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PURPOSE: to describe the patterns of the gastric myoelectrical activity, pre-and postprandially, in clinically stable neonates of different gestational ages, during their first two weeks of life by means of Electrogastrography. PATIENTS AND METHODS: Electrogastrography was recorded in forty-five clinically stable neonates of different gestational ages (group I: 15 neonates of > 37 weeks, group II: 15 premature neonates of 32-37 weeks; Group III: 15 premature neonates of 28-31 weeks) receiving intermittent enteral feedings during their first two weeks of life. Electrogastrography recordings were performed for 1 hour pre-and postprandially. The Electrogastrography signal was recorded using the portable MicroDigitrapper Electrogastrography recording device and after motion artifacts were deleted, the remaining Electrogastrography data were submitted to quantitative analysis based on the "Running Spectrum Analysis". RESULTS: The percentages of normogastria, pre-and postprandially were greater than the percentages of gastric dysrythmias in all three studied groups. Furthermore, all neonates had the mean values of the Electrogastrography dominant frequency predominantly within the normogastria range, in both periods analyzed. There were no significant differences in the relative change of the Electrogastrography dominant power among the groups. CONCLUSION: This study demonstrates that the Electrogastrography patterns are similar between premature and full term neonates during the pre-and postprandial periods. The results of this study also indicate that the gastric myoelectrical activity in premature and full term neonates is immature, as compared to that described for older neonates, children and adults.OBJETIVO: Descrever os padrões da atividade mioelétrica gástrica, durante os períodos pré e pós-prandial, em recém-nascidos de diferentes idades gestacionais e clinicamente estáveis, durante as duas primeiras semanas de vida, através da Eletrogastrografia. PACIENTES E MÉTODOS: A Eletrogastrografia foi realizada em 45 recém-nascidos, de diferentes idades gestacionais e clinicamente estáveis (grupo I: 15 recém-nascidos > 37 semanas, grupo II: 15 recém-nascidos de 32-37 semanas; Grupo III: 15 recém-nascidos de 28-31 semanas) que estavam recebendo dieta enteral de forma intermitente durante as duas primeiras semanas de vida. Registros eletrogastrográficos foram realizados por 1 hora antes e por 1 hora após terem sido alimentados. O sinal eletrogastrográfico foi obtido com o aparelho portátil "MicroDigitrapper Eletrogastrografia recording device" e após eliminação de artefatos relacionados a movimentação corporal, o traçado eletrogastrográfico remanescente foi submetido à analise quantitativa baseada no método "Running Spectrum Analysis". RESULTADOS: As porcentagens de normogastria, pré e pós-prandial, foram maiores que as porcentagens de arritmias gástricas nos três grupos estudados. Além disso, todos os recém-nascidos apresentaram freqüência dominante do sinal eletrogastrográfico dentro do intervalo correspondente a normogastria, em ambos os períodos analisados. Não houve diferença estatisticamente significante nas mudanças relativas da amplitude dominante do sinal eletrogastrográfico entre os três grupos estudados. CONCLUSÃO: Este estudo demonstrou que recém-nascidos prematuros e de termo apresentam padrões eletrogastrográficos semelhantes durante os períodos pré e pós-prandial. Os resultados deste estudo também demonstraram que a atividade mioelétrica gástrica em recém-nascidos prematuros e de termo é imatura quando comparada com a descrita para lactentes, crianças e adultos.

PURPOSE: to describe the patterns of the gastric myoelectrical activity, pre-and postprandially, in clinically stable neonates of different gestational ages, during their first two weeks of life by means of Electrogastrography. PATIENTS AND METHODS: Electrogastrography was recorded in forty-five clinically stable neonates of different gestational ages (group I: 15 neonates of > 37 weeks, group II: 15 premature neonates of 32-37 weeks; Group III: 15 premature neonates of 28-31 weeks) receiving intermittent enteral feedings during their first two weeks of life. Electrogastrography recordings were performed for 1 hour pre-and postprandially. The Electrogastrography signal was recorded using the portable MicroDigitrapper Electrogastrography recording device and after motion artifacts were deleted, the remaining Electrogastrography data were submitted to quantitative analysis based on the "Running Spectrum Analysis". RESULTS: The percentages of normogastria, pre-and postprandially were greater than the percentages of gastric dysrythmias in all three studied groups. Furthermore, all neonates had the mean values of the Electrogastrography dominant frequency predominantly within the normogastria range, in both periods analyzed. There were no significant differences in the relative change of the Electrogastrography dominant power among the groups. CONCLUSION: This study demonstrates that the Electrogastrography patterns are similar between premature and full term neonates during the pre-and postprandial periods. The results of this study also indicate that the gastric myoelectrical activity in premature and full term neonates is immature, as compared to that described for older neonates, children and adults. OBJETIVO: Descrever os padrões da atividade mioelétrica gástrica, durante os períodos pré e pós-prandial, em recém-nascidos de diferentes idades gestacionais e clinicamente estáveis, durante as duas primeiras semanas de vida, através da Eletrogastrografia. PACIENTES E MÉTODOS: A Eletrogastrografia foi realizada em 45 recém-nascidos, de diferentes idades gestacionais e clinicamente estáveis (grupo I: 15 recém-nascidos > 37 semanas, grupo II: 15 recém-nascidos de 32-37 semanas; Grupo III: 15 recém-nascidos de 28-31 semanas) que estavam recebendo dieta enteral de forma intermitente durante as duas primeiras semanas de vida. Registros eletrogastrográficos foram realizados por 1 hora antes e por 1 hora após terem sido alimentados. O sinal eletrogastrográfico foi obtido com o aparelho portátil "MicroDigitrapper Eletrogastrografia recording device" e após eliminação de artefatos relacionados a movimentação corporal, o traçado eletrogastrográfico remanescente foi submetido à analise quantitativa baseada no método "Running Spectrum Analysis". RESULTADOS: As porcentagens de normogastria, pré e pós-prandial, foram maiores que as porcentagens de arritmias gástricas nos três grupos estudados. Além disso, todos os recém-nascidos apresentaram freqüência dominante do sinal eletrogastrográfico dentro do intervalo correspondente a normogastria, em ambos os períodos analisados. Não houve diferença estatisticamente significante nas mudanças relativas da amplitude dominante do sinal eletrogastrográfico entre os três grupos estudados. CONCLUSÃO: Este estudo demonstrou que recém-nascidos prematuros e de termo apresentam padrões eletrogastrográficos semelhantes durante os períodos pré e pós-prandial. Os resultados deste estudo também demonstraram que a atividade mioelétrica gástrica em recém-nascidos prematuros e de termo é imatura quando comparada com a descrita para lactentes, crianças e adultos.

