20 views 0 likes

Dr. CCHMC Pediatric Surgery

GCMD Space · View profile →

Intestinal Rehabilitation Webinar 2023 - Top 5 Key Takeaways

Video Published 2024-06-24 Updated 2026-08-01

Timestops (7)

Introduction to Pediatric Short Bowel Syndrome

Intestinal Length and Growth in Children

Bowel Function and Adaptation Physiology

Surgical Strategy for Intestinal Loss

Enteral Nutrition and Feeding Approaches

Formula Selection and Breast Milk

Lipid Management and Fat Composition

Topic Overview

This webinar summary presents five key principles for managing pediatric intestinal failure and short bowel syndrome, delivered by experts from Cincinnati Children's Hospital Intestinal Rehabilitation Center. The discussion emphasizes that infants have tremendous gut growth potential, with small bowel length nearly tripling from birth to age five, making percentage of expected gut length more prognostically relevant than absolute centimeters. Preservation of the distal ileum and proximal colon is prioritized over the ileocecal valve itself, as these segments drive bile reclamation and produce critical hormones like GLP-2. Surgical strategy focuses on proximal diversion to enable early feeding while preserving questionable bowel for later reconstruction. Nutritional management favors enteral feeding with breast milk when possible, long-chain fats to stimulate GLP-2 release, and judicious use of parenteral nutrition with SMOF lipids, though SMOF may be suboptimal for preterm infants due to insufficient arachidonic acid for neurodevelopment.

Key Takeaways

Infants have tremendous gut growth potential—small bowel nearly triples from 160cm at birth to 425-450cm by age 5; assess residual bowel as percentage, not absolute length.
Distal ileum and proximal colon are critical for bile salt reclamation and incretin hormone production (GLP-2, PYY)—more important than ileocecal valve presence alone.
Staged surgical approach: provide proximal diversion to enable early enteral feeding while leaving questionable bowel in situ for potential healing at second-look operation.
Prioritize enteral nutrition with age-appropriate formulas (breast milk first) using bolus gastric feeds; if intolerant, feed post-pylorically and decompress stomach.
Enteral autonomy achievable with as little as 10% expected small bowel length if majority of colon remains in continuity—functionality matters more than length alone.

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Speaker 2 — host
Dr. Paul Weil — guest
Dr. Michael Helmrath — guest
Speaker 5

Chapters

0:00Introduction and Intestinal Growth Potential — Introduction to the webinar and first key takeaway: infants have tremendous gut growth potential, with bowel length tripling from birth to age five, making percentage of expected gut length the appropriate prognostic measure rather than absolute centimeters.
2:18Importance of Distal Ileum and Functional Bowel — Discussion of the second key takeaway: the distal ileum and proximal colon are more critical than the ileocecal valve itself, as these segments enable bile reclamation and produce hormones like GLP-2, GLP-1, and PYY that drive adaptation.
3:21Surgical Strategy for Early Healing — Third key takeaway: surgical planning should prioritize proximal diversion to enable early feeding while preserving questionable bowel for potential use at later reconstructive procedures, as bowel deemed non-viable initially may heal and contribute significantly.
4:55Enteral Feeding Strategy and Formula Selection — Fourth key takeaway: enteral nutrition is preferred, with breast milk as first choice. Feeding strategy progresses from gastric bolus to continuous gastric to post-pyloric with gastric decompression if needed. Long-chain fats are preferred over MCT to stimulate GLP-2 release and drive adaptation.
8:47Parenteral Nutrition Management — Fifth key takeaway: parenteral nutrition management, including discussion of SMOF lipid emulsions, which lack sufficient arachidonic acid for preterm brain development. Cholestasis can be managed by reducing total fat or switching to omega-3-enriched lipids, with SMOF requiring minimum 2 g/kg/day dosing.
10:55Summary and Conclusion — Recap of the five key principles and closing remarks.

