Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Intestinal Failure with Dr. Brad Warner
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Discussion with Dr. Brad W. Warner about intestinal failureWhat is intestinal failure?An umbrella term for when the small bowel is unable to digest and absorb an adequate amount of nutrients to sustain a patient through enteral means alone.
podcast52:46 · Dec 2020
Intestinal Failure with Dr. Brad Warner
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Dr. Brad Warner discusses intestinal failure management in pediatric patients, covering diagnostic criteria, bowel length thresholds for survival, and long-term outcomes. Key topics include short bowel syndrome following necrotizing enteroc
podcast52:46 · Jan 2019
Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1
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We're back with a new episode from the Intestinal Rehabilitation Center at Cincinnati Children's Hospital. This time we're talking about enteral autonomy with Drs. Helmrath and Wales. This is the first of two parts on this topic, stay tuned
podcast16:18 · Mar 2022
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Short gut syndrome happens when a baby or child doesn't have enough small intestine to absorb the nutrition and fluids they need to grow [e296-c1, e927-c1]. The most common reasons children develop this condition include necrotizing enterocolitis (a serious intestinal disease in premature babies), gastroschisis (a birth defect where intestines develop outside the body), midgut volvulus (a twisted intestine), and intestinal atresias (blockages present at birth) [e296-c11, e927-c10]. When babies are born very early, their intestines are still growing—a 24-25 week premature infant with only 20-25 cm of bowel will likely grow to at least 50 cm just from normal development . Doctors explained that the remaining intestine can adapt over one to two years by growing longer, developing better blood supply, and becoming more efficient at absorbing nutrients [e296-c9, e5141-c5, e5141-c6]. According to research on children who need long-term IV nutrition (TPN) for short gut syndrome, about half can eventually stop needing it, a quarter may need a transplant, and a quarter may not survive [e296-c7, e927-c6]. The main causes of death include liver failure, infections from IV lines or bacterial overgrowth, bleeding from liver disease, and loss of IV access [e296-c8, e927-c7]. Recent advances in care—including specialized nutrition teams, better IV nutrition formulas, infection prevention strategies, and sometimes surgical procedures to lengthen or reshape the bowel—have improved outcomes, with 60-80% of patients now achieving independence from IV nutrition [e5141-c20, e927-c33].
Short gut syndrome happens when a baby or child doesn't have enough small intestine to absorb the nutrition and fluids they need to grow [e296-c1, e927-c1]. The most common reasons children develop this condition include necrotizing enterocolitis (a serious intestinal disease in premature babies), gastroschisis (a birth defect where intestines develop outside the body), midgut volvulus (a twisted intestine), and intestinal atresias (blockages present at birth) [e296-c11, e927-c10]. When babies are born very early, their intestines are still growing—a 24-25 week premature infant with only 20-25 cm of bowel will likely grow to at least 50 cm just from normal development . Doctors explained that the remaining intestine can adapt over one to two years by growing longer, developing better blood supply, and becoming more efficient at absorbing nutrients [e296-c9, e5141-c5, e5141-c6]. According to research on children who need long-term IV nutrition (TPN) for short gut syndrome, about half can eventually stop needing it, a quarter may need a transplant, and a quarter may not survive [e296-c7, e927-c6]. The main causes of death include liver failure, infections from IV lines or bacterial overgrowth, bleeding from liver disease, and loss of IV access [e296-c8, e927-c7]. Recent advances in care—including specialized nutrition teams, better IV nutrition formulas, infection prevention strategies, and sometimes surgical procedures to lengthen or reshape the bowel—have improved outcomes, with 60-80% of patients now achieving independence from IV nutrition [e5141-c20, e927-c33].
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Intestinal Failure with Dr. Brad Warner
Intestinal failure is an umbrella term for when the small intestine is unable to absorb or digest enough nutrition to support the patient entirely by oral or enteral feeding.
clinicalBrad Warner1:42 ↗
The intestine of a newborn or fetus doubles in length in the last trimester of gestation.
clinicalBrad Warner3:03 ↗
For a neonate with an ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for potential salvageability.
clinicalBrad Warner4:03 ↗
Without the colon and ileocecal valve, at least 15 to 20 centimeters of small intestine would be needed for potential salvageability in neonates.
clinicalBrad Warner4:37 ↗
In adult studies, adults with less than 50 centimeters of intestine have about 40% mortality after 5 to 10 years.