Objective. Necrotizing enterocolitis (NEC) is primarily a disease of the premature infant. Among children born at term, however, congenital heart disease may be an important predisposing factor for this condition. To determine risk factors for NEC in patients with congenital heart disease, we conducted a case–control study of neonates with cardiac disease admitted to the cardiac intensive care unit at our center during the 4-year period from January 1995 to December 1998. Methods. Cardiac diagnosis and age at admission were analyzed for association with NEC among the 643-patient inception cohort. Demographic, preoperative, and operative variables were recorded retrospectively in 21 neonates with congenital heart disease who developed NEC and 70 control neonates matched by diagnosis and age at admission. Using parametric and nonparametric analysis, cases and controls were compared with respect to previously identified risk factors for NEC. Results. Among the entire cohort of 643 neonates with heart disease admitted to the cardiac intensive care unit, diagnoses of hypoplastic left heart syndrome (odds ratio [OR] = 3.8 [1.6–9.1]) and truncus arteriosus or aortopulmonary window (OR = 6.3 [1.7–23.6]) were independently associated with development of NEC by multivariable analysis. In the case–control analysis, earlier gestational age at birth (36.7 ± 2.7 weeks vs 38.1 ± 2.3 weeks), prematurity (OR = 3.9 [1.2–12.5]), highest dose of prostaglandin >0.05 μg/kg/minute (OR = 3.9 [1.2–12.5]), and episodes of low cardiac output (meeting specific laboratory criteria) or clinical shock (OR = 6.5 [1.8–23.5]) correlated with the development of NEC. Earlier gestational age and episodes of low output were the only factors that remained significantly associated with NEC by multivariable analysis. Although there was no difference in hospital mortality between patients with and without NEC, mean hospital stay was significantly longer in those who developed NEC (36 ± 22 days vs 19 ± 14 days). Conclusions. The risk of NEC in neonates with congenital heart disease is substantial. Factors associated with an elevated risk of NEC in infants with heart disease include premature birth, hypoplastic left heart syndrome, truncus arteriosus, and episodes of poor systemic perfusion or shock. Heightened suspicion is warranted in newborns with these risk factors.

Objective: To evaluate the effect of sweet taste stimulation in augmenting the reported growth-enhancing effects of nonnutritive sucking in preterm infants who are gavage-fed. Design: Random assignment of preterm infants to receive stimulation by one of three methods during each feeding until totally orally fed. Setting: Hospital intensive-care and infant transitional units. Patients: Eligibility criteria included body weight greater than or equal to 1,250 g, gestational age younger than 34 weeks, growth parameters appropriate for gestational age, tolerating at least 100 kcals/kg/day by gavage feeding with evidence of weight gain, and no clinical evidence of health complications. Data are presented for 42 infants who completed 14 days of treatment. Interventions: Exposure to a sweet pacifier, a latex pacifier, or maternal heartbeat sounds during gavage feedings. Main outcome measures: Growth, time to total oral feeding, and sucking responses. Results: No significant differences in sucking measures were noted among treatment groups. Differences in progression time to total oral feedings and weight gain favored the sweet-pacifier group but were not statistically significant. Conclusions: Oral stimulation of gavage-fed, preterm infants during a 2-week hospitalization was not sufficient to elicit a significant improvement in growth efficiency, progression to total oral feedings, or sucking maturation. Additional studies may show a beneficial effect of chemosensory Stimulation in preterm infants.

Nutritional requirements of extremely premature infants are greater than those of other premature and full-term neonates. Nutrition support for these infants should be initiated early in the neonatal period combined with the use of parenteral nutrition and minimal enteral feedings. Intermittent gastric gavage is the preferred method to provide enteral feeding until sucking and swallowing mechanisms are mature. Fortified preterm human milk is the first choice of feeding, and the best substitute is premature infant formulas. Multivitamin supplementation may be necessary, depending on the daily intake of infant formula. Iron supplementation can be initiated as early as two weeks of age.

