Operation Stork Speed was launched to modernize infant formula oversight after 2022 shortages and other evidence of supply chain and safety issues. Current Food and Drug Administration (FDA) processes to regulate formulas are at times slow and complex, making it difficult for new formulas to enter the market. One key pathway to adding bioactive substances or other compounds to infant formula is via the generally recognized as safe (GRAS) route. GRAS and food additive pathways require safety data, but food additive petitions require more safety information and cannot be marketed until FDA approval is granted. Concern has been expressed about the safety of the formula related to the possible presence of toxic substances in the formula. Heavy metals, perfluoroalkyl and polyfluoroalkyl substances, and other toxins can be found in formulas, and infants can be at increased risk of effects. United States lacks enforceable limits, unlike the European Union, Canadian, and Australian counterparts. To enhance the regulatory environment for infant formula, legislative updates, supply chain transparency, and alignment with global safety standards are needed.

Operation Stork Speed was launched to modernize infant formula oversight after 2022 shortages and other evidence of supply chain and safety issues. Current Food and Drug Administration (FDA) processes to regulate formula are at times slow and complex, making it difficult for new formulas to enter the market. One key pathway to adding bioactive substances or other compounds to infant formula is via the Generally Recognized as Safe (GRAS) route. GRAS and food additive pathways require safety data, but food additive petitions require more safety information and cannot be marketed until FDA approval is granted. Concern has been expressed about the safety of formula related to the possible presence of toxic substances in formula. Heavy metals, PFAS and other toxins can be found in formulas and infants can be at increased risk of effects. US lacks enforceable limits, unlike EU, Canadian and Australian counterparts. To enhance the regulatory environment for infant formula, legislative updates, supply chain transparency and alignment with global safety standards are needed.

The United States formula industry uses aggressive marketing strategies that exploit parental anxieties, undermine breastfeeding, and violate ethical international standards, all of which contribute to early formula introduction and disparities in breastfeeding. In addition, misleading or complex labeling contributes to caregiver and provider confusion regarding the content of formulas. A centralized, Food and Drug Administration-maintained database of infant formulas could support caregivers and healthcare professionals in countering misinformation and making evidence-based decisions. Human milk remains the reference standard for infant nutrition, with strong evidence supporting its role in reducing morbidity and mortality, especially in the neonatal intensive care unit (NICU). Despite this, disparities persist in breastfeeding rates, particularly among Black and Hispanic mothers. These are driven by structural barriers, including lack of paid parental leave and inadequate lactation support. Donor human milk (DHM) is the recommended alternative for high-risk infants in the NICU when the mother's own milk is unavailable. However, due to lack of federal funding and oversight, high cost and inconsistent insurance coverage, the use of DHM is limited, especially in safety-net hospitals. Specialized hypoallergenic and metabolic formulas are essential for managing medical conditions including cow's milk-protein allergy and inborn errors of metabolism. These are regulated as exempt formulas but must meet rigorous clinical standards. In the NICU, adequate early nutrition for preterm infants is crucial to reduce morbidity and mortality and improve long-term neurodevelopmental outcomes. Human milk fortifiers are composed of similar ingredients to infant formula and are used to improve the nutritional content of feedings given in the NICU and postdischarge. The use of live bio therapeutic products or probiotics as additives to preterm infants has been demonstrated in multiple studies to reduce the incidence of necrotizing enterocolitis, late-onset sepsis, and all-cause mortality.

