John Kerner

Abstract

Pediatric home parenteral nutrition (PN) patients present a unique challenge with risks of catheter-associated bloodstream infections (CABSIs), sometimes requiring subsequent catheter removal. Recurrent infections can lead to line removal and potential loss of venous access in the future.Demonstrate that weekly ethanol lock therapy decreases CABSIs in long-term home PN patients and decreases line removals due to infections.Beginning August 2007, patients receiving PN with a history of multiple previous CABSIs were started on ethanol lock therapy. Seventy percent ethanol solution was instilled into the central venous catheter (CVC) for 2 hours weekly. Episodes of CABSIs and catheter removal due to infection were documented in patients prior to and after ethanol lock therapy.Fourteen patients were followed for an average of 690 days after ethanol lock therapy was initiated. These patients were found to average 9.8 CABSIs per 1000 catheter days prior to starting ethanol lock therapy and only 2.7 CABSIs per 1000 catheter days after ethanol lock therapy (P < .001). Prior to ethanol lock therapy, the group averaged 4.3 catheter removals per 1000 catheter days but only 1.0 catheter removal per 1000 catheter days after ethanol lock therapy.Our group of patients showed a 73% reduction in CABSIs and a 77% reduction in catheter removal due to infection after ethanol lock therapy. In our patient population, weekly ethanol lock therapy for 2 hours is an effective technique to reduce CABSIs and catheter removal in long-term home PN patients.

View details for DOI 10.1177/0884533612468009

View details for PubMedID 23232749

Abstract

Ethanol lock therapy has been implemented to prevent infections of central venous catheters as well as to treat infections. Fungal catheter-associated blood stream infections are historically more difficult to treat and have required removal of central venous catheters. We report the largest case series to date, successfully treating 5 of 7 fungal catheter-associated blood stream infections with ethanol lock therapy and systemic echinocandin administration.

View details for DOI 10.1097/INF.0b013e3182784867

View details for Web of Science ID 000314932700027

View details for PubMedID 23076381

Abstract

Aluminum (Al) is a contaminant in all parenteral nutrition (PN) solution component products. Manufacturers currently label these products with the maximum Al content at the time of expiry. We recently published data to establish the actual measured concentration of Al in PN solution products prior to being compounded in the clinical setting [1]. The investigation assessed quantitative Al content of all available products used in the formulation of PN solutions. The objective of this study was to assess the Al exposure in neonatal patients using the least contaminated PN solutions and determine if it is possible to meet the FDA “safe limit” of less than 5 μg/kg/day of Al. The measured concentrations from our previous study were analyzed and the least contaminated products were identified. These concentrations were entered into our PN software and the least possible Al exposure was determined. A significant decrease (41%–44%) in the Al exposure in neonatal patients can be achieved using the least contaminated products, but the FDA “safe limit” of less than 5 μg/kg/day of Al was not met. However, minimizing the Al exposure may decrease the likelihood of developing Al toxicity from PN.

View details for DOI 10.3390/nu4111566

View details for Web of Science ID 000311426800004

View details for PubMedID 23201834

View details for DOI 10.1177/0148607111422069

View details for PubMedID 22190603

Abstract

Aluminum is a contaminant in all parenteral nutrition solutions. Manufacturers currently label these products with the maximum aluminum content at the time of expiry, but there are no published data to establish the actual measured concentration of aluminum in parenteral nutrition solution products prior to being compounded in the clinical setting. This investigation assessed quantitative aluminum content of products commonly used in the formulation of parenteral nutrition solutions. The objective of this study is to determine the best products to be used when compounding parenteral nutrition solutions (i.e., those with the least amount of aluminum contamination).All products available in the United States from all manufacturers used in the production of parenteral nutrition solutions were identified and collected. Three lots were collected for each identified product. Samples were quantitatively analyzed by Mayo Laboratories. These measured concentrations were then compared to the manufacturers' labeled concentration.Large lot-to-lot and manufacturer-to-manufacturer differences were noted for all products. Measured aluminum concentrations were less than manufacturer-labeled values for all products.The actual aluminum concentrations of all the parenteral nutrition solutions were significantly less than the aluminum content based on manufacturers' labels. These findings indicate that 1) the manufacturers should label their products with actual aluminum content at the time of product release rather than at the time of expiry, 2) that there are manufacturers whose products provide significantly less aluminum contamination than others, and 3) pharmacists can select products with the lowest amounts of aluminum contamination and reduce the aluminum exposure in their patients.