In a two-phased retrospective study, clinical factors associated with the development of necrotizing enterocolitis (NEC) in neonates were identified. The first phase found 13 infants with NEC who had been treated more frequently with enteral theophylline (P150 mL/kg/day; P 1,250 g who developed NEC in the first week of life. Maternal preeclampsia helped protect against the development of NEC (P

Plasma cholesterol and lecithin concentrations are regulated by the serum enzyme lecithin: cholesterol acyltransferase (LCAT). LCAT activity is low in cord blood of premature infants, suggesting that in these infants the hypercholesterolemia associated with Intralipid infusion might be due to low LCAT activity. The serum LCAT activity has not been quantitated in preterm infants receiving intravenous fat emulsions. We have therefore quantitated LCAT activity in eleven premature infants maintained on total parenteral nutrition (TPN). Ten infants were studied during the first 2 weeks after birth; they received daily infusions of Intralipid at a rate of 0.5-2.0 g/kg/day over 15 h. One infant received 3.8 g/kg/day during the second week. In addition to LCAT, serum apoprotein A1 (the cofactor of LCAT), cholesterol, triglycerides, and free fatty acids were quantitated. Blood specimens were taken before the start of the infusion and 15-45 min before its completion. The LCAT activity and apoprotein A1 concentrations remained, respectively, 21-24% and 30-35% of adult levels. However, serum cholesterol levels remained in the normal range during the fat infusion. It remains to be established whether low LCAT activity and apoprotein A1 levels are due to the administration of Intralipid (which lowers LCAT activity in rats), to the lack of enteral feedings, or to prematurity per se. Our data suggest that administration of Intralipid at a rate not exceeding 1-2 g/kg/day does not impair the clearing of Intralipid-lecithin and the metabolism of cholesterol.

Critically ill premature infants often require lipid emulsions with parenteral nutrition until enteral feedings can be safely initiated. Because thrombocytopenia has been listed as a potential side effect of fat emulsions, we examined the effect of varying doses of intravenous fat infusions on platelet concentrations in premature infants. An initial validation study demonstrated no artifactual effect of fat infusions on the electronic cell counter method of platelet enumeration. We observed no adverse effect of fat emulsions administered at doses of 0.8 to 3.3 g/kg/day on platelet concentration either during short-term (48 hr) or long-term study periods (4 weeks).

The last trimester of pregnancy is a period of rapid accretion of long-chain polyunsaturated fatty acids, both in the central nervous system and the body as a whole. Human milk contains these fatty acids, whereas some preterm infant formulas do not. Infants fed formulas without these fatty acids have lower plasma and erythrocyte concentrations than infants fed human milk. Preclinical and clinical studies have demonstrated that single-cell sources (algal and fungal) of long-chain polyunsaturated fatty acids are bioavailable. A balanced addition of fatty acids from these oils to preterm formula results in blood fatty acid concentrations in low birth weight infants comparable to those of infants fed human milk.In the present study the growth, acceptance (overall incidence of discontinuation, reasons for discontinuation, overall incidence and type of individual adverse events), and plasma fatty acid concentrations were compared in three groups of infants fed a long-chain polyunsaturated fatty acid-supplemented preterm infant formula, an unsupplemented control formula, or human milk. The study was prospective, double-blind (formula groups only), and randomized (formula groups only). Two hundred eighty-eight infants were enrolled (supplemented formula group, n = 77; control formula group, n = 78; human milk group, n = 133).Anthropometric measurements at enrollment, at first day of full oral feeding, and at both 40 and 48 weeks postconceptional age did not differ between the formula groups, whereas the human milk-fed group initially grew at a lower rate. The incidence of severe adverse events was rare and not significantly different between formula groups. The groups fed either human milk or supplemented formula had long-chain polyunsaturated fatty acid concentrations higher than those in the control formula group.The results of this study demonstrate the safety and efficacy of a preterm formula supplemented with long-chain polyunsaturated fatty acids from single-cell oils.

Both surfactant replacement and positive end-expiratory pressure (PEEP) increase lung volume in infants with respiratory distress syndrome (RDS). We measured pulmonary mechanics and functional residual capacity (FRC) in 21 preterm infants with RDS, > 48 hr post-surfactant therapy (BW, 1,168 +/- 441 g; GA, 28.3 +/- 2.8 weeks; postnatal age, 3-7 days). A non-linear but significant increase in mean FRC was noted as PEEP increased from 2 to 5 cmH2O: 18.4 +/- 4.7 mL/kg at 2 cmH2O; 19.7 +/- 4.3 mL at 3 cmH2O; 22.6 +/- 5.5 ml/kg at 4 cmH2O; and 26.2 +/- 6.2 mL/kg at 5 cmH2O (P < 0.01). Because of the synergistic combined effect on lung volume, surfactant treated neonates should be weaned cautiously from PEEP during ventilatory management. Our study also suggests that the occurrence of inadvertent end-distending pressure during FRC measurement in the ventilated neonate lead to erroneous results.

The use of dietary fat in preference to carbohydrate offers the theoretic advantage of diminishing carbon dioxide production and thus the respiratory quotient, which may be beneficial for babies with chronic lung disease. Ten premature infants (birth weight (mean +/- SEM), 1.13 +/- 0.12 kg; postnatal age, 9 +/- 1 weeks) with bronchopulmonary dysplasia were alternately fed a high-fat and a high-carbohydrate formula each for 1 week, in randomized order. Lower rates of carbon dioxide production (6.6 +/- 0.3 versus 7.4 +/- 0.4 ml/kg per minute; p0.05), and consequently lower respiratory quotients (0.80 +/- 0.02 versus 0.94 +/- 0.01 ml/kg per minute; p0.005), were observed during the administration of the high-fat formula. There were no significant differences in results of pulmonary function tests with the use of either formula. Both formulas were equally well tolerated and able to promote adequate growth and normal biochemical profiles. However, weight gain was significantly greater with the administration of the high-carbohydrate formula, possibly because of an increase in the accretion of body fat. We conclude that the short-term use of high-fat formula for infants with bronchopulmonary dysplasia decreases carbon dioxide production while maintaining adequate growth and nutritional status.

