One thing I just want to say about oral feeding is that even in the scenario where it's really non-nutritive. I think it's important for people to sort of look at that oral feeding, not so much as an internal nutrition perspective, but more of a skill development perspective that they never learn how to eat by mouth and suck and swallow and process, then they won't eat solids later when you want them to, and you're stuck basically with tube feeding on an older child.
One thing I just want to say about oral feeding is that even in the scenario where it's really non-nutritive. I think it's important for people to sort of look at that oral feeding, not so much as an internal nutrition perspective, but more of a skill development perspective that they never learn how to eat by mouth and suck and swallow and process, then they won't eat solids later when you want them to, and you're stuck basically with tube feeding on an older child.
an intestinal rehabilitation program, as we defined also in these Aspen guidelines that just came out, is a multidisciplinary or interdisciplinary collaborative patient care paradigm that that brings coordinated care for children with intestinal failure through comprehensive management of Their specialized nutrition and other associated needs that they have.
an intestinal rehabilitation program, as we defined also in these Aspen guidelines that just came out, is a multidisciplinary or interdisciplinary collaborative patient care paradigm that that brings coordinated care for children with intestinal failure through comprehensive management of Their specialized nutrition and other associated needs that they have.
an intestinal rehabilitation program, as we defined also in these Aspen guidelines that just came out, is a multidisciplinary or interdisciplinary collaborative patient care paradigm that that brings coordinated care for children with intestinal failure through comprehensive management of Their specialized nutrition and other associated needs that they have.
an intestinal rehabilitation program, as we defined also in these Aspen guidelines that just came out, is a multidisciplinary or interdisciplinary collaborative patient care paradigm that that brings coordinated care for children with intestinal failure through comprehensive management of Their specialized nutrition and other associated needs that they have.
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
▶Ep 23 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program.↗
▶Ep 23 · 2:03
quoteIt it's, it's really a functional problem. Essentially, when someone's gut for whatever the diagnosis, whatever the reason, their gut function is insufficient to absorb enough nutrients, fluids, calories to support survival and in the in the case of children, growth, which is a big distinction between adults and children.↗
▶Ep 23 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 23 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm providing coordinated care for children with intestinal failure through comprehensive management of specialized nutrition and associated needs↗
▶Ep 23 · 3:03
quotean intestinal rehabilitation program, as we defined also in these Aspen guidelines that just came out, is a multidisciplinary or interdisciplinary collaborative patient care paradigm that that brings coordinated care for children with intestinal failure through comprehensive management of Their specialized nutrition and other associated needs that they have.↗
▶Ep 23 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management.↗
▶Ep 23 · 4:39
quotePatients that are gonna come to intestinal rehab program have intestinal failure, and we can divide the causes of intestinal failure into three categories.↗
▶Ep 23 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 23 · 4:50
quoteThere's short bowel syndrome, which by far is the most common category in pediatric patients with intestinal failure↗
▶Ep 23 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 23 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis cause short bowel syndrome↗
▶Ep 23 · 5:45
clinicalMotility disorders occur when abnormalities of the intestinal muscle itself or the nerves that control that muscle prevent coordinated movement of food and stool↗
▶Ep 23 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle.↗
▶Ep 23 · 6:10
clinicalChildren with motility disorders are dependent on intravenous support↗
▶Ep 23 · 6:17
clinicalEnteropathies or congenital diarrheas are conditions where the patient has all of their bowel but the mucosal lining that digests and absorbs does not work↗
▶Ep 23 · 6:17
quotethese are conditions where the patient has all of their bowel, but the mucosa, the inside lining that, that absorbs, uh, digests and absorbs doesn't work.↗
▶Ep 23 · 7:11
quoteThe reason it's important to at least identify these three categories is that some patients will have elements of 12, or 3 of the categories, the way they present.↗
▶Ep 23 · 7:11
clinicalSome patients will have elements of one, two, or all three categories of intestinal failure↗
▶Ep 23 · 7:45
epidemiologicalMost intestinal failure patients are infants or babies, but some older kids develop intestinal failure↗
▶Ep 23 · 7:56
clinicalInflammatory bowel disease or Crohn's disease can lead to gut loss and intestinal failure in older patients↗
▶Ep 23 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 23 · 12:46
quoteBut now what we're seeing is we have kids that have developed chronic comorbidities, that comorbidities that never, we didn't really see to the same extent because they didn't live long enough.↗
▶Ep 23 · 12:46
clinicalLong-term survivors now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
▶Ep 24 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program↗
▶Ep 24 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 24 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and associated needs↗
▶Ep 24 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management↗
▶Ep 24 · 3:55
opinionIntestinal rehabilitation streamlines care and improves communication with families and between care providers and team members↗
▶Ep 24 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 24 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 24 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis can cause short bowel syndrome↗
▶Ep 24 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle↗
▶Ep 24 · 5:45
clinicalMotility disorders occur when the bowel is unable to push contents through in a coordinated way due to abnormalities of the muscle itself or the nerves that control that muscle↗
▶Ep 24 · 6:17
clinicalCongenital enteropathies are conditions where the patient has all of their bowel but the mucosa does not work, leading to hypersecretion and profuse fluid losses↗
▶Ep 24 · 7:11
clinicalSome patients will have elements of two or three categories of intestinal failure in the way they present↗
▶Ep 24 · 7:56
clinicalOlder pediatric patients can develop intestinal failure from inflammatory bowel disease or Crohn's disease where they have lost gut as a result of complications↗
▶Ep 24 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 24 · 12:46
clinicalChildren with intestinal failure who survive long-term now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
▶Ep 112 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program.↗
▶Ep 112 · 2:03
quoteIt it's, it's really a functional problem. Essentially, when someone's gut for whatever the diagnosis, whatever the reason, their gut function is insufficient to absorb enough nutrients, fluids, calories to support survival and in the in the case of children, growth, which is a big distinction between adults and children.↗
▶Ep 112 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 112 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm providing coordinated care for children with intestinal failure through comprehensive management of specialized nutrition and associated needs↗
▶Ep 112 · 3:03
quotean intestinal rehabilitation program, as we defined also in these Aspen guidelines that just came out, is a multidisciplinary or interdisciplinary collaborative patient care paradigm that that brings coordinated care for children with intestinal failure through comprehensive management of Their specialized nutrition and other associated needs that they have.↗
▶Ep 112 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management.↗
▶Ep 112 · 4:39
quotePatients that are gonna come to intestinal rehab program have intestinal failure, and we can divide the causes of intestinal failure into three categories.↗
▶Ep 112 · 4:50
quoteThere's short bowel syndrome, which by far is the most common category in pediatric patients with intestinal failure↗
▶Ep 112 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 112 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 112 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis cause short bowel syndrome↗
▶Ep 112 · 5:45
clinicalMotility disorders occur when abnormalities of the intestinal muscle itself or the nerves that control that muscle prevent coordinated movement of food and stool↗
▶Ep 112 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle.↗
▶Ep 112 · 6:10
clinicalChildren with motility disorders are dependent on intravenous support↗
▶Ep 112 · 6:17
clinicalEnteropathies or congenital diarrheas are conditions where the patient has all of their bowel but the mucosal lining that digests and absorbs does not work↗
▶Ep 112 · 6:17
quotethese are conditions where the patient has all of their bowel, but the mucosa, the inside lining that, that absorbs, uh, digests and absorbs doesn't work.↗
▶Ep 112 · 7:11
quoteThe reason it's important to at least identify these three categories is that some patients will have elements of 12, or 3 of the categories, the way they present.↗
▶Ep 112 · 7:11
clinicalSome patients will have elements of one, two, or all three categories of intestinal failure↗
▶Ep 112 · 7:45
epidemiologicalMost intestinal failure patients are infants or babies, but some older kids develop intestinal failure↗
▶Ep 112 · 7:56
clinicalInflammatory bowel disease or Crohn's disease can lead to gut loss and intestinal failure in older patients↗
▶Ep 112 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 112 · 12:46
clinicalLong-term survivors now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
▶Ep 112 · 12:46
quoteBut now what we're seeing is we have kids that have developed chronic comorbidities, that comorbidities that never, we didn't really see to the same extent because they didn't live long enough.↗
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
▶Ep 113 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program↗
▶Ep 113 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 113 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and associated needs↗
▶Ep 113 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management↗
▶Ep 113 · 3:55
opinionIntestinal rehabilitation streamlines care and improves communication with families and between care providers and team members↗
▶Ep 113 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 113 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 113 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis can cause short bowel syndrome↗
▶Ep 113 · 5:45
clinicalMotility disorders occur when the bowel is unable to push contents through in a coordinated way due to abnormalities of the muscle itself or the nerves that control that muscle↗
▶Ep 113 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle↗
▶Ep 113 · 6:17
clinicalCongenital enteropathies are conditions where the patient has all of their bowel but the mucosa does not work, leading to hypersecretion and profuse fluid losses↗
▶Ep 113 · 7:11
clinicalSome patients will have elements of two or three categories of intestinal failure in the way they present↗
▶Ep 113 · 7:56
clinicalOlder pediatric patients can develop intestinal failure from inflammatory bowel disease or Crohn's disease where they have lost gut as a result of complications↗
▶Ep 113 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 113 · 12:46
clinicalChildren with intestinal failure who survive long-term now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
▶Ep 34 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program.↗
▶Ep 34 · 2:03
quoteIt it's, it's really a functional problem. Essentially, when someone's gut for whatever the diagnosis, whatever the reason, their gut function is insufficient to absorb enough nutrients, fluids, calories to support survival and in the in the case of children, growth, which is a big distinction between adults and children.↗
