We’re back with a new episode from the intestinal rehabilitation center at Cincinnati Children’s Hospital.
This time we’re talking about Refeeding in older patients with Drs. Helmrath and Wales.
If you are looking for refeeding a Neonatal patient don't miss our Episode 7: https://staycurrentapp.app.link/nQHCEEKohDb
Type: podcast · 12 min · posted 2023-10-05 Canonical: https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227 ## Chapters - [0:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=5) Introduction and Patient Population - [1:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=110) Dietary Strategy for Refeeding - [3:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=223) Fluid Management and Hydration - [5:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=351) Growth Through Puberty and Team Approach - [8:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=514) Growth Monitoring and Assessment ## Statements - "Older children (8-16 years) who experience volvulus can lose 90+% of their bowel" — Michael Helmrath (clinical) [1:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=71) - "Older patients who have established eating behavior before bowel loss have both a benefit and curse in that they know how to eat" — Paul Wales (opinion) [1:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=84) - "In older children, normal feeding behavior is important for social aspects of life beyond nutrition" — Cecilia Gigena (clinical) [1:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=90) - "Even if a patient cannot be cured and weaned off TPN, compromises should be made to optimize quality of life" — Paul Wales (opinion) [1:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=110) - "The general strategy is to push macronutrient modules of protein and fat which are well tolerated" — Paul Wales (clinical) [2:14](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=134) - "Most short bowel patients don't tolerate simple sugars very well" — Paul Wales (clinical) [2:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=141) - "Pushing solids and minimizing fluid intake helps reduce dumping" — Paul Wales (clinical) [2:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=145) - "Smaller meals more frequently of solids separated from liquids and minimization of simple sugars is the recommended approach" — Paul Wales (clinical) [2:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=151) - "Patients who have transitioned off TPN often come back with problems when diet history reveals they have gotten loose with diet choices" — Paul Wales (clinical) [2:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=172) - "Increase in sugars can create problems with absorption and changes in stool output" — Cecilia Gigena (clinical) [3:12](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=192) - "Minimizing sugars reduces symptoms related to bacterial overgrowth such as bloating and gas" — Paul Wales (clinical) [3:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=211) - "Fluid losses whether by stoma or other source must be replaced" — Paul Wales (clinical) [3:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=228) - "If patients are on IV support, some fluid can be replaced intravenously" — Paul Wales (clinical) [3:56](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=236) - "When trying to wean off IV support, keeping patients hydrated through enteral replacements is important" — Paul Wales (clinical) [4:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=241) - "Fluid transport requires sodium and glucose, so replacement solution must contain both" — Paul Wales (clinical) [4:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=251) - "Gatorade doesn't work well for rehydration because it has too much sugar" — Paul Wales (clinical) [4:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=288) - "Some patients can come off TPN but still need a central line for IV fluids" — Michael Helmrath (clinical) [4:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=295) - "Without adequate IV fluids, patients end up sleeping most of the day and don't have energy" — Michael Helmrath (clinical) [4:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=295) - "Being in a hydrated state is extremely important to making the bowel work well" — Michael Helmrath (clinical) [5:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=308) - "Sometimes patients can't drink rehydration solution but the GI tract can use it via G-tube" — Michael Helmrath (clinical) [5:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=331) - "Energy use goes up dramatically during puberty" — Michael Helmrath (clinical) [5:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=351) - "Children doing well often hit the wall when they start puberty because energy needs overcome nutrient input" — Michael Helmrath (clinical) [5:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=351) - "Some kids end up back on parenteral support to get through puberty" — Paul Wales (clinical) [6:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=388) - "When not growing anymore as an adult, borderline or marginal gut function is often enough to sustain them" — Paul Wales (clinical) [6:33](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=393) - "There are very few conditions with intestinal failure that have restricted growth" — Michael Helmrath (clinical) [6:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=417) - "A 3rd percentile growth should not be accepted for most intestinal failure patients" — Michael Helmrath (opinion) [6:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=417) - "After getting off TPN, patients often get into trouble with micronutrient deficiencies" — Paul Wales (clinical) [7:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=442) - "Weight must be balanced