Whole body protein synthesis and energy expenditure in very low birth weight infants.

The aim of the present work was to study whole body protein synthesis and breakdown, as well as energy metabolism, in very low birth weight premature infants (less than 1500 g) during their rapid growth phase. Ten very low birth weight infants were studied during their first and second months of life. They received a mean energy intake of 114 kcal/kg X day and 3 g protein/kg X day as breast milk or milk formula. The average weight gain was 15 g/kg X day. The apparent energy digestibility was 88%, i.e. 99 kcal/kg X day. Their resting postprandial energy expenditure was 58 kcal/kg X day, indicating that 41 kcal/kg X day was retained. The apparent protein digestibility was 89%, i.e. 2.65 g/kg X day. Their rate of protein oxidation was 0.88 g/kg X day so that protein retention was 1.76 g/kg X day. There was a linear relationship between N retention and N intake (r = 0.78, p less than 0.001). The slope of the regression line indicates a net efficiency of N utilization of 67%. Estimates of body composition from the energy balance, coupled with N balance method, showed that 25% of the gain was fat and 75% was lean tissue. Whole body protein synthesis and breakdown were determined using repeated oral administration of 15N glycine for 60-72 h, and 15N enrichment in urinary urea was measured. Protein synthesis averaged 11.2 g/kg X day and protein breakdown 9.4 g/kg X day. Muscular protein breakdown, as estimated by 3-methylhistidine excretion, contributed to 12% of the total protein breakdown.(ABSTRACT TRUNCATED AT 250 WORDS)

Patient-ventilator asynchrony during noninvasive pressure support ventilation and neurally adjusted ventilatory assist in infants and children.

OBJECTIVES: To document the prevalence of asynchrony events during noninvasive ventilation in pressure support in infants and in children and to compare the results with neurally adjusted ventilatory assist. DESIGN: Prospective randomized cross-over study in children undergoing noninvasive ventilation. SETTING: The study was performed in a PICU. PATIENTS: From 4 weeks to 5 years. INTERVENTIONS: Two consecutive ventilation periods (pressure support and neurally adjusted ventilatory assist) were applied in random order. During pressure support (PS), three levels of expiratory trigger (ETS) setting were compared: initial ETS (PSinit), and ETS value decreased and increased by 15%. Of the three sessions, the period allowing for the lowest number of asynchrony events was defined as PSbest. Neurally adjusted ventilator assist level was adjusted to match the maximum airway pressure during PSinit. Positive end-expiratory pressure was the same during pressure support and neurally adjusted ventilator assist. Asynchrony events, trigger delay, and cycling-off delay were quantified for each period. RESULTS: Six infants and children were studied. Trigger delay was lower with neurally adjusted ventilator assist versus PSinit and PSbest (61 ms [56-79] vs 149 ms [134-180] and 146 ms [101-162]; p = 0.001 and 0.02, respectively). Inspiratory time in excess showed a trend to be shorter during pressure support versus neurally adjusted ventilator assist. Main asynchrony events during PSinit were autotriggering (4.8/min [1.7-12]), ineffective efforts (9.9/min [1.7-18]), and premature cycling (6.3/min [3.2-18.7]). Premature cycling (3.4/min [1.1-7.7]) was less frequent during PSbest versus PSinit (p = 0.059). The asynchrony index was significantly lower during PSbest versus PSinit (40% [28-65] vs 65.5% [42-76], p < 0.001). With neurally adjusted ventilator assist, all types of asynchronies except double triggering were reduced. The asynchrony index was lower with neurally adjusted ventilator assist (2.3% [0.7-5] vs PSinit and PSbest, p < 0.05 for both comparisons). CONCLUSION: Asynchrony events are frequent during noninvasive ventilation with pressure support in infants and in children despite adjusting the cycling-off criterion. Compared with pressure support, neurally adjusted ventilator assist allows improving patient-ventilator synchrony by reducing trigger delay and the number of asynchrony events. Further studies should determine the clinical impact of these findings.

