Pediatric Enteral Nutrition

By Axelrod, David; Kazmerski, Kimberly; Iyer, Kishore

ABSTRACT. Common to all pediatric patients receiving enteral nutrition is the inability to consume calories orally. This is often secondary to issues of inadequate weight gain, inadequate growth, prolonged feeding times, weight loss, a decrease in weight/age or weight/height ratios, or a persistent triceps skinfold thickness

The provision of adequate calories and essential nutrients is vital for childhood growth and development. Although provision of nutrition via oral intake is ideal, in patients unable to eat a sufficient volume, additional nutrition support is necessary. Currently, nutrition goals can be met using either parenteral nutrition (PN), an appropriate mixture of carbohydrate, protein, and fat with essential vitamins and trace elements, or enteral administration of an appropriate tube-feeding formula. When compared with PN, enteral nutrition has numerous potential advantages, including lower costs, reduced infectious complications, reduction in bacterial translocation as a result of improved enterocyte viability, and decreased incidence of PN-associated liver dysfunction (PNALD).1

This review will examine the indications for enteral nutrition in the pediatric population, methods and complications of obtaining and maintaining enteral access, choice of enteral formulas, and approach to long-term feeding. The particular case of patients with decreased intestinal length will be considered, with particular attention given to methods of securing PN independence.

Indications for Pediatric Enteral Nutrition

Common to all patients receiving enteral nutrition is a documented inability to consume adequate calories orally to maintain homeostasis. The common indications for enterai nutrition vary with the age of the patient (Table I).2 In the neonatal period, patients are commonly fed via a nasoenteric route as a result of prematurity and lack of coordination of the sucking and swallowing reflex. Furthermore, the high metabolic demands coupled with gastrointestinal (GI) immaturity and frequent fluid restrictions often render bolus oral feedings inadequate in significantly premature infants. The other principal indications for tube feeding in this period are patients with short gut due to gastroschisis, omphalocele, or a history of severe necrotizing enterocolitis (NEC). In these patients, reduced absorptive capacity requires a slow, continuous feeding regimen if the patient is to achieve early nutrition autonomy from PN.

In early childhood, prolonged enteral access is often indicated for patients with severe neurologic impairment due to a range of conditions, including cerebral palsy, anoxic brain injury, Down’s syndrome, or severe seizure disorders. These patients often had coincidental gastric dysmotility resulting in gastroesophageal reflux (GER) and aspiration. Although children with Down’s syndrome, Prader-Willi syndrome, or myelomeningocele may have decreased metabolic rates leading to obesity during later childhood (oftentimes presenting with failure to thrive in the first year of life), those with cerebral palsy may have increased energy demands as a result of severe contractures or choreoathetoid movements. When 1 or more of the following factors are identified, tube feeding should be considered after other aggressive oral interventions have been tried: (1) inability to consume at least 80% of calculated energy needs by mouth; (2) total feeding time >4 hours per day; (3) inadequate growth or weight gain for >1 month (under the age of 2); (4) weight loss or no weight gain for a period of 3 months (over the age of 2); (5) a change in weight/age or weight/height (length) over 2 growth channels on the Centers for Disease Control (CDC) growth chart; (6) triceps skin folds consistently

TABLE I

Indications for long-term enteral feeding

Acquired conditions of childhood and adolescence, which may result in markedly higher metabolic rates, may necessitate full or supplemental enterai nutrition. Common indications in this group for enterai nutrition include childhood burns, severe sepsis, and advanced human immunodeficiency virus (HIV). Patients with advanced malignancy often require enterai feedings to overcome the decreased appetite that accompanies chemotherapy and tumor cachexia. Finally, children with cystic fibrosis with significant pancreatic insufficiency and increased work of breathing may benefit from nutrition supplementation.

TABLE II

Methods to obtain long-term pediatric enteral access

Methods of Obtaining and Maintaining Enterai Access

Provision of enterai nutrition requires prolonged access to either the stomach or the proximal small intestine. Delivery routes for enterai nutrition include nasogastric, nasoduodenal, nasojejunal, gastrostomy, and jejunostomy (whether direct or through the stomach) feedings. The choice of access depends upon the length of time feeding will be needed, anatomic considerations (eg, inability to access the upper gastrointestinal tract endoscopically), and the presence of coexisting diseases, including GER disease.

