NUTRITIONAL S' UPPORT IN PEDIATRIC SURGERY Nurition Vol. 14, No. 1, 1998 Perioperative Nutritional Support in Pediatrics DANIEL H. TEITELBAUM, MD, AND ARNOLD G. CORAN, MD From the Section of Pediatric Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA INTRODUCTION Advancements in perioperative nutrition support has been one cof the most critically important factors contributing to the im- proved survival and outcome of pediatric patients. This applies both to parenteral as well as to enteral nutrition support. This chapter will serve as a guide to the perioperative nutrition care of the pediatric patient, Although many of the topics discussed are approached in other chapters, this chapter will relate these topics specifically :o the perioperative period, PREOPERATIVE ASSESSMENT OF NUTRITIONAL STATUS ‘Many infants and children who require operative interven- tion suffer from malnutrition either due to a variety feeding disorders or because of the underlying disease process for ‘which they will need surgery. Although malnutrition in surgical patients has been well documented since the 1970s, the degree ‘of malnutrition in pediatric surgical patients is less well de scribed. Nutrition assessment is a critical aspect of the initial evaluation of all surgical patients. The incidence of malnut tion in surgical patients has been well documented in several reviews; more recently, malnutrition in pediatric patients also has been demonstrated to be quite high? In one review, 95% of all surgical patients had one abnormal nutritional parameter and 35% had three indicators of malnutrition.> Although a signif cantly malnourished patient can be identified easily, those patients with mild or even moderate malnutrition are frequently difficult to identify. A baseline assessment begins with a sub- jective global assessment (SGA).* Such an assessment is easy to obtain and has a high degree of reliability with regard to the determination of the degree of malnutrition. A SGA consists of history and physical examination and should include an evaluation of weight loss (>10%), anorexia, or vomiting as well as physical evidence of muscle wasting (e-g.. palmar or temporal atrophy). Patients at particular risk for malnutrition include those with large open wounds with the concomitant loss of protein and increased metabolic needs, extensive burns blunt trauma, and sepsis. Beyond this initial screening. a vari- ety of indices can be used to further assess the child's nutri- tional status Nueritional Indices [Nutrition assessment can be divided in two areas, A subjective assessment is performed during the history and physical exami- ration, as discussed above. Importantly, despite the recent a ‘vances in nutrition assessment tools and laboratory measurements, 4 clinical evaluation of the patient's status can be as reliable as more sophisticated testing.*© The objective portion of the assess ‘ment begins with the basic anthropomorphic measurements. of height, weight, and head circumference. Children’s measurements are placed on a standardized growth curve. The most commonly used is that of the National Center for Health Statistics (Fig. 1) Using these growth charts, the expected weight for height index ccan be calculated. As length and head circumference are less affected by excess fat or fluid fluctuations, length is an excellent indicator of long-term body growth. Acute changes in nutritional status will have a more immediate affect on body weight than length and will decrease the child's weight for height index. Chronic undernutrition, however, will demonstrate a lag in both ody weight as well as linear growth, For a child whose nutritional status will require greater evaluation, the measurement of mid-upper arm circumference and triceps skinfold thickness can be quite helpful. Midarm circumference is a good indicator of the body's somatic muscle mass size. Triceps skinfold thickness best reflects the degree of subcutaneous fat reserves. Although both of these measure ‘ments are good indicators of a patient's calorie and protein reserves, they have two drawbacks, First, repeated measures by different observers result in considerable variability. Second these measurements can change dramatically with alterations in the child's fluid status Although one measurement of any of these parameters will not bbe as helpful as a long-term assessment of their nutritional status, it will help determine if the patient is within the Sth and 95th percentile of growth. Other parameters that can be useful for measuring nutritional status include bone age and dental status. Malnutrition is a common cause of delayed bone maturation.” Direct Measurement of Body Composition ‘A variety of methodologies have been created during the past 25 y to measure more directly the body composition of both adults and children. Many of these methods. because of high levels of radiation or inconvenience, are not readily ac- cessible to the average clinician. Some modalities, however, are becoming more commonly used in pediatric centers. Mea surement of body water has heen performed for a number of years using isotope dilution techniques. This is based on the principle that fat is anhydrous so that the majority of the isotope is directed into the water compartments of the body.* ‘Although this assumption is not always true, such measure- ments can give one an excellent indication of approximate Correspondence to; D. H. Teitelbaum, The University of Michigan Medical School, F2970 Mot Children’s Hospital, Section of Pediatric Surgery, Ann Arbor, MI 48109-0245, USA, Notion 14:130-142, 1998 Elsevier Science Inc. 1998 Printed inthe USA. Al rights reserved ELSEVIER (0899.9007798/319.00 IT $0899.-9007(97)0229-3PERIOPERATIVE NUTRITIONAL SUPPORT IN PEDIATRIC SURGERY GIRLS: BIRTH TO 36 MONTHS, PHYSICAL GROWTH NCHS PERCENTILES” (e405 a =5 Peaevsed Se ae 131 iaetae ta] 4} po ag : LESSER SESS eeeeelitet Sn | Hi Sh —i— FIG. 1. Example of a growth chart fora female from newborn to 36 mo old. The chart is from the National Center for Heath Statistics (Wright State University School of Medicine, Yellow Springs, Obio, USA), Charts are spociie for female or male and ace avaiable for 036 mo or 2-18 y amounts of body fat and water? Bioelectrical impedance analysis uses the measurement of the body's impedance to a flow of electrical current as a measure of total body water Extrapolation of these measurements can allow for the deter ‘mination of other body compartments including total body adipose tissue, More recently dual photon absorptiometry and ual energy x-ray absorptiometry have been used to measure both bone mineral content as well as amounts of fat and body ‘water.'