RESUMO
OBJECTIVE: To determine whether behavior therapy was more effective than nutritional therapy in obviating the need for enteral feeding in infants with resistance to feeding. STUDY DESIGN: Sixty-four children aged 4 to 36 months who were tube fed for at least 1 month and had resistance to feeding were randomly assigned to either behavioral or nutritional interventions (32 per group). For 7 consecutive weeks subjects and their primary feeders attended a weekly clinic with 1 of 2 dietitians followed by 4 follow-up visits. The nutritional intervention provided structured schedules and routines to stimulate the hunger/satiety cycle. The behavioral intervention provided the same schedules and routines plus behavioral therapy (extinction). The primary outcome measure was the proportion of successes, defined as infants no longer requiring tube feeding at the third follow-up visit in each group (4(1/2) months after start of trial). The decision to discontinue tube feeding was made by an independent observer who used criteria defined before the study commencement. RESULTS: Fifteen (47%) of 32 subjects in the behavioral group versus none in the nutritional group were successes (P <.001). CONCLUSION: Behavior therapy is more efficacious in eliminating the need for tube feeding than nutritional counseling alone.
Assuntos
Terapia Comportamental , Nutrição Enteral , Gastrostomia , Jejunostomia , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , Fatores de TempoRESUMO
We performed a cross-sectional evaluation of deep vein thrombosis (DVT) related to the use of central venous lines (CVLs) in all pediatric patients receiving home total parenteral nutrition at our institution (N = 12). All children (5 months to 17 years of age) were examined with bilateral upper limb venography. All CVLs were flushed daily with heparin (200 units). At the time of evaluation, 49 CVLs had been placed in the 12 children. Of the 39 CVLs removed, 27 (66%) were blocked; venograms had not been previously obtained except of one child. Eight children had clinical evidence of superficial collateral circulation in the upper portion of the chest and the upper extremities; five had intermittent symptoms of superior vena cava obstruction. On venography, 8 of the 12 children had extensive evidence of DVT; two were unilateral and six bilateral. Five children were treated with warfarin (0.12 to 0.28 mg/kg per day) to achieve an international normalized ratio of 1.4 to 1.8. Neither bleeding nor further CVL-related DVT has occurred. We conclude that the risk of CVL-related DVT in children requiring home total parenteral nutrition is high, and that venography should be performed early in the event of CVL blockage. A multicenter, controlled trial assessing optimal warfarin therapy in this patient population is indicated.
Assuntos
Cateterismo Venoso Central/efeitos adversos , Nutrição Parenteral Total/efeitos adversos , Trombose/etiologia , Adolescente , Criança , Pré-Escolar , Circulação Colateral , Estudos Transversais , Humanos , Lactente , Nutrição Parenteral Total/instrumentação , Radiografia , Trombose/tratamento farmacológico , Veias Cavas/diagnóstico por imagem , Varfarina/uso terapêuticoRESUMO
Because cysteine and histidine, two amino acids included in total parenteral nutrition regimens, bind zinc and increase its renal ultrafilterability, my objective was to quantify the effects of infusion of amino acids, including cysteine and histidine, on urinary zinc excretion. The effect of the infusion of high amounts of cysteine and no cysteine (100 mg/kg/day vs none) and of high and low amounts of histidine (165 vs. 95 mg/kg/day) on urinary zinc excretion was determined in 14 newborn infants receiving total parenteral nutrition who had similar zinc intakes (approximately 7 mumol/kg/day). After a 72-hour adaptation period, each infant's urine was collected for two 48-hour periods. Urinary zinc excretion during the high-dose histidine and cysteine infusion periods was significantly elevated compared with that during the no-cysteine and low-dose histidine periods. Therefore concurrent intakes of specific amino acids may have to be considered when zinc dosages are calculated.
Assuntos
Cisteína/farmacologia , Histidina/farmacologia , Fenômenos Fisiológicos da Nutrição do Lactente , Nutrição Parenteral Total , Zinco/urina , Cisteína/administração & dosagem , Histidina/administração & dosagem , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Espectrofotometria Atômica , Zinco/sangueRESUMO
To determine the intravenous zinc and copper intakes required to build up body stores in the preterm infant and achieve positive retention in full-term infants, balance studies were completed in 38 preterm, full-term, and full-term SGA infants who received complete intravenously delivered nutrient formulations excluding zinc and copper. Zinc as ZnSo4 and copper as CuCl2 were then added to individual infants' formulations, with intakes ranging from 91 to 824 micrograms/kg/day (zinc) and 8 to 92 micrograms/kg/day (copper). Samples of infusate as well as urine, stool, and aspirate were collected for 72 hours and analyzed for zinc and copper by atomic absorption spectrophotometry. Zinc and copper retention correlated significantly with intake (r = 0.89; 0.82, P less than 0.01) and were independent of gestational age, postnatal age, and birth weight. In full-term and full-term SGA infants, intakes of zinc at greater than 150 and copper at greater than 16 micrograms/kg/day were adequate to replace ongoing losses and prevent acute deficiencies. The dosage for copper is similar to the current recommendation of the American Medical Association; the zinc dosage is 50% higher. Preterm infants receiving intakes of zinc at 438 and copper at 63 micrograms/kg/day achieve in utero retention rates. These dosages are significantly higher than AMA recommendations. Both combinations can be delivered by peripheral or central line without complications.
Assuntos
Cobre/administração & dosagem , Recém-Nascido , Recém-Nascido Prematuro , Nutrição Parenteral Total , Nutrição Parenteral , Zinco/administração & dosagem , Cobre/sangue , Cobre/urina , Humanos , Transtornos da Nutrição do Lactente/prevenção & controle , Recém-Nascido Pequeno para a Idade Gestacional , Necessidades Nutricionais , Zinco/sangue , Zinco/urinaRESUMO
In order to determine the intravenous energy and nitrogen intakes required to achieve intrauterine rates of nitrogen accretion and growth, 30 studies were completed in 22 premature infants who were provided with various intakes of amino acids and energy (glucose +/- lipid) by peripheral vein infusion. At constant nitrogen intake, increasing energy intake (as lipid) from 50 to 80 nonprotein kcal/kg/day resulted in significant increases in nitrogen retention and weight gain. Increasing nitrogen intake from 494 to 655 mg/kg/day at constant low energy intake (mean = 53 kcal/kg/day) had no effect on nitrogen retention or weight change; however, at higher energy intakes (mean = 81 kcal/kg/day) increasing nitrogen intake correlated significantly with increasing nitrogen retention. At energy intakes greater than 70 kcal/kg/day the major determinant of nitrogen retention was nitrogen intake. When energy intake was greater than 70 kcal/kg/day, the infusion of nitrogen providing 430 to 560 mg/kg/day (2.7 to 3.5 gm protein/kg/day) resulted in the duplication of intrauterine nitrogen accretion rates.