epidemiologicalBrad Warner4:51 ↗
According to Pediatric Intestinal Failure Research Consortium data, approximately 25% of children with short gut syndrome die, 25% need a transplant, and 50% can wean off TPN.
epidemiologicalBrad Warner6:38 ↗
The most common causes of death in intestinal failure include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access.
clinicalBrad Warner7:11 ↗
Intestinal adaptation in humans probably takes place over about a year or two after small bowel resection.
clinicalBrad Warner7:49 ↗
Stool outputs of up to 40 cc per kilo per day are acceptable when advancing enteral feeding; beyond that threshold, enteral feeding should be reduced.
clinicalBrad Warner8:30 ↗
The most common causes of short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias, with trauma and inflammatory bowel disease further down the list.
epidemiologicalBrad Warner9:22 ↗
For TPN, the goal is about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and the remainder from fat and protein.
clinicalBrad Warner10:22 ↗
TPN should provide about 2 to 3 grams of protein per kilo per day and about 2 to 3 grams of fat per kilo per day.
clinicalBrad Warner10:45 ↗
Babies should gain about 20 to 30 grams a day, which approximates in utero weight gain for a newborn.
clinicalBrad Warner12:05 ↗
Lipid reduction strategy involves reducing fat from 2-3 g/kg/day given daily down to about 1 g/kg/day delivered twice or three times a week, which has been effective in reducing TPN-associated cholestasis.
clinicalBrad Warner12:53 ↗
Omegaven is a fish oil-based fat containing primarily omega-3 fatty acids that are anti-inflammatory, in contrast to soybean-based intralipid which contains pro-inflammatory omega-6 fatty acids.
clinicalBrad Warner13:46 ↗
SMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has recently been FDA approved in the United States.
clinicalBrad Warner15:08 ↗
Breast milk is the best choice for neonates because it contains proper fat composition plus growth factors such as epidermal growth factor and insulin-like growth factors that promote adaptation.
opinionBrad Warner18:11 ↗
Complex formulas fed enterally may stimulate adaptation better than elemental formulas because they cause secretion of enterotrophic hormones to a greater extent.
opinionBrad Warner19:26 ↗
There is a threshold percentage of enteral calories that prevents the onset of TPN-related liver damage, though the exact number is unknown; 90% enteral feeding carries far less risk than 10% enteral feeding.
clinicalBrad Warner20:56 ↗
Surgical intervention should be considered when patients regress in enteral tolerance (e.g., tolerating 50% enteral a month ago but now down to 20%), when there are multiple episodes of sepsis with abdominal distention and dilated bowel loops, or when the child develops jaundice.
clinicalBrad Warner22:33 ↗
Dilated bowel loops greater than 4 to 5 centimeters in diameter, combined with failure to advance enteral feeds or regression, is an indication for surgical intervention.
clinicalBrad Warner25:43 ↗
Less than 5 to 10% of patients with over 100 centimeters of intestine should require TPN, suggesting an underlying motility or mucosal problem if they remain TPN-dependent.
clinicalBrad Warner27:53 ↗
The STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation because it is easier to perform with less risk of injuring the mesenteric blood supply.
clinicalBrad Warner29:31 ↗
The Bianchi procedure takes advantage of the bifurcating blood supply to the bowel wall, allowing longitudinal division to create two tubes of bowel, effectively doubling the length.
clinicalBrad Warner30:00 ↗
STEP procedures can redilate and require redo operations, and outcomes are not as good when a STEP needs to be redone compared to never needing a redo.
clinicalBrad Warner32:54 ↗
A Bianchi can be performed first, then a STEP can be done later if needed, but a Bianchi cannot be done after a STEP has been performed (unless the STEP was inadequate).
clinicalBrad Warner33:26 ↗
Tapering should be considered for children with dilated bowel who have at least 90 to 100 centimeters of intestinal length.
clinicalBrad Warner38:21 ↗
Teduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1 to 2 liters per week.
clinicalBrad Warner43:45 ↗
Growth hormone and glutamine combinations have been administered to patients, but results are primarily mixed and it hasn't been a huge advance in weaning TPN.
clinicalBrad Warner45:40 ↗
Current survival for small bowel transplant is about 50 to 60% at 5 years, with one-year survivals now above 70 to 80%.
epidemiologicalBrad Warner46:51 ↗
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