La Detecció universal neonatal de la sordesa a Catalunya : situació actual i reptes de futur

Des de principi dels anys 90, els programes per a la detecció universal neonatal de la sordesa -DUNS- s'han anat implementant arreu del món. La seva aportació a la millora de la competència en llenguatge dels infants sords ha estat forca significativa. A l'Estat espanyol, la DUNS esta possibilitant una detecció molt més precç de la sordesa, cosa que accelera l'establiment del diagnostic i del tractament, i augmenta així les probabilitats que la rehabilitació auditiva dels infants sords sigui reeixida. Des de la perspectiva de l'atenció integral de la sordesa infantil, aquests programes tenen com a objectiu la detecció de la patologia dins el primer mes de vida, el diagnòstic als tres mesos i la instauració del tractament al voltant dels sis mesos. Aquests terminis suposen un autèntic repte que exigeix, d'una banda, la creació de centres qualificats i, de l'altra, la reformulació dels protocols d'actuació dels professionals de les distintes disciplines i la seva adaptació a les noves eines disponibles per al diagnòstic, l'adaptació protètica i la rehabilitació auditiva del nadó sord. Si en un article anterior abordava el futur de la intervenció amb infants sords, tot considerant els avenços tècnics ja existens (Valero, 2002); ara em proposo revisar breument l'estat de la qüestió a Catalunya, alhora que es faran una sèrie de reflexions sobre els canvis que la detecció molt primerenca d'infants sords pot reportar tant per als mateixos sords com per als professionals que els hem d'atendre.

Water, energy and early postnatal growth in preterm infants.

Non-invasive methods, including stable isotope techniques, indirect calorimetry, nutritional balance and skinfold thickness, have given a new insight into early postnatal growth in neonates. Neonates and premature infants in particular, create an unusual opportunity to study the fluid and metabolic adaptation to extrauterine life because their physical environment can be controlled, fluid and energy balance can be measured and the link between metabolism and the energetics of their postnatal growth can be assessed accurately. Thus the postnatal time course of total body water, heat production, energy cost of growth and composition of weight gain have been quantified in a series of "healthy" low-birth-weight premature infants. These results show that total body water is remarkably stable between postnatal days 3-21. Energy expenditure and heat production rates increase postnatally from mean values of 40 kcal/kg/day during the first week to 60 kcal/kg/day in the third week. An apparent energy balance deficit of 180 kcal/kg can be ascribed to premature delivery. The cost of protein metabolism is the highest energy demanding process related to growth. The fact that nitrogen balance becomes positive within 72 h after birth places the newborn in a transitional situation of dissociated balance between energy and protein metabolism during early postnatal growth: skinfold thickness, dry body mass and fat decrease, while there is a gain in protein and increase in supine length. This particular situation ends during the second postnatal week and soon thereafter the rate of weight gain matches statural growth. The goals of the following review are to summarize data on total body water and energy metabolism in premature infants and to discuss how they correlate with physiological aspects of early postnatal growth.

Recommendations for term and late preterm infants at risk for perinatal bacterial infection.

Since publication of the initial guidelines for the prevention of group B streptococcal disease in 1996, the incidence of perinatal infection has decreased significantly. Intrapartum antibiotic prophylaxis together with appropriate management of neonates at increased risk for early-onset sepsis not only reduces morbidity and mortality, but also decreases the burden of unnecessary or prolonged antibiotic therapy. This article provides healthcare workers in Switzerland with evidence-based and best-practice derived guidelines for the assessment and management of term and late preterm infants (>34 weeks) at increased risk for perinatal bacterial infection. Management of neonates at increased risk for early-onset sepsis depends on clinical presentation and risk factors. Asymptomatic infants with risk factors for early-onset sepsis should be observed closely in an inpatient setting for the first 48 hours of life. Symptomatic neonates must be treated promptly with intravenous antibiotics. As clinical and laboratory signs of neonatal infection are nonspecific, it is mandatory to reevaluate the need for continued antibiotic therapy after 48 hours.

