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U.S. Department of Agriculture/Agricultural Research Service Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX 77030
3To whom correspondence and reprint requests should be addressed at U.S. Department of Agriculture/ARS Children’s Nutrition Research Center, 1100 Bates Street, Houston TX 77030. E-mail: sabrams{at}bcm.tmc.edu.
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ABSTRACT |
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 TOP ABSTRACT The links among nutrition,...Effects of malnutrition on...Growth failure in infants...Specific condition:...Specific condition: cystic...Other conditionsREFERENCES |
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KEY WORDS: • prematurity • nutritional supplementation • bronchopulmonary dysplasia
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The links among nutrition, development and pulmonary status in children |
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TOPABSTRACTThe links among nutrition,...Effects of malnutrition on...Growth failure in infants...Specific condition:...Specific condition: cystic...Other conditionsREFERENCES |
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Effects of malnutrition on lung function |
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TOPABSTRACTThe links among nutrition,...Effects of malnutrition on...Growth failure in infants...Specific condition:...Specific condition: cystic...Other conditionsREFERENCES |
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) used spirometry to evaluate lung function in
school children in rural India. They found that lung function, when
normalized for body size, was significantly related to nutritional
indices in boys and girls. Lung function was also poorer in these
children than in size-matched children from Britain or from Asian
countries. The conclusion is that malnourished children have poor lung
function. This may be related to early maldevelopment and is
independent of their stature. An effect of malnutrition on respiratory
muscle weakness is also possible. |
Growth failure in infants and consequences for development |
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TOPABSTRACTThe links among nutrition,...Effects of malnutrition on...Growth failure in infants...Specific condition:...Specific condition: cystic...Other conditionsREFERENCES |
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). Although primary brain development and
neurogenesis occur during the prenatal period, postnatal events include
myelination of new axons, neuronal migration and formation of synaptic
connections (Wauben and Wainwright 1999
). Malnutrition
may effect these and thus alter behavioral development.
Deficiencies of specific nutrients may also affect neurological
development postnatally. For example, iron deficiency in early
childhood is well known to lead to long-standing behavioral and
cognitive deficits. Iodine deficiency in childhood also has a severe
effect on cognitive development (Scrimshaw 1998
).
Recently, considerable attention was paid to the effects of
long-chain polyunsaturated fats on development. Although data are
not conclusive, some evidence suggests that the addition of these to
infant formulas may, for example, enhance cognitive or visual
development in premature infants (Lucas 1997
).
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Specific condition: bronchopulmonary dysplasia (BPD) |
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TOPABSTRACTThe links among nutrition,...Effects of malnutrition on...Growth failure in infants...Specific condition:...Specific condition: cystic...Other conditionsREFERENCES |
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BPD was first described in 1967. Since then, it has become one of the
major problems facing those who care for premature infants. BPD is the
third leading cause of chronic lung disease in children and the primary
cause of lung disease in infants. It has been estimated that there are
at least 7000 infants with BPD in the United States at any given time.
Although various definitions of BPD have been used, one practical
definition is that proposed by Hansen and Corbet (1998
):
"respiratory sequelae in an infant who reaches 36 wk postmenstrual
age but cannot be discharged from the hospital because of continued
oxygen requirement or mechanical ventilatory requirement, or an infant
who is discharged home on oxygen or ventilatory support."
The etiology of BPD is unknown, although it is closely related to
extreme prematurity (< 26 wk), high oxygen exposure and prolonged
ventilatory support. Because of the relationship with oxygen exposure
and the possibility of oxidant damage to the lungs, it has been
proposed that antioxidant therapy may prevent or limit its course,
which is considered elsewhere (Welty 2001
).
Effects on growth.
Inadequate growth is a well-recognized complication of BPD. A
series of studies have demonstrated both increased energy utilization
and decreased energy intake in infants with BPD (Wilson and McClure 1994
). An important recent suggestion is that growth
failure may be an early occurrence in infants who ultimately develop
BPD. DeRegnier et al. (1996
) evaluated early growth in
very low birthweight infants. They found that between 2 and 4 wk of
age, infants with developing BPD consumed less protein and energy,
accreted less arm fat and muscle and grew more slowly than similarly
sized infants who did not develop BPD. After achieving full enteral
intakes, similar rates of growth were seen, but catch-up growth did
not occur. These data supported the idea that early growth failure
contributes to long-term problems in infants with BPD.
