Medical Management for Physicians

The medical management of children with SBS is extremely challenging and is comprised of a combination of enteral and parenteral nutritional support.

Enteral Nutrition

Enteral feedings [Tables 1 and 2 will both stimulate small bowel adaptation and prevent the development of parenteral nutrition associated cholestasis. The ideal enteral solution should be isotonic. The protein source should be predominately di- and tripeptides, because this source of protein is most easily and efficiently absorbed. The solution should have a fair amount of medium chain triglycerides, as this source of fat is well absorbed through the baso-lateral wall of the intestinal enterocytes, and into the portal venous circulation. However, medium chain triglycerides contain no essential fatty acids, thus these fats cannot be the sole source of lipids in these patients.

Total parenteral nutrition (TPN)

Parenteral nutrition has become the standard of care for the initial management of SBS. Prescriptions for infant TPN are challenging, and should be done with someone with specialized expertise in this area. The Figure below is a schematic diagram of TPN prescribing for a neonate and young infant. TPN management may involve the use of replacement fluids as well if fluid and electrolyte losses are high.

Parenteral Nutrition Orders for a Neonate or Young Infant

Figure 12 below is a schematic diagram of how to begin to approach writing parenteral nutrition orders for a neonate or young infant. Fluids should be adjusted based on the infant's gestation age and body weight. The overall goal should be the delivery of amino acids comprising 10 to 15% of calories, dextrose at 50 to 60%, and fats at 20 to 30%.

• Dextrose concentration should be used as the percent number (i.e. 20 for 20%).
• The concentration in this formula should be written as the percent number (i.e. 4.25 for 4.25%).

See relavent tables for each of these additives. If the amino acid concentration is >1.5% the precipitation factor should be <3. If the final amino acid concentration is >1% and <1.5% a precipitation factor should be <2; and for an amino acid concentration <1% calcium and phosphate should not be added. Adjustments to this formulation need to be done if additives (e.g cysteine) are placed in the parenteral nutrition.