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Fasting, feeding and regulation of the but warrant further validation. J Pediatr ; Pediatric Endocrinology and Postnatal control of water Inborn Errors of Metabolism. Acta nies, Inc; Paediatr Scand ; Dweck HS, Cassady G.
Glucose intolerance in infants of very low Comparison between birth weight, I: Incidence of hyperglycemia in infants of birth fraction excretions of urea and sodium in children with acute weights 1, grams or less. Pediatr ; Pediatr Nephrol ; Beardsall K, Dunger D. The physiology and clinical management Thurlbeck WM. Lung growth and development.
In: Thurlbeck of glucose metabolism in the newborn. Pathology of the Lung. New York: Thieme Medical Publishers; Body composition Growth ; Is surfactant therapy beneficial in the treatment of the term 5. Perinatal calcium metabolism: Physiology newborn infant with congenital diaphragmatic hernia?
J Pediatr and pathophysiology. Semin Neonatol ; Transient neonatal Surfactant does not hypocalcemia: Presentation and outcomes. Pediatrics ; improve survival rate in preterm infants with congenital diaphrag- e J Pediatr Surg ; Lung function in Parrillo JE. Septic shock in humans.
Advances in the understanding prematurely delivered rabbits treated with a synthetic surfactant. Ann Am Rev Respir Dis ; Intern Med ; Robertson B, Enhorning G. The alveolar lining of the premature Endotoxin determinations newborn rabbit after pharyngeal deposition of surfactant. Lab in patients with septic shock. Clin Res ;A. Invest ; Treatment of septic Surfactant for meco- shock with human monoclonal antibody HA-1A.
Cochrane double-blind, placebo-controlled trial. Database Syst Reviews Art. Ann Intern Med ; Seger N, Soll R. Animal derived surfactant extract for treatment of Anti-endotoxin respiratory distress syndrome.
Ann Surg ; 3 :Art. Soll R. Synthetic surfactant for respiratory distress syndrome in Treatment of gram- preterm infants. Cochrane Database Syst Reviews ; 3 :Art. A randomized, double-blind, Very early surfactant placebo-controlled trial. N Engl without mandatory ventilation in premature infants treated with J Med ; Chachectin: A hormone that trig- led trial.
J Infect Dis ; Prophylactic versus selective Effect of interleukin-2, infants. J Immunol ; Garg AK. Arterialized capillary blood [letter]. CMAJ ; Toxic shock syndrome toxin A comparison of descending 1 as an inducer of human tumor necrosis factors and gamma inter- aortic and arterialized capillary blood in the sick newborn.
CMAJ feron. J Exp Med ; Siggaard-Andersen O. Acid-base and blood gas parameters clonal antibodies prevent septic shock during lethal bacteraemia. Scand J Clin Lab Invest ; Guidelines for the use of pulse oximetry in Aust Paediatr J ; Science ; End-tidal carbon Extravasation of dioxide measurements in critically ill neonates: A comparison of intravascular fluid mediated by the systemic administration of sidestream capnometers.
Can J Anaesth ; Immunology ; Connors A. The effectiveness of right heart catheterization in the Interleukin-2 adminis- initial care of critically ill patients. JAMA ; Thompson AE. Pulmonary artery catheterization in children. New dysfunction similar to those seen in septic shock. Chest ; Horiz ; Effects of changes in vascular Pathol Immunopathol Res ; Hill HR. Biochemical, structural and functional abnormalities of thermodilution cardiac output measurements within an up to polymorphonuclear leukocytes in the neonate.
Pediatr Res 6-hour calibration-free period. Crit Care Med ; The reliability of pulse contour- Miller M. Chemotactic function in the human neonate: Humoral derived cardiac output during hemorrhage and after vasopressors and cellular aspects.
Pediatr Res ; Anesth Analg ; Granulocyte function Gazit A, Cooper DS. Emerging technologies. Nelson LD. Application of venous saturation monitoring. In: Pediatr Int ; Critical Care. Philadel- Miller ME. Phagocytosis in the newborn: Humoral and cellular phia: JB Lippincott; Continuous mixed venous oxygen satu- Impaired opsonic activity but normal ration measurement: A significant advance in hemodynamic moni- phagocytosis in low-birth-weight infants.
N Engl J Med toring? J Clin Monit Comput ; Continuous monitoring of venous Mohan P, Brocklehurst. Granulocyte transfusions for neonates with oxygen saturation in critically-ill infants. J Formos Med Assoc confirmed or suspected sepsis.
Cochrane Database Syst Reviews ; Evaluation of the right atrial The premature infant as a com- venous oxygen saturation as a physiologic monitor in a neonatal promised host.
