Short bowel syndrome in infants: the critical role of luminal nutrients in a management program

Abstract

Short bowel syndrome develops when the remnant mass of functioning enterocytes following massive resections cannot support growth or maintain fluid-electrolyte balance and requires parenteral nutrition. Resection itself stimulates the intestine's inherent ability to adapt morphologically and functionally. The capacity to change is very much related to the high turnover rate of enterocytes and is mediated by several signals; these signals are mediated in large part by enteral nutrition. Early initiation of enteral feeding, close clinical monitoring, and ongoing assessment of intestinal adaptation are key to the prevention of irreversible intestinal failure. The length of the functional small bowel remnant is the most important variable affecting outcome. The major objective of intestinal rehabilitation programs is to achieve early oral nutritional autonomy while maintaining normal growth and nutrition status and minimizing total parenteral nutrition related comorbidities such as chronic progressive liver disease. Remarkable progress has been made in terms of survivability and quality of life, especially in the context of coordinated multidisciplinary programs, but much work remains to be done.

Teduglutide‐Stimulated Intestinal Adaptation Is Complemented and Synergistically Enhanced by Partial Enteral Nutrition in a Neonatal Piglet Model of Short Bowel Syndrome

“…2 Consequently, in addition to promoting growth and development in pediatric patients, 11 one of the primary goals of SBS treatment is to maximize the functional capacity of the remnant intestine and ultimately eliminate the need for PN support. 4 Provision of partial enteral nutrition (PEN) maintains intestinal structural and functional integrity 12,13 and augments bowel adaptation following resection. 6,[14][15][16][17][18] Luminal nutrients are the primary stimulus for this adaptation, 19,20 as well as for the release of humoral factors, including glucagon-like peptide 2 (GLP-2).…”

Enteral Nutrition in Pediatric Short‐Bowel Syndrome

“…11 Infants and children with IF and SBS undergo variable degrees of intestinal adaptation depending on many factors, such as nutrition status, macronutrient and micronutrient needs, remaining bowel length and function, and presence of the ileocecal valve (ICV) and colon. 4,12 Intestinal adaptation is more robust in the ileum than the jejunum, which may account for improved outcomes in patients with residual ileum compared with residual jejunum of the same length. 13 Intestinal adaptation typically involves dilation and elongation of the remaining bowel and crypt cell proliferation, resulting in taller villi and deeper crypts.…”

Nutritional Feeding Strategies in Pediatric Intestinal Failure

“…Even though the surface area of the jejunum is greater and this is where the absorption of most nutrients takes place, the jejunum's ability to reabsorb water and electrolytes is poor. Furthermore, chyme moves slower in the ileum, due to the motility patterns and proximity of the ileocecal valve [21]. The ileum absorbs bile salts, vitamin B12, fat-soluble vitamins, and electrolytes.…”

“…Thus, the more digestion a nutrient (e.g., whole protein) needs, the more hyperplasia it will cause [25]. In other words, this "functional workload," which challenges the digestive and absorptive function of the remnant bowel, is key to its adaptation [21]. The composition of the diet should be considered in an effort to balance gastrointestinal tolerance with specific nutrients in a complex form that may further stimulate the adaptive process [26].…”

“…Disaccharides are more trophic than monosaccharides due to the higher functional workload of the bowel [21]. Lactose intolerance may occur in patients with proximal jejunum resection [25].…”