View details for DOI 10.5863/1551-6776-16.2.92

View details for PubMedID 22477831

Abstract

Parenteral nutrition (PN), containing fat emulsions derived from soybean, has been implicated in the progression of PN-associated liver disease and cholestasis, particularly in infants with short bowel syndrome. Clinical use of Omegaven, a parenteral fish-oil emulsion, has been shown in recent studies to be a promising therapy to reverse liver disease and cholestasis. This review summarizes the rationale, relevant clinical investigations and future direction of Omegaven therapy for PN-dependent infants.

View details for DOI 10.1038/jp.2010.182

View details for Web of Science ID 000289236900009

View details for PubMedID 21448206

Abstract

Aluminum (Al) is associated with significant central nervous system toxicity and bone and liver damage. Because Al is a contaminant of parenteral nutrition (PN) components including calcium and phosphate additives, premature infants are at potentially high risk for toxicity. The US Food and Drug Administration (FDA) has mandated PN component product labeling and recommended maximum Al daily exposure limits. The objective of this article is to determine the actual Al content of neonatal PN solutions, compare these values to the calculated amounts from manufacturers' PN product labels, and ascertain whether the actual Al exposure exceeds the FDA recommended maximum of 5 microg . kg(-1) . day(-1).Samples from 40 neonatal patient PN solutions were selected for sampling and Al content determination. Samples were also taken from 16 manufacturer's component products used in PN formulation. All of the samples were sent to Mayo Laboratories for Al content measurement. The calculated Al concentrations in PN samples were determined from the manufacturer's labeled content.Both measured and calculated Al concentrations exceeded the FDA recommended safe limit of <5 microg . kg(-1) . day(-1). The actual measured Al content was significantly lower than the calculated Al content in both the patient PN solutions and the component product samples.Al exposure exceeded the FDA recommended maximum limit for all patient samples; however, the actual measured Al content of all the samples was significantly less than the calculated Al content based on manufacturer's labels. These findings suggest that manufacturers label their products with actual Al content at the time of product release rather than at time of expiration. Periodic monitoring of Al levels should be considered with prolonged PN therapy. Changes in manufacturing processes, including the use of better raw materials, are essential to reduce Al contamination to meet FDA mandates.

View details for DOI 10.1097/MPG.0b013e3181aed70b

View details for Web of Science ID 000273994000018

View details for PubMedID 20038851

Abstract

Refeeding syndrome (RFS) is the result of aggressive enteral or parenteral feeding in a malnourished patient, with hypophosphatemia being the hallmark of this phenomenon. Other metabolic abnormalities, such as hypokalemia and hypomagnesemia, may also occur, along with sodium and fluid retention. The metabolic changes that occur in RFS can be severe enough to cause cardiorespiratory failure and death. This article reviews the pathophysiology, the clinical manifestations, and the management of RFS. The key to prevention is identifying patients at risk and being aware of the potential complications involved in rapidly reintroducing feeds to a malnourished patient.

View details for DOI 10.1016/j.pcl.2009.06.006

View details for Web of Science ID 000272846100011

View details for PubMedID 19931071

Abstract

Aluminum toxicity can cause serious central nervous system and bone toxicities. Aluminum is a contaminant of parenteral nutrition (PN) solution components. Premature neonates requiring high doses of calcium and phosphate to mineralize their bones, children with impaired renal function, and children on PN therapy for prolonged duration are at the highest risk. Effective in July 2004, the U.S. Food and Drug Administration (FDA) mandated labeling requirements for aluminum content in all PN solution components. To assess the aluminum exposure in neonatal and pediatric populations, this study aims to determine patients' daily aluminum load (mug/kg/d) delivered from PN solutions.The study included all inpatients who received PN during calendar year 2006 (13,384 PN patient days). The calculated parameters of mug/kg/d and mug/L of parentally administered aluminum were stratified according to patient age and weight. Aluminum content by product and manufacturer were tabulated.Forty-nine percent of the PN patient days were in patients weighing < 3 kg. These patients also received the largest amounts of aluminum (range, 30-60 mug/kg/d). Meeting the FDA regulation was possible only in patients weighing > 50 kg.Currently available parenteral products used to make PN solutions contain amounts of aluminum that make it impossible to meet the new FDA rule of <5 mug/kg/d of aluminum exposure. Manufacturers must identify, develop, and adopt new methods to reduce the aluminum contamination in their products. Health care professionals should calculate aluminum loads in patients and make informed decisions when choosing PN products.

