Predictors of Enteral Autonomy in Children with Intestinal Failure: A Multicenter Cohort Study

Abstract

Objectives: In a large cohort of children with intestinal failure (IF), we sought to determine the cumulative incidence of achieving enteral autonomy and identify patient and institutional characteristics associated with enteral autonomy.

Study design: A multicenter, retrospective cohort analysis from the Pediatric Intestinal Failure Consortium was performed. IF was defined as severe congenital or acquired gastrointestinal diseases during infancy with dependence on parenteral nutrition (PN) >60 days. Enteral autonomy was defined as PN discontinuation >3 months.

Results: A total of 272 infants were followed for a median (IQR) of 33.5 (16.2-51.5) months. Enteral autonomy was achieved in 118 (43%); 36 (13%) remained PN dependent and 118 (43%) patients died or underwent transplantation. Multivariable analysis identified necrotizing enterocolitis (NEC; OR 2.42, 95% CI 1.33-4.47), care at an IF site without an associated intestinal transplantation program (OR 2.73, 95% CI 1.56-4.78), and an intact ileocecal valve (OR 2.80, 95% CI 1.63-4.83) as independent risk factors for enteral autonomy. A second model (n = 144) that included only patients with intraoperatively measured residual small bowel length found NEC (OR 3.44, 95% CI 1.36-8.71), care at a nonintestinal transplantation center (OR 6.56, 95% CI 2.53-16.98), and residual small bowel length (OR 1.04 cm, 95% CI 1.02-1.06 cm) to be independently associated with enteral autonomy.

Conclusions: A substantial proportion of infants with IF can achieve enteral autonomy. Underlying NEC, preserved ileocecal valve, and longer bowel length are associated with achieving enteral autonomy. It is likely that variations in institutional practices and referral patterns also affect outcomes in children with IF.

Figure 1

A) Cumulative incidence of death/transplant and enteral autonomy in months after study entry in 272 infants with intestinal failure. B) Cumulative incidence of enteral autonomy by NEC diagnosis in months from time entry criteria was met. *P<0.001 from Gray’s test comparing cumulative incidence rates.

Figure 1

A) Cumulative incidence of death/transplant and enteral autonomy in months after study entry in 272 infants with intestinal failure. B) Cumulative incidence of enteral autonomy by NEC diagnosis in months from time entry criteria was met. *P<0.001 from Gray’s test comparing cumulative incidence rates.

Figure 2

Receiver operating characteristic curve analysis of threshold residual bowel length associated with achievement of enteral autonomy The threshold of 41cm for residual bowel length yields the highest combined value of sensitivity (78.3%) and 1-specificity (29.8%). The thresholds of 36 cm and 38 cm have sensitivity of 81.7% and 34.5% and 33.3%, respectively.