Altieri, K

Bronsther, O

Fung, J

Funovits, M

Kovalak, J

Nour, B

Reyes, J

Starzl, TE

Staschak-Chicko, S

Todo, S

Tzakis, A

Name not available

Eating difficulties in the pediatric small bowel recipient

D-Scholarship@Pitt

Eating Difficulties in the Pediatric Small Bowel Recipient: The Role of the Nutritional Management Team S. Staschak-Chicko, K. Altieri, M. Funovits, J. Kovalak, J. Reyes, B. Nour, O. Bronsther, A. Tzakis, J. Fung, S. Todo, and T.E. Starzl I NTESTINAL transplantation has become a feasible option for total parenteral nutrition (TPN)-dependent patients with short gut syndrome. Crucial to the long-term success of small intestine transplantation is the recipient's ability to maintain an adequate oral intake. It was of particular concern that some pediatric patients would not eat postoperatively and therefore required enteral feeds for total nutritional support. The objectives of this study were to identify factors that influence postoperative eating dif-ficulties in pediatric intestine transplant recipients and the development of therapeutic approaches to improve oral nutrition. PATIENTS AND METHODS Between July 1990. and March 1993. 22 children with intestinal failure underwent isolated small intestine transplantation (n '" 5). combined liveflsmall intestine transplantation tn = 15). or multi-visceral transplantation (n = 2). Of the total. 6 patients died and I had removal of the graft for rejection. The remaining 15 pediatric patients were studied for their preoperative and postoperative eating patterns With follow-up ranging from 3 to 36 months. RESULTS An eating difficulty was defined as refusal to eat for greater than <)() postoperative days in the presence of a functioning graft. A graft was considered functional when the patient hecame independent of TPN. Six patients (40'IC) were identified as having eating difficulties. None of these tl ..:hildren were eating preoperatively. Of these 6 patients. I ..:hild has a rejecting graft and posttransplant Iymphopro-liferative disease. and another child has severe dysmotility of the proximal native gastrointestinal tract. The 4 remain-ing patients received intensive intervention which included individual and group feeding therapy as well as continuous family support. Of the 4 patients who received feeding therapy . .2 have begun to eat. and the other .2 patients I:onllnue to refuse to eat. The other <) patients without .:atlng difficulties did experience initial hyporexia: how-.:ver. they had atlatned satisfactory eating habits. ~uch that 4 of these ratlcnts are completelv free of supplemental r.:edtn!!s. Five r:.IlIents still require supplemental enteral t'.:edin!!s. \\ hil:h are slowly being \\. eaned. DISCUSSION Whilt! Intl!stmal transplantation has achieved technical Dl1CCC~p \ restor,ilIon of normal small bowel anatomv and independence from TPN), it does not necessarily equate with the ability of the recipient to sustain adequate oral nutrition. The factors we identified as influencing postop-erative eating were age/duration of TPN, patients who had a lack of experience with eating pretransplant. and the presence of siblings as role models. We observed several similarities in the group of pediatric recipients who did not eat posttransplant. but the singie most significant factor was the lack of experience with eating pretransplant. As a result. a Nutritional Management Team was formed to encourage postoperative eating, which consisted of a clin-ical nurse specialist (ie. feeding specialist). occupational therapist. dietitian. and the clinical transplant coordinator. The team worked closely with the children on an individual as well as group basis. The dietitian chose developmentally appropriate menus with particular attention to taste and texture. monitoring the child's nutritional needs and calculated caloric require-ments. The occupational therapist and the feeding special-ist performed developmental assessments and taught swal-lowing and chewing techniques. The liver transplant coordinator was responsible for assessment and evaluation of outpatient follow-up and progress on a long-term basis. A daily food diary, patient's height and weight. and laboratory parameters were obtained to provide ongoing evaluation of the recipient's progress. As a direct outcome of our early experience with post-transplant eating difficulties. we have modified our preop-erative nutritional teaching. Presently. all new candidates for small intestine transplant are assessed by the feeding group as part of the routine candidate evaluation. This dietary assessment identifies the patient's baseline eating habits and allows for development of an individualized feeding plan. This plan strongly encourages all patients to eat pretransplant unless medically contraindicated. Other strategies stress the importance of patient and family education about continued oral feedings. and the encour-agement to eat pre- and posttransplant. Professional edu-cation is aimed at the same nutritional goals . From the Pittsburgh Transplantation Inslltute. University of Pitts-burgh Medical Center. Pittsburgh. Pennsylvania, Address reprint requests to Or Thomas E. Starzi. MD, PhD. Pittsburgh Transptantatlon Institute. UniverSity of Pittsburgh Med· Ical Center. 3601 Fifth Avenue. 5C Falk Clinic. Pittsburgh. PA 15213. c 1994 by Appleton & Lange 0041-1345/94,$3.00; .,..0 1434 TranSDlantatlon Proceeamgs. Vol 26. No 3 (June'. 1994: Po 1434-1435 EATING DIFFICULTIES Our experience suggests that though independence from TPN was achieved with intestinal transplantation. factors that may affect eating difficulties include age/duration of TPN. experience with eating pretransplant. and the pres-ence of role models. Our conclusions suggest the impor-tance of the awareness of this possibility and the possible 1435 risk factors. encouraging eating pretransplant and the use of a nutritional management team. REFERENCES I. Abu·Elmagd K. Fung JJ. Reyes J. et al: Transplant Proc ~4:PK 1992 

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Eating difficulties in the pediatric small bowel recipient

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