Malabsorptive Disorders and Short Bowel Syndrome 183
3
of cholestasis [2]. The cause of resection and the
age of a patient also influence the functional ca-
pacity of the remnant gut and its potential for ad-
aptation [2, 3]. Management of SBS involves mea-
sures aimed at promoting small bowel adaptation
and villous hyperplasia by enteral (oral or tube)
feeding, by providing normal somatic growth
with parenteral nutrition (PN), and by optimiz-
ing the bowel’s absorptive surface via nontrans-
plant surgical techniques. PN is the cornerstone
of management, but as much enteral feeding (EF)
as possible should be provided to the patient to
improve the physiological processes of small
bowel adaptation. Moreover, in infants or chil-
dren, oral feeding (OF) skills have to be acquired
or maintained. Different concepts exist with re-
spect to what the composition of feeds (elemental,
semi-elemental or polymeric) and their mode of
delivery (OF or gastric tube feeding) should be.
Current studies do not provide evidence-based
data for establishing recommendations for SBS
patients.
Rationale for EF
The use of the gastrointestinal (GI) tract is vital
for preserving or restoring normal intestinal
structure and function [3]. Functional intestinal
adaptation refers to the gross anatomic and histo-
logic changes that occur after extensive intestinal
resection. Following bowel enlargement and
lengthening of villi, the intestinal absorptive sur-
face area increases, and absorptive function grad-
ually improves. Changes in intestinal motility,
commensal microbiota and barrier function are
associated with the anatomic and histologic
changes. The use of the intestinal tract has a criti-
cal role in the process of intestinal adaptation,
based on the effects of direct nutrient contact with
the mucosa, pancreatic and hepatobiliary secre-
tions, and circulating hormones. OF promotes
the release of epidermal growth factor (EGF)
from salivary glands, increases GI secretion of
trophic factors and helps prevent feeding disor-
ders. Only few clinical trials have been performed
on patients with PDI or SBS, but they support that
EF maintains and/or promotes intestinal func-
tion [4–6]. The choice of diet as well the mode of
delivery remain debated ( tables 1 , 2 ).Which Diet Should Be UsedBreast milk contains lactose and theoretically is
considered to be not well tolerated by patients
with a reduced intestinal surface area. However,
breast milk contains many factors that may pro-
mote intestinal adaptation and has been shown to
improve immune function as well as the genesis
of a fecal microbiota rich in lactobacilli and bifi-
dobacteria. With infants with SBS, the percentage
of days that they received breast milk was corre-
lated with fewer days of PN use [7]. To patients
with neonatal SBS, breast milk should be given as
often as possible – by breastfeeding or, if neces-
sary, by tube feeding.
The choice of enteral formula is controversial.
A limited mucosal absorptive surface area can
lead to lactose, long-chain fatty acid and protein
malabsorption. In PDI, electrolyte and metabolic
balance can be difficult to achieve. In SBS pa-
tients, complex nutrients may promote mucosal
cell proliferation via direct contact with disac-
charides [8]. Additionally, colonic exposure to lu-
minal nutrients promotes the release of trophic
factors that enhance small bowel mucosal troph-
icity.
Oligo- and polysaccharides are poorly tolerat-
ed by these patients, being broken down into os-
motically active organic acids that can present a
major osmotic load to the distal small intestine
and colon. For patients with intractable diarrhea
of infancy, the carbohydrate content should not
exceed 40% of calories, and be lactose free.
Fiber supplementation , by promoting the pro-
duction of short-chain fatty acids such as butyrate,
has trophic effects on the small intestine. Short-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