!"2 The accuracy of the instruments is excellent and, because of the low amounts of x-ray exposure, dual energy Xray absorptiometry may become the eventual method of choice for measuring pediatric body composition, Biochemical Measurements of Nutritional Status Albumin ‘Albumin is the classic biochemical marker used £0 assess a malnourished state.' Levels of albumin, however, can be altered by a variety of factors including disturbances of hepatic synthesis, distribution in the plasma space, protein loss from the vascular ‘compartment, and alterations in the child’s hydration state, Fur ther, the biological half-life of albumin is rather long (20 d). Thus, determination of acute changes in nutritional status is not possible from measurements of albumin levels, A study that evaluated the nutritional status of a large pediatric oncology population found132 PERIOPERATIVE NUTRITIONAL SUPPORT IN PEDIATRIC SURGERY TABLE 1 KILOCALORIE AND PROTEIN REQUIREMENTS Age) Kilocalories (kealkg BW) Protein (gg BW) on 90-120 20-35 re] 75-90 20.25 m2 60-75 20 nis 30-60 1s >is 25.30 10 BW, body weight. that serum albumin levels lacked both the sensitivity and speci- ficity to identify malnutrition." Despite these drawbacks, hy- ppoalbuminemia has been associated with increased morbidity and ‘mortality rates in hospitalized children. Transferrin Transferrin is a transport glycoprotein that is synthesized in the liver and binds and transports feric iron. Its biological half-life is 8.8 d, which is considerably shorter than that of albumin. Further, the body pool of transferrin is also smaller than albumin, '® These later two facts make transferrin a beter indicator of protein epletion compared with serum albumin levels. Clearly, infants with iron deficiency anemia may have abnormal transferrin levels ‘unrelated to their nutritional status. Transferrin also may be ab- ‘normal in patients with liver failure, those receiving large doses of antibiotics, and surgical patients with large Muid shifts."6 Prealburin Binding Protein (Transthyretin) Prealbumin binding protein or transthyretin is a transport pro- tein for thyroxine, Like retinol-binding protein (see below), pre albumin binding protein has a relatively small distribution pool and a short half-life (2 4). Thus, prealbumin is good marker of nutritional status. Further, because prealbumin binding protein contains a large amount of the amino acid tryptophan, it better reflects visceral protein status, compared to albumin and trans ferrin, Levels of prealbumin correlate very nicely with nitrogen balance studies.'” Prealbumin levels also have been used to mon- itor nutritional therapy during the transition from total parenteral nutrition to enteral feedings. Rerinol-Binding Protein Retinol-binding protein isa useful marker of nutritional status, because of its extremely short biological half-life of 12 h as well a its small body pool size. It is excreted in the urine and thus is ‘not useful in patients with renal falure.'® PERIOPERATIVE NUTRITIONAL REQUIREMENTS Energy The energy needs of infants and children are quite unique. Hird et al. has estimated that a I-kg infant has only a 4-d nutritional reserve and a full-term infant may live for no more than | mo without nutrition. Energy in a child is required for both ‘maintenance of body metabolism as well as for growth, Estimated energy needs of an infant and older child are shown in Table 1 Calorie requirements in an infant may be calculated in a variety of ways, Most simply, caloric requirements can be viewed as being nearly equivalent to the child's daily water requirements. The Harris-Benedict equation is commonly used to determine energy expenditure for children who are > 10 y old. A modification of the Harris-Benedict equation has beea used for younger children and infans’: however, energy requirements for most postoperative Patients can be calculated bated on standard nomograms [eg Recommended Dietary Allowance (RDA) tables] of, more pre- cisely, by indinect calorimetry. Nomograms usualy provide an estimated bastl energy expenditure (BEF) based on age, height, and weight and provide an estimate of addtional energy needs rated to such conditions a postoperative stress, mtple trauma, fever, and severe infection, The aforementioned methods of na tition assessment also are used to classify the nutitioal status of Patients atthe time of injory, operation, or erica illness, Impor tantly a earful clinical examination iss accurate 38 more com plex and expensive laboratory and anthropometric measurements ven i identifying malnutrition in stessed patients. In the study by Baker et al.* measurement of boy cll mass showed that the depleted state could not be reliably detected on the basis of Wweightheight ratio, triceps skinfold, midarm circumference, hand Strength, albumin concentration, total protein level, or cretnine- height ratio. Actual measurement or estimation of metabolic rate is the best method of following the nutritional stats, Although a number of previous studies on nutritional requirements during heath and disease have been based on estimated energy expendi ture, atual measurement is much more accurate and fs becoming an important aspect of critical cae management ‘Toe most common method of measuring energy expenditure is indirect calorimetry. In this method, the amount of oxygen ab- sorbed across the Tung is assumed to be exactly equal to the mount of oxygen consumed in the metabolic processes. This is the basic assumption of the Fick equation and isthe reason why ‘oxygen consumption isa valid measure of metabolism, even in a patient with abnormal lung function. The enersy released by Oxidation of various food substrates is known fom direct mea: surements. The metabolic rate measured in cubic centimeters of ‘oxygen per minute can be converted to calories per hour or per day ifthe substrates ae known, For practical parposes, a conver- sion factor of 5 keal of energy por liter of oxygen consumed i @ reliable approximation, This shghiy overestimates the metabolic rate but isa much more accurate approximation ofthe metabolic fate than a number derived from a'chart ora table. A method of Closcd-creit, water-scald indirect calorimetry for infants breath- ing spontaneously has been developed, and these measurements have demonstrated a much wider range of enerey expenditure for infants of similar weight and gestational age than that calulated by nomograms.* Commonly used nomograms may significantly underestimate or overestimate energy expenditure '— ‘Advances and miniaturization have allowed the application of indirect calorimetry in increasingly smaller patients» Groner et 212" examined resting energy expenditure (REE) in children Un- dergoing major abdominal operations. In contrast to adults, no increase in REE was found in these patients. Further, use of the Harris Benedict equation to calculate preoperative energy needs failed to corclate with preoperative energy neods as measbred with indirect calorimetry. This study further speculated that the nergy that children typically use for growth is divened to com pensate for increased energy needs dering the postoperative pe Fiod, although this was not substaiated, Furter, this study ©x- mined a fairly inhomogenous population of children with ages Tanging from 8 to TB y and did not examine the young infant Mitchell et al21 also found that postoperative cardiac patients resting energy expenditure fell to values below that of normal healthy nonoperated children. This finding also was confimed in the sty by Lefton etal who examined energy expenditure in young infants in the postoperative period. Letton demonstrated ‘that many of these neonates required 50-60 kcal « kg~' - d' of energy to maintanthemscIves inthe postoperative period, far less than any previous recommendations