Decreased Bone Turnover Markers in Children on Long‐Term Parenteral Nutrition (PN) for Intestinal Failure (IF)

Background: Metabolic bone disease (MBD) is a well‐recognized but poorly understood complication of long‐term parenteral nutrition (PN). Bone histomorphometry in adults has provided useful information but does not provide quantitative measures of bone resorption and is to invasive for children. Measurement of bone turnover markers provides an alternative less invasive approach. We therefore aimed to measure bone turnover markers in children on long‐term PN for intestinal failure (IF), and to compare them to age‐ and gender‐matched controls. Methods: Serum concentrations of osteocalcin (OC), bone‐specific alkaline phosphatase (BSAP), and c‐telopeptide (CTx) were measured in IF patients treated at a multidisciplinary intestinal rehabilitation and home PN program at the Hospital for Sick Children, Toronto, Canada. Age‐ and gender‐matched control participants were recruited for comparison. Results: A total of 13 IF patients and 20 control participants were recruited. IF patients had lower serum OC and CTx concentrations when compared with controls: 42.43 ± 11.54 vs 68.39 ± 20.95 µg/L (P < .01) and 7.454 ± 2.17 vs 9.246 ± 1.92 (P < .05; mean ± SD) µg/L for OC and CTx, respectively. In a subgroup of 9 IF patients for whom BMD was available, OC and CTx concentration were negatively correlated to BMD (g/cm²) and BMD z score. Conclusion: Bone turnover markers may be useful indicators for identifying children on long‐term PN at risk of MBD. Further studies are needed to validate the current results and determine the factors that influence the occurrence and evolution of MBD in children on PN.     

Excessive Aluminum Accumulation in the Bones of Patients on Long‐Term Parenteral Nutrition

Background: Aluminum (Al) contamination of parenteral nutrition (PN) solutions remains a concern for long‐term PN patients. Al accumulates particularly in bone. Excessive exposure to Al may result in increased Al body burden and impaired bone formation and mineralization, leading to bone disease. Although the U.S. Food and Drug Administration (FDA) has limited Al contamination in large‐volume parenteral solutions, small‐volume parenterals may still contribute considerable amounts of Al to PN solutions. The goal of this study is to determine whether or not long‐term adult PN patients remain at risk for increased bone Al accumulation. Methods: We measured Al accumulation in autopsy bones from 7 patients who had received PN for 2–21 years and compared bone Al levels with those in living control patients undergoing hip or knee replacement. Electrothermal atomic absorption spectrometry was used for bone Al measurements. Results: When compared with bone Al content in controls, markedly elevated Al levels (P < .0001) were found in the bones of all but 1 patient, who received PN for only 2 years before death. Even greater Al accumulation was found for PN patients who developed late renal impairment (P = .0159). Conclusions: We conclude that long‐term adult PN patients continue to be at risk for Al toxicity.     

Long‐Term Fish Oil Lipid Emulsion Use in Children With Intestinal Failure–Associated Liver Disease

Background: Fish oil lipid emulsion (FOLE) and multidisciplinary care for infants with intestinal failure (IF) have been associated with reduced morbidity and mortality due to IF‐associated liver disease (IFALD). With increased survival, a greater proportion of infants with IF are now able to remain on parenteral nutrition (PN) in the long term. The purpose of this study was to examine outcomes in children with IFALD who have required long‐term PN and FOLE therapy due to chronic IF. Materials and Methods: A review of prospectively collected data was performed for children with IFALD who required at least 3 years of PN and FOLE therapy due to chronic IF. Outcomes examined include the incidence of death, transplantation, and essential fatty acid deficiency (EFAD), as well as growth parameters and the biochemical markers of liver disease. Results: Of 215 patients with IFALD treated from 2004–2015, 30 required PN and FOLE therapy for at least 3 years (median, 4.6 years). To date, no patients have died, required transplantation, or developed EFAD. Biochemical markers of liver disease normalized within the first year of therapy with no recurrent elevations in the long term. Weight‐for age and length‐for‐age z scores improved and PN dependence decreased in the first year of therapy, with a stable rate of growth in the long term. Conclusions: Children with IFALD who required long‐term PN and FOLE for chronic IF had no mortality, need for transplantation, EFAD, or recurrence of liver disease in the long term, allowing for continued intestinal rehabilitation.     