▶Ep 34 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 34 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm providing coordinated care for children with intestinal failure through comprehensive management of specialized nutrition and associated needs↗
▶Ep 34 · 3:03
quotean intestinal rehabilitation program, as we defined also in these Aspen guidelines that just came out, is a multidisciplinary or interdisciplinary collaborative patient care paradigm that that brings coordinated care for children with intestinal failure through comprehensive management of Their specialized nutrition and other associated needs that they have.↗
▶Ep 34 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management.↗
▶Ep 34 · 4:39
quotePatients that are gonna come to intestinal rehab program have intestinal failure, and we can divide the causes of intestinal failure into three categories.↗
▶Ep 34 · 4:50
quoteThere's short bowel syndrome, which by far is the most common category in pediatric patients with intestinal failure↗
▶Ep 34 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 34 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 34 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis cause short bowel syndrome↗
▶Ep 34 · 5:45
clinicalMotility disorders occur when abnormalities of the intestinal muscle itself or the nerves that control that muscle prevent coordinated movement of food and stool↗
▶Ep 34 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle.↗
▶Ep 34 · 6:10
clinicalChildren with motility disorders are dependent on intravenous support↗
▶Ep 34 · 6:17
clinicalEnteropathies or congenital diarrheas are conditions where the patient has all of their bowel but the mucosal lining that digests and absorbs does not work↗
▶Ep 34 · 6:17
quotethese are conditions where the patient has all of their bowel, but the mucosa, the inside lining that, that absorbs, uh, digests and absorbs doesn't work.↗
▶Ep 34 · 7:11
quoteThe reason it's important to at least identify these three categories is that some patients will have elements of 12, or 3 of the categories, the way they present.↗
▶Ep 34 · 7:11
clinicalSome patients will have elements of one, two, or all three categories of intestinal failure↗
▶Ep 34 · 7:45
epidemiologicalMost intestinal failure patients are infants or babies, but some older kids develop intestinal failure↗
▶Ep 34 · 7:56
clinicalInflammatory bowel disease or Crohn's disease can lead to gut loss and intestinal failure in older patients↗
▶Ep 34 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 34 · 12:46
clinicalLong-term survivors now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
▶Ep 34 · 12:46
quoteBut now what we're seeing is we have kids that have developed chronic comorbidities, that comorbidities that never, we didn't really see to the same extent because they didn't live long enough.↗
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
▶Ep 35 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program↗
▶Ep 35 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 35 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and associated needs↗
▶Ep 35 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management↗
▶Ep 35 · 3:55
opinionIntestinal rehabilitation streamlines care and improves communication with families and between care providers and team members↗
▶Ep 35 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 35 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 35 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis can cause short bowel syndrome↗
▶Ep 35 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle↗
▶Ep 35 · 5:45
clinicalMotility disorders occur when the bowel is unable to push contents through in a coordinated way due to abnormalities of the muscle itself or the nerves that control that muscle↗
▶Ep 35 · 6:17
clinicalCongenital enteropathies are conditions where the patient has all of their bowel but the mucosa does not work, leading to hypersecretion and profuse fluid losses↗
▶Ep 35 · 7:11
clinicalSome patients will have elements of two or three categories of intestinal failure in the way they present↗
▶Ep 35 · 7:56
clinicalOlder pediatric patients can develop intestinal failure from inflammatory bowel disease or Crohn's disease where they have lost gut as a result of complications↗
▶Ep 35 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 35 · 12:46
clinicalChildren with intestinal failure who survive long-term now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1
▶Ep 36 · 1:17
opinionThe outlook has changed and what's gone hand in hand with that is a bit more of an aggressive approach to surgical resection↗
▶Ep 36 · 1:39
clinicalComorbidities such as neurologic status, pulmonary function, cardiac function, or significant genetic or chromosomal anomaly factor into decision making about how to proceed↗
▶Ep 36 · 2:38
guidelineIntestinal transplant is not experimental therapy but part of the continuum of therapy for a child with short bowel syndrome↗
▶Ep 36 · 2:52
quoteIs it ethically appropriate to open and close a baby when you know that you could remove all of their intestines?↗
▶Ep 36 · 4:31
clinicalIn the very acute time after bowel infarction, the risk is dying of sepsis and multi-organ failure↗
▶Ep 36 · 4:44
clinicalIntermediate and longer term complications include intestinal failure associated liver disease, recurrent sepsis, or line problems↗
▶Ep 36 · 5:02
epidemiologicalSuccess in the last two decades is because we're way better at preventing sepsis and liver disease↗
▶Ep 36 · 6:14
clinicalBabies born with duodenal atresia or very proximal jejunal atresia are born with elevated direct or conjugated bilirubins↗
▶Ep 36 · 6:42
clinicalFactors affecting liver function include prematurity, sepsis, choice of TPN, and presence or absence of enteral nutrition↗
▶Ep 36 · 12:15
quoteLet the baby decide, you know, some may continue to spiral because of just overwhelming sepsis and may not make it, but many, many will.↗
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
▶Ep 8 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program.↗
▶Ep 8 · 2:03
quoteIt it's, it's really a functional problem. Essentially, when someone's gut for whatever the diagnosis, whatever the reason, their gut function is insufficient to absorb enough nutrients, fluids, calories to support survival and in the in the case of children, growth, which is a big distinction between adults and children.↗
▶Ep 8 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 8 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm providing coordinated care for children with intestinal failure through comprehensive management of specialized nutrition and associated needs↗
▶Ep 8 · 3:03
quotean intestinal rehabilitation program, as we defined also in these Aspen guidelines that just came out, is a multidisciplinary or interdisciplinary collaborative patient care paradigm that that brings coordinated care for children with intestinal failure through comprehensive management of Their specialized nutrition and other associated needs that they have.↗
▶Ep 8 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management.↗
▶Ep 8 · 4:39
quotePatients that are gonna come to intestinal rehab program have intestinal failure, and we can divide the causes of intestinal failure into three categories.↗
▶Ep 8 · 4:50
quoteThere's short bowel syndrome, which by far is the most common category in pediatric patients with intestinal failure↗
▶Ep 8 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 8 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 8 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis cause short bowel syndrome↗
▶Ep 8 · 5:45
clinicalMotility disorders occur when abnormalities of the intestinal muscle itself or the nerves that control that muscle prevent coordinated movement of food and stool↗
▶Ep 8 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle.↗
▶Ep 8 · 6:10
clinicalChildren with motility disorders are dependent on intravenous support↗
▶Ep 8 · 6:17
clinicalEnteropathies or congenital diarrheas are conditions where the patient has all of their bowel but the mucosal lining that digests and absorbs does not work↗
▶Ep 8 · 6:17
quotethese are conditions where the patient has all of their bowel, but the mucosa, the inside lining that, that absorbs, uh, digests and absorbs doesn't work.↗
▶Ep 8 · 7:11
quoteThe reason it's important to at least identify these three categories is that some patients will have elements of 12, or 3 of the categories, the way they present.↗
▶Ep 8 · 7:11
clinicalSome patients will have elements of one, two, or all three categories of intestinal failure↗
▶Ep 8 · 7:45
epidemiologicalMost intestinal failure patients are infants or babies, but some older kids develop intestinal failure↗
▶Ep 8 · 7:56
clinicalInflammatory bowel disease or Crohn's disease can lead to gut loss and intestinal failure in older patients↗
▶Ep 8 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 8 · 12:46
clinicalLong-term survivors now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
▶Ep 8 · 12:46
quoteBut now what we're seeing is we have kids that have developed chronic comorbidities, that comorbidities that never, we didn't really see to the same extent because they didn't live long enough.↗
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
▶Ep 9 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program↗
▶Ep 9 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 9 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and associated needs↗
▶Ep 9 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management↗
▶Ep 9 · 3:55
opinionIntestinal rehabilitation streamlines care and improves communication with families and between care providers and team members↗
▶Ep 9 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 9 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 9 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis can cause short bowel syndrome↗
▶Ep 9 · 5:45
clinicalMotility disorders occur when the bowel is unable to push contents through in a coordinated way due to abnormalities of the muscle itself or the nerves that control that muscle↗
▶Ep 9 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle↗
▶Ep 9 · 6:17
clinicalCongenital enteropathies are conditions where the patient has all of their bowel but the mucosa does not work, leading to hypersecretion and profuse fluid losses↗
▶Ep 9 · 7:11
clinicalSome patients will have elements of two or three categories of intestinal failure in the way they present↗
▶Ep 9 · 7:56
clinicalOlder pediatric patients can develop intestinal failure from inflammatory bowel disease or Crohn's disease where they have lost gut as a result of complications↗
▶Ep 9 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 9 · 12:46
clinicalChildren with intestinal failure who survive long-term now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1
▶Ep 10 · 1:17
opinionThe outlook has changed and what's gone hand in hand with that is a bit more of an aggressive approach to surgical resection↗
▶Ep 10 · 1:39
clinicalComorbidities such as neurologic status, pulmonary function, cardiac function, or significant genetic or chromosomal anomaly factor into decision making about how to proceed↗
▶Ep 10 · 2:38
guidelineIntestinal transplant is not experimental therapy but part of the continuum of therapy for a child with short bowel syndrome↗
▶Ep 10 · 2:52
quoteIs it ethically appropriate to open and close a baby when you know that you could remove all of their intestines?↗
▶Ep 10 · 4:31
clinicalIn the very acute time after bowel infarction, the risk is dying of sepsis and multi-organ failure↗
▶Ep 10 · 4:44
clinicalIntermediate and longer term complications include intestinal failure associated liver disease, recurrent sepsis, or line problems↗
▶Ep 10 · 5:02
epidemiologicalSuccess in the last two decades is because we're way better at preventing sepsis and liver disease↗
▶Ep 10 · 6:14
clinicalBabies born with duodenal atresia or very proximal jejunal atresia are born with elevated direct or conjugated bilirubins↗
▶Ep 10 · 6:42
clinicalFactors affecting liver function include prematurity, sepsis, choice of TPN, and presence or absence of enteral nutrition↗
▶Ep 10 · 12:15
quoteLet the baby decide, you know, some may continue to spiral because of just overwhelming sepsis and may not make it, but many, many will.↗
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2
▶Ep 11 · 1:23
quoteThe goalposts have moved over the last two decades.↗
▶Ep 11 · 1:37
clinicalIn Toronto, ultra-short gut is classified as less than 20% of expected bowel length for age↗
▶Ep 11 · 1:42
clinicalIn a term baby, ultra-short gut corresponds to 20 to 30 centimeters of bowel↗
