Edited by: Andrew S. Day, University of Otago, New Zealand
Reviewed by: Rishi Bolia, Queensland Children's Hospital, Australia; Tetsuya Ishimaru, Saitama Children's Medical Center, Japan
This article was submitted to Pediatric Gastroenterology, Hepatology and Nutrition, a section of the journal Frontiers in Pediatrics
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Postoperative enteral nutrition has a significant influence on the prognosis of patients with congenital intestinal atresia. Currently, there is no precise guidance on enteral nutrition management. This study aimed to compare the outcomes of different feeding strategies based on the initial volume and daily advancement in postoperative patients with congenital intestinal atresia.
This study was a retrospective study collected from October 2019 to July 2021 in Shenzhen Children's Hospital. According to the initial volume and daily advancement, the patients were divided into high-dose group and low-dose group. General basic information such as age, sex, and lesion type was gathered. The postoperative outcome included the levels of hemoglobin (HGB), albumin (ALB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), direct bilirubin (DB), length of stay, length of total PN, time to reach 100% enteral nutrition (EN) (120 kcal·kg-1·d-1), infection incidence and intestinal failure associated liver disease (IFALD) incidence (DB>2 mg·dL-1).
In total, 32 patients with congenital intestinal atresia were identified. There was no significant difference between the high-dose group and the low-dose group in the baseline characteristic. The length of time to reach 100% (
Within the limitations, the findings of this study suggest that High-dose feeding (initial volume>15 ml·kg-1·d-1, daily advancement>10 ml·kg-1·d-1) is beneficial for the prognosis of patients diagnosed with congenital intestinal atresia treated by intestinal.
Congenital intestinal atresia is one of the common congenital anomalies of the gastrointestinal tract in newborns, including duodenal atresia, small intestine atresia, and colonic atresia. There is about 95% of obstructions in the neonatal period are due to intestinal atresia (
Compared to PN, enteral nutrition (EN) is recommended as the preferred route for the development of the gastrointestinal system. Common complications of long-term PN include PN-associated liver disease (PNALD) and infection (
This study aimed to evaluate the clinical outcomes of different feeding strategies in postoperative patients with congenital intestinal atresia. By comparing two different strategies, we looked forward to finding out the appropriate volume of initial feeding and daily advancement which can be beneficial for prognosis.
This was a retrospective study approved by Shenzhen Children's Hospital. Patients with congenital intestinal atresia were treated at the neonatal surgery department of Shenzhen Children's Hospital from October 2019 to July 2021. The subjects included patients diagnosed with intestinal atresia. Patients with severe malformations of other systems, extreme malnutrition before surgery, or other preoperative complications (such as necrotizing enterocolitis, gastrointestinal perforation, etc.) were excluded. After clinical stabilization, small bowel resection and anastomosis were performed. The most common technique is resection of proximal dilated and atretic bowel with primary end-to-end anastomosis using 4–0 Vicryl threads. Confirmation of continuity of intestine was checked with the passage of warm saline solution in the distal atretic small bowel. After the enteroplasty, patients were divided into two groups according to the feeding strategies. The application of different feeding strategies was based on not only the surgeon's preference but also the clinical situation of the patients. The conditions of the patients included bloating, fever, and volume of gastrointestinal decompression. The patients were divided into two groups through initial volume based on previous research about feeding guidelines. It is suggested that feeding guideline implementation with higher initial feeding volume was well tolerated (
Numerous clinical factors were collected retrospectively in the electronic medical records as follows: sex, age, birth weight, gestational age, diagnosis, the length between atresia and the ligament of Treitz, total resection length, the levels of hemoglobin (HGB), albumin (ALB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), direct bilirubin (DB), length of stay, length of total PN, time to reach 50% EN (60 kcal·kg-1·d-1), time to reach 100% EN (120 kcal·kg-1·d-1), infection incidence and IFAND incidence (DB>2 mg·dL-1). Patients were monitored for postoperatine complications such as an anastomotic leak, vomiting, diarrhea, infection, etc. Every complication was noted carefully.
Statistical analysis of data was performed by SPSS version 19.0 at a significance level of
In total, 32 patients were considered eligible for the study. Seventeen patients were enrolled in the high-dose group and 15 patients were enrolled in the low-dose group. There were no significant differences in the baseline characteristic between the two groups except birth weight (
Baseline characteristics stratified by postoperative feeding strategies.
| Cases ( |
Total | 17 | 15 | |
| Male | 10 | 5 | 0.178 | |
| Female | 7 | 10 | ||
| Age (h) | 19.65 ± 17.83 | 16.60 ± 13.71 | 0.596 | |
| Gestational age(w) | 35.82 ± 2.09 | 34.60 ± 3.24 | 0.21 | |
| Birth weight(kg) | 2.87 ± 0.61 | 2.35 ± 0.68 | 0.033 | |
| Time to initiate EN(d) | 15.26 ± 8.95 | 13.72 ± 8.48 | 0.595 | |
| Length between atresia and the ligament of Treitz (cm) | 67.65 ± 47.73 | 55.13 ± 39.10 | 0.428 | |
| Length of intestinal resection (cm) | 23.82 ± 6.73 | 22.86 ± 11.38 | 0.771 | |
In the high-dose group, the length of PN was 19.11 ± 11.28 days, as for the low-dose group, it was 24.06 ± 12.51 days. There was a significant difference (
The levels of evaluating factors including DB, AST, ALT, ALB, and HGB were recorded before and after EN. There is no statistically significant difference in the levels of DB, AST, ALT, ALB, and HGB before EN between the two groups. After the implementation of different feeding strategies, the evaluating factors performed better in the high-dose group. In the high-dose group, the levels of DB (
Comparisons of postoperative outcome in children with intestinal atresia stratified by postoperative feeding strategies.