Curr Probl Pediatr ; Impaired chemotaxi- The cardiovascular effects genesis by type III group B streptococci in neonatal sera: Relation- of dopamine in the severely asphyxiated neonate.
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The human hematopoietic colony-stimulating tional study. Milrinone: Systemic and Ohlsson A, Lacy J. Intravenous immunoglobulin for preventing pulmonary hemodynamic effects in neonates after cardiac surgery.
Cochrane Crit Care Med ; Database Syst Reviews 1 :Art. Sieff CA. Hematopoietic growth factors. J Clin Invest ; Treatment of impaired per- The in vivo effect of fusion in septic shock. Ann Med ; Dellinger RP. Cardiovascular management of septic shock. Crit tropenic neonates with sepsis.
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J Clin Res Pediatr Endocrinol Mehta Tom Jaksic. Despite advances in the field of nutritional support, the nutritional support is a priority in sick neonates and chil- prevalence of malnutrition among hospitalized patients, dren.
The goal of nutrition in this setting is to augment especially those with a protracted clinical course, has the short-term benefits of the metabolic response to remained largely unchanged over the last two decades.
In The provision of optimal nutritional therapy requires a general, the metabolic stress response is characterized by careful assessment of energy needs and the provision of an increase in net muscle protein degradation and the macronutrients and micronutrients via the most suitable enhanced movement of free amino acids through the feeding route.
The profound and stereotypic metabolic circulation Fig. These amino acids serve as the response to injury places unique demands on the hospi- building blocks for the rapid synthesis of proteins that act talized child. Standard equations available for estimating as mediators for the inflammatory response and struc- energy needs have proven to be unreliable in this popula- tural components for tissue repair.
The remaining amino tion. The provision of additional tional regimen should be tailored for each child and dietary protein may slow the rate of net protein loss, but reviewed regularly during the course of illness. An under- does not eliminate the overall negative protein balance standing of the metabolic events that accompany illness associated with injury.
Overall, the energy needs of the critically ill or The metabolic response to illness due to stressors such injured child are governed by the severity and persistence as trauma, surgery, or inflammation has been well of the underlying illness or injury. Accurate assessment described. Cuthbertson was the first investigator to of energy requirements in individual patients allows realize the primary role that whole-body protein catabo- optimal caloric supplementation and avoids the deleteri- lism plays in the systemic response to injury.
Children his work, the metabolic stress response has been concep- with critical illness demonstrate a unique hormonal tually divided into two phases. The initial, brief ebb and cytokine profile characterized by an elevation in phase is characterized by decreased enzymatic activity, serum levels of insulin, the catabolic hormones gluca- reduced oxygen consumption, low cardiac output, and a gons, cortisol, catecholamines , and specific cytokines core temperature that may be subnormal. This is fol- known to interact with the inflammatory process.
During this phase, fat and protein sequences induced by the stress response are a focus of mobilization is manifested by increased urinary nitrogen research. Neonates and children share similar qualitative meta- The body composition of the young child contrasts with bolic responses to illness as adults, albeit with significant that of the adult in several ways that significantly affect quantitative differences.
The metabolic stress response nutritional requirements. Table lists the macronutri- is beneficial in the short term, but the consequences ent stores of the neonate, child, and adult as a percentage of sustained catabolism are significant as the child of total body weight.
Thus the prompt institution of glucose. In general, net protein catabolism predominates and amino acids are transported from muscle stores to the liver, where they are converted to inflamma- tory proteins and glucose through the process of gluconeogenesis.
Studies have demonstrated that the resting energy brain-to-body mass ratio because glucose is the primary expenditure for neonates is two to three times that of energy source for the central nervous system. Neonatal adults when standardized for body weight. Thus when infants are burdened with illness or young child may increase heat loss and further contrib- injury, they must rapidly turn to the breakdown of protein utes to elevations in energy expenditure.
Premature infants have the lowest listed in Table In premature infants, a minimum renders lipid less useful as a potential fuel source in the protein allotment of 2. The protein reserve of the adult is nearly nutritional support in times of injury and critical illness twofold that of the neonate.
Thus infants cannot afford to avoid negative nutritional consequences. An important feature of for planning nutritional intake, monitoring dynamic the metabolic stress response, unlike in starvation, is that changes in the body compartments such as the loss of the provision of dietary glucose does not halt gluconeo- lean body mass , and assessing the adequacy of nutritional genesis.
Consequently, the catabolism of muscle protein supportive regimens during critical illness. Although stress factors supplementation and may have clinical implications in ranging from 1.
However, current methods of body these variations, calculated standardized energy expendi- composition analysis such as anthropometry, weight and ture equations have not been satisfactorily validated in biochemical parameters are either impractical for clini- critically ill children.