The efficacy and safety of using umbilical venous catheters vs. peripheral venous catheters for the delivery of parenteral nutrition was studied in 129 critically ill premature infants who were treated in a neonatal intensive care unit for the first 3 weeks of life. Infants who received parenteral nutrition by umbilical venous catheter had greater parenteral caloric intake, lower physiologic weight loss and greater weight gain during the study as compared to infants who received parenteral nutrition by peripheral vein. While the overall incidence of sepsis was comparable in both groups (19% vs 19.7%), benign and transient episodes of hyperglycemia were seen more commonly in infants receiving parenteral nutrition by umbilical catheters. None of the hyperglycemic infants, however, required insulin therapy. The incidence of other metabolic complication was comparable in both groups. At follow up, no evidence of portal hypertension was detected in any of the infants up to 66 months of age treated with umbilical venous catheters. We conclude that the use of umbilical venous catheter allows for a comparably safe and a more appropriate parenteral nutrition support than peripheral catheters in critically ill premature neonates.

Lithium is widely used and the treatment of choice for patients with manic-depressive illness. For pregnant patients with manic-depressive illness, however, the use of lithium during the first trimester of pregnancy may present an increased risk for fetal maldevelopment. We have recently cared for several large-for-gestational-age, prematurely born infants whose mothers were treated with lithium throughout pregnancy. To determine whether maternal lithium use during pregnancy may predispose to the onset of premature labor and fetal macrosomia, we reviewed records from the International Register of Lithium Babies and from a cohort of manic-depressive pregnant women. More than one third (36%) of infants reported to the International Register were born prematurely, and 37% of the premature infants were large for gestational age; 15% of the term infants were born large for gestational age. In the cohort group, manic-depressive mothers who received lithium during pregnancy had a 2.5-fold higher incidence of premature births than manic-depressive pregnant patients who did not receive lithium treatment. The incidence of large-for-gestational-age births in lithium-treated women in the cohort was not different from that of the general population or from manic-depressive women not treated with lithium. In summary, an association between maternal lithium therapy and premature delivery is reported. We recommend that women receiving lithium therapy during pregnancy be closely monitored for the onset of premature labor.

Electrogastrography in Neonates: The Effect of Gestational Age and Type of Enteral Feedings

Objective: To evaluate growth, safety and tolerance of a preterm infant formula supplemented with ARA and DHA from microbial fermentation oils.

Objective: To evaluate phospholipid response of a preterm infant formula supplemented with Arachidonic Acid (ARA) and Docosahexanoic Acid (DHA) from microbial fermentation oils.

Exploration retrospective et prospective des rapports entre le type d'allaitement et les taux de thyroxine totale et libre chez les prematures. Vers l'âge de 4 semaines, ces taux sont plus eleves chez les prematures au sein que chez ceux au biberon demontrant l'influence du mode de nutrition, sans prejuger de la participation de T 3 , TSH ou de leurs metabolites. La signification clinique des observations rapportees demeure conjecturale

Mid-arm circumference/head circumference ratios (MAC/HC) and birth weights obtained in 73 neonates were studied to compare which of these growth measurements could more accurately predict risk of metabolic complications resulting from either acceleration or retardation of fetal growth. The MAC/HC ratio was more sensitive than birth weight in distinguishing (1) symptomatic large for gestational age (LGA) infants who were born to diabetic mothers from other LGA infants who were asymptomatic, and (2) symptomatic from asymptomatic small for gestational age infants. In addition, the MAC/HC ratio identified symptomatic appropriate for gestational age (AGA) infants born to diabetic mothers and AGA infants with signs and symptoms of growth retardation. The MAC/HC is more useful than birth weight in assessing newborn infants at risk for the metabolic complications associated with fetal growth disorders.

We studied the accuracy of the ponderal index and the mid-arm circumference/head circumference ratio for detecting newborn infants who were likely to be symptomatic because of aberrant intrauterine growth. Sixty infants were evaluated because of suspected intrauterine growth retardation; both the mean ponderal index and mid-arm circumference/head circumference ratio were significantly lower in the group of 30 symptomatic infants than in the group of 30 asymptomatic infants (p less than 0.05). However, the mid-arm circumference/head circumference ratio identified a significantly higher percentage of the symptomatic infants than the ponderal index (80% vs. 47%; p = 0.007). An additional 60 infants were evaluated because of suspected abnormal intrauterine growth acceleration. The mean mid-arm circumference/head circumference ratio, but not the ponderal index, was significantly higher in the group of 30 symptomatic infants than in the group of 30 asymptomatic infants (p less than 0.005). Again, the mid-arm circumference/head circumference ratio identified a significantly higher percentage of the symptomatic infants than the ponderal index (79% vs. 33%; p less than 0.001). The mid-arm circumference/head circumference ratio is more accurate than the ponderal index for the evaluation of potentially symptomatic newborn infants who suffered abnormal fetal growth. The ponderal index is not useful for the detection of symptomatic large-for-dates infants.