have stggested, These stdies suggest tht teliance on RDA. values, oF the Harss-BenedictPERIOPERATIVE NUTRITIONAL SUPPORT IN PEDIATRIC SURGERY 133 TABLE U. DAILY FLUID REQUIREMENTS Weight Volume Premature (<2 ka) [Neonates and infants (2-10 kg) Infans and children (10-20 ke) Children (20 ke) 130 mug 100 mL/kg for fist 10 kg 1000 ml. + $0 m Likg > 10 kg 1500 mL. + 20 m Likg > 20 ke equation, may result in overfeeding in the postoperative child ‘More recently, Jones et al* have demonstrated that postoperative rnewbom infants do, in fact, demonstrate increased oxygen con- sumption (based on indirect calorimetry) and increased resting ‘energy expenditure; however, such values peak 4 h after the start, of the operation and return t0 baseline levels some 12-14 h after surgery. More major surgeries were associated with greater in- creases in energy expenditure. Thus, many of the previous studies may have missed this inerease by assessing infants at later time points. Further, Anand=” has demonsirated a blunting of the in- ‘ease in postoperative energy expenditure with fentanyl; thus, the use of narcotic agents in many of these children may have led to the findings of a lack of change in postoperative energy expendi tures. Nevertheless, overfeeding of surgical patients (as. doc mented by a respiratory quotient >1.0 and the development of lipogenesis) may lead to fluid retention and compromise of respi- ratory function. Thus, more restricted caloric administration should be used to feed critically ill, postoperative infants and children. As indirect calorimetry devices in smaller patients be- come more readily availabe, their use will help guide nutritional therapy in these children Water and Electrolyies Water requirements depend on the patient’s age, size, and environment, Table II shows the normal water requirements based fon the age of the patient. The water content of infants is higher than that of adults (75% of body weight versus 60%). In addition to water provided by fluid intake, oxidation of food will provide ‘small amounts of water. Despite the large fluid intake of most infants and children, only 0.5~3% of fluids are retained; the rest are excreted by the kidney (50%) and lost through the gastroin- testinal tract (3-10%) and through insensible losses (40-S0%). Electrolyte requirements, as well, are unique in the pediatric patient. Table Il shows the typical electrolyte requirements of a term infant. In an attempt to define the changes that occur in total body water and extracellular fluid after neonatal surgery, Coran and Drongowski* prospectively studied newboms after surgery ‘while being maintained on total parenteral nutrition. They found that despite adequate weight gain, extracellular fluid actually decreased significantly in all infants, whereas no differences were noted in the intake and output of fluids. Protein The protein needs of most infants are based on a combina- tion of needs for growth as well as maintenance of body weight (Table 1). The average intake of protein should comprise ~ 15% of total calories administered. Two percent of the infant’s body ‘weight, compared with 3% of the adult's body weight, consists of nitrogen. The majority of the increase in body nitrogen ‘occurs during the first yeur of life. Protein needs are thus ‘markedly higher in the neonate and infant, and in the neonate range from 2 to 3.g+kgWt + d~t Of the 20 standard amino acids, 8 are classically essential, in that no enzymatic pathways are available in humans to synthesize them (see Table IV). Unique to the neonate are three or four additional “essential” amino acids, which, because of immature amino acid synthetic mechanisms, are not formed in sufficient amounts. This has become apparent by the development of defi- ciencies in cysteine, taurine, and tyrosine after chronic adminis tration of adult parenteral formulations to neonates272 The de- ficiencies are most likely due to low levels of phenylalanine hydroxylase and cystathionase activity2! It recently has been suggested that proline is also an essential amino acid in preterm infants, although this has yet to be confirmed by others.™? The administration of a specially designed pediatric formulation (see Enteral Feeding below) will lead to a normalization of the neo. nate’s plasma aminogram levels. However, despite claims that such formulas can lead to improved weight gain, nitrogen balance and a decreased incidence of parenteral nutrition-associated jaun- dice, no controlled study has effectively proven these claims.» Further, the cost of maintaining infants on these formulas far exceeds current nutrition support costs. One substantiated benefit of a formula with taurine supplementation is the prevention of retinal degenerative changes: These retinal changes, however, take a long time to occur, suggesting that short-term (<1 mo) standard parenteral nutrition in infants is acceptable ‘Similar to adults, there is a postoperative negative nitrogen ‘balance that occurs forthe first 72-96 h. Unlike adults, in neonates, there is a decreased amount of gluconeogenesis in the postoper- ative period that may be due to an immaturity of critical enzyme pathwvays, Table V reviews this difference, as well as several other critical differences, in metabolic response after surgery between neonates and adults.3> Importantly, however, postoperative neo- ‘TABLE Il, RECOMMENDED RANGES FOR ELECTROLYTE SUPPLEMENTS FOR PEDIATRIC AND ADOLESCENT (ADULT) PATIENTS ON TPN Electrolyte Infant range (<10 ke) Pediawic range (10-30 kg) Adolescent range (>30 kg) Calcium 05-30 mEq-kg! +d" 5-20 mEgié 10-15 mBq/d Magnesia 05-10 mEq-ke! = 424 mEqid 824 mEgid Potassium 4mEq-kg sd 20-240 melt 90-240 mEq Sodium Dab egekg"t +d? 20-150 mei 60-150 mEq/d Acetate 2-8 mEq: ke" +d"! 20-120 mEgit #0-120 mEqid Chloride 4212 mBq kg a" 20-150 mEq/d 60-150 mEqla Phosphorus 05-10 mmol kg! +d! 6-30 mmol 30-50 mmol TPN, total parenteral sutton134 PERIOPERATIVE NUTRITIONAL SUPPORT IN PEDIATRIC SURGERY TABLE IV. ESSENTIAL AMINO ACIDS Threonine Leucine Teoteucine Valine Lysine Methionine Phenylalanine Tryptophan Histidine Tyrosine? Cystnet Protnet Glotaminet *ssemil only in infancy, {May be essential in the premature infant {#May be essential in imes of excess sess and energy demands ‘nates do benefit from postoperative nitrogen administration. Zlot- kin’ demonstrated increased nitrogen retention with increasing amounts of nitrogen delivered. This has been confirmed more recently by Duffy and Pencharz:” who showed improved nitrogen tulization in those postoperative neonates receiving higher amounts of amino acids. “Two amino acids are discussed next, which, although not defined 1s essential, appear to have special functions relevant to the infant's ‘metabolism and may be classified as relatively essential Glutamine Several investigators have shown that glutamine is a vital source of protein and energy for several organs. Glutamine is not currently added to parenteral nutrition solutions. This absence is based on the fact that the enzyme necessary for glutamine syn: thesis, glutamine synthetase, is present in humans, This enzyme catalyzes the synthesis of glutamine from glutamate and ammonia An additional reason that glutamine is not currently added 10 amino