Key claims

0:49Young infants, babies, and young children have tremendous gut growth potential, with the gut growing for the first several years of life — Dr. Paul Weil
1:17A term baby will have 160 centimeters of small bowel, and by age 5 years it almost triples to about 425 to 450 centimeters — Dr. Paul Weil
1:51You can have as low as 10% expected gut length and still achieve enteral autonomy if you have the majority of your colon in continuity — Dr. Paul Weil
2:30The more important factor is the presence or absence of the distal small bowel or ileum and right colon that can act as reclamation of bile and support enterohepatic circulation — Dr. Michael Helmrath
2:43GLP-2, GLP-1, and hormones like PYY are produced in the distal ileum, not because of the ileocecal valve but because of the distal ileum itself — Dr. Michael Helmrath
3:29Strategy at the first operation should provide a pathway forward that allows early interval feeding — Dr. Michael Helmrath
3:38It is sometimes better to stage reconstruction under more controlled conditions rather than attempt immediate continuity — Dr. Michael Helmrath
4:02Many segments of bowel deemed non-usable actually have potential to heal in this population and can make a huge difference in the lifetime of the child — Dr. Michael Helmrath
4:26As long as you can divert proximally and the baby is stable, you can leave questionable bowel for potential use at later secondary reconstructive procedures — Speaker 5
5:08The overarching principle is to deliver adequate nutrition to have normal growth within normal parameters, ideally enterally — Dr. Paul Weil
5:28As much as possible, we should try to establish normal feeding behavior, realizing that enteral nutrition is more than just nutrition — Dr. Paul Weil
5:52If a patient needs tube support from the beginning, bolus feeding should be tried rather than defaulting to continuous feeding — Dr. Paul Weil
6:15If the child fails gastric approach (bolus then continuous), the strategy is to feed beyond the stomach and decompress the stomach through an NG tube — Dr. Paul Weil
6:42Breast milk is the formula of choice, not only for nutritional benefits but for all the other components within breast milk — Dr. Michael Helmrath
7:28Single amino acid level protein is the generalized preference to avoid high stool output, high fluid losses, wound breakdown, rashes, and emesis — Dr. Michael Helmrath
8:07Long chain fat is the preferred fat module rather than MCT, as long chain fat is a much stronger stimulus for GLP-2 release, which drives adaptation — Dr. Paul Weil
9:00Not every child needs to be on SMOF lipid emulsion — Dr. Paul Weil
9:03For preterm babies, SMOF is not the ideal lipid emulsion but is the best currently available — Dr. Paul Weil
9:16SMOF does not have enough arachidonic acid, which is really important for brain development — Dr. Paul Weil
9:34Two strategies to treat cholestasis are to reduce the total amount of fat or to change the composition to introduce SMOF lipids or omegaven — Speaker 5
9:50Lipid restrictions that reduce dose to 1 g/kg/day can reverse cholestasis but result in reduced calorie delivery that can impair growth and potentially impact neurocognitive development — Speaker 5
10:07Omegaven is essentially pure fish oil with omega-3 and is dosed at 1 g/kg, so babies take a calorie hit — Speaker 5
10:28SMOF lipids are a more well-balanced emulsion with an omega-3 to omega-6 ratio of 2.5 to 1, being less inflammatory than intralipid and promoting bile flow — Speaker 5
10:28SMOF lipids should not be restricted and must be given at no less than 2 or 2.5 g/kg/day — Speaker 5

Open questions

What are the newer lipid emulsions under research and development that may better serve preterm infants with adequate arachidonic acid?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Intestinal Rehabilitation in Infants: Surgical Strategy and Nutritional Management

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Teaching arc · AI-written, human-reviewed

Measure residual bowel as percentage, not absolute length

The gut triples in length during the first five years of life — a term baby has 160 centimeters of small bowel, which grows to 425-450 centimeters by age five 1:17. This growth potential means residual bowel must be expressed as a percentage of expected length for age, not in absolute centimeters 0:49. A child with 10% expected gut length can still achieve enteral autonomy if the majority of the colon remains in continuity 1:51. Quoting centimeters without age context obscures prognosis and misrepresents the child's adaptation potential.

The distal ileum matters more than the ileocecal valve

The presence or absence of the distal small bowel and right colon determines bile salt reclamation and enterohepatic circulation 2:30. The distal ileum produces GLP-2, GLP-1, and PYY — the hormones that drive intestinal adaptation 2:43. This is not about the ileocecal valve itself; it is about the functional capacity of the distal ileum and proximal colon. Papers that emphasize the valve miss the point.

