Agostino Pierro

Neonatal Nutrition and Metabolism: Nutrition in the neonatal surgical patient

© Cambridge University Press 2006 and 2009. The newborn infant is in a “critical epoch” of development not only for the organismas a wholebut also for the individual organs and most significantly for the brain.1 Adequate nutrition in the neonatal period is necessary to avoid the adverse effects of malnutritiononmorbidityandmortality2 and to minimise the future menace of stunted mental and physical development.1 The survival rate of newborn infants affected by isolated congenital gastrointestinal abnormalities has improved considerably over the past 20 years and is now in excess of 90% in most pediatric surgical centers. The introduction of parenteral nutrition and advancement in nutritional management are certainly among the main factors responsible for this improvement. Historical background Parenteral nutrition stepped forward from numerous historical anecdotes in the 1930s with the first successful infusion of protein hydrolysates in humans, 3 followed by the first report of successful total parenteral nutrition in an infant in 1944, 4 and given a huge boost by the first placementof a catheter in the superior vena cava to deliver nutrients for prolonged periods.5 Using this system, Dudrick and Wilmore showed that adequate growth and development could be achieved in beagle puppies and in a surgical infant.5 Following these initial reportsFillerandco-authors reported the first series of surgical neonates with gastrointestinal abnormalities treated with long-term total parenteral nutrition.

Fluid, Electrolyte and Nutritional Support of the Surgical Neonate

The newborn infant is in a “critical epoch” of development. A healthy term infant grows at a rate of 25–30 g per day over the first 6 months of life, so that weight has doubled by the age of 5 months. This growth clearly requires adequate nutrition, but especially where medical or surgical conditions exist, must also be carefully managed together with fluid and electrolytes. Thus a significant period of inadequate nutrition, or inappropriate fluid and electrolyte administration, may not only affect short-term outcomes, but may also be a risk factor for the long-term menace of stunted mental and physical development. Amongst preterm infants, lower in-hospital growth velocity is associated with impaired neurodevelopmental outcome. Fluids and electrolytes undergo changes during the perinatal period, so an understanding of the perinatal changes in body composition is useful to understand the principles behind the fluid, electrolyte and nutritional management of surgical neonates. As well as providing the components necessary for increase in tissue mass, adequate provision of nutrients is also required to mount an appropriate immune response is extremely important, as infection and sepsis may impair growth and neurodevelopmental outcome.

Evidence Based Neonatal Surgery

Surgical intervention has, quite rightly, a well-established role in the management of a number of congenital and acquired neonatal conditions. Surgical approaches have been developed over a period of time, from the initial endeavours of pioneering neonatal surgeons, to the procedures commonly in everyday use today. Such development has been predominantly a result of necessity, learning from past experience and translation of techniques in use in other surgical fields into neonatal surgery. As neonatal surgical experience has grown, surgeons have begun to develop alternatives to what were once thought to be traditional techniques such that for a number of conditions we now have the luxury of choice in the treatment of these often fragile infants. With choice, there comes a dilemma. Which approach should be used? How should we make the decision?