acid formulations is that glutamine is unstable in solution, i... easily precipitates, and has a short shelf half-life 'A large amount of evidence suggests that glutamine may well be an essential or at Teast a semi-essential amino acid. First, glutamine is the most abundant amino acid in both whole tissues ‘and the blood. Further, glutamine is the most important vehicle for transfer of nitrogen for renal ammoniagenesis and hepatic ure- agenesis. Finally, glutamine is an essential precursor for nucleic acid biosynthesis and is, therefore, essential for proliferation of cells that are rapidly turning over, such as the intestinal mucosa and lymphocytes. The gastrointestinal (GI) tract is the principal ‘organ of glutamine utilization, Glutamine plays multiple roles in {intestinal metabolism, structure, and function. Gut mucosal cells, have high glutaminase activity and the human GI tract extracts, 12-13% of circulating glutamine, Although glutamine is readily available in healthy individuals, this carefully balanced homeosta- sis may be lost in such pathologic conditions such as sepsis, trauma, surgery, ot shock. ‘A significant degree of intestinal mucosal atrophy has been demonstrated in rats maintained on standard total parenteral nu trition (TPN) compared with TPN that also contains glutamine. In addition, nitrogen retention was also higher in the rats receiving the 2% glutamine solution, ® Animal studies have shown potential benefits of glutamine in reducing radiation toxicity as well as intestinal injury from chemotherapy’. Ziegler® reported a well- controlled human study on bone marrow transplant patients. The high-dose glutamine group showed improved nitrogen balance, and the ineidence of infection, microbial colonization, and length ‘of hospitalization was decreased in the high-dose glutamine group. ‘A more recent study of a similar patient population has failed to TABLE V. METABOLIC RESPONSE TO OPERATIVE STRESS IN THE ADULT AND NEONATE Merabatite Adult Neonate Metabolic rate and oxygen eonsumption Carbohydrate 4 Briefly, then? 1 Hyperelycemie response J Gluconengenesis and | glucose use Protein [Negative nitrogen balance ‘light } protein breakdowrn—dependent on ty of stress, 1 with increased severity 41 Compared with adults (minimal change compared to age-matched controls) 1 Glucose 2 times immediately postoperatively (ess persistent } than in adults), probably secondary to ilyeogenolyss rather than 1 eluconcogenesis— neonates may be unable t carry out hepatic luconcogenesis secondary to lack of key enzyme [Negative nitogen balance 72-96 h postoperatively ‘Nitrogen loss in neonates compared with older infans Fat | Protein synthesis in extrahepatic tissues, 1 Amino acid utilization for gluconeogenesis, ‘acute phase reactant syhesis ad synthesis ‘of components of healing process 4 Nitrogen excretion—-sustained 5 d Aaipose tissue lipolysis > mobilization of ronesterified fatty acids and. ketone body fomation 18-9086 of postoperative requirements supplied by fat metabolism (10-25% by protein 1} Muscle protein breakdown, impaired nitrogen use, transient { nitrogen excretion, 4 (versus adult in gluconeogenic amino acids in postoperative plasma, J Lipolysis + Ketogenesis (possible catecholamine stimulated) — 7 total Ketone bodies f elycerol, 1 nonesterified fay acids, Postoperative {at ulization exceeds rate of mobilization of tree fany acidsPERIOPERATIVE NUTRITIONAL SUPPORT IN PEDIATRIC SURGERY 13s demonstrate many of these previous benefits! Although quite appealing, it remains to be proven whether glutamine will have a true impact on the clinical course of patients. Recently, investi- gators have developed glutamine dipeptides, which have pro- longed stability and improved solubility. Hopefully, the avsilabil- y of these newer products will allow a greater evaluation of, and use of glutamine in parenteral nutrition Arginine ‘Arginine isa dibasic amino acid that also has been considered as essential during times of metabolic stress“? Studies have dem- onstrated that arginine supplementation improves nitrogen reten- tion and wound healing in postoperative and malnourished states. Improvement in the immunologic status of patients mai tained on arginine-supplemented diets has been demonstrated. The mechanism of arginine’s actions has not been fully demor- strated, although its function requires an intact hypothalamic pituitary axis. Further, arginine infusion induces the secretion of growth hormone, insulin, prolactin, and somatostatin* During the past few years, the association between arginine metabolism and the formation ‘of nitric oxide has been examined extensively. Arginine serves as the substrate for nitric oxide synthesis. The production of nitric oxide requires the cellular incorporation of arginine and the enzyme nitrie oxide synthase, which mediates its formation. Inerestingly, a complex, interdependent control mech- anism for the formation arginine and nitric oxide exists, whereby the formation of argininosuccinate synthetase, the rate-limiting enzyme for arginine formation, is dependent on lipopolysaccha- ride and interferon-gamma, both of which also induce the for- ‘mation of nitric oxide synthetase.** Arginine is present in all commercially available amino acid mixtures, with higher concen- trations found in pediatric formulations (~123 mg/g of amino acid) compared with adult formulations (95-99 mg/). Carbohydrates Carbohydrates provide a major source of nutrition both, through parenteral as well as enteral routes. Because the body is capable of forming sugars from both lipids as well as amino acids, there is no essential amount of carbohydrate needed. However, the addition of small amounts of carbohydrates will prevent break- down of somatic protein sources, and thus act as a protein-sparing substrate. This latter effect leads both to the suppression of tendogenous glucose production as well as endogenous glucose ‘oxidation, thereby preventing the oxidation of amino acids derived from skeletal muscles. Dextrose is the most common source of carbohydrate and it yields 3.4 keal/g. Glucose metabolism may be either aerobic through the tricarboxylic acid cycle yielding 38 mol ATP/mol of ghicose or anaerobically to lactic acid through the glycolytic cycle to yield 2 mol ATP/mol of glucose. Glucose is formed in the liver via gluconeogenesis utilizing alanine from skeletal muscle and from lactic acid derived from skeletal muscle glycogen breakdown through the Cori cycle. Immediately after a ‘meal, glucose absorption contributes t0 the bulk of circulating glucose. As litle as 4h after the meal, these sources are depleted rapidly and glycogen ftom the liver Becomes a major source of energy for the next 8-12 h. The newborn has relatively limited glycogen reserves (34 g), most of which reside in the liver. Thus, relatively short periods of fasting can lead to a hypoglycemic state. ‘The administration of too little glucose may lead to a ketotic, state, whereby skeletal muscles are broken down for gluconco- ‘genesis. Importantly, however, the administration of too much slucose or the administration of glucose t00 rapidly may lead to a variety of adverse side effects that include an osmotic diuresis due to serum glucose levels exceeding renal