RESUMO
OBJECTIVE: To quantify the rate of venous thromboembolism (VTE) in patients with pediatric intestinal failure and identify associated risk factors. STUDY DESIGN: We performed a retrospective cohort study in pediatric patients (<21 years old) with severe pediatric intestinal failure (≥90 consecutive days of parenteral nutrition) secondary to short bowel syndrome who were treated from 2014 to 2021 at an interdisciplinary intestinal rehabilitation program. The primary outcome was the incidence of VTE. Multivariable regression was performed to identify independent clinical predictors of VTE. RESULTS: A total of 263 patients (59.7% male) met the criteria for inclusion. The cumulative incidence of VTE was 28.1%, with a rate of 0.32 VTEs per 1000 catheter-days. On univariate analysis, the number of catheter days, number of catheters, and history of central line-associated blood stream infection were associated with VTE. On multivariable logistic regression, a higher number of catheters was an independent risk factor for VTE (aOR, 1.17; 95% CI, 1.06-1.29). Additionally, earlier gestational age was a risk factor for VTE such that every week decrease in gestational age conferred a 9% increased risk of VTE (aOR, 1.09; 95% CI, 1.02-1.16). CONCLUSIONS: In this retrospective study, 28.1% of patients with severe pediatric intestinal failure developed VTE; the number of catheters and early gestational age were noted to be independent risk factors for VTE. This high incidence of VTE highlights the need to investigate VTE in pediatric intestinal failure prospectively, including the potential benefit of prophylactic anticoagulation.
Assuntos
Cateteres Venosos Centrais , Insuficiência Intestinal , Tromboembolia Venosa , Humanos , Criança , Masculino , Adulto Jovem , Adulto , Feminino , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Estudos Retrospectivos , Fatores de Risco , Coagulação Sanguínea , Incidência , Cateteres Venosos Centrais/efeitos adversosRESUMO
OBJECTIVE: To quantify outcomes and analyze factors predictive of morbidity and mortality in infants with gastroschisis. STUDY DESIGN: Clinical data regarding neonates with gastroschisis born between 2009 and 2014 were prospectively collected at 175 North American centers. Multivariate regression was used to assess risk factors for mortality and length of stay (LOS). RESULTS: Gastroschisis was diagnosed in 4420 neonates with median birth weight 2410 g (IQR 2105-2747). Survival (discharge home or alive in hospital at 1 year) was 97.8% with a 37 day median LOS (IQR 27-59). Sepsis, defined by positive blood or cerebrospinal fluid culture, was the only significant independent predictor of mortality (P = .04). Significant independent determinants of LOS and the percentage of neonates affected were as follows: bowel resection (9.8%, P < .0001), sepsis (8.6%, P < .0001), presence of other congenital anomalies (7.6%, including 5.8% with intestinal atresias, P < .0001), necrotizing enterocolitis (4.5%, P < .0001), and small for gestational age (37.3%, P = .0006). Abdominal surgery in addition to gastroschisis repair occurred in 22.3%, with 6.4% receiving gastrostomy or jejunostomy tubes and 6.3% requiring ostomy creation. At discharge, 57.0% were less than the 10th percentile weight for age. The mode of delivery (52.4% cesarean delivery) was not associated with any differences in outcome. CONCLUSIONS: Although neonates with gastroschisis have excellent overall survival they remain at risk for death from sepsis, prolonged hospitalization, multiple abdominal operations, and malnutrition at discharge. Outcomes appear unaffected by the use of cesarean delivery. Further opportunities for quality improvement include sepsis prevention and enhanced nutritional support.
Assuntos
Gastrosquise/epidemiologia , Gastrosquise/cirurgia , Estudos de Coortes , Anormalidades Congênitas/epidemiologia , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Enterocolite Necrosante/epidemiologia , Feminino , Gastrostomia/estatística & dados numéricos , Humanos , Transtornos da Nutrição do Lactente/epidemiologia , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Atresia Intestinal/epidemiologia , Atresia Intestinal/cirurgia , Jejunostomia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , América do Norte/epidemiologia , Fatores de Risco , Sepse/mortalidadeRESUMO
OBJECTIVES: To describe the natural history of growth patterns and nutritional support in a cohort of infants with short bowel syndrome (SBS), and to characterize risk factors for suboptimal growth. STUDY DESIGN: A retrospective chart review of 51 infants with SBS followed by our intestinal rehabilitation program. Weight and length data were converted to age, sex, and gestational age-standardized weight-for-age z-scores (WAZ) and length-for-age z-scores (LAZ). RESULTS: Median (IQR) age at enrollment was 8.3 (0.9-14.6) weeks, and follow-up duration was 10 (8-13) months, including both inpatient and outpatient visits. Both WAZ and LAZ followed a U-shaped curve, with median for newborns (WAZ = -0.28; LAZ = -0.41), a nadir at age 6 months (-2.38 and -2.18), and near recovery by age 1 year (-0.72 and -0.76). Using multivariable regression analysis, diagnosis of necrotizing enterocolitis was independently associated with significant decrements of WAZ (-0.76 ± 0.32; P = .02) and LAZ (-1.24 ± 0.32; P = .0001). ≥ 2 central line-associated bloodstream infections was also independently associated with decreases in WAZ (-0.95 ± 0.33; P = .004) and LAZ (-0.86 ± 0.32; P = .007). CONCLUSION: In a cohort of infants with SBS, we observed a unique pattern of somatic growth, with concomitant deceleration of both WAZ and LAZ and near recovery by 1 year. Inflammatory conditions (necrotizing enterocolitis and central line-associated bloodstream infections) represent potentially modifiable risk factors for suboptimal somatic growth.