Treatment of hypertriglyceridemia in patients receiving parenteral nutrition

Background: This study aims to evaluate whether withdrawal of a soy oil–based lipid emulsion from the parenteral nutrition (PN) regimen in humans is associated with improved triglyceride and liver enzyme concentrations. Methods: In this retrospective study, patients with hypertriglyceridemia (>4.50 mmol/L) while receiving PN were retrieved from a prospective complication registration database. Patients received Intralipid 20% as part of an all‐in‐one system containing all necessary macro‐ and micronutrients, electrolytes, trace elements, and vitamins. Results: Forty patients with hypertriglyceridemia were included. Lipid emulsions were withdrawn from the all‐in‐one mixture for a median of 5 (range, 1‐23) days, after which triglyceride concentrations decreased significantly (mean difference ?2.5 ± 0.30 mmol/L, P < .001). Aspartate aminotransaminase and leukocyte count decreased significantly (mean difference ?35 ± 17 U/L, P = .049 and ?3.8 ± 1.7*10E9/L, P = .028, respectively), whereas albumin level increased significantly (mean difference 2.1 ± 0.9 g/L, P = .027). Alanine aminotransaminase showed a nonsignificant reduction (mean difference ?30 ± 22 U/L, P = .194). In 11 patients, the lipid emulsion was reintroduced, after which triglyceride levels showed a significant increase (mean difference 1.5 ± 0.30 mmol/L, P = .001).Conclusions: Short‐term withdrawal of the lipid fraction in the PN mixture is associated with a significant reduction of plasma triglyceride concentration. Reintroduction was related to an increase of triglyceride concentration. In addition, liver enzyme abnormalities and leukocyte count reduced, whereas albumin levels increased, suggesting that even short withdrawal of the lipid emulsion diminished hepatocellular damage and systemic inflammation.     

Provision of a Soy‐Based Intravenous Lipid Emulsion at 1 g/kg/d Does Not Prevent Cholestasis in Neonates

Background: One of the most common and severe complications of long‐term parenteral nutrition (PN) is PN‐associated cholestasis. The soybean oil–based lipid emulsion administered with PN has been associated with cholestasis, leading to an interest in lipid reduction strategies. The purpose of this study was to determine whether the provision of a soybean oil–based lipid emulsion at 1 g/kg/d compared with 2–3 g/kg/d is associated with a reduced incidence of cholestasis. Methods: Retrospective review of neonates admitted between 2007 and 2011 with a gastrointestinal condition necessitating ≥21 days of PN support. Neonates were divided into 2 groups based on the intravenous lipid emulsion dose: 1‐g group (1 g/kg/d) and 2‐ to 3‐g group (2–3 g/kg/d). The primary outcome measure was the incidence of cholestasis. Results: Sixty‐one patients met inclusion criteria (n = 29, 1‐g group; n = 32, 2‐ to 3‐g group). The 2 groups did not differ in any baseline characteristics other than associated comorbidities that were more common in the 2‐ to 3‐g group. The duration of PN, the number of operative procedures and bloodstream infections, and enteral nutrition (EN) were similar between groups. The incidence of cholestasis was not different between groups (51.7%, 1‐g group; 43.8%, 2‐ to 3‐g group; P = .61), and there was no difference between groups in the time to cholestasis (32.6 ± 24.1 days, 1‐g group; 27.7 ± 10.6 days, 2‐ to 3‐g group; P = .48). Overall, 44.8% of patients with cholestasis were transitioned to full EN, and 55.2% were transitioned to a fish oil–based lipid emulsion after which the direct bilirubin normalized in all patients. Conclusion: Lipid reduction to 1 g/kg/d does not prevent or delay the onset of cholestasis in neonates.     

Hyperglycemia During Home Parenteral Nutrition Administration in Patients Without Diabetes

