Prolonged Parenteral Nutrition Research Articles

Peculiarities of surgical treatment of gastrointestinal tract combined congenital malformations in newborns

Congenital gastrointestinal (GI) malformations make up 21–25 % of all congenital anomalies and require surgical correction in the neonatal period. The aim was to analyze the methods of operative treatment of hard composite congenital gastrointestinal malformations in infants. Materials and Methods: There were 13 newborns with gastroschisis, omphalocele and esophageal atresia combined with intestinal atresia, anal atresia and also with congenital heart defects in our study. Results. We have designed new preoperative care strategies for the newborns. All combined GI defects were corrected in one step. In gastroschisis and omphalocele in combination with small intestine atresia we made a plastic of anterior abdominal wall, bowel segment resection and anastomosis end-to-end. In esophageal atresia and atresia of the anus direct esophago-esophagoanastomosis was applied with suturing of tracheoesophageal fistula, also in two patients proctoplasty by Pena 2 was carried out, and in one patient with high anal atresia colostomy was applied, which was closed in the age of 6 months. In case of esophageal atresia combined with small intestine atresia direct esophago-esophagoanastomosis with tracheoesophageal fistula suturing was carried out, and resection of the bowel segment with anastomosis end-to-end was applied. In a patient with a combination of esophageal atresia and duodenal obstruction esophagoplasty and closure of tracheoesophageal fistula with anastomosis by Kimur was made. Preference was given to the combined anesthesia with neuraxial blockade. Postoperative care included prolonged artificial lung ventilation, anesthesia, parenteral nutrition, antibacterial and antifungal medicines. Conclusions. One-step correction of the congenital GI malformations in newborns is effective and it gives opportunity to achieve the best results with a single surgical intervention. Extremely important links of the combined GI defects therapy is timely and balanced preoperative preparation, anesthetic management with the advantage of neuraxial blockade usage, as well as careful postoperative management of the patient.

A Rare Complication Developing After Hematopoietic Stem Cell Transplantation: Wernicke's Encephalopathy.

Thiamine is a water-soluble vitamin. Thiamine deficiency can present as a central nervous system disorder known as Wernicke’s encephalopathy, which classically manifests as confusion, ataxia, and ophthalmoplegia. Wernicke’s encephalopathy has rarely been reported following hematopoietic stem cell transplantation. Herein, we report Wernicke’s encephalopathy in a patient with acute myeloid leukemia who had been receiving prolonged total parenteral nutrition after haploidentical allogeneic hematopoietic stem cell transplantation. To the best of our knowledge, this is the first case reported from Turkey in the literature.

Quantitation of total fatty acids in plasma and serum by GC-NCI-MS

Polyunsaturated fatty acids (PUFAs), including essential omega-3 and omega-6 fatty acids, play important roles in diverse physiological and pathological processes. Diligent monitoring of PUFAs is recommended for individuals with increased risk of developing essential fatty acid deficiency (EFAD), including premature and very low birth weight infants, patients on prolonged parenteral nutrition, and those with dietary restrictions, for example due to inborn errors of metabolism. Here, we present a gas chromatography-negative chemical ionization-mass spectrometry (GC-NCI‐MS) method for the quantitation of total levels of twenty-two fatty acids (C12‐C22) in serum/plasma, including omega-3 and omage-6 PUFAs. Hydrolysis was used to release esterified fatty acids, which were analyzed by GC-NCI-MS as pentafluorobenzyl esters in selected-ion monitoring (SIM) mode. The calibration curves for all analytes had consistent slopes with R2 of ⩾0.990. Intra- and inter-assay precision CVs were ⩽9.0% and ⩽13.2%, respectively. Samples were found to be stable for 24h at room temperature, at least 7days at 4°C, at least 75days at −20°C, and for three freeze/thaw cycles. No matrix effects or interferences were observed. This method offers improvements over published studies including smaller sample volume, inclusion of additional internal standards, analysis in a single injection, and use of methane reagent gas. This method could be used in a clinical laboratory setting for the diagnosis of EFAD, evaluation of nutritional status, and diet monitoring.

