Table Of ContentPARENTERAL NUTRITION IN
INFA NCY AND CHILDHOOD
ADV ANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY
Editorial Board:
Nathan Back State University 0/ New York at Bu//alo
N. R. Di Luzio Tulane University School 0/ Medicine
Bernard Halpern College de France and Institute o/Immuno·Biology
Ephraim Katchalski The Weizmann Institute 0/ Science
David Kritehevsky Wistar Institute
Abel Lajtha New York State Research Institute /or Neltrochemistry and Drug Addiction
Rodolfo Paoletti University 0/ Milan
Recent V olumes in this Series
Volume 38
HUMAN HYPERLIPOPROTEINEMIAS: Prineiples and Methods
Edited by R. Fumagalli, G. Rieci, and S. Gorini • 1973
Volume 39
CURRENT TOPICS IN CORONARY RESEARCH
Edited by Colin M. Bloor and Ray A. Olsson • 1973
Volume 40
METAL IONS IN BIOLOGICAL SYSTEMS: Studies of Some Biochemical and
Environmental Problems
Edited by Sanat K. Dahr • 1973
Volume 41A
PURINE MET ABOLlSM IN MAN: Enzymes and Metabolie. Pathways
Edited by O. Sperling, A. De Vries, and J. B. Wyngaarden • 1974
Volume 41B
PURINE METABOLlSM IN MAN: Biochemistry and Pharmacology of Uric Acid Metabolism
Edited by O. Sperlin!!, A. De Vries, and J. B. Wyngaarden • 1974
Volume 42
IMMOBILIZED BIOCHEMICALS AND AFFINITY CHROMATOGRAPHY
Edited by R. B. Dunlap • 1974
Volume 43
ARTERIAL MESENCHYME AND ARTERIOSCLEROSIS
Edited by William D. Wagner and Thomas B. Clarkson • 1974
Volume 44
CONTROL OF GENE EXPRESSION
Edited by Alexander Kohn and Adam Shatkay • 1974
Volume 45
THE IMMUNOGLOBULIN A SYSTEM
Edited by Jiri Mestecky and Alexander R. Lawton • 1974
Volume 46
PARENTERAL NUTRITION IN INFANCY AND CHILDHOOD
Edited by Hans Henning Bode and Joseph B. Warshaw. 1974
Volume 47
CONTROLLED RELEASE OF BIOLOGICALLY ACTIVE AGENTS
Edited by A. C. Tanquary and R. E. Lacey. 1974
ARENTERAL NUTRITION
р
IN INFANCY AND
CHILDHOOD
Edited Ьу
Hans Henning Bode
Department оС Pediatrics, Harvard Medical School,
Massachusetts General Hospital, Shriners Burns InstitHte
Boston, Massachusetts
and
Ј oseph В. W arsha w
Departments оС Pediatrics, Obstetrics, and Gynecolo!ty
Уаlе University School оС Medicine
New Haven, ConnecticHt
Springer Science+Business Media, LLC
Library of Congress Cataloging in Publication Data
Main entry under title:
Parenteral nutrition in infancy and childhood.
(Advances in experimental medic in" and biology, v. 46)
Based in part on the papers of the International Symposium on Parenteral Nu.
trition in Infancy and Childhood, held in Boston in 1972.
Includes hibliographies.
1. Parenteral therapy-Congresses. 2. Pediatrics-Congresses. 1. Bode, Hans
Henning, ed. II. Warshaw, Joseph B., 1936- ed. III. Series. [DNLM: 1. Paren
teral feeding-In infancy and childhood-Congresses. WIAD559 v. 46 1972 I
WB4I0 I64p 19i2]
RJ53.F5P37 1972 615'.63 74·6060
ISBN 978-1-4684-3251-0 ISBN 978-1-4684-3249-7 (eBook)
DOI 10.1007/978-1-4684-3249-7
Based in part on papers of the International Symposium on Parenteral Nutrition in
Infancy and Childhood held at Boston, Massachusetts, August 29-31, 1972
© 1974 Springer Science+Business Media New York
Originally published by Plenum Press, New York 1974
Softcover reprint ofthe hardcover Ist edition 1974
A Division of Plenum Puhlishing Corporation
227 West 17tlt Street, New York, N.Y. 10011
United Kingdom edition puhlished hy Plenum Press, London
A Division of Plenum Puhlishing Company, Ltd.
