Pediatric Nutrition in Practice

Malabsorptive Disorders and Short Bowel Syndrome 187

3

Water electrolyte losses from persistent diar-
rhea or end jejunostomies should be replaced par-
enterally, based on the electrolyte concentration
of the lost f luids. Monitoring urine sodium con-
centration provides guidance for correcting or
preventing Na depletion (<10 mEq/l), even if se-
rum sodium is near normal. Magnesium and

trace element losses can occur with high stoma

output. Zinc supplements are often used empiri-

cally, given that serum values do not reliably re-

f lect body stores. Ileal resection or diversion leads

to fat-soluble vitamin and vitamin B 12 deficiency

requiring monitoring and (parenteral) supple-

mentation.

Ta b l e 5. Modes and management of feeding

Modes

OF is the most physiological and most stimulates intestinal adaptation

Continuous EF is beneficial to patients with SBS or intractable diarrhea of infancy by improving

saturation of carrier transport proteins, thus taking full advantage of the available absorptive

surface area as compared with intermittent feeding

Oropharyngeal shunting suppresses direct stimulation of the salivary glands, resulting in lower

release of EGF, an important intestinal mucosal trophic factor

Continuous infusion leads to a loss of self-regulation of intake with vomiting, or to intestinal

stasis with an increased risk of SIBO and subsequent mucosal injury, sepsis, liver disease, etc.

In the case of full EF, a small extent of OF should be introduced in infants 2 or 3 times a day, to

stimulate sucking and swallowing and to minimize the chances of eating disorders in the

future

A nasogastric tube may impair normal acquisition of oral behavior and induces eating disorders

Percutaneous gastrostomy is indicated with children who require EF for >3 months

Jejunal feeding

• Whatever the device (nasojejunal, gastrojejunal or jejunal), it should be limited to very
  special situations


• Exposes to the risk of intestinal contamination with subsequent SIBO and sepsis


• Excessive infusion rate may be responsible for severe diarrhea and dehydration
  Progression and monitoring of feeding program
  Intestinal transit must be well established by coloanal transit or ostomy
  Absence of contraindications


• Patient’s general condition (sepsis, bleeding, respiratory distress syndrome, etc.)


• Bloody stools


• High ostomy or stool output of >3 ml/kg/h


• Bilious and/or persistent vomiting


• Electrolyte imbalance
  Quantify feeding tolerance


• Stool or ostomy output


• Reducing substances in stools or ostomy output


• Recurrent vomiting and abdominal distension
  Ultimate goals


• Provide 150 – 200 ml/kg/day or 100 – 140 kcal/kg/day


• If ostomy/stool output precludes advancement at 20 cal/oz for 7 days


• Increasing caloric density of the formula can be performed


• Isocaloric reductions in PN support simultaneously with feeding advancement
  Warnings


• EF can induce severe adverse effects related to intestinal overload and/or bacterial
  contamination with subsequent SIBO


• A meticulous approach, avoidance of excessive enteral formula supply, strict hygiene measures


• Concomitant OF prevents psychological disorders and eating aversion

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