Collection
Parenteral Nutrition & Enteral Autonomy
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
The downside of Blake tubes is that they cannot be changed over a wire like JP drains with side holes; the ideal tube would be a Blake with a central hole for wire passage. — Michael Helmrath, Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2 · 14:59
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1
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We're back with a new episode from the Intestinal Rehabilitation Center at Cincinnati Children's Hospital. This time we're talking about the management of overwhelming intestinal damage in conditions such as necrotizing enterocolitis and vo
podcast13:27 · Feb 2022
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2
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We're back with the second part of episode 2, management of overwhelming intestinal damage along with Drs. Michael Helmrath and Paul Wales from Intestinal Rehabilitation Center at Cincinnati Children's Hospital. Article for further reading:
podcast17:21 · Feb 2022
Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 2
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We're back with the second part of episode 3, enteral autonomy along with Drs. Michael Helmrath and Paul Wales from Intestinal Rehabilitation Center at Cincinnati Children's Hospital. Hosts: Ellen Encisco & Rod GerardoRegister for Best of t
podcast13:37 · Mar 2022
Parenteral nutrition weaning in pediatric intestinal failure patients enrolled in remote patient monitoring: A descriptive study
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Remote patient monitoring appears safe for pediatric intestinal failure patients, with potential for higher PN reduction and shorter time to achieve it. Further research is needed to fully assess RPM's impact on this population.
article · Nov 2026
Composite Lipid Strategies3 items
Composite lipid emulsion use and essential fatty acid deficiency in pediatric patients with intestinal failure with high parenteral nutrition dependence: A retrospective cohort study
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Background: Reports of essential fatty acid deficiency (EFAD) in patients receiving parenteral nutrition (PN) and a composite lipid (mixed oil intravenous lipid emulsion [MO ILE]) are predominantly when managed by lipid restriction. The obj
article · Nov 2026
Composite Lipid Emulsion for the Infant at Risk of Intestinal Failure-associated Liver Disease: The Canadian Perspective
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Currently, in North America we are fortunate to have a number of available options for lipid emulsions to be used in the parenteral nutrition regimens for infants and children, including for long-term parenteral nutrition given intestinal f
article · Nov 2026
An Observational Study of Smoflipid vs Intralipid on the Evolution of Intestinal Failure-Associated Liver Disease in Infants With Intestinal Failure
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Background: SMOFlipid has a more diverse lipid profile than traditional Intralipid and has become the standard lipid for patients in our intestinal rehabilitation program. Our objective was to compare outcomes in neonates with intestinal fa
article · Nov 2026
Soybean Lipid Risks1 item
Soybean Lipid and Advanced Liver Disease in Infants: Risks and Future Solutions w/ Dr. Paul Wales
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Dr. Paul Wales discusses a paper showing that daily exposure of infants to soybean lipid (dosed at >2.5 grams per kilo per day) is associated with a 3% increase in the odds ratio of developing advanced liver disease. He highlights that curr
video0:31 · Oct 2026
A.S.P.E.N. clinical guidelines: support of pediatric patients with intestinal failure at risk of parenteral nutrition-associated liver disease
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Background: Children with severe intestinal failure and prolonged dependence on parenteral nutrition are susceptible to the development of parenteral nutrition-associated liver disease (PNALD). The purpose of this clinical guideline is to d
article · Nov 2026
ASPEN definitions in pediatric intestinal failure
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Pediatric intestinal failure (PIF) is a relatively rare disease entity that requires focused interdisciplinary care and specialized nutrition management. There has long been a lack of consensus in the definition of key terms related to PIF
article · Nov 2026
Response to "Definition of pediatric intestinal failure should not require ongoing dependence on parenteral nutrition"
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JPEN. Journal of parenteral and enteral nutrition · 2022
article · Nov 2026
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Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2
In Toronto, ultra-short gut is classified as less than 20% of expected bowel length for age; in a term baby that corresponds to 20–30 centimeters.
clinicalPaul Wales1:37 ↗
Overall survival in the ultra-short gut population in the current era of management is over 90%, actually 90–95%.
epidemiologicalPaul Wales1:52 ↗
Ultra-short gut patients in the current era do not die of liver failure anymore and are rarely transplanted.
