Collection
Intestinal Failure
Also covers: short bowel syndrome · necrotizing enterocolitis · gastroschisis · cholestasis · bacterial overgrowth · intestinal atresia · Hirschsprung disease · liver failure
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
Content of this collection
The current ASPEN guidelines define enteral autonomy as independence from parenteral support for 12 weeks with maintenance of adequate growth and hydration during that time period. — Paul Wales, Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1 · 6:39
Multidisciplinary Approach: Intestinal Failure Innovations
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Dr. Michael Helmrath leads a discussion amongst the panel including topics of intestinal failure, a team approach to intestinal patients, nutritional administration, complication rates, central line vs. PICC line use for total parenteral nu
video1:37:52 · Jan 2019
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
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We’re starting a new series about intestinal rehabilitation and all of its intricacies. We’re joined by Drs. Michael Helmrath and Paul Wales, leaders of the Intestinal Rehabilitation Program at Cincinnati Children’s. Hosted by: Todd Ponsky,
video14:33 · Dec 2021
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
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We’re starting a new series about intestinal rehabilitation and all of its intricacies. We’re joined by Drs. Michael Helmrath and Paul Wales, leaders of the Intestinal Rehabilitation Program at Cincinnati Children’s. Hosted by: Todd Ponsky,
podcast14:33 · Dec 2021
Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1
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We're back with a new episode from the Intestinal Rehabilitation Center at Cincinnati Children's Hospital. This time we're talking about enteral autonomy with Drs. Helmrath and Wales. This is the first of two parts on this topic, stay tuned
podcast16:18 · Mar 2022
In the intermediate and longer term, complications include intestinal failure-associated liver disease, recurrent sepsis, or line problems, which historically led to death or transplant. — Paul Wales, Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1 · 4:44
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1
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We're back with a new episode from the Intestinal Rehabilitation Center at Cincinnati Children's Hospital. This time we're talking about the management of overwhelming intestinal damage in conditions such as necrotizing enterocolitis and vo
podcast13:27 · Feb 2022
Pancreatic enzymes in short gut patients go through before they've released, and there is concern they may cause strictures or stoma problems in areas of stenosis and dysmotility. — Michael Helmrath, Intestinal Failure - Feeding Access and Nutrition · 1:49:07
Intestinal Failure - Feeding Access and Nutrition
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Dr. Michael Helmrath discusses alternative feeding techniques for intestinal failure, distal feeding, button insertion illustration, anastomosis, dilated bowel segments, small bowel length significance, liver disease, international patient
video1:58:06 · Nov 2018
Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 2
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We're back with the second part of episode 3, enteral autonomy along with Drs. Michael Helmrath and Paul Wales from Intestinal Rehabilitation Center at Cincinnati Children's Hospital. Hosts: Ellen Encisco & Rod GerardoRegister for Best of t
podcast13:37 · Mar 2022
Intestinal Rehabilitation, Episode 7: Refeeding in a neonatal patient
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We’re back with a new episode from the intestinal rehabilitation center at Cincinnati Children’s Hospital.
This time we’re talking about How to refeed a neonatal patient with a damage bowel, as always with the experts Drs. Helmrath and W
podcast16:09 · Sep 2023
Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient
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We’re back with a new episode from the intestinal rehabilitation center at Cincinnati Children’s Hospital.
This time we’re talking about Refeeding in older patients with Drs. Helmrath and Wales.
If you are looking for refeeding a Neon
podcast12:05 · Oct 2023
When proximal and distal stomas are placed close together, takedown is less stressful on patient and surgeon than complete laparotomy to find and reconnect distant bowel segments Practical Approach: Intestinal Failure Innovations · 8:02
Practical Approach: Intestinal Failure Innovations
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Dr. Michael Helmrath leads a discussion in alternative feeding techniques for intestinal failure, distal feeding, button insertion, the significant of small bowel length, liver disease, international patient management, breast milk therapy,
video1:56:52 · Jan 2019
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2
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We're back with the second part of episode 2, management of overwhelming intestinal damage along with Drs. Michael Helmrath and Paul Wales from Intestinal Rehabilitation Center at Cincinnati Children's Hospital. Article for further reading:
podcast17:21 · Feb 2022
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1
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We're back with a new topic, discussing surgical management with Drs. Michael Helmrath and Paul Wales from Intestinal Rehabilitation Center at Cincinnati Children's Hospital.
Hosts: Ellen Encisco & Em Tombash
Don't forget to like and
video19:07 · Oct 2022
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1
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We're back with a new topic, discussing surgical management with Drs. Michael Helmrath and Paul Wales from Intestinal Rehabilitation Center at Cincinnati Children's Hospital.