Body size and early growth in appropriate- and large-for-gestational-age infants.

AIMS: To study weight, length, body composition, sleeping energy expenditure (SEE), and respiratory quotient (RQ) at birth and at 5 mo of age in both adequate-for-gestational-age (AGA) and large-for-gestational-age (LGA) subjects; to compare the changes in body weight and body composition adjusting for gender, age, SEE, RQ and several maternal factors; to investigate the contribution of initial SEE and RQ to changes in body weight and body composition. METHODS: Sixty-nine neonates were recruited among term infants in the University Hospital of Verona, Italy. Forty-nine subjects participated until follow-up. At birth and follow-up, weight and length were measured and arm-fat area and arm-muscle area were calculated from triceps and subscapular skinfolds. SEE and RQ were measured by indirect calorimetry. RESULTS: At birth, weight, length, arm-muscle and arm-fat areas were significantly higher in LGA subjects than in AGA subjects. Weight status, SEE and RQ at birth did not explain the relative weight change after adjusting for gestational weight, placental weight, age at follow-up and gender. Arm-fat area and weight/length ratio at birth were negatively associated with relative changes in body weight after adjusting for the above variables (p < 0.05). CONCLUSION: Early growth from birth to 5 mo of life is significantly affected by body size and adiposity at birth. Fatter newborns had a slower growth rate than thinner newborns.

Long-term effects of neonatal hypoglycemia on brain growth and psychomotor development in small-for-gestational-age preterm infants.

OBJECTIVE: To investigate the effects of neonatal hypoglycemia on physical growth and neurocognitive function.Study design: A systematic detection of hypoglycemia (<2.6 mmol/L or 47 mg/dL) was carried out in 85 small-for-gestational-age preterm neonates. Prospective serial evaluations of physical growth and psychomotor development were performed. Retrospectively, infants were grouped according to their glycemic status. RESULTS: The incidence of hypoglycemia was 72.9%. Infants with repeated episodes of hypoglycemia had significantly reduced head circumferences and lower scores in specific psychometric tests at 3.5 years of age. Hypoglycemia also caused reduced head circumferences at 18 months and lower psychometric scores at 5 years of age. Infants with moderate recurrent hypoglycemia had lower scores at 3.5 and 5 years of age compared with the group of infants who had 1 single severe hypoglycemic episode. CONCLUSION: Recurrent episodes of hypoglycemia were strongly correlated with persistent neurodevelopmental and physical growth deficits until 5 years of age. Recurrent hypoglycemia also was a more predictable factor for long-term effects than the severity of a single hypoglycemic episode. Therefore repetitive blood glucose monitoring and rapid treatment even for mild hypoglycemia are recommended for small-for-gestational-age infants in the neonatal period.

Effects of nasal continuous airway pressure on pulmonary and systemic output in preterm infants

Objective: Respiratory assistance with nasal continuous positive airway pressure (n-CPAP) is an effective treatment in premature newborns presenting respiratory distress. The aim of the study was to depict cardiac function, systemic (Qs) and pulmonary output (Qp) by echocardiography in stable premature infants requiring prolonged n-CPAP. Our hypothesis was that n-CPAP could reduce pulmonary blood flow. Patients and methods: All premature infants < 32 weeks gestation, > 7 days-old, requiring n-CPAP without severe respiratory compromise nor need for additional oxygen were prospectively included. Every patient had a first echocardiography while on n-CPAP. N-CPAP was then discontinued for two hours and a second echocardiography was performed. Results: 17 premature infants were included. Mean gestational age was 28 ± 2 weeks and mean weight 1.1 ± 0.3 kg. Following retrieval of n-CPAP we observed an increase in Qp of 53 ml/kg/min (95% CI 19-87 ml/kg/min), but no significant change in Qs. Consecutively a significant increase in Qp/Qs ratio of 16% was found (95% CI 7-29%). Conclusions: Nasal continuous positive airway pressure has hemodynamic effects in preterm infants in stable pulmonary and cardiac conditions. It reduces pulmonary output without interference with systemic output.

