Therapeutic Nutrition 326

Literature Review
The use of hydrolysed formulas in short bowel syndrome

Alyssa Edeling 3635919

With advances and improvement in medical techniques, surgeons have become more

adept at saving infants with more complex gastrointestinal complications. The need

for more aggressive surgical procedures in these complex patients is resulting in the

increased prevalence of short bowel syndrome (SBS) (Wessel and Kocoshis, 2009).

Increased cases of gastrointestinal disorders have been documented in preterm infants,

Wessel and Kocoshis, 2009 hypothesis that this is due to the majority of intestinal

maturation occurring in the later periods of gestation. Therefore premature infants are

more likely to undergo gut surgery and in turn, are predisposed to suffering from

SBS. These advances in medical procedures drive the development of post-surgical

therapy by interdisciplinary teams, who challenge and improve on old treatment

methods. This literature review aims to explore and compare the dietary treatment of

SBS patients and more specifically the use of hydrolyzed feeds in post-surgical

therapy.

Previously short bowel syndrome and intestinal failure where two terms often used

interchangeably with blurred ideas of their differences until researcher encouraged a

more scientific distinction between them. O’keefe et al., 2006 defined short bowel as

a syndrome resulting from surgical intestinal resection, birth abnormality or a

decrease in intestinal functioning. The inadequate fluid and electrolyte or

micronutrient balance in conjunction with the inability to maintain protein-energy

characterize the syndrome. In contrast, intestinal failure results from obstruction,

surgical resection, birth abnormality or a decrease in intestinal functioning. Similarly

to short bowel syndrome, it is characterized as the inadequate fluid and electrolyte or

micronutrient balance in conjunction with the inability to maintain protein-energy.

Wessel and Kocoshis, 2009 simply summarized the entities as, A patient with short
bowel syndrome may possibly suffer from intestinal failure, whereas not all patients

who have intestinal failure have short bowel syndrome. Across literature, it is agreed

that the there are two dietary phases of treatment for postoperative SBS patients. The

first being characterized by short-term parenteral nutrition and the second being

characterized by weaning onto enteral nutrition and later the introduction of solid

foods if possible. Both having their advantages and associated complications.

Gutierrez et al., 2011 listed three main complications often observed in short bowel

patients. The inability to grow and develop without supplemental parenteral nutrition

was stated as the first area of concern. Secondly intestinal failure-associated liver

disease, the study stated that the cause was multifactorial. However, the main

contributing factors highlighted included prematurity, parenteral nutrition toxicity and

recurrent sepsis. Thirdly, catheter-associated infections and lastly bacterial

overgrowth in the intestine. Andorsky et al., 2001 concluded that early enteral feeding

post surgery is associated with reduced risk of cholestasis as well as a shorter duration

on parenteral nutrition. These four factors are mainly complications due to parenteral

nutrition therefore further reinforcing the idea of rapid weaning onto enteral nutrition.

As previously mentioned the nutritional management of short bowel syndrome

patients can be subdivided into entities. This section of the review will look at current

enteral feeding recommendations and compared to the idea of using hydrolyzed

formulas to improve the nutritional status of short bowel patients. Enteral nutrition is

a method of supplying nutrients to the gastrointestinal tract. It refers to breast milk,

formulas, oral feeding and enteral tube feeding. In 2010, Oliman described enteral

feeding as, nutrients that can be administered orally or with an enteral tube (e.g.

Nasoenteral, gastrostomy or jejunostomy) and is normally provided continuously or

as a bolus feed. The American Dietetic Association in 2010 (ADA) published

research in the current evidence and recommendations focusing on enteral nutrition in

that post bowel resection surgery enteral nutrition should be introduced as quickly as

possible to promote intestinal adaption and reduce hospital stay. In addition, they

stated that enteral nutrition should be administered in a continuous fashion to

increases intestinal absorption. Other recommendations stated that breast milk is

preferred due to many of its constituent’s supporting an infant’s immune system. In

the absence of breast milk infants between the ages of 12 and 24 months can be

weaned off total parenteral nutrition and on to a polymeric feed as most infants have

outgrown milk and soy intolerances by 12 months. It was also stated that there is little

to no difference in the absorption of an elemental feed and semi-elemental feed.

