# Pediatric Intestinal Failure & Rehabilitation Fundamentals — GCMD Library living collection

Updated: n/a · 8 episodes · 177 cited statements

## Episodes
### Overview & Innovations
- [Advances in pediatric intestinal failure management and rehabilitation](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667) — podcast · 17:45 · [machine version](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667.md)
- [Pediatric intestinal failure management and rehabilitation strategies](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668) — video · 17:59 · [machine version](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668.md)
- [Advancements in Pediatric Intestinal Failure: Innovative Therapies and Improved Outcomes](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892) — video · 17:45 · [machine version](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892.md)
- [Intestinal Failure: When is Transplant Still the Answer? Advances in Intestinal Rehabilitation](https://library.globalcastmd.com/watch/intestinal-failure-when-is-transplant-still-the-answer-advances-in-intestinal-re-16538) — video · 0:27 · [machine version](https://library.globalcastmd.com/watch/intestinal-failure-when-is-transplant-still-the-answer-advances-in-intestinal-re-16538.md)

### Medical Management
- [Insights into medical management of pediatric intestinal failure](https://library.globalcastmd.com/article/insights-into-medical-management-of-pediatric-intestinal-failure-16669) — article · [machine version](https://library.globalcastmd.com/article/insights-into-medical-management-of-pediatric-intestinal-failure-16669.md)
- [SMART method for parenteral nutrition review for gastroenterologists](https://library.globalcastmd.com/article/smart-method-for-parenteral-nutrition-review-for-gastroenterologists-16671) — article · [machine version](https://library.globalcastmd.com/article/smart-method-for-parenteral-nutrition-review-for-gastroenterologists-16671.md)
- [Evaluation and Management of Iron Deficiency in Children Undergoing Intestinal Rehabilitation-A Position Paper From the NASPGHAN Intestinal Rehabilitation Special Interest Group.](https://library.globalcastmd.com/article/evaluation-and-management-of-iron-deficiency-in-children-undergoing-intestinal-r-16670) — article · [machine version](https://library.globalcastmd.com/article/evaluation-and-management-of-iron-deficiency-in-children-undergoing-intestinal-r-16670.md)

### Referral Guidelines
- [Intestinal Failure: Essential Referral Guidelines for Physicians w/ Dr. Stephanie Oliveira](https://library.globalcastmd.com/watch/intestinal-failure-essential-referral-guidelines-for-physicians-w-dr-stephanie-o-15973) — video · 0:26 · [machine version](https://library.globalcastmd.com/watch/intestinal-failure-essential-referral-guidelines-for-physicians-w-dr-stephanie-o-15973.md)

## Chapters
- [0:09](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=9) Defining Intestinal Failure and the Role of Intestinal Rehabilitation (Ep 3)
- [5:10](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=310) Intestinal Rehabilitation Programs and Outcomes (Ep 3)
- [7:54](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=474) Evolution of Lipid Emulsions in Parenteral Nutrition (Ep 3)
- [11:55](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=715) Central Line Complications and Lock Solutions (Ep 3)
- [13:45](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=825) GLP-2 Analogs for Intestinal Adaptation (Ep 3)
- [16:29](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=989) Summary and Future Directions (Ep 3)
- [0:00](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=0) Defining Intestinal Failure and Intestinal Rehabilitation (Ep 1)
- [4:36](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=276) Multidisciplinary Intestinal Rehabilitation Programs and Outcomes (Ep 1)
- [7:54](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=474) Alternative Lipid Strategies in Parenteral Nutrition (Ep 1)
- [11:55](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=715) Central Line Complications and Protection Strategies (Ep 1)
- [13:45](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=825) GLP-2 Analogs for Short Bowel Syndrome (Ep 1)
- [16:54](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=1014) Summary: Integrated Approach to Intestinal Failure (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=0) Intestinal Failure Definition, Causes, and Rehabilitation Fundamentals (Ep 2)
- [5:10](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=310) Multidisciplinary Intestinal Rehabilitation Programs and Outcomes (Ep 2)
- [7:54](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=474) Evolution of Lipid Emulsions in Parenteral Nutrition (Ep 2)
- [11:56](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=716) Central Line Complications and Alternative Lock Solutions (Ep 2)
- [13:48](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=828) GLP-2 Analogs and Future Directions in Intestinal Adaptation (Ep 2)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Intestinal failure is defined as the reduction of functioning intestinal mass below that which can sustain life, resulting in dependence on supplemental parenteral support for a minimum of 60 days within a 74 consecutive day interval. — Stephanie Oliveira (clinical) [Ep 3 · 0:26](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=26)
- More than 50% of intestinal failure cases are related to short bowel syndrome, with additional cases from mucosal enteropathies and dysmotility disorders. — Stephanie Oliveira (epidemiological) [Ep 3 · 0:43](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=43)
- Most causes of short bowel syndrome in pediatrics occur during the neonatal period, including gastroschisis, necrotizing enterocolitis, bowel atresia, and intestinal volvulus. — Stephanie Oliveira (clinical) [Ep 3 · 0:55](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=55)
- The field is now focusing on neurocognitive outcomes, quality of life, and caregiver burnout as more children survive intestinal failure. — Stephanie Oliveira (opinion) [Ep 3 · 1:18](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=78)
- The cause of chronic intestinal inflammation in intestinal failure survivors is not known. — Stephanie Oliveira (clinical) [Ep 3 · 1:37](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=97)
- Intestinal rehabilitation treatment strategy lacks clear-cut guidelines because every patient is unique with different gestational age, bowel resection, anatomy, and comorbidities. — Stephanie Oliveira (clinical) [Ep 3 · 1:48](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=108)
- The goal of intestinal rehabilitation is to optimize intestinal function and adaptation before the development of irreversible complications. — Stephanie Oliveira (clinical) [Ep 3 · 2:07](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=127)
- Intestinal adaptation is an active compensatory process that starts immediately after bowel resection. — Stephanie Oliveira (clinical) [Ep 3 · 2:30](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=150)