▶Ep 11 · 1:52
clinicalOverall survival in ultra-short gut patients in the current era is over 90%↗
▶Ep 11 · 2:10
clinicalUltra-short gut patients who reached autonomy required multiple nutritional supplements↗
▶Ep 11 · 2:26
clinicalUltra-short gut patients with remnant ileum as part of residual bowel tended to do better↗
▶Ep 11 · 2:50
clinicalUltra-short gut patients with longer colonic remnants tended to adapt and get off TPN↗
▶Ep 11 · 6:10
quoteI don't subscribe to the notion that Every kid needs to die with a laparotomy indecision.↗
▶Ep 11 · 7:40
opinionLipid restriction was never a practice subscribed to by the Toronto program↗
▶Ep 11 · 11:53
quoteThe surgeon's role in the patient with short bowel syndrome is, is obviously significant. Partly for what we do and partly for what we don't do, right? Those intraoperative decisions have a lifelong impact.↗
▶Ep 11 · 12:00
opinionIntraoperative decisions in short bowel syndrome have a lifelong impact↗
▶Ep 11 · 12:08
opinionDecisions made at the time of intraabdominal catastrophe can make the difference between staying on or getting off TPN or whether the child survives↗
▶Ep 11 · 14:21
clinicalKids may look worse over the first 24-36 hours postoperatively, then stop getting worse before they start improving↗
▶Ep 11 · 14:21
quoteOften, some of these kids do get, they kind of look worse over the next 24, 36 hours, and then they start to, you know, they may not even be getting better, they just stop getting worse.↗
Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1
▶Ep 12 · 2:02
quoteThat remaining bowel, that residual intestine goes through this process of adaptation and where the bowel is trying to compensate to reestablish function, to absorb enough nutrients and fluids to maintain survival.↗
▶Ep 12 · 2:16
clinicalAdaptation is driven by intraluminal nutrients and their interaction with pancreatic biliary secretions and trophic gut peptides↗
▶Ep 12 · 2:42
clinicalStructural changes during adaptation include mucosal hypertrophy with increased villous length, increased blood supply through angiogenesis, bowel dilation, and gut lengthening in younger children, all increasing surface area for absorption↗
▶Ep 12 · 3:04
clinicalFunctional changes during adaptation include slowed motility to allow more contact time and upregulation of enterocyte transporters↗
▶Ep 12 · 3:18
quoteSo, each, each cell is working harder, if you will, to try to, to, Function better and our job as a team is to try to promote that the best we can.↗
▶Ep 12 · 5:35
clinicalUntil recently there was no standardized definition for enteral autonomy↗
▶Ep 12 · 6:04
clinicalTPN complications include line infections, liver disease, and vascular thrombosis↗
▶Ep 12 · 6:20
clinicalIn the past, patients were lost to complications such as liver disease before they could reach their adaptive potential; management of these complications has improved significantly↗
▶Ep 12 · 6:39
guidelineCurrent ASPEN guidelines define enteral autonomy as independence of parenteral support for 12 weeks with maintenance of adequate growth and hydration↗
▶Ep 12 · 6:53
quoteIt's one thing to turn off parenteral support, but, you know, you're not really off TPN or off parental support unless you can actually grow off TPN.↗
▶Ep 12 · 7:50
epidemiologicalA 2012 PIFCO paper by Squires showed 50% of patients achieved enteral autonomy over 5-6 years, 25% died, and 25% got transplanted↗
▶Ep 12 · 8:25
epidemiologicalRecent papers in the last 5-6 years show 60-80% of patients achieve enteral autonomy, with a higher proportion surviving to reach autonomy↗
▶Ep 12 · 9:55
clinicalSmall bowel length is an independently significant variable for adaptation capacity↗
▶Ep 12 · 10:18
clinicalThe ileum has a much greater capacity to adapt than the jejunum↗
▶Ep 12 · 10:40
clinicalAt 5 years old, a child has about 425 centimeters of small bowel, with the steepest growth rate between 35 weeks gestation to about 6 months postnatal↗
▶Ep 12 · 11:25
opinionThe ileocecal valve itself is not the important factor; most people who lose their ileocecal valve also lose their terminal ileum, which is the bigger factor for adaptive potential↗
▶Ep 12 · 11:53
clinicalIf a patient has the majority of their small bowel, it almost does not matter how much colon they have; probability of enteral autonomy is 85-100%↗
CAPS - The use of urine sodium to creatinine ratio as a marker of total body sodium in infants with intestinal failure - Sara Choi
▶Ep 14 · 5:58
quoteI encourage the audience to, to highly consider voting for this paper because it's, it has a massive clinical importance.↗
clinicalPatients with stomas, even those without intestinal failure, run the risk of sodium depletion which has a significant impact on their growth↗
▶Ep 14 · 6:19
clinicalStomas and high stool losses are a large source of sodium bicarb as well as magnesium loss↗
▶Ep 14 · 6:38
clinicalWhen we replace sodium, it does help restore growth, but it doesn't allow catch up growth↗
▶Ep 14 · 6:38
quoteit's important to remember that when we replace sodium, it does help restore growth, but it doesn't allow catch up growth.↗
▶Ep 14 · 6:45
quoteit's important that we track these patients serially, so that we can detect a trend evolving, so that we can avoid sodium depletion happening in the first place.↗
▶Ep 14 · 7:30
quoteI would argue that, that having potassium chloride and an osmolaity added to the urine lytes in addition to just the sodium gives you a better picture of, of whether someone is truly sodium depleted.↗
▶Ep 14 · 7:41
clinicalIf potassium level is higher than sodium level in urine, that often will tell you that the aldosterone pathway is turned on↗
Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations
▶Ep 15 · 10:35
clinicalAntibiotic locking solutions have been around for a long time but predominantly develop resistance↗
▶Ep 15 · 10:47
quoteAnd frankly, the problem with them is that you develop resistance.↗
▶Ep 15 · 10:56
clinicalEthanol locks are antimicrobial without resistance and kill both planktonic bacteria (floating in lumen) and sessile bacteria (embedded in biofilm)↗
▶Ep 15 · 10:56
quoteIt's antimicrobial, it doesn't have any resistance, and it'll kill bacteria that are both planktonic, meaning floating around in the, in the lumen, or sessile, meaning that they're embedded in a biofilm along the wall of the catheter.↗
▶Ep 15 · 11:24
clinicalKite lock is a 4% tetrasodium EDTA chemical found in Canada↗
▶Ep 15 · 11:36
clinicalKite lock is antimicrobial without resistance, antifibrinolytic, and antithrombotic↗
▶Ep 15 · 11:59
clinicalKite lock has been licensed in Canada for pediatric use, and is now licensed in Europe and Australia↗
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1
▶Ep 18 · 4:18
epidemiologicalThe point of intake for the majority of short bowel syndrome patients is at birth because etiologies are usually neonatal causes↗
▶Ep 18 · 4:36
epidemiologicalCongenital anomalies of the GI tract or acquired conditions like necrotizing enterocolitis are the main causes↗
▶Ep 18 · 4:50
quoteMaking rational decisions at that initial surgery will set that baby up for success or failure.↗
▶Ep 18 · 5:42
clinicalIf reestablishing bowel continuity, you must deal with size discrepancy between the two ends↗
▶Ep 18 · 5:42
quoteIf you are thinking of reestablishing continuity, I feel very strongly that you have to deal with the size discrepancy.↗
▶Ep 18 · 7:08
quoteIn general, gastroschisis, they don't tend to do as well regardless.↗
▶Ep 18 · 7:08
clinicalGastroschisis patients don't tend to do as well regardless of intervention↗
▶Ep 18 · 7:12
clinicalSTEP procedures tend to not work as well in gastroschisis patients↗
▶Ep 18 · 9:09
clinicalThe STEP procedure requires bowel diameter of about 5 centimeters to be worthwhile↗
▶Ep 18 · 11:29
clinicalThere is a risk of bowel twisting in longitudinal orientation if alignment is not maintained during STEP↗
▶Ep 18 · 13:23
guidelineTarget caliber for STEP in a baby is about 1.5 centimeters, and for older infant or child is 2 to 2.5 centimeters↗
▶Ep 18 · 13:36
clinicalMaking the bowel too narrow during STEP can obstruct the patient, especially in someone with borderline motility↗
▶Ep 18 · 14:19
clinicalA proposed advantage of STEP is that the surgeon can maintain caliber all the way from top to bottom by careful measurements↗
▶Ep 18 · 14:35
clinicalThere is potential for leak in the crotch of the staple line if not reinforced↗
▶Ep 18 · 15:08
clinicalDog ears at the top and bottom of the STEP segment can dilate over time and form blind loops↗
▶Ep 18 · 16:56
quoteI don't step the duodenum. I start where the bowel starts to dilate.↗
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1
▶Ep 19 · 4:18
epidemiologicalThe majority of pediatric short bowel syndrome cases present at birth due to neonatal causes: congenital GI anomalies or acquired conditions like necrotizing enterocolitis↗
▶Ep 19 · 5:42
quoteIf you are thinking of reestablishing continuity, I feel very strongly that you have to deal with the size discrepancy.↗
▶Ep 19 · 5:42
clinicalWhen reestablishing bowel continuity, size discrepancy between bowel ends must be addressed or a functional obstruction will result even if the anastomosis is patent↗
▶Ep 19 · 6:02
clinicalIf adequate bowel length exists, size discrepancy can be managed by resection back to appropriate caliber or tapering enteroplasty↗
▶Ep 19 · 6:28
clinicalIn short bowel cases, serial transverse enteroplasty (STEP) can address size discrepancy without resecting mucosa↗
▶Ep 19 · 7:08
clinicalGastroschisis patients don't tend to do as well regardless of intervention; STEP procedures in gastroschisis patients consistently underperform↗
▶Ep 19 · 7:08
quoteIn general, gastroschisis, they don't tend to do as well regardless. If, and if I look at the step procedures that I've done over the years, the ones that tend to not do as well or tend to always be the gastroschisis.↗
▶Ep 19 · 9:09
clinicalSTEP procedure requires bowel diameter of at least 5 centimeters to be worthwhile↗
▶Ep 19 · 9:09
quoteI don't usually do that operation anyway unless the bowel is an adequate diameter to make it worthwhile, and in my head over the years, it's always been about 5 centimeters anyway.↗
▶Ep 19 · 9:50
clinicalIn scenarios where immediate anastomosis is not prudent, distal bowel can be accessed with a feeding tube to provide distal feeding and grow the bowel in caliber before a subsequent operation↗
▶Ep 19 · 10:45
clinicalThe STEP procedure was originally described by HP Kim and Tom Jackson↗
▶Ep 19 · 11:29
clinicalMaintaining bowel alignment during STEP is critical; there is risk of longitudinal twisting if alignment is not maintained↗
▶Ep 19 · 12:26
clinicalAn endo GIA stapler with vascular (white) load cartridge (2.5mm crimping to 1mm) is preferred over open GIA and prevents leaks better than the classic blue load↗
▶Ep 19 · 12:34
clinicalSTEP staple lines should be oriented perpendicular to the mesentery at 90 and 270 degrees (3 o'clock and 9 o'clock positions)↗
▶Ep 19 · 13:23
clinicalTarget bowel caliber after STEP is 1.5 cm in babies and 2 to 2.5 cm in older infants or children↗
▶Ep 19 · 13:36
clinicalMaking the bowel too narrow during STEP can cause obstruction, especially in patients with borderline motility↗
▶Ep 19 · 14:35
clinicalA U-stitch with 4-0 PDS should be placed in the crotch of each staple line to prevent potential leaks↗
▶Ep 19 · 15:08
clinicalDog ears (blind loops) can form at the top and bottom of the STEP segment where bowel transitions in and out, and these can dilate over time↗
▶Ep 19 · 16:51
clinicalThe duodenum should not be stepped; STEP should start where the bowel begins to dilate, usually distal to the duodenum↗
▶Ep 19 · 16:56
quoteI don't step the duodenum. I start where the bowel starts to dilate.↗
▶Ep 19 · 17:20
clinicalIf duodenal narrowing is needed, a stapler should be used on the lateral side away from the bile duct and ampulla; plication sutures usually fail↗
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 2
▶Ep 20 · 1:52
quoteI think we have to remember that the biggest benefit of the step, for instance, is the fact that you're tapering the bowel and reestablishing a more normal caliber to improve motility.↗
▶Ep 20 · 1:52
clinicalThe biggest benefit of the STEP procedure is tapering the bowel and reestablishing a more normal caliber to improve motility↗
▶Ep 20 · 3:04
clinicalIt can take up to 6 months before significant improvement in absorptive capacity is seen after STEP↗
▶Ep 20 · 3:04
quoteIt can take up to 6 months before you actually start to see a significant improvement in absorptive capacity.↗
▶Ep 20 · 3:12