with height as a growth metric" — Paul Wales (clinical) [8:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=531) - "This population commonly shows round babies where weight for height is elevated" — Paul Wales (clinical) [8:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=537) - "There is increasing data looking at quality of weight - how much is fat weight versus lean body mass" — Paul Wales (clinical) [9:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=541) - "For any child not meeting growth potential, numerous other diagnoses must be considered including endocrine issues, pancreatic insufficiency, and micronutrient deficiencies" — Michael Helmrath (clinical) [9:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=574) - "After addressing growth issues, improvements should be assessed on the order of weeks not months" — Michael Helmrath (clinical) [9:54](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=594) - "Growth monitoring can be done remotely and should not wait until the next appointment" — Michael Helmrath (clinical) [10:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=615) ## Transcript Hello everyone. Welcome back to the Stay Current podcast. I'm Cecilia Gigena from Cincinnati Children's Hospital, and along with Stay Current, we are sharing knowledge to improve child health around the globe. Today we have another episode of the intestinal rehabilitation podcast, and as always, we have Doctor Paul Wales, the current director of the intestinal rehabilitation Program at Cincinnati Children's Hospital. I'm Paul Wales. I'm a pediatric surgeon here at Cincinnati Children's Hospital, and Doctor Michael Helmrad. The prior director of the intestinal rehabilitation program. I'm Michael Helmrath. I'm a pediatric surgeon also doing intestinal failure surgery and research here at Cincinnati Children's. Today we have the 8th episode of the intestinal rehabilitation podcast, and we are going to talk about refeeding in an older patient. If you want to know how to refeed a neonatal patient, go back to episode 7 where you can find everything you need to know about that. So now let's start. Like the recent slew of kids we have that are between 8 and 16 that were eating just fine, and one day boom, they had a volvulus and they've lost 90+% of the bowel. The benefit in the curse in a patient like that is that they do know how to eat. They've established that that behavior. We know that enteral feeding is really. Important for nutrition, but in older children that is not the only main thing we get out of feeding because the normal feeding behavior is important in many social aspects of life. That is why it's very important to take this into consideration when we are treating older patients. So 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. Perfect. So let's talk about how to restart oral sleeping. We want to try to mimic the most normal seeding behavior that we possibly can. I still prefer. Letting them eat by mouth orally. The general strategy is you want to push the macronutrient modules of protein and fat are well tolerated. Most of these kids don't tolerate simple sugars very well. So the general concept of pushing solids. And minimizing fluid intake helps. They don't tend to dump as much smaller meals more frequently of solids separated from their liquids to a certain extent, and minimization of simple sugars. Understood. So reduce simple sugars and make smaller meals and try to separate them from liquids. Eventually they'll be able to tolerate more and more, but we'll see a lot of these patients that have transitioned off of TPN and truly fed, and then they come back having some problems later, and you find out when you take a close diet history that they've sort of fallen off the wagon a little bit, and they've gotten a little bit loose when it comes to some of the diet choices. And something important they highlight is to be very careful with the diet because the increase in sugars can create some problems with the absorption and changes in the stool. So if you encounter a patient that comes with high stool output, you will probably want to see how it's diet change. And not only that, but also sort of symptoms related to bacterial overgrowth, by minimizing some of those sugars, they tend to be less bloated and gassy. Now let's talk about rehydration and fluid management in these kids. So we're in the older child that has fluid losses, whether it be by stoma or any other source, we have to replace. If they are perpetually supported, that some of that fluid can be replaced IV. But as you're trying to move forward and get off IV support, if you can keep them hydrated by replenishing losses through enteral replacements, then that's important. For transport requires sodium and glucose, and so your solution that you're replacing with has to contain some glucose and some salt. So take into consideration if the patient has some IV parenteral support to replace fluids. If not, or you're trying to wean them off, you have to use a rehydration solution because the ionic composition is really important. And there are some homemade recipes for oral rehydration solutions. There's some over the counter type preps that you can get as well. Some people will resort to things like Gatorade and stuff like that, but that doesn't always work that well. It's actually too much sugar in it. I think some patients actually can come off a TPN but still need a central line for IV fluids, and that in the absence of IV fluids, really, they end up sleeping most of the days, they don't have a lot of energy. And it's hard to recommend back to a family that's lost the, you know, the kids come off TPM and you're seeing them, but being in a hydrated state is extremely important to making the bowel work well, and the compromise over time is the ability to stay hydrated, whether