In patients with a short-term need for enterai access, including hospitalized patients, nasoenteric access with a thin feeding tube (eg, Dobhoff, Corpak Inc, Wheeling, IL) meets the limited enterai access requirements. Specific to infants and children, soft, small- bore tubes should be used with nasal feedings (5, 6, or 8 Fr). The choice of gastric or small bowel intubation remains controversial. Purported advantages of gastric intubation include ease of tube placement, ability to use bolus feedings, which may be more physiologically appropriate, and reduced cost by avoiding the need for radiographic confirmation. Advocates of small bowel feedings report a reduced incidence of aspiration and improved caloric intake. Recently, several techniques have been introduced that may allow small bowel tube placement without radiologie confirmation including the use of magnets, pH monitoring, or a simple aspiration test. Inability to aspirate 2 mL of air after introduction of 10 mL of air into a nasoenteric tube accurately predicted small bowel placement with 99% certainty in a study of 75 pediatric feeding tubes.3

Although naso-small bowel feeding has been shown to be beneficial compared with nasogastric tubes in single center adult studies, a meta-analysis of adult trials failed to demonstrate a clear advantage of either route regarding infection rates or degree of caloric support.4 In the single randomized trial in acutely ill children, Meert and colleagues5 demonstrated that patients receiving small bowel feedings achieved a higher percentage of daily caloric goal (47% vs 30%) when compared with patients fed into the stomach. In this population, there was no difference in the percentage of positive tracheal aspirates for pepsin (JD = .3) or in the number of tube-related complications between the 2 groups.

Patients who require feedings for longer than 4 weeks are candidates for a surgically, endoscopically, or radiologically placed feeding tube (Table II). Surgical gastrostomy was first introduced by Verneuil in 1876 and remained the standard of care until the introduction of the percutaneous endoscopically guided gastrostomy tube (PEG) by Gauderer et al6 in 1980. A PEG tube is a “blindly” placed gastrostomy tube placed under local, regional, or general anesthesia using endoscopie guidance. During the procedure, the stomach is insufflated and a needle is placed into the gastric lumen and visualized by the endoscopist. A wire is then passed through the abdominal wall into the stomach and used to guide a gastrostomy tube with an internal bolster throughout the abdominal wall. Placement is confirmed endoscopically. Overall success rates range from 91% to 96%. Major and minor complications occur in 4%- 22% of cases but \are principally limited to local wound infections. More serious complications, including colocutaneous fistulas (1.7%), can occur as a result of the blind technique.7 When compared with operatively placed G-tubes, there is a higher risk of developing peritonitis if the tube should become inadvertently dislodged early, as the stomach can fall away from the abdominal wall. Overall, PEG procedural mortality rates are reported to be between 0% and 10%. This technique appears safe even in very small children, including those under 3.5 kg.8 Late complications, although rare, include intragastric buried bumper or extruded gastrostomy, gastric metaplasia, granulation tissue around the PEG site, intragastric pseudotumoral proliferative gastric mucosa, and cutaneous necrosis.9

PEG tubes are reported to be less expensive, safer, and more time efficient to place compared with operatively placed gastrostomy tubes.10 However, operatively placed gastrostomy tubes in conjunction with Nissen fundoplication continues to be recommended for children with severe neurologic impairment. These children have a higher incidence of gastric dismobility, leading to greater GER and aspiration. The need for a combined antireflux procedure and feeding-tube placement is not universal, even in this population. Patients who are likely to require a combined procedure can be accurately predicted using pH probe monitoring. Only 5% of neurologically impaired patients with a normal pH probe study undergoing a PEG required a subsequent Nissan fundoplication compared with 30% of patients with an abnormal study.11

Radiologically placed gastric or gastrojejunostomy (GJ) tubes offer an alternative, minimally invasive method of obtaining enterai access. As originally introduced in 1981 by Preshaw,12 this technique involves distending the stomach and placing the tube under fluoroscopic guidance. One technique, which can be applied to the pdiatrie population, uses a commercially available kit (Carey- Alzate-Soons; Cook, Inc, Bloomington, IN).13 After the introduction of 500-1000 mL of air, lateral and frontal fluoroscopic images are obtained to ensure apposition of the gastric and abdominal wall. Next, the stomach is anchored using 3 percutaneously placed T anchors. Using a 4th puncture, a 6 Fr catheter is introduced and a guidewire is passed into the duodenum. Next a 14 Fr gastrojejunal catheter is inserted and secured with an intragastric mushroom device. The jejunal extension is 10 Fr.