Hosts: Ellen Encisco & Em Tombash
Resources:
Bianchi A.
podcast19:07 · Oct 2022
Cincinnati Children's Hospital institutionally defined cholestasis as conjugated bilirubin greater than 3 mg/dL or 50 micromoles/L sustained for 2 weeks and not associated with a septic event. — Paul Wales, Intestinal Rehabilitation, Episode 6: Cholestasis · 1:09
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 2
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We're back with the second part of discussing surgical management with Drs. Michael Helmrath and Paul Wales from Intestinal Rehabilitation Center at Cincinnati Children's Hospital.
Hosts: Ellen Encisco & Em Tombash
Don't forget to lik
podcast12:24 · Oct 2022
Intestinal Rehabilitation, Episode 6: Cholestasis
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We’re back with a new episode from the intestinal rehabilitation center at Cincinnati Children’s Hospital.
This time we’re talking about Cholestasis with Drs. Helmrath and Wales.
Hosts: Cecilia Gigena & Ellen Encisco.
podcast15:25 · Jun 2023
If it becomes part of practice to order urine electrolytes at the time that someone's doing their TPN blood work, it's easy to calculate the fractional excretion of sodium ratio. — Paul Wales, CAPS - The use of urine sodium to creatinine ratio as a marker of total body sodium in infants with intestinal failure - Sara Choi · 7:12
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
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Audio Journal with Dr. Von Allmen about usingCorticosteroids After Hepatoportoenterostomy for Bile Drainage, Dr. Whit Holcomb aboutsurgical site infections (SSI) are an important source of morbidity and mortality.andfeasibility and safety o
podcast44:19 · Jan 2019
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
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Audio Journal with Dr. Von Allmen about using Corticosteroids After Hepatoportoenterostomy for Bile Drainage, Dr. Whit Holcomb about surgical site infections (SSI) are an important source of morbidity and mortality. and feasibility and safe
podcast44:19 · Dec 2020
CAPS - The use of urine sodium to creatinine ratio as a marker of total body sodium in infants with intestinal failure - Sara Choi
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Listen to Sara Choi gave her presentation of "The use of urine sodium to creatinine ratio as a marker of total body sodium in infants with intestinal failure" at the first ever Best of the Best in Pediatric Surgery event.Controlar el sodio
video8:40 · May 2022
Journal of Pediatric Surgery Article Review: June 2022, AAP Issue
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Here's the June 2022 issue of JPS article highlights. This time we're talking to Dr. Nicole Chandler and authors Drs. Elizabeth Beierle, Marcus Malek, Biren Modi, Amelia Collings and Katherine Flynn O'Brien.
Hosts: Ellen Encisco, Em Tomb
video15:54 · Sep 2022
Journal of Pediatric Surgery Article Review: June 2022, AAP Issue
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Here's the June 2022 issue of JPS article highlights. This time we're talking to Dr. Nicole Chandler and authors Drs. Elizabeth Beierle, Marcus Malek, Biren Modi, Amelia Collings and Katherine Flynn O'Brien.
Hosts: Ellen Encisco, Em Tomb
podcast15:54 · Sep 2022
Outcomes of Children With Short Bowel Syndrome: Experiences in a Multidisciplinary Intestinal Rehabilitation Unit Over Two Decades
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Jaime Tsz-wing Tsang, Adrian Chi-heng Fung , Stephen Cheuk-lam Lau,Kenneth Kak-yuen Wong
Background: Short bowel syndrome (SBS) is a rare but serious form of organ failure, and patients with SBS depend on total parenteral nutrition (PN)
video0:45 · Mar 2025
Impact of social determinants of health on outcomes in pediatric short bowel syndrome...
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This video discusses a retrospective cohort study from Cincinnati Children's, presented by Lizzy Lee, examining the impact of social determinants of health on outcomes for children with pediatric short bowel syndrome. The study found that f
video0:43 · Aug 2026
Patients should be referred to intestinal rehabilitation programs when not making progress, on prolonged TPN, or have significant comorbidities, preferably sooner rather than later. — Stephanie Oliveira, Advancements in Pediatric Intestinal Failure: Innovative Therapies and Improved Outcomes · 4:19
Intestinal Failure with Dr. Brad Warner
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Dr. Brad Warner discusses intestinal failure management in pediatric patients, covering diagnostic criteria, bowel length thresholds for survival, and long-term outcomes. Key topics include short bowel syndrome following necrotizing enteroc
podcast52:46 · Jan 2019
Intestinal Failure with Dr. Brad Warner
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Discussion with Dr. Brad W. Warner about intestinal failureWhat is intestinal failure?An umbrella term for when the small bowel is unable to digest and absorb an adequate amount of nutrients to sustain a patient through enteral means alone.
podcast52:46 · Dec 2020
Intestinal Rehabilitation Webinar 2023 - Top 5 Key Takeaways
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In November 2023 we held the first Intestinal Rehabilitation webinar with Dr. Paul Wales & Dr. Michael Helmrath, 2 experts from the Intestinal Rehab center at Cincinnati Children's.
