Nutritional survey of hospitalized pediatric patients.

A nutrition survey in a pediatric referral center revealed one-third of patients had evidence of acute malnutrition. Weight for height was below 90% of standard in 46 of 129 (36%), arm muscle area was below the 15th percentile in 67 of 180 (37%), triceps skinfold was below the 15th percentile in 34 of 181 (19%), and total lymphocyte count was below 1500 in 26 of 137 (19%) subjects. Protein-energy malnutrition may be an important contributor to prolonged hospitalization and hospital-acquired morbidity amond United States pediatric patients.

Biennial survey of physician clinical nutrition training programs.

This is the third survey of physician clinical nutrition training programs. Current training programs were identified, descriptive information obtained, and training program content was compared with that recommended at the 1984 Conference on Clinical Nutrition Training. In general, goals as to the quantity of research, clinical, and teaching training are being met. Virtually all programs provide training in nutritional support activities. Most training programs are not as broad in scope of exposure to the less clinical aspects of nutrition nor to all the illness and age groups recommended by the 1984 conference. Consideration of broadening the scope of physician training programs or redefinition of training guidelines is warranted. A program-certifying agency may be helpful in identifying programs achieving certain minimal standards.

Observations of vitamin A toxicity in three patients with renal failure receiving parenteral alimentation.

Elevated serum retinol concentrations have been previously reported in patients with renal failure, although overt clinical toxicity has been described only rarely. We present three patients with renal failure receiving total parenteral nutrition (TPN) who developed biochemical and clinical findings of hypervitaminosis A. Improvement followed deletion of vitamin A from the TPN. These cases demonstrate that patients with renal failure may be at risk for symptomatic vitamin A toxicity if given TPN with standard retinol supplementation. Such patients should be carefully observed clinically and biochemically if supplementation is given.

Biennial survey of clinical nutrition training programs.

Three posttraining program surveys have been done by The American Society for Clinical Nutrition Committee on Subspecialty Training to evaluate the status of training programs in clinical nutrition. This survey updates demographic data about programs and determines which classes are offered or required as a part of basic nutrition-science requirements for nutrition training programs. In addition, the importance of board certification and accreditation of training programs is examined.

Consequences of modified fasting in obese pediatric and adolescent patients: effect of a carbohydrate-free diet on serum proteins.

Serum proteins were monitored during three studies of obese adolescents treated with protein-supplemented fasting in a clinical research center. In the first study of nine patients, small but significant decreases were noted for total serum protein, albumin, transferrin, retinol-binding protein, and complement beta 1c after 4 wk of carbohydrate-free protein-supplemented fast. In a further study of four of these same patients, the substitution of 400 glucose cal for 400 fat cal in a 5th wk of dietary study returned the total protein and retinol-binding protein concentrations to base-line levels. In a 3rd study of four patients, only complement beta 1c was significantly below base-line concentrations after 3 wk on a carbohydrate-containing protein-supplemented fast. There is an apparent metabolic effect of carbohydrate ingestion on maintaining usual concentrations of serum proteins.

Growth failure in infants with bronchopulmonary dysplasia: nutrition and elevated resting metabolic expenditure.

The mechanisms underlying growth failure in infants with bronchopulmonary dysplasia are poorly understood. Thirteen infants with bronchopulmonary dysplasia at 6 months of corrected age and 12 full-term healthy control infants matched for age or size were studied. Resting oxygen consumption was measured during natural sleep, and an estimation of the resting metabolic expenditure by indirect calorimetry was performed. Growth parameters were measured, and a nutritional profile including dietary intake, stool analysis, and serum albumin, cholesterol, glucose, and prealbumin was obtained. Seven of the 13 infants with bronchopulmonary dysplasia had growth failure (defined as length and weight less than the tenth percentile of the Babson growth curves). These infants had lower birth weight, lower gestational age, and a greater number of days spent in supplemental oxygen or on mechanical ventilation. There was no statistical difference between the bronchopulmonary dysplasia-growth failure and bronchopulmonary dysplasia-normal growth infants for dietary intake or stool or serum analyses. However, serum prealbumin showed a significant linear correlation with body weight in infants with bronchopulmonary dysplasia. Resting metabolic expenditure was elevated in infants with bronchopulmonary dysplasia with growth failure and was inversely correlated with body weight in all infants with bronchopulmonary dysplasia. Thus, infants with bronchopulmonary dysplasia and growth failure have increased metabolic demands and decreased prealbumin values suggesting a relative state of protein-calorie malnutrition.