When compared with PEG placement, the radiologie procedures have several disadvantages, including the need for ionizing radiation and increased cost due to the need for the fluoroscopic suite. Hoffer and colleagues13 performed a randomized study involving 135 patients, which demonstrated improved success (100% vs 91%; p = .01) with radiologic gastrostomy placement compared with PEG tube placement, with a lower number of overall complications. The latter did not reach statistical significance. These results were similar to a meta-analysis of cohort studies in which the radiologic techniques were found to be successful and require fewer anesthesias than PEG placement. These advantages may offset the higher cost of the initial procedure.14

The jejunally placed position of a radiologically placed GJ feeding tube may offer a particular advantage to patients with established GER. In these patients, distal feeding may eliminate the need for surgical antireflux procedures without increasing the risk of aspiration pneumonia. Wales and colleagues15 performed a retrospective analysis comparing operative Nissen fundoplication and gastrostomy tube with a radiologically placed GJ tube of 111 patients with established GER. Although patients in the GJ tube group were more likely to require continued medication for reflux, only 8% eventually required fundoplication for symptom control. Furthermore, there was a trend to a reduced incidence of aspiration pneumonia in the patients with a GJ tube.

Each of the initial enterai access placement procedures appears to have advantages and a particular population to which it is best suited. No matter which procedure is performed, long-term maintenance of the gastrocutaneous fistula for feeding is best accomplished with a low-profile device (eg, the MIC-Key button, Medical Innovations Inc, Santa Clara, CA). The button has a lower profile and is more cosmetically appealing, particularly for older children. Conversion from an initially placed PEG tube to a low- profile device generally requires sedation in young children and has been associated with a low incidence of serious complications, including tract disruption, gastrostomy leak, or loss of access. Minor long-term problems include hypertrophie granulation tissue, tube leakage, local yeast infection, and dislodgement (Table III). These problems can, in general, be managed with parent/patient education and simple local interventions. Low-profile devices also require the use of an access tube to engage and open a 1-way valve contained within a low-profile device to allow the instillation of medications, feedings, or fluids.

Tube-Feeding Formulation and Feeding Regimens

Physicians and nutrition specialists caring for patients with long-term enterai feeding requirements now have access to a diverse group of tube-feeding preparations that can be tailored to the needs of the child. Feeding preparations vary by the age or size of the child. Feedings in small infants are beyond the scope of this review and will not be discussed. For children

TABLE III

Management of common complications of enteral access

For most children, tube feeding with a mixture of fat, protein, and carbohydrate is indicated. Examples include Pediasure (Ross Laboratories, Columbus, OH), Peptamen Jr (Nestle Nutrition, Glendale, CA), and Nutren Jr (Nestle Nutrition). The average caloric density of these formulas is 1 kcal/mL. Vitamin and mineral requirements can be met with a total intake of 950-2000 mL per day. The feedings can also be supplemented with free-water bolus to ensure adequate free-water intake. Using these formulas, children will receive appropriate levels of essential fatty acids and trace minerals. Other guidelines to ensure nutrition adequacy in the use of enterai feedings include assessing and calculating the appropriate calorie goal, which will not be discussed in this review; identifying appropriate protein needs (>7% and 30% but age of 10 or >50 kg) may tolerate adult formula, including Osmolite (Ross Laboratories) and Isocal (Novartis Nutrition, Minneapolis, MN).

Several specialized formulas are available for particular disease conditions. In patients with decreased intestinal length, absorptive capacity, or pancreatic function, elemental tube feedings (eg, Neocate [infantl/Neocate Jr/Neocate One Plus [SHS North America, Gaithersburg, MD]; Vivonex Pdiatrie [Novartis Nutrition], and EleCare [Ross Laboratories]) may be particularly useful. Protein content in these feedings consists primary of dipeptides and tripeptides that do not require additional digestion. Additional calories are provided as fat with a blend of mediumchain and long- chain triglycrides and simple carbohydrates. In general, these formulas provide 1 kcal/mL and can be diluted, if needed. Low-fat formulas (ToIerex, 0.15 g fat/L; Novartis Nutrition) may be useful immediately after bowel transplantation or temporarily in patients with chylous ascites or severe pancreatitis.

