Monitorização por absortometria com duplo raio X na síndrome do intestino curto pediátrica: uma revisão integrativa

Blum, Angelica Godoi Romagnoli; Russo, Tais Daiene Hortencio; Nogueira, Roberto José Negrão

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Revista Paulista de Pediatria

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Sumário

Review Article • Rev. paul. pediatr. 42 • 2024 • https://doi.org/10.1590/1984-0462/2024/42/2023064 copiar

Monitorização por absortometria com duplo raio X na síndrome do intestino curto pediátrica: uma revisão integrativa

Autoria SCIMAGO INSTITUTIONS RANKINGS

Objetivo:

Analisar a saúde óssea de pacientes pediátricos com síndrome do intestino curto — falência intestinal (SIC-FI).

Fontes de dados:

Revisão integrativa da literatura usando os dados publicados nas bases de dados Medical Literature Analysis and Retrieval System Online/ United States National Library of Medicine (MEDLINE/PubMed) e Scientific Electronic Library Online (SciELO) entre janeiro de 2010 e abril de 2021 e por meio de busca manual nas listas de referências de estudos relevantes. Foram incluídos estudos em inglês que avaliaram a densidade mineral óssea pela técnica de absorciometria de raio X duplo (DXA), incluíram pacientes pediátricos (até 20 anos de idade) com SIC sob terpia nutricional parenteral. Onze fontes primárias preencheram os critérios de inclusão para este estudo.

Síntese dos dados:

A pesquisa revelou que pacientes pediátricos com SIC-FI sob nutrição parenteral (NP) de longo prazo tiveram alterações frequentes no metabolismo ósseo, levando a fraturas osteoporóticas e falha de crescimento. Esses pacientes apresentam deficiências de múltiplos nutrientes, como cálcio, magnésio, fósforo e vitamina D. Consequentemente, houve variações na secreção e regulação do hormônio da paratireoide. Além disso, as limitações farmacotécnicas relacionadas ao cálcio e fósforo na solução de NP, o uso de glicocorticoides e dificuldade para realizar atividade física são fatores de risco para o desenvolvimento de doença óssea metabólica em pacientes pediátricos com SIC-FI.

Conclusões:

A baixa densidade mineral óssea foi associada a um alto risco de desenvolver osteoporose, fraturas e deficiência de crescimento em pacientes pediátricos com SIC-FI sob terapia nutricional parenteral em longo prazo.

Palavras-chave:
Insuficiência intestinal; Pediatrico; Nutrição parenteral; Absorciometria de fóton