Associated anomalies in multi-malformed infants with cleft lip and palate: An epidemiologic study of nearly 6 million births in 23 EUROCAT registries.

We studied 5,449 cases of cleft lip (CL) with or without cleft palate (CL/P) identified between 1980 and 2000 from the EUROCAT network of 23 registers (nearly 6 million births) in 14 European countries. We investigated specific types of defects associated with clefts. Among CL/P cases (prevalence = 9.1 per 10,000), 1,996 (36.6%) affected only the lip (CL) and 3,453 (63.4%) involved CL and palate (CLP). A total of 3,860 CL/P cases (70.8%) occurred as isolated anomalies and 1,589 (29.2%) were associated with other defects such as multiple congenital anomalies of unknown origin (970), chromosomal (455) and recognized syndromes (164). Associated malformations were more frequent in infants who had CLP (34.0%) than in infants with CL only (20.8%). Among multi-malformed infants, 2 unrelated anomalies were found in 351 cases, 3 in 242 cases, and 4 or more in 377 cases. Among 5,449 CL/P cases, 4,719 were live births (LB) (86.6%), 203 stillbirths (SB) (3.7%), while 508 (9.3%) were terminations of pregnancy (ToP). CL/P occurred significantly more frequently in males (M/F = 1.70), especially among total isolated cases (M/F = 1.87) and CLP isolated cases (M/F = 1.92). The study confirmed that musculoskeletal, cardiovascular, and central nervous system defects are frequently associated with CL/P. An association with reduction anomalies of the brain was found. This association suggests that clinicians should seek to identify structural brain anomalies in these patients with CL/P as the potential functional consequences may be important for rehabilitation and clinical management.

Estudi de la situació actual i necessitats futures de tractament de les instal.lacions de tractament de residus a les comarques del Montsià i Baix Ebre

Aquest projecte duu a terme una anàlisi de quina és la situació actual quant a la generació de residus de les comarques del Montsià i Baix Ebre, així com de l’estat de les instal·lacions que hi ha quant a tractament de residus. Tenint en compte l’evolució de les quantitats recollides i de la població es fa una prognosi de quina serà la generació de residus en l’horitzó 2008-2012, per així, tenint també en compte la normativa vigent quant a residus, determinar les necessitats i fer una proposta per tal de donar solució a la problemàtica detectada.

Influència del consell nutricional en pacients en tractament de deshabituació tabàquica per minimitzar l'augment de pes

El consum de tabac és causa de pèrdua de salut i la primera causa de mort prematura prevenible en els països desenvolupats. Deixar de fumar aporta grans beneficis per a la salut però hi ha un fet que fa que moltes persones es plantegin no deixar aquest hàbit i és la preocupació pel guany ponderal. Diversos estudis consultats apunten a que es produeix un guany mig de 3-4 kg durant el procés de deshabituació tot i que en un percentatge considerable pot ser superior. Les causes d’aquest guany de pes són degudes a diversos factors: recuperació dels sentits del gust i l’olfacte, l’ansietat, la falta d’activitat física i sobre tot el paper que juga la nicotina. La nicotina augmenta la despesa energètica en l’activitat física, augmenta la termogènesi, incrementa el metabolisme basal, inhibeix la gana, produeix pèrdua de pes, afavoreix el buidament gàstric i recentment s’ha vist en rosegadors que la nicotina regula mecanismes cerebrals a nivell del hipotàlem, això ho fa perquè actua inactivant l’acció de l’enzim adenosine 5′-monophosphate-activated protein kinase (AMPK) provocant una pèrdua de la gana i un augment de la despesa energètica al incrementar la temperatura corporal i accelerar el metabolisme de les grasses. Explicar que la majoria dels efectes tenen una base bioquímica pot ajudar al pacient a comprendre la simptomatologia que pateix en el procés de la deshabituació tabàquica.