tubular reabsorption threshold and immunologic suppression due to inactivation of the complement system.” As well, glucose that is not oxidized will be ‘converted into fat (lipogenesis) which, in tur, will lead to exces- sively high triglyceride levels, hepatic steatosis, as well as high CO, production and a respiratory quotient that is >1.0. The implications of this latter complication include overt liver injury (ie, hepatic steatosis) and the potential to exacerbate ventilatory impairment in a critically ill child from the increased CO, pro- duction, Stable infants should receive approximately 40-45% of their total caloric intake as carbohydrate. During parenteral nutrition, the infant should receive ~6-8 mg - kg! min ' of glucose to ‘maintain adequate glacose levels (see Parenteral Nutrition sec- tion). Lower amounts of glucose in a young neonate will lead to hypoglycemia due to inadequate hepatic production of glucose Older infants can tolerate greater loads of glucose provided itis, administered through a central venous catheter (10-14 mg = kg!» ‘min ') because of significant hyperosmolality. Postoperative glu- cose intolerance is not uncommon and is not only manifested by hyperglycemia but quite commonly by hypertriglyceridemia. This relative hyperglycemia is due to both increased levels of cat- echolamines and to a relative decrease in the utilization of circu lating. glucose in the immediate postoperative period (insulin resistance). Unlike adults this state of hyperglycemia is tran- sient and tends to Tast for ~12 h after surgery Lipids Intravenous fats have the highest caloric density of the three ‘major nutrients (9 Keal/g). In general, fats should comprise be- tween 30% and 50% of all nonnitrogen calories. Lipids have the advantage of being an excellent source of energy a well as essential fatty acids. Linoleic acd is essential for both neonate’ as ‘well as older children and adults, Deficiencies of linoleic acid may ‘occur rapidly in neonates, Withbolding of lipids from a neonate’s parenteral nutrition for as little as 2d may lead to fatty acid deficiency * A deficiency in infants may result when <1% of the calorie intake is linoleic acd; in general, 2~4% of dietary energy should come from essential fatty acids. Manifestations of fatty acid deficiency include scaly skin, hair loss, diarrhea, and im- paired wound healing.’ Absence of trace amounts of linolenic acid, a potential essential fatty acid in infants and children, also may be the cause of visual and behavioral disorders. Fatty acids are an excellent source of energy to all tissues of the body except red blood cells and the brain. In neonates undergoing surgery, an increase in the blood level of total ketone bodies and glycerol can be seen, consistent with a preferred use of lipids by the neonate in the perioperative period. It is possible that this preferred use of lipids is one of the many etiologies of hyperglycemia in the immediate postoperative period. NUTRITIONAL DELIVERY SYSTEMS Enteral Feedings ‘The most ideal route of feeding is enteral. Even small amounts, of enteral feedings will allow for the preservation of normal intestinal villus and microvillus structure and may prevent the development of bacterial translocation from the intestine and septicemia.* Such preservation helps maintain normal absorptive processes. Enteral feeding is also a more economical route, cost- ing less than one-tenth the daily cost of parenteral nutrition Finally, septic complications in patients on parenteral nutrition are far more common compared with patients on enteral nutrition Feeding routes may range from oral intake to nasogastric, naso- duodenal, gastrostomy, and jejunostomy feeding tubes. Oral in- take is ertical in preventing the occurrence of feeding aversion, although gavage feedings should be used in very premature neo- nates as suck and swallow reflexes are not developed until the 34th ‘week of gestation.5$ Once enteral nutrition is chosen, the route of136 PERIOPERATIVE NUTRITIONAL SUPPORT IN PEDIATRIC SURGERY access needs 10 be determined. In general, most healthy term infants will tolerate oral feeds without difficulty. For those infants who either have ain abnormal suck or swallow or those infants that are not alert enough to swallow, consideration should be given 10 feeding tube placement. Gastric feedings are preferred because this allows for normal digestive process. Children receiving gastric feeds will tolerate higher osmolarity and volume than those being fed via the small bowel. Furthermore, gastric acid may benefit digestion and has a bactericidal effect, thus resulting in less frequent gastrointestinal complications.*° Transpyloric tube place- ment should be considered for those infants who are ata high risk for aspiration, such as those with documented gastroesophageal reflux and coma or those with a depressed gag reflux (see below). The verification of tube location is mandatory as current feeding tubes are small enough to easily pass into the tracheao-bronchial ‘uce. Thus, auscultation of air insuflated into the tube is not sufficient. Confirmation must be obtained by either aspiration of ‘gasirointestinal contents or by x-ray.*7 For passage of a trans Toric tube, a weighted tube can be placed and passed either using. ‘gastric peristalsis or by fluoroscopic guidance. A gastrostomy tube should be placed for those infants that will require enteral nutri- tional support for >6-8 wk. The decision to place & gastrostomy tube generally requires an evaluation of the patient for the pres- cence of gastroesophageal reflux, If refux is present, itis usually made worse by the placement of either an open or percutaneous gastrostomy’ tube2* Aspiration is 8 major risk associated with perioperative enteral feedings. Rapid bolus nasogastric feedings may lead to a high incidence of reflux. Complications can be decreased with the use of a slow continuous infusion or preferably with jejunal feed ings.* This later statement has become more controversial, and, in fact, although patients with delayed gastric emptying (e.g.. infants’ with sepsis, recent trauma, electrolyte imbalance, or on ‘opiates postoperatively) or comatose patients may be at risk for aspiration, in table patients a continuous infusion via a nasogas- trie tbe is associated with no higher incidence of aspiration than is seen with infusion through a nasodvodenal tube. Formula Selection Choice of formula will depend on the age of the patient and the condition of their gastrointestinal tract. In general, term infants should be maintained on human milk (See below) or standard 20, keal/ounce formula. Compositions of various formulas are given in Table VI. A lactose-based formula is generally the first choice a8 it is the most physiologic (most like human milk) and least expensive. For those infants who are intolerant of Tactose, the formula may be changed to a Ictose-free. soy protein-based one Additional ealories can be provided by increasing the volume delivered, increasing the concentration of the formula, or by supplementing the feedings. Formula concentration may be in- creased to 30 kealfounce; however, high concentrations may be dificult for some infants to digest, and it may take time for the infant to build up