The assessment of growth parameters remains one of the most practical and valuable tools to estimate nutritional status in neonates. Growth assessment in full-term infants is performed by using charts developed by the National Center for Health and Statistics. The assessment of post-natal growth in premature infants is controversial and can be performed by using either intrauterine or extrauterine standards. The selection of appropriate growth charts should be based on clinical, demographic, ethnic, and socioeconomic similarities of the population used for reference. Daily energy intakes ranging from 100 to 120 kcal/kg/day have been recommended for full-term infants, while higher intakes ranging from 114 to 181 kcal/kg/day have been recommended for premature neonates. Full-term infants should be nursed or nipple fed on demand; however, premature infants should ideally be tube fed by intermittent gastric feeding (gavage). Continuous gastric and transpyloric feedings are indicated in selected infants. Human milk is a preferred food for full-term infants during the first six months of life; however, this precept does not suggest that all infants who are exclusively breast-fed will grow adequately. Preterm human milk is also a preferred food for the low birthweight infant, provided nutritional supplements are used. It is unclear whether the supplementation of vitamin D, iron, and fluoride in full-term breast-fed infants should be started at birth, at the time of initiation of solid foods, or at the age of six months. The routine supplementation of multivitamins, folic acid, and vitamin E to all low birthweight infants is controversial. Most investigators suggest vitamin supplementation be given until the intake of formula or breast milk is sufficient to meet daily requirements. Vitamin E appears to exert a protective effect in premature infants against the development of severe retinopathy. The supplementation of vitamin E should be dependent upon the serum vitamin E concentration. It is controversial whether iron supplementation for premature infants should be initiated soon after birth or at two months of age, or whether higher doses of iron should be given to very low birthweight infants. If iron supplementation is started at birth, vitamin E status should be closely monitored. Although the optimal intakes of calcium and phosphorus in infant feedings have not been firmly established, the levels of calcium and phosphorus in human milk appear to be inadequate for the growing low birthweight infant.(ABSTRACT TRUNCATED AT 400 WORDS)

Due to medical complications related to stiffness developed in polyvinyl chloride (PVC) feeding tubes presently manufactured with di-octylphthalate (DOP), we have assessed the flexibility of PVC tubes manufactured with a nonmigrating plasticizer, ti-octyltrimellitate (TOTM) (National Catheter Co., Argyle, NY). Two sizes of DOP and TOTM PVC feedings tubes were evaluated, #5 French and #8 French. Number 5 French DOP tubes became significantly stiffer as early as 1 to 2 days after intubation and continued to stiffen up to 8 days of use. Among the #5 French DOP tubes, those placed in the jejunum were found to become significantly stiffer than those placed in the stomach. No correlations were found between the development of stiffness and gestational age, postnatal age, sex, birthweight, or kinds of feedings. In contrast, #5 French TOTM and #8 French tubes (DOP and TOTM) did not develop any significant stiffness up to 5 to 8 days of use. This study demonstrates the sustained flexibility of TOTM tubes, and important factor to increase the safety of enteral feedings in newborn infants.

Urinary excretion of NG,N'G-dimethylarginine (NG,N'G-Me2Arg) and NG,NG-dimethylarginine (NG,NG-Me2Arg) was measured in premature infants. The NG,N'G-Me2Arg/NG,NG-Me2Arg ratio was much higher in newborn infants than in older children or adults. Linear regression analysis showed a significant negative correlation between the degree of maturity and the excretion of NG,N'G-Me2Arg. A significant direct linear relationship also was found between the excretion of NG,N'G-Me2Arg and the rate of whole body nitrogen flux and of protein synthesis and catabolism. No correlation was found between the excretion of the dimethylarginines and 3-methylhistidine, but the dimethylarginine/3-methylhistidine ratio declined with advancing conceptual age. A direct linear relationship was found between excretion of NG,N'G-Me2Arg and NG,NG-Me2Arg and whole body nonskeletal muscle protein breakdown. No correlation was found between nonskeletal muscle protein catabolism and 3-methylhistidine excretion. We estimate that approximately 0.34 mumole of dimethylarginine are excreted per gram of nonskeletal muscle protein catabolized. Dietary intake did not affect the excretion of either NG,N'G-Me2Arg or NG,NG-Me2Arg. The data suggest that measurement of urinary dimethylarginines might be useful in the nutritional assessment of premature infants.

There were 53 appropriate for gestational age infants with a birth weight of less than 1,700 gm admitted to the Children's Hospital in Denver who were randomly assigned to two groups for gavage or transpyloric (nasojejunal) feedings. The two groups were not significantly different in terms of gestational age, birth weight, and morbidity. No significant differences were observed for caloric intake after 4 days of age, growth parameters (weight, length, and head circumference), serum total protein levels, feeding-related complications, duration of intravenous fluid supplementation, and length of hospitalization. The results indicate that intermittent gastric gavage feedings are as efficacious as transpyloric feedings in supplying nutrition to the low birth-weight infant. Because of inherently greater risks, costs, radiation, and requisite personnel expertise, transpyloric feedings cannot be recommended as a routine method of feeding for the low birth-weight infant.

In a clinical trial based on the direct relationship between heart rate activity and energy expenditure during awake and asleep states, 21 healthy 18-month-old infants had their heart rate monitored over a period of 24 h and correlated with their nutritional intake, growth parameters, and measurements of adiposity (fat cell size and skinfold thickness). Infants with higher 24-h and asleep heart rates had smaller fat cells (r = -0.50) and skinfold thickness (abdominal r = -0.70, suprailiac r = -0.80, triceps r = -0.67). Infants with higher relative weight had higher heart rates during awake periods (r = 0.60). Infants sleeping for longer periods had higher weight gain velocity from birth (r = 0.51) and higher relative weight (r = 0.54). This study demonstrates the heart rate activity and duration of sleep are related to growth and adipose tissue deposition during infancy.