View details for DOI 10.1177/0148607108316187

View details for Web of Science ID 000259016300003

View details for PubMedID 18443135

Abstract

Alteplase is approved for use in the restoration of function to occluded central venous access devices (CVADs); however, there are few prospective studies in children. This study was undertaken to evaluate the safety and efficacy of alteplase in the treatment of CVAD occlusions in a pediatric population.A prospective, multicenter, open-label, single-arm study evaluating a maximum of two doses (< or =2 mg per dose) of alteplase was performed in pediatric patients. Inclusion criteria included patient age less than 17 years with an occluded CVAD (single-, double-, and triple-lumen catheter or implanted port). Patients with hemodialysis catheters, those with known mechanical occlusion, or those considered at high risk for bleeding or embolization were excluded. Assessment of function was made 30 and 120 minutes (if required) after each dose. The primary objective of the study was to evaluate the safety of alteplase as measured by the incidence of intracranial hemorrhage (ICH); secondary objectives included the evaluation of specific targeted serious adverse events and efficacy of alteplase in the restoration of catheter function.A total of 310 patients (174 male patients, 136 female patients; mean age, 7.2 years; range, 0.04-18.3 y) were treated; 55 of the patients (17.7%) were younger than 2 years of age. No patients experienced ICH (95% CI, 0%-1.2%). Nine serious adverse events were noted in eight patients (2.6% incidence), two of which were attributed by the investigator to study drug administration (one case of sepsis and one case of a ruptured catheter lumen). The cumulative rate of restoration of CVAD function after serial administration of a maximum of two instillations of alteplase, each with a maximum dwell time of 120 minutes, was 82.9% (95% CI, 78.2%-86.9%). Similar rates of catheter function restoration were seen among all catheter types studied; there were no clinically meaningful differences among age or sex subgroups.The administration of alteplase is safe and effective for the restoration of function to CVADs in pediatric patients.

View details for DOI 10.1097/01.RVI.0000241542.71063.83

View details for Web of Science ID 000242482400003

View details for PubMedID 17142704

Abstract

IV fat emulsion (IVFE) is an integral part of the parenteral nutrition (PN) regimen in neonates. It provides a concentrated isotonic source of calories and prevents or reverses essential fatty acid deficiency. Continuous administration of IV fat with PN regimens prolongs the viability of peripheral IV lines in infants who might have limited venous access. IVFE must be administered separately from the PN solution in neonates. The acidic pH of a PN solution is necessary for maximum solubility of calcium and phosphorus. If fat emulsion is added to the PN solution, as is done in 3-in-1 (total nutrient admixture) solutions, the high amount of calcium and phosphorus needed by these infants may result in an unseen precipitate with serious consequences. Continuous fat infusion over 24 hours is the preferred method in neonates. The administration rate of 0.15 g/kg/hour for IVFE in the neonate should not be exceeded. Essential fatty acid deficiency can be prevented in neonates by providing IVFE in a dose of 0.5-1.0 g/kg/day. Carnitine is not routinely required to metabolize IVFE in the neonate. Infants should receive 20% lipid emulsion to improve clearance of triglycerides and cholesterol. Serum triglyceride levels should be maintained at <150-200 mg/dL in neonates. There are concerns about potential adverse effects of early administration of IV fat in very-low-birth-weight infants weighing <800 g. We hold the IV fat dose at 1.0-1.5 g/kg/day until the second week of life in infants <30 weeks gestation.