Other studies showed that poor growth often continues in infants with
BPD, even after hospital discharge. Estimates of growth failure range
from 30% to 67% during the initial postdischarge period
(Johnson et al. 1998
). Of note is the suggestion of a
previous study that growth failure was less in infants with BPD who
were receiving oxygen at home than in those not receiving home oxygen
(Chye 1995
). If confirmed, this finding may imply that
adequate tissue oxygenation may ameliorate some growth limitation in
infants with BPD.
Medications utilized to treat infants with BPD may also affect growth.
The most important of these are corticosteroids. Short- and
long-term steroid administration is a common feature of management
of infants with BPD. Gibson et al. (1993)
reported that
knee-ankle growth, which is usually approximately 0.5 mm/d in
premature infants, was reduced to zero after 9 d of dexamethasone
therapy, and did not return to predicted values until 30 d after
treatment was stopped.
Leitch et al. (1999)
recently showed that although, as
expected, growth was severely impaired in infants with BPD during
dexamethasone treatment compared to a nontreatment phase, this
difference could not be related to differences in energy expenditure or
energy intake. This finding suggests that dexamethasone alters the
composition of weight gain by increasing fat and decreasing protein
accretion relative to growth when dexamethasone is not administered.
Effects on development.
Lifschitz et al. (1987
) reported a 68% incidence of
suspected or confirmed abnormal neurodevelopmental problems in infants
with BPD who were followed postdischarge. Singer et al.
(1997
) reported a prospective, longitudinal study of
very low birth weight (VLBW) and term infants to 3 y of age. BPD
was shown to be an independent predictor of poorer motor outcome at
3 y of age. After adjustment for cofounders, a 10- to 12-point
lower PDI was shown in BPD infants compared with other VLBW infants
without BPD.
This study confirms findings by others including Northway
(1990
), Vohr (1991
) and Robertson
(1992
), whose studies in the aggregate found
neuromuscular problems, poorer development and smaller head
circumference in infants with BPD.
In contrast to some of these earlier studies, the Singer et al.
(1997
) study did not identify differences in mental
outcome related to BPD once data were adjusted for race, social class,
birthweight and neurological risk score (a summary score of specific
neurological outcomes such as periventricular leukomalacia). This
result may primarily relate to the overriding effect of neurological
risk score on mental outcome. Nonetheless, it is likely that the
combination of lower socioeconomic status and prematurity and BPD led
to a high risk for lowered mental outcome.
Giacoia et al. (1997
) evaluated a small group of
children with BPD compared with groups of VLBW and full-term
infants at school age. They did not find any differences in verbal or
performance IQ in comparing the BPD infants with other preterm infants,
but did find that the infants with BPD had lower scores than
full-term infants.
There is also concern that BPD may affect development of visual
functioning, independent of the existence of retinopathy of
prematurity. However, in a long-term follow-up study, Harvey et al.
(1997
) did not find evidence of abnormalities of grating
acuity or visual-field development defects in children with BPD who
did not have significant neurological problems or retinopathy. They did
report lowered recognition acuity at 3 y of age in BPD infants,
but this may have been related to cognitive differences.
Nutritional management of infants with BPD.
The need for fluid restriction often leads to premature infants’
having lower-than-optimal energy intakes. For example, Wilson et al.
(1991
) showed that actual energy intakes were far below
optimal intakes throughout the first 8 wk of life in small infants who
developed BPD.
Evidence of an increased energy requirement in infants with BPD comes
from a series of studies using indirect calorimetry in babies with BPD.
As reviewed by Wilson and McClure (1994
), these studies
all show an increase in energy expenditure in infants with BPD compared
with controls. Differences of 15–25 kcal · kg-1 ·
d-1 are frequently reported. These studies are discussed
in detail elsewhere in this journal by Denne (2001
).
However, significant methodological questions regarding these studies
persist and the exact level of increased energy intake required by
infants with BPD remains uncertain.
Fewtrell et al. (1997
) randomized 60
oxygen-dependent 28-d-old preterm infants to either a 24
cal/oz (812 kcal/L) formula fed at 180 mL · kg-1 ·
d-1 or a 30 cal/oz formula fed at 145 mL ·
kg-1 · d-1. The infants fed the 30 cal/oz
(1014 kcal/L) formula had a slightly greater energy intake (9 kcal ·
kg-1 · d-1) because the feeding volume was
not readily maintained in the lower density–intake group. No
differences between groups in growth or respiratory outcome were seen.