Background: Parenteral nutrition (PN) is a life‐sustaining therapy in appropriate clinical settings. In the hospital setting, some nondiabetic patients develop hyperglycemia and subsequently require long‐term insulin while receiving PN. Whether similar hyperglycemia is seen in the outpatient setting is unclear. Methods: We studied patients enrolled in the Mayo Clinic Home Parenteral Nutrition (HPN) program between January 1, 2010, and December 31, 2012. Patients were excluded if they had diabetes mellitus type 2 (DM2), had previously received HPN, had taken corticosteroids, or were at risk for refeeding syndrome. Results: Of 144 enrolled patients, 93 met inclusion criteria with 39 patients requiring the addition of insulin to HPN. The mean age of the insulin‐requiring group (IR) was higher than that of the non–insulin‐requiring group (NIR) (60.74 ± 13.62 years vs 48.97 ± 17.62 years, P < .001). There were 17 (44%) men in the IR group and 26 (48%) men in the NIR group. Mean blood glucose at baseline before starting the infusion was 131.82 ± 49.55 mg/dL in IR patients and 106.16 ± 59.01 mg/dL in NIR patients (P = .03). In the stepwise multivariate analysis for assessing the risk for developing hyperglycemia, HR for age was 1.020 (1.010–1.031), P < .001. Conclusions: Hyperglycemia is a common finding with the use of PN in both the hospital and ambulatory setting in patients without a previous diagnosis of DM2. Age was the most significant predictor of the requirement of insulin in the present study. When hyperglycemia is managed appropriately with insulin therapy, the long‐term complications can be minimized.     

Correlation between exposure to phthalates and concentrations of malondialdehyde in infants and children undergoing cyclic parenteral nutrition

Background: Plasticizers such as di(2‐ethylhexyl) phthalate (DEHP) are added to polyvinyl chloride (PVC) to confer flexibility. However, DEHP is associated with reproductive disorders in humans. Because of its noncovalent bond to the PVC matrix, this plasticizer tends to leach easily. Infants and children undergoing cyclic, long‐term parenteral nutrition (PN) could be particularly at risk of potential toxicity from DEHP due to regular exposure. Malondialdehyde (MDA) is one of the most commonly used markers of free radical activity. The purpose of this study was to investigate how long‐term exposure to phthalate affects the plasmatic rate of MDA. Methods: Studies were performed on 7 randomized infants and children on regular cyclic, long‐term PN, and the results were compared with those of 5 nontreated infants. The circulating concentrations of DEHP in children and infants during the PN therapy were measured by high‐performance liquid chromatography. The concentrations were assessed before and after the PN session. In the same way, plasma MDA concentrations were measured. Results: The circulating concentrations of DEHP before and after a 10‐ to 11‐hour cyclic PN treatment in 7 infants and children under regular perfusion ranged widely, showing a significant increase after the treatment among all the patients. The same phenomenon observed with the rate of MDA showed that the 2 events are closely dependent. Therefore, long‐term exposure to DEHP during cyclic PN raised plasma MDA levels, indicating increased oxidative stress. Conclusion: Long‐term exposure to DEHP during PN increased free radical activity in vivo.     

Hospital Readmissions for Catheter‐Related Bloodstream Infection and Use of Ethanol Lock Therapy

Background: Catheter‐related bloodstream infection (CRBSI) is the most serious long‐term infectious complication of long‐term home parenteral nutrition (PN). Ethanol is being used more commonly as a catheter locking solution in the home PN setting for prevention of CRBSI; however, no current literature reports the use of ethanol lock (ETL) in skilled nursing facility (SNF) patients. Methods: The authors evaluated the number of hospital readmissions for CRBSI and length of stay between SNF (not receiving ETL) and home patients (receiving or not receiving ETL) receiving PN or intravenous fluid therapy. Results: SNF patients had a significantly longer length of stay (LOS) for CRBSI hospital admissions compared with patients receiving PN at home with or without ETL (P < .001; 16 vs 8 vs 8 days). There was no LOS difference for CRBSI between home patients with or without ETL. Home PN patients not receiving ETL were more likely to have a CRBSI from Staphylococcus sp (48% vs 27%; P = .015), whereas SNF PN patients not receiving ETL were more likely to have a CRBSI from Enterococcus sp (16% vs 3%; P = .004). Conclusion: Despite different causative organisms and medical acuity likely affecting the differences observed in LOS, the SNF population is another setting ETL can be used to prevent CRBSI.     