These are the top 5 key takeaways from this webinar!!
video12:14 · Jun 2024
Advancements in Pediatric Intestinal Failure: Innovative Therapies and Improved Outcomes
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This podcast from Cincinnati Children's Hospital Medical Center explores the definition, causes, and management of pediatric intestinal failure, emphasizing advancements in treatment. Dr. Stephanie Bachi de Castro Oliveira and Dr. Paul W. W
video17:45 · Aug 2026
Reliance on total parenteral nutrition (TPN) and travelling abroad
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Intestinal failure in children: Reliance on total parenteral nutrition (TPN) and travelling abroad - An ERNICA animation for patients and families
Click here to access the tool and find out more information: https://www.ern-ernica.eu/int
video1:42 · Dec 2023
Patients who transitioned to adult care showed no obvious differences in medical complexity or disease burden compared to those who remained in pediatric care — Julian Goddard, Care transition from a pediatric intestinal rehabilitation program to adult care and the risk of all-cause mortality: A retrospective cohort study · 0:29
Care transition from a pediatric intestinal rehabilitation program to adult care and the risk of all-cause mortality: A retrospective cohort study
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Gillian R Goddard, Stephanie Oliveira, Crystal Slaughter, Kim Klotz, Marilyn Stoops, Julie Schletker, Jackie Wessel, Michael Helmrath, Samuel Kocoshis, Monique Goldschmidt, Paul W WalesBackground: As patients with intestinal failure reach a
video1:01 · May 2026
Common questions
What did Paul Wales say about Intestinal Failure?
Dr. Wales defined intestinal failure as a functional problem where gut function is insufficient to absorb enough nutrients, fluids, and calories to support survival and, in children, growth. He noted that until recently there was no standardized definition for the condition. Dr. Wales identified that causes of intestinal failure can be divided into three categories, though some patients present with elements of two or all three categories. He also described intermediate and longer-term complications including intestinal failure-associated liver disease, recurrent sepsis, and line problems.
Sources
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation? 2:03
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation? 4:39
Intestinal rehabilitation: What is intestinal rehab? - Episode 1 7:11
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1 4:44
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Intestinal failure (IF) is defined as insufficient gut function requiring parenteral nutrition (PN) for ≥60 days [e296-c1, e4741-c2]. Short bowel syndrome—most commonly from necrotizing enterocolitis, gastroschisis, volvulus, or atresia—accounts for the majority of pediatric IF [e296-c10, e4741-c4, e4741-c5]. Survival in modern intestinal rehabilitation programs now exceeds 90%, with 60–80% achieving enteral autonomy [e5141-c18, e5141-c19, e10183-c8]. Residual bowel length remains predictive, but the 50% autonomy threshold has shifted from 30–40 cm (2001) to 10–20 cm (2014) . Preserved ileum and colon confer the greatest adaptive advantage via GLP-2 secretion, bile reclamation, and short-chain fatty acid production [e4993-c7, e4993-c8, e5141-c10, e5141-c27]. Necrotizing enterocolitis patients paradoxically fare best, likely because enteral feeding was established before disease onset [e929-c25, e5141-c30, e10183-c12]. Multidisciplinary teams, lipid-sparing strategies (SMOF at 2–2.5 g/kg/day), aggressive enteral feeding, and ethanol/EDTA line locks have driven dramatic reductions in IF-associated liver disease and catheter sepsis [e1036-c1, e1036-c8, e6734-c5, e6734-c11, e6734-c12, e13892-c12, e13892-c13]. Teduglutide (GLP-2 analog, 0.05 mg/kg/day) produces ≥20% PN reduction in 69% of children and complete autonomy in 10% [e6180-c8, e6180-c9, e13892-c42]. Surgical lengthening (STEP, Bianchi) is reserved for patients plateaued on maximal medical therapy with dilated bowel (≥4–5 cm); early procedures in the first year often fail because motility has not matured [e927-c23, e927-c26, e5909-c19, e10183-c47]. Intestinal transplant—now indicated primarily for end-stage liver disease or unreconstructable anatomy—carries 5-year survival of ~65%, inferior to rehabilitation (>90%) [e927-c43, e10271-c12, e10271-c13, e13892-c46].