Perinatal transmitted acute icteric hepatitis B in infants born to hepatitis B surface antigen-positive and anti-hepatitis Be-positive carrier mothers.

Three infants born to mothers who were hepatitis B surface antigen (HBsAg) positive and had antibody to hepatitis Be antigen (anti-HBe), developed acute icteric hepatitis B within three months of birth. All three infants clinically recovered and developed circulating anti-HBs. Contrary to previous studies, these three cases indicate that mother-infant transmission of the hepatitis B virus (HBV) does occur in infants born to HBsAg-positive, HBe-Ag-negative carrier mothers, and these infants may develop severe acute icteric hepatitis. Therefore, immunoprophylaxis in such newborns may be indicated.

Vitamin A sorption to polyvinyl and polyolefin intravenous tubing.

The loss of vitamin A to plastic infusion tubing from a total parenteral nutrition solution was studied using an in vitro infusion system and HPLC quantification of vitamin A. Polyolefin tubing was compared to polyvinyl chloride at varied vitamin A concentration, infusion temperature, and flow rate. Significantly enhanced recovery of vitamin A was found with the polyolefin tubing compared to that of the polyvinyl chloride under all conditions tested. After 24 hours under the varied conditions of the study, vitamin A availability ranged from 47 to 87% with polyolefin and 19 to 74% with polyvinyl chloride. These differences may be expected to result in significantly greater vitamin A delivery from polyolefin compared to polyvinyl chloride tubing to patients treated in neonatal intensive care units.

Vitamin E measurement in patients receiving intravenous lipid emulsions.

Two methods for the determination of plasma vitamin E--high-pressure liquid chromatography and spectrophotofluorometry--were compared on samples from four groups of pediatric patients: children and infants receiving lipid emulsion as part of their parenteral nutrition regimen, neonates receiving parenteral nutrition who were not receiving lipid emulsion at the time of blood sampling, and short admission surgery control subjects. In control subjects and patients not receiving lipid emulsions, both methods yielded similar results for vitamin E as alpha-tocopherol. In contrast, in patients receiving lipid emulsion, the fluorometric method yielded values ranging from 200% to 300% greater than did high-pressure liquid chromatography. The source of the discrepancy is most probably the presence of naturally occurring non-alpha-tocopherol isomers in the lipid products, which add to the fluorescent measurement but are resolved by high-pressure liquid chromatography. This study confirms clinically that fluorescent measurement of vitamin E is no longer the method of choice for monitoring tocopherol status in intensive care nurseries.

Phenobarbital does not prevent total parenteral nutrition-associated cholestasis in noninfected neonates.

Cholestasis associated with total parenteral nutrition (TPN) is a serious complication of this therapy for which there is no known treatment other than beginning enteral feeds. Phenobarbital is commonly used in other cholestatic disease states, but its benefit in this syndrome has not been demonstrated. We conducted a retrospective review of phenobarbital use in neonates receiving concurrent TPN. Thirty-one noninfected neonates were studied. They were without evidence of intrinsic liver disease at the institution of exclusive TPN therapy. For the purposes of this study, TPN-associated cholestasis was defined as a serum bilirubin in excess of 3 mg/dl at postnatal age of 3 weeks or more. Fourteen of the study infants received phenobarbital therapy for neurologic indications. Sixty percent of the phenobarbital-treated infants developed TPN-associated cholestasis, as compared to 33% of the untreated patients. Phenobarbital therapy was not effective in preventing TPN-associated cholestasis.

In vitro study of in line filtration of medications commonly administered to pediatric cancer patients.

Intravenous administration of drugs commonly used in patients with acute nonlymphocytic leukemia was simulated using a .22 micrometers air-eliminating filter. Drug concentrations were measured pre- and postfiltration using standard pediatric drug doses and concentrations. The percentage of administered dose recovered in the postfilter sample for chemotherapy drugs was adriamycin, 92%; dactinomycin, 87%; cytarabine, 96%; and vincristine, 90%. For antibiotics, the per cent recovery was carbenicillin, 90%; cephalothin, 96%; and gentamicin, 38%. Gentamicin, and perhaps other drugs evaluated, should not be administered through a filter of the type used in this study.