A Third-Generation Lipid Emulsion that Contains n–3 Long-Chain PUFAs Preserves Retinal Function in Parenterally Fed Neonatal Piglets

Background: Preterm neonates and those with intestinal failure require prolonged parenteral nutrition (PN) during a critical time of early central nervous system maturation. Conventional lipid emulsions fed to preterm neonates lack n–3 (ω-3) long-chain polyunsaturated fatty acids (LC-PUFAs; >20 carbon chain in length). Recently, fish oil lipid emulsions have been developed that provide both n–6 (ω-6) and n–3 LC-PUFAs, precursors of very long–chain PUFAs (VLC-PUFAs; >24 carbon chain in length).Objective: Our objective was to determine the effect of fish oil lipid on retinal function in neonatal piglets fed total PN with the use of the lipid emulsions available in clinical practice. We hypothesized that fish oil–containing parenteral lipid would preserve retinal function more than conventional parenteral lipid.Methods: Male neonatal piglets (2–5 d of age) were fed isonitrogenous (16 g · kg−1 · d−1), isocaloric (1.1 MJ · kg−1 · d−1) PN that varied only in the lipid emulsion: Intralipid or SMOFlipid at 10 g · kg−1 · d−1 (n = 8/group). Retinal function was assessed after 14 d of treatment by recording electroretinograms under various light intensity conditions. Retinas were then harvested for histology and to determine fatty acid composition.Results: Electroretinogram intensity response curves showed greater photoreceptor a-wave amplitude in piglets fed SMOFlipid than in those fed Intralipid (percentage), for postsynaptic depolarizing bipolar cell b-waves (percentage) and for flicker electroretinogram amplitudes (percentage) (P < 0.05). Compared with those fed Intralipid, SMOFlipid-fed piglets had greater retinal total n–3 LC-PUFAs (15.7% compared with 18.4%; P = 0.04) and n–3 VLC-PUFAs (0.9% compared with 1.5%; P = 0.02), whereas Intralipid-fed piglets had greater total n–6 LC-PUFAs (13.1% compared with 10.5%; P < 0.01) and n–6 VLC-PUFAs (0.7% compared with 0.5%; P = 0.01). Histologically, retinas were indistinguishable between groups.Conclusions: In a neonatal piglet model of PN feeding, the inclusion of fish oil–based n–3 LC-PUFAs in the lipid emulsion leads to their accretion and endogenous elongation to VLC-PUFAs in the retina, which is associated with better retinal function.

Treatment of short bowel syndrome in children. Value of the Intestinal Rehabilitation Program.

The main cause of acute intestinal failure is short bowel syndrome, generally as a result of resection of extensive segments of small intestine. As a result, the main symptoms are watery diarrhea, malabsorption syndrome, chronic malnutrition, and death, if the patient is not properly treated. If the length of the remaining intestine is greater than 30 cm, complete adaptation is possible and the patient may not require parenteral nutrition. The currently recommended treatment includes the use of prolonged parenteral nutrition and enteral nutrition, always aimed at constant weight gain, in conjunction with surgeries aimed at elongating the dilated bowel. This set of procedures constitutes what is called an Intestinal Rehabilitation Program. This therapy was used in 16 children in periods ranging from 8 months to 7.5 years, with survival in 75% of the cases. Finally, the last resort to be used in children with complete resection of the small bowel is an intestinal transplant. However, to date there is no record of a Brazilian child that has survived this procedure, despite it being attempted in seven patients. We conclude that the results of the intestinal rehabilitation program are encouraging for the continuation of this type of treatment and stimulate the creation of the program in other pediatric care institutions.

Inflammatory Response Using Different Lipid Parenteral Nutrition Formulas in Children After Hematopoietic Stem Cell Transplantation

ABSTRACTNutritional support is an integral part of the supportive care of hematopoietic stem cell transplantation (HSCT) patients. Omega-3 fatty acids (n-3 FA) emulsions in parenteral nutrition (PN) may modify the inflammatory response. The purpose of this study is to compare plasma cytokine levels in children after HSCT using an n-3 FA-containing lipid emulsion (LE) and a soybean oil-based formulation in PN. A randomized double-blind controlled trial was conducted on 14 children following HSCT. Children were randomized to receive either a fish oil or a soybean oil LE. Blood samples were drawn at baseline, on Day 10 and after completion of PN to analyze plasma interleukin 1 beta (IL-1β), 2 (IL-2), 6 (IL-6), 8 (IL-8), 10 (IL-10), and tumor necrosis factor alpha (TNF-α). After 10 days of PN, there were no significant changes in interleukins levels when comparing the two groups or time points (baseline vs. Day 10 of PN). In children requiring PN >21 days, IL-10 and TNF-α levels (P ≤ 0.05) were lower in the fish-oil-containing LE group. Fish oil- and soybean oil-supplemented PN administered for at least 10 days does not cause inflammatory changes. Prolonged PN based on fish oil LE may modulate the inflammatory response.

