title: A review of enteral strategies in infant short bowel syndrome: evidence-based or NICU culture?
abstract: BACKGROUND
  Short bowel syndrome (SBS) is an increasingly common condition encountered across neonatal intensive care units. Improvements in parenteral nutrition (PN), neonatal intensive care and surgical techniques, in addition to an improved understanding of SBS pathophysiology, have contributed in equal parts to the survival of this fragile subset of infants. Prevention of intestinal failure associated liver disease (IFALD) and promotion of intestinal adaptation are primary goals of all involved in the care of these patients. While enteral nutritional and pharmacological strategies are necessary to achieve these goals, there remains great variability in the application of therapeutic strategies in units that are not necessarily evidence-based.
  
  
  METHODS
  A search of major English language medical databases (SCOPUS, Index Medicus, Medline, and the Cochrane database) was conducted for the key words short bowel syndrome, medical management, nutritional management and intestinal adaptation. All pharmacological and nutritional agents encountered in the literature search were classified based on their effects on absorptive capacity, intestinal adaptation and bowel motility that are the three major strategies employed in the management of SBS. The Oxford Center for Evidence-Based Medicine (CEBM) classification for levels of evidence was used to develop grades of clinical recommendation for each variable studied.
  
  
  RESULTS
  We reviewed various medications used and nutritional strategies included soluble fiber, enteral fat, glutamine, probiotics and sodium supplementation. Most interventions have scientific rationale but little evidence to support their role in the management of infant SBS. While some of these agents symptomatically improve diarrhea, they can adversely influence pancreatico-biliary function or actually impair intestinal adaptation. Surgical anatomy and liver function are two important variables that should determine the selection of pharmacological and nutritional interventions.
  
  
  CONCLUSIONS
  There is a paucity of research investigating optimal clinical practice in infant SBS and the little evidence available is consistently of lower quality, resulting in a wide variation of clinical practices among NICUs. Prospective trials should be encouraged to bridge the evidence gap between research and clinical practice to promote further progress in the field.
authors.affiliation: Department of Nutrition, Maimonides Medical Center, Brooklyn, NY 11219, USA.
authors.forename: Malki
authors.initials: M
authors.lastname: Miller
authors.forename: Sathyaprasad
authors.initials: S
authors.lastname: Burjonrappa
mesh_terms: D001284:Atrophy; D016022:Case-Control Studies; D015331:Cohort Studies; D003131:Combined Modality Therapy; D003422:Critical Care / Q000379:methods; D003968:Diarrhea, Infantile / Q000209:etiology / Q000517:prevention & control; D004041:Dietary Fats / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D004043:Dietary Fiber / Q000627:therapeutic use; D004750:Enteral Nutrition / Q000379:methods*; D019317:Evidence-Based Medicine; D010188:Exocrine Pancreatic Insufficiency / Q000209:etiology / Q000517:prevention & control; D005526:Food, Formulated; D005765:Gastrointestinal Agents / Q000494:pharmacology / Q000627:therapeutic use; D005768:Gastrointestinal Hormones / Q000378:metabolism; D005769:Gastrointestinal Motility / Q000187:drug effects; D005973:Glutamine / Q000627:therapeutic use; D006801:Humans; D007223:Infant; D007225:Infant Food; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D008107:Liver Diseases / Q000209:etiology / Q000517:prevention & control; D046790:Pancreas, Exocrine / Q000378:metabolism / Q000473:pathology; D010184:Pancreatic Extracts / Q000627:therapeutic use; D010288:Parenteral Nutrition / Q000009:adverse effects; D010455:Peptides / Q000627:therapeutic use; D019936:Probiotics / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D012778:Short Bowel Syndrome / Q000150:complications / Q000503:physiopathology / Q000534:rehabilitation / Q000628:therapy*
chemical_list: D004041:Dietary Fats; D004043:Dietary Fiber; D005765:Gastrointestinal Agents; D005768:Gastrointestinal Hormones; D010184:Pancreatic Extracts; D010455:Peptides; D005973:Glutamine; C494910:teduglutide