clinicalAbsorptive capacity improvement is measured with fecal fat, alpha-1 antitrypsin clearance, xylose absorption, and citrulline levels↗
▶Ep 20 · 3:24
clinicalThe delay in improvement is due to inflamed, sick, leaky mucosa in the setting of bacterial overgrowth needing time to heal↗
▶Ep 20 · 6:24
clinicalStaple-line ulcer bleeding is an underreported complication that is difficult to manage↗
▶Ep 20 · 6:49
quoteMy hypothesis is that this is a microbiome problem. I think you have a pro-inflammatory environment.↗
▶Ep 20 · 6:52
clinicalStaple-line ulcers tend to occur in type 2 anatomy (small bowel to colonic remnant in the absence of an intact colon ileocecal valve)↗
▶Ep 20 · 7:12
clinicalPathology of staple-line ulcers shows non-specific inflammation with no vasculitis, viral elements, or obvious ischemia↗
▶Ep 20 · 7:12
quoteIt's non-specific inflammation. There's no vasculitis, there's no viral elements, there's no obvious ischemia, and the management can be super difficult.↗
▶Ep 20 · 10:05
clinicalMost referrals for intestinal failure have had multiple operations before coming to a specialized center↗
▶Ep 20 · 10:09
opinionSurgical planning may not be conducive to just one operation and may require setting up for the next case↗
Intestinal Rehabilitation, Episode 6: Cholestasis
▶Ep 21 · 1:09
guidelineCholestasis is institutionally defined as conjugated bilirubin greater than 3 mg/dL or 50 micromoles/L sustained for 2 weeks and not associated with a septic event↗
▶Ep 21 · 1:09
quoteInstitutionally defined it as a conjugated bilirubin greater than 3 mg per deciliter or 50 micromoles per liter sustained for 2 weeks and not associated with a septic event.↗
▶Ep 21 · 1:20
guidelineA 2021 JPN publication defines cholestasis as conjugated bilirubin around 2 mg/dL or 34 micromoles/L for 2 weeks, not associated with a septic event↗
▶Ep 21 · 2:57
clinicalIn young children, intestinal failure causes cholestatic liver disease, whereas in adolescents and adults it tends to cause steatosis (fatty deposition)↗
▶Ep 21 · 2:57
quoteIn the setting of young children, it's more of a cholestatic liver disease, whereas in older people, adolescents and adults, they tend to have Steatosis, there's a fatty deposition within the liver, and the term we use now is intestinal failure associated liver disease because that sort of indicates that it's a multifactorial process.↗
▶Ep 21 · 3:30
clinicalPrematurity is not modifiable by the clinical team, but other risk factors (enteral feeding, sepsis, TPN components) are modifiable↗
▶Ep 21 · 3:30
quoteNow, prematurity, we as clinicians, as a team, we don't have much control over that. But the other factors are modifiable, and we can have an impact on that.↗
▶Ep 21 · 4:09
clinicalPrevention requires aggressive introduction of enteral feeding and surgical procedures to optimize anatomy for feed delivery↗
▶Ep 21 · 7:08
clinicalConventional intralipid (soybean-based) when metabolized leads to production of prostaglandins and eicosanoids that are pro-inflammatory↗
▶Ep 21 · 7:19
clinicalSMOF lipid promotes bile flow, is hepatoprotective, and can be delivered at conventional dose while supporting somatic growth and neurologic development↗
▶Ep 21 · 7:45
clinicalSMOF lipid does not have enough arachidonic acid, so dose restriction can lead to essential fatty acid deficiency↗
▶Ep 21 · 7:57
clinicalWhen SMOF is delivered at conventional dosing, nobody develops essential fatty acid deficiency↗
▶Ep 21 · 8:06
guidelineRecommended lipid dosing is settling around 2.5 g/kg, but nutrition guidelines for preterms and babies state 3-4 g/kg/day↗
▶Ep 21 · 8:29
opinionA bilirubin of 2 mg/dL is not advanced liver disease, is not dangerous, and is usually transient; approximately 90% of patients will improve with observation alone↗
▶Ep 21 · 8:52
quoteMy opinion is that a billy of 2 is not by any stretch advanced liver disease, and it's not dangerous, and it's usually transient. So I personally would not change the lipid emulsion out of Billy to.↗
▶Ep 21 · 12:11
clinicalLiver biopsy is commonly performed during secondary surgical or autologous reconstruction procedures to provide an up-to-date microscopic snapshot↗
▶Ep 21 · 13:00
clinicalElastography or fibroscan is available for monitoring but is good for mild/no fibrosis or very advanced fibrosis; it is less sensitive for patients in the middle range↗
▶Ep 21 · 13:31
clinicalOutpatient follow-up frequency for children on TPN at home ranges from every 1-4 months depending on patient stability↗
Intestinal Rehabilitation, Episode 7: Refeeding in a neonatal patient
▶Ep 22 · 0:57
clinicalRefeeding goals include establishing normal feeding habits to promote gut function and optimize quality of life and social aspects of eating↗
▶Ep 22 · 0:57
quoteEven if a kid has a complicated disease process, one of our goals as a team is to try to establish the most normal feeding habits we can that not only promote gut function and everything else, but also to optimize quality of life and the importance of the social aspects of eating that we all experience with our families and friends.↗
▶Ep 22 · 4:34
clinicalIn short bowel syndrome, protein absorption is fairly well preserved, so the benefit of hydrolyzed or amino acid formulas is primarily from an allergy perspective↗
▶Ep 22 · 5:04
clinicalLong-chain fat is a stronger driver for intestinal adaptation than MCT↗
▶Ep 22 · 6:06
clinicalOne milliliter of parenteral nutrition is not isocaloric with one milliliter of formula↗
▶Ep 22 · 6:06
quoteYou're right, and they're not isocaloric, and so 1 mL of PN is not 1 mL of formula.↗
▶Ep 22 · 6:11
clinicalAdvancing enteral feeds beyond 100-120 mL/kg can cause problems with sodium and calcium in addition to calorie and protein deficits, because milk composition differs from parenteral solution↗
▶Ep 22 · 8:05
guidelineContinuous feeds can be used as a supplemental approach, with bolus feeds during the day and continuous feeds overnight↗
▶Ep 22 · 8:05
guidelineBolus feeds are preferred as the default feeding method; patients should fail bolus feeds before transitioning to continuous feeds as the sole delivery mode↗
▶Ep 22 · 8:40
quoteOne thing I just want to say about oral feeding is that even in the scenario where it's really non-nutritive. I think it's important for people to sort of look at that oral feeding, not so much as an internal nutrition perspective, but more of a skill development perspective that they never learn how to eat by mouth and suck and swallow and process, then they won't eat solids later when you want them to, and you're stuck basically with tube feeding on an older child.↗
▶Ep 22 · 8:40
clinicalOral feeding is important for skill development even when non-nutritive; children who never learn to suck, swallow, and process food by mouth will not eat solids later and will remain tube-dependent↗
▶Ep 22 · 12:17
clinicalDistally fed bowel has improved size discrepancy at the time of anastomosis because the bowel has been used↗
▶Ep 22 · 13:51
clinicalA gastric tube provides versatility for nutrition supplementation, medication delivery, and venting for gassy or bloated patients to improve enteral tolerance↗
Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient
▶Ep 23 · 1:24
quoteThe benefit in the curse in a patient like that is that they do know how to eat.↗
▶Ep 23 · 1:24
opinionOlder patients who have established eating behavior before bowel loss have both a benefit and curse in that they know how to eat↗
▶Ep 23 · 1:50
quoteSo even if you can't cure this patient and get them off TPN. It's important to make compromises to optimize quality of life the best you can.↗
▶Ep 23 · 1:50
opinionEven if a patient cannot be cured and weaned off TPN, compromises should be made to optimize quality of life↗
▶Ep 23 · 2:14
clinicalThe general strategy is to push macronutrient modules of protein and fat which are well tolerated↗
▶Ep 23 · 2:21
quoteMost of these kids don't tolerate simple sugars very well.↗
▶Ep 23 · 2:21
clinicalMost short bowel patients don't tolerate simple sugars very well↗
▶Ep 23 · 2:25
clinicalPushing solids and minimizing fluid intake helps reduce dumping↗
▶Ep 23 · 2:31
clinicalSmaller meals more frequently of solids separated from liquids and minimization of simple sugars is the recommended approach↗
▶Ep 23 · 2:52
clinicalPatients who have transitioned off TPN often come back with problems when diet history reveals they have gotten loose with diet choices↗
▶Ep 23 · 3:31
clinicalMinimizing sugars reduces symptoms related to bacterial overgrowth such as bloating and gas↗
▶Ep 23 · 3:48
clinicalFluid losses whether by stoma or other source must be replaced↗
▶Ep 23 · 3:56
clinicalIf patients are on IV support, some fluid can be replaced intravenously↗
▶Ep 23 · 4:01
clinicalWhen trying to wean off IV support, keeping patients hydrated through enteral replacements is important↗
▶Ep 23 · 4:11
clinicalFluid transport requires sodium and glucose, so replacement solution must contain both↗
▶Ep 23 · 4:11
quoteFor transport requires sodium and glucose, and so your solution that you're replacing with has to contain some glucose and some salt.↗
▶Ep 23 · 4:48
clinicalGatorade doesn't work well for rehydration because it has too much sugar↗
clinicalSome kids end up back on parenteral support to get through puberty↗
▶Ep 23 · 6:33
clinicalWhen not growing anymore as an adult, borderline or marginal gut function is often enough to sustain them↗
▶Ep 23 · 7:22
clinicalAfter getting off TPN, patients often get into trouble with micronutrient deficiencies↗
▶Ep 23 · 8:51
clinicalWeight must be balanced with height as a growth metric↗
▶Ep 23 · 8:57
clinicalThis population commonly shows round babies where weight for height is elevated↗
▶Ep 23 · 9:01
clinicalThere is increasing data looking at quality of weight - how much is fat weight versus lean body mass↗
Advancements in Pediatric Intestinal Failure: Innovative Therapies and Improved Outcomes
▶Ep 28 · 5:23
clinicalLiver disease in intestinal failure ranges from mild cholestasis to profound steatosis in older children or adolescents and adults, with ongoing inflammation, fibrosis, and ultimately cirrhosis↗
▶Ep 28 · 5:41
clinicalRisk 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↗
▶Ep 28 · 6:12
clinicalIntestinal rehab programs improve outcomes through integration of care, improved communication, and better continuity↗
▶Ep 28 · 6:54
quoteWhat we ask our Families to do at home is significant.↗
▶Ep 28 · 7:11
quoteWe educate and empower our parents because we've all seen. High-quality families that over time demonstrate evidence of burnout.↗
▶Ep 28 · 7:25
epidemiologicalLiterature shows improvement of outcomes with intestinal rehab programs including improved survival related to liver dysfunction, decreased septic episodes, reduction in central line complications, reduced ICU admissions, and patients coming off transplant lists↗
▶Ep 28 · 8:02
clinicalLipids 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↗
▶Ep 28 · 8:15
clinicalSoybean-based lipid emulsions have high phytosterol content, high omega-6 long chain polyunsaturated fatty acid content, and low antioxidant content↗
▶Ep 28 · 8:31
clinicalProlonged soybean-based lipid exposure is associated with deterioration of liver dysfunction, specifically cholestasis↗
▶Ep 28 · 8:51
clinicalFor every day an infant is exposed to soybean lipid dosed at greater than 2.5 g per kilo per day, there is a 3% increase in the odds ratio of developing advanced liver disease↗
▶Ep 28 · 8:51
quoteFor every day that an infant is exposed to soybean lipid dosed at greater than 2.5 g per kilo per day, which is more conventional dosing. That is associated with a 3% increase in the odds ratio of developing advanced liver disease.↗
▶Ep 28 · 9:51
clinicalOmega-6 lipids are metabolized to arachidonic acid, which produces leukotrienes and prostaglandins with a more pro-inflammatory profile↗
▶Ep 28 · 10:01
clinicalOmega-3 lipids are metabolized through EPA and DHA and lead to production of cytokines with a less inflammatory profile↗
▶Ep 28 · 10:15
clinicalOmega-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↗
▶Ep 28 · 10:42
clinicalRestricting soybean lipid exposure improves cholestasis when dosed at 1 g per kilo per day or less↗
▶Ep 28 · 11:00
clinicalIn preterm 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↗
▶Ep 28 · 11:22
clinicalDHA and arachidonic acid are important for retinal and brain development↗
▶Ep 28 · 11:26
quoteNone of the lipid emulsions today were designed for premature babies. They were all designed for adults in a critical care setting.↗
▶Ep 28 · 11:26
clinicalNone of the current lipid emulsions were designed for premature babies; they were all designed for adults in a critical care setting↗
▶Ep 28 · 12:03
