Adding Dietary Green Beans Resolves the Diarrhea Associated With Bowel Surgery in Neonates: A Case Study
* Department of Division of Neonatology and Correspondence: Douglas Drenckpohl, MS, RD, CNSD, LDN, Children's Hospital of Illinois at OSF Saint Francis Medical Center, 530 NE Glen Oak Avenue, Peoria, IL 61637. Electronic mail may be sent to douglas.c.drenckpohl{at}osfhealthcare.org. Feeding intolerance is a common problem in infants who have had multiple or extensive resections of their small bowel. Chronic malabsorption and diarrhea are common side effects that inhibit the advancement of enteral feedings and prolong dependence on parenteral nutrition (PN). Poor growth, recurrent central line infections, cholestasis, and osteopenia are well-known complications associated with long-term PN dependency. It has been shown that, in adults with short bowel syndrome, providing dietary fiber can improve tolerance to enteral feeding. There are no published studies that have addressed the influence of dietary fiber on feeding intolerance in infants after bowel resections. The ensuing case studies illustrate the positive outcomes of fiber use in infants with diarrhea secondary to small bowel resections. Feeding intolerance is common in infants after multiple bowel resections for gastrointestinal disorders. The initial nutrition therapy for such infants begins parenteral nutrition (PN) to maintain the patient's nutrition status while the patient remains nil per os (NPO). Although PN has improved the outcome for infants who cannot be fed enterally, it has side effects that can increase the morbidity and mortality of an infant who is dependent on long-term PN as a source of nutrition. Complications associated with long-term PN include sepsis,1 cholestasis,2–6 and osteopenia.7,8 When enteral nutrition can be initiated for infants who have had bowel surgery, a semielemental formula can be prescribed to meet their nutrition needs. The casein hydrolystate formulas, such as Pregestimil (Mead Johnson, Evansville, IN) and Alimentum (Ross, Columbus, OH), require less digestion by the small intestine for absorption than standard formulas. Even though these formulas are semielemental, depending on the extent of small bowel resection, infants can still develop feeding intolerance. It has been suggested that adding dietary fiber to infant formulas may help correct the incidence of chronic diarrhea. A specific fiber sometimes used to treat diarrhea, pectin, is a soluble fiber that is an amylase-resistant polysaccharide found in the cell wall of many fruits and vegetables.9 The effect of adding dietary fiber to formulas in the treatment of infants with feeding intolerance associated with small bowel resection has not been well studied. The following are 3 case studies illustrating the beneficial effect of adding dietary fiber to an infant's diet to improve feeding intolerance secondary to bowel resection.
A small-for-gestational age infant twin boy was born at 32 weeks 5 days gestation to a 28-year-old woman, gravida 1, para 2. The infant had in utero intestinal perforation of unclear etiology. Soon after the infant was born, he was taken to surgery where he was found to have jejunal perforation secondary to an isolated jejunal volvulus. He underwent resection of about 7 cm of his small intestine. PN was initiated to maintain the infant's nutrition status, and NPO status was maintained until bowel function returned. Two weeks later, the patient required a second surgery for a bowel obstruction, and an additional 12 cm of small bowel were removed and a mucous fistula was created. For the next several weeks, the patient's nutrition needs were met by providing 50% of his calories from enteral nutrition and 50% from PN. His stoma output was refed into the mucous fistula10,11; the purpose of refeeding stool through the mucous fistula was to encourage intestinal adaptation,prevent gut atrophy, and stimulate weight gain.11 The pediatric surgeons recommended that  tablespoon of rice cereal be
added to each oz of stool before being refed. This diet regimen continued
until the small intestine was reanastomosed. After the patient's small intestine was reconnected, enteral feedings were restarted with 24 kcal/oz Enfamil AR (Mead Johnson) and he was nippling 100% of his feedings. According to the infant's level of prematurity and small-for-gestational-age (SGA) status, the formula was changed to Neosure 22 kcal/oz (Ross Laboratories) with 1 tablespoon of rice cereal added per oz of formula in anticipation for discharge home. (Neosure is a formula designed for premature infants after hospital discharge that improves weight and length gain until 9 months' corrected age.12) On postoperative day 53, the infant developed necrotizing enterocolitis (NEC) and was taken to the operating room for an exploratory laparotomy. No bowel perforation was identified; however, the surgeon remarked that the infant had profound NEC throughout the entire bowel, although no resection was needed. PN was restarted, and the patient required bowel rest for approximately 14 days. When enteral feedings could be reintroduced, a 24 kcal/oz formula (Peptamen Jr, Nestle, Glendale, CA) was initiated. Peptamen Jr is a formula typically intended for children age 1–10 and contains peptides from enzymatically hydrolyzed whey protein and 60% of fat as medium-chain triglycerides (MCT) oil. The patient was nippling all feedings without difficulty. He was tolerating the advancement of enteral feedings and was having mushy brown stools. PN was discontinued, and enteral feedings were gradually advanced to provide 120 kcal/kg/day. However, after 24 hours, the patient began having frequent, liquid stools. According to the article by Rabbani et al,9 one 4-oz jar of stage-2 infant food green beans (Del Monte, San Francisco, CA) was added to every 8 oz of 24 kcal/oz Peptamen Jr. This provided 2 g/kg/day of fiber but diluted the caloric content of the formula to 18 kcal/oz. Within 24 hours, the patient's stool consistency improved and became mushy, green, and formed. A few days later, the caloric value of the Peptamen Jr was increased by adding one 4-oz jar of stage-2 infant food green beans to every 8 oz of 30 kcal/oz Peptamen Jr. The final concentration of the formula was 22 kcal/oz. The patient had formed, mushy, green stools while taking 50 mL every 3 hours, but he was not gaining weight. A decision was made to reduce the enteral feedings to 30 mL every 3 hours and restart PN at 4 mL/h to assist with promoting weight gain. The patient continued receiving supplemental PN for the next 2 weeks, and it was gradually weaned as the patient demonstrated appropriate weight gain. The PN was discontinued and feedings were advanced to 58 mL every 3 hours. The patient continued to gain weight appropriately, and he was discharged to home 3 days later. His weight was 2420 g, and he was consuming 60–65 mL of Peptamen Jr with green beans (22 kcal/oz) every 3 hours at the time of discharge.
An appropriate-for-gestational-age (AGA) boy was born at 32 weeks and 5 days gestation. This patient is the twin of case 1. He was also diagnosed with perinatal intestinal perforation. The patient underwent an exploratory laparotomy soon after birth. He was found to have a jejunal volvulus of an isolated loop with a perforation; 8 cm of small intestine were removed. After surgery, PN was initiated and the patient remained NPO for several weeks. When it was medically appropriate, enteral feeding with Enfamil Premature 24 kcal/oz formula was initiated. Enteral feedings were advanced by 1 mL/kg/day every fourth feeding. He developed feeding intolerance due to green-colored aspirates, so feedings were discontinued. After bowel rest for 1 week, enteral feedings were restarted again using Enfamil Premature formula 24 kcal/oz. The patient tolerated the advancement of enteral feedings this time without difficulty, and PN was discontinued once enteral feedings reached a volume of 100 mL/kg/day. Once full enteral feedings were attained, the formula was changed to 24 kcal/oz Enfamil AR (Mead Johnson) for suspected gastroesophageal reflux. The patient was discharged to home after additional observation. The patient was readmitted to the pediatric intensive care unit (PICU) a month later due to dehydration from vomiting and diarrhea. The patient had tolerated the Enfamil AR for approximately 1 week after discharge before starting to have frequent, liquid stools that caused skin breakdown on his buttocks. His pediatrician changed his formula from Enfamil AR to Neosure (Ross), then Isomil (Ross), and finally Nutramigen (Mead Johnson), but the diarrhea continued. (Enfamil AR and Neosure are specialty products for neonates. Nutramigen is a hypoallergenic infant formula. Isomil is a soy-based product. It is important to note that the policy statement from the American Academy of Pediatrics states that soy protein–based formulas are contraindicated for premature infants because they can cause significantly less weight gain and length growth, can lower serum albumin levels, and can place premature infants at greater risk for osteopenia than if fed a cow milk–based formula.13) The patient lost 600 g of weight. Upon admission to the PICU, he was volume resuscitated and then underwent an exploratory laparotomy for peritonitis and suspected NEC. He was found to have extensive NEC, predominantly affecting the colon, but bowel resection was not required. After surgery, PN was restarted and the patient remained NPO for 2 weeks. When enteral feedings were reintroduced, 24 kcal/oz Peptamen Jr was initiated at 10 mL every 3 hours. The enteral feedings were progressively advanced to 50 mL every 3 hours, and the PN was discontinued. Like case 1, this patient began having frequent, liquid stools. One tablespoon of rice cereal was added per oz of formula, but after 48 hours, the liquid stools persisted and the patient developed skin breakdown on his buttocks. The formula was changed to Peptamen Jr with one 4-oz jar of stage-2 infant food green beans per 8 oz of formula, which provided 22 kcal/oz. Within 24 hours, the patient began having mushy, formed stools. A few days later, the feedings were successfully advanced to 70 mL every 3 hours, and the infant was discharged to home a month after his readmission.
