Necrotizing enterocolitis is associated with earlier achievement of enteral autonomy in children with short bowel syndrome

Abstract

Purpose Necrotizing enterocolitis (NEC) remains one of the most common underlying diagnoses of short bowel syndrome (SBS) in children. The relationship between the etiology of SBS and ultimate enteral autonomy has not been well studied. This investigation sought to evaluate the rate of achievement of enteral autonomy in SBS patients with and without NEC. Methods Following IRB approval, 109 patients (2002–2014) at a multidisciplinary intestinal rehabilitation program were reviewed. The primary outcome evaluated was achievement of enteral autonomy (i.e. fully weaning from parenteral nutrition). Patient demographics, primary diagnosis, residual small bowel length, percent expected small bowel length, median serum citrulline level, number of abdominal operations, status of the ileocecal valve (ICV), presence of ileostomy, liver function tests, and treatment for bacterial overgrowth were recorded for each patient. Results Median age at PN onset was 0 weeks [IQR 0–0]. Median residual small bowel length was 33.5cm [IQR 20–70]. NEC was present in 37 of 109 (33.9%) of patients. 45 patients (41%) achieved enteral autonomy after a median PN duration of 15.3 [IQR 7.2–38.4] months. Overall, 64.9% of patients with NEC achieved enteral autonomy compared to 29.2% of patients with a different primary diagnosis (p=0.001, Figure 1). Patients with NEC remained more likely than those without NEC to achieve enteral autonomy after two (45.5% vs. 12.0%) and four (35.7% vs. 6.3%) years on PN (Figure 1). Logistic regression analysis demonstrated the following parameters as independent predictors of enteral autonomy: diagnosis of NEC (p<0.002), median serum citrulline level (p<0.02), absence of a jejunostomy or ileostomy (p=0.013), and percent expected small bowel length (p=0.005). Conclusions Children with SBS due to NEC have a significantly higher likelihood of fully weaning from parenteral nutrition compared to children with other causes of SBS. Additionally, patients with NEC may attain enteral autonomy even after long durations of parenteral support.

Early postoperative outcomes of surgery for intestinal perforation in NEC based on intestinal location of disease

“…The resection and anastomosis are not advisable because invariably they will result in short bowel syndrome. [ 17 , 18 , 19 ]…”

Long-Term Outcomes and Disease Burden of Neonatal Onset Short Bowel Syndrome

“…Those who were able to wean off PN had a longer residual neonatal small bowel length of 65 (43, 87) cm compared to 32 (21, 54) cm in those remaining on PN. Median serum citrulline concentration was also higher in the weaned cohort at 26 (19,36) μmol/L compared to 11 (8,20) μmol/L in those who remained on PN ( Table 2). SBS associated morbidity and growth outcomes are outlined on Table 3.…”

“…Survivors with 50 to 100 cm of neonatal residual bowel length had an 88% chance of weaning from PN by 1 year of life compared to 23% in children who had b50 cm in one study [18]. Several other factors associated with the likelihood of weaning from PN include treatment at a multidisciplinary intestinal rehabilitation center, bowel in continuity, lack of intestinal dilatation and bacterial overgrowth, higher serum citrulline concentration, a diagnosis of necrotizing enterocolitis, normal motility, and greater proportion of residual colon [17,[20][21][22]. Multiple strategies may have promoted intestinal adaption, helping these adolescents eventually achieve enteral autonomy.…”

Treatment of congenital hypothyroidism in a newborn with malabsorption after subtotal ileum resection

“…Mucosal injuries secondary to NEC and the post-surgical state may have led to further decrease in absorption capacity. Patients with short bowel syndrome in the context of NEC seem more likely to regain enteral autonomy than patients with other underlying diseases ( 6 ). The neonatal intestinal tissue can adapt to partial loss of the small intestine by upregulation of nutrient absorption in the remaining bowel.…”

“…Since not all patients seem to regain this autonomy following NEC ( 6 ) consideration of long-term alternatives to oral L-T4 administration may be necessary in neonates with CH and malabsorption. A few adult case studies have reported long-term use of L-T4 formulations other than oral or intravenous, including subcutaneous ( 9 ) and intramuscular administration ( 10 ).…”