Successful treatment of superior vena cava syndrome with urokinase in an infant.

An 11-month-old infant with a central venous catheter for total parenteral nutrition for short gut syndrome developed head and neck swelling. A thrombus at the catheter tip occluding the superior vena cava was demonstrated roentgenographically. A 48-hr infusion of urokinase (4400 units/kg/hr) was administered for thrombolysis. The thrombus cleared clinically and roentgenographically without adverse effects. There has been no recurrence of the superior vena cava syndrome. Urokinase infusion is an alternative to immediate catheter removal in selected patients.

Serum vitamin A and E concentrations in pediatric total parenteral nutrition patients.

There is uncertainty as to optimal doses of fat soluble vitamins required by pediatric total parenteral nutrition (TPN) patients. We compared serum vitamin A (A) and E (E) concentrations analyzed by HPLC in chronic (greater than 2 weeks) TPN patients aged 1 month to 12 years to values obtained in out-patient surgery patients of the same age. TPN patients received 1500 micrograms of retinol and 2.5 IU of E as alpha-tocopheryl acetate (2.5 ml LyphoMed Multi Vitamin Concentrate). These doses were 214% of the recommended dose of A and 36% for E. Oral intake was minimal in most patients. The results of our study revealed a mean serum A level for TPN patients (N = 29) of 26.0 +/- 15.0 (SD) micrograms/dl vs 25.0 +/- 10.0 (SD) micrograms/dl in controls (N = 52). Mean serum E was 0.63 +/- 0.24 (SD) mg/dl vs 0.89 +/- 0.31 (SD) mg/dl for TPN patients and controls, respectively. There was no consistent trend related to duration of TPN for 23 patients with serial values. Seven (24%) TPN patients had serum A greater than mean + 2 SD of control (p less than 0.01). No values were less than mean - 2 SD. Infants on TPN had a significantly lower mean serum A (22.3 +/- 10.9 micrograms/dl) than TPN patients greater than 1 year of age (34.1 +/- 16.0 micrograms/dl; p less than 0.001). Fifty-two percent of TPN patients vs 26% of control had serum A less than 20 micrograms/dl (p greater than 0.1). For E, one patient had a high value and two patients low values relative to control.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of hypoalbuminemia in pediatric oncology patients--malnutrition or infection?

Nutritional status was evaluated on 210 occasions in 90 pediatric oncology inpatients during a 7-month period; 39 had solid tumors and 51 leukemia. Ages ranged from 3 months to 20 yr. Nutritional parameters were defined as normal, "at risk," or "probably malnourished." Fifty-seven and 29% of assessments revealed at least one parameter "at risk" or "probably malnourished," respectively. Prognosis was negatively related to the number of abnormal nutritional parameters. Serum albumin was most frequently abnormal. However, on most occasions, hypoalbuminemia was associated with weight/height, arm muscle area, and triceps skinfold measurements in the normal range. In order to further identify determinants of serum albumin, we analyzed dietary, chemotherapy, and temperature data in 10 prospectively studied leukemia patients, half of whom received parenteral nutrition. In these patients there was little relationship of serum albumin to chemotherapy or dietary intake. In all of these patients, especially those receiving total parenteral nutrition, low serum albumin was highly associated with fever (p less than 0.0005). We concluded that febrile illness is an important determinant of abnormal serum albumin concentrations. In pediatric cancer patients, abnormal serum albumin may more often reflect the acute metabolic response to fever and infection than depletion of body mass.

Partial peritoneal alimentation in an infant.

We provided partial peritoneal alimentation to a 1.69-kg 11-month-old premature infant who had no available central venous access, depleted peripheral venous access, and gastrointestinal dysfunction. A cuffed silastic catheter was surgically inserted into the suprahepatic space. An alimentation solution was continuously infused into the peritoneum for 28 days to supplement peripheral venous and nasogastric alimentation and contributed 42 +/- 15% of total calories daily. Weight gain was achieved, but complications included hypoglycemia, hypophosphatemia, intravascular dehydration, catheter site leakage, ascites, and hydrocele. At autopsy 11 months later, lipid accumulation was present in the upper peritoneum and the hilar regions of the lungs secondary to preexisting lymphatic obstruction. Partial peritoneal alimentation may be feasible when other access routes are inadequate, but lymphatic obstruction is a contraindication to the peritoneal administration of lipid emulsions.