- Food, bacteria, and hormones in the gut are important factors that enhance intestinal adaptation. — Stephanie Oliveira (clinical) [Ep 3 · 2:42](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=162)
- Enteral autonomy is defined as getting off TPN with all nutrition going to the gut, either by mouth or by feeding tube. — Stephanie Oliveira (clinical) [Ep 3 · 3:11](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=191)
- From 2010 to 2015, a repeat study with double the number of patients showed approximately 50% still reached enteral autonomy, but the number of transplants and deaths significantly decreased. — Stephanie Oliveira (epidemiological) [Ep 3 · 3:33](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=213)
- The establishment of multidisciplinary teams is one factor that changed outcomes in intestinal failure. — Stephanie Oliveira (clinical) [Ep 3 · 3:46](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=226)
- Predictors of reaching enteral autonomy include residual bowel length (more is better), follow-up at an institution with an intestinal rehabilitation program, and no STEP procedure. — Stephanie Oliveira (clinical) [Ep 3 · 4:03](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=243)
- Patients should be referred to intestinal rehabilitation programs when not making progress, on prolonged TPN, or have significant comorbidities, preferably sooner rather than later. — Stephanie Oliveira (guideline) [Ep 3 · 4:19](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=259)
- Patients should not be referred to intestinal rehabilitation when several irreversible complications have already occurred and transplant is the only remaining option. — Stephanie Oliveira (guideline) [Ep 3 · 4:39](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=279)
- Intestinal transplantation is considered when there are irreversible complications, though the number of transplants has significantly decreased over the last several decades. — Stephanie Oliveira (clinical) [Ep 3 · 4:49](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=289)
- Liver disease associated with intestinal failure ranges from mild cholestasis to profound steatosis (in older children/adolescents/adults), with progression through inflammation, fibrosis, and ultimately cirrhosis leading to death or transplantation. — Paul Wales (clinical) [Ep 3 · 5:23](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=323)
- Risk factors for intestinal failure-associated liver disease include prematurity, lack of enteral feeding, inability to feed due to anatomy, recurrent infections/sepsis, and components of TPN. — Paul Wales (clinical) [Ep 3 · 5:41](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=341)
- The term 'intestinal rehabilitation program' was coined in the year 2000. — Paul Wales (clinical) [Ep 3 · 6:08](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=368)
- Intestinal rehabilitation teams improve outcomes through integration of care, improved communication, and better continuity. — Paul Wales (clinical) [Ep 3 · 6:12](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=372)
- Intestinal rehabilitation programs rely heavily on speech, language, and occupational therapy specialists. — Paul Wales (clinical) [Ep 3 · 6:34](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=394)
- While patients are on TPN, the goal is to mitigate progression of liver disease, sepsis, and vascular complications. — Paul Wales (clinical) [Ep 3 · 6:38](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=398)
- Families of intestinal failure patients manage significant tasks at home including running TPN pumps, adding vitamins, programming pumps, recording ins and outs, managing G-tubes, and managing stomas. — Paul Wales (clinical) [Ep 3 · 6:54](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=414)
- High-quality families demonstrate evidence of burnout over time despite education and empowerment efforts. — Paul Wales (clinical) [Ep 3 · 7:11](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=431)
- Literature shows intestinal rehabilitation programs improve survival related to liver dysfunction, decrease septic episodes, reduce central line complications, reduce ICU admissions, and enable patients listed for transplant to come off the list due to improved status. — Paul Wales (epidemiological) [Ep 3 · 7:25](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=445)
- Mortality in intestinal failure has decreased with intestinal rehabilitation programs. — Paul Wales (epidemiological) [Ep 3 · 7:43](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=463)
- Lipids in parenteral nutrition are a source of essential fatty acids, a non-protein energy source important for growth, and fatty acids have a major role in cellular pathways. — Paul Wales (clinical) [Ep 3 · 8:02](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=482)
- Historically, most lipid emulsions in North America are soybean-based with high phytosterol content, high omega-6 long-chain polyunsaturated fatty acid content, and low antioxidant content. — Paul Wales (clinical) [Ep 3 · 8:15](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=495)
- Prolonged soybean-based lipid exposure is associated with deterioration of liver function, specifically cholestasis. — Paul Wales (clinical) [Ep 3 · 8:31](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=511)
- For every day an infant is exposed to soybean lipid dosed at greater than 2.5 g/kg/day, there is a 3% increase in the odds ratio of developing advanced liver disease. — Paul Wales (epidemiological) [Ep 3 · 8:51](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=531)
- First-generation lipid emulsions were soybean-based, rich in omega-6 PUFA (such as Intralipid), and have been in use for 40 years. — Paul Wales (clinical) [Ep 3 · 9:15](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=555)
- Third-generation lipid emulsions reduce omega-6 component and change the omega-6 to omega-3 ratio by adding omega-3 lipids. — Paul Wales (clinical) [Ep 3 · 9:32](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=572)
- Omega-6 lipids are metabolized to arachidonic acid, which produces leukotrienes and prostaglandins with a more pro-inflammatory profile. — Paul Wales (clinical) [Ep 3 · 9:51](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=591)
- Omega-3 lipids are metabolized through EPA and DHA, leading to production of cytokines with a less inflammatory profile. — Paul Wales (clinical) [Ep 3 · 10:01](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=601)
- Omega-3 lipids improve bile flow by decreasing lithogenicity of bile, decreasing steatosis, stimulating improved beta-oxidation and clearance, lowering oxidative stress, and supporting immune function. — Paul Wales (clinical) [Ep 3 · 10:15](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=615)
- The two main strategies for improving lipids in parenteral nutrition are lipid minimization and change in composition. — Paul Wales (clinical) [Ep 3 · 10:32](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=632)