it's at night, through hydration, maybe even via G tube, or emphasizing. The need to stay hydrated. Sometimes they can't drink it, but the GI tract can use it. OK, so keeping the patient hydrated is very important, and for that we have many options. It can be by mouth, by nasogastric tube at night, or IV fluids. The other key point to remember is that the energy use goes up dramatically during puberty, and so you often will find a child who is actually doing well, and they hit the wall when they start puberty because their energy needs are overcoming their nutrient input. The goal is always healthy growth, and so it's not lost. Go backwards and to add things and supplement things and to hope sometimes that they'll take that one extra can of boost. It's all about normal growth parameters and get them through puberty. It is true some kids end up back on parental support, you know, to get through puberty. And then when you're not growing anymore as an adult, often that borderline or marginal gut function is enough to sustain them. That's really important. We have to be aware of puberty and moments of increased energy needs to guarantee a healthy growing, as the doctor said, we have to be proactive and keep our patients ahead of that to avoid losing opportunities for healthy growing. I can't emphasize enough to look at the growth chart, both the weight, but also the height, and don't accept a 3rd percentile. There are very few conditions with intestinal failure that have restricted growth, so, you know, you really need to put them in a healthy growth range, and the family needs to recognize that they have the potential. To do that, and so it's just setting expectations. A, you have to grow off TPM, but also then you have to monitor for a lot of the time you get into trouble after you get off TPM with micronutrient deficiencies, etc. That all needs to be followed, and then their long-term growth and outcome needs to be followed. So, hence the importance of teams, these multi-D teams. As always, we emphasize the need for a multidisciplinary team to help with the long-term follow-up and surveillance. Guaranteeing healthy growing is very important, and many of these patients don't have restricted growth, so we don't have to settle for a 3rd percentile. A, you have to grow off TPM, but also then you have to monitor. For a lot of the time you get into trouble after you get off TPN with micronutrient deficiencies, etc. that all needs to be followed, and then their long term growth and outcome needs to be followed. So, hence the importance of teams, these multi-D teams. There's times that you do not get to go back. So, a multidisciplinary approach highlighting this really from the get-go, um. It is really important. Again, to help our patients, we need a multidisciplinary team and set expectations to be met. Because I think we can't emphasize enough that these patients can and should achieve a normal growth. Now let's talk about how we follow these patients and make sure that they are normally growing. We track meat a lot as a major metric for growth, but it has to be balanced with their height. What we commonly see in this type of population is. Round babies where their weight for height is elevated, weight and height are basic metrics, anthropometrics that you can follow in a clinic setting or a hospital, but there's an increasing amount of data looking at, you know, quality of weight, how much is fat weight and how much is lean body mass. Great, so check weight and height, but also it's important to assess the type of weight they are gaining, because it's not the same fat as body mass. And now let's hear what we have to do if these patients are not achieving a good weight. Any child that's not meeting growth potential, there's numerous other diagnoses that can do it that range from endocrine issues to pancreatic insufficiency issues to micronutrient issues that that aren't there. There's a lot of things that you have to, to check off, but your concept is that they're capable. Of having normal growth and then as you address the issues and you improve something you need to then have a reasonable follow-up time and assess that you're making improvements in that which are on the orders of weeks and not months and they don't need to travel for us to get away and to check them. You can do a lot of this stuff remotely, but you can't wait till the next appointment. Amazing take home poets. Let's summarize. Eternal feeding in older patients is not the only main thing we get out of feeding because many social aspects are involved. Diet is really important and we have to avoid simple sugars, make smaller meals, and try to separate them from liquids. One main thing about these patients is that we have to keep them hydrated and to achieve that we need our special rehydration solutions, anti tubes with rehydration by the nights or even IV fluids because if our patients are not hydrated, they will not achieve a healthy growing as we always say, multidisciplinary team is really important and they will help us to follow our patients in the long term. To check our patients we not only have to see the weight but also the height and compare them to avoid having fat short heads. And in some cases we need to have another tools to acknowledge that the patient is having a healthy growing. So that was everything for today about how to re-feed older patients. If you like it, leave us a rating and a review. Follow us on social media and our YouTube channel. Download the Stay Current app in the Apple App Store or Google Play Store, where you can find this podcast and a lot more. But until then, I'm Cecilia Jigena from Cincinnati Children's Hospital, and along with Stay Current, we are sharing knowledge to improve child health around the globe. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai