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Letters to the Editor

Authors’ Response

Ubesie, Agozie*; Cole, Conrad R.

Author Information
Journal of Pediatric Gastroenterology and Nutrition: November 2014 - Volume 59 - Issue 5 - p e46
doi: 10.1097/MPG.0000000000000509
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To the Editor: Diamanti et al referred to our earlier work, wherein we reported a high prevalence of vitamin D deficiency (39.8%) in children with intestinal failure (IF) (1). In their letter, they found that fat-soluble vitamin (A, D, and E) deficiencies were common among patients with IF receiving home parenteral nutrition (PN), especially those with nonsurgical IF. This is extremely interesting and revealing. Our group has also published our evaluation comparing micronutrient deficiencies among patients with IF during and after transition to full enteral nutrition (EN) (2). In that study we reported that deficiencies of the fat-soluble vitamins were more common than those of the water-soluble vitamins, both during and after transition to EN. The proportion of patients with vitamin A and E deficiencies after transition to EN improved, whereas the incidence of vitamin D deficiency remained relatively stable. Finally, primary gastrointestinal diagnosis of Hirschsprung disease, dysmotility, and complex gastroschisis were significantly associated with micronutrient deficiencies (P = 0.003) during but not after successful transition to EN. The high rate of fat-soluble vitamin deficiencies reported in these studies and the letter by Diamanti et al (1,2) may be explained by the following observations: impaired absorption, particularly in patients with resected terminal ileum owing to interrupted enterohepatic circulation; dysmotility secondary to a generalized malabsorption state, related to bacterial overgrowth, which may lead to deconjugation of bile salts and increased inflammation with further small intestinal injury; and PN-associated cholestasis from prolonged PN, even after successful transition to full EN, as shown by our group.

In conclusion, we agree with Diamanti et al that closer monitoring (as recommended by the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (3)) for at-risk patients such as those with dysmotility, cholestasis, and extensive ileal resection is necessary while they are receiving long-term PN. Encouraging intestinal adaptation and ultimately weaning patients with IF off PN could ameliorate deficiencies. Issues of compliance, however, must be addressed, especially among patients weaned to full oral or enteral feeds only.


1. Ubesie AC, Heubi JE, Kocoshis SA, et al. Vitamin D deficiency and low bone mineral density in pediatric and young adult intestinal failure. J Pediatr Gastroenterol Nutr 2013; 57:372–376.
2. Ubesie AC, Kocoshis SA, Mezoff AG, et al. Multiple micronutrient deficiencies among patients with intestinal failure during and after transition to enteral nutrition. J Pediatr 2013; 163:1692–1696.
3. Koletzko B, Goulet O, Hunt J, et al. Guidelines on pediatric parenteral nutrition of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr 2005; 41:S70–S75.
© 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,