249 Impact of presence, level and closure of a stoma on growth in young children Chapter 11 for early closure. In young children there is no consensus on the optimal timing of stoma closure. Some surgeons would wait for a safe weight (e.g. >2.5kg) to reduce the risk of surgery in a fragile patient.(22) Other, more recent studies report no significant difference in post-operative complications when a stoma is closed early (within 6 to 8 weeks), even with a low bodyweight.(18, 23) An argument against early closure is the assumed risk of adhesions which might result in a difficult operation. However, in patients treated for necrotizing enterocolitis, there was no difference in the presence of adhesions between early and late closure of stomas (24). Within our own cohort we could not provide evidence that early closure may also lead to higher Z-scores at closure compared to non-early closure. A reason could be that early closure in our cohort was mostly performed due to stoma complications, such as high-output or repeated prolapses, which might themselves have negatively influenced growth. Still, we showed that early closure results in the same amount of catch-up growth within a year following closure as in those non-early closed. Since early closure results in a significantly lower age at closure compared to non-early closure, we can at least say that it seems that early closure results in an early shift to catch-up growth gaining weeks of advantage. Besides growth impairment, other complications after stoma creation can occur such as surgical site infections and high output stomas.(3) Moreover, closing the stoma also leads to both short-term complications, such as anastomotic leakage, and long-term morbidity, such as adhesion related small bowel obstruction and incisional hernia.(12, 25) Taking into account the high risk of complications and the risk of growth impairment, one might consider performing primary anastomosis instead of stoma creation with a lower threshold. Primary anastomosis has been shown to be feasible in selected patients treated for necrotizing enterocolitis or intestinal atresia.(12, 26, 27) Some situations, such as bowel perforation or meconium peritonitis, might necessitate stoma creation, but the associated risk of morbidity should be taken into account when deciding on whether or not to create a stoma. In the presence of a stoma, oral sodium supplementation has been reported to improve weight gain.(14, 15, 28) Supplementation will counter the loss of sodium, which is partly excreted via stoma production, predominantly in small bowel stomas. However, sodium is also lost via renal excretion which is most prominent in premature born children.(29) This might explain why patients with a colostomy in this study were sometimes also found to be sodium depleted. Both the diagnosis and risk of sodium depletion in young children with a stoma are poorly understood. However, young children with a low urine sodium concentration (< 30 mmol/L) have been shown to gain significantly less weight than those with normal urine sodium levels.(19) We could not verify these results in our cohort. There are currently no guidelines for correct sodium supplementation in young children with a
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