Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient
With Dr. Paul Wales & Dr. Michael Helmrath · hosted by Dr. Cecilia Gigena · StayCurrentMD
Cued at 5:08 · stops at 5:53 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Older patients (ages 8-16) who experience volvulus can lose 90+% of their bowel.
The benefit and curse in older patients with bowel loss is that they already know how to eat and have established that behavior.
Even if you cannot cure the patient and get them off TPN, it is important to make compromises to optimize quality of life.
The general strategy is to push the macronutrient modules of protein and fat, which are well tolerated.
Most patients with short bowel do not tolerate simple sugars very well.
The general concept of pushing solids and minimizing fluid intake helps prevent dumping.
Smaller meals more frequently of solids separated from liquids, with minimization of simple sugars, reduces dumping tendency.
Patients who have transitioned off TPN often come back with problems when diet history reveals they have gotten loose with diet choices, particularly increased sugars.
Minimizing sugars reduces symptoms related to bacterial overgrowth, making patients less bloated and gassy.
In older children with fluid losses (by stoma or other source), if they are on parenteral support, some fluid can be replaced IV.
As you try to get patients off IV support, keeping them hydrated by replenishing losses through enteral replacements is important.
Transport requires sodium and glucose, so the rehydration solution must contain some glucose and some salt.
There are homemade recipes for oral rehydration solutions and over-the-counter preparations available.
Gatorade does not always work well for rehydration because it has too much sugar in it.
Some patients can come off TPN but still need a central line for IV fluids; without IV fluids they end up sleeping most of the day and lack energy.
Being in a hydrated state is extremely important to making the bowel work well.
Sometimes patients cannot drink rehydration solution, but the GI tract can use it (via G-tube).
Energy use goes up dramatically during puberty.
Children who are doing well often hit the wall when they start puberty because their energy needs overcome their nutrient input.
The goal is always healthy growth, and it is important to be proactive, add supplements, and hope they will take extra nutritional support.
It is all about normal growth parameters and getting patients through puberty.
Some kids end up back on parenteral support to get through puberty.
When patients are not growing anymore as adults, borderline or marginal gut function is often enough to sustain them.
Clinicians should look at the growth chart for both weight and height, and not accept a 3rd percentile.
There are very few conditions with intestinal failure that have restricted growth.
Patients need to be monitored for micronutrient deficiencies after getting off TPN, as this is when they often get into trouble.
Long-term growth and outcome need to be followed, highlighting the importance of multidisciplinary teams.
Weight is tracked as a major metric for growth, but it has to be balanced with height.
What is commonly seen in this population is round babies where their weight for height is elevated.
There is increasing data looking at quality of weight: how much is fat weight versus lean body mass.
For any child not meeting growth potential, numerous other diagnoses can be responsible, ranging from endocrine issues to pancreatic insufficiency to micronutrient issues.
The concept is that patients are capable of having normal growth, and as you address issues and improve something, you need reasonable follow-up time on the order of weeks, not months.
Much of the growth monitoring can be done remotely; patients do not need to travel for assessment, but you cannot wait until the next appointment.
In older children, normal feeding behavior is important in many social aspects of life, not just nutrition.