Operation Stork Speed, launched by the Food and Drug Administration in March 2025, represents a comprehensive initiative to update infant formula regulations that have remained largely unchanged since the 1980s. This expert panel review addresses recommendations for nutrients considering 4 decades of accumulated scientific evidence. Current Food and Drug Administration fatty acid regulations specify only total fat content and minimum linoleic acid requirements, despite substantial international consensus on polyunsaturated fatty acid specifications. Evidence strongly supports establishing maximum linoleic acid concentrations and docosahexaenoic acid and arachidonic acid requirements, reflecting the critical role of omega-3 (ω-3) fatty acids in neurocognitive development and visual acuity. The panel emphasizes that saturated and monounsaturated fatty acids comprise over 80% of human milk fatty acids, while acknowledging recent concerns about seed oils and supporting balanced PUFA formulations. Carbohydrate composition presents significant concerns, as over half of United States formulas contain glucose polymers (e.g., corn syrup solids) despite lactose being the primary carbohydrate energy source in human milk. Observational studies have linked corn syrup-based formulas to multiple potential health risks, including excess weight gain, warranting reconsideration of the value of non-lactose carbohydrate substitutions in formulas for healthy children. Protein content recommendations support decreasing the upper range of allowable intake, aligning with European standards and addressing concerns about excessive protein intake contributing to later obesity risk. Micronutrient evaluation reveals the need to reduce the iron content in routine formulas, consistent with European Food Safety Authority recommendations and emerging safety data, and a need to set upper limits for the concentration of calcium and phosphorus. Overall, infant formula is a healthy product that has been successfully feeding infants for many decades. These comprehensive updates aim to more closely align United States infant formula regulations with current scientific understanding and international standards while supporting optimal infant growth, development, and long-term health outcomes.

Adults undergoing hematopoietic cell transplantation often develop serious complications that cause rapid nutritional decline. We developed and evaluated an AI approach to standardize intravenous nutrition (total parenteral nutrition, TPN) during this vulnerable period. Using real-world records from Stanford Health Care (6402 transplants, 2008-2025), we analyzed 1473 adults who received TPN, totaling 27,447 patient-days, linking each day's clinical state to the next day's prescription. We created a library of 30 standardized TPN regimens and trained a model to recommend next-day dose adjustments based on laboratory data and the existing prescription. (Pearson r ≈ 0.71). We then assessed an AI policy learned from past care and found that the Reinforcement learning agent selected dose adjustments with a higher composite score than the existing clinical policy. These results show that AI-guided TPN is feasible and may enhance bedside decision-making for adult transplant care, warranting prospective evaluation.

Operation Stork Speed, launched by the Food and Drug Administration (FDA) in March 2025, represents a comprehensive initiative to update infant formula regulations that have remained largely unchanged since the 1980’s. This expert panel review addresses recommendations for nutrients considering four decades of accumulated scientific evidence. Current FDA fatty acid regulations specify only total fat content and minimum linoleic acid requirements despite substantial international consensus on polyunsaturated fatty acid specifications. Evidence strongly supports establishing maximum linoleic acid levels and docosahexaenoic acid (DHA) and arachidonic acid (ARA) requirements, reflecting the critical role of omega-3 fatty acids in neurocognitive development and visual acuity. The panel emphasizes that saturated and monounsaturated fatty acids comprise over 80% of human milk fatty acids, while acknowledging recent concerns about seed oils and supporting balanced PUFA formulations. Carbohydrate composition presents significant concerns, as over half of US formulas contain glucose polymers (e.g. corn syrup solids) despite lactose being the primary carbohydrate energy source in human milk. Observational studies have linked corn syrup-based formulas to multiple potential health risks, including excess weight gain, warranting reconsideration of the value of non-lactose carbohydrate substitutions in formulas for healthy children. Protein content recommendations support decreasing the upper range of allowable intake, aligning with European standards and addressing concerns about excessive protein intake contributing to later obesity risk. Micronutrient evaluation reveals the need to reduce the iron content in routine formulas, consistent with European Food Safety Authority recommendations and emerging safety data and a need to set upper limits for the concentration of calcium and phosphorus. Overall, infant formula is a healthy product that has been successfully feeding infants for many decades. These comprehensive updates aim to more closely align US infant formula regulations with current scientific understanding and international standards while supporting optimal infant growth, development, and long-term health outcomes.