tolerance, Further, higher concentrations acca- sionally have been associated with an enterocolitis-like picture. A second way in which formula concentration can be increased is by the addition of a glucose polymer (Polycose) or fats as medium- chain triglycerides or vegetable oil. Each 0.50 g of Polycose added to an ounce of standard formula increases calories by 0.06 keal/mL ot a total caloric delivery of 0.73 keal/m., ‘The addition (of 005 g of oil to formula raises calories by 0.13 Keal/mL or a total of 0.8 kcal/mL. Caution must be taken when supplementing calories in this fashion as this may compromise the ability of the infant to take in sufficient amounts of protein or minerals if the ‘amount of formula is limited. The addition of up to2g of Polycose ‘or 1g of oil per ounce of feedings can be done quite safely Complications of Enteral Feeding The GI tract generally tolerates feedings quite well once the postoperative ileus has resolved. Not uncommonly, however, the child, after major gastrointestinal surgery, will sustain a loss of a significant portion of absorptive function. Symptoms generally are manifested by cramping, diarthea, or emesis. This intolerance often is due (0 a lactase deficiency. Symptoms often will improve with the initiation of a lactose-free diet. Other alterations in the administration of the diet also can improve feeding tolerance. First, as previously indicated, the GI wract generally tolerates increased volume more readily than increased osmolarity (Table VD. Therefore, such adverse symptoms can be avoided by initi- ating 0.125 or 0.25 strength formula and slowly advancing the formula concentration. Second, administration of formula by con: tinuous drip is tolerated better than bolus feedings. The threat of gastroesophageal reflux, vomiting, and subsequent aspiration thereby is reduced greatly. Third, care must be taken to ensure that ihe enteral formula does not become contaminated, either during, preparation or atthe bedside. Expiration times should be observed. Finally. pectin, Metamucil. lomotil.paregoric, or Imodium will be required for those who have lost a significant amount of their bowel length, Assessment of adequate absorption can be carried cout most readily by the testing of the stool for the absorption of carbohydrates, by measuring stool pH, and by detecting for re- ducing substances. The presence ofa stool pH =5.5 or a reducing substance of greater than one-half percent indicates the passage of unabsorbed carbohydrates into the stool. This finding indicates that an alteration inthe feeding regimen should occur, generally a decline in formula concentration of carbohydrates. Alternatively, 3 change in the type formula may be belprul, such as changing from, a lactose-predominate formula to a sucrose-based formula (Table Vb), Detection of fat malabsorption using a qualitative or quanti- tative fecal fat test may be helpful, but, in general, isolated fat malabsorption is unusual unless due to pancreatic insuffi Ge. cystic fibrosis) Parenteral Nutrition ‘The decision to institute parenteral nutrition to reduce mortal: ity and morbidity must be weighed against the risk of serious ‘complications of the technique, especially sepsis. Two general approaches can be taken to intravenous feeding in infants and children, These are a central venous infusion of a hypertonic ‘glucose Solution and peripheral infusion of 2 moderately hyper- tonic glucose solution, Figure 2 describes a suggested approach to the initiation and maintenance of parenteral nuuition in the neo: rate and young infant. This serves as a guide for writing orders tnd supplements the remainder of this section Indications for Parenteral Nutrition Parenteral nutrition is an ideal way of maintaining nutrition in those infants and children who are unable to tolerate enteral feedings. In the newborn period, extremely premature infants are generally intolerant of Gl feedings. Parenteral nutrition should Sart after the first 24 h of life and should be advanced slowly. Other infants who may require parenteral nutrition are those who ‘vill be in an anticipated state of prolonged starvation. A. prime example of this is the infant undergoing Gl surgery (see Indica- tions for Perioperative Nutrition section). Older children and adults generally do not require parenteral nutrition unless periods ‘of starvation go beyond 7-10 d. The young infant, however, will require parenteral nutrition suppor: if periods of starvation will go beyond a period of 4- d, Adverse signs of starvation actually ‘may be seen in premature infants who are not fed for as lite as 1-2 d. Those with inadequate intestinal length will require long~ term parenteral nutrition. Other indications for parenteral nutition Include GI dysfunction, including chronic malabsorption or diar-PERIOPERATIVE NUTRITIONAL SUPPORT IN PEDIATRIC SURGERY 137 TABLE VI. FORMULAS FOR ROUTINE INFANT FEEDING Mature SMA fnuman with SMA. Whole SMA ilk cont Pregestimil RCE? Nursoy “Premie"” cow milk Proteing u 1s 19 18 2a 20 36 Casein 4% 40% 40% 2% Whey ae 60 oor 18% Soy 100% 100% Hydrotyzed easein 100% Fats 27 37 44 Long-chain 100% 100% eo 100% 100% 875% 100% triglycerides Medium-chain = 40% = = 5% - triglycerides Carbohydrates 212 90 ° 69 86 48. Type Lactose Lactose Partially hydrolyzed starch Sucrose Lactose, starch Lactose hydrolyzed Selected mineral a) Sodium 150150 ais 320 200 320 520 Potassium™* 350560 730 950 700 750 1430 Calcium 340420 630 70 600 750 120 Phosphorus lo 280 415 si0 20 400 960 Iron os 2 Bs 2 2 3 06 nergy 4 Indication Malabsorption, hypoallergenic, CHO Lactose For premature, also for short bowel imolerance imtolerance_—_up to full- syndrome and biliary atresia (CHO term beth added as weight tolerated) Similar formulas Enfamil Nutamigen* RIDA Isom Similac Portagen Prosebee Gerber Alimenturn FSoyalae * Lacks medium-chain triglycerides + Ross Carbohydrate Free formula. This is not a complete formula as provided by the manufacturer. It contains no carbohydrates. Ideal for carboby rae intolerance, particulary in infants with malabsorption or a severe enteritis. Carbohydrate can be reintroduced as dextrose, up to 7 gd, and slowly change from dextzose to surose. + For comparison only. Whole cow milk should na be fed to infants until they are =6 mo old and have developed renal maturity § Values stated are percentages of weight per volume. Percents are the relative percentages of long versus medium chain wiglycerides. {[To determine mEajL, divide by 23. ** To determine mEq/L, divide by 39.1 CHO, carbohydrate thea; requirement for prolonged periods of GI tract rest (€-8-. inflammatory bowel disease); and conditions such as adhesive bowel obstruction, peritoneal inflammation, and enterocutane- us fistulas. Finally, other children who may require parenteral nutrition are those Feceiving either radiotherapy to the GI tract, fr those on extensive courses of chemotherapy with resultant GI dysfunction. Composition of Parenteral Solutions “The composition of peripheral and centeral venous parenteral nutrition solutions is given in Tables VI and VID Neonates ‘generally are kept on a dextrose and electrolyte solution (¢.8., Dyo 0.2. NS_w/20 Meq KCVL) at maintenance rates (120 mL+ke-'=d"! for the first day, 100 mL