Stage reconstruction to enable early feeding, not immediate continuity

The first operation should provide a pathway forward that allows early interval feeding 3:29. In cases of overwhelming intestinal loss, establish proximal control through diversion to permit feeding while leaving questionable bowel in situ 4:26. Many segments initially deemed non-viable have potential to heal and can make a substantial difference in the child's lifetime 4:02. It is sometimes better to stage reconstruction under controlled conditions rather than attempt immediate continuity 3:38. Plan for what the patient needs — T-tube, drain, proximal diversion — before operating.

Progress feeding routes systematically: gastric bolus first, post-pyloric last

The goal is adequate nutrition for normal growth, delivered enterally whenever possible 5:08. Establish normal feeding behavior from the start, recognizing that enteral nutrition serves more than caloric needs 5:28. If tube support is required, begin with gastric bolus feeding rather than defaulting to continuous feeds 5:52. If the child fails gastric bolus and then continuous feeding due to motility issues or delayed emptying, feed beyond the stomach and decompress the stomach through an NG tube 6:15. This sequence respects physiology and preserves the possibility of normal feeding behavior.

Use long-chain fat to drive adaptation, not MCT

Breast milk is the formula of choice for its nutritional and immunologic components 6:42. For protein, single amino acid formulas are preferred to avoid high stool output, fluid losses, wound breakdown, rashes, and emesis 7:28. For fat, long-chain fat is the preferred module over medium-chain triglycerides because long-chain fat is a much stronger stimulus for GLP-2 release, which drives adaptation 8:07. The instinct to use MCT for better absorption is wrong here — adaptation depends on GLP-2, and long-chain fat delivers it.

SMOF lipids are not universal, and restriction trades cholestasis for growth

Not every child needs SMOF lipid emulsion 9:00. For preterm babies, SMOF is not ideal but is the best currently available 9:03. It lacks sufficient arachidonic acid, which is critical for brain development 9:16. Two strategies exist to treat cholestasis: reduce total fat to 1 g/kg/day or switch to omega-3-enriched lipids like SMOF or Omegaven 9:34. Lipid restriction reverses cholestasis but reduces calorie delivery, impairing growth and potentially neurocognitive development 9:50. Omegaven is pure fish oil dosed at 1 g/kg, so the child takes a calorie hit 10:07. SMOF is more balanced, with an omega-3 to omega-6 ratio of 2.5:1, less inflammatory than Intralipid, and promotes bile flow 10:28. SMOF must not be restricted below 2-2.5 g/kg/day 10:28. The choice is not between good and bad lipids; it is between managing cholestasis and supporting growth and brain development.

Takeaways from this story

Express residual bowel as percentage of expected length for age—a child with 10% can reach autonomy if colon is intact
Distal ileum produces GLP-2, GLP-1, and PYY that drive adaptation; its presence matters more than the ileocecal valve
Leave questionable bowel in situ with proximal diversion—many segments deemed non-viable can heal and contribute later
Use long-chain fat over MCT to maximize GLP-2 release and drive intestinal adaptation
SMOF lipids must not be restricted below 2-2.5 g/kg/day; lower doses trade cholestasis reversal for impaired growth

Building Enteral Autonomy in Pediatric Short Bowel Syndrome

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Growth potential changes the prognostic frame

Residual bowel length in young children must be expressed as a percentage of expected gut length for age, not in absolute centimeters 0:49. A term infant has 160 cm of small bowel; by age five that figure nearly triples to 425–450 cm 1:17. A child with 14 cm of residual bowel at birth has 10% of expected length — a figure that carries prognostic weight only when anchored to the denominator. Enteral autonomy is achievable with as little as 10% expected gut length if the majority of the colon remains in continuity 1:51. The absolute number tells you almost nothing; the percentage and the anatomy tell you everything.

The distal ileum matters more than the valve

The ileocecal valve receives attention in the literature, but the functional priority lies with the distal ileum and proximal colon 2:30. These segments reclaim bile salts to sustain enterohepatic circulation and produce the hormones that drive adaptation: GLP-2, GLP-1, and peptide YY 2:43. The valve itself contributes little; the tissue upstream of it does the work. When you assess residual anatomy, map the hormone-producing segments — not the sphincter.

