Nutrition during lung disease,

sepsis & other special consideration

Risma Kerina Kaban

Division of Perinatology, Faculty of Medicine, University
of Indonesia, Jakarta
Objective
Describe the factor that
List the factor on which
illnesses alter, thereby
the nutritional needs of the
changing nutrient
neonate depend
requirement

Describe the level of

Delineate the adverse
amino acids that can be
effect of protein
initiated without causing
malnutrition following an
intolerance/toxicity in the
acute/prolonged
most ill infants & special
illness/insult
sircumstance
 Introduction
 The nutrition needs of ill physiologically unstable infant
have been neglected .
 Nutritional investigator have concentrated on the needs of
the ideal healthy preterm infant
 Review current knowledge about the metabolic changes
induced by common neonatal illneses
 Comparing the nutritional needs of ill infants vs standards
for healthy newborn

Premer DM, Georgieff MK. Pediatr. Rev. 1999;20;56

Ben XM. World journal of gastroenterology. 2008;14(40):6133-6139
Normal requirement
 Understanding the nutritional requirement of healthy term
& preterm infants forms a basis for assessing the effect of
disease processess on nutrient needs
Premer DM, Georgieff MK. Pediatritr. 1999;20;56
Acute pulmonary disease

 Most common admission diagnosis in NICU

 Most common severe illness of neonate
 RDS, pneomonia, meconium aspiration syndrome,
congenital diafragmatic hernia
 Oxygen consumption ↑ → energy requirement ↑
 Resting energy expenditure: 40 to 60 kcal/kg per day.
 Caloric needs directly proportional to the severity of
the illness

Premer DM, Georgieff MK. Pediatr. Rev. 1999;20;56

Acute pulmonary disease (Energy needs)
 The nutritional goal: to achieve a possitive energy
balance
Acute phase :
 Insulin resistant + counter regulatory hormones 
(cortisol, epinephrine, NE)  tissue catabolism 

 Energy delivered in excess of the amount needed to

fuel the basal metabolic rate is likely to be wasted at
best to increase energy demand at worst
Acute pulmonary disease (Energy needs)

High rate of carbohydrate delivery (> 12,5 mg/kg per

minute) → carbon dioxide production ↑

Increased rate of CO2 production in infants who has respiratory disease 

increase the work of breathing /exposure to barotrauma in infants who are receiving mechanical
ventilation

Lipids: calorically dense, create less CO2 when metabolized → advantage when mechanical
ventilated
Acute pulmonary disease (Energy needs)

 Lipid emulsion 1 g/kg per day

  0,5 to 1g/kg per day (monitor serum triglyceride)
 Energy expenditure increases with worsening acute
pulmonary disease
 A balanced delivery of energy from carbohydrate & lipids
is indicated
 The initial goal: to meet resting energy expenditure (60
kcal/kg per day) to reduce catabolism  advancing energy
intake to level that supports weight gain
Acute pulmonary disease (Protein Needs)

 Poor protein status  low oncotic pressure 

pulmonary edema
 Plasma amino acid  if no protein intake
 The degree of protein loss: 1,2 to 1,4 g/kg per day
 The daily in utero protein accretion : 2,1 g/kg per day
 ≥ 3,5 g/kg per day  in utero accretion rate on track
 1,5 g/kg per day  achieve positive nitrogen balance
  0,5 to 1 g/kg per day  3 to 4 g/kg per day of amino acid
parenterally
Acute pulmonary disease (Minerals)

 Disorders of calsium, phosphorus, Mg metabolism 

common in acute pulmonary disease
 hypocalcemia, hypophosphatemia, hypomagnesemia 
effect optimal respiratory & cardiac function
 Transient neonatal hypocalcemia → exacerbated by acute
respiratory disease, tetany, cardiac arrhythmia
 600 mg of calsium gluconate per 100 ml of iv fluids on
day 1 → provide prophylaxis against hypocalcemia
 Hypophosphatemia & hypomagnesemia → muscle weakness,
lethargy, poor respiratory effort
 Hypermagnesemia → lead to apnea
Acute pulmonary disease (Vitamins)
 Low vitamin A levels → give vitamin supplementation
 Recommended dose: at least 2000 U IM every other
day
 The goal: to achieve a serum retinol level of greater
than 20 mcg/dL
 Bronchopulmonary Displasia