quoteSo our patients with central lines, it's literally their lifeline. And without venous access, we can't support our families.↗
▶Ep 28 · 12:24
epidemiologicalThere are approximately 240,000 central line-associated bloodstream infections in the United States annually, with each costing about $30,000, totaling about $2 billion per year nationwide↗
▶Ep 28 · 12:48
clinical4% tetrasodium EDTA (kite lock) is an antithrombotic, anti-fibrinolytic, and antimicrobial that satisfies all three criteria important for a good lock solution↗
▶Ep 28 · 13:23
clinicalKite lock is licensed in Europe and Australia but not available in the United States↗
▶Ep 28 · 13:29
clinicalA multi-center randomized trial of kite lock versus heparin went live 4 weeks ago and is actively recruiting patients↗
▶Ep 28 · 13:58
clinicalIn short bowel syndrome, there are 3 anatomical subtypes: Type 1 is high jejunostomy, Type 2 has lost distal small bowel and ileum with small bowel-colonic anastomosis, and Type 3 has lost mid-small bowel but retains some ileum and intact colon↗
▶Ep 28 · 14:26
epidemiologicalThe most common anatomical subtype of short bowel syndrome in pediatrics is Type 2↗
▶Ep 28 · 14:33
clinicalType 1 and Type 2 short bowel syndrome patients struggle because they lack an ileum, which is where GLP-2 is naturally produced↗
▶Ep 28 · 14:53
clinicalNative GLP-2 hormone has a half-life of 7 minutes, making it impractical for clinical use↗
▶Ep 28 · 14:58
clinicalTeduglutide 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↗
▶Ep 28 · 15:23
clinicalPatients receiving teduglutide show a 40% reduction in TPN fluid and calorie requirements over a six-month period↗
▶Ep 28 · 15:32
clinical70% of patients receiving teduglutide achieved the study endpoint of a 20% reduction in TPN requirements↗
▶Ep 28 · 15:48
clinicalTeduglutide is licensed for children greater than 1 year of age↗
▶Ep 28 · 16:02
clinicalApraglutide is another GLP-2 analog with a longer half-life that can be given once a week and works even better than teduglutide, producing more bowel lengthening↗
▶Ep 28 · 16:36
epidemiologicalThese interventions have led to a decrease in transplantation since 2008, largely because of the successes of intestinal rehabilitation↗
▶Ep 28 · 16:41
epidemiologicalOutcomes of intestinal transplant at 5 years are about 65%↗
▶Ep 28 · 16:49
quoteWhatever we can do to avoid transplant and lifelong immunosuppression, that is our goal.↗
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
▶Ep 46 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program.↗
▶Ep 46 · 2:03
quoteIt it's, it's really a functional problem. Essentially, when someone's gut for whatever the diagnosis, whatever the reason, their gut function is insufficient to absorb enough nutrients, fluids, calories to support survival and in the in the case of children, growth, which is a big distinction between adults and children.↗
▶Ep 46 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 46 · 3:03
quotean intestinal rehabilitation program, as we defined also in these Aspen guidelines that just came out, is a multidisciplinary or interdisciplinary collaborative patient care paradigm that that brings coordinated care for children with intestinal failure through comprehensive management of Their specialized nutrition and other associated needs that they have.↗
▶Ep 46 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm providing coordinated care for children with intestinal failure through comprehensive management of specialized nutrition and associated needs↗
▶Ep 46 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management.↗
▶Ep 46 · 4:39
quotePatients that are gonna come to intestinal rehab program have intestinal failure, and we can divide the causes of intestinal failure into three categories.↗
▶Ep 46 · 4:50
quoteThere's short bowel syndrome, which by far is the most common category in pediatric patients with intestinal failure↗
▶Ep 46 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 46 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 46 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis cause short bowel syndrome↗
▶Ep 46 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle.↗
▶Ep 46 · 5:45
clinicalMotility disorders occur when abnormalities of the intestinal muscle itself or the nerves that control that muscle prevent coordinated movement of food and stool↗
▶Ep 46 · 6:10
clinicalChildren with motility disorders are dependent on intravenous support↗
▶Ep 46 · 6:17
quotethese are conditions where the patient has all of their bowel, but the mucosa, the inside lining that, that absorbs, uh, digests and absorbs doesn't work.↗
▶Ep 46 · 6:17
clinicalEnteropathies or congenital diarrheas are conditions where the patient has all of their bowel but the mucosal lining that digests and absorbs does not work↗
▶Ep 46 · 7:11
clinicalSome patients will have elements of one, two, or all three categories of intestinal failure↗
▶Ep 46 · 7:11
quoteThe reason it's important to at least identify these three categories is that some patients will have elements of 12, or 3 of the categories, the way they present.↗
▶Ep 46 · 7:45
epidemiologicalMost intestinal failure patients are infants or babies, but some older kids develop intestinal failure↗
▶Ep 46 · 7:56
clinicalInflammatory bowel disease or Crohn's disease can lead to gut loss and intestinal failure in older patients↗
▶Ep 46 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 46 · 12:46
clinicalLong-term survivors now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
▶Ep 46 · 12:46
quoteBut now what we're seeing is we have kids that have developed chronic comorbidities, that comorbidities that never, we didn't really see to the same extent because they didn't live long enough.↗
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
▶Ep 47 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program↗
▶Ep 47 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 47 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and associated needs↗
▶Ep 47 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management↗
▶Ep 47 · 3:55
opinionIntestinal rehabilitation streamlines care and improves communication with families and between care providers and team members↗
▶Ep 47 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 47 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 47 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis can cause short bowel syndrome↗
▶Ep 47 · 5:45
clinicalMotility disorders occur when the bowel is unable to push contents through in a coordinated way due to abnormalities of the muscle itself or the nerves that control that muscle↗
▶Ep 47 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle↗
▶Ep 47 · 6:17
clinicalCongenital enteropathies are conditions where the patient has all of their bowel but the mucosa does not work, leading to hypersecretion and profuse fluid losses↗
▶Ep 47 · 7:11
clinicalSome patients will have elements of two or three categories of intestinal failure in the way they present↗
▶Ep 47 · 7:56
clinicalOlder pediatric patients can develop intestinal failure from inflammatory bowel disease or Crohn's disease where they have lost gut as a result of complications↗
▶Ep 47 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 47 · 12:46
clinicalChildren with intestinal failure who survive long-term now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1
▶Ep 48 · 1:17
opinionThe outlook has changed and what's gone hand in hand with that is a bit more of an aggressive approach to surgical resection↗
▶Ep 48 · 1:39
clinicalComorbidities such as neurologic status, pulmonary function, cardiac function, or significant genetic or chromosomal anomaly factor into decision making about how to proceed↗
▶Ep 48 · 2:38
guidelineIntestinal transplant is not experimental therapy but part of the continuum of therapy for a child with short bowel syndrome↗
▶Ep 48 · 2:52
quoteIs it ethically appropriate to open and close a baby when you know that you could remove all of their intestines?↗
▶Ep 48 · 4:31
clinicalIn the very acute time after bowel infarction, the risk is dying of sepsis and multi-organ failure↗
▶Ep 48 · 4:44
clinicalIntermediate and longer term complications include intestinal failure associated liver disease, recurrent sepsis, or line problems↗
▶Ep 48 · 5:02
epidemiologicalSuccess in the last two decades is because we're way better at preventing sepsis and liver disease↗
▶Ep 48 · 6:14
clinicalBabies born with duodenal atresia or very proximal jejunal atresia are born with elevated direct or conjugated bilirubins↗
▶Ep 48 · 6:42
clinicalFactors affecting liver function include prematurity, sepsis, choice of TPN, and presence or absence of enteral nutrition↗
▶Ep 48 · 12:15
quoteLet the baby decide, you know, some may continue to spiral because of just overwhelming sepsis and may not make it, but many, many will.↗
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2
▶Ep 49 · 1:23
quoteThe goalposts have moved over the last two decades.↗
▶Ep 49 · 1:37
clinicalIn Toronto, ultra-short gut is classified as less than 20% of expected bowel length for age↗
▶Ep 49 · 1:42
clinicalIn a term baby, ultra-short gut corresponds to 20 to 30 centimeters of bowel↗
▶Ep 49 · 1:52
clinicalOverall survival in ultra-short gut patients in the current era is over 90%↗
▶Ep 49 · 2:10
clinicalUltra-short gut patients who reached autonomy required multiple nutritional supplements↗
▶Ep 49 · 2:26
clinicalUltra-short gut patients with remnant ileum as part of residual bowel tended to do better↗
▶Ep 49 · 2:50
clinicalUltra-short gut patients with longer colonic remnants tended to adapt and get off TPN↗
▶Ep 49 · 6:10
quoteI don't subscribe to the notion that Every kid needs to die with a laparotomy indecision.↗
▶Ep 49 · 7:40
opinionLipid restriction was never a practice subscribed to by the Toronto program↗
▶Ep 49 · 11:53
quoteThe surgeon's role in the patient with short bowel syndrome is, is obviously significant. Partly for what we do and partly for what we don't do, right? Those intraoperative decisions have a lifelong impact.↗
▶Ep 49 · 12:00
opinionIntraoperative decisions in short bowel syndrome have a lifelong impact↗
▶Ep 49 · 12:08
opinionDecisions made at the time of intraabdominal catastrophe can make the difference between staying on or getting off TPN or whether the child survives↗
▶Ep 49 · 14:21
clinicalKids may look worse over the first 24-36 hours postoperatively, then stop getting worse before they start improving↗
▶Ep 49 · 14:21
quoteOften, some of these kids do get, they kind of look worse over the next 24, 36 hours, and then they start to, you know, they may not even be getting better, they just stop getting worse.↗
Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1
▶Ep 52 · 2:02
quoteThat remaining bowel, that residual intestine goes through this process of adaptation and where the bowel is trying to compensate to reestablish function, to absorb enough nutrients and fluids to maintain survival.↗
▶Ep 52 · 2:16
clinicalAdaptation is driven by intraluminal nutrients and their interaction with pancreatic biliary secretions and trophic gut peptides↗
▶Ep 52 · 2:42
clinicalStructural changes during adaptation include mucosal hypertrophy with increased villous length, increased blood supply through angiogenesis, bowel dilation, and gut lengthening in younger children, all increasing surface area for absorption↗
▶Ep 52 · 3:04
clinicalFunctional changes during adaptation include slowed motility to allow more contact time and upregulation of enterocyte transporters↗
▶Ep 52 · 3:18
quoteSo, each, each cell is working harder, if you will, to try to, to, Function better and our job as a team is to try to promote that the best we can.↗
▶Ep 52 · 5:35
clinicalUntil recently there was no standardized definition for enteral autonomy↗
▶Ep 52 · 6:04
clinicalTPN complications include line infections, liver disease, and vascular thrombosis↗
▶Ep 52 · 6:20
clinicalIn the past, patients were lost to complications such as liver disease before they could reach their adaptive potential; management of these complications has improved significantly↗
▶Ep 52 · 6:39
guidelineCurrent ASPEN guidelines define enteral autonomy as independence of parenteral support for 12 weeks with maintenance of adequate growth and hydration↗
▶Ep 52 · 6:53
quoteIt's one thing to turn off parenteral support, but, you know, you're not really off TPN or off parental support unless you can actually grow off TPN.↗
▶Ep 52 · 7:50
epidemiologicalA 2012 PIFCO paper by Squires showed 50% of patients achieved enteral autonomy over 5-6 years, 25% died, and 25% got transplanted↗
▶Ep 52 · 8:25
epidemiologicalRecent papers in the last 5-6 years show 60-80% of patients achieve enteral autonomy, with a higher proportion surviving to reach autonomy↗
▶Ep 52 · 9:55
clinicalSmall bowel length is an independently significant variable for adaptation capacity↗
▶Ep 52 · 10:18
clinicalThe ileum has a much greater capacity to adapt than the jejunum↗
▶Ep 52 · 10:40
clinicalAt 5 years old, a child has about 425 centimeters of small bowel, with the steepest growth rate between 35 weeks gestation to about 6 months postnatal↗
▶Ep 52 · 11:25
opinionThe ileocecal valve itself is not the important factor; most people who lose their ileocecal valve also lose their terminal ileum, which is the bigger factor for adaptive potential↗
▶Ep 52 · 11:53
clinicalIf a patient has the majority of their small bowel, it almost does not matter how much colon they have; probability of enteral autonomy is 85-100%↗
CAPS - The use of urine sodium to creatinine ratio as a marker of total body sodium in infants with intestinal failure - Sara Choi
▶Ep 58 · 5:58
quoteI encourage the audience to, to highly consider voting for this paper because it's, it has a massive clinical importance.↗
clinicalPatients with stomas, even those without intestinal failure, run the risk of sodium depletion which has a significant impact on their growth↗
▶Ep 58 · 6:19
clinicalStomas and high stool losses are a large source of sodium bicarb as well as magnesium loss↗
▶Ep 58 · 6:38
clinicalWhen we replace sodium, it does help restore growth, but it doesn't allow catch up growth↗
▶Ep 58 · 6:38
quoteit's important to remember that when we replace sodium, it does help restore growth, but it doesn't allow catch up growth.↗
▶Ep 58 · 6:45
quoteit's important that we track these patients serially, so that we can detect a trend evolving, so that we can avoid sodium depletion happening in the first place.↗
▶Ep 58 · 7:30
quoteI would argue that, that having potassium chloride and an osmolaity added to the urine lytes in addition to just the sodium gives you a better picture of, of whether someone is truly sodium depleted.↗
▶Ep 58 · 7:41
clinicalIf potassium level is higher than sodium level in urine, that often will tell you that the aldosterone pathway is turned on↗
Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations
▶Ep 63 · 10:35
clinicalAntibiotic locking solutions have been around for a long time but predominantly develop resistance↗
▶Ep 63 · 10:47
quoteAnd frankly, the problem with them is that you develop resistance.↗
▶Ep 63 · 10:56
clinicalEthanol locks are antimicrobial without resistance and kill both planktonic bacteria (floating in lumen) and sessile bacteria (embedded in biofilm)↗
▶Ep 63 · 10:56
quoteIt's antimicrobial, it doesn't have any resistance, and it'll kill bacteria that are both planktonic, meaning floating around in the, in the lumen, or sessile, meaning that they're embedded in a biofilm along the wall of the catheter.↗
▶Ep 63 · 11:24
clinicalKite lock is a 4% tetrasodium EDTA chemical found in Canada↗
▶Ep 63 · 11:36
clinicalKite lock is antimicrobial without resistance, antifibrinolytic, and antithrombotic↗
▶Ep 63 · 11:59
clinicalKite lock has been licensed in Canada for pediatric use, and is now licensed in Europe and Australia↗
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1
▶Ep 66 · 4:18
epidemiologicalThe point of intake for the majority of short bowel syndrome patients is at birth because etiologies are usually neonatal causes↗
▶Ep 66 · 4:36
epidemiologicalCongenital anomalies of the GI tract or acquired conditions like necrotizing enterocolitis are the main causes↗
▶Ep 66 · 4:50
quoteMaking rational decisions at that initial surgery will set that baby up for success or failure.↗
▶Ep 66 · 5:42
clinicalIf reestablishing bowel continuity, you must deal with size discrepancy between the two ends↗
▶Ep 66 · 5:42
quoteIf you are thinking of reestablishing continuity, I feel very strongly that you have to deal with the size discrepancy.↗
▶Ep 66 · 7:08
quoteIn general, gastroschisis, they don't tend to do as well regardless.↗
▶Ep 66 · 7:08
clinicalGastroschisis patients don't tend to do as well regardless of intervention↗
▶Ep 66 · 7:12
clinicalSTEP procedures tend to not work as well in gastroschisis patients↗
▶Ep 66 · 9:09
clinicalThe STEP procedure requires bowel diameter of about 5 centimeters to be worthwhile↗
▶Ep 66 · 11:29
clinicalThere is a risk of bowel twisting in longitudinal orientation if alignment is not maintained during STEP↗
▶Ep 66 · 13:23
guidelineTarget caliber for STEP in a baby is about 1.5 centimeters, and for older infant or child is 2 to 2.5 centimeters↗
▶Ep 66 · 13:36
clinicalMaking the bowel too narrow during STEP can obstruct the patient, especially in someone with borderline motility↗
▶Ep 66 · 14:19
clinicalA proposed advantage of STEP is that the surgeon can maintain caliber all the way from top to bottom by careful measurements↗
▶Ep 66 · 14:35
clinicalThere is potential for leak in the crotch of the staple line if not reinforced↗
▶Ep 66 · 15:08
clinicalDog ears at the top and bottom of the STEP segment can dilate over time and form blind loops↗
▶Ep 66 · 16:56
quoteI don't step the duodenum. I start where the bowel starts to dilate.↗
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1
▶Ep 67 · 4:18
epidemiologicalThe majority of pediatric short bowel syndrome cases present at birth due to neonatal causes: congenital GI anomalies or acquired conditions like necrotizing enterocolitis↗
▶Ep 67 · 5:42
clinicalWhen reestablishing bowel continuity, size discrepancy between bowel ends must be addressed or a functional obstruction will result even if the anastomosis is patent↗
▶Ep 67 · 5:42
quoteIf you are thinking of reestablishing continuity, I feel very strongly that you have to deal with the size discrepancy.↗
▶Ep 67 · 6:02
clinicalIf adequate bowel length exists, size discrepancy can be managed by resection back to appropriate caliber or tapering enteroplasty↗
▶Ep 67 · 6:28
clinicalIn short bowel cases, serial transverse enteroplasty (STEP) can address size discrepancy without resecting mucosa↗
▶Ep 67 · 7:08
clinicalGastroschisis patients don't tend to do as well regardless of intervention; STEP procedures in gastroschisis patients consistently underperform↗
▶Ep 67 · 7:08
quoteIn general, gastroschisis, they don't tend to do as well regardless. If, and if I look at the step procedures that I've done over the years, the ones that tend to not do as well or tend to always be the gastroschisis.↗
▶Ep 67 · 9:09
quoteI don't usually do that operation anyway unless the bowel is an adequate diameter to make it worthwhile, and in my head over the years, it's always been about 5 centimeters anyway.↗
▶Ep 67 · 9:09
clinicalSTEP procedure requires bowel diameter of at least 5 centimeters to be worthwhile↗
▶Ep 67 · 9:50
clinicalIn scenarios where immediate anastomosis is not prudent, distal bowel can be accessed with a feeding tube to provide distal feeding and grow the bowel in caliber before a subsequent operation↗
▶Ep 67 · 10:45
clinicalThe STEP procedure was originally described by HP Kim and Tom Jackson↗
▶Ep 67 · 11:29
clinicalMaintaining bowel alignment during STEP is critical; there is risk of longitudinal twisting if alignment is not maintained↗
▶Ep 67 · 12:26
clinicalAn endo GIA stapler with vascular (white) load cartridge (2.5mm crimping to 1mm) is preferred over open GIA and prevents leaks better than the classic blue load↗
▶Ep 67 · 12:34
clinicalSTEP staple lines should be oriented perpendicular to the mesentery at 90 and 270 degrees (3 o'clock and 9 o'clock positions)↗
▶Ep 67 · 13:23
clinicalTarget bowel caliber after STEP is 1.5 cm in babies and 2 to 2.5 cm in older infants or children↗
▶Ep 67 · 13:36
clinicalMaking the bowel too narrow during STEP can cause obstruction, especially in patients with borderline motility↗
▶Ep 67 · 14:35
clinicalA U-stitch with 4-0 PDS should be placed in the crotch of each staple line to prevent potential leaks↗
▶Ep 67 · 15:08
clinicalDog ears (blind loops) can form at the top and bottom of the STEP segment where bowel transitions in and out, and these can dilate over time↗
▶Ep 67 · 16:51
clinicalThe duodenum should not be stepped; STEP should start where the bowel begins to dilate, usually distal to the duodenum↗
▶Ep 67 · 16:56
quoteI don't step the duodenum. I start where the bowel starts to dilate.↗
▶Ep 67 · 17:20
clinicalIf duodenal narrowing is needed, a stapler should be used on the lateral side away from the bile duct and ampulla; plication sutures usually fail↗
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 2
▶Ep 68 · 1:52
quoteI think we have to remember that the biggest benefit of the step, for instance, is the fact that you're tapering the bowel and reestablishing a more normal caliber to improve motility.↗
▶Ep 68 · 1:52
clinicalThe biggest benefit of the STEP procedure is tapering the bowel and reestablishing a more normal caliber to improve motility↗
▶Ep 68 · 3:04
clinicalIt can take up to 6 months before significant improvement in absorptive capacity is seen after STEP↗
▶Ep 68 · 3:04
quoteIt can take up to 6 months before you actually start to see a significant improvement in absorptive capacity.↗
▶Ep 68 · 3:12
clinicalAbsorptive capacity improvement is measured with fecal fat, alpha-1 antitrypsin clearance, xylose absorption, and citrulline levels↗
▶Ep 68 · 3:24
clinicalThe delay in improvement is due to inflamed, sick, leaky mucosa in the setting of bacterial overgrowth needing time to heal↗
▶Ep 68 · 6:24
clinicalStaple-line ulcer bleeding is an underreported complication that is difficult to manage↗
▶Ep 68 · 6:49
quoteMy hypothesis is that this is a microbiome problem. I think you have a pro-inflammatory environment.↗
▶Ep 68 · 6:52
clinicalStaple-line ulcers tend to occur in type 2 anatomy (small bowel to colonic remnant in the absence of an intact colon ileocecal valve)↗
▶Ep 68 · 7:12
clinicalPathology of staple-line ulcers shows non-specific inflammation with no vasculitis, viral elements, or obvious ischemia↗
▶Ep 68 · 7:12
quoteIt's non-specific inflammation. There's no vasculitis, there's no viral elements, there's no obvious ischemia, and the management can be super difficult.↗
▶Ep 68 · 10:05
clinicalMost referrals for intestinal failure have had multiple operations before coming to a specialized center↗
▶Ep 68 · 10:09
opinionSurgical planning may not be conducive to just one operation and may require setting up for the next case↗
Intestinal Rehabilitation, Episode 6: Cholestasis
▶Ep 73 · 1:09
quoteInstitutionally defined it as a conjugated bilirubin greater than 3 mg per deciliter or 50 micromoles per liter sustained for 2 weeks and not associated with a septic event.↗
▶Ep 73 · 1:09
guidelineCholestasis is institutionally defined as conjugated bilirubin greater than 3 mg/dL or 50 micromoles/L sustained for 2 weeks and not associated with a septic event↗
▶Ep 73 · 1:20
guidelineA 2021 JPN publication defines cholestasis as conjugated bilirubin around 2 mg/dL or 34 micromoles/L for 2 weeks, not associated with a septic event↗
▶Ep 73 · 2:57
quoteIn the setting of young children, it's more of a cholestatic liver disease, whereas in older people, adolescents and adults, they tend to have Steatosis, there's a fatty deposition within the liver, and the term we use now is intestinal failure associated liver disease because that sort of indicates that it's a multifactorial process.↗
▶Ep 73 · 2:57
clinicalIn young children, intestinal failure causes cholestatic liver disease, whereas in adolescents and adults it tends to cause steatosis (fatty deposition)↗
▶Ep 73 · 3:30
clinicalPrematurity is not modifiable by the clinical team, but other risk factors (enteral feeding, sepsis, TPN components) are modifiable↗
▶Ep 73 · 3:30
quoteNow, prematurity, we as clinicians, as a team, we don't have much control over that. But the other factors are modifiable, and we can have an impact on that.↗
▶Ep 73 · 4:09
clinicalPrevention requires aggressive introduction of enteral feeding and surgical procedures to optimize anatomy for feed delivery↗
▶Ep 73 · 7:08
clinicalConventional intralipid (soybean-based) when metabolized leads to production of prostaglandins and eicosanoids that are pro-inflammatory↗
▶Ep 73 · 7:19
clinicalSMOF lipid promotes bile flow, is hepatoprotective, and can be delivered at conventional dose while supporting somatic growth and neurologic development↗
▶Ep 73 · 7:45
clinicalSMOF lipid does not have enough arachidonic acid, so dose restriction can lead to essential fatty acid deficiency↗
▶Ep 73 · 7:57
clinicalWhen SMOF is delivered at conventional dosing, nobody develops essential fatty acid deficiency↗
▶Ep 73 · 8:06
guidelineRecommended lipid dosing is settling around 2.5 g/kg, but nutrition guidelines for preterms and babies state 3-4 g/kg/day↗
▶Ep 73 · 8:29
opinionA bilirubin of 2 mg/dL is not advanced liver disease, is not dangerous, and is usually transient; approximately 90% of patients will improve with observation alone↗
▶Ep 73 · 8:52
quoteMy opinion is that a billy of 2 is not by any stretch advanced liver disease, and it's not dangerous, and it's usually transient. So I personally would not change the lipid emulsion out of Billy to.↗
▶Ep 73 · 12:11
clinicalLiver biopsy is commonly performed during secondary surgical or autologous reconstruction procedures to provide an up-to-date microscopic snapshot↗
▶Ep 73 · 13:00
clinicalElastography or fibroscan is available for monitoring but is good for mild/no fibrosis or very advanced fibrosis; it is less sensitive for patients in the middle range↗
▶Ep 73 · 13:31
clinicalOutpatient follow-up frequency for children on TPN at home ranges from every 1-4 months depending on patient stability↗
Intestinal Rehabilitation, Episode 7: Refeeding in a neonatal patient
▶Ep 79 · 0:57
quoteEven if a kid has a complicated disease process, one of our goals as a team is to try to establish the most normal feeding habits we can that not only promote gut function and everything else, but also to optimize quality of life and the importance of the social aspects of eating that we all experience with our families and friends.↗
▶Ep 79 · 0:57
clinicalRefeeding goals include establishing normal feeding habits to promote gut function and optimize quality of life and social aspects of eating↗
▶Ep 79 · 4:34
clinicalIn short bowel syndrome, protein absorption is fairly well preserved, so the benefit of hydrolyzed or amino acid formulas is primarily from an allergy perspective↗
▶Ep 79 · 5:04
clinicalLong-chain fat is a stronger driver for intestinal adaptation than MCT↗
▶Ep 79 · 6:06
clinicalOne milliliter of parenteral nutrition is not isocaloric with one milliliter of formula↗
▶Ep 79 · 6:06
quoteYou're right, and they're not isocaloric, and so 1 mL of PN is not 1 mL of formula.↗
▶Ep 79 · 6:11
clinicalAdvancing enteral feeds beyond 100-120 mL/kg can cause problems with sodium and calcium in addition to calorie and protein deficits, because milk composition differs from parenteral solution↗
▶Ep 79 · 8:05
guidelineBolus feeds are preferred as the default feeding method; patients should fail bolus feeds before transitioning to continuous feeds as the sole delivery mode↗
▶Ep 79 · 8:05
guidelineContinuous feeds can be used as a supplemental approach, with bolus feeds during the day and continuous feeds overnight↗
▶Ep 79 · 8:40
quoteOne thing I just want to say about oral feeding is that even in the scenario where it's really non-nutritive. I think it's important for people to sort of look at that oral feeding, not so much as an internal nutrition perspective, but more of a skill development perspective that they never learn how to eat by mouth and suck and swallow and process, then they won't eat solids later when you want them to, and you're stuck basically with tube feeding on an older child.↗
▶Ep 79 · 8:40
clinicalOral feeding is important for skill development even when non-nutritive; children who never learn to suck, swallow, and process food by mouth will not eat solids later and will remain tube-dependent↗
▶Ep 79 · 12:17
clinicalDistally fed bowel has improved size discrepancy at the time of anastomosis because the bowel has been used↗
▶Ep 79 · 13:51
clinicalA gastric tube provides versatility for nutrition supplementation, medication delivery, and venting for gassy or bloated patients to improve enteral tolerance↗
Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient
▶Ep 80 · 1:24
quoteThe benefit in the curse in a patient like that is that they do know how to eat.↗
▶Ep 80 · 1:24
opinionOlder patients who have established eating behavior before bowel loss have both a benefit and curse in that they know how to eat↗
▶Ep 80 · 1:50
opinionEven if a patient cannot be cured and weaned off TPN, compromises should be made to optimize quality of life↗
▶Ep 80 · 1:50
quoteSo even if you can't cure this patient and get them off TPN. It's important to make compromises to optimize quality of life the best you can.↗
▶Ep 80 · 2:14
clinicalThe general strategy is to push macronutrient modules of protein and fat which are well tolerated↗
▶Ep 80 · 2:21
clinicalMost short bowel patients don't tolerate simple sugars very well↗
▶Ep 80 · 2:21
quoteMost of these kids don't tolerate simple sugars very well.↗
▶Ep 80 · 2:25
clinicalPushing solids and minimizing fluid intake helps reduce dumping↗
▶Ep 80 · 2:31
clinicalSmaller meals more frequently of solids separated from liquids and minimization of simple sugars is the recommended approach↗
▶Ep 80 · 2:52
clinicalPatients who have transitioned off TPN often come back with problems when diet history reveals they have gotten loose with diet choices↗
▶Ep 80 · 3:31
clinicalMinimizing sugars reduces symptoms related to bacterial overgrowth such as bloating and gas↗
▶Ep 80 · 3:48
clinicalFluid losses whether by stoma or other source must be replaced↗
▶Ep 80 · 3:56
clinicalIf patients are on IV support, some fluid can be replaced intravenously↗
▶Ep 80 · 4:01
clinicalWhen trying to wean off IV support, keeping patients hydrated through enteral replacements is important↗
▶Ep 80 · 4:11
clinicalFluid transport requires sodium and glucose, so replacement solution must contain both↗
▶Ep 80 · 4:11
quoteFor transport requires sodium and glucose, and so your solution that you're replacing with has to contain some glucose and some salt.↗
▶Ep 80 · 4:48
clinicalGatorade doesn't work well for rehydration because it has too much sugar↗
clinicalSome kids end up back on parenteral support to get through puberty↗
▶Ep 80 · 6:33
clinicalWhen not growing anymore as an adult, borderline or marginal gut function is often enough to sustain them↗
▶Ep 80 · 7:22
clinicalAfter getting off TPN, patients often get into trouble with micronutrient deficiencies↗
▶Ep 80 · 8:51
clinicalWeight must be balanced with height as a growth metric↗
▶Ep 80 · 8:57
clinicalThis population commonly shows round babies where weight for height is elevated↗
▶Ep 80 · 9:01
clinicalThere is increasing data looking at quality of weight - how much is fat weight versus lean body mass↗
Advancements in Pediatric Intestinal Failure: Innovative Therapies and Improved Outcomes
▶Ep 108 · 5:23
clinicalLiver disease in intestinal failure ranges from mild cholestasis to profound steatosis in older children or adolescents and adults, with ongoing inflammation, fibrosis, and ultimately cirrhosis↗
▶Ep 108 · 5:41
clinicalRisk 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↗
▶Ep 108 · 6:12
clinicalIntestinal rehab programs improve outcomes through integration of care, improved communication, and better continuity↗
▶Ep 108 · 6:54
quoteWhat we ask our Families to do at home is significant.↗
▶Ep 108 · 7:11
quoteWe educate and empower our parents because we've all seen. High-quality families that over time demonstrate evidence of burnout.↗
▶Ep 108 · 7:25
epidemiologicalLiterature shows improvement of outcomes with intestinal rehab programs including improved survival related to liver dysfunction, decreased septic episodes, reduction in central line complications, reduced ICU admissions, and patients coming off transplant lists↗
▶Ep 108 · 8:02
clinicalLipids 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↗
▶Ep 108 · 8:15
clinicalSoybean-based lipid emulsions have high phytosterol content, high omega-6 long chain polyunsaturated fatty acid content, and low antioxidant content↗
▶Ep 108 · 8:31
clinicalProlonged soybean-based lipid exposure is associated with deterioration of liver dysfunction, specifically cholestasis↗
▶Ep 108 · 8:51
clinicalFor every day an infant is exposed to soybean lipid dosed at greater than 2.5 g per kilo per day, there is a 3% increase in the odds ratio of developing advanced liver disease↗
▶Ep 108 · 8:51
quoteFor every day that an infant is exposed to soybean lipid dosed at greater than 2.5 g per kilo per day, which is more conventional dosing. That is associated with a 3% increase in the odds ratio of developing advanced liver disease.↗
▶Ep 108 · 9:51
clinicalOmega-6 lipids are metabolized to arachidonic acid, which produces leukotrienes and prostaglandins with a more pro-inflammatory profile↗
▶Ep 108 · 10:01
clinicalOmega-3 lipids are metabolized through EPA and DHA and lead to production of cytokines with a less inflammatory profile↗
▶Ep 108 · 10:15
clinicalOmega-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↗
▶Ep 108 · 10:42
clinicalRestricting soybean lipid exposure improves cholestasis when dosed at 1 g per kilo per day or less↗
▶Ep 108 · 11:00
clinicalIn preterm 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↗
▶Ep 108 · 11:22
clinicalDHA and arachidonic acid are important for retinal and brain development↗
▶Ep 108 · 11:26
quoteNone of the lipid emulsions today were designed for premature babies. They were all designed for adults in a critical care setting.↗
▶Ep 108 · 11:26
clinicalNone of the current lipid emulsions were designed for premature babies; they were all designed for adults in a critical care setting↗
▶Ep 108 · 12:03
quoteSo our patients with central lines, it's literally their lifeline. And without venous access, we can't support our families.↗
▶Ep 108 · 12:24
epidemiologicalThere are approximately 240,000 central line-associated bloodstream infections in the United States annually, with each costing about $30,000, totaling about $2 billion per year nationwide↗
▶Ep 108 · 12:48
clinical4% tetrasodium EDTA (kite lock) is an antithrombotic, anti-fibrinolytic, and antimicrobial that satisfies all three criteria important for a good lock solution↗
▶Ep 108 · 13:23
clinicalKite lock is licensed in Europe and Australia but not available in the United States↗
▶Ep 108 · 13:29
clinicalA multi-center randomized trial of kite lock versus heparin went live 4 weeks ago and is actively recruiting patients↗
▶Ep 108 · 13:58
clinicalIn short bowel syndrome, there are 3 anatomical subtypes: Type 1 is high jejunostomy, Type 2 has lost distal small bowel and ileum with small bowel-colonic anastomosis, and Type 3 has lost mid-small bowel but retains some ileum and intact colon↗
▶Ep 108 · 14:26
epidemiologicalThe most common anatomical subtype of short bowel syndrome in pediatrics is Type 2↗
▶Ep 108 · 14:33
clinicalType 1 and Type 2 short bowel syndrome patients struggle because they lack an ileum, which is where GLP-2 is naturally produced↗
▶Ep 108 · 14:53
clinicalNative GLP-2 hormone has a half-life of 7 minutes, making it impractical for clinical use↗
▶Ep 108 · 14:58
clinicalTeduglutide 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↗
▶Ep 108 · 15:23
clinicalPatients receiving teduglutide show a 40% reduction in TPN fluid and calorie requirements over a six-month period↗
▶Ep 108 · 15:32
clinical70% of patients receiving teduglutide achieved the study endpoint of a 20% reduction in TPN requirements↗
▶Ep 108 · 15:48
clinicalTeduglutide is licensed for children greater than 1 year of age↗
▶Ep 108 · 16:02
clinicalApraglutide is another GLP-2 analog with a longer half-life that can be given once a week and works even better than teduglutide, producing more bowel lengthening↗
▶Ep 108 · 16:36
epidemiologicalThese interventions have led to a decrease in transplantation since 2008, largely because of the successes of intestinal rehabilitation↗
▶Ep 108 · 16:41
epidemiologicalOutcomes of intestinal transplant at 5 years are about 65%↗
▶Ep 108 · 16:49
quoteWhatever we can do to avoid transplant and lifelong immunosuppression, that is our goal.↗
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
▶Ep 5 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program.↗
▶Ep 5 · 2:03
quoteIt it's, it's really a functional problem. Essentially, when someone's gut for whatever the diagnosis, whatever the reason, their gut function is insufficient to absorb enough nutrients, fluids, calories to support survival and in the in the case of children, growth, which is a big distinction between adults and children.↗
▶Ep 5 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 5 · 3:03
quotean intestinal rehabilitation program, as we defined also in these Aspen guidelines that just came out, is a multidisciplinary or interdisciplinary collaborative patient care paradigm that that brings coordinated care for children with intestinal failure through comprehensive management of Their specialized nutrition and other associated needs that they have.↗
▶Ep 5 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm providing coordinated care for children with intestinal failure through comprehensive management of specialized nutrition and associated needs↗
