Nutrition in necrotizing enterocolitis and following intestinal resection

This review aims to discuss the role of nutrition and feeding practices in necrotizing enterocolitis (NEC), NEC prevention, and its complications, including surgical treatment. A thorough PubMed search was performed with a focus on meta-analyses and randomized controlled trials when available. There are several variables in nutrition and the feeding of preterm infants with the intention of preventing necrotizing enterocolitis (NEC). Starting feeds later rather than earlier, advancing feeds slowly and continuous feeds have not been shown to prevent NEC and breast milk remains the only effective prevention strategy. The lack of medical treatment options for NEC often leads to disease progression requiring surgical resection. Following resection, intestinal adaptation occurs, during which villi lengthen and crypts deepen to increase the functional capacity of remaining bowel. The effect of macronutrients on intestinal adaptation has been extensively studied in animal models. Clinically, the length and portion of intestine that is resected may lead to patients requiring parenteral nutrition, which is also reviewed here. There remain significant gaps in knowledge surrounding many of the nutritional aspects of NEC and more research is needed to determine optimal feeding approaches to prevent NEC, particularly in infants younger than 28 weeks and \u3c1000 grams. Additional research is also needed to identify biomarkers reflecting intestinal recovery following NEC diagnosis individualize when feedings should be safely resumed for each patient

Expedited Recovery Pain Management Pathway for Minimally Invasive Repair of Pectus Excavatum (MIRPE)

Introduction: Pectus Excavatum (PEX) is the most common anterior chest wall deformity. While minimally invasive repair of pectus excavatum (MIRPE) has improved perioperative outcomes, there continue to be opportunities to optimize postoperative pain management and reduce length of stay (LOS). We compared the impact of a multimodal expedited protocol utilizing a combination of systemic and regional analgesia (with single shot paravertebral truncal blocks), along with coping techniques (such as meditation), and physical therapy, with systemic analgesia on LOS and opioid requirements. Methods: 51 patients underwent MIRPE with an expedited recovery protocol in comparison with 112 historical control patients at a single center over 18 years. LOS and opioid analgesic morphine milliequivalent (MME) were compared. Data were stratified for age, biological sex, and Haller index (HI) to identify potential confounding variables. Results: There was no difference in age or HI between cohorts. LOS was reduced by 59.1% in the enhanced recovery group compared to the historic group (1.8 days vs 4.4 days, SD=0.5664 and 0.9503 respectively, P\u3c 0.0001). On postoperative day (POD)1, the expedited patients required an average of 100.7 MME (IQR 61.65-124.3) compared to 123.6 MME (IQR 79.5-161.1) for historic control patients (P=0.04). Cumulative MME for POD0-2 was 34.8% less in the expedited recovery patients (P= Conclusions: This MIRPE expedited recovery pain protocol using a standardized multimodal analgesia strategy and regional anesthesia is a safe and effective therapeutic plan that results in decreased opioid analgesic requirements and a significantly decreased LOS

Antibiotic-driven intestinal dysbiosis in pediatric short bowel syndrome is associated with persistently altered microbiome functions and gut-derived bloodstream infections

Surgical removal of the intestine, lifesaving in catastrophic gastrointestinal disorders of infancy, can result in a form of intestinal failure known as short bowel syndrome (SBS). Bloodstream infections (BSIs) are a major challenge in pediatric SBS management. BSIs require frequent antibiotic therapy, with ill-defined consequences for the gut microbiome and childhood health. Here, we combine serial stool collection, shotgun metagenomic sequencing, multivariate statistics and genome-resolved strain-tracking in a cohort of 19 patients with surgically-induced SBS to show that antibiotic-driven intestinal dysbiosis in SBS enriches for persistent intestinal colonization with BSI causative pathogens in SBS. Comparing the gut microbiome composition of SBS patients over the first 4 years of life to 19 age-matched term and 18 preterm controls, we find that SBS gut microbiota diversity and composition was persistently altered compared to controls. Commensals including Ruminococcus, Bifidobacterium, Eubacterium, and Clostridium species were depleted in SBS, while pathobionts (Enterococcus) were enriched. Integrating clinical covariates with gut microbiome composition in pediatric SBS, we identified dietary and antibiotic exposures as the main drivers of these alterations. Moreover, antibiotic resistance genes, specifically broad-spectrum efflux pumps, were at a higher abundance in SBS, while putatively beneficial microbiota functions, including amino acid and vitamin biosynthesis, were depleted. Moreover, using strain-tracking we found that the SBS gut microbiome harbors BSI causing pathogens, which can persist intestinally throughout the first years of life. The association between antibiotic-driven gut dysbiosis and enrichment of intestinal pathobionts isolated from BSI suggests that antibiotic treatment may predispose SBS patients to infection. Persistence of pathobionts and depletion of beneficial microbiota and functionalities in SBS highlights the need for microbiota-targeted interventions to prevent infection and facilitate intestinal adaptation