Further studies using higher intake volumes and more concentrated
formulas would be useful to evaluate the benefits to various
caloric-density formulas.
A second approach to nutritional management of BPD involves altering
the composition of formula to increase the fat intake relative to the
carbohydrate intake. This has the potential benefit of decreasing
carbon dioxide production and the respiratory quotient in infants with
chronic lung disease. This approach was effective in a short-term
study by Periera et al. (1994
). In contrast, however,
although Chessex et al. (1995
) also found higher carbon
dioxide production associated with high fat intakes, they did not find
any rise in oxygen consumption, but did find an increase in the
transcutaneously measured partial pressure of oxygen in the blood.
Longer-term studies of these and other nutritional strategies to
treat BPD are ongoing, as described elsewhere in this issue by Atkinson
(2001
).
Even after hospital discharge, infants with BPD are at risk for ongoing
growth failure. Reports have indicated very high rates of growth
failure after hospital discharge. This poor growth is probably caused
by the infants’ ongoing increased energy utilization (Kurzner et al. 1988
). In addition to increased energy expenditure,
other factors contributing to this growth failure may be poor oral
feeding skills and tolerance, and recurrent infections and
hospitalizations. Reliance on high caloric-density feedings
postdischarge may not entirely resolve these issues without close
nutritional supervision (Johnson et al. 1998
). Singer et
al. (1996
) reported that postdischarge, infants with BPD
spent less time sucking and took in less formula per feeding than
infants without BPD, whereas this difference was not observed in
comparing other VLBW infants with full-term infants. Of particular
interest was their observation that symptoms of maternal depression or
anxiety may have led to less prompting by some mothers of their infant
to feed.
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Specific condition: cystic fibrosis (CF) |
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TOPABSTRACTThe links among nutrition,...Effects of malnutrition on...Growth failure in infants...Specific condition:...Specific condition: cystic...Other conditionsREFERENCES |
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CF affects approximately 30,000 Americans. Approximately one third of patients with CF are below the 5th percentile of weight for age. CF represents a good example of the bilateral relationship between pulmonary function and nutritional status. Whereas nutritional deficiency can lead to poor lung growth and increased infection, poor pulmonary function also causes increased energy utilization and growth failure. Therefore, management of these patients, as with others with chronic lung disease, requires a combination of pulmonary and nutritional management.
Nutritional requirements of children with CF.
A link between malnutrition in children with CF and worsening pulmonary
status has long been known and is well described (Borowitz 1996
). Modern body composition techniques have furthered our
understanding of this relationship. Thomson et al.
(1995
) used total body potassium (TBK) counting to show
that deterioration in pulmonary function can be predicted by changes in
body cell mass identified by TBK measurement. Of note was that this
relationship was more apparent than the relationship between
z-scores for height or weight and pulmonary function. The
authors suggest that subtle deterioration in nutritional status is
related to deterioration in pulmonary status in children moderately
affected by CF.
An increased resting energy expenditure was previously identified in
children with CF. Zemel et al. (1996
) demonstrated this
difference in prepubertal children with mild respiratory disease.
However, in their study, the level of resting energy expenditure was
not associated with a decline in pulmonary status over a 3-y period.
Rather, markers of nutritional status, such as percentage ideal body
weight, were predictive of changes in pulmonary function over time.
Fat-free mass and height were predictors of resting energy
expenditure.
Macro- and micronutrient deficiencies and their effects on pulmonary function in CF patients.
Protein-energy malnutrition (PEM) may develop in children with CF. In
addition to its other consequences, PEM may lead to increased
susceptibility to infections and further clinical deterioration
(Rappaz and Roulet 1997
).
Micronutrient deficiencies may also occur in CF patients as a result of their pancreatic insufficiency. Deficiencies of vitamins A and E, as well as minerals including zinc and magnesium, may be present when either intake or nutrient absorption is inadequate. These deficiencies may also affect lung status either directly or via an increased susceptibility to infections. Although vitamin A supplementation is widely used for children with CF, mineral requirements and intake levels for CF patients remain to be determined.
