Standard management of paediatric SBS

The goal of treatment in children with SBS is to provide all the fluids and nutrition that they need for growth and development and to reduce the effect the condition has on them by encouraging intestinal adaptation and use of enteral feeding.1

The primary measurable outcomes of early management are:2

  • The reduction in level of parenteral support (PS) that the child needs, and
  • The extent to which enteral feeding can replace PS.

Management of paediatric SBS

Following removal of the affected intestine, management aims to stabilise all losses of fluids and required electrolytes and to start the child on PS.2,3 This supportive nutrition is tailored to the child based on how much, and what type, of bowel was removed, so they can receive suitable levels of the nutrients that their intestines are no longer able to absorb efficiently.2,3

Supportive parenteral nutrition is tailored to the needs of the child2,3

PS is continued while the child fully stabilises after surgery. During this time, the growth and nutritional status of the child is continually monitored. Where possible, the child will be transferred from only PS to enteral feeding, with the aim of decreasing PS to the lowest possible level the child needs.4

Adaptation

Intestinal adaptation, stimulated by both oral and enteral nutrition, is important in both children and adults.1,5 In patients with SBS, the remaining bowel can recover some of its function by adapting to its new situation. This involves the small intestine slowly increasing how much it is able to absorb, making up for the loss of some (or all) of the surface area needed for absorption of nutrients.1

Adaptation in children can occur for at least 3 to 4 years following the removal of the bowel, compared with only 1 to 2 years in adults. The process continues over a longer period in children because their intestinal growth is further influenced by their general growth and development.2,3 If PS is still required after this length of time, the child will usually continue to remain dependent on PS.2

Intestinal adaptation in children can occur for at least 3 to 4 years following bowel resection, slowly increasing how much the remaining bowel is able to absorb2,3

Surgical management of SBS

In some children, who are at risk of life-threatening complications from PS, both bowel transplant and non-transplant surgery can be used to lengthen the intestine. These help to slow the movement of food improving absorption and decrease the need for PS. The techniques, however, aren't always successful and are often associated with the risk of certain complications.3,6–9

Supportive therapies

Children who need ongoing PS for their SBS also often need other medication to manage symptoms of their disorder. These supportive treatments help reduce the symptoms of the disorder, but typically do not improve absorption in the intestine (anti-motility agents can slow the passage of food, increasing absorption).3,10–14

 

Therapeutic class Symptom
Proton pump inhibitors1,12

Histamine H2 receptor antagonists1,12

Gastric acid overproduction1,12
Diphenylate-atropine10,11

Loperamide10,11

To adjust the motility

(movement of the intestine)10–11

Antibiotics2,14 Bacterial overgrowth2,14

References

  1. Van Gossum A, Cabre E, Hébuterne X, et al. ESPEN Guidelines on Parenteral Nutrition: gastroenterology. Clin Nutr 2009;28:415–427
  2. Kaufman SS, Matsumoto CS. Management of pediatric intestinal failure. Minerva Pediatr 2015;67:321–340
  3. Coletta R, Khalil BA, Morabito A. Short bowel syndrome in children: surgical and medical perspectives. Semin Pediatr Surg 2014;23:291–297
  4. Gosselin KB, Duggan C. Enteral nutrition in the management of pediatric intestinal failure. J Pediatr 2014;165:1085–1090
  5. Tappenden KA. Intestinal adaptation following resection. JPEN J Parenter Enteral Nutr 2014;38:23S–31S
  6. Frongia G, Kessler M, Weih S, et al. Comparison of LILT and STEP procedures in children with short bowel syndrome – a systematic review of the literature. J Pediatr Surg2013;48:1794–1805
  7. Sommovilla J, Warner BW. Surgical options to enhance intestinal function in patients with short bowel syndrome. Curr Opin Pediatr 2014;26:350–355
  8. Sudan D, Thompson J, Botha J, et al. Comparison of intestinal lengthening procedures for patients with short bowel syndrome.Ann Surg 2007;246:593-601; discussion 601–604
  9. Yildiz BD. Where are we at with short bowel syndrome and small bowel transplant? World J Transplant 2012;2:95–103
  10. King RF, Norton T, Hill GL. A double-blind crossover study of the effect of loperamide hydrochloride and codeine phosphate on ileostomy output. Aust NZ J Surg 1982;52:121–124
  11. McDoniel K, Taylor B, Huey W, et al. Use of clonidine to decrease intestinal fluid losses in patients with high-output short-bowel syndrome. J Parenter Enteral Nutr 2004;28:265–268
  12. Williams NS, Evans P, King RF. Gastric acid secretion and gastrin production in the short-bowel syndrome. Gut 1985;26(9):914–919
  13. Nehra V, Camilleri M, Burton D, Oenning L, Kelly DG. An open trial of octreotide long-acting release in the management of short bowel syndrome. Am J Gastroenterol 2001;96:1494–1498
  14. Kaufman SS, Loseke CA, Lupo JV, et al. Influence of bacterial overgrowth and intestinal inflammation on duration of parenteral nutrition in children with short bowel syndrome. J Pediatr 1997;131:356–361
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