- Literature dating back decades shows that restricting exposure to soybean lipid improves cholestasis, particularly when dosed at 1 g/kg/day or less. — Paul Wales (clinical) [Ep 3 · 10:42](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=642)
- In preterm babies, fat is important for growth, especially for neurocognitive development, creating a risk of essential fatty acid deficiency if lipid dosing is restricted too much. — Paul Wales (clinical) [Ep 3 · 11:00](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=660)
- DHA and arachidonic acid are important for retinal and brain development. — Paul Wales (clinical) [Ep 3 · 11:22](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=682)
- None of the current lipid emulsions were designed for premature babies; they were all designed for adults in critical care settings. — Paul Wales (clinical) [Ep 3 · 11:26](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=686)
- Work is currently underway with industry to create a lipid emulsion specifically tailored to preterm babies with higher arachidonic acid content. — Paul Wales (clinical) [Ep 3 · 11:38](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=698)
- Central lines are the lifeline for intestinal failure patients, and without venous access, families cannot be supported. — Paul Wales (clinical) [Ep 3 · 12:03](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=723)
- Central lines are at risk for complications including infections, blockages, thrombosis, and breakage. — Paul Wales (clinical) [Ep 3 · 12:10](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=730)
- In the United States, there are approximately 240,000 central line-associated bloodstream infections (CLABSIs) annually, with each costing about $30,000, totaling approximately $2 billion per year nationwide. — Paul Wales (epidemiological) [Ep 3 · 12:24](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=744)
- The team pivoted to 4% tetrasodium EDTA (Taurolock/Kitelock) when ethanol became too expensive and difficult to obtain. — Paul Wales (clinical) [Ep 3 · 12:48](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=768)
- 4% tetrasodium EDTA (Kitelock) is antithrombotic, anti-fibrinolytic, and antimicrobial, satisfying all three criteria important for a good lock solution. — Paul Wales (clinical) [Ep 3 · 12:48](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=768)
- Kitelock is licensed in Europe and Australia but not available in the United States. — Paul Wales (clinical) [Ep 3 · 13:23](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=803)
- A multi-center randomized trial of Kitelock versus heparin went live 4 weeks ago and is actively recruiting patients, with results expected within the next year. — Paul Wales (clinical) [Ep 3 · 13:29](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=809)
- In short bowel syndrome, there are three anatomical subtypes: Type 1 (high jejunostomy), Type 2 (loss of distal small bowel/ileum and part of colon with small bowel-colonic anastomosis), and Type 3 (loss of mid-small bowel with retained ileum and intact colon). — Paul Wales (clinical) [Ep 3 · 13:58](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=838)
- The most common anatomical subtype of short bowel syndrome in pediatrics is Type 2. — Paul Wales (epidemiological) [Ep 3 · 14:26](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=866)
- Type 1 and Type 2 short bowel syndrome patients struggle because they lack an ileum. — Paul Wales (clinical) [Ep 3 · 14:31](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=871)
- Native GLP-2 hormone has a half-life of 7 minutes, making it impractical for clinical use. — Paul Wales (clinical) [Ep 3 · 14:53](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=893)
- GLP-2 has been altered by one amino acid to create an analog called teduglutide, which has a half-life of 2 hours and is given once daily by subcutaneous injection. — Paul Wales (clinical) [Ep 3 · 14:58](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=898)
- A multi-center phase 3 study published in 2020 at Cincinnati Children's showed patients receiving teduglutide had a 40% reduction in TPN fluid and calorie requirements over a six-month period. — Paul Wales (epidemiological) [Ep 3 · 15:23](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=923)
- 70% of patients who received teduglutide achieved the study endpoint of a 20% reduction in TPN requirements. — Paul Wales (epidemiological) [Ep 3 · 15:32](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=932)
- Teduglutide is licensed for children greater than 1 year of age. — Paul Wales (guideline) [Ep 3 · 15:48](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=948)
- Teduglutide has made a big difference in practice, with even children with very extreme anatomy able to get off TPN. — Paul Wales (clinical) [Ep 3 · 15:50](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=950)
- Another GLP-2 analog, apraglutide, has a longer half-life and can be given once weekly. — Paul Wales (clinical) [Ep 3 · 16:02](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=962)
- Apraglutide works even better than teduglutide, producing more bowel lengthening. — Paul Wales (clinical) [Ep 3 · 16:10](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=970)
- These interventions (optimized lipids, central line infection prevention, GLP-2 analogs) have led to a decrease in transplantation since 2008. — Paul Wales (epidemiological) [Ep 3 · 16:36](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=996)
- The decrease in transplantation is in large part because of the successes of intestinal rehabilitation. — Paul Wales (opinion) [Ep 3 · 16:41](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=1001)
- Outcomes of intestinal transplant at 5 years are approximately 65%. — Paul Wales (epidemiological) [Ep 3 · 16:41](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=1001)
- The goal is to avoid transplant and lifelong immunosuppression whenever possible. — Paul Wales (opinion) [Ep 3 · 16:49](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=1009)
- Intestinal failure is defined as the reduction of functional intestinal mass below which can sustain life, resulting in dependence on supplemental parenteral support for a minimum of 60 days within a 74 consecutive day interval. — Stephanie Oliveira (clinical) [Ep 2 · 0:26](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=26)
- More than 50% of intestinal failure cases are related to short bowel syndrome, with additional cases from mucosal enteropathies and dismotility disorders. — Stephanie Oliveira (epidemiological) [Ep 2 · 0:43](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=43)
- Most causes of short bowel syndrome in pediatrics occur during the neonatal period, including gastroschisis, necrotizing enterocolitis, bowel atresias, and intestinal volvulus. — Stephanie Oliveira (clinical) [Ep 2 · 0:55](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=55)
- The field is now focusing on neurocognitive outcomes, quality of life, and caregiver burnout as more children survive intestinal failure. — Stephanie Oliveira (opinion) [Ep 2 · 1:18](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=78)
- The cause of chronic intestinal inflammation in intestinal failure patients is not known. — Stephanie Oliveira (clinical) [Ep 2 · 1:37](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=97)
- The goal of intestinal rehabilitation is to optimize intestinal function and adaptation before the development of irreversible complications. — Stephanie Oliveira (clinical) [Ep 2 · 2:07](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=127)
- Intestinal adaptation is an active compensatory process that starts immediately after bowel resection. — Stephanie Oliveira (clinical) [Ep 2 · 2:30](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=150)
- Food, bacteria, and hormones in the gut are important factors that enhance intestinal adaptation. — Stephanie Oliveira (clinical) [Ep 2 · 2:41](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=161)
- Intestinal rehabilitation strategies to avoid transplant include enteral nutrition, parenteral nutrition, medication, surgical procedures, feeding therapy, and central line locks. — Stephanie Oliveira (clinical) [Ep 2 · 2:54](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=174)
- Enteral autonomy is defined as getting off TPN with all nutrition going into the gut, either by mouth or by feeding tube. — Stephanie Oliveira (clinical) [Ep 2 · 3:11](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=191)
- From 2010 to 2015, a repeat study with double the number of patients showed approximately 50% still reached enteral autonomy, but the number of transplants and deaths significantly decreased. — Stephanie Oliveira (epidemiological) [Ep 2 · 3:33](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=213)
- The establishment of multidisciplinary teams is one factor that changed outcomes in intestinal failure. — Stephanie Oliveira (clinical) [Ep 2 · 3:46](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=226)
- Predictors of reaching enteral autonomy include residual small bowel length (more bowel is better), follow-up at an institution with an intestinal rehabilitation program, and no STEP procedure. — Stephanie Oliveira (clinical) [Ep 2 · 4:03](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=243)
- Patients should be referred to intestinal rehabilitation programs when they are not making progress, are on prolonged TPN, or have significant comorbidities, and referral should occur sooner rather than later. — Stephanie Oliveira (guideline) [Ep 2 · 4:19](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=259)
- Patients should not be referred to intestinal rehabilitation programs when several complications have already occurred and transplant is the only remaining option. — Stephanie Oliveira (guideline) [Ep 2 · 4:39](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=279)
- Intestinal transplantation is considered when there are irreversible complications. — Stephanie Oliveira (clinical) [Ep 2 · 4:49](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=289)
- The number of intestinal transplants has significantly decreased over the last several decades due to multiple interventions available to avoid transplantation. — Stephanie Oliveira (epidemiological) [Ep 2 · 4:53](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=293)
- Liver disease associated with intestinal failure ranges from mild cholestasis to profound steatosis (seen in older children, adolescents, and adults), with ongoing inflammation, fibrosis, and ultimately cirrhosis leading to death or need for transplantation. — Paul Wales (clinical) [Ep 2 · 5:23](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=323)
- Risk factors for intestinal failure-associated liver disease include patient factors related to prematurity, lack of enteral feeding, inability to feed due to anatomy, recurrent infections, sepsis (which affects the liver directly and indirectly), and components of TPN. — Paul Wales (clinical) [Ep 2 · 5:41](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=341)
- The term 'intestinal rehabilitation program' was coined in the year 2000. — Paul Wales (clinical) [Ep 2 · 6:08](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=368)
- Intestinal rehabilitation teams improve outcomes through integration of care, improved communication, and better continuity. — Paul Wales (clinical) [Ep 2 · 6:14](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=374)
- Literature shows that intestinal rehabilitation programs improve survival related to liver dysfunction, decrease septic episodes, reduce central line complications, reduce ICU admissions, and enable patients listed for transplant to come off the list due to improved status. — Paul Wales (epidemiological) [Ep 2 · 7:25](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=445)
- Mortality in intestinal failure has decreased with intestinal rehabilitation programs. — Paul Wales (epidemiological) [Ep 2 · 7:44](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=464)
- Lipids in parenteral nutrition are a source of essential fatty acids, a non-protein energy source important for growth, and fatty acids have a major role in cellular pathways. — Paul Wales (clinical) [Ep 2 · 8:02](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=482)
- Historically, most lipid emulsions in North America are soybean-based with high phytosterol content, high omega-6 long chain polyunsaturated fatty acid content, and low antioxidant content. — Paul Wales (clinical) [Ep 2 · 8:15](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=495)
- Prolonged soybean-based lipid exposure is associated with deterioration of liver dysfunction, specifically cholestasis. — Paul Wales (clinical) [Ep 2 · 8:31](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=511)
- For every day an infant is exposed to soybean lipid dosed at greater than 2.5 grams per kilogram per day, there is a 3% increase in the odds ratio of developing advanced liver disease. — Paul Wales (epidemiological) [Ep 2 · 8:51](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=531)
- First-generation lipid emulsions were soybean-based lipids rich in omega-6 polyunsaturated fatty acids, exemplified by Intralipid, which has been in use for 40 years. — Paul Wales (clinical) [Ep 2 · 9:15](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=555)
- Third-generation lipids attempt to reduce the omega-6 component and change the omega-6 to omega-3 ratio by adding omega-3 lipids. — Paul Wales (clinical) [Ep 2 · 9:32](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=572)
- Omega-6 lipids are metabolized to arachidonic acid, which produces leukotrienes and prostaglandins with a more pro-inflammatory profile. — Paul Wales (clinical) [Ep 2 · 9:52](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=592)
- Omega-3 lipids are metabolized through EPA and DHA and lead to production of cytokines with a less inflammatory profile. — Paul Wales (clinical) [Ep 2 · 10:02](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=602)
- Omega-3 lipids improve bile flow by decreasing lithogenicity of bile, decreasing steatosis, and stimulating improved beta oxidation and clearance. — Paul Wales (clinical) [Ep 2 · 10:16](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=616)
- The main goals of improving lipids in parenteral nutrition are lipid minimization and change in composition. — Paul Wales (clinical) [Ep 2 · 10:33](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=633)
- Literature dating back decades shows that restricting exposure to soybean lipid improves cholestasis when lipid is dosed at 1 gram per kilogram per day or less. — Paul Wales (clinical) [Ep 2 · 10:42](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=642)
- In pre-term babies, fat is important for growth, especially for neurocognitive development, and there is risk of essential fatty acid deficiency if lipid dosing is restricted too much. — Paul Wales (clinical) [Ep 2 · 11:00](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=660)
- DHA and arachidonic acid are important for retinal and brain development. — Paul Wales (clinical) [Ep 2 · 11:22](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=682)
- None of the current lipid emulsions were designed for premature babies; they were all designed for adults in critical care settings. — Paul Wales (clinical) [Ep 2 · 11:26](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=686)
- Dr. Wales' team is currently working with industry to create a lipid emulsion specifically tailored to pre-term babies with higher arachidonic acid content. — Paul Wales (clinical) [Ep 2 · 11:39](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=699)
- Central lines are the lifeline for intestinal failure patients, and without venous access, families cannot be supported. — Paul Wales (clinical) [Ep 2 · 12:03](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=723)
- Central lines carry risks of complications including infections, blockages, thrombosis, and breakage. — Paul Wales (clinical) [Ep 2 · 12:11](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=731)
- There are approximately 240,000 central line-associated bloodstream infections (CLABSIs) in the United States annually. — Paul Wales (epidemiological) [Ep 2 · 12:24](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=744)
- The cost of one CLABSI is approximately $30,000, totaling about $2 billion per year nationwide. — Paul Wales (epidemiological) [Ep 2 · 12:31](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=751)
- When ethanol became too expensive and difficult to obtain, Dr. Wales' team pivoted to 4% tetrasodium EDTA (Kitelock), which is antithrombolytic, anti-fibrinolytic, and antimicrobial. — Paul Wales (clinical) [Ep 2 · 12:48](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=768)
- Kitelock satisfies three criteria important for a good lock solution: addressing organisms, clot thrombosis, and biofilm. — Paul Wales (clinical) [Ep 2 · 12:59](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=779)
- Kitelock is licensed in Europe and Australia but not available in the United States. — Paul Wales (clinical) [Ep 2 · 13:24](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=804)
- A multi-center randomized trial of Kitelock versus Heparin launched four weeks ago and is actively recruiting patients, with results expected within the next year. — Paul Wales (clinical) [Ep 2 · 13:30](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=810)
- In short bowel syndrome, there are three anatomical subtypes: type one is high output jejunostomy; type two involves loss of distal small bowel (ileum) and part of colon with small bowel-colonic anastomosis; type three involves loss of mid small bowel with retained ileum and intact colon. — Paul Wales (clinical) [Ep 2 · 13:58](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=838)
- The most common anatomical subtype of short bowel syndrome in pediatrics is type two. — Paul Wales (epidemiological) [Ep 2 · 14:27](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=867)
- Type one and type two short bowel syndrome patients struggle because they lack an ileum. — Paul Wales (clinical) [Ep 2 · 14:32](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=872)
- Native GLP-2 hormone has a half-life of seven minutes, making it impractical for clinical use. — Paul Wales (clinical) [Ep 2 · 14:53](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=893)
- Teduglutide is a GLP-2 analog with one amino acid alteration that has a half-life of two hours and is given once daily by subcutaneous injection. — Paul Wales (clinical) [Ep 2 · 14:58](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=898)
- In a multi-center phase three study, patients who received Teduglutide showed a 40% reduction in TPN fluid and calorie requirements over a six-month period. — Paul Wales (epidemiological) [Ep 2 · 15:23](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=923)
- 70% of patients who received Teduglutide achieved the study endpoint of a 20% reduction in TPN requirements. — Paul Wales (epidemiological) [Ep 2 · 15:32](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=932)
- Teduglutide is licensed for children greater than one year of age. — Paul Wales (guideline) [Ep 2 · 15:48](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=948)
- Teduglutide has enabled children with very extreme anatomy to get off TPN. — Paul Wales (clinical) [Ep 2 · 15:51](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=951)
- Apraglutide is another GLP-2 analog with a longer half-life that can be given once weekly and is currently being studied. — Paul Wales (clinical) [Ep 2 · 16:02](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=962)
- Apraglutide works better than Teduglutide, producing more bowel lengthening. — Paul Wales (clinical) [Ep 2 · 16:09](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=969)
- These interventions (optimizing lipids, preventing line infections, and using peptide therapies) have led to a decrease in transplantations since 2008, largely because of the successes of intestinal rehabilitation. — Paul Wales (epidemiological) [Ep 2 · 16:37](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=997)
- The outcomes of intestinal transplant at five years are approximately 65%. — Paul Wales (epidemiological) [Ep 2 · 16:46](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=1006)
- The goal is to avoid transplant and lifelong immunosuppression whenever possible. — Paul Wales (opinion) [Ep 2 · 16:49](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=1009)
- Intestinal failure is defined as reduction of functional intestinal mass below that which can sustain life, resulting in dependence on supplemental parenteral support for a minimum of 60 days within a 74 consecutive day interval. — Stephanie Oliveira (clinical) [Ep 1 · 0:26](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=26)
- More than 50% of intestinal failure cases are related to short bowel syndrome, with additional cases from mucosal enteropathies and dysmotility disorders. — Stephanie Oliveira (epidemiological) [Ep 1 · 0:43](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=43)
- Most short bowel syndrome cases in pediatrics occur during the neonatal period from gastroschisis, necrotizing enterocolitis, bowel atresia, and intestinal volvulus. — Stephanie Oliveira (clinical) [Ep 1 · 0:55](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=55)
- The field is now focusing on neurocognitive outcomes, quality of life, and caregiver burnout as more children survive intestinal failure. — Stephanie Oliveira (opinion) [Ep 1 · 1:18](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=78)
- The cause of chronic intestinal inflammation in intestinal failure survivors is not known. — Stephanie Oliveira (clinical) [Ep 1 · 1:37](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=97)
- The goal of intestinal rehabilitation is to optimize intestinal function and adaptation before the development of irreversible complications. — Stephanie Oliveira (clinical) [Ep 1 · 2:07](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=127)
- Intestinal adaptation is an active compensatory process that starts immediately after bowel resection. — Stephanie Oliveira (clinical) [Ep 1 · 2:30](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=150)
- Food, bacteria, and hormones in the gut enhance intestinal adaptation. — Stephanie Oliveira (clinical) [Ep 1 · 2:42](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=162)
- Enteral autonomy is defined as getting off TPN with all nutrition going through the gut, either by mouth or by feeding tube. — Stephanie Oliveira (clinical) [Ep 1 · 3:11](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=191)
- From 2010 to 2015, a repeat study with double the number of patients showed approximately 50% still reached enteral autonomy, but transplant rates and death rates significantly decreased. — Stephanie Oliveira (epidemiological) [Ep 1 · 3:33](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=213)
- Establishment of multidisciplinary teams is one factor that changed outcomes in intestinal failure. — Stephanie Oliveira (clinical) [Ep 1 · 3:46](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=226)
- Predictors of reaching enteral autonomy include greater residual bowel length, follow-up at an institution with an intestinal rehabilitation program, and no STEP procedure. — Stephanie Oliveira (clinical) [Ep 1 · 4:03](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=243)
- Patients should be referred to intestinal rehabilitation programs when not making progress, on prolonged TPN, or have significant comorbidities—sooner rather than later. — Stephanie Oliveira (guideline) [Ep 1 · 4:19](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=259)
- Patients should not be referred to intestinal rehabilitation programs when several complications have already occurred and transplant is the only remaining option. — Stephanie Oliveira (guideline) [Ep 1 · 4:39](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=279)
- Intestinal transplantation is considered when irreversible complications occur, but the number of transplants has significantly decreased over the last several decades. — Stephanie Oliveira (clinical) [Ep 1 · 4:49](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=289)
- Liver disease in intestinal failure ranges from mild cholestasis to profound steatosis (in older children/adolescents/adults), with ongoing inflammation, fibrosis, and ultimately cirrhosis leading to death or transplantation. — Paul Wales (clinical) [Ep 1 · 5:23](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=323)
- Risk factors for intestinal failure-associated liver disease include prematurity, lack of enteral feeding, inability to feed due to anatomy, recurrent infections/sepsis, and components of TPN. — Paul Wales (clinical) [Ep 1 · 5:41](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=341)
- The term 'intestinal rehabilitation program' was coined in the year 2000. — Paul Wales (clinical) [Ep 1 · 6:08](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=368)
- Intestinal rehabilitation teams improve outcomes through integration of care, improved communication, and better continuity. — Paul Wales (clinical) [Ep 1 · 6:12](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=372)
- Literature shows intestinal rehabilitation programs improve survival related to liver dysfunction, decrease septic episodes, reduce central line complications, reduce ICU admissions, and allow patients listed for transplant to come off the list due to improved status. — Paul Wales (epidemiological) [Ep 1 · 7:25](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=445)
- Lipids in parenteral nutrition are a source of essential fatty acids, a non-protein energy source important for growth, and fatty acids have a major role in cellular pathways. — Paul Wales (clinical) [Ep 1 · 8:02](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=482)
- Historically, most lipid emulsions in North America are soybean-based with high phytosterol content, high omega-6 long-chain polyunsaturated fatty acid content, and low antioxidant content. — Paul Wales (clinical) [Ep 1 · 8:15](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=495)
- Prolonged soybean-based lipid exposure is associated with deterioration of liver dysfunction, specifically cholestasis. — Paul Wales (clinical) [Ep 1 · 8:31](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=511)
- For every day an infant is exposed to soybean lipid dosed at greater than 2.5 g/kg/day, there is a 3% increase in the odds ratio of developing advanced liver disease. — Paul Wales (clinical) [Ep 1 · 8:51](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=531)
- First-generation lipid emulsions were soybean-based, rich in omega-6 PUFA (intralipid), available for 40 years. — Paul Wales (clinical) [Ep 1 · 9:15](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=555)
- Third-generation lipid emulsions reduce omega-6 and change the omega-6 to omega-3 ratio by adding omega-3 lipids. — Paul Wales (clinical) [Ep 1 · 9:32](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=572)
- Omega-6 lipids are metabolized to arachidonic acid, which produces leukotrienes and prostaglandins with a more pro-inflammatory profile. — Paul Wales (clinical) [Ep 1 · 9:51](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=591)
- Omega-3 lipids are metabolized through EPA and DHA and lead to production of cytokines with a less inflammatory profile. — Paul Wales (clinical) [Ep 1 · 10:01](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=601)
- Omega-3 lipids improve bile flow by decreasing lithogenicity of bile, decreasing steatosis, stimulating improved beta-oxidation and clearance, lowering oxidative stress, and supporting immune function. — Paul Wales (clinical) [Ep 1 · 10:15](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=615)
