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Neonates with short bowel syndrome: an optimistic future for parenteral nutrition independence
Erica M Fallon1, Paul D Mitchell2, Deepika Nehra1
1Vascular Biology Program, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
Insights
Neonates with short bowel syndrome (SBS) can often wean from parenteral nutrition (PN) even with limited intestinal length, thanks to modern management strategies and multidisciplinary care.
Area of Science:
- Neonatology
- Pediatric Surgery
- Gastroenterology
Background:
- Short bowel syndrome (SBS) in neonates necessitates parenteral nutrition (PN).
- Advances in hepatoprotective strategies and multidisciplinary management have improved outcomes for neonates with SBS requiring PN.
Purpose of the Study:
- To evaluate the probability of weaning from PN in neonates with SBS.
- To determine the correlation between remaining intestinal length and successful PN weaning.
Main Methods:
- Retrospective review of medical records from a single academic institution.
- Included neonates with ≤100 cm of small intestine, diagnosed with surgical gastrointestinal disease, and dependent on PN for ≥2 weeks.
- Analyzed data from January 2004 to June 2012.
Main Results:
- Sixty-three neonates were analyzed; 63% were successfully weaned from PN.
- Small intestinal length was the primary predictor of weaning success.
- Patients with ≥50 cm of small intestine had an 88% probability of weaning by 12 months, versus 23% for those with <50 cm.
Conclusions:
- Most neonates with SBS can be weaned from PN, irrespective of initial intestinal length.
- Improved management strategies and a multidisciplinary approach are key factors in successful PN weaning.
- Small intestinal length remains a critical prognostic indicator for PN independence in SBS patients.
Importance:
The introduction of hepatoprotective strategies and multidisciplinary management has significantly improved the outcome of neonates with short bowel syndrome (SBS) who require parenteral nutrition (PN).
Objective:
To determine the probability of weaning from PN based on intestinal length in neonates with SBS amidst the new era of hepatoprotective strategies and multidisciplinary management.
Design, Setting, And Participants:
Retrospective medical record review at a single-center academic institution. Neonates with no more than 100 cm of small intestine at a corrected gestational age of no more than 30 days who were diagnosed with a surgical gastrointestinal disease and PN dependent for at least 2 weeks were included. Data were collected from January 1, 2004, through June 1, 2012.
Exposure:
Neonates with SBS requiring PN.
Main Outcomes And Measures:
The probability of wean from PN without reinitiation for at least 1 year, as determined by logistic regression. Predictors of wean were evaluated using exact conditional logistic regression. Predictors of time to wean were determined by Cox proportional hazards regression.
Results:
Sixty-three patients with a median (25th percentile, 75th percentile [interquartile range (IQR)]) gestational age of 31 (27, 35) weeks, birth weight of 1423 (895, 2445) g, small intestinal length of 41.0 (24.0, 65.0) cm, and predicted length of 29.0% (17.1%, 45.5%) underwent analysis. Fifty-one patients (81%) received a fish oil-based lipid emulsion (1 g/kg/d), 40 (63%) were weaned, 11 (17%) remained PN dependent, 4 (6%) underwent transplant, and 8 (13%) died while on PN. Excluding patients who underwent transplant or died, the median (IQR) small intestinal length was 55.0 (28.0, 75.0) cm in weaned and 26.0 (14.0, 41.0) cm in PN-dependent patients (P = .006), with 40 of 51 (78%) weaned by study end. The cumulative probability of wean for patients with at least 50 cm of small intestine was 88% after 12 and 96% after 24 months. Patients with less than 50 cm of small intestine had a cumulative probability of wean of 23% after 12, 38% after 24, and 71% after 57 months. Small intestinal length was found to be the primary predictor of wean. Notable predictors of time to wean included the amount of small intestine remaining (hazard ratio, 1.94 [95% CI, 1.45-2.58] per 20 cm of intestine; P < .001), entirety of care within our institution (3.27 [1.59-6.72]; P = .001), and intestinal lengthening procedure (0.19 [0.04-0.84]; P = .03).
Conclusions And Relevance:
The majority of patients will wean from PN despite short intestinal length, likely as a result of new management strategies combined with a multidisciplinary team approach.
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