Stage the reconstruction to enable early feeding

In cases of massive bowel loss, the first operation should establish proximal control and create a pathway for early enteral feeding rather than attempting immediate anastomosis 3:29. Staged reconstruction under controlled conditions often outperforms a single heroic attempt at continuity 3:38. Bowel that appears nonviable at the index operation frequently recovers if left in situ with proximal diversion 4:02 4:26. The strategy is to divert, decompress, feed, and reassess — not to commit irreversibly to what the tissue looks like on the worst day.

Advance enteral feeding through a hierarchy of routes

The goal is adequate nutrition for normal growth, delivered enterally whenever possible 5:08. Enteral nutrition establishes feeding behavior and provides benefits beyond caloric delivery 5:28. Start with gastric bolus feeds; if the child cannot tolerate boluses, advance to continuous gastric feeding 5:52. If gastric feeding fails due to motility dysfunction or delayed emptying, feed beyond the stomach and decompress the stomach via NG tube 6:15. The sequence matters: you are testing the gut's capacity at each level before bypassing it.

Choose fats and proteins to drive adaptation

Breast milk is the first-line formula for both its nutritional content and its bioactive components 6:42. When fortification is required, single amino acid protein formulas are preferred to minimize stool output, fluid losses, and mucosal injury 7:28. For fat, long-chain triglycerides are superior to medium-chain triglycerides because long-chain fats are a much stronger stimulus for GLP-2 release, which is the primary driver of intestinal adaptation 8:07. The choice of fat module is not about absorption tolerance — it is about signaling the gut to grow.

Lipid strategy for cholestasis requires trade-offs

Not every child requires SMOF lipid emulsion 9:00. For preterm infants, SMOF is suboptimal because it lacks sufficient arachidonic acid, which is critical for neurodevelopment 9:03 9:16. When cholestasis develops, two strategies are available: reduce total lipid dose or switch to omega-3-enriched emulsions 9:34. Restricting lipids to 1 g/kg/day reverses cholestasis but impairs growth and may compromise neurocognitive outcomes 9:50. Omegaven, dosed at 1 g/kg, imposes a similar caloric penalty 10:07. SMOF is the better choice when switching emulsions: it is more balanced, less inflammatory, promotes bile flow, and must not be restricted below 2–2.5 g/kg/day 10:28 10:28. The discussants emphasized that managing cholestasis is not a matter of eliminating lipid — it is a matter of choosing the right lipid at a dose that supports both liver function and brain development.

Takeaways from this story

Express residual bowel as percentage of expected length for age—10% can achieve autonomy if colon is preserved.
Distal ileum produces GLP-2 and reclaims bile; prioritize preserving it over the ileocecal valve itself.
Stage reconstruction to enable early feeding; questionable bowel often recovers if diverted and reassessed later.
Use long-chain fats over MCT to stimulate GLP-2 release and drive intestinal adaptation.
SMOF lipids at ≥2 g/kg/day manage cholestasis better than restriction; avoid dropping below this to protect growth.

Intestinal Rehabilitation: Managing Pediatric Intestinal Failure Through Growth, Adaptation, and Staged Recovery

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Discipline Exists

Intestinal rehabilitation emerged because children with massive bowel loss—from necrotizing enterocolitis, midgut volvulus, gastroschisis, or congenital anomalies—face a binary outcome without specialized care: lifelong parenteral nutrition with its attendant complications, or death. The discipline exists to exploit the pediatric gut's remarkable capacity for adaptation and growth, converting what would have been permanent TPN dependence into enteral autonomy through coordinated surgical, nutritional, and medical management 0:49.

The Core Problem

When a child loses most of their small bowel, the remaining gut cannot absorb sufficient nutrients or fluid to sustain life. The clinical challenge is threefold: preserve every centimeter of potentially viable bowel, maximize the adaptive capacity of what remains, and support normal growth during the months to years this process requires. Unlike adult short bowel, where anatomy is fixed, the pediatric gut triples in length from birth to age five 1:17. This growth potential changes the entire calculus—but only if you can keep the child alive and growing while it happens.

