Dietary treatment of cows' milk protein allergy in childhood: a commentary by the Committee on Nutrition of the French Society of Paediatrics.

The diagnosis of cows' milk protein allergy (CMPA) requires first the suspicion of diagnosis based on symptoms described in the medical history, and, second, the elimination of cows' milk proteins (CMP) from the infant's diet. Without such rigorous analysis, the elimination of CMP is unjustified, and sometimes harmful. The elimination diet should be strictly followed, at least until 9-12 months of age. If the child is not breast fed or the mother cannot or no longer wishes to breast feed, the first choice is an extensively hydrolysed formula (eHF) of CMP, the efficacy of which has been demonstrated by scientifically sound studies. If it is not tolerated, an amino acid-based formula is warranted. A rice protein-based eHF can be an alternative to a CMP-based eHF. Soya protein-based infant formulae are also a suitable alternative for infants >6 months, after establishing tolerance to soya protein by clinical challenge. CMPA usually resolves during the first 2-3 years. However, the age of recovery varies depending on the child and the type of CMPA, especially whether it is IgE-mediated or not, with the former being more persistent. Once the child reaches the age of 9-12 months, an oral food challenge is carried out in the hospital ward to assess the development of tolerance and, if possible, to allow for the continued reintroduction of CMP at home. Some children with CMPA will tolerate only a limited daily amount of CMP. The current therapeutic options are designed to accelerate the acquisition of tolerance thereof, which seems to be facilitated by repeated exposure to CMP.

[Feeding during the first months of life and prevention of allergy]. / Alimentation des premiers mois de vie et prévention de l'allergie.

Allergy consists in the different manifestations resulting from immune reactions triggered by food or respiratory allergens. Both its frequency and severity are increasing. The easiest intervention process for allergy prevention is the reduction of the allergenic load which, for a major allergen such as peanuts, has to begin in utero. The primary prevention strategy relies first on the detection of at risk newborns, i.e. with allergic first degree relatives. In this targeted population, as well as for the general population, exclusive breastfeeding is recommended until the age of 6 months. The elimination from the mother's diet of major food allergens potentially transmitted via breast milk may be indicated on an individual basis, except for peanut, which is systematically retrieved. In the absence of breastfeeding, prevention consists in feeding at-risk newborns until the age of 6 months with a hypoallergenic formula, provided that its efficiency has been demonstrated by well-designed clinical trials. Soy based formulae are not recommended for allergy prevention. Complementary feeding should not be started before the age of 6 months. Introduction of egg and fish into the diet can be made after 6 months but the introduction of potent food allergens (kiwi, celery, crustaceans, seafood, nuts, especially tree nuts and peanuts) should be delayed after 1 year. This preventive policy seems partially efficacious on early manifestations of allergy but does not restrain the allergic march, especially in its respiratory manifestations. Probiotics, prebiotics as well as n-3 fatty polyunsaturated acids have not yet demonstrated any definitive protective effect.

[Folic acid and prevention of neural tube closure defects: the question is not solved yet]. / Prévention par l'acide folique des défauts de fermeture du tube neural: la question n'est toujours pas réglée.

Between 1981 and 1996, several interventional studies proved the efficacy of periconceptional folic acid supplementation in the prevention of neural tube closure defects (NTCD), first in women at risk (with a previous case of NTCD) and also in women of the general population in age to become pregnant. The poor observance of this supplementation led several countries (USA, Canada, Chile...) to decide mandatory folic acid fortification of cereals, which permitted a 30% (USA) to 46% (Canada) reduction in the incidence of NTCD. Moreover, this benefit was accompanied by a diminished incidence of several other malformations and of stroke and coronary accidents in elderly people. However, several papers drew attention to an increased risk of colorectal and breast cancer in relation with high blood folate levels and the use of folic acid supplements. A controlled interventional study showed a higher rate of recurrence of colic adenomas and a higher percentage of advanced adenomas in subjects receiving 1mg/day of folic acid. A recent study demonstrated an abrupt reversal of the downward trend in colorectal cancer 1 year after the beginning of cereal folic acid fortification in the USA and Canada. Two studies also reported impaired cognitive functions in elder persons with defective vitamin B(12) status. Taken in aggregate, these studies question the wisdom of a nationwide, mandatory, folic acid fortification of cereals. As of today, despite their limited preventive efficacy, a safe approach is to keep our current French recommendations and to increase the awareness of all caregivers, so as to improve the observance of these recommendations.

Effect of polyunsaturated fatty acids deficiency on oxidative phosphorylation in rat liver mitochondria.

Liver mitochondria isolated from controls or polyunsaturated fatty acid (PUFA) deficient rats were studied for oxidative phosphorylation. A PUFA-deficient diet led to a dramatic change in the fatty acid composition of mitochondrial lipid content, similar to that reported in the literature. Besides the changes in lipid composition, mitochondrial volume was enlarged (+45% in state 4 and two-fold in state 3). State 4 respiration was increased together with a decrease in protonmotive force. The non-ohmicity of the relationship between non-phosphorylating respiration and protonmotive force was more pronounced in the PUFA-deficient group. State 3 oxygen consumption as well as the rate of ATP synthesis showed no difference between the two groups, whereas the protonmotive force decreased substantially in mitochondria from PUFA-deficient animals. In contrast, ATP/O ratios were decreased in the PUFA-deficient group when determined at subsaturating ADP concentration. Taken together, these results are in agreement with both an increased non-ohmic proton leak and an increased redox slipping. The relative importance of these two effects on the overall efficiency of oxidative phosphorylation depends on both the rate of oxidative phosphorylation and the maintained protonmotive force. Hence, in isolated mitochondria the respective role of each effect may vary between state 4 and state 3.

Micronutrient levels in HIV-1-infected children.

OBJECTIVE: Micronutrients (zinc, copper, selenium, vitamin A, E, and carotenoids) are essential for the integrity of host defences. This study was designed to determine the prevalence of abnormalities of the micronutrient levels in HIV-1-seropositive children. DESIGN: Prospective study. SETTING: The study was performed on HIV-1-infected children at the Paediatric Haematology and Oncology Unit of Toulouse Hospital, France. PATIENTS: Twenty-one children, suffering from HIV-1 infection and 21 control subjects of similar age (2-9 years) were included in the study. In the HIV-1-infected children, two subgroups were considered according to stage (non-AIDS or AIDS), based on the Centers for Disease Control and Prevention 1987 criteria. RESULTS: The first statistically significant deficiencies occurred at non-AIDS stage and were confirmed at AIDS stage: P < 0.05 for lycopene, retinol, tocopherol and P < 0.001 for transthyretin and serum albumin. Levels of copper (40%) and long-chain polyunsaturated fatty acids (21%) were higher in the non-AIDS group than the controls. CONCLUSION: Biological impairing of the micronutrient levels was observed in the non-AIDS stage without clinical sign. This information is useful in delineating eventual and well considered nutritional intervention strategies that may improve the clinical status of HIV-1-infected children and perhaps alter the course of their disease.

Fatty acid composition and kinetic behaviour of liver retinyl esters in vitamin A sufficient and deficient rats.

Weanling rats were fed vitamin A deficient diets (-A) or diets supplemented with vitamin A (+A) (4.4 mg retinol equivalents/kg diet) for a period of 7 or 6 wk, respectively. In liver tissues of these two groups of animals both the subcellular localization as well as the fatty acid composition of the retinyl esters was studied. During vitamin A supplementation or deprivation, the kinetics of the different ester forms were investigated. Results indicate that the subcellular localization of all retinyl esters is similar and dependent on age. Two pools exist, ie one consisting of the nuclear/cell debris and mitochondrial-lysosomal fractions and the other containing the microsomal and cytosol fractions. HPLC analysis showed retinyl palmitate as the predominating (80%) form of the various retinyl esters. By supplementation clearly two kinetic behaviours can be demonstrated: one being a relatively stable storage of the palmitate and stearate, increasing with time and the second one being a more labile pattern for the ester forms with other saturated and unsaturated fatty acids. By vitamin A depletion all retinyl esters are affected indicating that the ester forms other than palmitate and stearate are also storage forms of vitamin A.

In vivo effects of olive oil-based lipid emulsion on lymphocyte activation in rats.

Numerous studies suggest that immune function may be compromised by lipid emulsions rich in polyunsaturated fatty acids, especially linoleic acid. In our study, we compared the effect of a new olive oil-based lipid emulsion (ClinOleic(R)) containing 18% linoleic acid, and an emulsion based on soybean oil (Ivelip(R); 52% linoleic acid) on lymphocyte functions. Weaning Wistar rats (n= 24) were fed for 4 weeks on an oral diet that contained 12% of total energy as lipids from soybean oil. Then they received, during 6 days, a total parenteral nutrition (260 kcal/kg/d) in which 12% of total energy was brought by one of the two lipid emulsions. The fatty acid profile of spleen lymphocyte phospholipids reflected lipid intakes, with a higher content of oleic acid in ClinOleic(R) group and linoleic acid in Ivelip(R) group. A greater proportion of cells expressed the interleukin-2 receptor a-chain (CD25) after administration of ClinOleic(R) when compared to Ivelip(R) (55.43 +/- 3.47 vs 45.48 +/- 3.26%, P<< 0.05). Moreover, the CD25 expression was positively correlated with oleic acid content of spleen lymphocyte phospholipids (r= 0.500, P<< 0.018). These results show that ClinOleic(R) is able to induce, in vivo, a greater proportion of cells expressing CD25, and suggest that oleic acid could have a role in the observed effects.

Metabolic utilization of linoleic acid from fat emulsion in infants during total parenteral nutrition.

The metabolic utilization of linoleic acid (C18:2w6) from intravenous (iv) soybean oil emulsion via its conversion to higher homologues and prostaglandin biosynthesis was studied in 21 infants. The infants were of normal birth weight, in good clinical and metabolic condition, and aged from 1-4 months. They all received total parenteral nutrition after birth for more than 1 month; the only lipid was provided by iv Intralipid 20%, at levels approximating 350 mg/kg/24 h of linoleic acid (2.5% of the infants' total daily energy intake). Study of the fatty acids of plasma and erythrocyte phospholipids in these infants, compared to healthy controls of the same age (N = 26), showed that 350 mg/kg/24 hr of C18:2w6 supply resulted in normalization of erythrocyte phospholipid fatty acid distribution. This was particularly true of the higher homologues of C18:2w6 (C18:3w6, C20:3w6, and C20:4w6). This suggested that delta 6 and delta 5 desaturation activities are normal in these conditions with this C18:2w6 supply. These results were confirmed by the study of 24-hr urinary excretion of prostaglandins PGE1 and PGE2. With 350 mg/kg/24 hr of C18:2w6 supply their urinary levels were not significantly different from those observed in normal children of the same age receiving an equivalent oral C18:2w6 intake.

Plasma phospholipid fatty acids and urinary excretion of prostaglandins PGE1 and PGE2 in infants during total parenteral nutrition, with continuous or sequential administration of fat emulsion.

During total parenteral nutrition, using an identical supply of fat emulsion (350 mg/kg/24 hr) to correct essential fatty acid deficiency in children, the efficacy of two methods of administration was studied: continuous over 24 hr, or discontinuous 3 hr/day. At the beginning of the study, all the infants (1-4 months old) had proven essential fatty acid deficiency. After at least 1 month of one of the two nutritional protocols (continuous or discontinuous), plasma phospholipid fatty acid composition and PGE1 and PGE2 urinary excretion were measured. The results obtained indicate better utilization of the fat emulsion when it is administered almost every day, in continuous infusion over 24 hr (1 g/kg/24 hr of Intralipid 20%).

Fatty acid composition of adipocyte membrane phospholipids and stored triglycerides in infants receiving total parenteral nutrition.

Fatty acid (FA) composition of membrane phospholipids (PL) and stored triglycerides (TG) from adipose tissue was studied in eight infants aged 1 to 4 months receiving total parenteral nutrition (TPN) since birth. During this period, essential fatty acid (EFA) intake consisted exclusively of soybean oil emulsion administered by intravenous route (Intralipid 20%) representing 301 +/- 88 mg/kg/24 hr of linoleic acid and 58 +/- 18 mg/kg/24 hr of alpha-linolenic acid, or 2.3 +/- 0.6% and 0.4 +/- 0.1%, respectively, of total energy intake. The results were compared with those of eight control infants of the same age receiving orally a normal milk diet with an intake of 660 +/- 260 mg/kg/24 hr of linoleic acid and 101 +/- 35 mg/kg/24 hr of alpha-linolenic acid, or 4.5 +/- 0.7% and 0.7 +/- 0.3%, respectively, of total energy intake. Although their EFA intake was significantly lower (p less than 0.01) and administered only parenterally, after 1 to 4 months the infants receiving TPN still had a membrane phospholipid FA pattern of adipose tissue which was not significantly different from that of normal children of the same age. In stored adipocyte TG, the percentage of linoleic acid was significantly lower (p less than 0.01) in infants receiving TPN. This is probably of nutritional importance as at this stage of life the child builds up its stores of EFA. The proportion of the other fatty acids in adipocyte TG was not significantly modified.