kg! = d~! for the second day) and then begun on parenteral nutrition ~24 hours after birth. Typically the small neonate will be somewhat incoler- ant of large amounts of dextrose or amino acids for the first 2 or 3 d of life, Dextrose solution concentrations are generally initiated ‘at 10-12.5% and slowly advanced on a daily basis to between 20% and 25%. Monitoring of the patient's glucose levels and electrolyte balance and checking for glucosuria will confirm that the child is tolerating this level of dextrose administration. In general, the small neonate has limited glycogen reserves and thus will need to be maintained on ~8 mg * kg! min”! of dextrose. Dextrose administration in the neonate should generally not ex ceed 12-15 mg + kg! + min~'. Amino acid administration should begin at 05-10 g+kg"'+d"!. Amino acids are advanced138 Assess fluid and caloric needs: 100 mi/ky/day (see Table 2) v Carbohydrates: Start: 4 to 6 me/kg/min Advance: 1 to 2 mg/kg/min Goal: 12 mg/ke/min, 45% of calories Protei Start: 0.5 to 1 wkg/day Advance: 0.5 to 1 g/kg/day Goal: 2.5 to 3 p/kg/day, 15% of calories Lipid Start: 0.5 10 1 gikg/day ‘Advance: 0.5 to 1 g/kg/day Goal: 3 pkg/day, —_— 40% of calories Additivest: Vitamins: Trace Elements; Electrolytes; Minerals * Evaluate lab values: Adjust additives *Add extra sodium, acetate and zinc with increased stool output Adjust chloride/acetate ratio based on acid/base status + Adjust calcium/phosphate ratio based on ppt. factor v Nutritional Goal: 100 Keal/kyday (see Table 1) PERIOPERATIVE NUTRITIONAL SUPPORT IN PEDIATRIC SURGERY Format mgykg/min 0.69 x Dextrose’? x 24 x Rate(mi/no) Kg. Formula for proteins and lipids: (Cone.)* x0.24 x Rate ehke/day = fa Formuls precipitation factor* (Calcium (mg/kg) + Phosphorus (mMV/kg)] x wt (kg) x 100 PN volume (ml) Formula: Calories delivered Kealkylday) = 248 Rates Keatini FIG. 2, Scheratie diagram of how to write parenteral nutrition orders for a neonate or young infant. Fluids should be adjusted based on the infant’ gestation lage and body weight. "Dextrose concentration shouldbe used asthe percent number (Le. 20 for 20%); tthe concentration inthis formula should be writen {a the percent umber (ie. 4.25 for 4.25% crystaline amino acids or 20 for 20% lipids): fsee relevant bles for each ofthese additives: ifthe amino acid Concentration is >1.5%, the precipitation factor should be <3. Ifthe final amino acid concentration is >1% and <1.S%, the precipitation fector should be <2. For an aming acid concentration <1%, calcium and phosphate should not be added. Adjustments to this formulation need tobe done if additives (equ cysteine) are placed inthe parenteral nutrition; St convert to keal= kg" =", use: 4 keal/g for protein and 9 Keal/ for lipids. Note thatthe fet temuision has a eeori value of 1.1 kea/m. forthe 10% solution and 2.0 keaV/mL for the 20% solution because the 10% emulsion contains 5% eral to maintain isotonicity and both the 10% and 20% have phospoholipds ab emulsifiers, both of which provide exia calories beyond the 9 Keal/g of iglyoerdesPERIOPERATIVE NUTRITIONAL SUPPORT IN PEDIATRIC SURGERY 139 TABLE VIL TABLE VIL PERIPHERAL PARENTERAL NUTRITION WITH FAT IN INFANTS Constituent Amount (per kg/24 h) Glucose 15-206 Protein 20-408, Sodium 2-4 mEq Potassium, 24 mEq Chloride 346 mEq Magnesium 05-1.0 mEq Calcium 05-30 meq Phosphate 05-1.0 mmol ‘Trace elements* Multivitamin infasion (MVDt (04 mi (03 mL for neonates) 1 vial ilted to 3 mL) Heparin 10 tui, Glucose-proeia volume 120-160 ml Fat 4g 10% fat emulsion volume 40 mt Total volume 160-200 ml. Total kiloalores 102-121 kcal Each 1000 mi. of a standard solution is prepared by mixing $00 mi of 208 dextrose and water with $00 ml of 45% amino acids to give a ina concentration of 10% dextrose and 2% amino acids. The sppropiate amounts of electrolytes, vitamins, and trace elements are added accord: ing tothe patien's weight. * Each 0.5 mL of trace element solution (Coiversty of Michigan Pharmacy) contains zinc, 100 ys: copper, 20, ug; manganese, 10 ig; and chromium, 0.2 yg. F Each tL of MVT (USV Pharmaceutical Corp.) contains vitamin A, 2000 TU; vitamin D, 200 IU; ascorbic seid, 100 TU: thiamine (vitamin B,), 10 mg; riboflavin (vitamin B,) 2 mgs niacinamide, 20 mg: pyridoxine (vitamin By), 3 mg: dexpanthenol,$ mg; and vitamin E, 1 1U ~05-1 g+kg~' sd! to a maximal goal of 2.5-30 g kg? 4°! This level of amino acids appears to be the ideal range for ‘most neonates. Markedly higher levels will result in elevation of the blood urea nitrogen level and aminoaciduria, Lipid adminis- tration begins at 05-1 g kg” -d~!and is similarly advanced to a total of 30 2° kg™!-d-'. This amount of lipid is generally uite well jolerated in children. previous reluctance to advance lipids in the face of an indirect hyperbilirubinemia was based on the fact lipids might displace bilicbin, which is bound to albumin ‘The kinetics of this reaction, however, are such that bilirubin will, not be displaced from albumin by free fatty acids (which also are transported in the serum bound to albumin) at this level of lipid administration " Standard amounts of electrolytes, trace elements, ‘and vitamins are added to this parenteral nutrition solution (Tables, TX and X), In addition, heparin at a concentration of 0.5 UfmL. also may be added to the solution. The addition of heparin may have the beneficial effect of decreasing thrombotic events“? Cau- tion should be taken with the use of heparin, as only slightly larger doses of hepann may interfere with drug absorption.®* Neonates, may not be able to fully metabolize lipids in the face of large amounts of heparin added to the parenteral nutrition solution, ‘although beparin, in general, will allow for improved utilization of lipids In addition, medications such as H-2 blockers also may be added to the parenteral nutrition solution. Nutrition goals for total, energy delivery are shown in Fig. 2 and Table I Monitoring of Laboratory Values Monitoring of laboratory values is essential, as abberations in these measurements is common in small infants and children, CENTRAL PARENTERAL NUTRITION IN INFANTS CConstieuent Amount (per kg/24 h) Glucose Protein Sodium Potassium Chloride Magnesium Calcium Phosphate “Trace elements™ Multivitamin infusion (MVE 15-30¢ 20-408, 24 mEq 24 meq 3-6 mBq 05-10 meq 05-30 mEq 05-10 mmol, (0.1 mi (0.3 mi for neonates) 1 vial (ited to 3 mL) Heparin Lo Tui Glucose-protein volume 60-114 mL Fat Lag 10% fat emulsion volume 10-420 mt, Total volume 0-158 mL Tova kilocalories| 0-154 KCat Fach 1000 mi ofa standard solution is prepared by mixing 500 mL of 50% dextrose and water with $00 ml of 74 amine acids to give a final concentration of 25% dextrose and 3.5% amino acids. The appropriate amounts of electrolytes, vitamins, nd trace elements are added aecord- ing tothe patient's weight, * Each 0.1 mL of trace element solution (University of Michigan Pharmacy) contains zine, 100 wg; copper, 20, ug: manganese, 10 4g: chromium, 0.2 yg; and selenium, 1.2 pg. Spe- Cal neonatal trace element solution contains 300 jg of zine in 0.3 ral and the same amounts of the other elements. * Each vial (ited to 3 L) of pediatric MVI (USV Pharmaceutical Conporation) contains vite min A, 2300 TU; vitamin D, 400 TU; ascorbic acid, $0 TU thiamine ‘amin By). 