How the Approach Works

Measuring what matters. Residual bowel must be expressed as percentage of expected length for age, not absolute centimeters 1:17. A term infant with 14 cm of jejunum has roughly 10% expected gut length—a figure that carries prognostic weight. Children can achieve enteral autonomy with as little as 10% expected small bowel length if the majority of the colon remains in continuity 1:51. This is not about the ileocecal valve, despite older literature. What matters is the distal ileum and proximal colon, which reclaim bile salts to maintain enterohepatic circulation and produce GLP-2, GLP-1, and PYY—the hormones that drive intestinal adaptation 2:30 2:43.

Surgical strategy at the index operation. The first operation sets the trajectory. The goal is to provide proximal diversion that allows early enteral feeding while preserving questionable bowel for later use 3:29 4:26. Segments that appear non-viable in the acute setting often heal and contribute significantly to long-term outcomes 4:02. Staging reconstruction under controlled conditions is often preferable to attempting immediate continuity in a septic, unstable infant 3:38. This requires surgical restraint—leaving bowel in discontinuity when your instinct is to restore anatomy.

Enteral feeding strategy. The overarching principle is to deliver adequate nutrition for normal growth, ideally enterally 5:08. Enteral nutrition is more than calories—it establishes feeding behavior and drives adaptation 5:28. Start with gastric bolus feeds even if the child requires tube support; do not default to continuous 5:52. If gastric feeding fails—due to motility dysfunction or delayed emptying—feed post-pylorically and decompress the stomach with an NG tube 6:15.

Breast milk is first-line 6:42. When formula is required, single amino acid protein is preferred to minimize stool output, fluid losses, and skin breakdown 7:28. For fat, use long-chain triglycerides rather than MCT 8:07. Long-chain fat is a much stronger stimulus for GLP-2 release, which is the primary driver of adaptation. The goal is not simply to get calories in but to signal the gut to grow.

Parenteral nutrition management. Not every child requires SMOF lipid emulsion 9:00. For preterm infants, SMOF is suboptimal—it lacks sufficient arachidonic acid, which is critical for brain development—but it remains the best available option 9:03 9:16. Cholestasis can be managed by reducing total lipid dose or switching to omega-3-enriched emulsions 9:34. Lipid restriction to 1 g/kg/day reverses cholestasis but impairs growth and potentially neurocognitive development 9:50. Omegaven, dosed at 1 g/kg, delivers a calorie deficit 10:07. SMOF is better balanced, with an omega-3 to omega-6 ratio of 2.5:1, and promotes bile flow while being less inflammatory than standard intralipid 10:28. Critically, SMOF must be dosed at no less than 2–2.5 g/kg/day 10:28. Restricting it defeats the purpose.

Where Practice Is Contested

The role of the ileocecal valve remains debated in the literature, though the discussants argue persuasively that it is the distal ileum itself—not the valve—that matters 2:30 2:43. The choice of lipid emulsion in preterm infants represents an unresolved trade-off between managing cholestasis and supporting neurodevelopment 9:03 9:16. Surgical timing for reconstruction is individualized; no consensus exists on when to attempt continuity after initial diversion.

When to Involve This Team

Refer any infant with massive bowel loss at the index operation—before you decide what is viable and what is not. Refer any child requiring prolonged parenteral nutrition. Refer before cholestasis becomes severe, before central line complications accumulate, and before growth falters. The value of intestinal rehabilitation is highest early, when surgical options are preserved and the gut's adaptive window is wide open.

Takeaways from this story

Residual bowel in children must be expressed as percentage of expected length for age, not absolute centimeters, because gut length triples from birth to age five.
The distal ileum and proximal colon drive adaptation through bile reclamation and GLP-2 production—not the ileocecal valve itself.
At the index operation, provide proximal diversion for early feeding and preserve questionable bowel; segments deemed non-viable often heal and contribute significantly.
Use long-chain fats rather than MCT to stimulate GLP-2 release and drive intestinal adaptation; start with gastric bolus feeds, not continuous.
SMOF lipids must be dosed at minimum 2 g/kg/day and are preferred over Omegaven for balanced nutrition, but lack sufficient arachidonic acid for preterm brain development.