Total parenteral nutrition decreases liver oxidative metabolism and antioxidant defenses in healthy rats: comparative effect of dietary olive and soybean oil.

BACKGROUND: Total parenteral nutrition (TPN) is used for critically ill patients undergoing surgery, after trauma, or during disease conditions that favor oxidative stress. We studied the effect of TPN on liver oxidative metabolism and antioxidant defenses in rats, and we compared the effect of soybean oil- and olive oil-based diets. METHODS: Seven-week-old rats (n = 28) were divided into four groups. Two experimental groups received a TPN solution containing soybean oil (TPN-S) or a mixture of olive/soybean oil, 80/20 (TPN-O), IV for 6 days. Orally fed animals received a solid diet including soybean oil (Oral-S) or olive/soybean oil, 80/20 (Oral-O). The following parameters were measured: DL-alpha-tocopherol, vitamin A, malondialdehyde and thiobarbituric acid reactive substances (MDA-TBARS), and total radical-trapping antioxidant parameter (TRAP) in serum; DL-alpha-tocopherol, vitamin A, glutathione (GSH), and catalase (Cat) activity in liver homogenate; fatty acids from phospholipid, cytochrome P-450 content, NADPH-cytochrome c2 reductase activity in liver microsomes; superoxide dismutase (SOD), glutathione peroxidase (Gpx), glutathione reductase (GR), glutathione transferase (GST), and glucose-6-phosphate dehydrogenase (G6PD) in liver cytosol. RESULTS: The soybean or olive oil diets modified the liver microsomal fatty acid phospholipid composition, but the unsaturation index remained unchanged. TPN specifically increased the saturation of the membrane. The cytochrome P-450 level and the NADPH-cytochrome c2 reductase, SOD, Gpx, Cat, and GST activities were unchanged by soybean oil or olive oil diet but decreased receiving TPN. CONCLUSIONS: In rats, TPN decreased the liver oxidative metabolism and enzymatic antioxidant defenses. This may be related to saturation of the liver microsomal fatty acids.

Effects of retinoic acid on hepatic cytochrome P-450 dependent enzymes in rats under different vitamin A status.

The temporal effects of retinoic acid supplementation on hepatic cytochrome P-450-dependent enzymes were studied on the rat. Four groups of male weanling rats were fed semi synthetic diets: two groups containing 0 or 4.4 mg retinol equivalents per kg diet as retinyl palmitate (A- RA- and A+ RA- groups) and two similar groups supplemented with all trans retinoic acid (12 mg/kg diet) (A- RA+ and A+ RA+ groups). After five or ten weeks of feeding, the rats were killed, liver microsomes were prepared and assayed for aniline hydroxylase, aminopyrine N demethylase activities and cytochrome P-450 levels. Whereas no change was observed between the four groups after 5 weeks, the following modifications appeared after 10 weeks: Vitamin A deficiency decreased hepatic drug metabolism by phase I enzymes (hydroxylase and N demethylase) but only when liver storage pool was not detectable. Vitamin A concentration as low as 4 micrograms/g is sufficient to avoid any perturbation of these enzymes. Parallel to a sparing effect on liver reserves of vitamin A, retinoic acid maintained a normal activity of enzymes of xenobiotic metabolism. However, retinoic acid treatment produced an alteration of phase I enzymes in vitamin A supplemented group (A+ RA+). As this was accompanied by a doubling of vitamin A liver reserves, compared to A+ RA- group, it is suggested that this might result from a liver vitamin A overloading, leading to membrane damage perturbing microsomal enzymes. These results indicate the need for a more careful use of retinoids as a therapeutic agent.

Evidence for two subcellular pools and different kinetic behaviour of retinyl palmitate in rat liver.