One in ten neonates are admitted to neonatal intensive care units, highlighting the need for precise interventions. However, the application of artificial intelligence (AI) in guiding neonatal care remains underexplored. Total parenteral nutrition (TPN) is a life-saving treatment for preterm neonates; however, implementation of the therapy in its current form is subjective, error-prone and resource-consuming. Here, we developed TPN2.0—a data-driven approach that optimizes and standardizes TPN using information collected routinely in electronic health records. We assembled a decade of TPN compositions (79,790 orders; 5,913 patients) at Stanford to train TPN2.0. In addition to internal validation, we also validated our model in an external cohort (63,273 orders; 3,417 patients) from a second hospital. Our algorithm identified 15 TPN formulas that can enable a precision-medicine approach (Pearson’s R = 0.94 compared to experts), increasing safety and potentially reducing cost. A blinded study (n = 192) revealed that physicians rated TPN2.0 higher than current best practice. In patients with high disagreement between the actual prescriptions and TPN2.0, standard prescriptions were associated with increased morbidities (for example, odds ratio = 3.33; P value = 0.0007 for necrotizing enterocolitis), while TPN2.0 recommendations were linked to reduced risk. Finally, we demonstrated that TPN2.0 employing a transformer architecture enabled guideline-adhering, physician-in-the-loop recommendations that allow collaboration between the care team and AI. An artificial intelligence model defines a data-driven set of total parenteral nutrition compositions to assist clinicians in personalized treatment of neonates in intensive care and is able to adapt recommendations to patient status, with validation from large external cohorts and a blinded reader study.

Vitamin A is a fat-soluble vitamin that plays an important role in immune function, vision, and growth. We analyzed serum-free retinol deficiency in pediatric patients with intestinal failure (IF) or short bowel syndrome (SBS) to determine which clinical factors contribute to vitamin A deficiency in this population. A single-center, retrospective review of 32 children with IF or SBS was conducted examining 6 categorical classifications of patients to test for increased risk of vitamin A deficiency, building a univariate logistic regression model for each category. Few serum assessments were consistent with deficiency (11 out of 347 tests obtained over 153 patient-years). Among these 11 low levels occurring in three patients, 6 were borderline or nearly normal for age and without associated symptoms, and 4 were obtained from one patient with significant ileal inflammation in the context of a STAT1 mutation. One level was obtained in one patient without a corresponding C-reactive protein level, and this patient had 23 subsequently normal serum-free retinol levels. In this small sample size, no patients were symptomatic. In patients who had at least 1 vitamin A test during the prior year without any deficient measurements, there was a 1.3

Background: It is well known that small bowel length is a dominant prognostic indicator inpatients with short bowel syndrome (SBS). The relative importance of jejunum, ileum, and colon is less well defined in children with SBS. Here we review the outcome of children with SBS with respect to the type of remnant intestine.Methods: A retrospective review of 51 children with SBS was conducted at a single institution. The duration of parenteral nutrition use was the main outcome variable. The length of the remaining intestine as well as the type of intestine were recorded for each patient. Kaplan-Meier analyses were conducted to compare the subgroups.Results: Children with greater than 10% expected small bowel length or more than 30 cm of small bowel achieved enteral autonomy faster than those with less. The presence of ileocecal valve enhanced the ability to wean from parenteral nutrition. The presence of ileum significantly enhanced the ability to wean from parenteral nutrition. Patients with the entire colon also achieved enteral autonomy sooner than those with partial colon.Conclusions: The preservation of ileum and colon is important in patients with SBS. Approaches to preserve or lengthen ileum and colon may be beneficial for these patients. Level of evidence: IV.