	Criteria	Appleman et al.²⁰20 Appleman SS, Kalkwarf HJ, Dwivedi A, Heubi JE. Bone deficits in parenteral nutrition-dependent infants and children with intestinal failure are attenuated when accounting for slower growth. J Pediatr Gastroenterol Nutr. 2013;57:124-30. https://doi.org/10.1097/MPG.0b013e318291fec5 https://doi.org/10.1097/MPG.0b013e318291...	Demehri et al.¹⁶16 Demehri FR, Simha S, Stephens L, Harris MB, Arnold MA, Brown PI, et al. Pediatric intestinal failure: predictors of metabolic bone disease. J Pediatr Surg. 2015;50:958-62. https://doi.org/10.1016/j.jpedsurg.2015.03.018 https://doi.org/10.1016/j.jpedsurg.2015....	Diamanti et al.¹³13 Diamanti A, Bizzarri C, Basso MS, Gambarara M, Cappa M, Daniele A, et al. How does long-term parenteral nutrition impact the bone mineral status of children with intestinal failure? J Bone Miner Metab. 2010;28:351-8. https://doi.org/10.1007/s00774-009-0140-0 https://doi.org/10.1007/s00774-009-0140-...	Khan et al.²⁴24 Khan FA, Fisher JG, Bairdain S, Sparks EA, Zurakowski D, Modi BP, et al. Metabolic bone disease in pediatric intestinal failure patients: prevalence and risk factors. J Pediatr Surg. 2015;50:136-9. https://doi.org/10.1016/j.jpedsurg.2014.10.010 https://doi.org/10.1016/j.jpedsurg.2014....	Kvammen et al.²⁵25 Kvammen JA, Thomassen RA, Kjeserud CN, Sæland C, Godang K, Bollerslev J, et al. Bone mineral density and vitamin D in paediatric intestinal failure patients receiving home parenteral nutrition. Clin Nutr ESPEN. 2020;39:234-41. https://doi.org/10.1016/j.clnesp.2020.06.006 https://doi.org/10.1016/j.clnesp.2020.06...	Louazon et al.²¹21 Louazon T, Poinsot P, Restier L, Belmalih A, Loras-Duclaux I, Marotte S, et al. A prospective case-control pilot study to evaluate bone microarchitecture in children and teenagers on long-term parenteral nutrition using HR-pQCT. Sci Rep. 2021;11:9151. https://doi.org/10.1038/s41598-021-88366-6 https://doi.org/10.1038/s41598-021-88366...	Mutanen et al.²²22 Mutanen A, Mäkitie O, Pakarinen MP. Risk of metabolic bone disease is increased both during and after weaning off parenteral nutrition in pediatric intestinal failure. Horm Res Paediatr. 2013;79:227-35. https://doi.org/10.1159/000350616 https://doi.org/10.1159/000350616...	Nader et al.²³23 Nader EA, Lambe C, Talbotec C, Acramel A, Pigneur B, Goulet O. Metabolic bone disease in children with intestinal failure is not associated with the level of parenteral nutrition dependency. Clin Nutr. 2021;40:1974-82. https://doi.org/10.1016/j.clnu.2020.09.014 https://doi.org/10.1016/j.clnu.2020.09.0...	Olieman et al.¹⁴14 Olieman JF, Penning C, Spoel M, Ijsselstijn H, van den Hoonaard TL, Escher JC, et al. Long-term impact of infantile short bowel syndrome on nutritional status and growth. Br J Nutr. 2012;107:1489-97. https://doi.org/10.1017/S0007114511004582 https://doi.org/10.1017/S000711451100458...	Pichler et al.¹²12 Pichler J, Chomtho S, Fewtrell M, Macdonald S, Hill SM. Growth and bone health in pediatric intestinal failure patients receiving long-term parenteral nutrition. Am J Clin Nutr. 2013;97:1260-9. https://doi.org/10.3945/ajcn.112.057935 https://doi.org/10.3945/ajcn.112.057935...	Poinsot et al.⁹9 Poinsot P, Geoffroy P, Braillon P, Denis A, Loras-Duclaux I, Marotte S, et al. Longitudinal bone mineralization assessment in children treated with long-term parenteral nutrition for severe intestinal failure. JPEN J Parenter Enteral Nutr. 2018;42:613-22. https://doi.org/10.1177/0148607117701399 https://doi.org/10.1177/0148607117701399...
1	Aims and objectives clearly stated	+		+	+	+	+	+	+	+	+	+
2	Hypothesis/research questions clearly specified	+	+	+	+	+	+	+	+	+	+	+
3	Dependent and independent variables clearly stated	+	+	+	+	+	+	+	+	+	+	+
4	Variables operationalized	+	+			+	+		+	+		+
5	Design adequately described		+	+	+	+	+	+	+	+	+	+
6	Appropriate methods	+	+	+	+	+	+	+	+		+	+
7	Instruments used tested for reliability and validity	+	+	+	+	+	+	+	+	+	+	+
8	Source of sample, inclusion/exclusion, and response rates described	+	+	+	+	+	+	+	+	+	+	+
9	Statistical errors discussed									+		+
10	Ethical considerations	+		+	+	+		+	+	+	+	+
11	Was the piloted study						+
12	Statistically appropriate analysis	+	+	+	+	+	+	+	+		+	+
13	Results reported and clear	+	+	+	+	+	+	+	+	+	+	+
14	Results reported related to hypothesis and literature	+	+	+	+	+	+	+	+	+	+	+
15	Limitations reported	+	+	+	+	+	+	+		+		+
16	Conclusions do not go beyond limit of data and results		+				+			+
17	Findings able to be generalized								+
18	Implications discussed	+	+	+	+	+	+	+	+	+	+	+
19	Existing conflict of interest with sponsor					+
20	Data available for scrutiny and reanalysis	+	+	+	+	+	+	+	+	+	+	+