4a Lower John Street, London WIR 3PD, England
AU righte reserved
No part of this hook may be reproduced, stored in a retrieval system, or transmitted, in any
lorm or hy any means, electronic, mechanicai, photocopying, microfiiming, recording, or
otlterwise, without written permission from tlte Publisher
PREFACE
"A tranquil mind puts flesh on a man"
English proverb
After aperiod of relative neglect, nutrition as a medical
science is now an area of great clinical and investigative activ
ity. This renewed interest in clinical nutrition derives in large
part from observations suggesting that early nutritional depriva
tion not only interferes with the maintenance of health, growth
and resistance to disease but if present during critical periods
of central nervous system development may also cause permanent
impairment of intellectual capacity.
Studies on brain development during malnutrition have contin
ued to demonstrate the vulnerability of the developing brain to
nutritional insult. Winick (1968) has emphasized that nutritional
deficiency occurring while cells of the central nervous system are
actively dividing results in a permanent decrease in central ner
vous system cell number. Later nutritional deficiency which re
sults in decrease in cell size appears to be recoverable. Perhaps
even more important than effects of malnutrition on brain cell
number is the effect on brain protein synthesis and myelination.
As different regions of the prain grow at different rates and
human cerebellar and cerebral cell number increase for the first
few months of life, newborn nutritional deficiency may compromise
brain development. Dobbing (1973) has focused attention on the
vulnerability of the brain to nutritional insult during the brain
growth spurt which occurs around the time of birth. In the human,
this period extends throughout the third trimester of pregnancy
and into the second postnatal year.
The full implication of nutritional deprivation on the devel
opment of intelligence is not entirely clear. However, the data
v
vi PREFACE
avai1ab1e do suggest a permanent decrease in inte11ectua1 function
in infancy (Cravioto, J. and DeLicardie, 1971; Cabak, V. and
Majanvik, 1965; Winick, M. and Rosso, P., 1969). Thus, great de
mands are p1aced on the pediatricians and obstetricians who super
vise the hea1th of pregnant mothers and infants to e1iminate sub
normal substrate provision to the human fetus and the newborn dur
ing this critica1 period when the infant is at its greatest risk.
Wor1dwide, the most frequent cause of infant malnutrition is,
unfortunate1y, still the 1imited avai1abi1ity of foodstuffs to
both pregnant mothers and newborn infants. However, even in the
more aff1uent societies malnutrition is frequent1y a consequence
of utero-p1acenta1 insufficiency, prematurity or neonata1 starva
tion due to surgica1 procedure, congenita1 anoma1ies or other
forms of distress which prevent adequate oral feeding. Provision
of ca10ries by means other than oral feeding are important not
on1y during critica1 periods of ear1y brain deve10pment but may
also be necessary in the older infant or chi1d with chronic dis
ease associated with severe nutritiona1 impairment or in chi1dren
requiring good nutrition for optimal recovery from an acute ai1-
ment. Dudrick's work with intravenous feeding has paved the way
for an aggressive nutritiona1 approach to infants ma1nourished or
at risk of becoming ma1nourished. Dudrick showed that beagle
puppies receiving a hypertonic mixture of glucose, pro tein hydro-
1ysate, minerals and vitamins by a centra1 vein cou1d maintain
normal growth and deve10pment over pro1onged periods of time.
This technique of intravenous feeding was adapted to human use and
a110wed apremature newborn with intestinal atresia to sustain
normal growth and deve10pment for aperiod of 44 days. Since this
original case, total intravenous nutrition has been successfu11y
administered to hundreds of infants, and the technique now occu
pies a prominent p1ace in the therapy of the nutritiona11y endan
gered chi1d. The technica1 details, the range of indications, and
the modes of intravenous feeding are being refined, especia11y in
the case of infants and chi1dren. New deve10pments and recent
experience have accumu1ated at a rapid pace. For this reason, we
arranged a Symposium on Parenteral Nutrition in Chi1dren in the
Fall of 1972. This volume is an outgrowth of that conference.
The editors are gratefu1 to J. Pfrimmer Company, Norwich Pharmaca1
Company and Vitrum Company for their support which made the con
ference and this volume possib1e.