INTRODUCTION Factitious disorder imposed on another, or Munchausen by proxy (MSP), is the fabrication of symptoms by a caregiver imposed on another to promote medical interventions for self-fulfillment (1). Thiamine deficiency (TD) in total parenteral nutrition (TPN)-dependent children has only been seen in the United States during intravenous multivitamin infusion (MVI) shortages (2), outside of the United States where MVIs were not administered with TPN (3), and unintentional human error corrected with caregiver reeducation (4,5). We present the first known case of TD in a TPN-dependent child as evidence for MSP. CASE REPORT A 9-year-old female was exclusively TPN-dependent due to caregiver-reported feeding intolerance and presumed dysmotility. Her complex medical history included chronic pain with opioid dependence. She had previous extensive diagnostic workup at 8 different facilities, including unremarkable endoscopies, whole exome/mitochondrial sequencing, and immunodeficiency testing. No motility studies were performed. She had several surgeries: gastrojejunostomy tube placement, diverting end ileostomy for frequent fecal impactions, splenectomy, thymectomy, and cholecystectomy. She had recurrent hospitalizations for unexplained acute loss of ambulation with wheelchair dependence and episodes of severe lactic acidosis with coagulopathy attributed to infectious etiologies despite negative pan-cultures. These episodes resolved with hydration, TPN, vitamin K, and antibiotics. She presented with minimal responsiveness and shock physiology. She had severe lactic acidosis, hyperglycemia, hypokalemia, hyperammonemia, and elevated international normalized ratio. Renal function, thyroid function, toxicology, infectious evaluation, and lumbar puncture were unremarkable (Table 1). Electrocardiogram demonstrated prolonged QT interval (530 milliseconds). Echocardiogram was normal; electroencephalogram did not identify subclinical seizures. Brain magnetic resonance imaging with spectroscopy demonstrated signal abnormalities in the bilateral frontal cortex, hippocampus, putamen, and thalamus (Fig. 1). Single-voxel brain magnetic resonance spectroscopy demonstrated no lactate doublet (typically seen at 1.3 parts per million chemical shift); a nonspecific slightly elevated choline level was identified in the left internal capsule/basal ganglia junction (3.2 mm chemical shift) (Fig. 2) (6). Table 1. - Laboratory Values at Presentation Laboratory Markers (Units) Normal Range Laboratory Value at Presentation pH 7.320–7.420 7.052 Partial pressure of carbon dioxide (mm Hg) 40–50 27.1 Lactate (mmol/L) <2.0 30 Thiamine (nmol/L) 70–180 32 White blood cell (thousand [k]/uL) 4.5–13.5 46.8 Hemoglobin (g/dL) 11.5–15.5 12.9 Platelets (thousand/uL) 150–400 380 Procalcitonin (mg/mL) <0.5 1.08 Sodium (mmol/L) 135–145 142 Potassium (mmol/L) 3.5–5.5 2.8 Magnesium (mg/dL) 1.7–2.1 2.2 Phosphorous (mg/dL) 3.1–5.5 4.3 Calcium (mg/dL) 8.8–10.8 10.4 Bicarbonate (mmol/L) 22–29 8 Anion gap (mmol/L) 5–15 31 Glucose (mg/dL) 70–100 229 INR (none) 0.9–1.2 1.9 Ammonia (umol/L) 11–35 52 Urinalysis 1+ blood, rare bacteria Blood urea nitrogen (mg/dL) 7–20 32 Creatinine (mg/dL) 0.2–0.73 0.34 INR = international normalized ratio; PCO2 = partial pressure of carbon dioxide. FIGURE 1.: MRI brain imaging of patient. Multiple axial T2 FLAIR-weighted brain MR images demonstrate symmetric areas of signal abnormality in the frontal cortical (A, white arrows), putamen (B–C, white arrows), posteromedial thalami (B–C, white arrowheads), hippocampi (D, white arrowheads), and tectum/periaqueductal gray (D, white arrow). Multiple axial diffusion-weighted brain MR images demonstrate symmetric areas of restricted diffusion corresponding to T2 FLAIR signal abnormalities in the frontal cortical (E, white arrows), putamen (F–G, white arrows), posteromedial thalami (F–G, white arrowheads), hippocampi (G–H, white arrowheads), and tectum/periaqueductal gray (H, white arrow). FLAIR = fluid-attenuated inversion recovery; MR = magnetic resonance.FIGURE 2.: Axial T2-weighted brain MR images with single-voxel 1H-MRS. A, Spectroscopy voxel centered at the left temporal white matter shows a normal spectrum, which includes the progressively ascending metabolites choline (3.2 mm ppm chemical shift), creatine (3.0 mm ppm chemical shift), and NAA (2.0 mm ppm chemical shift). B, Spectroscopy voxel centered at the left internal capsule/basal ganglia junction shows an elevated choline level at 3.2 mm chemical shift (white arrowhead). 1H-MRS = proton magnetic resonance spectroscopy; MR = magnetic resonance; NAA = N-acetyl aspartate; ppm = parts per million.When her neurological status improved, she was noted to have intermittent vertical nystagmus/saccadic eye movements and abnormal gait, prompting discovery of a low thiamine level. Diagnosed with TD, she improved with fluid resuscitation, electrolyte repletion, vitamin K supplementation, and a 5-day course of intravenous thiamine (100 milligrams daily). Her thiamine levels remained stable within normal limits 1 month after replacement; her eye/gait abnormalities resolved. Her coagulopathy resolved with vitamin K. Comprehensive vitamins and trace minerals levels 2 weeks after presentation were unremarkable. Retrospective review of prior hospitalizations for recurrent lactic acidosis and coagulopathy were attributed to thiamine and vitamin K deficiency despite prescribed MVI with her home TPN. Given her unusual symptoms and extensive unremarkable workup, a multidisciplinary team of pediatricians, pediatric gastroenterologists, neurologists, psychiatrists, social workers, nurses, and a child abuse expert relayed concern of MSP and provided expert testimonial to child protective services. This led to the patient’s removal from the caregiver’s custody. The patient’s symptomatology resolved after separation. She no longer requires TPN, ambulates well without a wheelchair, and has no active clinical concerns. DISCUSSION The differential diagnosis for severe lactic acidosis includes metabolic disorders, tissue hypoperfusion, infection, and rarely TD (7). Our patient’s TD diagnosis was based on abnormal neurologic symptoms, brain imaging, low serum thiamine level, and clinical status improvement after restarting prescribed MVI with additional thiamine. Nystagmus, gait disturbances, and altered mental status comprise the classic triad of Wernicke encephalopathy, which is seen in 21% of children with TD, and was demonstrated in our patient (3). Our patient did not have cardiac manifestations of TD (wet beriberi), such as dilated cardiomyopathy and high-output congestive heart failure. Her laboratory workup was consistent with abnormalities observed in TD: severe lactic acidosis, hyperglycemia, electrolyte disturbances (3), and hyperammonemia (2). An erythrocyte transketolase activation assay, which can aid in diagnosis, was not obtained. Our patient’s brain imaging was consistent with previously reported cases of TD (Fig. 1). Encephalitis/infection and to a lesser extent hypoxic-ischemic encephalopathy may demonstrate overlapping magnetic resonance features, although this was not supported by the clinical presentation (6). Most importantly, our patient’s clinical condition stabilized with thiamine replacement and correct use of prescribed TPN. TD in TPN-dependent children has been reported in patients with a known lack of MVI, such as nationwide shortages (2), and in global areas where MVI is not used as standard of care (3). There have been 2 reported cases of TPN-dependent (with prescribed MVI) children who developed TD, attributed to human error and corrected with caregiver reeducation (4,5). Our patient’s TD and vitamin K responsive coagulopathy with prior similar presentations were suspicious for purposeful avoidance of MVI administration. This case highlights red flags that should raise suspicion for MSP: unusual symptoms, extensive medical history without validation from diagnostic procedures, frequent changes of medical locations due to caregiver’s dissatisfaction, and illnesses with no identifiable cause (1). Our patient’s caregiver had characteristics of an MSP perpetrator: female gender, knowledgeable of the medical system, seldom away from the abused child, and close connections with staff (1). A multidisciplinary team reviewed the patient’s clinical history and provided effective guidance for acute therapeutic intervention. The team was essential in providing expert testimonial, resulting in the patient’s removal from caregiver’s custody and subsequent resolution of symptoms. Pediatric gastroenterologists are consulted in up to two-thirds of MSP cases (8). Common MSP presentations in gastroenterology are nausea, abdominal pain, and TPN dependence (1). The development of TD in a TPN-dependent child with prescribed MVI is unusual and should raise suspicion for noncompliance or MSP. Prompt recognition of MSP is essential and should be addressed swiftly by a multidisciplinary team, which can aid with faster evidence discovery, earlier therapeutic intervention, and improved patient outcomes. ACKNOWLEDGMENTS The authors thank Colleen Nespor and Kristine Laguit.