Growth hormone to improve short bowel syndrome intestinal autonomy: a pediatric randomized open-label clinical trial

Background: The ability of growth hormone (GH) to promote the weaning‐off of parenteral nutrition (PN) in short bowel syndrome (SBS) is unclear. No randomized controlled study is available in children. This study was undertaken to determine if GH could enhance the weaning off of PN in PN‐dependent children with SBS. Methods: A prospective randomized open‐label multicenter study was performed in 14 patients (mean age, 9 ± 1.4 years) with SBS (average small bowel length, 33 cm) and long‐term PN dependency (8 years) on an unrestricted diet. A standardized PN decrease with and without GH (0.14 mg/kg/d) was conducted. The patients were randomized to either a GH group (4 months of GH) or a control (CTR) group (4 months without GH, followed by 4 months with GH). Blood tests and a nutrition assessment of enteral and parenteral intakes were performed. Groups were compared with the Wilcoxon test. Results: Treatment with GH did not improve the weaning off of PN (decrease in PN caloric intake of 32.5% ± 9.6% in the GH group vs 35.2% ± 8.7% in the CTR group, nonsignificant). In the CTR group, GH treatment induced an additional but not statistically significant decrease of 8.8% ± 12.4% in daily calories. Parenteral needs returned to near basal rates 6 months after GH discontinuation (GH: 77.6% ± 10.6% vs CTR: 73.2% ± 7.4%). Weight decreased slightly in both groups. No biological parameters varied significantly. Conclusions: GH did not improve the weaning off of PN in PN‐dependent children with SBS.     

Computer‐Assisted Glucose Regulation During Rapid Step‐Wise Increases of Parenteral Nutrition in Critically Ill Patients

Background: Early delivery of calories is important in critically ill patients, and the administration of parenteral nutrition (PN) is sometimes required to achieve this goal. However, PN can induce acute hyperglycemia, which is associated with adverse outcome. We hypothesized that initiation of PN using a rapid “step‐up” approach, coupled with a computerized insulin‐dosing protocol, would result in a desirable caloric intake within 24 hours without causing hyperglycemia. Methods: In our surgical intensive care unit (ICU), glucose is regulated by a nurse‐centered computerized glucose regulation program. When adequate enteral feeding was not possible, PN was initiated according to a simple step‐up rule at an infusion rate of 10 mL/h (approximately 10 kcal/h) and subsequently increased by steps of 10 mL/h every 4 hours, provided glucose was <10 mmol/L, until the target caloric intake (1 kcal/kg/h) was reached. All glucose levels and insulin doses were collected during the step‐up period and for 24 hours after achieving target feeding. Results: In all 23 consecutive patients requiring PN, mean intake was 1 kcal/kg/h within 24 hours. Of the 280 glucose samples during the 48‐hour study period, mean ± standard deviation glucose level was 7.4 ± 1.4 mmol/L. Only 4.5% of glucose measurements during the step‐up period were transiently ≥10 mmol/L. After initiating PN, the insulin requirement rose from 1.1 ± 1.5 units/h to 2.9 ± 2.5 units/h (P < .001). Conclusions: This proof of concept study shows that rapid initiation of PN using a step‐up approach coupled with computerized glucose control resulted in adequate caloric intake within 24 hours while maintaining adequate glycemic control.     

Serum vitamins in adult patients with short bowel syndrome receiving intermittent parenteral nutrition

Background: Short bowel syndrome (SBS) occurs after massive intestinal resection, and parenteral nutrition (PN) therapy may be necessary even after a period of adaptation. The purpose of this study was to determine the vitamin status in adults with SBS receiving intermittent PN. Methods: The study was conducted on hospitalized adults with SBS who were receiving intermittent PN therapy (n = 8). Nine healthy volunteers, paired by age and sex, served as controls. Food ingestion, anthropometry, plasma folic acid, and vitamins B₁₂, C, A, D, E, and K were evaluated. Results: The levels of vitamins A, D, and B₁₂ in both groups were similar. SBS patients presented higher values of folic acid (21.3 ± 4.4 vs 14.4 ± 5.2, P = .01) and lower values of vitamin C (0.9 ± 0.4 vs 1.2 ± 0.3 mg/dL, P = .03), α‐tocopherol (16.3 ± 3.4 vs 24.1 ± 2.7 µmol/L, P < .001), and phylloquinone (0.6 ± 0.2 vs 1.0 ± 0.5 nmol/L, P < .03). Eight‐seven percent of patients had vitamin D deficiency, and all patients presented with serum vitamin E levels below reference values. Conclusions: Despite all efforts to offer all the nutrients mentioned above, SBS patients had lower serum levels of vitamins C, E, and K, similar to those observed in patients on home PN. These findings suggest that the administered vitamins were not sufficient for the intermittent PN scheme and that individual adjustments are needed depending on the patient's vitamin status.     