Hyperammonemia in neonates receiving intravenous nutrition.

Inadequate arginine intake has been suggested as an etiology for hyperammonemia in neonates on parenteral nutrition. We randomized 26 nonasphyxiated neonates to receive amino acid solutions containing either 3.6 or 10.4% of total nitrogen as arginine when intravenous nutrition (IVN) therapy was initiated. Neonates in both amino acid solution study groups were observed to have significantly elevated blood ammonia (BA) concentrations during IVN (p less than 0.01) as compared to pre-IVN levels. Blood ammonia concentrations tended to be higher in infants receiving the 3.6% arginine amino acid solution. Septic infants were at particular risk for hyperammonemia as compared to nonseptic patients (p less than 0.025). Other clinical parameters including birth weight, gestational age, oxygen requirements, enteral nutritional intake, congenital anomalies, and heart disease did not appear to be related to BA concentration.

Calorie and protein requirements of pediatric patients with acute nonlymphocytic leukemia.

The calorie and protein requirements wer studied in 6 pediatric patients with acute nonlymphocytic leukemia treated in a laminar air flow unit. Calorie and protein requirements were estimated from anthropometric data. Mean total caloric requirement for weight maintenance was 136% of estimated basal metabolic rate, which is much lower than the RDA for healthy children. The mean protein requirement was 108% RDA. Provision of intravenous nutrients depressed oral intake. Infection had a deleterious effect on visceral protein status as determined by serum albumin.

Use of Hickman right atrial catheter in pediatric oncology patients.

Eighteen pediatric oncology inpatients had 21 Hickman right atrial catheters placed for total venous access; 16 patients received parenteral nutrition. Mean duration of catheterization was 43 +/- 29 (SD) days. Four catheters had to be removed for infection or clotting. The catheter-related sepsis rate was 10%. Serious catheter-related complications were no more frequent in this population than in patients receiving only parenteral nutrition via Broviac or pediatric Broviac catheters.

Repeated dose study of sucralose tolerance in human subjects.

Two tolerance studies were conducted in healthy human adult volunteers. The first study was an ascending dose study conducted in eight subjects, in which sucralose was administered at doses of 1, 2. 5, 5 and 10mg/kg at 48-hour intervals and followed by daily dosing at 2mg/kg for 3 days and 5mg/kg for 4 days. In the second study, subjects consumed either sucralose (n=77) or fructose (50g/day) (n=31) twice daily in single blind fashion. Sucralose dosage levels were 125mg/day for weeks 1-3, 250mg/day during weeks 4-7, and 500mg/day during weeks 8-12. No adverse experiences or clinically detectable effects were attributable to sucralose in either study. Similarly, haematology, serum biochemistry, urinalysis and EKG tracings were unaffected by sucralose administration. In the 13-week study, serial slit lamp ophthalmologic examination performed in a random subset of the study groups revealed no changes. Fasting and 2-hour post-dosing blood sucralose concentrations obtained daily during week 12 of the study revealed no rising trend for blood sucralose. Sucralose was well tolerated by human volunteers in single doses up to 10mg/kg/day and repeated doses increasing to 5mg/kg/day for 13 weeks. Based on these studies and the extensive animal safety database, there is no indication that adverse effects on human health would occur from frequent or long-term exposure to sucralose at the maximum anticipated levels of intake.

An unusual case presentation: pericardial tamponade complicating central venous catheter.

The use of central venous catheters in very low birthweight infants to provide adequate calories for growth is an integral part of the care of the high-risk neonate. The use of surgically placed Broviac catheters has been associated with infectious and mechanical complications. Recently, there has been increasing use of silastic central venous catheters inserted through a peripheral vein and advanced to the right atrium. These catheters have a reported low rate of complications. However, we report a case of a very low birthweight infant in whom a peripherally inserted silastic catheter perforated the wall of the right atrial appendage and led to fatal pericardial tamponade. This is a very rare but nearly always fatal complication. It is potentially avoidable by careful placement of the tip of the central venous catheter, so that it is not impinging on a wall of the heart. Serial venograms may be useful to reconfirm the position of the catheter.