Some of the studies reported on at the conference were con
troversia1, and even though the editors and many of the partici
pants did not agree with some of the views expressed, we fe1t that
the data presented had created sufficient stimulation to justify
pub1ication. For examp1e, the very aggressive approach for treat
ment of the fetus subjected to utero-p1acenta1 insufficiency out-
1ined by Dr. Heller opens a comp1ete1y unexp10red area of treat-
PREFACE vii
ment and preventive medicine. Much more research in this area is
needed and should probably be performed in primates. The varying
incidences of catheter sepsis in different centers clearly empha
sizes the importance of aseptic techniques and supervision and
improvement of these techniques should probably take precedence
over the prophylactic administration of amphotericin B as sugges
ted by Dr. Brennen.
In this volume we have attempted to provide information con
cerned with biochemical and metabolie adaptations during develop
ment. We have organized this book so that the more basic chapters
dealing with nutritional and metabolie development are presented
early so as to provide a foundation for later chapters dealing
with technique and application. It is our belief that only through
an appreciation and understanding of biochemical and metabolie
development can we rationally approach nutritional therapy of
infants and children.
Hans H. Bode
Joseph B. Warshaw
REFERENCES
Cabak, V. and Majanvik, R. ~. Dis. Childh., 40:532, 1965.
Carvioto, J. and DeLicardie, E. R. Nutr. Reviews, 29:107, 1971.
Dobbing, J. Lipids, Malnutrition and the Developing Brain. Ciba
Foundation Symposium. Associated Scientific Publishers.
p. 1, Amsterdam, 1973.
Winick, M. Pediat. Res., l:352, 1968.
Winick, M. and Rosso, P. Pediat. Res., l:18l, 1969.
CONTENTS
page
The his tory of parenteral alimentation
by H. H. Bode 1
The regulation of energy intake by developing and adult
animals
by R. A. McCance 4
Factors influencing amino acid utilization
by H. N. Munro 11
Amino Acid Requirements in childhood
by D. M. Hegsted 27
Intravenous carbohydrate tolerance in infancy
by G. W. Chance 38
Substrate supply and utilization in.various conditions
by J. F. Biebuyck 54
The utilization of xylitol, fructose and sorbitol
by H. Förster 71
Fatty acid oxidation during development
by J. B. Warshaw 88
Utilization and tolerance of intravenous fat emulsions
by R. P. Geyer 98
Alcohol metabolism during development
by E. Mezey 112
Fluid and electrolyte requirements and tolerance
by J. D. Crawford 119
Trace elements and vitamins
by H. L. Greene, M. Hambidge and Y. F. Herrnan 131
ix
x CONTENTS
Page
The rapid rehabilitation of severely undernourished children
by E. M. Widdowson 146
Technique of total parenteral nutrition in infants
by S. J. Dudrick, B. V. MacFadyen and R. W. Wint2rs 151
Postoperative parenteral feeding of neonates: Peripheral
vein infusion technique, fat administration and metabolie
studies
by H. C. B~rresen, R. Bjordal and o. Knutrud 165
Controlled parenteral nutrition of premature infants
by P. Jurgens, D. Dolif, C. Panteliadis and C. Hofert 178
Total intravenous alimentation in low birth weight premature
infants
by W. C. Heird, J. M. Driscoll and R. W. Winters 199
Intrauterine amino acid feeding of the fetus
by L. Heller 206
The role and effect of parenteral nutrition on the liver and
its use in chronic inflammatory bowel disease in childhood
by M. I. Cohen, S. J. Boley, F. Daum, I. F. Litt and
S. K. Schonberg 214
Parenteral nutrition of renal disease
by J. E. Fischer 225
Parenteral nutrition in critical illness
by J. T. Herrin 231
PARENTERAL NUTRITION IN CHILDREN WITH BURNS 239
Experience in the Shriners Burns Institute in Cincinnati
by M. P. Popp, E. J. Law and B. G. MacMillan 240
Experience in the Shriners Burns Institute in Boston
by A. Antoon and H. H. Bode 247
Experience with central venous catheters
by C. Burri and H. H. Pässler 250
Metabolie complications of total parenteral nutrition
by W. C. Heird, R. W. Winters and S. J. Dudrick 256
Infection in association with intravenous feeding
by M. F. Brennan 269
CONTENTS xi
Page
Contributors 279
Author Index 283
Subject Index 29l