Expediting Transition to Home Parenteral Nutrition With Fast‐Track Cycling

Background. Delivery of home parenteral nutrition (PN) is typically cycled over 12 hours. Discharge to home on PN is often delayed due to potential adverse events (AEs) associated with cycling PN. The purpose was to determine whether patients requiring long‐term PN can be cycled from 24 hours to 12 hours in 1 day instead of 2 days without increasing the risk of PN‐related AEs. Methods. Hospitalized patients receiving PN at goal calories infused over 24 hours without severe electrolyte or blood glucose abnormalities were eligible. Patients were randomly assigned to a 1‐step “fast‐track” protocol or 2‐step “standard” protocol. AEs were defined as hypoglycemia or hyperglycemia, new‐onset or worsening dyspnea, tachycardia, tachypnea, lower extremity or sacral edema, pulmonary edema, or abdominal ascites and were graded as minor or major. Results. In the 63 patients studied, the most prevalent PN‐related AE was hyperglycemia, occurring in 24.2% and 30.0% of patients in the fast‐track and standard groups, respectively. Overall, there was no significant difference in the prevalence of PN‐related minor AEs between fast‐track and standard groups (33.3% and 53.3%, P = .5). No major PN‐related AEs occurred in the fast‐track group, while 1 major PN‐related AE (pulmonary edema) occurred in the standard group. Conclusions. Fast‐track cycling is as safe as standard cycling in patients without diabetes mellitus or major organ dysfunction requiring long‐term PN. Fast‐track cycling could potentially expedite hospital discharge, resulting in decreased healthcare costs and improved patient satisfaction.     

Vitamin D Deficiency in Children With Intestinal Failure Receiving Home Parenteral Nutrition

Background: Vitamin D plays important roles in both skeletal and nonskeletal health. Limited data suggest that patients with intestinal failure (IF) receiving home parenteral nutrition (PN) are at risk for vitamin D deficiency due to inadequate oral intake, poor absorption, and chronic illness. The purpose of this study was to document vitamin D status in pediatric patients with IF receiving home PN. Materials and Methods: We performed a 2‐year retrospective review of children with IF followed at our center who had been on home PN for ≥6 months and had ≥1 serum 25‐hydroxyvitamin D (25‐OHD) level checked as part of routine clinical care. Patients were then categorized as deficient (<20 ng/mL), insufficient (20–29 ng/mL), or normal (≥30 ng/mL) based on their lowest vitamin D level. Demographic data and clinical characteristics were also assessed. Results: Eleven of 27 children (41%) had ≥1 insufficient 25‐OHD level, including one child with vitamin D deficiency. Diagnosis of short bowel syndrome (compared with dysmotility or malabsorption syndromes) was associated with decreased likelihood of suboptimal vitamin D status, with an odds ratio of 0.12 (95% confidence interval, 0.02–0.8, P = .028). Osteopenia was noted in 59% of the cohort. There was a trend toward higher risk for osteopenia in patients with low 25‐OHD levels compared with those with normal 25‐OHD levels (82% vs 44%, P = .109). Conclusion: Suboptimal 25‐OHD levels are common in children with IF on home PN. This emphasizes the critical importance of routine surveillance of serum vitamin D levels and consideration of enteral supplementation when indicated.     

Plasma Levels of Conjugated Bile Acids in Newborns After a Short Period of Parenteral Nutrition

Background: Patients receiving parenteral nutrition (PN) frequently exhibit liver dysfunction. The authors previously reported that plant sterols of lipid emulsions added to the nutritional solution of newborns receiving PN accumulate in plasma and cell membranes and may contribute to the development of cholestasis. Conjugated bile acids (BA) have been shown to be useful markers of cholestasis. Plasma levels of several BA in newborns were quantified after administration of PN for less than 2 weeks. Methods: Plasma samples from 15 healthy control infants (CN), 22 patients who had received PN for 3–15 days (T1), and 9 patients scheduled to receive PN (T0) were analyzed. After a simple extraction procedure, plasma BA were analyzed by liquid chromatography–tandem mass spectrometry using a quantitative isotope dilution method. Results: The concentrations of BA did not differ significantly between controls and patients before PN (CN vs T0), with the exception of glycocholic acid (GCA; 2.30 ± 2.60 µM vs 7.29 ± 5.39 µM, respectively). There was a significant difference in several BA between controls and patients after PN (2.30 ± 2.60 µM vs 7.61 ± 6.46 µM for GCA, respectively; 4.02 ± 3.49 µM vs 11.88 ± 11.05 µM for taurocholic acid [TCA], respectively; and 4.81 ± 3.49 µM vs 13.58 ± 12.22 µM for taurochenodeoxycholic + taurodeoxycholic + tauroursodeoxycholic acids [TCDCA+TDCA+TUDCA], respectively). Conclusions: In newborns receiving PN, a short period of PN is associated with an early increase of some conjugated BA. These results suggest that GCA, TCA, and TCDCA+TDCA+TUDCA levels could be used as early markers of PN‐related cholestasis.     