Intravenous fat emulsions (1, 2, and 3 g/kg) were administered over 15 hr to 20 appropriate for gestational age premature infants with physiologic hyperbilirubinemia to determine the effect of fat infusions on the serum free fatty acid:albumin molar ratio (F/A) and on unbound bilirubin. Significant increases (p less than 0.05) in F/A occurred with each increase in lipid dose in infants less than 30 wk gestation, but not in infants greater than or equal to 30 wk gestation. There was a direct linear correlation (r = 0.65, p less than 0.001) between F/A ratio and unbound bilirubin (estimated fluorometrically by the ratio of albumin-bound bilirubin/reserve bilirubin binding capacity, B/R). The largest increases in unbound bilirubin (albumin-bound bilirubin/reserve bilirubin binding capacity) were seen in infants with F/A greater than 4.0. The gestational age of infants with F/A greater than 4.0 was significantly less (p less than 0.01) than infants with F/A less than 4.0 (28.7 +/- 0.47 vs. 31.1 +/- 0.40 wk, mean +/- SEM). In 10/58 infusions there was a fall in unbound bilirubin, unrelated to birthweight, gestational age, postnatal age, however, during these infusions the end-infusion F/A was greater than or equal to 3.0. We conclude that 1 g/kg of lipid emulsion infused over a 15-hr period has minimal risk of decreasing bilirubin binding in premature infants less than 30 wk gestation. As doses of 2 or 3 g/kg are used, these infants may be at risk of decreased bilirubin binding, due to elevations in the F/A ratio. Monitoring of the F/A ratio may identify infants at risk for decreased bilirubin binding during lipid infusion and provide guidelines for determining the appropriate lipid dose.

This article reviews common nutritional deficiencies that have been identified in newborn infants, including deficiencies of protein; vitamins A, D, K, C, and E; calcium and phosphorus; folate; zinc; and copper. The etiology, clinical presentation, diagnosis, and treatment of these nutritional deficiencies are discussed.

Protein turnover was studied in eight premature infants of conceptual age 26-37 weeks. A stochastic model based upon [15N]urea or [15N]ammonia excretion following a single injection of [15N]glycine was used to estimate rates of whole body protein synthesis and catabolism. The urinary 3-methylhistidine/creatinine ratio was determined to differentiate skeletal muscle protein breakdown from total protein catabolism. The rates of whole body protein synthesis ranged from 5.2 to 13.2 g X kg-1 X day-1 and protein catabolism ranged from 4.1 to 12.4 g X kg-1 X day-1. Linear regression analyses of conceptual age versus (a) whole body nitrogen flux, (b) protein synthesis, and (c) protein catabolism showed significant inverse relationships. A similar relationship obtained between conceptual age and the urine 3-methylhistidine/creatinine ratio. Muscle protein breakdown did not vary with conceptual age, but the fraction of whole body protein breakdown derived from muscle protein breakdown increased significantly with advancing maturation. The ratio net tissue protein gain/total body protein synthesis increased significantly with increasing body weight. Net tissue protein gain appeared to be directly related to protein and caloric intake. The ratio of the rate of whole body protein synthesis and protein intake was greatest in the youngest infants and declined with maturation. A similar relationship was not found between the ratio of protein synthesis and caloric intake and the degree of maturity. More than 90% of nitrogen entering the metabolic pool was used for protein synthesis and more than 50% of calories administered were similarly utilized. We conclude that: (a) protein turnover in premature infants is far more rapid than in term infants, children, or adults and is inversely related to conceptual age; (b) muscle protein turnover constitutes a greater fraction of overall turnover with advancing maturity; (c) energy and protein intake affect net tissue protein gain significantly in rapidly growing infants; and (d) the efficiency of protein synthesis as a function of protein intake is higher in the most immature infants.

Summary Plasma lipolytic activity (lipoprotcin lipase and hepatic lipase). free fatty acids (FFA). triglyceridcs. cholesterol, and glucose levels were measured in 21 premature infants [gestational age 26–37 weeks (mean ± SEM 30.4 ± 0.63 weeks), aged 1–8 days (mean ± SEM 3.00 ± 0.35 days)]. All infants were maintained on total parenteral nutrition with heparin (1 U/ml) and were given Intralipid, 1. 2, and 3 g/kg/day. over 15 h on days 1, 2, and 3. respectively. Blood samples were drawn before and at the end of Intralipid administration. Baseline plasma lipolytic activity, before the start of lipid infusion, was 1.54 ± 0.24 U/ml (1 U = I μmol [3H]oleic acid released from tri[3H]olein/h). Lipolytic activity increased after lipid infusion to 4.04 ± 0.96, 4.32 ± 0.63. and 6.09 ± 1.00 U/ml on days 1, 2, and 3 of the study. Hepatic lipase amounted to 38–47% of total lipolytic activity. During the 3 days of lipid infusion, there were dose-dependent increases in plasma FFA, triglyceride, and cholesterol. Whereas FFA and triglyceride concentrations returned to prelipid infusion levels 9 h after stopping the infusion of Intralipid, 1, 2, or 3 g/kg, there was a cumulative increase in plasma cholesterol and glucose concentrations. The close correlation between FFA concentrations and plasma lipolytic activity (r = 0.655, p < 0.001) suggests considerable in-travascular lipolysis. The positive correlation between plasma FFA and triglycerides (r = 0.632, p < 0.001) and FFA and cholesterol (r = 0.582. p < 0.001) indicate, however, that intravascular lipolysis does not prevent the lipemia associated with Intralipid infusion to low birth weight infants. This study suggests that the infusion of a mixture of small amounts of heparin and Intralipid leads to detachment of lipoprotcin lipase and hepatic lipase from the capillary endothelium of low birth weight infants. The resulting intravascular lipolysis probably exceeds the FFA disposal capacity of premature infants. The rise in plasma FFA concentration to 2.0 μmol/ml warrants caution in the combined use of Intralipid (at rates exceeding 2 g/kg/day) and low levels of heparin for the clinical management of premature infants maintained on total parenteral nutrition.

