Bodil Larsen

Low Energy Intakes Are Associated With Adverse Outcomes in Infants After Open Heart Surgery

BACKGROUND Infants with congenital heart lesions who undergo open heart surgery may experience physiologic and metabolic stress in the postoperative period, leading to altered metabolism and hypercatabolism. The purpose of this study was to determine the relationship between energy intake and hospital outcomes during the first 10 days following neonatal open heart surgery. MATERIALS AND METHODS A post hoc analysis of all patients in a prospective randomized controlled trial was performed. Nutrition intake and hospital outcomes were assessed in 32 infants (40 ± 2.2 weeks, 3.4 ± 0.5 kg) in the neonatal and pediatric intensive care units. Infants received parenteral nutrition (PN) for 1-4 days before and 10 days after open heart surgery. Infants were separated into those who received a cumulative energy intake of <689 kcal (average 63 kcal/kg/d) and those who received an intake ≥689 kcal during postoperative days 0-10. RESULTS Lower energy intake was associated with a significantly increased duration of artificial ventilation (5 ± 1.2 days), time to chest closure (1.4 ± 0.5 days), time in intensive care (5 ± 1.8 days), and stay in the hospital (25 ± 6.4 days). Lower energy intake was also associated with a significant increase in the length of time infants required PN (8 ± 2.9 days) and longer time to achieve full enteral intake of 100 mL/kg/d (7 ± 2.2 days) and before enteral feeds could be initiated (5 ± 1.5 days). CONCLUSIONS Providing <63 kcal/kg/d to infants after open heart surgery was associated with adverse pediatric intensive care outcomes.

A Canadian survey of perceived barriers to initiation and continuation of enteral feeding in PICUs.

Objective: Clinicians believe nutrition support is important; however, delivery of enteral nutrition may be delayed or interrupted due to a lack of guidelines or perceived contraindications to administration. The aim of this national survey was to examine the knowledge and perceived barriers among clinicians which prevent enteral nutrition administration to PICU patients. Design: The survey consisted of 23 questions (19 primary and four branching). The survey was validated using a semistructured pilot test by three pediatric critical care intensivists and two pediatric critical care registered dietitians external to the study team. Setting: The survey was electronically distributed to clinicians in all PICUs across Canada. Population: One hundred sixty-two PICU clinicians, including 96 staff intensivists, eight clinical assistants, 36 fellows, and 22 registered dietitians from PICUs across Canada. Interventions: None. Measurements and Main Results: The survey was administered from January to March 2013. The response rate was 50% (55 staff intensivists, two clinical assistants, nine fellows, and 15 registered dietitians). There was high variability among clinicians regarding reasons to delay the onset of enteral nutrition or interrupt enteral nutrition administration. High variability (> 70% agreement and < 10% disagreement or vice versa) was found for some reasons to delay or interrupt enteral nutrition, including lactates (rising or > 2 or > 4 mmol/L), high gastric residual volumes, CT/MRI scans, and hypoplastic left heart syndrome. Sixty-eight percent of PICU clinicians reported no written feeding protocol to be in place. Conclusions: Overall, there is high variability among clinicians regarding acceptable procedural and clinical barriers to enteral nutrition administration; this may be improved by a standardized feeding protocol. Therefore, further research must be conducted to provide clinicians with evidence to support their practices for enteral nutrition administration.

The profile of the systemic inflammatory response in children undergoing ventricular assist device support

OBJECTIVES Serum C-reactive protein (CRP) has been used as a systemic inflammatory response (SIR) marker in the critical ill, including children after cardiopulmonary bypass surgery. Ventricular assist devices (VAD) have been increasingly used as a bridge support to heart transplantation in children. We aimed to examine the profiles of CRP in children receiving VAD support. METHODS Charts of 13 children receiving Berlin Heart EXCOR(®) from 2005 to 2009 were reviewed. The data obtained prior to and during VAD support included: CRP, white blood cells, inotropes and steroid use, VAD mode and duration of VAD support. Ten patients received left VAD (LVAD) and 3 biventricular VAD (BiVAD). RESULTS The median duration of VAD support was 59 days (ranged 3-678 days). Pre-VAD CRP was 35 ± 51 mg/l and increased to 109 ± 59 mg/l on days 1-3 after the VAD implantation (P = 0.01), then gradually decreased to 28 ± 28 mg/l by 4 months and normalized by 5 months (P < 0.0001). CRP was higher in BiVAD than in LVAD patients throughout the study period (P = 0.003). CRP positively correlated with the doses of the epinephrine and norepinephrine and the monocyte counts, and negatively correlated with the lymphocyte count. The lymphocyte count was 2.5 ± 0.4 x 10(9)/l prior to implantation, and decreased to 2.1 ± 1.3 x 10(9)/l on days 1-3 (P = 0.5) and then to 0.6 ± 0.1 x 10(9)/l by 6 months (P = 0.08). It tended to be lower in BiVAD patients (P = 0.06). CONCLUSIONS SIR exists in children prior to VAD support. VAD implantation is associated with a significant and prolonged increase in CRP and a decrease in lymphocyte count, indicating a suppressed immune function, being more pronounced in BiVAD patients.