Rats were fed vitamin A deficient diets (-A) or supplemented with vitamin A (+A) (4.4 mg retinol equivalents/kg diet), either without (-RA) or with retinoic acid (+RA) (12 mg/kg diet) supplementation for up to six weeks. Plasma and liver levels as well as the subcellular localization of vitamin A were determined. In rats reared on the vitamin A rich diet the localization of retinyl palmitate (principal reserve form) is shown to be dependent on age. Two pools exist, i.e. one consisting of the nuclear and mitochondrial-lysosomal fractions and the other containing the microsomal and cytosol fractions. A rapid replenishment of mitochondrial-lysosomal fractions occurs in the first weeks after the weaning. During six weeks of deficient diet an identical mobilization was seen from the different subcellular fractions. Supplementation with RA caused an immediate and sustained reduction of serum vitamin A levels but did not disturb the subcellular localization of retinyl palmitate. A relationship between these phenomena and the subcellular distribution of the retinyl palmitate hydrolase (RPH) and the cellular vitamin A binding proteins (CRBP) is likely to exist.

[T lymphocyte populations of the intestinal mucosa in celiac disease in children. Immunohistochemical study]. / Populations lymphocytaires T de la muqueuse intestinale au cours de la maladie coeliaque chez l'enfant. Etude immunohistochimique.

In order to study the distribution of lymphocyte subpopulations in a pathologic intestinal mucosa, the authors, instead of using the classic method by counting the number of lymphocytes, present an original method permitting the exploitation of quantified data from labelled surface cells by texture analyser coupled with a computerized system. We investigated 25 children presenting with chronic diarrhea and villous atrophy and 5 control subjects. Fifteen of the 25 children had celiac disease (10 active with total villous atrophy and 5, celiac disease in remission with healing mucosa), 5 cow's milk protein intolerance with total or partial villous atrophy and 5, chronic diarrhea with partial villous atrophy. Immunohistochemical study with monoclonal antibodies was carried out on frozen sections using a three-step immunoperoxidase technique. Compared with the 5 controls, patients with food intolerance (celiac disease and cow's milk protein intolerance) showed a significant increase of T suppressor lymphocytes (p less than 0.01 and p less than 0.05) in the epithelium, whereas there were more T helper lymphocytes in the lamina propria (p less than 0.05 and p less than 0.01). Non-treated celiac disease was distinguished from treated celiac disease by a marked increase in intra-epithelial T cytotoxic-suppressors. These results suggest that T cytotoxic-suppressors may be the mediators of the lesions observed in celiac disease.

[Screening of essential fatty acid deficiency in children. Respective value of the assay of fatty acids in total lipids and lipid fractions of the serum]. / Dépistage d'une carence en acides gras essentiels chez l'enfant. Intérêt respectif du dosage des acides gras dans les lipides totaux et les fractions lipidiques du sérum.

This study was carried out in metabolically stable infants aged from one to six months receiving artificial food. The lipid serum fraction presenting changes characteristic of essential fatty acid (EFA) deficiency was determined. A preliminary study (n = 13 samples) showed that analysis of total fatty acids (TFA) and of phospholipids (PL) was more discriminatory than analysis of free fatty acids (FFA), triglycerides (TG) or esterified cholesterol (EC). Comparison of TFA and PL (n = 25 samples) confirmed literature data; in particular, C18: 2 n-6 and C20: 4 n-6 decreased whereas C20: 3 n-9 increased. These changes were clearer and significantly greater (p less than 0.001) for C20: 3 n-9 and C20: 4 n-6 of the PL, but were also very significant for the TFA compared to healthy controls. The C20: n-9/C20: n-6 ratio was identical for all fractions. TFA analysis by gas-liquid chromatography is faster and less costly than analysis of lipid fractions and provides sufficient data for screening of EFA deficiency.

[Plasma amino acid disturbances and depression]. / Perturbations des acides aminés plasmatiques et dépression.

Plasmatic amino acids concentrations were measured in 59 depressive patients and compared with that of a control population. Serine, glutamine, cystine, lysine and arginine have increased levels in the depressed males and females; so are 3 competitors of the tryptophan for the transport through the blood-brain barrier: valine, leucine and isoleucine. The tryptophan ratio is decreased in the depressive males. The sum of the competitors of the tryptophan is increased in the depressive males and females. All these results are discussed in relation with an abnormality of the carrier through the blood-brain barrier in the depressive state, without no proof thereof being however given.