Effect of Liraglutide Treatment on Jejunostomy Output in Patients With Short Bowel Syndrome: An Open‐Label Pilot Study

Background: An impaired hormonal “ileo‐colonic brake” may contribute to rapid gastric emptying, gastric hypersecretion, high ostomy losses, and the need for parenteral support in end‐jejunostomy short bowel syndrome (SBS) patients with intestinal failure (IF). Liraglutide, a glucagon‐like peptide 1 receptor agonist, may reduce gastric hypersecretion and dampen gastric emptying, thereby improving conditions for intestinal absorption. Materials and Methods: In an 8‐week, open‐label pilot study, liraglutide was given subcutaneously once daily to 8 end‐jejunostomy patients, aged 63.4 ± 10.9 years (mean ± SD) and with small bowel lengths of 110 ± 66 cm. The 72‐hour metabolic balance studies were performed before and at the end of treatment. Food intake was unrestricted. Oral fluid intake and parenteral support volume were kept constant. The primary end point was change in the ostomy wet weight output. Results: Liraglutide reduced ostomy wet weight output by 474 ± 563 g/d from 3249 ± 1352 to 2775 ± 1187 g/d (P = .049, Student t test). Intestinal wet weight absorption tended to increase by 464 ± 557 g/d (P = .05), as did urine production by 765 ± 759 g/d (P = .02). Intestinal energy absorption improved by 902 ± 882 kJ/d (P = .02). Conclusion: Liraglutide reduced ostomy wet weight output in end‐jejunostomy patients with SBS‐IF and increased their intestinal wet weight and energy absorption. If larger, randomized, placebo‐controlled studies confirm these effects, it adds to the hypothesis that many ileo‐colonic brake hormones in conjunction may be involved in the process of intestinal adaptation. By identification of key hormones and addressing their potential synergistic effects, better treatments may be provided to patients with SBS‐IF. This trial was registered at clinicaltrialsregister.eu as 2013‐005499‐16.     

Effect of Recombinant Human Growth Hormone on Intestinal Absorption and Body Composition in Children With Short Bowel Syndrome

This prospective study aimed to establish the effect of recombinant human growth hormone (rhGH) on intestinal function in children with short bowel syndrome (SBS). Eight children with neonatal SBS were included. All were dependent on parenteral nutrition (PN) for >3 years (range, 3.8–11.6 years), with PN providing >50% of recommended dietary allowance for age (range, 50%–65%). The subjects received rhGH (Humatrope) 0.13 mg/kg/d subcutaneously over a 12‐week period. The follow‐up was continued over a 12‐month period after rhGH discontinuation. Clinical and biological assessments were performed at baseline, at the end of the treatment period, and 12 months after the end of treatment. No side effects related to rhGH were observed. PN requirements were decreased in all children during the course of rhGH treatment. Between baseline and the end of treatment, significant increases were observed in concentrations (mean ± standard deviation) of serum insulin‐like growth factor 1 (103.1 ± 49.9 µg/L vs 153.5 ± 82.2 µg/L; P < .01), serum insulin‐like growth factor–binding protein 3 (1.7 ± 0.6 mg/L vs 2.5 ± 0.9 mg/L; P < .001), and plasma citrulline (16.5 ± 14.8 µmol/L vs 25.2 ± 18.3 µmol/L; P < .05). A median 54% increase in enteral intake (range, 10%–244%) was observed (P < .001) and net energy balance improved significantly (P < .002). It was necessary for 6 children to be maintained on PN or restarted after discontinuation of rhGH treatment, and they remained on PN until the end of the follow‐up period. A 12‐week high‐dose rhGH treatment allowed patients to decrease PN, but only 2 patients could be definitively weaned from PN. Indications and cost‐effectiveness of rhGH treatment for SBS pediatric patients need further evaluation.