- Modern intestinal rehabilitation achieves >90% survival and 60–80% enteral autonomy; the 50% autonomy threshold dropped from 30–40 cm to 10–20 cm residual bowel over the past decade.
- Preserved ileum and colon are the strongest anatomic predictors of autonomy via GLP-2 secretion, bile reclamation, and colonic short-chain fatty acid production.
- SMOF lipid at 2–2.5 g/kg/day prevents cholestasis without essential fatty acid deficiency; soybean lipid >2.5 g/kg/day increases liver disease risk 3% per day.
- Teduglutide 0.05 mg/kg/day produces ≥20% PN reduction in 69% of children; fluid reclamation is the primary mechanism, requiring concurrent enteral nutrition.
- STEP/Bianchi should be deferred until patients plateau on maximal medical therapy; early lengthening in the first year often fails due to immature motility.
For patients & families
Intestinal failure happens when the small intestine cannot absorb enough nutrition or fluids to keep a child growing and healthy. Doctors often see this in babies born with conditions like gastroschisis or necrotizing enterocolitis, or after surgery removes part of the bowel. [e4741-c5, e4741-c6] When a child has intestinal failure, they need nutrition delivered through a vein—called parenteral nutrition or TPN—because their gut cannot do the job alone. [e7654-c13, e7654-c14] The good news: survival rates have improved dramatically. Today, more than 90% of children in specialized intestinal rehabilitation programs survive long-term. [e4741-c20, e10183-c4] About half of these children eventually learn to eat and drink enough on their own to stop TPN completely—a milestone called enteral autonomy. The bowel has a remarkable ability to adapt over time, especially in young children, and feeding the gut—even small amounts—helps that healing happen. [e5141-c2, e5141-c3] Breast milk, when available, offers unique benefits beyond nutrition. [e296-c15, e7209-c4] Specialized teams—surgeons, dietitians, nurses, and others—work together to prevent complications like liver disease and line infections, which used to be much more common. [e927-c47, e13892-c12] Newer treatments, including a medication called teduglutide, can help some children absorb more and need less TPN. [e6180-c8, e6180-c9] While the journey is long and requires frequent hospital visits, many families report their child's quality of life exceeds what they feared at diagnosis.
Intestinal failure happens when the small intestine cannot absorb enough nutrition or fluids to keep a child growing and healthy. Doctors often see this in babies born with conditions like gastroschisis or necrotizing enterocolitis, or after surgery removes part of the bowel. [e4741-c5, e4741-c6] When a child has intestinal failure, they need nutrition delivered through a vein—called parenteral nutrition or TPN—because their gut cannot do the job alone. [e7654-c13, e7654-c14] The good news: survival rates have improved dramatically. Today, more than 90% of children in specialized intestinal rehabilitation programs survive long-term. [e4741-c20, e10183-c4] About half of these children eventually learn to eat and drink enough on their own to stop TPN completely—a milestone called enteral autonomy. The bowel has a remarkable ability to adapt over time, especially in young children, and feeding the gut—even small amounts—helps that healing happen. [e5141-c2, e5141-c3] Breast milk, when available, offers unique benefits beyond nutrition. [e296-c15, e7209-c4] Specialized teams—surgeons, dietitians, nurses, and others—work together to prevent complications like liver disease and line infections, which used to be much more common. [e927-c47, e13892-c12] Newer treatments, including a medication called teduglutide, can help some children absorb more and need less TPN. [e6180-c8, e6180-c9] While the journey is long and requires frequent hospital visits, many families report their child's quality of life exceeds what they feared at diagnosis.
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Expert statements from the recordings in this collection.
Advancements in Pediatric Intestinal Failure: Innovative Therapies and Improved Outcomes
Intestinal failure is defined as the reduction of functioning intestinal mass below that which can sustain life, resulting in dependence on supplemental parenteral support for a minimum of 60 days within a 74 consecutive day interval.
clinicalStephanie Oliveira0:26 ↗
More than 50% of intestinal failure cases are related to short bowel syndrome, with additional cases from mucosal enteropathies and dysmotility disorders.
epidemiologicalStephanie Oliveira0:43 ↗
Most causes of short bowel syndrome in pediatrics occur during the neonatal period, including gastroschisis, necrotizing enterocolitis, bowel atresia, and intestinal volvulus.
clinicalStephanie Oliveira0:55 ↗
The field is now focusing on neurocognitive outcomes, quality of life, and caregiver burnout as more children survive intestinal failure.
opinionStephanie Oliveira1:18 ↗
Chronic intestinal inflammation resembling Crohn's disease is now being observed in intestinal failure patients, requiring management with inflammatory bowel disease therapies like biologics.