 Energy need who have BPD: 25 % higher resting

energy expenditures →related to pulmonary status &
increased work of breathing

 Enery requirement for growth: 130 to 150 kcal/kg per

day

 Fat: good nutritional adjuvant

 High caloric density
 Should not provide > 60 % of the total calories

Premer DM, Georgieff MK. Pediatr. Rev. 1999;20;56

BPD (Protein)

 High dose dexamethasone (0,5 mg/kg per day) reduced

linear growth & weight gain  increasing protein
breakdown

 Fed infant > 120 kcal/kg per day

 Protein intakes of at least 3,5 g/kg per day

 caloric intake  (supplement of fat / carbohydrate ) 

protein delivery 
BPD (Mineral)
 Diuretic therapy (furosemide, bumetaside) → increase
urinary sodium, potassium, chloride, calsium losses
 Sodium requirement for a healthy preterm infant: 3 to
4 mEq/kg per day
 Diuretic  increase to as high as 12 mEq/kg per day
 Potassium requirement: 2 to 4 mEq/kg per day in the
healthy infant,
 Diuretic  rise to 7 to 10 mEq/kg per day
 Persistent hyponatremia exhibit poor growth & severe
hypochloremia → sudden death in those who have
BPD
BPD (Vitamins)
 Vitamin A: biological antioxidant, influences epithelial
growth, differentiation, repair
 Low serum retinol concentrations (<20 mcg/dL)  risk of
BPD ↑ → treatment with at least 2000 IU administered
IM every other day → effective strategy for reducing
BPD risk
 Vitamin E: a biological antioxidant, protect the
polyunsaturated fatty acids of cell membrane from
peroxidation
 Deficiency of vitamin E: a severe hemolytic anemia →
treatment with 50 to 75 IU / day
 Zinc sufficiency ,increased body weight
Premer DM, Georgieff MK. Pediatr. Rev. 1999
,valentine nutr clin practice 2011
Sepsis (Energy need)

 Hypermetabolic state: a marked catabolic response,

profound changes in energy & protein metabolism
 Increase level of cytokine (TNF alpha, interleukin 6,
interleukin 1b ) increased sympathetic nervous ststem
 Increased oxygen requrement and negative nitrogen
balance
 In septic infants: Energy delivery during acute phase >
nonseptic infants
 Least 60 kcal/kg per day

Premer DM, Georgieff MK. Pediatr. Rev. 1999;20;56

Sepsis (Protein)
 Causes the most profound changes in negative
nitrogen balance
 Cytokines & acute phase reactant protein
concentration 
 The mean nitrogen balance: -141 ± 316 mg/kg per day
 The concern: duration of negative nitrogen balance
would lead to long term morbidity & growth delay
 To provide at least 2,5 g/kg per day of protein
Sepsis (Minerals)

 No known spesific effect on mineral homeostasis

 Iron → an essential nutrient for bacterial proliferation
 The body appears to hide iron during infection by
decreasing serum concentration
Sepsis (Vitamins)

 Vitamin A & E have not been well defined

 Vitamin E supplementation: no proven to be beneficial
in decreasing infection / improving response to
infection
 Antibiotic + vitamin K 1 mg at least 2 times per
weeks: reduce bacterial colonization of the
gastrointestinal tract
 The inherent production of vitamin K by
gastrointestinal tract
Conclusion

 It’s important for the clinician to appreciate the

spesific nutrient requirements associated with various
disease states & their therapies in the ill newborn

 Neonatal illness significantly alter energy, protein,

mineral metabolism in disease spesific manner

 Failure to provide appropriate nutritional support

during illnesss may delay recovery from / even
exacerbate common neonatal disease