12 mg; riboflavin (vitamin B,), 14 mg: niacinamide, 17 mgs pyridoxine (vitamin B,), 1 mig; dexpansheno. 5 mg: vitamin E, 71 folie acid, 40 ip; eyanocobalamin (vitamin By) 1 gm: phytonadione (vitamin K,), 200 igs and biotin, 20 wg. particularly at the onset of parenteral nutrition. A complete blood ‘count should be obtained at the initiation of TPN. Glucose, blood urea nitrogen, creatinine, and electrolyte (Na, K, Cl, CO.) serum TABLE IX. RECOMMENDED DAILY TRACE ELEMENT SUPPLEMENTS, FOR PEDIATRIC AND ADOLESCENT (ADULT) PATIENTS RECEIVING TPN Infant amount Child amount Element packed pgs kg teat Zine (sulfate) 2504 50 ‘Copper (suite) 20 20 Manganese (sulfate) Lo 10 ‘Chromium (chloride) 020 005 tw 020 Selenium (as slenious acid) 20 20 Note amounts are less than the RDA, assuming that significant amoutt of the enteral wace clements will not be absorbed. +400 yg ke" +d should be added for preterm infants. TPN, total parenteral nutrition140 PERIOPERATIVE NUTRITIONAL SUPPORT IN PEDIATRIC SURGERY TABLE X. RECOMMENDED DAILY VITAMIN SUPPLEMENTS FOR PEDIATRIC AND ADOLESCENT (ADULT) PATIENTS ON TPN (ACCORDING TO AMA GUIDELINES) ‘Adolescent (adult) Vitamin Pediatric amounv’D amountday Ascorbic acid 80 mg 100 mg Vitamin A 2300 TU 330010 Vitamin D 400 Tu 200 10 ‘Thiamine HCI(B,) 12 mg 30mg Ribotavin (B,) 1h mg 36mg Pyridoxine HC! BQ) 10 mg 40mg ‘Niacinamide 17 me. 400 mp Pantothenic aid 5 mg 150mg Vitamin E sw loo w Biotin 20 ue 60 ue Folie acid 140 pg 400 ws ‘Cyanocobalamin (2) 1 ng. Sue Phytonadione (K,) 200 He Tor 5 mgiwk Adapted from Shils, ME. Paventeral nutrition in modern nutrition in health and disease, th ed. ME Shils, JA Olsoa, M Shike, Baltimore, Williams & Wilkens, 1994-1488, ‘AMA, American Medical Association: TPN, total parenteral nutition, levels should be obtained at initiation and biweekly. Liver fune- tion tests (AST, ALT, LDH, alkaline phosphatase and total/irect bilirubin), magnesium, albumin, calcium, and phosphorus should ‘be obtained at initiation and weekly. Triglyceride levels should be watched until the child reaches hisfher goal of fat intake. INDICATIONS FOR PERIOPERATIVE NUTRITION Indications for Preoperative Nutrition ‘A great deal of controversy has arisen over the need for preoper~ ative nutition support. Although the vast majority of literature on this subject relates to adults, an extrapolation of many of these studies can help guide the pediatrician and pediatric surgeon in the care of their patien’s. Although enteral feedings have been associated with a reduction in postoperative complication, the associated medical con- ditions may prevent the use of such feedings. Two well-conducted studies have examined the use of preoperative enteral feedings, Pa- tients in these studies were given between 10 and 21 d of an enteral dit ®t These studies showed a reduction in postoperative wound infections, anastomotic leakage, hepatic and renal failure, and length of hospital stay, Parenteral utrtion in the preoperative setting is somewhat, ‘more controversial. Several early clinical evaluations have led 10 conflicting results. Some studies have not been able to document any benefit from preoperative parenteral nurition but have noted increased rates of sepsis with the use of parenteral nutrition.*” Other investigators have shown a benefit with either parenteral tutrtion or enteral nutrition with no specific advantage to either except for the low cost of enteral feedings. A meta-analysis of several previously performed studies has demonstrated only a ‘marginal benefit to preoperative nutrtion.®* The most definitive statement comes from the Veterans Administration Cooperative Studies Program,” which showed that perioperative parenteral nutrition given 7-15 d preoperatively and 3 d postoperatively was ‘of no benefit to mild or even moderately malnourished patients, In severely malnourished patients, however, a demonstratable benefit was noted in that there were fewer noninfectious complications. Infection rates, however, were overall higher in the TPN group, and this association could not totally be explained by the use of central venous catheters, suggesting that use of TPN may actually predispose patients to increased infectious complications. Thus, unless there are clear indications of severe malnuirition, a delay in ‘operative management to provide preoperative TPN is not indi- cated. An extrapolation of these findings to neonatal patients is difficult; however, because of similarities in the metabolic re sponse to surgery, it seems reasonable to apply these same con- clusions to the pediatric population Indications for Postoperative Nutrition Use of aggressive postoperative nutition support is an even ‘more controversial area, For enteral feedings, some studies have noted a benefit in terms of a decreased level of septic morbidity and lower cost in the enterally fed group.7!7? However, it is important to note that other series have shown that a number of patients are intolerant of very early enteral feedings-after a major GI operation,” and others have noted deaths due to patients receiving enteral feedings." Although these data are confined to adult patients, it suggests conservative use of early enteral feeds, ‘which should be applied only after the recovery of full GI fune tion. Finally, although the use of enteral feeding has been consid ered by many to be a more efficient route for the delivery of futrition and the development of positive nitrogen balance, a randomized controlled trial examining this issue has failed’ 10 substantiate any benefit of enteral feeding over parenteral. ‘The benefit of parenteral nutrition in the postoperative period is, also unclear. Although some studies have shown the advantages of decreased healing time and shortened hospital stay,”> other studies have shown little or no benefit.”7” A comparison of the use of parenteral versus enteral nutrition in the postoperative period shows higher infection rates in parenteral autrition patients and Title benefit in the enteral group due to feeding intolerance in some patients; a lack of improved outcome was noted in both ‘groups. Similar studies on the effects of enteral versus paren- feral feeding in the postinjury patient have been carried out. These studies have demonstrated findings similar to the previous study, ‘namely more infectious episodes in the parenterally fed group and improved immunologic status in the enterally fed patients °° Because results in the arca of postoperative nutrition support are not clear, we support aggressive postoperative feedings in only those patients who can receive enteral nutrition without compli- cation, In those children who require parenteral nutrition, it should be restricted to those neonates who will not tolerate even a short period of starvation or to older children in whom itis anticipated that they will not start enteral nutrition for at least 7 d REFERENCES |, Bistrian BR. Nurtional assessment and therapy of protein-calorie ‘malnuttion inthe hospital. J Am Diet Assoc 1977:71:393 2, Wright IA, Ashenburg CA, Whitaker RC. Comparison of methods fo ‘clegorize underutsiton in children. J Pediatr 1994;124:944 3. Maller JL, Bucby GP, Waldman MT. 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