[Milk feeding of infants and cow's milk protein hypersensitivity]. / Alimentation lactée du nourrisson et allergie aux protéines du lait de vache.

BACKGROUND: Cow milk protein intolerance (CMPI) is characterized by a wide range of symptoms and signs affecting the gastro-intestinal tract, the respiratory system and the skin. A better definition, a stricter application of diagnostic criteria and critical evaluation of certain immunologic correlates can contribute to a better understanding and preventive treatment of this entity. POPULATION AND METHODS: Two hundred-seventeen infants with CMPI seen between January 1980 and December 1993 were included in the study. They were classified into two groups: 1) acute reaginic CMPI (type I): 125 infants and 2) CMP enteropathy or colitis (type III or IV): 92 infants, according to classical diagnostic criteria. Careful investigation concerning the type of milk feeding (breast or artificial) proposed prior to clinical manifestations was performed. RESULTS: Among the 125 infants (aged 3 to 20 weeks) with acute reaginic CMPI, 121 (97%) had been breast-fed with a sudden weaning; 30 of these infants had also received one to three formula bottles during the first 3 days of life and 14 certainly had not received such formula bottles. Among the 92 infants with CMPI, type III or IV, 33 (38%) had been exclusively breast-fed, a figure quite similar to the breast feeding incidence in our region. CONCLUSIONS: These results clearly show the importance of breast-feeding in the personal history of CMPI. Acute reaginic type of CMPI is favored by early ingestion of formula bottles in breast-fed infants and by early sudden weaning. Hypoallergenic formula in five cases was unable to protect infants against further allergic manifestation.

[Iron and pregnancy]. / Fer et grossesse.

Infants, young children, and childbearing aged women are particularly exposed to iron deficiency. Pregnancy further increases iron requirements. Nevertheless the consequences of anemia and/or iron deficiency on pregnancy outcome, development of the foetus and postnatal iron status of the infant, remain to be determined. There is a 3-fold increase of premature deliveries in iron deficient anemic pregnant women whose anemia is discovered in early pregnancy: however this increased risk of premature delivery is not observed when iron deficiency anemia is discovered in late pregnancy. Iron supplementation during pregnancy improves the maternal hematological parameters but it is still unclear whether it also improves the maternal health and the pre and postnatal development of the child. Based on our actual knowledge, iron supplementation during pregnancy is to be recommended in risk groups only (ie mainly adolescents, low income women, women with multiple pregnancies), using ferrous iron at a dosage of 30 mg per day.

[Iodine nutrition in the infant. Committee on Nutrition of the French Society of Pediatrics]. / La nutrition iodée chez l'enfant. Comité de Nutrition de la Société française de pédiatrie.

Iodine is a trace element essential for the synthesis of thyroid hormones. It is present in the human body in minute amounts (15-20 mg in adults). The thyroid is very sensitive to iodine deficiency in newborns and infants because of its very low iodine content. Daily iodine requirements in humans vary from 40 micrograms in neonates to 150 micrograms in adults. Iodine deficiency represents the first cause of avoidable mental deficiency in developed countries; it has not yet disappeared in Europe, especially in the East, where it is responsible for a high prevalence of goiter. Iodine deficiency during pregnancy increases the risk of neonatal transient hypothyroidism, with a high recall rate in programs of systematic screening for congenital hypothyroidism. Data available in France suggest that screening for iodine deficiency should be performed during pregnancy, and that the minimal iodine concentration in formula milk should be increased to 10 micrograms/100 kcal for term infants and 20 micrograms/100 kcal for premature infants. Iodine deficiency is ideally prevented by the use of iodized salt. Because of the risk of iodine overexposure and secondary transient hypothyroidism, the use of iodinated antiseptics must be avoided in premature babies and neonates as well as in pregnant and lactating women. The fight against iodine deficiency, associated with oral stable preventive iodine administration, decreases sharply the risk of thyroid cancer in case of nuclear exposure, by diminishing thyroid uptake of iodine radioactive isotopes.

[Protein requirements in children during states of stress. Committee on Nutrition of the French Society of Pediatrics]. / Apports protéiques chez l'enfant au cours des états d'agression. Comité de nutrition de la Société française de pédiatrie.

Acute and chronic stress conditions affecting critically ill children are characterized by severe protein breakdown and growth failure. This paper describes the disorders of protein metabolism, and gives recommendations for protein and energy intakes during stress conditions in children.