Author/Country	Type of study	Study period	N	Results/findings
Appleman et al.²⁰20 Appleman SS, Kalkwarf HJ, Dwivedi A, Heubi JE. Bone deficits in parenteral nutrition-dependent infants and children with intestinal failure are attenuated when accounting for slower growth. J Pediatr Gastroenterol Nutr. 2013;57:124-30. https://doi.org/10.1097/MPG.0b013e318291fec5 https://doi.org/10.1097/MPG.0b013e318291... /USA	Cross-sectional	Not reported	20	Vitamin D deficiency, growth retardation
Demehri et al.¹⁶16 Demehri FR, Simha S, Stephens L, Harris MB, Arnold MA, Brown PI, et al. Pediatric intestinal failure: predictors of metabolic bone disease. J Pediatr Surg. 2015;50:958-62. https://doi.org/10.1016/j.jpedsurg.2015.03.018 https://doi.org/10.1016/j.jpedsurg.2015.... /USA	Retrospective, cohort	2006–2012	36	Fractures, bone pain, vitamin D deficiency^* * No statistical significance. , hyperparathyroidism
Diamanti et al.¹³13 Diamanti A, Bizzarri C, Basso MS, Gambarara M, Cappa M, Daniele A, et al. How does long-term parenteral nutrition impact the bone mineral status of children with intestinal failure? J Bone Miner Metab. 2010;28:351-8. https://doi.org/10.1007/s00774-009-0140-0 https://doi.org/10.1007/s00774-009-0140-... /Italy	Longitudinal prospective	2005–2007	24	Fractures
Khan et al.²⁴24 Khan FA, Fisher JG, Bairdain S, Sparks EA, Zurakowski D, Modi BP, et al. Metabolic bone disease in pediatric intestinal failure patients: prevalence and risk factors. J Pediatr Surg. 2015;50:136-9. https://doi.org/10.1016/j.jpedsurg.2014.10.010 https://doi.org/10.1016/j.jpedsurg.2014.... /USA	Retrospective, cohort	2004–2013	65	Vitamin D deficiency^* * No statistical significance. , hyperparathyroidism
Kvammen et al.²⁵25 Kvammen JA, Thomassen RA, Kjeserud CN, Sæland C, Godang K, Bollerslev J, et al. Bone mineral density and vitamin D in paediatric intestinal failure patients receiving home parenteral nutrition. Clin Nutr ESPEN. 2020;39:234-41. https://doi.org/10.1016/j.clnesp.2020.06.006 https://doi.org/10.1016/j.clnesp.2020.06... /Norway	Observational cross-sectional	2007 (March to September)	69	Impaired growth
Louazon et al.²¹21 Louazon T, Poinsot P, Restier L, Belmalih A, Loras-Duclaux I, Marotte S, et al. A prospective case-control pilot study to evaluate bone microarchitecture in children and teenagers on long-term parenteral nutrition using HR-pQCT. Sci Rep. 2021;11:9151. https://doi.org/10.1038/s41598-021-88366-6 https://doi.org/10.1038/s41598-021-88366... /France	Cross-sectional, case-control	March 2014 to June 2015	11and 22 (patients and controls)	No diferences for bone densities in patients undergoing chronic PN
Mutanen et al.²²22 Mutanen A, Mäkitie O, Pakarinen MP. Risk of metabolic bone disease is increased both during and after weaning off parenteral nutrition in pediatric intestinal failure. Horm Res Paediatr. 2013;79:227-35. https://doi.org/10.1159/000350616 https://doi.org/10.1159/000350616... /Finland	Cross-sectional	1984–2010	41	Fractures, vitamin D deficiency, hyperparathyroidism
Nader et al.²³23 Nader EA, Lambe C, Talbotec C, Acramel A, Pigneur B, Goulet O. Metabolic bone disease in children with intestinal failure is not associated with the level of parenteral nutrition dependency. Clin Nutr. 2021;40:1974-82. https://doi.org/10.1016/j.clnu.2020.09.014 https://doi.org/10.1016/j.clnu.2020.09.0... /France	Single center retrospective, cross-sectional	January 2016 to December 2018	40	Bone fractures^* * No statistical significance. after a mild trauma, and vitamin D deficiency^* * No statistical significance.
Olieman et al.¹⁴14 Olieman JF, Penning C, Spoel M, Ijsselstijn H, van den Hoonaard TL, Escher JC, et al. Long-term impact of infantile short bowel syndrome on nutritional status and growth. Br J Nutr. 2012;107:1489-97. https://doi.org/10.1017/S0007114511004582 https://doi.org/10.1017/S000711451100458... /Netherlands	Cross-sectional	2005–2007	31	Short stature
Pichler et al.¹²12 Pichler J, Chomtho S, Fewtrell M, Macdonald S, Hill SM. Growth and bone health in pediatric intestinal failure patients receiving long-term parenteral nutrition. Am J Clin Nutr. 2013;97:1260-9. https://doi.org/10.3945/ajcn.112.057935 https://doi.org/10.3945/ajcn.112.057935... /Austria	Prospective, cohort	2002–2010	12	Short stature
Poinsot et al.⁹9 Poinsot P, Geoffroy P, Braillon P, Denis A, Loras-Duclaux I, Marotte S, et al. Longitudinal bone mineralization assessment in children treated with long-term parenteral nutrition for severe intestinal failure. JPEN J Parenter Enteral Nutr. 2018;42:613-22. https://doi.org/10.1177/0148607117701399 https://doi.org/10.1177/0148607117701399... /France	Retrospective, cohort	2004–2014	31	Vitamin D deficiency