Assuntos
Bacteriemia/complicações , Infecções Relacionadas a Cateter/complicações , Cateterismo Venoso Central/efeitos adversos , Enterocolite Necrosante/complicações , Transtornos do Crescimento/etiologia , Síndrome do Intestino Curto/complicações , Estatura , Peso Corporal , Ingestão de Energia , Feminino , Humanos , Lactente , Recém-Nascido de Baixo Peso , Recém-Nascido , Masculino , Análise Multivariada , Estudos RetrospectivosRESUMO
OBJECTIVES: In a large cohort of children with intestinal failure (IF), we sought to determine the cumulative incidence of achieving enteral autonomy and identify patient and institutional characteristics associated with enteral autonomy. STUDY DESIGN: A multicenter, retrospective cohort analysis from the Pediatric Intestinal Failure Consortium was performed. IF was defined as severe congenital or acquired gastrointestinal diseases during infancy with dependence on parenteral nutrition (PN) >60 days. Enteral autonomy was defined as PN discontinuation >3 months. RESULTS: A total of 272 infants were followed for a median (IQR) of 33.5 (16.2-51.5) months. Enteral autonomy was achieved in 118 (43%); 36 (13%) remained PN dependent and 118 (43%) patients died or underwent transplantation. Multivariable analysis identified necrotizing enterocolitis (NEC; OR 2.42, 95% CI 1.33-4.47), care at an IF site without an associated intestinal transplantation program (OR 2.73, 95% CI 1.56-4.78), and an intact ileocecal valve (OR 2.80, 95% CI 1.63-4.83) as independent risk factors for enteral autonomy. A second model (n = 144) that included only patients with intraoperatively measured residual small bowel length found NEC (OR 3.44, 95% CI 1.36-8.71), care at a nonintestinal transplantation center (OR 6.56, 95% CI 2.53-16.98), and residual small bowel length (OR 1.04 cm, 95% CI 1.02-1.06 cm) to be independently associated with enteral autonomy. CONCLUSIONS: A substantial proportion of infants with IF can achieve enteral autonomy. Underlying NEC, preserved ileocecal valve, and longer bowel length are associated with achieving enteral autonomy. It is likely that variations in institutional practices and referral patterns also affect outcomes in children with IF.
Assuntos
Enteropatias/terapia , Nutrição Parenteral , Canadá/epidemiologia , Pré-Escolar , Estudos de Coortes , Enterocolite Necrosante/epidemiologia , Feminino , Seguimentos , Humanos , Valva Ileocecal , Lactente , Recém-Nascido , Enteropatias/epidemiologia , Intestinos/transplante , Masculino , Análise Multivariada , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To determine the prevalence of micronutrient deficiencies in children with intestinal failure as they transitioned from parenteral nutrition (PN) to enteral nutrition (EN). STUDY DESIGN: We reviewed medical records of all patients with severe intestinal failure treated from 1999 to 2008 at a multidisciplinary intestinal rehabilitation program who had undergone micronutrient biochemical monitoring. RESULTS: The cohort of 30 children (mean age, 5 years; range, 2 to 9 years; 18 boys) had median PN duration of 23 weeks (IQR, 13 to 34 weeks). Median transition from PN to full EN lasted 12 weeks (IQR, 8 to 20 weeks); during this transition, 33% of patients had at least one vitamin deficiency and 77% at least one mineral deficiency. After transition to 100% EN, 70% had at least one vitamin deficiency and 77% had at least one mineral deficiency, with the most common deficiencies being vitamin D (68%), zinc (67%), and iron deficiency (37%). After transition to 100% EN, multivariate analysis identified regular use of a multivitamin supplement (P=.004) and intact ileocecal valve (P=.02) as protective against the development of vitamin deficiencies, independent of bowel length, gestational age, and days on PN. CONCLUSIONS: Children with intestinal failure exhibit a high prevalence of micronutrient deficiencies during intestinal rehabilitation. Regular monitoring and aggressive supplementation in children with intestinal failure is warranted.
Assuntos
Anemia Ferropriva/etiologia , Nutrição Enteral , Micronutrientes/deficiência , Nutrição Parenteral , Síndrome do Intestino Curto/complicações , Anemia Ferropriva/terapia , Estatura , Peso Corporal , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Estudos Longitudinais , Masculino , Estudos Retrospectivos , Síndrome do Intestino Curto/terapia , Vitaminas/uso terapêuticoRESUMO
OBJECTIVE: To determine risk factors for intestinal failure (IF) in infants undergoing surgery for necrotizing enterocolitis (NEC). STUDY DESIGN: Infants were enrolled in a multicenter prospective cohort study. IF was defined as the requirement for parenteral nutrition for >or= 90 days. Logistic regression was used to identify predictors of IF. RESULTS: Among 473 patients enrolled, 129 had surgery and had adequate follow-up data, and of these patients, 54 (42%) developed IF. Of the 265 patients who did not require surgery, 6 (2%) developed IF (OR 31.1, 95% CI, 12.9 - 75.1, P < .001). Multivariate analysis identified the following risk factors for IF: use of parenteral antibiotics on the day of NEC diagnosis (OR = 16.61, P = .022); birth weight < 750 grams, (OR = 9.09, P < .001); requirement for mechanical ventilation on the day of NEC diagnosis (OR = 6.16, P = .009); exposure to enteral feeding before NEC diagnosis (OR=4.05, P = .048); and percentage of small bowel resected (OR = 1.85 per 10 percentage point greater resection, P = .031). CONCLUSION: The incidence of IF among infants undergoing surgical treatment for NEC is high. Variables characteristic of severe NEC (low birth weight, antibiotic use, ventilator use, and greater extent of bowel resection) were associated with the development of IF.