View details for PubMedID 16870805

Abstract

A proper initial assessment of catheter occlusion is the key to successful management. The assessment screens are for both thrombotic and nonthrombotic causes (including mechanical occlusion). If mechanical occlusion is excluded, thrombotic occlusion is treated with alteplase. Nonthrombotic occlusions are treated according to their primary etiologies: lipid occlusion is treated with 70% ethanol, mineral precipitates are treated with 0.1-N hydrochloric acid (HCl), drug precipitates are treated according to their pH-acidic drugs can be cleared with 0.1-N HCl, basic medications can be cleared with sodium bicarbonate or 0.1-N sodium hydroxide (NaOH). Prevention of occlusion of central venous access devices is also critical. To date, no data conclusively show heparin flushes to be superior to saline flushes. No prophylactic regimen, including low-dose warfarin, low-molecular-weight heparin, or 1 unit heparin/mL of parenteral nutrition has been endorsed by any major medical, nursing, or pharmacy group due to lack of scientific evidence. The most encouraging information on decreasing occlusion rate comes from experience with positive-pressure devices that attach to the hub of most catheter lumens and prevent retrograde blood flow and, consequently, decrease the risk of thrombus formation in the catheter lumen.

View details for Web of Science ID 000248557900013

View details for PubMedID 16387916

Abstract

Foods that account for 90% of allergic reactions in children are cow's milk protein, eggs, peanut, soy, tree nuts, fish, and wheat. Food allergy can manifest as urticaria/angioedema, anaphylaxis, atopic dermatitis, respiratory symptoms, or a gastrointestinal (GI) disorder. GI allergic manifestations can be classified as immunoglobulin E (IgE) mediated (immediate GI hypersensitivity and oral allergy syndrome); "mixed" GI allergy syndromes (involving some IgE components and some non-IgE or T-cell-mediated components) include eosinophilic esophagitis and eosinophilic gastroenteritis. Non-IgE-mediated or T-cell-mediated allergic GI disorders include dietary protein enteropathy, protein-induced enterocolitis, and proctitis. All these conditions share a common denominator: the response of the immune system to a specific protein leading to pathologic inflammatory changes in the GI tract. This immunological response can elicit symptoms such as diarrhea, vomiting, dysphagia, constipation, or GI blood loss, symptoms consistent with a GI disorder. The detection of food allergies can be accomplished by the use of radioallergosorbent (RAST) testing and skin prick tests in helping to assess the IgE-mediated disorders. Patch tests may help evaluate delayed hypersensitivity reactions. Treatment of GI allergic disorders ranges from strict dietary elimination of offending food(s), use of protein hydrolysates, and use of L-amino acid-based formula when protein hydrolysates fail. Treatment with topical (for eosinophilic esophagitis) or systemic steroids is used if all dietary measures are unsuccessful. Maternal breast feeding or the use from birth of hydrolysate formulas (extensive or partial hydrolysates) may be efficacious in the prevention of atopic disease in "high-risk" families (with at least 1 parent or sibling with a history of atopic disease).

View details for PubMedID 16207693

Abstract

The standard of care for patients with cholestasis (direct bilirubin >or=2 mg/dL) while receiving parenteral nutrition (PN) solutions is to reduce or discontinue the copper and manganese. The repercussions of this action have not been studied. Two adult case reports document low serum copper levels associated with clinical symptoms of copper deficiency after the removal of copper from their PN solutions. We now describe the first known series of pediatric patients to develop copper deficiency after copper was removed from their PN solutions.

View details for PubMedID 16215119

Abstract

Both physiologic and psychological reasons for cycling total parenteral nutrition (TPN) have been well established. Despite widespread acceptance of this practice, the only previously published method for calculating TPN cycle rates is inherently flawed.A mathematical formula was derived to facilitate reliable calculation of cyclic TPN flow rates as a function of total volume and cycle time. A publicly accessible website was subsequently developed to expedite rapid determination of TPN cycles.A fail-safe method of calculating TPN cycle flow rates can be expressed as F = V/(4T-10), where F is equal to the basal flow rate (mL/h), T is equal to the desired cycle time (hours), and V is equal to the total volume of TPN (mL) to be delivered in 24 hours. The basal flow rate and twice the basal flow rate are used for the first and last 2 hours of the TPN cycle, and the remainder of the cycle runs at 4 times the basal flow rate. TPN cycles may be easily calculated online using this formula at http://peds.stanford.edu/tpn.html.We have developed a fail-safe method of calculating TPN cycle flow rates that will consistently deliver the desired volume and have made an online implementation of this formula publicly available.