Author	Age	BMD	Time of PN	DXA assessments and time after weaned off PN
Appleman et al.²⁰20 Appleman SS, Kalkwarf HJ, Dwivedi A, Heubi JE. Bone deficits in parenteral nutrition-dependent infants and children with intestinal failure are attenuated when accounting for slower growth. J Pediatr Gastroenterol Nutr. 2013;57:124-30. https://doi.org/10.1097/MPG.0b013e318291fec5 https://doi.org/10.1097/MPG.0b013e318291...	Median: 26 Min-Max (6–127) months	Lumbar (15%), Total (12%), ↓ in IF than the control group	Median: 18.5 Min-Max (4–103) months	Not reported
Demehri et al.¹⁶16 Demehri FR, Simha S, Stephens L, Harris MB, Arnold MA, Brown PI, et al. Pediatric intestinal failure: predictors of metabolic bone disease. J Pediatr Surg. 2015;50:958-62. https://doi.org/10.1016/j.jpedsurg.2015.03.018 https://doi.org/10.1016/j.jpedsurg.2015....	≥6 years and diagnosed until 18 years	Lumbar: Mean±SD: -1.36±1.47 First DXA Mean±SD: -1.36±1.18 Second DXA	Mean±SD: 5.1±5.4 years	Not reported
Diamanti et al.¹³13 Diamanti A, Bizzarri C, Basso MS, Gambarara M, Cappa M, Daniele A, et al. How does long-term parenteral nutrition impact the bone mineral status of children with intestinal failure? J Bone Miner Metab. 2010;28:351-8. https://doi.org/10.1007/s00774-009-0140-0 https://doi.org/10.1007/s00774-009-0140-...	Mean±SD: (5.1±2.9) years	Total Mean±SD: -2.5±1.2^* * p<0.001	Mean±SD: 32.4±28.8 months	Not reported
Khan et al.²⁴24 Khan FA, Fisher JG, Bairdain S, Sparks EA, Zurakowski D, Modi BP, et al. Metabolic bone disease in pediatric intestinal failure patients: prevalence and risk factors. J Pediatr Surg. 2015;50:136-9. https://doi.org/10.1016/j.jpedsurg.2014.10.010 https://doi.org/10.1016/j.jpedsurg.2014....	≥5 to 20 years	DXA less or equal–2 Mean±SD: 1772.9±1453.7 DXA greater–2 Mean±SD: 1126.1±1194.3 p=0.09 ↓ 22 childrens (22/65)–40%	Mean±SD: 44.2± 43.2 (unity)	DXA less or equal – 2 Mean±SD: 2127.9±1921.9 DXA greater – 2 Mean±SD: 2187.2±1300.0 p=0.92 32 days
Kvammen et al.²⁵25 Kvammen JA, Thomassen RA, Kjeserud CN, Sæland C, Godang K, Bollerslev J, et al. Bone mineral density and vitamin D in paediatric intestinal failure patients receiving home parenteral nutrition. Clin Nutr ESPEN. 2020;39:234-41. https://doi.org/10.1016/j.clnesp.2020.06.006 https://doi.org/10.1016/j.clnesp.2020.06...	Mean±SD: 10.1±3.5 years	Total median: -0.4 and Lumbar: -0.9	>6 months	Not reported
Louazon et al.²¹21 Louazon T, Poinsot P, Restier L, Belmalih A, Loras-Duclaux I, Marotte S, et al. A prospective case-control pilot study to evaluate bone microarchitecture in children and teenagers on long-term parenteral nutrition using HR-pQCT. Sci Rep. 2021;11:9151. https://doi.org/10.1038/s41598-021-88366-6 https://doi.org/10.1038/s41598-021-88366...	Median: 16 Min-Max (9–19) years	Spine total: Median (Min-Max) and BMC (g): 40 (14–66) and BMD (g/cm²): 0.8 (0.4–0.9) and Whole body: Median (Min-Max) BMC (g): 1198 (441–1832) and BMD (g/cm²): 0.81 (0.54–0.96)	Median: 10.3 Min-Max (6.4–18.3) years	Not reported