Risk factor analysis of parenteral nutrition-associated cholestasis in extremely low birth weight infants.

Parenteral nutrition (PN) provides an alternative nutrition source for preterm infants who are intolerant of enteral nutrition. However, prolonged PN increases the risk of PN-associated cholestasis (PNAC). We conducted this study to determine the incidence and risk factors of PNAC in extremely low birth weight (ELBW) infants. We retrospectively reviewed the medical records of ELBW infants from March 2010 to April 2015. PNAC was diagnosed in infants with a history of PN for at least two weeks and direct bilirubin concentrations >2 mg/dL after other causes of neonatal cholestasis were excluded. Of the 114 eligible ELBW infants, 41 (36%) were diagnosed with PNAC. The multivariate analysis showed that birth weight, sepsis, necrotising enterocolitis, fluconazole prophylaxis and the duration of PN and hospitalisation were independent risk factors for the development of PNAC (p < 0.05). However, parenteral fish oil-based lipid preparation (FOLP) did not reduce the risk of PNAC. Although PNAC was not a direct cause of death, it was associated with an increased risk of mortality. PNAC was common in ELBW infants, was associated with various clinical factors and increased the risk of mortality. However, we did not observe the protective effect of FOLP against PNAC.

ESPGHAN Committee on Nutrition Position Paper. Intravenous Lipid Emulsions and Risk of Hepatotoxicity in Infants and Children: a Systematic Review and Meta-analysis.

The aim of the present article was to perform a systematic review with meta-analysis of available scientific evidence regarding the role of different intravenous lipid emulsions (ILE) in the pathogenesis of cholestasis and parenteral nutrition-associated liver disease. A systematic review of the literature (up to March 2015) identified 23 randomized controlled trials (RCTs). Of these, 17 were performed in preterm infants or critically ill neonates with a short duration of intervention, 2 in older children with short-term use (following surgery or bone marrow transplantation), 1 in neonates with long-term use, and 3 in infants and children receiving long-term parenteral nutrition (PN). Meta-analysis showed no differences in the rate of cholestasis or bilirubin levels associated with short-term use of different ILEs. Because of high heterogeneity of the long-term studies no meta-analysis could be performed. Available studies found that the use of multicomponent fish oil (FO)-containing ILE compared with pure soya bean oil (SO), ILE-reduced liver enzymes, and bilirubin levels in noncholestatic children on long-term PN and one other RCT found that FO-based ILE-reversed cholestasis in a proportion of patients. The ESPGHAN Committee on Nutrition concludes that there is no evidence of a difference in rates of cholestasis or bilirubin levels between different ILE for short-term use in neonates. The use of multicomponent FO-containing ILE may contribute to a decrease in total bilirubin levels in children with IF on prolonged PN. Well-designed RCTs are, however, lacking and long-term effects have not been determined.

Oligohydramnios and growth restriction do not portend worse prognosis in gastroschisis pregnancies

Objectives: Gastroschisis is a common abdominal wall defect. While most neonates have an excellent prognosis, complications do occur. Several risk factors for adverse neonatal outcomes have been identified, however, the impact of intrauterine growth restriction (IUGR) and oligohydramnios on neonatal morbidity and mortality has not been fully elucidated. Methods: In this retrospective cohort study of pregnancies complicated by gastroschisis at two tertiary-care centers during an eight-year period, maternal, fetal and neonatal data were analyzed to estimate the impact of IUGR and oligohydramnios upon neonatal outcomes. Adverse outcomes were defined as five-minute Apgar score <7, umbilical cord pH <7.12, neonatal sepsis, prolonged ventilator support, prolonged total parenteral nutrition, extended NICU stay, death and a composite of the above. Results: Among the 179 cases of gastroschisis, there were no differences in maternal demographics between cases with and without IUGR or oligohydramnios. Fetuses with oligohydramnios demonstrated a trend toward lower birthweight (p = 0.06). Small for gestational age infants showed a trend toward prolonged ventilator support (p = 0.06). Oligohydramnios and IUGR were otherwise not associated with adverse neonatal outcomes. Conclusions: While risk factors for adverse neonatal outcomes have been identified in pregnancies complicated by gastroschisis, IUGR and oligohydramnios do not appear to be among them.