| Cases ( |
17 | 15 | ||
| DB (μmol/L) | Pre-feeding | 16.06 ± 10.64 | 17.19 ± 9.84 | 0.759 |
| Post-feeding | 11.75 ± 5.91 | 21.54 ± 12.94 | 0.009 | |
| change | −4.37 ± 9.71 | 4.34 ± 12.61 | 0.035 | |
| AST (IU/L) | Pre-feeding | 19.23 ± 6.43 | 27.46 ± 19.65 | 0.113 |
| Post-feeding | 23.05 ± 8.72 | 31.20 ± 18.11 | 0.109 | |
| change | 4.64 ± 7.56 | 3.73 ± 26.17 | 0.891 | |
| ALT (IU/L) | Pre-feeding | 8.94 ± 4.05 | 12.33 ± 11.41 | 0.262 |
| Post-feeding | 10.64 ± 4.12 | 24.06 ± 26.13 | 0.045 | |
| change | 1.70 ± 4.39 | 11.73 ± 25.42 | 0.119 | |
| ALB (g/L) | Pre-feeding | 32.62 ± 3.59 | 31.18 ± 4.93 | 0.346 |
| Post-feeding | 33.77 ± 3.69 | 32.81 ± 3.54 | 0.459 | |
| change | 1.14 ± 4.74 | 1.63 ± 4.86 | 0.777 | |
| HGB (g/L) | Pre-feeding | 121.76 ± 27.49 | 111.60 ± 38.44 | 0.392 |
| Post-feeding | 102.94 ± 27.49 | 96.13 ± 19.38 | 0.354 | |
| change | −18.23 ± 18.94 | −15.46 ± 37.25 | 0.746 | |
| Hospital stay (d) | 38.35 ± 20.68 | 49.86 ± 16.12 | 0.092 | |
| 50% EN(d) | 5.47 ± 1.94 | 9.80 ± 3.87 | <0.001 | |
| 100% EN(d) | 9.58 ± 3.16 | 19.13 ± 10.16 | 0.001 | |
| Discharge weight (kg) | 3.27 ± 0.38 | 3.02 ± 0.62 | 0.030 | |
| Length of PN(d) | 19.11 ± 11.28 | 24.06 ± 12.51 | 0.249 | |
| IFALD ( |
5 | 11 | 0.032 | |
| Infection ( |
1 | 2 | 0.589 | |
| Complication ( |
2 | 3 | 0.645 | |
DB, direct bilirubin; AST, aspartate aminotransferase; ALT, alanine aminotransferase; ALB, hemoglobin; HGB, hemoglobin; EN, enteral nutrition; PN: parenteral nutrition.
Comparison of weight change stratified by postoperative feeding strategies.
| High-dose group | 2.87 ± 0.61 | 3.27 ± 0.38 | 0.33 ± 0.44 | 0.003 |
| Low-dose group | 3.02 ± 0.62 | 2.35 ± 0.68 | 0.66 ± 0.34 | <0.001 |
Postoperative EN of congenital intestinal atresia has received more and more attention in recent years. However, there is no guideline to state the suitable feeding strategy. The traditional idea is that feeding should be initiated when the patient has defecated and the normal bowel function has recovered. PN plays a role in providing nutritional support to the patients during the fasting period. However, some studies have pointed out that long-term PN can cause complications such as intestinal mucosal atrophy, cholestatic liver disease, and infection (
After the surgical resection of the obstructed intestinal segment, the remaining segment undergoes a series of physiological changes. First of all, the stress stage of the intestines leads to the dysfunction of intestinal peristalsis. The incidence of postoperative diarrhea increases, which leads to electrolyte imbalance and dehydration (
Postoperative EN should process step by step. As the clinical condition is suitable for EN, feeding should be started as soon as possible. DR Shores et al. pointed out that higher initial feeding volume was well tolerated and resulted in the faster achievement of 50% goal EN calories (
The limitations of this study are the small sample size and single-center. Although these limitations can't be ignored, this study reflects the experience of EN in patients with relatively rare surgical disorders. We plan to draft a feeding guideline and conduct a randomized controlled trial to evaluate the guideline.
Higher initial feeding volume and faster daily advancement after surgery for patients with congenital intestinal atresia are well-tolerated and effective for the decrease of hospital stay and time to reach 100% of goal EN calories. We also reported improved liver function in the high-dose group.
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethical review and approval was not required for the study on human participants in accordance with the Local Legislation and Institutional Requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.
DX: conceptualization, supervision, and funding acquisition. JiW: methodology, investigation, data curation, and writing-original draft. JuW and HX: writing-review and editing and validation. All authors contributed to the article and approved the submitted version.
Science and Technology Program of Shenzhen, China (General Program: JCYJ20210324135409025).
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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