- Literature dating back decades shows that restricting soybean lipid exposure to 1 g/kg/day or less improves cholestasis. — Paul Wales (clinical) [Ep 1 · 10:42](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=642)
- In preterm babies, fat is important for growth, especially neurocognitive development, and there is risk of essential fatty acid deficiency if lipid dosing is restricted too much. — Paul Wales (clinical) [Ep 1 · 11:00](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=660)
- DHA and arachidonic acid are important for retinal and brain development. — Paul Wales (clinical) [Ep 1 · 11:22](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=682)
- None of the current lipid emulsions were designed for premature babies; they were all designed for adults in critical care settings. — Paul Wales (clinical) [Ep 1 · 11:26](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=686)
- Dr. Wales's team is working with industry to create a lipid emulsion specifically tailored to preterm babies with higher arachidonic acid content. — Paul Wales (clinical) [Ep 1 · 11:38](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=698)
- Central lines are the lifeline for intestinal failure patients, and without venous access, families cannot be supported. — Paul Wales (clinical) [Ep 1 · 12:03](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=723)
- Central lines carry risks of complications including infections, blockages, thrombosis, and breakage. — Paul Wales (clinical) [Ep 1 · 12:10](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=730)
- In the United States, there are approximately 240,000 central line-associated bloodstream infections (CLABSIs) annually, costing about $30,000 per infection, totaling approximately $2 billion per year nationwide. — Paul Wales (epidemiological) [Ep 1 · 12:24](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=744)
- 4% tetrasodium EDTA (Kitelock) is an antithrombotic, anti-fibrinolytic, and antimicrobial lock solution that satisfies all three criteria important for a good lock solution. — Paul Wales (clinical) [Ep 1 · 12:48](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=768)
- Kitelock is licensed in Europe and Australia but not available in the United States. — Paul Wales (clinical) [Ep 1 · 13:23](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=803)
- A multi-center randomized trial of Kitelock versus heparin launched 4 weeks ago and is actively recruiting patients, with results expected within the next year. — Paul Wales (clinical) [Ep 1 · 13:29](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=809)
- In short bowel syndrome, there are three anatomical subtypes: Type 1 (high jejunostomy), Type 2 (loss of distal small bowel/ileum and part of colon with small bowel-colonic anastomosis), and Type 3 (loss of mid-small bowel with retained ileum and intact colon). — Paul Wales (clinical) [Ep 1 · 13:58](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=838)
- Type 2 short bowel syndrome is the most common anatomical subtype in pediatrics. — Paul Wales (epidemiological) [Ep 1 · 14:26](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=866)
- Type 1 and Type 2 short bowel syndrome patients struggle because they lack an ileum. — Paul Wales (clinical) [Ep 1 · 14:31](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=871)
- Native GLP-2 hormone has a half-life of 7 minutes, making it impractical for clinical use. — Paul Wales (clinical) [Ep 1 · 14:53](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=893)
- Teduglutide is a GLP-2 analog with one amino acid alteration that has a half-life of 2 hours and is given once daily by subcutaneous injection. — Paul Wales (clinical) [Ep 1 · 15:00](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=900)
- Patients receiving teduglutide show a 40% reduction in TPN fluid and calorie requirements over a six-month period. — Paul Wales (clinical) [Ep 1 · 15:23](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=923)
- 70% of patients receiving teduglutide achieved the study endpoint of a 20% reduction in TPN requirements. — Paul Wales (clinical) [Ep 1 · 15:32](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=932)
- Teduglutide is licensed for children greater than 1 year of age. — Paul Wales (guideline) [Ep 1 · 15:48](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=948)
- Teduglutide has enabled children with very extreme anatomy to get off TPN. — Paul Wales (clinical) [Ep 1 · 15:50](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=950)
- Apraglutide is another GLP-2 analog with a longer half-life that can be given once weekly and is currently being studied. — Paul Wales (clinical) [Ep 1 · 16:02](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=962)
- Apraglutide works even better than teduglutide, producing more bowel lengthening. — Paul Wales (clinical) [Ep 1 · 16:10](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=970)
- These interventions (lipid optimization, central line protection, GLP-2 analogs) have led to a decrease in transplantation since 2008, largely because of the successes of intestinal rehabilitation. — Paul Wales (clinical) [Ep 1 · 16:36](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=996)
- Five-year outcomes of intestinal transplant are approximately 65%. — Paul Wales (epidemiological) [Ep 1 · 16:41](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=1001)
- The goal is to avoid transplant and lifelong immunosuppression whenever possible. — Paul Wales (opinion) [Ep 1 · 16:49](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=1009)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Chronic intestinal inflammation resembling Crohn's disease is now being observed in intestinal failure patients, requiring management with inflammatory bowel disease therapies like biologics. — Lizzy Lee summarizing the discussion [Ep 3 · 1:24](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=84)
- A 2012 Pediatric Intestinal Failure Consortium study showed 50% of intestinal failure patients achieved enteral autonomy, while 25% either died or had intestinal transplant. — Lizzy Lee summarizing the discussion [Ep 3 · 3:19](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=199)
- Studies from Canada, Michigan, and Spain show that multidisciplinary intestinal rehabilitation teams improve survival. — Lizzy Lee summarizing the discussion [Ep 3 · 3:51](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=231)
- Second-generation lipid emulsions attempt to reduce omega-6 exposure by diluting the soybean component. — Lizzy Lee summarizing the discussion [Ep 3 · 9:26](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=566)
- Omega-6 fatty acids promote inflammation while omega-3 fatty acids lead to a more anti-inflammatory response. — Lizzy Lee summarizing the discussion [Ep 3 · 9:43](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=583)
- In utero, babies receive significant amounts of DHA and arachidonic acid through the placenta, but standard lipid emulsions in TPN fall short of providing these. — Lizzy Lee summarizing the discussion [Ep 3 · 11:12](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=672)