Parenteral nutrition in short bowel syndrome patients, regardless of its duration, increases serum proinflammatory cytokines

Short bowel syndrome is a severe malabsorption disorder, and prolonged parenteral nutrition is essential for survival in some cases. Among the undesirable effects of long-term parenteral nutrition is an increase in proinflammatory cytokines. The aim of the present study was to measure the serum levels of interleukin-6, interleukin-10, tumor necrosis factor alpha, and transforming growth factor beta, in patients with short bowel syndrome on cyclic parenteral nutrition and patients who had previously received but no longer require parenteral nutrition. The study was cross-sectional and observational. Three groups were studied as follows: Parenteral nutrition group, 9 patients with short bowel syndrome that receive cyclic parenteral nutrition; Oral nutrition group, 10 patients with the same syndrome who had been weaned off parenteral nutrition for at least 1 year prior to the study; Control group, 13 healthy adults, matched for age and sex to parenteral and oral groups. The following data were collected: age, tobacco use, drug therapies, dietary intake, body weight, height, blood collection. All interleukins were significantly higher in the parenteral group compared with the control group as follows: interleukin-6: 22 ± 19 vs 1.5 ± 1.4 pg/mL, P= .0002; transforming growth factor β: 854 ± 204 vs 607 ± 280 pg/mL, P= .04; interleukin-10: 8 ± 37 vs 0.6 ± 4, P= .03; tumor necrosis factor α: 20 ± 8 vs 8 ± 4 pg/mL, P< .0001. We concluded that parenteral nutrition in short bowel syndrome patients, regardless of its duration, increases serum proinflammatory cytokines.

Wernicke's encephalopathy after total parenteral nutrition in patients with Crohn's disease.

Micronutrient deficiencies in Crohn's disease (CD) patients are not uncommon and usually result in a combination of reduced dietary intake, disease-related malabsorption, and a catabolic state. Decreased serum thiamine levels are often reported in patients with CD. Wernicke's encephalopathy (WE) is a severe form of thiamine deficiency that can cause serious neurologic complications. Although WE is known to occur frequently in alcoholics, a number of non-alcoholic causes have also been reported. Here, we report two cases of non-alcoholic WE that developed in two severely malnourished CD patients who were supported by prolonged total parenteral nutrition without thiamine supplementation. These patients complained of sudden-onset ophthalmopathy, cerebellar dysfunction, and confusion. Magnetic resonance imaging allowed definitive diagnosis for WE despite poor sensitivity. The intravenous administration of thiamine alleviated the symptoms of WE dramatically. We emphasize the importance of thiamine supplementation for malnourished patients even if they are not alcoholics, especially in those with CD.

SHORT BOWEL SYNDROME AND NUTRITIONAL ENTERAL

The particularity of this case is the nutritional management that has managed to avoid the use of prolonged parenteral nutrition and possible complications by placing jejunal tube at the distal end in patients with short bowel. It is a 34-year-old colecistectomizado complicated with postoperative peritonitis and dehiscence; two years he studied with small bowel obstruction, he was made de-volvulus and was complicated with two leak at different times after the second escape took place jejunostomy side double barreled shotgun level dehiscence, presented high debits by afferent loop of the terminal jejunostomy; during admission, polyurethane probe enteral feeding was inserted by the efferent loop jejunostomy. He received jejunal tube feeding laundry in the efferent loop terminal with decreased weight gain and subsequent reconstruction of intestinal transit debit proximal jejunostomy.

Intestinal transplantation: The anesthesia perspective.