Keywords

intestinal failure short bowel syndrome cholestasis delayed gastric emptying motility issues intestinal rehabilitation proximal diversion secondary reconstructive procedures gastric decompression SMOF lipids Omegaven intralipid GLP-2 GLP-1 PYY

Hashtags

#IntestinalRehabilitation #IntestinalFailure #ShortBowelSyndrome #PediatricSurgery #Gastroenterology #ChildHealth #EnteralAutonomy #IntestinalGrowth #PediatricGastroenterology

Transcript

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello everyone. In November 2023, we held the first intestinal rehabilitation webinar here at Cincinnati Children's Hospital. For that, we have the experts of the intestinal rehabilitation Center at Cincinnati Children's. Doctor Paul Well, the current director of the Industrial Rehabilitation Center, and Doctor Michael Hamrad, the prior director of the Industrial Rehabilitation Center and the director of the Center of Stem Cell and Organoid Medicine. So today we are going to highlight the five main topics they talk at the webinar. Let's start. First, infants and babies have a great potential for intestinal growth. One key thing to, to acknowledge is that young infants, babies, infants, and young children have tremendous gut growth potential. The gut grows for the first several years of life. Um, and that's why when we're, we're talking about residual bowel, it's really important to talk about it, not in absolute centimeters, as I did in this case, 14 centimeters. It's to talk about it in relationship to what is normal for a child of that age. So, a term baby uh will have 160 centimeters of small bowel, and by the time you're 5 years old, it, it almost triples, about 425 to 450 centimeters. So talking about centimeters without the age is not appropriate because we need to know the percentage of God that we have to know the prognostic and autonomy potential of that intestine. That's why it's really important in the context of young children. We talked about it as a percentage. So we have 10% of small bowel, 75% of colon. But you can have as low as 10% expected gut length and still achieve enteral autonomy if you have the majority of your colon in continuity. So another key factor for enteral autonomy is functionality, and to assess it, we need to know the underlying diagnosis. Remember, Babies are born with their intestines capable of adapting and growing. It's not only about the length, but how we support the growth journey. Second key takeaway is the importance of the distal ileum and the function of the remaining bowel. Lots of papers will quote the importance of the ICV. What do you think about that? So, to me, I believe the more important fact is the presence or absence of the distal small bowel or the ileum and even right colon that can act as a reclamation of bile and get the inneroppatic circulation. As well as producing hormones and incretins like uh GLP-2 is in everyone's mind these days, but you know all the incretin GLP-1 and, and even hormones like PYY are produced in the distal ileum, but it's not because of the ileocecal valve, it's because of to me the. So remember, the ileocecal bulb is not the main part of the intestine. Where it's important is the discal ileum and proximal colon, where the bilioenteric circulation is key, and where we produce hormones and peptides that help intestinal growth and intestinal absorption. Third key takeaway, it is really important to have a surgical strategy to promote early healing. I think sometimes strategy at the first operation is to be able to provide a pathway forward that allows early interval feeding. And it's oftentimes, sometimes better to stage the idea that you're going to put this back in continuity under more control. So what do the experts suggest to avoid or palliate huge intestinal losses? In a situation of overwhelming intestinal loss like here, um, the strategy for us is to um provide uh. Control proximally that allows feeding to occur without the enter stream going and to actually leave a lot of questionable bowel later with the experience that many of the many segments of bowel that are deemed to be non-usable actually in this population has a potential to heal and can really make a huge difference in the lifetime of this child. So. As long as you can divert proximal and the baby's stable, you can leave question of avowal for potential at a later secondary reconstructive procedures. So plan your surgery ahead, take in consideration what the patients need. Do they need a T tube? Do they need a train? Do they need a proximal diversion? Do we need to leave questionable bowels for a second look? Planning is key for these patients, so think before acting. 