Eighteen appropriate-for-gestational-age premature infants with birth weights ranging from 0.77 to 1.89 kg received 1 gm/kg of body weight of fat emulsion, intravenously, over a four-hour period. Infants less than 1 week of age developed a significant decrease in Po2 levels (P < .05) during the fat infusion period. There were no changes in other pulmonary function parameters. Infants less than 1 week of age also developed significantly higher peak levels of plasma triglycerides than infants 2 to 3 weeks old (P < .05). A correlation between increment in triglyceride levels and postnatal age was demonstrated (r = .75), with the younger infants presenting the higher triglyceride levels. This study demonstrates that: (1) small premature infants receiving intravenous fat are more susceptible to hyperlipemia and hypoxemia during the first week of life; (2) hypoxemia associated with intravenous fat infusion does not result from changes in lung dynamics; (3) the capacity to tolerate intravenous fats is enhanced after the first week of life.

The surgical neonate is at great risk of developing nutritional deficiencies. However, recent advances in nutritional support, including the development of special elemental diets, infant formulas, nutritional supplements and more suitable additives for parenteral nutrition, have allowed health professionals effectively to prevent the occurrence of malnutrition in sick neonates. Strict monitoring of dietary intake, growth velocity, and biochemical parameters are essential while providing nutritional support. The complication of parenteral nutrition can be reduced by following standard recommendations for preparing solutions, caring for the central and the peripheral catheters, and biochemically monitoring the infant. The organization of a hospital nutrition support service composed of physicians, nurses, nutritionists, and pharmacists is essential in establishing guidelines for the safe delivery of nutritional therapy and in educating hospital personnel and parents on how to best meet the nutritional needs of the surgical neonate.

The effects of nonnutritive sucking (NNS) by means of a pacifier during gavage feeding were studied in 30 premature infants whose birth weight was

The mean fat cell diameter was determined from measurements of abdominal adipose cells, obtained during inguinal hernia repair, of 126 white and 95 black males ranging in age from 1 through 48 months of age. The mean diameters of black and white subjects did not differ significantly, suggesting that differences in fatness among adults of these two ethnic groups have their origin beyond the age range of this study. The mean fat cell diameter increased through the 6-8 month age group, decreased until the end of the first year, and then levelled off through 48 months of age. Comparison of this curve with those for the triceps, subscapular, abdominal, and suprailiac skinfolds of the same subjects showed generally parallel courses except for the triceps, which continued to increase in size after the means of fat cell diameters and the other skinfolds had levelled off. Our data indicate that changes in body fatness on the trunk at least in the first 4 years of life may be accounted for by changes in fat cell size.

Optimal central catheter care includes restriction usage for blood sampling and blood product administration on enhance continued sterility, but our experience with 25 children receiving bone marrow transplants after cytoreduction challenges this concept. Prior to transplantation, bilateral percutaneous subclavian vein silastic catheters were inserted without incident, one utilized for continuous nutritional support in caloric quantity to assure body weight maintenance, and the contralateral catheter utilized for daily venous sampling plus administration of medications including blood products. Patients subsequently entered a protective environment and bi-weekly surveillance cultures were monitored. Nutritional therapy was given for 876 days through 53 catheters. One patient developed culture-proven sepsis, an organism first cultured from the skin. The patient complication rate of 4% and the per diem rate of 0.11% in this immunocompromised population compares favorably to the 10.5 and 0.32% incidence we previously reported for 200 children with unilateral catheters. These data demonstrate that bilateral central catheters can be safely utilized in children for nutrition and sampling.

A scoring system was developed to predict the need for transferring infants with respiratory distress syndrome (RDS) from community hospitals to specialized respiratory care centers. Five clinical and laboratory determinations (birthweight, clinical RDS score, FI02, PCO2 and pH) recorded from 100 infants with RDS during one year were utilized in a score with values ranging from 0 to 10. Application of the score to 159 infants with RDS during the following year showed that: (1) 73 per cent of infants scoring less than or equal to 3 received only oxygen by hood; (2) 75 per cent of infants scoring 4--5 required continuous positive airway pressure (CPAP); and (3) 87 per cent of infants scoring greater than or equal to 6 needed mechanical ventilation (7V). Mean scores were significantly different (p less than 0.02) for each type of respiratory therapy employed: oxygen by hood (2.30 +/- 0.19 S.E.M.); CPAP (4.27 +/- 0.16 S.E.M.); MV (6.72 +/- 0.25 S.E.M.). The accuracy and simplicity of the score make it valuable for the physician in the community hospital to assist in deciding when to transfer a neonate with RDS for more intensive respiratory therapy.

Nutritional intakes, transthyretin (prealbumin) levels, and anthropometric measurements were measured weekly in 26 preterm infants from week 2 of life throughout hospitalization. A sustained significant increase in protein intake occurred in 14 infants over a 2-week period. When mean protein intake increased, mean transthyretin levels increased during the same week (p less than 0.001), followed 1 week later by significant increases in mean weight, occipitofrontal head circumference (OFC), and mid-arm circumference (MAC). In the other 12 infants, a sustained significant decrease in protein intake occurred over 2 weeks. When mean protein intake decreased (p less than 0.01), transthyretin levels decreased during the same week (p less than 0.05), followed 1 week later by significant decreases in mean weight and MAC growth. Over all hospitalization weeks (n = 95), rates of weight gain were more significantly associated with previous trends in transthyretin levels (p = 0.007) than with protein intake alone (p = 0.08). In particular, declines in rates of weight gain were predicted significantly more frequently by the prior week's transthyretin trend (70%) than by the trend in protein intake (47%). In growing premature infants, changes in transthyretin levels occur 1 week before changes in anthropometric measurements. Changes in transthyretin levels are more predictive than changes in protein intake alone for monitoring growth velocity in preterm infants.