One of the principal problems oxygen consumed and VCO2 the volume of CO2 pro- in critically ill children is the presence of capillary leak, duced , and uses a correlation factor based on urinary manifesting as edema and large fluid shifts.
These make nitrogen excretion to calculate the overall rate of energy anthropometric measurements invalid and other bedside production. Oxidation of carbohy- For children with illness or undergoing operative inter- drate yields an RQ of 1. However, the role of the RQ as a for the design of appropriate nutritional strategies. The bodys ability to metab- energy needs are associated with injurious consequences. The sum of these components where an RQ higher than 0. In absence of underfeeding and an RQ higher than 1.
Furthermore, in the setting of wide diurnal and day-to- REE can be measured using direct or indirect methods.
The use of that all energy is eventually converted to heat. In practice, steady-state measurements may decrease these errors. The time. Direct calorimetry is not prac- may be used as an accurate representation of the hour tical for most hospitalized children and REE is often TEE in patients with low levels of physical activity. Unfortunately, REE a patient who fails to achieve steady state and is metaboli- estimates using standardized World Health Organization cally unstable, prolonged testing is required minimum WHO predictive equations are unreliable, particularly of 60 minutes , and hour indirect calorimetry should in underweight subjects.
With the advent of newer technology, the REE estimation is difficult in critically ill or postop- application of indirect calorimetry at the bedside for con- erative children. Their energy requirements show indi- tinuous monitoring shows promise. For instance, an infant with respiratory distress air leaks around the endotracheal tube, ventilator circuit on pressure support is likely to have high energy or through a chest tube, or in subjects on ECMO.
High requirement due to increased work of breathing. Indirect calorimetry is difficult to with muscle relaxants, is unlikely to have sustained high use in babies on ECMO because a large proportion of energy requirements. Infants with congenital diaphrag- the patients oxygenation and ventilation is performed matic hernia on extracorporeal membrane oxygenation through the membrane oxygenator.
Following extu- intake requires attention to its limitations and expertise bation, the same patients may have energy requirements in the interpretation. On the other hand, unrecognized hyper- may be helpful. Stable in energy requirements may result in cumulative energy isotope technology has been available for many years and imbalances in the intensive care unit ICU over a period was first applied for energy expenditure measurement in of time.
Regular anthropometric only as water. The difference in the rates of loss of the measurements plotted on a growth chart to assess the isotopes 18O and 2H from the body reflects the rate of adequacy of caloric provision will allow relatively prompt CO2 production, which can be used to calculate the detection of underfeeding or overfeeding in most cases.
In general, any increase in energy expenditure during illness or after an operation is variable, and studies suggest that the increase is far less than originally hypothesized. Proteins are continually hours postoperatively, provided no major complications degraded into their constituent amino acids and resyn- develop. Synthesis of proteins from agement may play a significant role in muting the stress the recycling of amino acids is more than two times response of the neonate.
Studies have demonstrated no greater than from dietary protein intake. An advantage of discernible increase in REE in neonates undergoing high protein turnover is that a continuous flow of amino patent ductus arteriosus ligation who received intraop- acids is available for the synthesis of new proteins.
This erative fentanyl anesthesia and postoperative intravenous allows the body tremendous flexibility in meeting ever- analgesic regimens. However, the process of gical infants into low- and high-stress cohorts based on protein turnover requires the input of energy to power the severity of underlying illness found that high-stress both protein degradation and synthesis. At baseline, infants undergo moderate short-term elevations in energy infants are known to have higher rates of protein expenditure after operation, whereas low-stress infants turnover than adults.
Although children have increased growth and development, whereas the healthy adult can energy requirements from increased metabolic turnover subsist with a neutral protein balance. The factors required for protein stores and elevated protein demands.
Unless the the inflammatory response acutely needed enzymes, inciting stress is eliminated, the progressive breakdown serum proteins, and glucose are thereby synthesized of diaphragmatic, cardiac, and skeletal muscle can lead to from degraded body protein stores. The well-established respiratory compromise, fatal arrhythmia, and loss of increase in hepatically derived acute phase proteins lean body mass.
Moreover, a prolonged negative protein including C-reactive protein, fibrinogen, transferrin, balance may have a significant impact on the childs and acid glycoprotein , along with the concomitant growth and development. ECMO have exceedingly high rates of protein loss, with However, protein breakdown predominates, thereby a net negative protein balance of 2.
For example, Fortunately, amino acid supplementation tends to infants with sepsis demonstrate a severalfold increase in promote increased nitrogen retention and positive protein the loss of urinary nitrogen that directly correlates with balance in critically ill patients.
The quantity of protein needed to esis during illness and injury is seen in both children and enhance protein accrual is greater in hospitalized sick adults, and this process appears to be accentuated in children than in healthy children. Table lists recom- infants with low body weight.
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