OBJECTIVES:Unnecessary use of antibiotics is an increasing problem. In this study, we sought to determine the diagnostic accuracy of procalcitonin in predicting bacteremia in children with a central line and fever, and we sought to determine optimal cutoff values to maximize sensitivity and specificity. This is the largest study to date in which procalcitonin is examined as a predictive marker of bacteremia in pediatric patients with a central line and fever.METHODS:We conducted a retrospective cohort study of children aged 0 to 23 years with a central line and fever of 38°C who had procalcitonin and blood cultures drawn before initiation of antibiotics and had no other identified bacterial infection. Patients were also prospectively monitored via a custom-built electronic medical record dashboard for eligibility.RESULTS:There were 523 patients and >2500 procalcitonin values reviewed for eligibility. Of these, 169 (47%) patients and 335 blood cultures with procalcitonin were included. There were 94 (28%) positive bacterial blood cultures and 241 (72%) negative bacterial blood cultures. In bacteremic cultures, the mean procalcitonin level was 9.96 ± 15.96 ng/mL, and the median procalcitonin level was 4.85 ng/mL (interquartile range 18.5). In nonbacteremic cultures, the mean procalcitonin level was 1.23 ± 10.37 ng/mL, and the median procalcitonin level was 0.3 ng/mL (interquartile range 0.7). A receiver operating characteristic analysis indicated a procalcitonin level of ≥0.6 ng/mL as the best cutoff point that produced a sensitivity of 85.6% and a specificity of 65.7% (area under the curve 0.85).CONCLUSIONS:Procalcitonin is a sensitive biomarker in predicting bacteremia in children with a central line and fever.

