Factors Related to the Development of Small Bowel Bacterial Overgrowth in Pediatric Intestinal Failure

Abstract

Background: Small bowel bacterial overgrowth (SBBO) is a challenge in the management of pediatric intestinal failure (PIF). The development of SBBO may delay or prevent weaning of parenteral nutrition (PN) contributing to other complications. Our goal was to determine the proportion of patients treated for SBBO by an intestinal rehabilitation program and factors related to its development. Methods: A retrospective analysis of PIF patients referred between 2008–2014. Data was collected on factors related to IF and SBBO. Patients were also evaluated for refractory SBBO (use of 3 or more antimicrobial agents). Diagnosis of SBBO was based on clinical symptoms. Statistical testing completed using T-test, Chi square and logistic regression. Results: 35 of 102 patients followed by our (IRP) developed SBBO (34%) and 16 (16%) had refractory SBBO. Children with SBBO had an older gestational age (34.8 vs 32.3 weeks, p=0.01) and higher birth weight (2345 vs 1843g, p=0.001). Those with gastroschisis were more likely to develop SBBO (40.0 vs 19.4%, p=0.025). The development of SBBO was more likely in those with shorter percentage residual small bowel (SB) (45.4 vs 66.5%, p=0.004). Those with SBBO were more likely to have had a serial transverse enteroplasty (STEP) (22.9 vs 3.0%, p=0.004). Patients with SBBO were less likely to wean from parenteral nutrition (PN) (51.4 vs 85.1%, p < 0.0001). Similar to those with SBBO, refractory SBBO patients had a higher birth weight (2557 vs 1903g, p=0.007) and were likely to have gastroschisis (50.0 vs 22.1%, p=0.020). Refractory SBBO patients had shorter percentage small and large bowel remaining (23.2 vs 65.9%, p < 0.0001 and 60.6 vs 79.4%, p=0.03), more likely to have had a STEP procedure (50.0 vs 2.3%, p < 0.0001) and less likely to wean from PN (37.5 vs 80.2%, p=0.001). Logistic regression for development of SBBO demonstrated that longer small bowel residual was protective (p=0.001, OR 0.95; CI 0.93-0.99) and IF category (SBS) was as risk factor (p=0.001, OR 0.04; CI 0.01-0.27). The presence of an ileocecal valve (ICV), stoma and method of delivery (vaginal vs cesarian section) was not significant. Conclusion: SBBO has management challenges in PIF. A longer SB remnant was protective against the development of SBBO. Patients with SBBO were more likely to have a diagnosis of SBS and remain PN dependent. The presence of the ileocecal valve, stoma or method of delivery did not predict development of SBBO in our cohort.