Host summaryLizzie Lee summarizing the discussion — not the host's own clinical position1:24 ↗
The cause of chronic intestinal inflammation in intestinal failure survivors is not known.
clinicalStephanie Oliveira1:37 ↗
Intestinal rehabilitation treatment strategy lacks clear-cut guidelines because every patient is unique with different gestational age, bowel resection, anatomy, and comorbidities.
clinicalStephanie Oliveira1:48 ↗
The goal of intestinal rehabilitation is to optimize intestinal function and adaptation before the development of irreversible complications.
clinicalStephanie Oliveira2:07 ↗
Intestinal adaptation is an active compensatory process that starts immediately after bowel resection.
clinicalStephanie Oliveira2:30 ↗
Food, bacteria, and hormones in the gut are important factors that enhance intestinal adaptation.
clinicalStephanie Oliveira2:42 ↗
Enteral autonomy is defined as getting off TPN with all nutrition going to the gut, either by mouth or by feeding tube.
clinicalStephanie Oliveira3:11 ↗
A 2012 Pediatric Intestinal Failure Consortium study showed 50% of intestinal failure patients achieved enteral autonomy, while 25% either died or had intestinal transplant.
Host summaryLizzie Lee summarizing the discussion — not the host's own clinical position3:19 ↗
From 2010 to 2015, a repeat study with double the number of patients showed approximately 50% still reached enteral autonomy, but the number of transplants and deaths significantly decreased.
epidemiologicalStephanie Oliveira3:33 ↗
The establishment of multidisciplinary teams is one factor that changed outcomes in intestinal failure.
clinicalStephanie Oliveira3:46 ↗
Studies from Canada, Michigan, and Spain show that multidisciplinary intestinal rehabilitation teams improve survival.
Host summaryLizzie Lee summarizing the discussion — not the host's own clinical position3:51 ↗
Predictors of reaching enteral autonomy include residual bowel length (more is better), follow-up at an institution with an intestinal rehabilitation program, and no STEP procedure.
clinicalStephanie Oliveira4:03 ↗
Patients should be referred to intestinal rehabilitation programs when not making progress, on prolonged TPN, or have significant comorbidities, preferably sooner rather than later.
guidelineStephanie Oliveira4:19 ↗
Patients should not be referred to intestinal rehabilitation when several irreversible complications have already occurred and transplant is the only remaining option.
guidelineStephanie Oliveira4:39 ↗
Intestinal transplantation is considered when there are irreversible complications, though the number of transplants has significantly decreased over the last several decades.
clinicalStephanie Oliveira4:49 ↗
Liver disease associated with intestinal failure ranges from mild cholestasis to profound steatosis (in older children/adolescents/adults), with progression through inflammation, fibrosis, and ultimately cirrhosis leading to death or transplantation.
clinicalPaul Wales5:23 ↗
Risk factors for intestinal failure-associated liver disease include prematurity, lack of enteral feeding, inability to feed due to anatomy, recurrent infections/sepsis, and components of TPN.
clinicalPaul Wales5:41 ↗
The term 'intestinal rehabilitation program' was coined in the year 2000.
clinicalPaul Wales6:08 ↗
Intestinal rehabilitation teams improve outcomes through integration of care, improved communication, and better continuity.
clinicalPaul Wales6:12 ↗
Intestinal rehabilitation programs rely heavily on speech, language, and occupational therapy specialists.
clinicalPaul Wales6:34 ↗
While patients are on TPN, the goal is to mitigate progression of liver disease, sepsis, and vascular complications.
clinicalPaul Wales6:38 ↗
Families of intestinal failure patients manage significant tasks at home including running TPN pumps, adding vitamins, programming pumps, recording ins and outs, managing G-tubes, and managing stomas.
clinicalPaul Wales6:54 ↗
High-quality families demonstrate evidence of burnout over time despite education and empowerment efforts.
clinicalPaul Wales7:11 ↗
Literature shows intestinal rehabilitation programs improve survival related to liver dysfunction, decrease septic episodes, reduce central line complications, reduce ICU admissions, and enable patients listed for transplant to come off the list due to improved status.
epidemiologicalPaul Wales7:25 ↗
Mortality in intestinal failure has decreased with intestinal rehabilitation programs.
epidemiologicalPaul Wales7:43 ↗
Lipids in parenteral nutrition are a source of essential fatty acids, a non-protein energy source important for growth, and fatty acids have a major role in cellular pathways.
clinicalPaul Wales8:02 ↗
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