BACKGROUND:Children with short bowel syndrome (SBS) receiving home parenteral nutrition (HPN) are predisposed to ambulatory central line-associated bloodstream infection (A-CLABSI). Data describing risk factors of this infection in children are limited.METHODS:Retrospective cohort, single-center, case-crossover study of children ≤18 years old with SBS receiving HPN from January 2012 to December 2016. Univariate and multivariate mixed effect Poisson regression identified the relative risk (RR) of A-CLABSI with proposed risk factors.RESULTS:Thirty-five children were identified; median follow-up was 30 months. A-CLABSI rate was 4.2 per 1000 central line (CL) days. Univariate analysis identified younger age (RR: 0.92 per 12-month increase [95% confidence interval {CI}: 0.85-0.99; P = 0.036]), shorter small intestine length (RR: 0.96 per 10-cm increase [95% CI: 0.92-0.99; P = 0.008]), lower citrulline level (RR: 0.86 per 5-nmol/mL increase [95% CI: 0.75-0.99; P = 0.036]), and recent CL break (RR: 1.55 [95% CI: 1.06-2.28; P = 0.024]) as risk factors for A-CLABSI. Multivariate analysis showed increased A-CLABSI with clinical diagnosis of small intestine bacterial overgrowth (SIBO) (RR: 1.87 [95% CI: 1.1-3.17; P = 0.021]) and CL breaks (RR: 1.49 [95% CI: 1-2.22; P = 0.024]).CONCLUSIONS:Factors influencing gut integrity increase A-CLABSI rate, supporting translocation as an important mechanism and target for prevention. Clinical diagnosis of SIBO increases A-CLABSI rate, but whether dysbiosis or diarrhea is responsible is an area for future research. CL maintenance is crucial, and prevention of breaks would likely decrease A-CLABSI rate.

Background: Pectin and other water-soluble fibers have been used in certain patients with short bowel syndrome. Fermented fibers may provide energy contribution via short chain fatty acids produced by colonic bacteria, while soluble fibers that retain a gel may improve the consistency of watery or loose stools and thus decrease stool output. At our institution, we aimed to study the effects of pureed green beans, a good source of pectin, given in a reliable and easy manner, through a G-tube. Methods: Pureed green beans administered via syringe directly into the G-tube was prescribed in a handful of patients with short bowel syndrome. Dose of green beans was adjusted at regularly scheduled clinical visits. Patients and their stools were closely monitored. Results: Of the 71 intestinal rehabilitation patients at our center, 7 are currently receiving pureed green beans through G-tube. All patients experienced a decrease in stool frequency and 6 of them experienced improvement in stool consistency. Over half of the patients also tolerated a decrease in loperamide. Of the 6 patients receiving either TPN or IV hydration, 5 tolerated a decrease in the overall volume. One patient was weaned off of IV hydration fluids entirely. Please refer to Table 1. Conclusion: Overall, our cases highlight the improvement in stool frequency and consistency, TPN volume requirements, and loperamide administration following the administration of pureed green beans into a G-tube. For our patients with G-tubes and difficult to manage loose stools, the introduction of pureed green beans is now being considered more frequently. Potential future research may include: examining if higher doses of green beans increase the risk of malabsorption of certain nutrients (such as magnesium, zinc, and iron), monitoring the incidence of central line infections following stool normalization, and studying the effects of specific fibers or foods on the microbiome in patients with short bowel syndrome.