Intestinal transplantation is a complex and challenging surgery. It is very effective for treating intestinal failure, especially for those patients who cannot tolerate parenteral nutrition nor have extensive abdominal disease. Chronic parental nutrition can induce intestinal failure associated liver disease (IFALD). According to United Network for Organ Sharing (UNOS) data, children with intestinal failure affected by liver disease secondary to parenteral nutrition have the highest mortality on a waiting list when compared with all candidates for solid organ transplantation. Intestinal transplant grafts can be isolated or combined with the liver/duodenum/pancreas. Organ Procurement and Transplantation Network (OPTN) has defined intestinal donor criteria. Living donor intestinal transplant (LDIT) has the advantages of optimal timing, short ischemia time and good human leukocyte antigen matching contributing to lower postoperative complications in the recipient. Thoracic epidurals provide excellent analgesia for the donors, as well as recipients. Recipient management can be challenging. Thrombosis and obstruction of venous access maybe common due to prolonged parenteral nutrition and/or hypercoaguability. Thromboelastography (TEG) is helpful for managing intraoperative product therapy or thrombosis. Large fluid shifts and electrolyte disturbances may occur due to massive blood loss, dehydration, third spacing etc. Intestinal grafts are susceptible to warm and cold ischemia and ischemia-reperfusion injury (IRI). Post-reperfusion syndrome is common. Cardiac or pulmonary clots can be monitored with transesophageal echocardiography (TEE) and treated with recombinant tissue plasminogen activator. Vasopressors maybe used to ensure stable hemodynamics. Post-intestinal transplant patients may need anesthesia for procedures such as biopsies for surveillance of rejection, bronchoscopy, endoscopy, postoperative hemorrhage, anastomotic leaks, thrombosis of grafts etc. Asepsis, drug interactions between anesthetic and immunosuppressive agents and venous access are some of the anesthetic considerations for this group.

Abstract 18891: Racial Differences in End-of-life Care Associated With Heart Failure Hospitalizations in the United States: A Population-based Analysis From 2011-2012

Background and objectives: Racial disparities in healthcare delivery constitute a major public health problem in the US. There are few studies evaluating the effect of race on utilization of end-of-life (EOL) procedures in HF hospitalizations in the US. Hypothesis: Utilization of EOL procedures differs significantly between racial-ethnic groups independent of socioeconomic status (SES) or probability of in-hospital death. Methods: We used the 2011-2012 Nationwide/National Inpatient Sample to identify primary HF hospitalizations. EOL procedures of interest were intubation, tracheostomy and prolonged mechanical ventilation, hemodialysis, cardiopulmonary resuscitation, gastrostomy, enteral or parenteral nutrition. Relevant ICD-9 codes were used. We used residential ZIP code as a proxy for SES. Multivariate logistic models were used to evaluate racial differences in EOL care while adjusting for SES and probability of in-hospital mortality. Results: 375,740 hospitalizations representing 1.8 million hospitalizations nationwide were included in the study. Mean age was 72.6 (SD 14.6) years and 50.1% were women. Overall 7.81% were intubated, 0.69% underwent tracheostomy, and 6.55% underwent hemodialysis, 0.55% underwent CPR, 0.22% had a gastrostomy and 0.45% received enteral or parenteral nutrition. Blacks, Hispanics, Asians or Pacific Islanders and Other races were more likely to receive EOL procedures compared to Whites after adjusting for SES and probability of in-hospital death. (Fig) Use of any EOL procedure was associated with higher age and sex adjusted odds of in-hospital mortality (OR 6.54, 6.09 - 7.04; p&lt;0.001) and average charges ($76,917 vs. 35,841, p&lt;0.001). Conclusions: Racial-ethnic minorities hospitalized for HF are significantly more likely to receive aggressive EOL care compared to Whites. The reasons for racial differences in utilization of EOL care in HF should be investigated in future studies.

