Factors Related to the Development of Small‐Bowel Bacterial Overgrowth in Pediatric Intestinal Failure: A Retrospective Cohort Study

Abstract

Background Small bowel bacterial overgrowth (SBBO) is a challenge in the management of pediatric intestinal failure (PIF). Our goal was to determine the proportion of patients treated for SBBO and factors related to its development. Methods We completed a retrospective analysis of PIF patients referred between 2008 and 2014. Data were collected on factors related to intestinal failure (IF) and SBBO. The cohort was stratified on the diagnosis of SBBO and refractory SBBO. Statistical testing completed using t‐test, χ2 test, and logistic regression. Results Thirty‐five of 102 patients developed SBBO (34%), and 16 (16%) had refractory SBBO. SBBO was more likely in gastroschisis (40.0% vs 19.4%, P = .025), a shorter residual small bowel (SB) (45.4% vs 66.5%, P = .004), and patients were less likely to wean from parenteral nutrition (PN) (51.4% vs 85.1%, P < .0001). Refractory SBBO patients were likely to have gastroschisis (50.0% vs 22.1%, P = .020) and a shorter residual SB and large bowel remaining (23.2% vs 65.9%, P < .0001 and 60.6% vs 79.4%, P = .03, respectively) and less likely to wean from PN (37.5% vs 80.2%, P = .001). Logistic regression demonstrated that longer SB residual was protective (P = .001; odds ratio [OR], 0.95; 95% CI, 0.93–0.99), and short bowel syndrome (SBS) as a cause of IF was a risk factor (P = .001; OR, 0.04; 95% CI, 0.01–0.27). Conclusion A longer SB remnant was protective against SBBO. Patients with SBBO were more likely to have PIF caused by SBS.

Paediatric intestinal failure and transplantation

“…Small bowel bacterial overgrowth, common in children with IF, 15,35 is associated with delayed PN weaning, a reduced intestinal adaptive response and an increased risk of IFALD and CLABSI. 35,36 Gastrointestinal anatomical factors (gastroschisis, shorter residual bowel length), intestinal dysmotility and stasis and the use of acid-suppressive therapy are linked with the development of small bowel bacterial overgrowth. 35 Clinical symptoms are often non-specific.…”

“…35,36 Gastrointestinal anatomical factors (gastroschisis, shorter residual bowel length), intestinal dysmotility and stasis and the use of acid-suppressive therapy are linked with the development of small bowel bacterial overgrowth. 35 Clinical symptoms are often non-specific. Diagnosis by quantitative culture of small intestinal aspirate is challenging in children.…”

“…37 A combination therapeutic approach can include minimisation of gastric acid suppression, use of cycled enteral antibiotics and limiting dietary simple carbohydrates. 35 There is limited evidence to support the routine use of probiotics, which may also pose a risk of bacterial translocation and sepsis in patients with abnormal intestinal barrier function. 35 Autologous intestinal reconstruction surgery is aimed at restoring gut function, particularly in SBS with dilatation or dysmotility in the remnant segment resulting in refractory small bowel bacterial overgrowth.…”

“…35 There is limited evidence to support the routine use of probiotics, which may also pose a risk of bacterial translocation and sepsis in patients with abnormal intestinal barrier function. 35 Autologous intestinal reconstruction surgery is aimed at restoring gut function, particularly in SBS with dilatation or dysmotility in the remnant segment resulting in refractory small bowel bacterial overgrowth. 38 Pioneered by Bianchi in the 1980s, the Bianchi technique or longitudinal intestinal lengthening and tailoring (LILT) to increase intestinal absorptive area and reduce dilatation.…”

“…The use of non‐invasive surrogate markers such as urinary metabolic screen has shown promise when used in conjunction with a high level of clinical suspicion 37 . A combination therapeutic approach can include minimisation of gastric acid suppression, use of cycled enteral antibiotics and limiting dietary simple carbohydrates 35 . There is limited evidence to support the routine use of probiotics, which may also pose a risk of bacterial translocation and sepsis in patients with abnormal intestinal barrier function 35 …”