Following publication of the original article [1], the authors reported error on the images/figures used which also resulted in un-sequential order. The updated figures and captions are provided below.

Abstract Background Children with intestinal failure (IF) represent 20% of bloodstream infection (BSI) pediatric hospitalizations. We studied the microbiology and associated outcomes of this population. Methods Retrospective cohort study of children ≤18 years with IF dependent on parenteral nutrition (PN), with ≥1 BSI from January 2007 to December 2016. Organisms causing BSI were divided into skin or GI bacteria and fungi based on human habitat and kingdom. The impact of ethanol lock therapy (ELT) and clinical diagnosis of small intestine bacterial overgrowth (SIBO) on the type of these organisms was evaluated. Antimicrobial utilization and outcome measures for BSI were collected. Results There were 254 BSIs in 54 children resulting from GI bacteria (58%), skin bacteria (39%), and fungi (16%) with 11% containing >1 group. The proportion of skin bacteria was significantly higher on ELT (27% off vs. 45% on ELT; P = 0.003), while the proportion of GI bacteria was lower (67% off vs. 52% on ELT; P = 0.018). Significantly more fungal BSIs were seen in older children: mean age 4.2 years (95% CI: 2.9–5.5) vs. 2.7 years (95% CI: 2.3–3) with other organisms; P = 0.014. Fungal BSIs were more common with SIBO (18% vs. 5% with and without SIBO; P = 0.013). Twenty-eight organisms were resistant to ceftazidime, and five to cefepime. Hospitalization days totaled 2,432 (median 8 days), with 21 pediatric critical care admissions totaling 156 days. There were six deaths, none related to BSI, 18/54 children were weaned off PN, and four had liver and intestinal transplants. Median course of antimicrobial therapy was 14 days. Conclusion The majority BSIs in children resulted from GI bacteria, suggesting intestinal translocation; these infections were not less common in older children despite increased intestinal mass, signifying continued translocation. BSI with GI organisms was not more common in children with SIBO despite increased intestinal bacterial load, possibly due to antibiotic suppressive therapy, which instead lead to more fungal BSIs. Prevention of BSI by ELT was less effective for skin bacteria which may require different regimens or strategies. BSI causes frequent and prolonged hospitalizations including need for intensive care, but deaths are rare. Disclosures All authors: No reported disclosures.

Short bowel syndrome is a potentially devastating morbidity for the very low birth weight infant and family with a high risk for mortality. Prevention of injury to the intestine is the ideal, but, if and when the problem arises, it is important to have a systematic approach to manage nutrition, use pharmaceutical strategies and tools to maximize the outcome potential. Safely maximizing parenteral nutrition support by providing adequate macronutrients and micronutrients while minimizing its hepatotoxic effects is the initial postoperative strategy. As the infant stabilizes and starts to recover from that initial injury and/or surgery, a slow and closely monitored enteral nutrition approach should be initiated. Enteral feeds can be complemented with medications and supplements emerging as valuable clinical tools. Engaging a multidisciplinary team of neonatologists, gastroenterologists, pharmacists, skilled clinical nutrition support staff including registered dietitians and nutrition support nurses will facilitate optimizing each and every infant’s long term result. Promoting intestinal rehabilitation and adaptation through evidence-based practice where it is found, and ongoing pursuit of research in this rare and devastating disease, is paramount in achieving optimal outcomes.