- Kitelock addresses three issues of central line complications: organisms, clot/thrombosis, and biofilm. — Lizzy Lee summarizing the discussion [Ep 3 · 13:09](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=789)
- Patients with Type 3 short bowel syndrome have the best prognosis because they still have residual ileum. — Lizzy Lee summarizing the discussion [Ep 3 · 14:19](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=859)
- The ileum is where GLP-2 is naturally produced. — Lizzy Lee summarizing the discussion [Ep 3 · 14:36](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=876)
- Without an ileum, infants cannot generate the necessary GLP-2 hormone surge to drive their own intestinal adaptation. — Lizzy Lee summarizing the discussion [Ep 3 · 14:39](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=879)
- Children have much greater adaptive potential than adults because of their inherent gut growth capacity. — Lizzy Lee summarizing the discussion [Ep 3 · 16:54](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=1014)
- The proportion of children reaching enteral autonomy has improved over the past 20 years. — Lizzy Lee summarizing the discussion [Ep 3 · 17:00](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=1020)
- Controlling liver disease buys time for intestinal adaptation. — Lizzy Lee summarizing the discussion [Ep 3 · 17:06](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-o-13892?t=1026)
- Chronic intestinal inflammation resembling Crohn's disease is now being observed in intestinal failure patients, requiring management with inflammatory bowel disease therapies like biologics. — Lizzy Lee summarizing the discussion [Ep 2 · 1:24](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=84)
- A 2012 Pediatric Intestinal Failure Consortium study showed 50% of intestinal failure patients achieved enteral autonomy, while 25% either died or had intestinal transplant. — Lizzy Lee summarizing the discussion [Ep 2 · 3:19](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=199)
- Studies from Canada, Michigan, and Spain show that multidisciplinary intestinal rehabilitation teams improved survival. — Lizzy Lee summarizing the discussion [Ep 2 · 3:51](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=231)
- Second-generation lipid emulsions attempted to reduce omega-6 exposure and dilute the soybean component. — Lizzy Lee summarizing the discussion [Ep 2 · 9:26](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=566)
- Omega-6 fatty acids tend to promote inflammation while omega-3s lead to a more anti-inflammatory response. — Lizzy Lee summarizing the discussion [Ep 2 · 9:43](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=583)
- Omega-3 lipids lower oxidative stress and support immune function. — Lizzy Lee summarizing the discussion [Ep 2 · 10:26](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=626)
- In utero, babies receive significant amounts of DHA and arachidonic acid through the placenta, but standard lipid emulsions in TPN fall short of providing these. — Lizzy Lee summarizing the discussion [Ep 2 · 11:12](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=672)
- Patients with type three short bowel syndrome have the best prognosis because they still have residual ileum. — Lizzy Lee summarizing the discussion [Ep 2 · 14:19](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=859)
- The ileum is where GLP-2 is naturally produced, so without it, infants cannot generate the necessary hormone surge to drive their own intestinal adaptation. — Lizzy Lee summarizing the discussion [Ep 2 · 14:36](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=876)
- Children have much greater adaptive potential than adults because of their inherent gut growth capacity. — Lizzy Lee summarizing the discussion [Ep 2 · 16:54](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=1014)
- The proportion of children reaching enteral autonomy has improved over the past 20 years. — Lizzy Lee summarizing the discussion [Ep 2 · 17:00](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=1020)
- If liver disease can be controlled, time is bought for intestinal adaptation. — Lizzy Lee summarizing the discussion [Ep 2 · 17:07](https://library.globalcastmd.com/watch/pediatric-intestinal-failure-management-and-rehabilitation-strategies-16668?t=1027)
- Chronic intestinal inflammation resembling Crohn's disease is now seen in intestinal failure patients and requires management with inflammatory bowel disease therapies like biologics. — Lizzy Lee summarizing the discussion [Ep 1 · 1:24](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=84)
- A 2012 Pediatric Intestinal Failure Consortium study showed 50% of intestinal failure patients achieved enteral autonomy, while 25% either died or had intestinal transplant. — Lizzy Lee summarizing a resource [Ep 1 · 3:19](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=199)
- Studies from Canada, Michigan, and Spain show that multidisciplinary intestinal rehabilitation teams improve survival. — Lizzy Lee summarizing the discussion [Ep 1 · 3:51](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=231)
- Second-generation lipid emulsions attempt to reduce omega-6 exposure by diluting the soybean component. — Lizzy Lee summarizing the discussion [Ep 1 · 9:26](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=566)
- Omega-6 fatty acids promote inflammation while omega-3s lead to a more anti-inflammatory response. — Lizzy Lee summarizing the discussion [Ep 1 · 9:43](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=583)
- In utero, babies receive significant amounts of DHA and arachidonic acid through the placenta, but standard lipid emulsions in TPN fall short of this. — Lizzy Lee summarizing the discussion [Ep 1 · 11:12](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=672)
- Patients with Type 3 short bowel syndrome have the best prognosis because they retain residual ileum. — Lizzy Lee summarizing the discussion [Ep 1 · 14:19](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=859)
- The ileum is where GLP-2 is naturally produced, so infants without it cannot generate the necessary hormone surge to drive their own intestinal adaptation. — Lizzy Lee summarizing the discussion [Ep 1 · 14:36](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=876)
- Children have greater adaptive potential than adults because of their inherent gut growth capacity. — Lizzy Lee summarizing the discussion [Ep 1 · 16:54](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=1014)
- The proportion of children reaching enteral autonomy has improved over the past 20 years. — Lizzy Lee summarizing the discussion [Ep 1 · 17:00](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=1020)
- Controlling liver disease buys time for intestinal adaptation. — Lizzy Lee summarizing the discussion [Ep 1 · 17:06](https://library.globalcastmd.com/watch/advances-in-pediatric-intestinal-failure-management-and-rehabilitation-16667?t=1026)

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