Minerals and extremely low birth weight infants

The 80% of bone mineralisation occurs in the third trimester of pregnancy. The daily fetal requirement is 310 mg of calcium and 170 mg of phosphorus[1]. The bone mineral density (BMD) correlates positively with gestational age, weight and length[2]. At birth, extremely premature infants (ELBWI)canpresent hypocalcaemiabecause of interruption of the maternal calcium supply, high level of calcitoninand immature response to PTH. Early parenteral nutrition solutionisnecessary to maintain normal serum calcium and phosphorus levels. Indeed, the exclusive use of dextrose and calcium gluconate leads to thehypophosphatemia, deleterious to intermediary metabolism, intracellular energy transfer and bone mineral homeostasis[3]. The ELBWI are at risk of Osteopenia of prematurity, also known as neonatal metabolic bone disease (MBD). The pathophysiology includesreduction in organic protein matrix (osteopenia) and/or a reduction in mineral component (osteomalacia). MBD causes rickets, fractures and may affect growth in infancy and childhood. The structural basis of osteopenia is decreased thickness or number of trabeculae and/or decreased thickness of the bone cortex. Osteomalaciais a disorder of the physiological process of mineralisation, when the incorporation of mineral into the organic bone matrix is disturbed, whereas “rickets” describes defective mineralisation of growth plate cartilage and its morphological consequences[4]. The ethiology is multifactorial: placental dysfunction, prolonged (>4 weeks) parenteral nutrition, diureticsand steroids treatment, immobilization and inadequate nutrient intake of calcium, phosphorus, and vitamin D[5]. The main ethiology factor is deficit of mineral substrates, whereas the critical factor is lack of phosphorus[4]. It should be needed an adequate mineral supplementation with parenteral and enteral nutrition, although the difficulties to fortify appropriately the human milk. The dosage recommended of vitamin D is between, 400 IU/d (AAP) and 1000 IU/d (ESPGHAN)[6]. Moreover hypotonia and immobilization are an additional risk factors [7], daily passive exercise canimproves the bone mineral content [8]. MBD could be detected by X-Ray, dual-energy x-ray absorptiometry (DEXA) or quantitative ultrasound. The serumdiagnostic markers are alkaline phosphatases, calcium and phosphateserum levels. Preterm infants with low serum phosphate (<2 mmol/l) are at risk of MBD and levels less than 1.8 mmol/l have been strongly associated with the presence of radiographically evident rickets. Because of preterm has a much lower renal phosphate threshold and this is not bound in the plasma like calcium, the tubular reabsorption is the best guide to calculate itssupplementation[8].

Surgical manifestations of gastrointestinal cytomegalovirus infection in children: Clinical audit and literature review

IntroductionGastrointestinal sequelae of cytomegalovirus are rare, usually associated with significant immune compromise, and carry a high morbidity and mortality. Gastrointestinal disease frequently requires surgical intervention for diagnosis and management. AimThe aim of the study is to evaluate the incidence, presentation and management of gastrointestinal cytomegalovirus disease in a pediatric population. MethodBetween January 2003 and June 2011, a retrospective folder review was conducted of all symptomatic children with proven CMV disease, presenting to the surgical service. Eligible patients were identified using the surgical, histopathology and serology databases. ResultsThirty-eight patients (1.8/1000 surgical admissions) were identified with a median presenting age of 5months (range 3days–12years). Esophagitis (n=18) and small bowel disease (n=16) predominated, but CMV was seen throughout the gastrointestinal tract. Risk factors included HIV infection (n=21, 55%) and recent gastrointestinal surgery or infection (n=10, 26%). Characteristic multiple jejunoileal perforations were seen in six patients. Compared to upper GIT disease, intestinal involvement was associated with younger age and doubled mortality. In HIV-infected children, median CD4 (%) was lower in intestinal compared to upper gastrointestinal disease. Morbidities included anastomotic breakdowns (5), anastomotic strictures (3), relook laparotomies (10), resistant esophageal strictures (5) and prolonged parenteral nutrition (5). Anti-CMV drugs were given in 63%. Overall mortality was 32% (12/38) and was associated with lower GIT disease. ConclusionInvasive CMV gastrointestinal disease in our children was predominantly HIV-associated, or followed a major lower gastrointestinal inflammatory insult in infants younger than 6months. Successful therapy requires a high index of suspicion of active CMV disease to allow early implementation of CMV viral load control and aggressive treatment of the underlying immune impairment. Multiple surgical interventions are often required for both tissue diagnosis and management of acute and chronic complications. CMV-viral-load-tailored anti-CMV therapy is supported by recent literature.

Delivery planning for pregnancies with gastroschisis: findings from a prospective national registry