View details for PubMedID 16215087

View details for Web of Science ID 000089207500005

View details for PubMedID 11016049

Abstract

Human milk fortification has been advocated to enhance premature infants' growth. We, therefore, undertook this study of a new human milk fortifier containing more protein than a reference one.Open, randomized, controlled, multiclinic trial, with weekly growth parameters and safety evaluations in premature infants <1,500 g.The 2 groups did not differ in demographic and baseline characteristics. The adjusted daily milk intake was significantly higher in the infants fed reference human milk fortifier (n = 29; 154.2 +/- 2.1 vs. 144.4 +/- 2.5 ml/kg/day, mean +/- SE; p < 0.05). Both human milk fortifiers produced increases over baseline in weight, length, and head circumference, with greater gains observed in the new human milk fortifier-fed infants for the former two parameters (weight gain 26.8 +/- 1.3 and 20.4 +/- 1.2 g/day, p < 0.05; head circumference 1.0 +/- 0.1 and 0.8 +/- 0.1 cm/week; length 0.9 +/- 0.1 and 0.8 +/- 0.1 cm/week, respectively). Serum chemistries were normal and acceptable for age. Study events were typical for premature infants and similar in both groups.This new human milk fortifier had comparable safety to the reference human milk fortifier and promoted faster weight gain and head circumference growth.

View details for Web of Science ID 000087619400001

View details for PubMedID 10838460

Abstract

The nutrition support team at Lucile Salter Packard Children's Hospital at Stanford developed a clinical pathway for infants and children receiving parenteral nutrition (PN). Use of clinical pathways for health care delivery is one way in which clinicians and institutions are responding to pressure from managed care organizations to reduce costs and maintain or improve quality. This pathway was developed to standardize the process for ordering, implementing, and monitoring PN. Specific goals for the pathway are as follows: to decrease the number of patients receiving PN inappropriately, to decrease the duration of PN for those patients who require it, to determine complication rates, and to monitor outcomes of therapy. Such comprehensive monitoring will help identify areas for improvement. By developing and implementing action plans to address these issues, we expect to improve continuously the processes and outcomes associated with PN therapy.

View details for PubMedID 9155406

Abstract

There are two major types of adverse reactions in infant formulas: (1) formula allergy/hypersensitivity, which is an immunologic response, and (2) formula intolerance, which is a nonimmunologic response. Formula intolerance can occur in infants with an underlying congenital or acquired enzyme deficiency (disaccharidase deficiency, galactosemia, hereditary fructose intolerance). The clinical presentation, diagnosis, and treatment of both reactions are reviewed in this article. The appropriateness of the use of a variety of infant formulas is discussed. Guidelines for the prevention of allergic disease are described as well.

View details for Web of Science ID A1995QH18800002

View details for PubMedID 7729855

Abstract

It has become a common practice to supplement human milk with a variety of additives to improve the nutritive content of the feeding for the premature infant. Twenty-two freshly frozen human milk samples were measured for lysozyme activity, total IgA, and specific IgA to Escherichia coli serotypes 01, 04, and 06. One mL aliquots were mixed with the following: 1 mL of Similac, Similac Special Care, Enfamil, Enfamil Premature Formula, and sterile water; 33 mL of Poly-Vi-Sol, 33 mg of Moducal, and 38 mg of breast-milk fortifier, and then reanalyzed. Significant decreases (41% to 74%) in lysozyme activity were seen with the addition of all formulas; breast-milk fortifier reduced activity by 19%, while no differences were seen with Moducal, sterile water, or Poly-Vi-Sol. No differences were seen in total IgA content, but some decreases were seen in specific IgA to E. coli serotypes 04 and 06. E. coli growth was determined after 3 1/2 hours of incubation at 37 degrees C after mixing. All cow-milk formulas enhanced E. coli growth; soy formulas and other additives preserved inhibition of bacterial growth. Nutritional additives can impair anti-infective properties of human milk, and such interplay should be considered in the decision on the feeding regimen of premature infants.