An AGA boy was born at 39 weeks to a 25-year-old gravida 1, para 1, woman. The patient was transferred from another Neonatal Intensive Care Unit (NICU) for the management of midgut malrotation with a volvulus. He underwent an emergency laparotomy, and the diagnosis was confirmed. A significant amount of his small intestine was necrotic and had to be removed. Sixty-five centimeters of jejunum and 18 cm of ileum remained. The patient's ileocecal value and colon were intact. PN was initiated and the patient remained NPO until bowel function returned. Thirteen days after surgery, enteral feedings were started with unfortified breast milk; feedings were advanced slowly. As the enteral feedings increased, the patient developed liquid stools. One 4-oz jar of stage-2 infant food green beans was added to 8 oz of 30 kcal/oz breast milk fortified with Peptamen Jr powder. This formula provided 22 kcal/oz and 2 g/kg/day of dietary fiber. Feedings continued to be advanced as tolerated. When a rate of 70 mL every 3 hours was attained, the patient was having frequent stools of mushy to liquid consistency. It was concluded that the patient required additional fiber to help reduce his liquid stools, but the fiber content found in the infant food green beans could not be manipulated. Another dietary fiber source was added; 1 teaspoon of Benefiber (Novartis, Minneapolis, MN) was added to each bottle to provide an additional 2 g/kg/day of soluble fiber. The patient received a total of 4 g/kg/day of dietary fiber. The combination of dietary fibers assisted the patient in having formed mushy stools, but the patient was not consistently gaining weight. Enteral feedings were decreased to 30 mL every 3 hours, and the patient's remaining nutrition needs were supplemented with PN. After 24 hours, the patient had less frequent stools and began gaining weight consistently. The patient was discharged to home, receiving approximately 60% of nutrition needs by enteral feedings and supplemented with PN. The patient's diet order at discharge was as follows: 50 mL every 3 hours of 30 kcal/oz breast milk fortified with Peptamen Jr powder, infant food green beans (one 4-oz jar to every 8 oz of breast milk) and Benefiber (1 teaspoon to each 50-mL feeding). The formula provided 22 kcal/oz. At the time of discharge, the patient weighed 4510 g.
