Small Intestinal Failure in Children

The treatment of children with intestinal failure should be predicated upon three overriding goals: 1) to keep the patient well nourished by parenteral nutrition (TPN), 2) to minimize the fecal loss of fluid, electrolytes, and nutrients, and 3) to enhance the natural process of intestinal adaptation whenever possible. The first goal is relatively easy to accomplish in the short- or intermediate-term, but difficult to accomplish for more than a few years because of recurrent septicemia, loss of venous access, and cholestatic liver disease. The risks of sepsis and loss of venous access can be minimized through meticulous central line care and the use of appropriate antibiotics when indicated. Cycling TPN and limiting parenteral protein intake sometimes ameliorates cholestasis. The second goal is only partially achievable regardless of the cause of intestinal failure. Fluid and electrolyte secretion often can be reduced but not normalized with antisecretory drugs. Bacterial overgrowth can be treated with the judicious use of antibiotics. The third goal generally can be accomplished only in a subpopulation of patients with surgically created short bowel. In these children, a satisfactory increase in surface area can occur only if nutrients are delivered directly into the bowel lumen. The trophic effects of glutamine, growth hormone, and other hormones remain to be universally accepted. Surgical bowel lengthening or bowel tapering can sometimes enhance intestinal function among patients with short bowel syndrome. If medical or nontransplantation surgical management of intestinal failure is unsuccessful, and the patient develops irreversible TPN-associated complications, transplantation of the intestine should be strongly considered.