View details for Web of Science ID A1994NR58100002

View details for PubMedID 8200164

Abstract

Growth failure is the most common extraintestinal manifestation of Crohn's disease in childhood, occurring in up to 50% to 88% of affected patients. Previous studies have shown malnutrition to be the most likely cause of the decrease in height and weight velocities in these children. The purpose of this study was to determine the effect of an intermittent defined formula diet on growth and disease activity in children with Crohn's disease and growth failure. Six Tanner stage I-II patients, mean age 13.6 years with height less than the 5th percentile or height velocity less than the 3rd percentile were enrolled in a 1-year prospective study. An isotonic, hydrolyzed whey, medium-chain triglyceride formula was given by nocturnal nasogastric infusion at a caloric equivalent of 50th percentile for age, as the exclusive nutrient source 1 out of 4 months during a 1-year period. A 2-week exclusion diet and a 2-week low-residue diet followed the defined formula diet before resuming the regular diet for 2 months. Patients served as their individual control based on observations of at least 1 year before the study. Height and weight velocity significantly increased. Prednisone intake significantly decreased, and significant improvement was seen in disease activity, albumin, and somatomedin C. The results indicate that an intermittent defined formula diet can improve growth failure and significantly decrease disease activity in children with Crohn's disease.

View details for Web of Science ID A1992JY70000001

View details for PubMedID 1494204

Abstract

In intensive care nurseries it has become common practice to use microwave thawing of frozen human milk for more rapid accessibility. Twenty-two freshly frozen human milk samples were tested for lysozyme activity, total IgA, and specific secretory IgA to Escherichia coli serotypes 01, 04, and 06. The samples were heated by microwave for 30 seconds at a low- or high-power setting and then reanalyzed. One-mL aliquots of 10 additional human milk samples were microwaved at low (20 degrees C to 25 degrees C), medium (60 degrees C to 70 degrees C), and high (greater than or equal to 98 degrees C) setting before the addition to each of 1 mL of diluted E coli suspension. E coli growth was determined after 3 1/2 hours of incubation at 37 degrees C. Microwaving at high temperatures (72 degrees C to 98 degrees C) caused a marked decrease in activity of all the tested antiinfective factors. E coli growth at greater than or equal to 98 degrees C was 18 times that of control human milk. Microwaving at low temperatures (20 degrees C to 53 degrees C) had no significant effect on total IgA, specific IgA to E coli serotypes 01 and 04, but did significantly decrease lysozyme and specific IgA to E coli serotype 06. Even at 20 degrees C to 25 degrees C, E coli growth was five times that of control human milk. Microwaving appears to be contraindicated at high temperatures, and questions regarding its safety exist even at low temperatures.

View details for Web of Science ID A1992HM25100018

View details for PubMedID 1557249

Abstract

We report two cases of microvillous inclusion disease (MID) occurring in a set of siblings. Although it is a rare disorder, MID appears to be a common cause of familial intractable secretory diarrhea. Diagnosis rests on the ultrastructural finding of intracytoplasmic inclusions that are lined by intact microvilli. These inclusions are present in the absorptive surface epithelial cells of the small and large intestine and are associated with poorly developed surface brush border microvilli. The prognosis of MID is poor and curative therapy is not currently available. Because MID appears to be a hereditary disorder, genetic counseling of affected families is essential.

View details for Web of Science ID A1991GV11600006

View details for PubMedID 1660676

Abstract

We treated four patients with chronic vomiting during childhood in whom a tentative diagnosis of psychogenic vomiting was made after an extensive evaluation. In each case, the diagnosis was reconsidered during the course of treatment, as observations about the patients and their response to interventions accumulated. In three instances, these observations did not fit those expected if the diagnosis of psychogenic vomiting was correct. This led to a reexamination of the organic evaluation and the discovery of an undiagnosed organic contribution to the vomiting. In the fourth patient, gastric emptying studies confirmed that there was a strong psychological contribution to the vomiting, and helped to more carefully define this contribution. Family and individual psychotherapy and treatment were aided by the greater clarity in diagnosis.

View details for Web of Science ID A1991FZ98300026

View details for PubMedID 1858729

View details for PubMedID 3694523

Abstract

Due to calcium and phosphorus solubility problems in parenteral nutrition solutions, it is difficult to provide the premature infant with enough of these two minerals for adequate bone mineralization. In order to determine the maximum amounts of both Ca and P soluble in neonatal parenteral nutrition solutions, we employed the following procedure: (1) using concentrations of dextrose 10 to 25% and amino acid 0.5 to 4.0% with standard electrolyte and vitamin concentrations, Ca and P additions were sequentially made to determine the critical concentrations at which precipitates formed; (2) the pH of each test solution was determined; (3) all test solutions were incubated for 30 hr at room temperature; (4) following incubation, all tests were visually observed for calcium-phosphate crystals; (5) the solutions not obviously precipitated were filtered using black Millipore filters to determine the presence of any microprecipitates. Multiple graphs of Ca and P solubility in various dextrose/amino acid solutions were prepared from data generated by the study. The Ca and P interaction is primarily pH sensitive. Factors affecting the solution pH include both dextrose and amino acid concentrations. Our study showed that increases in amino acid concentrations enabled us to increase both Ca and P in the solutions.

