipid supply appropriate for most infants
  with SBS


• Excessive intake can cause diarrhea


• Recommended use of formulas containing no more
  than 60% MCT as fat
  Nitrogen
  HPF


• Have changed the incidence and outcome of PDI


• No demonstrated advantages in comparison with
  intact protein infant formulas


• Lactose free and containing MCT


• Recommended for SBS patients
  Elemental amino acid-based formulas


• Not yet established whether this type of formula can
  influence the outcome of SBS


• Contain lower amounts of MCT than HPF
  Glutamine


• Currently no benefit demonstrated

MCT = Medium-chain triglycerides; HPF = hydrolyzed protein
formulas.

Ta b l e 2. Management and outcome of neonatal SBS ac-

cording to anatomic characteristics

SBS is a very variable condition, which can be as mild as that

following terminal ileal resection and also very debilitating follo-

wing total jejunoileal and colonic resection. Management and

outcome vary according to the cause, extent and site of resecti-

on and the degree of adaptation of the remaining bowel. Pati-

ents with dilated, poorly motile segments of small bowel (gast-

roschisis, atresia and necrotizing enterocolitis) should benefit

from an approach aiming to reduce bowel dilatation and SIBO,

since they may develop progressive liver disease. PN should be

delivered, as soon as tolerance permits, by cyclical infusion. Ear-

ly OF should be promoted, while the benefits of continuous EF

should be balanced in combination with PN, the risk of ‘intesti-

nal overload’ with subsequent SIBO, and tube feeding-induced

food aversion and eating disorders

SBS with SBL of <40 cm with loss of the ICV and associated partial

or large colectomy

Patients need home PN over a very long period of time. Indica-

tions for reducing PN are appropriate weight gain and tolerance

to other feeds. However, digestive outcome for patients with

SBL <40 cm and loss of the colon is poor; they will mostly remain

dependent on permanent PN or intestinal transplantation

SBS with SBL of <40 cm or only duodenum, with totally or largely

intact colon

Patients need long-term home PN. However, many infants and

children may have a degree of adaptation and require less PN

and benefit from orally and/or enterally administered nutrients.

Some of them may be progressively weaned from PN. Infants

with duodeno-right colon anastomosis have little chance of

being weaned from PN and should receive OF to promote opti-

mal psychological behavior. These patients are at risk of develo-

ping D-lactic acidosis

SBS with SBL of 40 – 100 cm with loss of the ICV and associated par-

tial or large colectomy

Patients require midterm home PN and can immediately be fed

orally. Combination of continuous EF and OF may help in re-

ducing PN duration. Bile salt-induced diarrhea may impede ra-

pid weaning from PN

SBS with SBL of 40 – 100 cm with terminal ileum and the entire co-

lon

Patients require very short-term PN and can immediately be fed

orally. EF in combination with OF may help in reducing PN dura-

tion. These patients are at risk of developing D-lactic acidosis

SBS with terminal ileum resection

Patients have bile salt-induced diarrhea and benefit from the ad-

ministration of 1 – 2 g of cholestyramine 3 times a day to bind

bile salts left unabsorbed by the resected ileum. Vitamin B 12 plas-

ma levels should be measured, and if low, supplemental vitamin

B 12 should be provided by intramuscular injection at a dose of

100 – 150 μg per month or 1,000 μg every 6 months

SIBO = Small intestinal bacterial overgrowth; SBL = small bowel

length.

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 182–189

DOI: 10.1159/000360339