The effect of heparin dose and infusion rate on plasma lipids, lipases, and unbound bilirubin was investigated in 22 premature infants with physiologic jaundice. Infants were randomly assigned to receive low or high intravenous doses (24 vs 137.3 U/day) of heparin. Each patient then received 2 g/kg/day of 10% Intralipid on 2 successive days: one day during a 15-hour period and the other day over 24 hours, with the order assigned randomly. The results demonstrate a significantly greater change in serum-free fatty acids in infants receiving the high heparin dose during the 15-hour lipid infusion period. Lipoprotein lipase activity rose more with the high heparin dose and equally at either infusion rate. We conclude that lipid infusions of 2 g/kg/day with low heparin dosage infused over 24 hours resulted in less elevation in serum-free fatty acids. There were no adverse effects on unbound bilirubin at either infusion rate or heparin dosage.

The long-term effect of necrotizing enterocolitis on growth, nutritional status, and gastrointestinal function was assessed in premature infants at the age of 1 year. Of the 22 of 40 infants who developed NEC, 18 were given medical treatment and four required surgical treatment consisting of intestinal resection of less than one fourth of the small bowel. Eighteen infants who did not develop NEC served as controls. At 1 year follow-up, NEC survivors and controls had normal and comparable anthropometric measurements, biochemical values (serum iron, albumin, prealbumin, retinol binding protein, liver function studies) and gastrointestinal tract function (vitamin E absorption, fasting serum bile acids concentration, lactose breath test). This study demonstrates that, in the absence of short bowel syndrome, there is no detectable long-term effect on growth, nutritional status, and gastrointestinal tract function in premature infants who had NEC in the newborn period.

The relationships between maternal and umbilical cord levels of prealbumin and retinol binding protein (RBP) were studied in 68 mothers and in their appropriate-for-gestational-age neonates delivered between 25 and 42 weeks gestation. Arterial and venous concentrations of prealbumin and RBP in cord sera were also studied in a subsample of eight infants. In cord sera, prealbumin and RBP levels increased with gestational age (prealbumin, r = 0.47; RBP, r = 0.40, p less than 0.01), and were significantly different in neonates born at term compared to those born prematurely (mean +/- SD, prealbumin 12.0 +/- 3.9 mg/dl vs. 8.8 +/- 2.3 mg/dl, p less than 0.001; RBP, 2.3 +/- 0.8 vs. 1.8 +/- 0.5 mg/dl, p less than 0.005). No significant differences between arterial and venous concentrations of prealbumin and RBP were observed in cord blood. In maternal blood, serum prealbumin and RBP concentrations did not increase with length of gestation (25-42 weeks). Maternal prealbumin was not correlated significantly with infants' cord serum levels; the correlation coefficient for RBP was 0.29, p less than 0.05. Maternal prealbumin and RBP serum levels were approximately twice the values seen in neonates born both at term and prematurely. Although the difference between premature and full-term cord levels of prealbumin and RBP may reflect an increase in hepatic protein synthesis that occurs with maturation of the fetus and/or a change in placental function after 37 weeks gestation, neither of these factors sufficiently explains the variance in neonatal prealbumin and RBP levels.

The effects of neonatal illness and caloric intake on head growth velocity and on 1-year developmental outcome were studied in 73 appropriate (AGA) and small for gestational age (SGA) premature infants of (mean +/- SD) 30 +/- 2 weeks gestation who received intensive care during the neonatal period. Head growth from birth to 1 year of corrected age was characterized by a triphasic curve initiated by a period of growth arrest or suboptimal growth followed by a period of catch-up growth and terminated by a period of growth along standard curves. Head growth arrest or suboptimal head growth were directly related to the duration of the initial period of caloric deprivation (less than 85 kcal/kg/day) and to the duration of mechanical ventilation. Catch-up head growth was influenced by the duration of the preceding period of caloric deprivation in all infants and by the caloric intake during that phase only in SGA infants; catch-up growth was unrelated to the duration of mechanical ventilation. Head growth along standard curves occurred in all infants by 3 months of corrected age and persisted up to 1 year of corrected age. Infants calorically deprived the longest (AGA 4 to 6 weeks, SGA 2 to 3 weeks) had head growth along standards at curves below -1 SD on the growth chart; all other groups had this phase of head growth at curves between the mean and -1 SD. Infants calorically deprived for more than 4 weeks had developmental scores below normal ranges by 1 year of corrected age.

We assessed cord prealbumin concentrations in 214 appropriate for gestational age newborn infants, 21 small for gestational age infants, and 27 large for gestational age infants to establish normal values and to assess the effect of intrauterine growth, prenatal steroids, and pulmonary maturity on prealbumin levels. Cord prealbumin values were significantly correlated with increasing gestational age (r = 0.33; P less than 0.001) and birth weight (r = 0.40, P less than 0.001) in the AGA neonates. Neonates born before 37 weeks gestation had significantly lower prealbumin levels than those born at term (P less than 0.001). The SGA infants had significantly lower levels than age-matched AGA controls (P less than 0.01), and LGA infants had significantly higher levels than age-matched AGA controls (P less than 0.001). In preterm infants, those with exposure to prenatal steroids (betamethasone or premature rupture of membranes) had significantly higher prealbumin values than control infants of comparable age and weight (P less than 0.001). Infants without respiratory distress syndrome had higher levels than those of comparable age and weight with hyaline membrane disease (P less than 0.05). This study demonstrates that a correlation of gestational age and birth weight exists with cord prealbumin levels, and that the large variability at each gestational age may be accounted for in part by appropriateness of size for dates, prenatal steroid exposure, and pulmonary maturity.