View details for Web of Science ID A1983QY84500005

View details for PubMedID 6413711

Abstract

A combination of pancreatic insufficiency and inadequate caloric intake may produce essential fatty acids (EFA) deficiency in patients with cystic fibrosis. Seventy-five percent of the adolescents and young adults with poor weight gain in our clinic were EFA-deficient by total plasma linoleic acid criteria. Twenty of these patients were placed on an oral hyperalimentation regimen containing 230% of calories required for basal energy expenditure, 40% as fat. Forty percent of these (8/20) achieved normal EFA levels on this diet. Eight of the nonresponding patients were given an additional 5% of their caloric intake as linoleic acid monoglyceride. All who maintained caloric intake achieved normal EFA levels. Normalization of EFA levels was associated with a number of clinical benefits including increase in weight and activity and, in five teenage girls, regulation of menses. The 16 control patients who received standard pancrelipase therapy and nutritional supplements remained fatty acid deficient. We conclude that oral hyperalimentation can restore EFA levels in cystic fibrosis patients if adequate calories are available to provide energy needs.

View details for Web of Science ID A1981MZ06200007

View details for PubMedID 6801283

Abstract

Weekly determinations of the fatty acid/albumin molar ratio (FA/SA) were obtained 136 times on 50 neonates (birthweight range, 675-4300 grams; median, 1360 grams) to determine if our use of intravenous fat (IVF) was putting these newborns at risk for kernicterus. The FA/SA was measured using a convenient spectrophotometric technique which we have previously described (Berde CB, Kerner JA, Johnson JD: Clin Chem 26:1173-1177, 1980). Twenty-nine infants received IVF with doses from 0.5 to 3.3 gram/kilogram/day (mean 1.5 gram/kilogram/day), given over 24 hours whenever possible, most commonly begun in the second week of life when the bilirubin level was less than one half of the potential exchange level. Twenty-one infants received no IVF. Previous studies show that fatty acids do not begin to displace bilirubin from albumin until the FA/SA is greater than 6 in vivo, and greater than 4 in vitro. All our infants had safe values with mean FA/SA values of approximately 1.0. Continuous IVF as we administer it does not place neonates at risk for kernicterus. Centers administering IVF in the first week of life or by bolus should consider close monitoring of their infants with the FA/SA.

View details for Web of Science ID A1981MZ06200011

View details for PubMedID 7199590

Abstract

Of 40 survivors of necrotizing enterocolitis 19 were completely normal children at the time of follow-up, one to three years later. Among the other 21 children, only six had moderate to severe neurologic impairment, representing 15% of all survivors. Despite the fact that intestinal injury is the main feature of the neonatal disease, only four children were symptomatic from gastrointestinal sequelae, and none of these suffered failure to thrive. Thus, 81% (17) of the children with late morbidity had problems unrelated to the gastrointestinal tract. The nongastrointestinal morbidity was associated with prematurity and the degree of perinatal stress.

View details for Web of Science ID A1980KU96100021

View details for PubMedID 7454483

Abstract

We describe a method for rapidly assaying fatty acid concentrations in plasma or serum. This method is particularly appropriate for monitoring increased concentrations of fatty acids that may be present during intravenous lipid infusion, especially in neonates. Binding cisparinaric acid (9, 11, 13, 15-cis-trans-trans-cis-octadecatetraenoic acid) to albumin shifts the absorption spectrum of the acid. If fatty acids are present in serum, they will compete with parinaric acid for binding, changing the extent of this absorption shift. The measurement requires a spectrophotometer, 30 microL of serum or plasma, and knowledge of the sample's albumin concentration.

View details for Web of Science ID A1980KB48600011

View details for PubMedID 7389088

View details for Web of Science ID A1979HR74500011

View details for PubMedID 120008

View details for Web of Science ID A1979GT31000004

View details for PubMedID 429466