Host summaryThe host summarizing the discussion — not the host's own clinical position2:03 ↗
Ultra-short gut patients who reached enteral autonomy required multiple nutritional supplements but were able to grow within normal parameters.
clinicalPaul Wales2:07 ↗
Long-term risks of death from liver disease or sepsis in ultra-short gut patients have been transformed in the current era of management.
clinicalPaul Wales2:13 ↗
Ultra-short gut patients who did better tended to have some remnant ileum and longer colonic remnants.
clinicalPaul Wales2:26 ↗
The ileum reclaims bile, tells the liver what to do, and produces hormones like GLP-2, PYY, and others that slow motility and signal the jejunum to reabsorb fluid.
clinicalMichael Helmrath2:55 ↗
The colon can account for one-third to one-half of the caloric needs of these babies when exposed to undigested nutrients.
clinicalMichael Helmrath3:15 ↗
These children with overwhelming intestinal catastrophe are largely neurologically fine—they are running and playing—and their life expectancy is not associated with lifelong care needs that most parents would not want.
clinicalMichael Helmrath3:24 ↗
The child should be the one driving the care, not the surgeon's expectations or lack thereof; without changing that early paradigm, nothing else can improve in this population.
opinionMichael Helmrath3:48 ↗
Bowel removed is bowel never to be used; the fear that delayed surgery drives neurocognitive harm needs to be supported with data.
opinionMichael Helmrath4:26 ↗
NEC totalis in NEC patients is fairly rare; most NEC patients do not have overwhelming totalis.
epidemiologicalMichael Helmrath4:48 ↗
A dozen or more children with NEC totalis at Cincinnati have survived, are off TPN, and have done remarkably well; the comparative group is dead children who have no neurological function.
clinicalMichael Helmrath4:54 ↗
Once these patients survive the acute phase, the opportunities to rehabilitate the bowel and the new tools that will be developed in the next decade are going to be profound.
opinionMichael Helmrath5:25 ↗
The opportunity given to the child is made at the time the surgeon opens the belly and sees catastrophe; removing all bowel eliminates all future potential based on clinical acumen that the outcome will be bad.
opinionMichael Helmrath5:34 ↗
The first team that must be convinced of this approach is the neonatology team, because historically they are the ones who removed breathing tubes and allowed these babies to pass.
clinicalMichael Helmrath5:49 ↗
Neonatologists see some of the survivors—ex-premature infants with intestinal failure—return to their follow-up clinics, which informs their perspective.
clinicalPaul Wales5:59 ↗
Not every child needs to die with a laparotomy decision; the data will tell whether the unoperated septic/inflammatory response leads to negative outcomes.
opinionPaul Wales6:10 ↗
Long-term neurocognitive tracking of this population is part of the program's responsibility and is beneficial to patients.
opinionPaul Wales6:29 ↗
If you see protein growth, linear growth, and head growth in the baby, that is brain growth; a baby will not grow well with an unhealthy liver or poor management.
clinicalMichael Helmrath6:47 ↗
An unhealthy liver does not provide the protein necessary for neurocognitive development; liver health is the number one priority early in management.
clinicalMichael Helmrath6:59 ↗
Lipid restriction as a way of controlling liver disease was never a practice subscribed to by the speakers.
opinionPaul Wales7:20 ↗
Babies, especially premature babies in the first year of life, have caloric needs of 80–120 kcal/kg because they are growing and developing; when critically ill they are no longer growing and their livers are catabolic, so feeding 150 kcal/kg will not result in growth.
clinicalMichael Helmrath7:43 ↗
For a 30-week baby with extensive NEC and a long segment of dead bowel, the surgeon knows the baby will need multiple operations, so a transverse incision is used because it causes the least problems over time.
clinicalMichael Helmrath8:21 ↗
The surgeon finds a segment of bowel just beyond what is expected to heal (1–2 cm margin) and brings in an 8 or 10 French Blake drain, often from the left lower quadrant if normally rotated, placing it through bowel that is not expected to do well and advancing it retrograde to the pylorus.
clinicalMichael Helmrath8:31 ↗
A loose tie is placed around the most healthy part of the bowel around the drain to control secretions, and a purse-string is placed at the insertion site and secured to the skin, essentially stemming the bowel to the abdominal wall; this takes minutes.
clinicalMichael Helmrath8:53 ↗
If the stomach is visible, a purse-string is placed in the stomach and a 5–7 French feeding tube is inserted into the proximal bowel and tied, taking one to two minutes; this avoids having to access the left upper quadrant later for a G-tube.
clinicalMichael Helmrath9:29 ↗
The surgeon tries to close the abdomen primarily, but if there is concern about dead bowel, Alloderm is placed; if very worried, a drain is placed in the abdomen to allow drainage.
clinicalMichael Helmrath9:54 ↗
The surgeon tries to avoid significant dissection of the distal ileum to preserve blood supply and allow collateralization to recover as much proximal bowel as possible.
clinicalMichael Helmrath10:08 ↗
If the distal diverted bowel is baggy and filled with bloody enteric fluid, and there are distal perforations with patchy necrosis, the surgeon may place stitches distal to proximal to bring the bowel together to preserve muscle, planning to manage it later.
clinicalMichael Helmrath10:30 ↗
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