Nutrition Interventions for Children with Special Health Care Needs

Chapter 20 - Nutrition Interventions for Short Bowel Syndrome
keep bacteria from the large bowel from refluxing into the small bowel. Resection of
the ileocecal valve results in decreased fluid and nutrient absorption, and increased
bacterial overgrowth in the small bowel (2,3).
Nutritional Support in Short Bowel Syndrome
Immediately after a bowel surgery which results in short bowel syndrome, total
parenteral nutrition (TPN) is required until bowel function returns (bowel sounds are
detected and stool is produced). Depending on the severity of short bowel syndrome,
full enteral/oral nutrition may be achieved in a matter of weeks, months, or may
never be achieved.
It is important that a patient be given as much enteral/oral nutrition as possible
to facilitate bowel growth and increased absorption of nutrients and to decrease
the deleterious effects of TPN on the liver (2,3). Patients may require specialized
enteral formulas with altered fat, protein, or carbohydrate. Infants are typically
given hydrolyzed protein or amino acid-based formula to decrease risk of allergylike
reactions, common with a compromised gastro-intestinal tract (3). If the ileum
is resected, fat malabsorption is likely, and fat may be provided as part medium
chain triglycerides (MCT) and part long chain fat. Medium chain triglycerides do
not require bile salts for absorption and can be absorbed anywhere in the small
intestine. Even with fat malabsorption, it is essential to provide some long chain fatty
acids, as they are important for gut adaptation after resection (3). Carbohydrate
often needs to be decreased to less than that contained in standard formulas, as its
malabsorption is a significant problem with a shortened bowel and decreased nutrient
transit time. Carbohydrate malabsorption results in an increased osmotic load in the
colon and thus watery diarrhea, with increased fluid and electrolyte losses. This can
actually be more of a problem than fat malabsorption, because malabsorbed fat does
not increase colonic osmotic load and increase fluid and electrolyte losses (2). There
are many commercially available formulas that contain free amino acids or peptides
for protein and medium chain triglycerides for a portion of the fat. The carbohydrate
content of formula varies; choosing the lowest carbohydrate formula available
that also meets protein and fat criteria is often helpful in decreasing osmotic
diarrhea. Very low carbohydrate modular formulae can be prepared if carbohydrate
malabsorption is severe.
Introduction of oral feedings are important for development and prevention of
oral feeding aversion. Small boluses of oral feedings of breast milk, formula or an
electrolyte solution should be introduced as soon as an infant is stable and increased
as tolerated. Solid foods should be introduced when developmentally appropriate
(typically by 6 months of age). Foods such as strained meats may be better tolerated
228 Nutrition Interventions for Children With Special Health Care Needs