4. The best way to feed the baby is enterly with the appropriate nutrition according to the age. You have to properly manage lipids and proteins for achieving a healthy growth. The overarching principle is we want to, we want to deliver adequate nutrition to, to have normal growth. Within normal parameters. Ideally, that's integral. But, uh, you know, as these kids are adapting, uh, they're gonna be either partially or totally parenterally dependent for at least some period of time. The other guiding principle is, as much as possible, we'd like to try to establish normal feeding behavior. Realizing that enteral nutrition is more than just nutrition. Perfect. So, the guiding principles to start feeding are achieving healthy growth. And trying to establish normal feeding behavior. Now, what about patients that needs a tube for feeding? If a patient needed to be tube supported from the beginning, I would typically try to do that with bolus feeding, uh, rather than default to continuous feeding. Sometimes, when they've had, uh, you know, a septic event or they're premature or an insult, there's, there's motility issues, delayed gastric emptying, um, and they just don't tolerate food into the stomach. And often, you know, our strategy here would be if, if the child failed a gastric approach, bolus and then continuous, then we would consider feeding beyond the stomach and decompressing the stomach, uh, through an NG. Great, so start with stomach feeding, but if it fails, feed beyond the stomach and decompress it to promote its motility. And what about which formula we should use? Obviously, formula of choice coming from the breast, breast milk, always mess. Breast milk. Yes. Breast milk, not only for its nutritional uh benefits, obviously, but, uh, all the other goodies that are within the breast milk. OK. So no doubt breast milk from ama or a donor. But if we don't have breast milk, what is the best formula? There's a myriad of formulas out there, but the, the principles are, you know, we have intact formulas and we have either semi-elemental or elemental formulas. And yeah, two modules I think that are important to talk about are the protein module and the fat module. So let's talk about the protein module first. Starting at the, the bare bones, you know, single amino acid level is gonna be, you know, our generalized preference and making sure they're not having high stool output, high fluid losses, wound breakdown, rashes, um, emesis are all the limiting factors. Regarding the protein level, we have to know that single amino acid level is good from an allergy point of view, not absorption. But what about fat? There's this feeling out there that especially in the setting of short bowel syndrome, that an MCT fat. is better tolerated, better absorbed. But I would argue that uh long chain fat is the preferred module rather than MCT. Long chain fat is a much stronger stimulus for GLP-2 release, and that's what we want when we're trying to drive adaptation. Awesome. So, we use long tin fat instead of middle tin fat or MCT to drive adaptation and stimulate the secretion of GLP2. Fifth, parental nutrition plays a huge role in getting the species to achieve healthy growth. So managing its volume and components are crucial for this. So, let's talk about um TPF. Should every kid be on smoth? Smoth lipid means soybean, medium tin triglyceride, olive oil, and fish oil. No, I don't think that's absolutely necessary. Um, for preterm babies, smoth is not the ideal lipid emulsion, but it's kind of the best we have. There is some ongoing research and development into newer lipid emulsions. Um, the, the deficit with, with smoth is that it doesn't have enough arachidonic acid in it. Um, and arachidonic acid is really important for brain development. OK, so lipid emulsions with smoth are not always the best option. So we have two strategies to treat cholestasis. The first one is to reduce the total amount of fat, and the second one is to change the composition to introduce smuff lipids or omegaban. Those restrictions essentially reduce lipid dose to 1 g per kilo per day and can reverse cholestasis, but results in reduced calorie delivery. That can impair growth and potentially impact neurocognitive development. Changing composition usually means using alternative lipid with added omega 3 fatty acids that can be either agave, which is essentially pure fish oil with omega 3 and is dosed at 1 g kilo, so babies take a calorie head, or smuff. Lipids, which is the better choice as it is more well balanced emulsion with an omega 3 and omega 6 ratio of 2.5 to 1, being less inflammatory than intralipid and promoting bile flow, and remember you should not restrict smuff lipids, so they can't be given at less than 2 or 2.1 g per kilo per day. So now it is time to summarize. Infants and young children have a great potential for gut work, with the vowel increasing them in the first few years of life. Preservation of the digital ileum and proximal colon is more critical than solely focusing on the ileocecal bowel. Planning surgeries with controlling on proximal fecal flow, diverted if necessary, and leaving questionable bowel can promote long-term and. Breast milk is the preferred option for these patients, but if unavailable, selecting a formula that manages protein and fat intakes is key. Parental nutrition plays a vital role in achieving healthy growth. While muff is commonly used, there's ongoing research of new lipid emulsions. Thank you for watching this top key takeaways from the first intestinal rehabilitation web. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.

Comments

Loading comments…