Feeding delivery regimens vary widely according to the nutrition needs of the child, type of enterai access, and degree of intestinal adaptation. In general, feedings are begun at a low rate and gradually advanced as tolerated. Feeding intolerance is manifested by emesis, diarrhea, or bloating. Rarely, rapid advancement of high- osmolar formula has been reported to precipitate NEC, which can be life threatening. However, a metaanalysis of randomized or quasirandomized trials that examined rapid us slow advancement of feedings in low-birth-weight infants failed to demonstrate a difference in NEC. Patients whose feedings were advanced more quickly, however, reached goal feeding more rapidly and required less time to regain their birth weight. The choice of bolus us continuous feedings depends mainly on the type of enterai access. In general, bolus feeding can be accomplished best with a gastric tube in patients without evidence of GER. In patients with GJ tubes or those who fail to tolerate bolus feedings, continuous infusion feedings must be used. Over time, these continuous feedings can be cycled and the time of administration reduced to evening hours for outpatients.

Weaning from tube feedings is often possible and should be the goal for children with app\ropriate neurologic function. As oral feeding is introduced, total calories can be gradually reduced in the enterai feeding. This can be accomplished by reducing the hours of continuous feeding or the rate of the feedings. After successful weaning (defined as >80% of nutrition needs met orally and consistent/adequate growth), enterai access can, in general, be easily removed and the gastrocutaneous fistula allowed to close on its own.

Approach to Enterai Feeding in Children With Short Bowel Syndrome (SBS)

Patients with severe SBS represent a particularly difficult population to support with enterai feedings. SBS is the end-stage manifestation of a variety of pathologic causes of small intestinal loss in children, including atresias, gastroschisis, malrotation, NEC, and long-segment Hirschsprung’s disease. Nutrients absorbed by the small intestine include fluids, magnesium, zinc, carbohydrates, proteins, fats, iron, calcium, copper, folate, fat-soluble vitamins, vitamin B12, and bile salts, among other micronutrients. Traditionally, patients with severe SBS were managed with PN. Unfortunately, long-term PN is often associated with progressive hepatic dysfunction, loss of mucosal integrity, frequent catheter- related complications, and in some cases, mortality. Aggressive use of enterai nutrition is not only an important factor in promoting intestinal adaptation; it also avoids the numerous complications associated with long-term PN.17 This process, however, may take months to years to complete in some patients. PN is cycled or weaned while adjusting enterai feedings and maintaining appropriate growth. The Children’s Memorial Hospital (Chicago, IL) approach to these children is outlined below.

Initial evaluation is conducted as an inpatient to assure accurate assessment of the child’s intake and output, nutrition status, to facilitate skin care (particularly in the perianal area), and to conduct radiologie investigations. Standard contrast radiography and endoscopy are used to determine the length and caliber of remnant small and large intestine. Particular attention is paid to areas of stricture or significant dilation, which would benefit from surgical intervention. Every effort should be made to recruit all available small and large intestine and restore bowel continuity to improve salt and water resorption. Finally, permanent, noninfected vascular access must be established because line infections impair efforts to increase enterai tolerance.

The type of enterai formula used and the timing of initiation of enterai feedings in the SBS pdiatrie patient are very important. Although residual small bowel length remains an important predictor of the duration of the use of PN, use of breast milk (for infants

Tube feeding should be introduced in a slow and deliberate manner. Dilute elemental tube feeding (15 cal/oz) is initially used to decrease intraluminal residual, facilitate absorption, and decrease the possibility of allergy. Continuous feedings are begun at 5 mL/h and advanced over several weeks or even months to tolerated volumes. Goal enterai feedings are difficult to determine. Goal seems to be the rate at which the child is tolerating the feedings, maintaining consistent weight gain and nutrition status. Feedings are held if the stool output exceeds 30-40 mL/kg/d and slowly reintroduced at a slower rate. Once goal feeding is achieved using dilute, elemental tube feedings, the concentration is gradually increased. Feedings are increased incrementally over a period of time to 18 cal per oz, 20 cal per oz, etc. The addition of protein and calorie modulars has been useful in the nutrition management when increased volumes are not tolerated. Supplements such as Microlipid (Novartis Nutrition; 50% fat emulsion using safflower oil) and Duocal (SHS North America, Gaithersburg, MD), which is a combination of carbohydrate (hydrolyzed corn starch) and fats (corn/coconut oils, MCT/LCT), provide an additional 4.5 kcal/ mL and 4.9 kcal/g respectively. These products have proven to be well tolerated and easy to use in our practice.

