250 Chapter 11 stoma, and there are only small reports with suggested treatment protocols specifically for premature born neonates.(15) The lack of sufficient sodium supplementation in our cohort is indicating the need for a clearly defined protocol for oral sodium supplementation in young children with a stoma. An important part of such a protocol is how to evaluate the true body sodium levels and what substrate to use. There are multiple possibilities opted, the best method of which is suggested to be a 24-hours urine collection.(15) This method is often too burdensome for young children who recently underwent surgery, and insertion of a urinary catheter would be required. Another suggested option is to make use of serum sodium.(15) However, venipuncture for diagnosis is the primary cause for neonatal anemia, and therefore regular determination of serum sodium is not recommended.(30) In practice, urinary sodium concentration measured from a spot urine sample is an acceptable, noninvasive and inexpensive method. Still, the question is what level of spot urine sodium reflects true sodium deficiency. It could be that a change in definitions, for instance only defining inadequate supplementation after three measurements ≤30 mmol/L, would prove a better reflection of the true sodium levels. This could explain why we could not find a correlation between adequate supplementation and positive growth and why it seemed that adequately supplemented children showed a trend towards lower Z-scores at closure than non-adequately supplemented children, although other explanations, such as delayed growth, might apply. Limitations of this study are the retrospective design which resulted in exclusion of a proportion of our cohort due to missing data regarding Z-scores. This might have led to selection bias, for instance due to over/under inclusion of certain types of diseases, and possibly type II errors, for instance in the evaluation of patients receiving early closure. Also, patients were not randomly assigned to receive certain treatments, such as early closure or major small bowel resection. This could have resulted in allocation bias, possibly influenced by factors such as disease severity or occurrence of stoma related complications. Moreover, weight measurement was all single measurement which could vary from day to day. Growth is a complex process affected directly or indirectly by a multitude of interrelated factors which is why it is hard to determine the exact etiology of growth impairment. Our results seem to show that growth decreases in the presence of a stoma, which in most patients is only reversed after stoma closure. It could be that other confounding factors, for instance diet, might explain at least some of these changes in growth. Lastly, due to the retrospective nature of this study, we were limited in the factors we could retrieve. There are, for instance, other manners of assessing nutritional status of patients such as weight for height and middle upper arm circumference and other factors that could influence weight such as fluid balance. We also could not retrieve information on refeeding, which has been opted to have a positive effect on growth in neonates, specifically prematures with low birthweight, treated with an intestinal stoma.(31)
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