The purpose of this study was to determine the influence of planned mode and planned timing of delivery on neonatal outcomes in infants with gastroschisis. Data from the Canadian Pediatric Surgery Network cohort were used to identify 519 fetuses with isolated gastroschisis who were delivered at all tertiary-level perinatal centers in Canada from 2005-2013 (n = 16). Neonatal outcomes (including length of stay, duration of total parenteral nutrition, and a composite of perinatal death or prolonged exclusive total parenteral nutrition) were compared according to the 32-week gestation planned mode and timing of delivery with the use of the multivariable quantile and logistic regression. Planned induction of labor was not associated with decreased length of stay (adjusted median difference, -2.6 days; 95% confidence interval [CI], -9.9 to 4.8), total parenteral nutrition duration (adjusted median difference, -0.2 days; 95% CI, -6.4 to 6.0), or risk of the composite adverse outcome (relative risk, 1.7; 95% CI, 0.1-3.2) compared with planned vaginal delivery after spontaneous onset of labor. Planned delivery at 36-37 weeks' gestation was not associated with decreased length of stay (adjusted median difference, 5.9 days; 95% CI, -5.7 to 17.5), total parenteral nutrition duration (adjusted median difference, 3.2 days; 95% CI, -7.9 to 14.3), or risk of composite outcome (relative risk, 2.3; 95% CI, 0.8-5.4) compared with planned delivery at ≥38 weeks' gestation. Infants with gastroschisis who were delivered after planned induction or planned delivery at 36-37 weeks' gestation did not have significantly better neonatal outcomes than planned vaginal delivery after spontaneous onset of labor and planned delivery at ≥38 weeks' gestation.

Intestinal dysbiosis in children with short bowel syndrome is associated with impaired outcome.

BackgroundThe composition of the intestinal microbiota seems to be an important factor in determining the clinical outcome in children with short bowel syndrome (SBS). Alterations in the microbiota may result in serious complications such as small bowel bacterial overgrowth (SBBO) and intestinal mucosal inflammation that lead to prolonged parenteral nutrition (PN) dependency with subsequently increased risk of liver failure and sepsis. To date, there are no reported mappings of the intestinal microbiome in children with SBS. Here, we present the first report on the intestinal microbial community profile in children with SBS.FindingsThe study includes children diagnosed with SBS in the neonatal period. Healthy siblings served as controls. Fecal samples were collected, and microbial profiles were analyzed by using 16S rRNA gene sequencing on the Illumina MiSeq platform. We observed a pronounced microbial dysbiosis in children with SBS on PN treatment with an increased and totally dominating relative abundance of Enterobacteriacae in four out of five children compared to children with SBS weaned from PN and healthy siblings.ConclusionsThe overall decreased bacterial diversity in children with SBS is consistent with intestinal microbiome mappings in inflammatory bowel diseases such as Crohn’s disease and necrotizing enterocolitis in preterm infants. Our findings indicate that intestinal dysbiosis in children with SBS is associated with prolonged PN dependency.Electronic supplementary materialThe online version of this article (doi:10.1186/s40168-015-0084-7) contains supplementary material, which is available to authorized users.

Intestinal Microbiota Signatures Associated With Histological Liver Steatosis in Pediatric-Onset Intestinal Failure.

Intestinal failure (IF)-associated liver disease (IFALD) is the major cause of mortality in IF. The link between intestinal microbiota and IFALD is unclear. We compared intestinal microbiota of patients with IF (n = 23) with healthy controls (n = 58) using culture-independent phylogenetic microarray analysis. The microbiota was related to histological liver injury, fecal markers of intestinal inflammation, matrix metalloproteinase 9 and calprotectin, and disease characteristics. Overabundance of Lactobacilli, Proteobacteria, and Actinobacteria was observed in IF, whereas bacteria related to Clostridium clusters III, IV, and XIVa along with overall diversity and richness were reduced. Patients were segregated into 3 subgroups based on dominating bacteria: Clostridium cluster XIVa, Proteobacteria, and bacteria related to Lactobacillus plantarum. In addition to liver steatosis and fibrosis, Proteobacteria were associated with prolonged current parenteral nutrition (PN) as well as liver and intestinal inflammation. Lactobacilli were related to advanced steatosis and fibrosis mostly after weaning off PN without associated inflammation. In multivariate permutational analysis of variance, liver steatosis, bowel length, PN calories, and antibiotic treatment best explained the microbiota variation among patients with IF. Intestinal microbiota composition was associated with liver steatosis in IF and better predicted steatosis than duration of PN or length of the remaining intestine. Our results may be explained by a model in which steatosis is initiated during PN in response to proinflammatory lipopolysaccharides produced by Proteobacteria and progresses after weaning off PN, as the L plantarum group Lactobacilli becomes dominant and affects lipid metabolism by altering bile acid signaling.

Colitis May Enhance Liver Injury in a Preterm Porcine Model of Parenteral Nutrition

Aim Prematurity, prolonged parenteral nutrition (PN), and concurrent intestinal injury, are considered to be risk factors in the development and severity of PN-associated liver disease (PNALD). The aim of this study was to develop a preterm porcine model of PNALD. Methods