Loss of enterai tolerance in short bowel patients should prompt a rapid search for sources of infection. For patients with indwelling lines, blood cultures should be immediately obtained, and if possible, the line must be removed. Other common infections include rotavirus and upper respiratory infections. Finally, bacterial overgrowth in dilated bowel segments may lead to bloating and feeding intolerance. Rotating antibiotics may assist with intestinal decontamination. Children who fail to tolerate feedings despite a persistent effort should be evaluated for intestinal transplantation. Indications for small bowel transplant in these children include impending loss of vascular access, worsening hepatic dysfunction, or recurrent catheter-related infections. Intestinal transplant either alone or with the liver offers the sole definitive therapy for children with refractory intestinal failure. One-year graft and patient survival now exceeds 90% and 70%, respectively.21 After successful small intestinal transplant, patients can achieve freedom from PN and resume linear growth, although few demonstrate catch-up growth.22 Unfortunately, late graft loss remains a problem due to acute and chronic rejection.

Although weaning from PN is important in the management of the short-bowel pdiatrie patient, enterai feedings or oral feedings can pose an increased risk for nutrition deficiencies. A child’s absorptive capacity may continue to be limited and set the stage for subclinical immune deficiencies.23 Many biologic and growth deficiencies are frequently seen in patients with SBS, even after adaptation to enteral/oral feedings. Frequent deficiencies found in these enterally fed children included persistent decreased height for age, a decreased fat body mass, macrocytosis, anemia, and low serum levels of vitamin B12, folate, and ferritin. Many children will develop profound oral aversions as a result of ongoing illness, obnoxious oral stimuli (prolonged ventilation, nasogastric intubation, and suctioning), prolonged periods of not eating by mouth and thereby missing the “window of opportunity” to learn how to eat orally. Although the child is receiving combined PN and enterai feedings, the use of ongoing pleasant oral experiences, in conjunction with speech/feeding therapy by a speech pathologist, should be implemented.

A multidisciplinary approach using pediatric gastroenterologists, pediatric surgeons, transplant surgeons, pediatric dietitians, and an experienced pediatric nurse has been found to improve the care of these patients. After inception of an interdisciplinary team, Koehler et al24 evaluated 103 short-bowel patients. At the beginning of the study, 74% of these patients were PN dependent, 6% enterai feeding dependent, and 20% were eating orally. After intensive management of the 76 PN patients, 29% were weaned to oral, oral- enteral, or enterai feedings. Of the 6 patients who were receiving enterai feedings, 4 (67%) were transitioned to oral feedings.

Conclusions

Enteral nutrition is the preferred method of nutrition support for children unable to consume sufficient calories orally. Both temporary and permanent enterai access can be secured safely. Low- profile buttons improve patient satisfaction without significantly increasing risk. Enterai nutrition support is crucial for patients with SBS, many of whom can be weaned from PN through a careful, stepwise multidisciplinary approach. For patients failing enterai nutrition, small intestinal transplant has emerged as a viable and durable treatment modality.

REFERENCES

1. Kelly D. Liver complications of pdiatrie parenteral nutrition: epidemiology. Nutrition. 1998; 14:153-157.

2. Kleinman RE. Enterai nutrition support. In: Kleinman RE, ed. Pdiatrie Nutrition Handbook. Elk Grove Village, IL: American Academy of Pediatrics; 2004:280-290.

Excellent reference and review for physicians and nutritionists caring for children with enterai and parenteral nutrition needs.

3. Harrison AM, clay B, Grant MJ, et al. Nonradiographic assessment of enterai feeing tube position. Crit Care Med. 1997;25: 2055-2059.

4. Marik PE, Zaloga GP. Gastric versus post-pyloric feeding: a systematic review. Crit Care. 2003;7:R46-R51.

5. Meert KL, Daphtary KM, Metheny NA. Gastric vs small bowel feeding in critically ill children receiving mechanical ventilation: a randomized controlled trial. Chest. 2004;126:872-878.

Excellent study. One of the few, randomized trials in pediatric enteral nutrition which demonstrates that small bowel feeds allow increase nutritional delivery but do not prevent aspiration.

6. Gauderer MWL, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous end\oscopie technique. J Pediatr Surg. 1980;15:872-875.

Original paper describing the technique of PEG placement.

7. Gauderer MWL. Gastrostomy techniques and devices. Surg Clin North Am. 1992;72:1285-1298.

8. Wilson L, Oliva-Hemker M. Percutaneous endoscopie gastrostomy in small medically complex infants. Endoscopy. 2001;33: 433-436.