▶Ep 5 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management.↗
▶Ep 5 · 4:39
quotePatients that are gonna come to intestinal rehab program have intestinal failure, and we can divide the causes of intestinal failure into three categories.↗
▶Ep 5 · 4:50
quoteThere's short bowel syndrome, which by far is the most common category in pediatric patients with intestinal failure↗
▶Ep 5 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 5 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 5 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis cause short bowel syndrome↗
▶Ep 5 · 5:45
clinicalMotility disorders occur when abnormalities of the intestinal muscle itself or the nerves that control that muscle prevent coordinated movement of food and stool↗
▶Ep 5 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle.↗
▶Ep 5 · 6:10
clinicalChildren with motility disorders are dependent on intravenous support↗
▶Ep 5 · 6:17
quotethese are conditions where the patient has all of their bowel, but the mucosa, the inside lining that, that absorbs, uh, digests and absorbs doesn't work.↗
▶Ep 5 · 6:17
clinicalEnteropathies or congenital diarrheas are conditions where the patient has all of their bowel but the mucosal lining that digests and absorbs does not work↗
▶Ep 5 · 7:11
quoteThe reason it's important to at least identify these three categories is that some patients will have elements of 12, or 3 of the categories, the way they present.↗
▶Ep 5 · 7:11
clinicalSome patients will have elements of one, two, or all three categories of intestinal failure↗
▶Ep 5 · 7:45
epidemiologicalMost intestinal failure patients are infants or babies, but some older kids develop intestinal failure↗
▶Ep 5 · 7:56
clinicalInflammatory bowel disease or Crohn's disease can lead to gut loss and intestinal failure in older patients↗
▶Ep 5 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 5 · 12:46
quoteBut now what we're seeing is we have kids that have developed chronic comorbidities, that comorbidities that never, we didn't really see to the same extent because they didn't live long enough.↗
▶Ep 5 · 12:46
clinicalLong-term survivors now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
▶Ep 6 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program↗
▶Ep 6 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 6 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and associated needs↗
▶Ep 6 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management↗
▶Ep 6 · 3:55
opinionIntestinal rehabilitation streamlines care and improves communication with families and between care providers and team members↗
▶Ep 6 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 6 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 6 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis can cause short bowel syndrome↗
▶Ep 6 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle↗
▶Ep 6 · 5:45
clinicalMotility disorders occur when the bowel is unable to push contents through in a coordinated way due to abnormalities of the muscle itself or the nerves that control that muscle↗
▶Ep 6 · 6:17
clinicalCongenital enteropathies are conditions where the patient has all of their bowel but the mucosa does not work, leading to hypersecretion and profuse fluid losses↗
▶Ep 6 · 7:11
clinicalSome patients will have elements of two or three categories of intestinal failure in the way they present↗
▶Ep 6 · 7:56
clinicalOlder pediatric patients can develop intestinal failure from inflammatory bowel disease or Crohn's disease where they have lost gut as a result of complications↗
▶Ep 6 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 6 · 12:46
clinicalChildren with intestinal failure who survive long-term now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
▶Ep 3 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program.↗
▶Ep 3 · 2:03
quoteIt it's, it's really a functional problem. Essentially, when someone's gut for whatever the diagnosis, whatever the reason, their gut function is insufficient to absorb enough nutrients, fluids, calories to support survival and in the in the case of children, growth, which is a big distinction between adults and children.↗
▶Ep 3 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 3 · 3:03
quotean intestinal rehabilitation program, as we defined also in these Aspen guidelines that just came out, is a multidisciplinary or interdisciplinary collaborative patient care paradigm that that brings coordinated care for children with intestinal failure through comprehensive management of Their specialized nutrition and other associated needs that they have.↗
▶Ep 3 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm providing coordinated care for children with intestinal failure through comprehensive management of specialized nutrition and associated needs↗
▶Ep 3 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management.↗
▶Ep 3 · 4:39
quotePatients that are gonna come to intestinal rehab program have intestinal failure, and we can divide the causes of intestinal failure into three categories.↗
▶Ep 3 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 3 · 4:50
quoteThere's short bowel syndrome, which by far is the most common category in pediatric patients with intestinal failure↗
▶Ep 3 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 3 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis cause short bowel syndrome↗
▶Ep 3 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle.↗
▶Ep 3 · 5:45
clinicalMotility disorders occur when abnormalities of the intestinal muscle itself or the nerves that control that muscle prevent coordinated movement of food and stool↗
▶Ep 3 · 6:10
clinicalChildren with motility disorders are dependent on intravenous support↗
▶Ep 3 · 6:17
clinicalEnteropathies or congenital diarrheas are conditions where the patient has all of their bowel but the mucosal lining that digests and absorbs does not work↗
▶Ep 3 · 6:17
quotethese are conditions where the patient has all of their bowel, but the mucosa, the inside lining that, that absorbs, uh, digests and absorbs doesn't work.↗
▶Ep 3 · 7:11
clinicalSome patients will have elements of one, two, or all three categories of intestinal failure↗
▶Ep 3 · 7:11
quoteThe reason it's important to at least identify these three categories is that some patients will have elements of 12, or 3 of the categories, the way they present.↗
▶Ep 3 · 7:45
epidemiologicalMost intestinal failure patients are infants or babies, but some older kids develop intestinal failure↗
▶Ep 3 · 7:56
clinicalInflammatory bowel disease or Crohn's disease can lead to gut loss and intestinal failure in older patients↗
▶Ep 3 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 3 · 12:46
clinicalLong-term survivors now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
▶Ep 3 · 12:46
quoteBut now what we're seeing is we have kids that have developed chronic comorbidities, that comorbidities that never, we didn't really see to the same extent because they didn't live long enough.↗
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
▶Ep 4 · 1:46
quotelet's go back one step before that and sort of define what is intestinal failure because that sort of leads into who's going to benefit from an intestinal rehab program↗
▶Ep 4 · 2:05
clinicalIntestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth↗
▶Ep 4 · 3:03
clinicalAn intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and associated needs↗
▶Ep 4 · 3:44
quoteIt's an amalgamation of experts that come from different aspects of care, providing a holistic, comprehensive, coordinated approach to patient management↗
▶Ep 4 · 3:55
opinionIntestinal rehabilitation streamlines care and improves communication with families and between care providers and team members↗
▶Ep 4 · 4:50
epidemiologicalShort bowel syndrome is by far the most common category of intestinal failure in pediatric patients↗
▶Ep 4 · 5:06
clinicalCauses of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease↗
▶Ep 4 · 5:18
clinicalAcquired diseases of the newborn such as necrotizing enterocolitis can cause short bowel syndrome↗
▶Ep 4 · 5:45
quoteSo if we think of the intestine like a pipe, and that pipe is made of muscle that contracts in a coordinated way to push food and stool from one end to the other, you can have abnormalities of the muscle itself, or of the nerves that control that muscle↗
▶Ep 4 · 5:45
clinicalMotility disorders occur when the bowel is unable to push contents through in a coordinated way due to abnormalities of the muscle itself or the nerves that control that muscle↗
▶Ep 4 · 6:17
clinicalCongenital enteropathies are conditions where the patient has all of their bowel but the mucosa does not work, leading to hypersecretion and profuse fluid losses↗
▶Ep 4 · 7:11
clinicalSome patients will have elements of two or three categories of intestinal failure in the way they present↗
▶Ep 4 · 7:56
clinicalOlder pediatric patients can develop intestinal failure from inflammatory bowel disease or Crohn's disease where they have lost gut as a result of complications↗
▶Ep 4 · 8:04
epidemiologicalTrauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics↗
▶Ep 4 · 12:46
clinicalChildren with intestinal failure who survive long-term now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues↗
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1
▶Ep 5 · 4:18
epidemiologicalThe majority of pediatric short bowel syndrome cases present at birth due to neonatal causes: congenital GI anomalies or acquired conditions like necrotizing enterocolitis↗
▶Ep 5 · 5:42
quoteIf you are thinking of reestablishing continuity, I feel very strongly that you have to deal with the size discrepancy.↗
▶Ep 5 · 5:42
clinicalWhen reestablishing bowel continuity, size discrepancy between bowel ends must be addressed or a functional obstruction will result even if the anastomosis is patent↗
▶Ep 5 · 6:02
clinicalIf adequate bowel length exists, size discrepancy can be managed by resection back to appropriate caliber or tapering enteroplasty↗
▶Ep 5 · 6:28
clinicalIn short bowel cases, serial transverse enteroplasty (STEP) can address size discrepancy without resecting mucosa↗
▶Ep 5 · 7:08
clinicalGastroschisis patients don't tend to do as well regardless of intervention; STEP procedures in gastroschisis patients consistently underperform↗
▶Ep 5 · 7:08
quoteIn general, gastroschisis, they don't tend to do as well regardless. If, and if I look at the step procedures that I've done over the years, the ones that tend to not do as well or tend to always be the gastroschisis.↗
▶Ep 5 · 9:09
clinicalSTEP procedure requires bowel diameter of at least 5 centimeters to be worthwhile↗
▶Ep 5 · 9:09
quoteI don't usually do that operation anyway unless the bowel is an adequate diameter to make it worthwhile, and in my head over the years, it's always been about 5 centimeters anyway.↗
▶Ep 5 · 9:50
clinicalIn scenarios where immediate anastomosis is not prudent, distal bowel can be accessed with a feeding tube to provide distal feeding and grow the bowel in caliber before a subsequent operation↗
▶Ep 5 · 10:45
clinicalThe STEP procedure was originally described by HP Kim and Tom Jackson↗
▶Ep 5 · 11:29
clinicalMaintaining bowel alignment during STEP is critical; there is risk of longitudinal twisting if alignment is not maintained↗
▶Ep 5 · 12:26
clinicalAn endo GIA stapler with vascular (white) load cartridge (2.5mm crimping to 1mm) is preferred over open GIA and prevents leaks better than the classic blue load↗
▶Ep 5 · 12:34
clinicalSTEP staple lines should be oriented perpendicular to the mesentery at 90 and 270 degrees (3 o'clock and 9 o'clock positions)↗
▶Ep 5 · 13:23
clinicalTarget bowel caliber after STEP is 1.5 cm in babies and 2 to 2.5 cm in older infants or children↗
▶Ep 5 · 13:36
clinicalMaking the bowel too narrow during STEP can cause obstruction, especially in patients with borderline motility↗
▶Ep 5 · 14:35
clinicalA U-stitch with 4-0 PDS should be placed in the crotch of each staple line to prevent potential leaks↗
▶Ep 5 · 15:08
clinicalDog ears (blind loops) can form at the top and bottom of the STEP segment where bowel transitions in and out, and these can dilate over time↗
▶Ep 5 · 16:51
clinicalThe duodenum should not be stepped; STEP should start where the bowel begins to dilate, usually distal to the duodenum↗
▶Ep 5 · 16:56
quoteI don't step the duodenum. I start where the bowel starts to dilate.↗
▶Ep 5 · 17:20
clinicalIf duodenal narrowing is needed, a stapler should be used on the lateral side away from the bile duct and ampulla; plication sutures usually fail↗
