Anjali Parish

Nutrition and the Lung

The use of surfactant replacement, ‘kinder gentler’ modes of ventilation combined with prenatal corticosteroids have all played a role in improved survival rates of very-low-birth-weight infants but have not reduced the prevalence of chronic lung disease. The increased rates of prematurity being observed in the United States along with the increased survival makes the overall problem of treatment of infants with established disease expensive spanning neonatology, pediatric critical care and general pediatrics and involving a myriad of specialists over the life of the surviving infant. However, none of the therapies used over the years have proven to be effective or have long-term adverse effects, nor have they been accepted as methods to prevent chronic lung disease. Although intuitively an appropriate nutritional therapy may be a useful adjunct in the care of the premature sick infant, perinatal malnutrition remains a major problem. The role of nutrition therapy in health and disease as it pertains to the lung will be reviewed.

Early Aggressive Nutrition for the Premature Infant

Nutrition for sick newborn infants, both term and preterm, has been evolving since the first published report of use of total parenteral nutrition (TPN) in an infant. The more preterm infants have posed an even greater challenge, because optimal timing for use of enteral nutrition is an additional factor for completing their nutritional demands. Although benefiting the immune system among other physiological benefits, human milk has many nutritional gaps for the premature infant. The development of premature infant formulas and milk fortifiers has helped fill these gaps, but questions still exist about safety and efficacy of human milk versus formula. This article will focus on the use of TPN as well as early initiation of enteral feedings and the challenges this brings.

GERD or not GERD: the fussy infant

A global evidence-based consensus has defined gastroesophageal reflux disease (GERD) as ‘a condition, which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.’ The manifestations of GERD can be divided into esophageal and extraesophageal syndromes, and include vomiting, poor weight gain, dysphagia, abdominal or substernal/retrosternal pain, esophagitis and respiratory disorders. The extraesophageal syndromes have been divided into established and proposed associations: established would include cough, laryngitis, asthma and dental erosion ascribable to reflux, whereas proposed associations would include pharyngitis, sinusitis, idiopathic pulmonary fibrosis and recurrent otitis media. Uninvestigated patients with esophageal symptoms without evidence of esophageal injury would be considered to have asymptomatic esophageal syndromes, whereas those with demonstrable injury are considered to have esophageal syndromes with esophageal injury. Therefore, this allows symptoms to define the disease but permits further characterization if mucosal injury is found. Within the syndromes with associated injury are reflux esophagitis, stricture, Barretts esophagitis and adenocarcinoma. This review will address definitions of GER and GERD-associated symptoms and treatment options.

Seizures as a predictor of long-term neurodevelopmental outcome in survivors of neonatal extracorporeal membrane oxygenation (ECMO)

A longitudinal, prospective study was conducted to determine the long-term neurodevelopmental outcome in neonatal extracorporeal membrane oxygenation (ECMO) survivors with and without seizures. One hundred sixty-two ECMO survivors from March 1985 until November 1995 were eligible for follow-up. Sixty-four returned at preschool age (4—6 years). Thirty-nine infants did not experience neonatal seizures (group 1); however, 25 exhibited seizures before or during ECMO (group 2). Twelve infants referred for ECMO, but managed medically, served as a clinical comparison group (group 3). At school age (7—9 years), 32 ECMO children (16 with seizures) returned for neuropsychologic evaluation. The results indicated that the preschool seizure group (group 2) demonstrated a significantly lower mean IQ than group 1 or 3 (P = .002). Furthermore, 56% of group 2 had IQ scores ≤ 84 (≥ 1 SD below the mean). Group 2 also exhibited significantly higher rates of cerebral palsy (P ≤ .001) and speech-language disorder than group 1 or 3 (P < .001). At school age, the seizure group continued to perform below average on intelligence testing, with 50% scoring ≤ 84 and 38% receiving special education. This study extends the previous findings that seizures associated with neonatal ECMO are a primary risk factor for neurodevelopmental sequelae and confirms the need for long-term follow-up to assist with academic programming. (J Child Neurol 2004;19:930—934).

Feeding strategies in the ELBW infant

Necrotizing enterocolitis (NEC) remains a common emergency that carries high morbidity and mortality for extremely low birth weight infants. To date there have been no multicenter randomized controlled trials to evaluate different feeding strategies and NEC. Clinicians must weigh their experience against small amounts of data in deciding the best way to feed their patients. Currently published feeding protocols and evidence for the same will be reviewed. Also reviewed is the evidence for use of human milk, initiation and advancement of feedings, and the use of probiotics.

Medical management of short gut syndrome.

The provision of appropriate nutritional support is an essential part of the primary and adjunctive management of many gastrointestinal (GI) disorders in neonatology and pediatrics. Few conditions in neonatology pose as great a challenge as intestinal failure or short bowel syndrome (SBS). The latter, SBS, is a complex disorder affecting normal intestinal physiology with nutritional, metabolic and infectious consequences. It is a result of the alteration of intestinal digestion and absorption following extensive bowel resection. Medical management of SBS is a very labor-intensive problem. Nutritional support and monitoring are of paramount importance, and long-term morbidity and mortality will depend on recognition and careful management of associated complications. With the increased use of intestine or intestine–liver transplant, maintaining these infants in good ‘health’ to allow transplantation will go a long way in achieving good long-term outcomes.

Hypothermia for hypoxic-ischemic brain injury.

Hypoxic–ischemic brain injury and hypoxic–ischemic encephalopathy (HIE) remain a serious problem for both preterm and term neonates with the spectrum of injury ranging from neuronal injury to encephalopathy and death. Neonatal encephalopathy due to such injury occurs in 3–9 of every 1000 term infants. Of these, it is estimated that nearly a third to a half will either have severe adverse outcomes or die. Treatment of infants with HIE remains generally supportive with attention to resuscitation, fluid and electrolyte homeostasis, maintenance of acid-base balance, nutrition and feeding issues and treatment of seizures.

Infant with MRSA necrotizing fasciitis

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Contents Vol. 95, 2009

S. Andersson, Helsinki E. Bancalari, Miami, Fla. G. Buonocore, Siena W.A. Carlo, Birmingham, Ala. V.P. Carnielli, Ancona W.J. Cashore, Providence, R.I. I.A. Choonara, Derby T. Curstedt, Stockholm O. Dammann, Boston, Mass. C. Dani, Florence B. Darlow, Christchurch P. Gluckman, Auckland M. Hallman, Oulu B. Jonsson, Stockholm S.E. Juul, Seattle, Wash. A. Llanos, Santiago R.J. Martin, Cleveland, Ohio C.J. Morley, Cambridge J. Neu, Gainesville, Fla. P.C. Ng, Hong Kong M. Obladen, Berlin A.G.S. Philip, Palo Alto, Calif. M. Post, Toronto E. Saliba, Tours O.D. Saugstad, Oslo B. Schmidt, Philadelphia, Pa. E. Shinwell, Rehovot J. Smith, Cape Town B. Sun, Shanghai H. Togari, Nagoya F. van Bel, Utrecht N. Vain, Buenos Aires M. Vento Torres, Valencia M. Weindling, Liverpool J.A. Widness, Iowa City, Iowa Fetal and Neonatal Research