9. Segal D, Michaud L, Guimber D, Ganga-Zandzou PS, Turck D, Gottrand F. Late-onset complications of percutaneous endoscopie gastrostomy in children. J Pediatr Gastroenterol Nutr. 2001;33:495- 500.

Large case series reviewing the early and late complications of PEG in children.

10. Songster W, Cuddington GD, Bachulis BL. Percutaneous endoscopic gastrostomy. Am J Surg. 1988;155:677-678.

11. Sulaeman E, Udall JN Jr, Brown RF, et al. Gastroesophageal reflux and Nissen fundoplication following percutaneous endoscopie gastrostomy in children. J Pediatr Gastroenterol Nutr. 1998;26:269- 273.

12. Preshaw RM. A percutaneous method for inserting a feeding gastrostomy tube. Surg Gynecol Obstet. 1981;152:659-660.

13. Hoffer EK, Cosgrove JM, Levin DQ, et al. Radiologie gastrojejunostomy and percutaneous endoscopie gastrostomy: a prospective, randomized comparison. J Vase Interv Radial. 1999;10:413420.

Excellent clinical study with appropriate randomization of patients to radiologie or endoscopie techniques. One of the few randomized trials reported in this area.

14. Wollman B, D’Agostine HB. Percutaneous radiologie and endoscopie gastrostomy: a 3-year institutional analysis of procedure performance. AJR Am J Roentgenol. 1997;169:1551-1553.

15. Wales PW, Diamond IR, Dutta S, et al. Fundoplication and gastrostomy versus gastrojejunal tube for enterai feeding in neurologically impaired children with gastroesophageal reflux. J Pediatr Surg. 2002;37:407-412.

16. Kennedy KA, Tyson JE, Chamnanvanakij S. Rapid versus slow rate of advancement of feedings for promoting growth and preventing necrotizing enterocolitis in parenterally fed low-birthweight infants [Review]. Cochrane Database Syst Rev. 2000;2: CD001241.

17. Vanderhoof JA, Young RJ. Enterai nutrition in short bowel syndrome. Semin Pediatr Surg. 2001;10:65-71.

18. Andorsky DJ, Lund DP, Lillehei CW, et al. Nutritional and other post-operative management of neonates with short bowel syndrome correlates with clinical outcomes. J Pediatr. 2001;139:2733.

19. Ksiazyk J, Kierkus PM, Lyskowska M. Hydrolyzed versus nonhydrolyzed protein diet in short bowel syndrome in children. J Pediatr Gastroenterol Nutr. 2002;35:615-618.

20. Weiming Z, Ning L, Jieshou L. Effect of recombinant human growth hormone and enterai nutrition on short bowel syndrome. JPEN J Parenter Enterai Nutr. 2004;28:377-381.

21. Iyer KR, Srinath C, Horslen S, et al. Late graft loss and longterm outcome after isolated intestinal transplantation in children. J Pediatr Surg. 2002;37:151-154.

22. Iyer K, Horslen S, Iverson A, et al. Nutritional outcome and growth of children after intestinal transplantation. J Pediatr Surg. 2002;37:464-466.

This review of the largest institutional experience with pdiatrie intestinal transplant demonstrates improved growth after transplant. However, there was a very limited amount of catch up growth in growth delayed patients.

23. Gonzalez HF, Perez NB, Malpeli A, Martinez MI, DelBuono B, Vileri FE. Nutrition and immunological status in long-term follow up of children with short bowel syndrome. JPEN J Parenter Enterai Nutr. 2005;29:186-191.

24. Koehler AN, Yaworksi JA, Gardner M, Kocoshis S, Reyes J, Barksdale EM. Coordinated interdisciplinary management of pediatric intestinal failure: a 2-year review. J Pediatr Surg. 2000;35:380- 385.

David Axelrod, MD, MBA; Kimberly Kazmerski, MS, RD, CSP; and Kishore Iyer, MBBS, FRCS Eng, FACS

From the Intestinal Rehabilitation and Transplantation Program, Division of Transplant Surgery, Children’s Memorial Hospital, Chicago, Illinois

Received for publication June 1, 2005.

Accepted for publication October 3, 2005.

Correspondence: Kishore R. Iyer, MBBS, FRCS (Eng), FACS, Intestinal Rehabilitation and Transplantation Program, Children’s Memorial Hospital, 2300 Children’s Plaza, Box 57, Chicago, IL 60614. Electronic mail may be sent to [email protected].

Copyright American Society for Parenteral and Enteral Nutrition Jan/ Feb 2006