Vanderhoof et al., 2004 suggested that 1ml/hr/day increments of feed should be

administered when initiating weaning off parenteral nutrition.

Ksiazyk et al., 2002 conducted a study comparing the use of hydrolyzed and non-

hydrolyzed feeds in short bowel patients, they stated that the idea of using a

hydrolyzed feed was suggested over 25 years ago and is still the common practice. It

was also highlighted that objective studies in this area of research is lacking. The

research done faces the challenge of infants suffering from various degrees of

reaming bowel length, resection occurring at differing locations and the presence or

absence of the ileocecal valve, are additional cofactors that make identifying

comparisons in cases difficult. Ksiazyk et al., 2002 research compared the infants on

intentional permeability, weight gain and nitrogen balance and found that there was

no quantifiable difference between the infants feed on hydrolyzed and non-

hydrolyzed feeds. They hypothesized that hydrolyzed feeds contain more complex

macronutrients, which are better tolerated and increase gut adaptation.

Complementary to Ksiazyk et al., 2002, Gutierrez et al., 2011 stated that there the
choice of feed in sort bowel patients is still controversial with great variation in which

is the correct method. They later stated that newer research is proving that both breast

milk and elemental formula have been associated with a decrease in total parenteral

nutrition even in sever SBS cases. Some studies such as the one conducted by Bines

et al., 1998 concluded that amino acid base formulas were a useful aid in weaning

children off total parenteral nutrition.

Across both the older and newer literature, the idea of weaning off parenteral nutrition

as early as possible and onto continuous feeding was widely accepted. Breast milk

having a favourable outcome when weaning off total parenteral was a shared

conclusion. Beast milk was associated with decreases in hospital stay, increased of

immunity, gut adaptation and can be used to feed premature infants. However, there

are differing ideas in the research consulted of which feed is best when breast milk is

not available. Some studies stated that there is little difference in the intestinal

absorption between hydrolyzed and non-hydrolyzed. Another study introduced the

idea of using an Amino acid based formula when weaning of total parenteral

nutrition. There is still a need for more current research to be conducted looking at a

larger sample of patients and making used of an interdisciplinary team to introduce a

more commonly accepted treatment regime.

Andorsky, D., Lund, D., Lillehei, C., Jaksic, T., DiCanzio, J., Richardson, D., Collier,
S., Lo, C. and Duggan, C. (2001). Nutritional and other postoperative management of
neonates with short bowel syndrome correlates with clinical outcomes. The Journal of
Pediatrics, 139(1), pp.27-33.

Bines, J., Francis, D. and Hill, D. (1996). The impact of Neocate on parenteral
nutrition requirement in children with short bowel syndrome. Nutrition, 12(7-8),
p.575.

Brewster, D., Kukuruzovic, R. and Haase, A. (1998). Short Bowel Syndrome,

Gutierrez, I., Kang, K. and Jaksic, T. (2011). Neonatal short bowel

Ksiazyk, J., Piena, M., Kierkus, J. and Lyszkowska, M. (2002). Hydrolyzed Versus
Nonhydrolyzed Protein Diet in Short Bowel Syndrome in Children. Journal of
Pediatric Gastroenterology and Nutrition, 35(5), pp.615-618.

Olieman, J., Penning, C., IJsselstijn, H., Escher, J., Joosten, K., Hulst, J. and Tibboel,
D. (2010). Enteral Nutrition in Children with Short-Bowel Syndrome: Current
Evidence and Recommendations for the Clinician. Journal of the American Dietetic
Association, 110(3), pp.420-426.

O’Keefe, S., Buchman, A., Fishbein, T., Jeejeebhoy, K., Jeppesen, P. and Shaffer, J.
(2006). Short Bowel Syndrome and Intestinal Failure: Consensus Definitions and
Overview. Clinical Gastroenterology and Hepatology, 4(1), pp.6-10.

Wessel, J. and Kocoshis, S. (2009). Nutritional management of infants with short