Mutanen et al.²²22 Mutanen A, Mäkitie O, Pakarinen MP. Risk of metabolic bone disease is increased both during and after weaning off parenteral nutrition in pediatric intestinal failure. Horm Res Paediatr. 2013;79:227-35. https://doi.org/10.1159/000350616 https://doi.org/10.1159/000350616...	Mean: 9.9 Min-Max (0.2–27^† † adults with infantile SBS ) years	Lumbar: Mean: -2.1 Min-Max (-4.1–0.9) Femur: Mean: -0.9 Min-Max (-2.7–1.1)	Mean: 41 Min-Max (0.7–250) months	Lumbar: Mean: -1.2 Min-Max (-3.2–0.9). Femur: Mean: -0.8 Min-Max (-2.6–0.7) 9.0 years min-max (0.3–27)
Nader et al.²³23 Nader EA, Lambe C, Talbotec C, Acramel A, Pigneur B, Goulet O. Metabolic bone disease in children with intestinal failure is not associated with the level of parenteral nutrition dependency. Clin Nutr. 2021;40:1974-82. https://doi.org/10.1016/j.clnu.2020.09.014 https://doi.org/10.1016/j.clnu.2020.09.0...	Mean±SD: 12.4±4.5 years Median: 12.2 years	BMI mean±SD: -0.5±1.3 – Median: -0.4 BMI ≤-2 SD [n(%)]: 7 (18)	Mean±SD: 12.4±4.4 years Median: 12.4 years	Not reported
Olieman et al.¹⁴14 Olieman JF, Penning C, Spoel M, Ijsselstijn H, van den Hoonaard TL, Escher JC, et al. Long-term impact of infantile short bowel syndrome on nutritional status and growth. Br J Nutr. 2012;107:1489-97. https://doi.org/10.1017/S0007114511004582 https://doi.org/10.1017/S000711451100458...	Mean±SD: 11.8±4.2) years	Total: Mean±SD: -0.04±1.4 and Lumbar: Mean±SD: -0.47±1.2 – BMC: Mean±SD: -1.0±1.1	Median: 110 Min-Max (43–2345) days	Not reported
Pichler et al.¹²12 Pichler J, Chomtho S, Fewtrell M, Macdonald S, Hill SM. Growth and bone health in pediatric intestinal failure patients receiving long-term parenteral nutrition. Am J Clin Nutr. 2013;97:1260-9. https://doi.org/10.3945/ajcn.112.057935 https://doi.org/10.3945/ajcn.112.057935...	5 to 14 years	Total: Mean±SD: -1.3±1	Median: 4.5 Min-Max (2–11.4) years	Not reported
Poinsot et al.⁹9 Poinsot P, Geoffroy P, Braillon P, Denis A, Loras-Duclaux I, Marotte S, et al. Longitudinal bone mineralization assessment in children treated with long-term parenteral nutrition for severe intestinal failure. JPEN J Parenter Enteral Nutr. 2018;42:613-22. https://doi.org/10.1177/0148607117701399 https://doi.org/10.1177/0148607117701399...	Median 2.9 Min-Max (0.40–13.3) years	TBMC^‡ ‡ Low bone mass was defined by a TBMC z score ≤-2). Median: -1.9(-5.3 to 2.6) – first DXA TBMC^‡ ‡ Low bone mass was defined by a TBMC z score ≤-2). : Median: -1.14(-2.25 to 1.84) – Last DXA	Median: 2.7 Min-Max (0.1–12.7) years	Not reported

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[1] Corresponding author: E-mail: a.romagnoli@hotmail.com (A. G. R. Blum)