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Other conditions |
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TOPABSTRACTThe links among nutrition,...Effects of malnutrition on...Growth failure in infants...Specific condition:...Specific condition: cystic...Other conditionsREFERENCES |
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The effect of diet in determining the etiology and clinical severity of
asthma is unknown. There are epidemiological data to suggest that
antioxidants, magnesium and fat consumption may have important roles in
the severity of asthmatic symptoms. However, the relative importance of
these individual nutrients is unclear. Interventional studies are
beginning to help clarify the importance of diet in patients with
asthma, and early studies suggest that antioxidants in particular may
be beneficial (Fogarty and Britton 2000
). However, there
are too few data to draw conclusions at this time regarding antioxidant
supplementation and asthma (Smit 1999
).
A recent study showed that prepubertal males with mild to moderate
asthma had a higher metabolic rate per unit fat-free mass than did
nonasthmatic males (Maffeis 1998
). This is compensated
for by increased energy intake. However, further data are needed
regarding energy metabolism in asthmatic children before conclusions
can be reached regarding nutritional supplementation.
The effects of the widespread use of inhaled corticosteroids (ICs) on
growth in asthmatic children have caused concern. In one retrospective
study (Van Bever 1999
), adult height was assessed in
young adult asthmatics who were treated with ICs during childhood and
compared to asthmatic patients who were never treated with ICs during
childhood. Mean adult height was the same in subjects who took ICs
during childhood as compared to that of subjects who had never received
ICs. However, subjects who took ICs during childhood showed a
statistically significant lower value of adult height minus target
height than that of subjects who never received ICs. Patients on ICs
during childhood who had ever been hospitalized for asthma showed a
lower value for adult height minus target height than those who took
ICs but were never hospitalized. The authors concluded that, although
adult height was the same in young adults who were treated with ICs
during childhood compared to those who were not, their findings
suggested mild growth retardation in patients who took ICs during
childhood. They noted that this finding may have been related partly to
disease severity rather than the IC use.
In a short-term study Heuck et al. (1998
) showed a
significant decrease in short-term (4-wk) growth velocity among
children treated twice daily with oral budesonide compared with
children who received the same total daily dose administered once in
the morning. The implications of this study are controversial
(Brook 1998
), but suggest that further investigation is
needed on the short- and long-term effects of oral corticosteroids,
as well as their optimal dosing regimen (Inoue 1999
).
Congenital lung malformations.
Numerous congenital lung malformations exist, which can lead to chronic
pulmonary insufficiency and mimic the finding of premature infants with
BPD. Among the most common and severe is congenital diaphragmatic
hernia (CDH). This condition has an incidence of between 1 in 2000 and
1 in 10,000 live births. Because of the prenatal herniation, the lung
volume on the affected side is small and there is frequently marked
pulmonary hypertension. In addition to supportive care, management
frequently involves the use of cardiopulmonary bypass, referred to as
extracorporeal membrane oxygenation (ECMO). Although the benefits of
this approach are controversial, there is little doubt that most
survivors of CDH and ECMO are left with substantial chronic lung
disease. Furthermore, many have feeding difficulties, including
dysmotility with reflux and poor oral feeding (Hansen et al. 1998
).
There are few follow-up data on these infants. However, several
recent studies showed that development abnormalities and severe
nutritional problems persist in these infants. For example, Bernbaum et al. (1995
) reported that among ECMO survivors, those
with CDH had slower growth and more feeding and developmental problems
than those who required ECMO for other problems. Further evaluation of
these relationships is required, but there a substantial possibility
exists of a link between nutritional inadequacies in CDH patients and
their persistent developmental problems.
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FOOTNOTES |
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2 This work is a publication of the U.S. Department of Agriculture (U.S. Department of Agriculture)/Agricultural Research Service (ARS) Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX. This project has been funded in part with federal funds from the U.S. Department of Agriculture/ARS under Cooperative Agreement number 58-6250-6-001. Contents of this publication do not necessarily reflect the views or policies of the U.S. Department of Agriculture, nor does mention of trade names, commercial products or organizations imply endorsement by the U.S. Government.
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TOPABSTRACTThe links among nutrition,...Effects of malnutrition on...Growth failure in infants...Specific condition:...Specific condition: cystic...Other conditionsREFERENCES |
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