Reduction of Arachidonate Is Associated With Increase in B-cell Activation Marker in Infants: A Randomized Trial

Background: Infants who are not breast-fed benefit from formula with both docosahexaenoic acid (C22:6n3) and arachidonic acid (ARA; C20:4n6). The amount of ARA needed to support immune function is unknown. Infants who carry specific fatty acid desaturase (FADS) polymorphisms may require more dietary ARA to maintain adequate ARA status. Objective: The aim of the study was to determine whether ARA intake or FADS polymorphisms alter ARA levels of lymphocytes, plasma, and red blood cells in term infants fed infant formula. Methods: Infants (N = 89) were enrolled in this prospective, double-blind controlled study. Infants were randomized to consume formula containing 17 mg docosahexaenoic acid and 0, 25, or 34 mg ARA/100 kcal for 10 weeks. Fatty acid composition of plasma phosphatidylcholine and phosphatidylethanolamine, total fatty acids of lymphocytes and red blood cells, activation markers of lymphocytes, and polymorphisms in FADS1 and FADS2 were determined. Results: Lymphocyte ARA was higher in the 25-ARA formula group than in the 0- or 34-ARA groups. In plasma, 16:0/20:4 and 18:0/20:4 species of phosphatidylcholine and phosphatidylethanolamine were highest and 16:0/18:2 and 18:0/18:2 were lowest in the 34-ARA formula group. In minor allele carriers of FADS1 and FADS2, plasma ARA content was elevated only at the highest level of ARA consumed. B-cell activation marker CD54 was elevated in infants who consumed formula containing no ARA. Conclusions: ARA level in plasma is reduced by low ARA consumption and by minor alleles in FADS. Dietary ARA may exert an immunoregulatory role on B-cell activation by decreasing 16:0/18:2 and 18:0/18:2 species of phospholipids. ARA intake from 25 to 34 mg/100 kcal is sufficient to maintain cell ARA level in infants across genotypes.

Prevalence of inadequate vitamin d status and associated factors in children with cystic fibrosis.

BACKGROUND This study aimed to determine the prevalence of inadequate serum 25-hydroxyvitamin D (25(OH)D) levels in a pediatric Canadian cystic fibrosis (CF) population and to assess the effectiveness of a vitamin D supplementation protocol on improving vitamin D status. A secondary objective was to analyze factors that may be associated with inadequate 25(OH)D levels. METHODS Vitamin D supplementation, 25(OH)D levels, and factors hypothesized to be associated with 25(OH)D levels were collected through a retrospective chart review (2010 and 2011) of 96 patients (1-18 years) at one CF clinic in Canada. Adequacy of 25(OH)D was set at ≥75 nmol/L. Patients with inadequate 25(OH)D levels in 2010 were prescribed an additional 1000 IU/d for levels <60 nmol/L or 400 IU/d for levels 60-75 nmol/L. RESULTS Inadequate 25(OH)D levels were observed in 26% of patients in 2010 and 23% in 2011. After supplementation was increased for those with inadequate 25(OH)D levels in 2010 (n = 20), a significant increase in 25(OH)D levels was observed in 2011 (P = .03). Adequate status was achieved in 50% of these patients (n = 10). Age was significantly negatively associated with 25(OH)D levels in both years (P = .002). Percentage of forced expiratory volume in 1 second was significantly positively associated with 25(OH)D levels in 2011 (P = .03). CONCLUSION While vitamin D supplementation was effective at increasing serum 25(OH)D, this protocol did not achieve optimal serum 25(OH)D levels in 25% of the population. Increasing age had the strongest association with 25(OH)D. Current supplementation protocols may require reevaluation based on emerging evidence and revised Cystic Fibrosis Foundation guidelines.

Ganglioside Intake Increases Plasma Ganglioside Content in Human Participants

Background: Preclinical studies reveal associations between intestinal ganglioside content and inflammatory bowel disease (IBD). Since a low level of ganglioside is associated with higher production of proinflammatory signals in the intestine, it is important to determine safety and bioavailability of dietary ganglioside for application as a potential therapeutic agent. Materials and Methods: Healthy volunteers (HVs; n = 18) completed an 8-week supplementation study to demonstrate safety and bioavailabity of ganglioside consumption. HVs were randomized to consume a milk fat fraction containing 43 mg/d ganglioside or placebo, and patients with IBD (n = 5) consumed ganglioside supplement in a small pilot study. Plasma gangliosides were characterized using reverse-phase liquid chromatography–QQQ mass spectrometry. Intestinal permeability was assessed by oral lactulose/mannitol, and quality of life was assessed by quality of life in the IBD questionnaire. Results: There were no adverse events associated with dietary ganglioside intake. Ganglioside consumption increased (P < .05) plasma content of total GD3 by 35% over 8 weeks. HVs consuming ganglioside exhibited a 19% decrease in intestinal permeability (P = .04). Consumption of ganglioside was associated with a 39% increase (P < .01) in emotional health and a 36% improvement (P < .02) in systemic symptoms in patients with IBD. Conclusion: Impaired intestinal integrity characteristic of IBD results in increased permeability to bacterial antigens and decreased nutrient absorption. Intestinal integrity may be improved by dietary treatment with specific species of ganglioside. Ganglioside is a safe, bioavailable dietary compound that can be consumed to potentially improve quality of life in patients with IBD and treat other disorders involving altered ganglioside metabolism. This study was registered at clinicaltrials.gov as NCT02139709.

Feeding Practices and Outcomes of Infants Undergoing the Norwood Procedure

Objective. To determine if early pre- and postoperative enteral feeding was associated with improved postoperative outcomes in infants with hypoplastic left heart syndrome undergoing the Norwood pr...

The profile of inflammatory and metabolic response in children undergoing heart transplantation

Yu X, Larsen B, Urschel S, Cheung P‐Y, Ross DB, Rebeyka I, West L, Li J. The profile of inflammatory and metabolic response in children undergoing heart transplantation. 
Clin Transplant 2011 DOI: 10.1111/j.1399‐0012.2011.01566.x. 
© 2011 John Wiley & Sons A/S.