Three-and-a-half months after the patient's surgery, he was consuming 105
mL every 3 hours of 30 kcal/oz breast milk fortified with Peptamen Jr powder,
green beans, and Benefiber. The patient weighed 7.4 kg, which placed him on
the growth chart above the 90th percentile of weight for age. PN
was discontinued. When patient was 5
In adults who are dependent on enteral nutrition, the addition of dietary fiber has been successfully used to resolve diarrhea.14 There are limited data in adults diagnosed with short bowel syndrome that a modified, high-fiber diet, along with glutamine and growth hormone therapy, improves absorption of nutrients and decreases feeding intolerance.15 The average length of a neonate's small intestine is between 200 and 300 cm, with appropriately 45 cm of colon.16 Only 1 infant in these 3 case studies was diagnosed with short bowel syndrome, whereas the other 2 infants had resections where only small amounts of small intestine were removed. Some of the formulas used for these patients are not traditionally chosen for neonates. Peptamen Jr is a complete elemental formula that is designed for children (ages 1–10 years) with a number of different gastrointestinal disorders such as chronic diarrhea and short bowel syndrome. Pediasure (Ross) is another formula designed for children over the age of 1; however, it has been evaluated in premature infants with bronchopulmonary dysplasia (BPD).17 Puangco and Schanler17 compared the feeding tolerance, growth, and biochemical indicators of nutrition status in 27 premature infants with BPD. The infants received either 30 kcal/oz ready-to-feed formula (Pediasure) or a premature 24 kcal/oz formula with additives (Casec [Novartis], Polycose [Ross], and corn oil). The infants entered the study when they were either 4 months old or 44 weeks postmenstrual age. Puangco and Schanler17 showed that the premature infants tolerated both types of formulas well, and growth was similar between the 2 formula groups. Puangco and Schanler17 showed that premature infants fed Pediasure had significantly higher serum albumin concentrations than infants fed the premature formula with additives. Puangco and Schanler17 concluded that using Pediasure was a safe alternative formula for premature infants with BPD. Because Pediasure was shown to be a safe alternative for premature infants, it was concluded that other enteral formulas designed for children between 1 and 10 years old could be used as an alternative formula for infants with a history of feeding intolerance, especially if they were dependent On long-term PN with worsening cholestasis and osteopenia. Peptamen Jr with stage-2 green beans added provides 22 kcal/oz and has a calcium (mg):phosphorus (mg) ratio of 1.3:1. This is lower than the calcium:phosphorus ratio in standard preterm formulas, which is between 1.7:1 and 1.8:1. The rationale for using stage-2 infant food green beans was based on the article by Rabbani et al,9 where cooked unripened green plantains or pectin was added to infants' diets to control persistent diarrhea. Boys from 4 to 12 months of age were either given a rice-based diet containing 250 g/L of cooked, green plantains or 4 g/kg/day of pectin.9 The control group was given a rice-based diet.9 Adding one 4-oz jar of stage-2 infant food green beans to every 8 oz of 30 kcal/oz Peptamen Jr allowed the infants to receive approximately 2 g/kg/day of dietary fiber and diluted the formula to 22 kcal/oz. Baby food fruits (pears) were trialed on the infant in the first case study, with unsatisfactory results. Even though stage-2 infant food pears have 3 g of fiber per serving (the same as green beans), the infant developed loose, liquid stools, which resolved after changing back to green beans. Benefiber contains soluble fiber in the form of a partially hydrolyzed guar gum; it completely dissolves in water and is fermented in the colon to produce short-chain fatty acids (SCFA).18 These SCFA provide metabolic fuel for the colonocytes, stimulate epithelial cell proliferation, and exert a trophic effect on the colonic mucosa.18 The SCFA are absorbed by the colon and stimulate sodium transport from the colon, which in turn increases the colon's ability to absorb water. Adult patients in intensive care units receiving enteral nutrition supplemented with Benefiber have been reported to have a decreased incidence of diarrhea compared with control subjects.18 Benefiber has also been trialed in children. Alam et al18 conducted a doubleblind, randomized, controlled trial in 150 male children aged 4–18 months who had watery diarrhea of <48 hours' duration. The children were randomized to receive either WHO ORS (World Health Organization Oral Hydration Solution) or WHO ORS supplemented with Benefiber. The children supplemented with Benefiber showed a greater reduction in their diarrhea episodes than the children who received only the WHO ORS. The children who were supplemented with Benefiber had less daily stool output from day 2 to 7 than the children treated with WHO ORS (in which the reduction of stool output did not decrease until day 7). According to this research, it was decided to add Benefiber to the formula (providing an additional 2 g/kg/day of dietary fiber) for the infant in case number 3. Bene-fiber was chosen over the additional infant food because if the formula:infant food ratio was further manipulated by increasing the proportion of infant food to increase the dietary fiber intake, nutrient deficiencies would be created in the end product. Another advantage of Benefiber was that it did not change the viscosity of the formula or alter the taste of the formula. These 3 cases anecdotally showed that the addition of dietary fiber to an enteral formula (via infant food or Benefiber) improved the feeding tolerance for 3 infants who underwent small bowel resection. A prospective, randomized trial is needed to determine the effects dietary fiber has in reducing diarrhea in infants who have had small bowel resections.
Nutrition in Clinical Practice, Vol. 20, No. 6,
674-677 (2005)
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
|
|
 |
|
Top
Case 1
Case 2