Energy metabolism in infants with growth failure due to maternal deprivation, undernutrition, or causes unknown. II. Relationship between nitrogen balance, weight gain, and postprandial excess heat production

Emotional Deprivation in Children: Growth Faltering and Reversible Hypopituitarism

Emotional deprivation can lead to growth faltering of infants and children. The mechanism(s) involved differ in that for infants, the major metabolic problem is inadequate energy intake for growth. In young children, it is likely that the emotional deprivation causes a syndrome not only of growth faltering, but with bizarre behaviors, especially with regard to food: hoarding, gorging and vomiting, hyperphagia, drinking from the toilet, and eating from garbage pails. Other disturbed behaviors include, poor sleep, night wanderings, and pain agnosia. The pathophysiology appears to be reversible hypopituitarism, at least for the growth hormone and hypothalamic-pituitary- adrenal axes. The review begins with an historical perspective concerning stress, children and growth and then moves to the issue of hospitalism, where young infants failed to thrive (and died) due to inadequate stimulation and energy intake. Refeeding programs at the end of World Wars I and II noted that some children did not thrive despite an adequate energy intake. It appeared that in addition taking care of their emotional needs permitted super-physiologic (catch-up) growth. Next came the first notions from clinical investigation that hypopituitarism might be the mechanism of growth faltering. Studies that address this mechanism from a number of observational and clinical research studies are reviewed in depth to show that the hypopituitarism was relieved upon removal from the deprivational environment and occurred much too quickly to be due to adequate energy alone. These findings are then compared to those from malnourished children and adoptees from emerging countries, especially those from orphanages where their psychosocial needs were unmet despite adequate caloric intake. Together, these various conditions define one aspect of the field of psychoneuroendocrinology.

Psychosocial short stature: a syndrome with many variables

PSS is at least two syndromes of significant frequency, which often go unrecognized. It occurs in all socioeconomic groups. It is variable in its presentation and often masquerades in its subtle forms as other pathological causes of short stature such as GHD, CDGP, malabsorption and failure to thrive. It is an entity about which we understand little in respect to biochemical pathophysiology, and one which offers a challenge to both clinicians and basic scientists.

Energy expenditure and substrate utilization in the course of renutrition of malnourished children

Energy expenditure (EE) and substrate utilization in the course of renutrition of malnourished children is not well understood in children receiving total parenteral nutrition (TPN). The aim of this study was to evaluate, during protein-glucose renutrition, EE and substrate utilization and the relationship between EE and growth and/or protein metabolism. Seven malnourished children were studied during the first 3 weeks of TPN. Weight-for-height = 81.4 +/- 8.0%, with an initial weight of 4.5 +/- 3.3 kg. Caloric support was progressively increased according to a preestablished protocol. Every 7 days the following were determined: (1) EE at 3 different 3-hour intervals per day using an open circuit indirect calorimetric system, (2) anthropometrically defined fat free mass (FFM), and (3) 24-hour urinary 3-methylhistidine (3-M-His) and protein balance. Compared to initial values, EE increased 13% at day 7 and 36% at day 14. A negative relationship was found between the amount of perfused glucose and lipid utilization (r = -0.82; p less than 0.0001). EE per kilogram of total body FFM changes during renutrition were more than EE changes per kilogram of total body weight. There was a relationship between EE and weight gain (r = 0.62; p less than 0.005) and a positive relationship between EE and protein gain (r = 0.48; p = 0.012) and 3-M-His excretion (r = 0.51; p less than 0.026).(ABSTRACT TRUNCATED AT 250 WORDS)

Growth failure in bronchopulmonary dysplasia: elevated metabolic rates and pulmonary mechanics

Growth failure is a major problem in infants with bronchopulmonary dysplasia (BPD), but the cause is unknown. We studied 13 infants with BPD but without other medical problems that could contribute to growth failure at 6 months' corrected age. We measured resting oxygen consumption (Vo2), Pao2, airway resistance, specific airway conductance, and dynamic pulmonary compliance (Cdyn) by body plethysmography and growth. Growth failure was defined as height and weight less than the tenth percentile of the Babson growth curves. Vo2 in infants with growth failure and BPD was markedly elevated compared with that in control infants and infants with BPD and normal growth. Vo2 showed an inverse correlation with body weight in infants with BPD but not in control infants. Although Vo2 was inversely related to Cdyn, the total work of breathing only partially explained the increased metabolic demands of the growth failure group. We speculate that growth failure in infants with BPD is partially the result of increased metabolic demands from increased work of breathing but that other mechanisms may act to elevate the metabolic expenditure of these infants.

Influence of postnatal age, energy intake, and weight gain on energy metabolism in the very low-birth-weight infant

The relative importance and interrelationship of postnatal age, energy intake, and weight gain on metabolic rate is evaluated in 28 studies in 13 formula-fed very low-birth-weight AGA infants. The relationships between metabolic rate, energy intake, weight gain, and age all follow a similar pattern, increasing in the first two weeks of life and subsequently stabilizing. Significant linear correlations are demonstrated between metabolic rate and both energy intake (r = 0.88, P less than 0.001) and weight gain (r = 0.86, P less than 0.001). For each gram of weight gain, 0.67 kcal (2.8 kj) are expended in addition to the maintenance energy requirement of 51 kcal/kg/day. The increase in metabolic rate in the early postnatal period appears to be a consequence of the energy cost of tissue synthesis. Changes in metabolic rate with postnatal age are modulated by increasing energy intake and weight gain.

Oxygen consumption and evaporative water loss in infants with congenital heart disease

The relation between environmental temperature, heat production, oxygen consumption, and evaporative water loss was studied in 67 infants with congenital heart disease. The majority of the cyanosed infants had a low minimum oxygen consumption, a low evaporative water loss, and a diminished metabolic response to cold stress. Minimum oxygen consumption and evaporative water loss rose in 6 of these infants after the construction of a surgical shunt. Many of the ill acyanotic infants had an abnormally high minimum oxygen consumption, and those in cardiac failure often continued to sweat in an environment below the thermoneutral temperature zone.

Food restriction as a form of child abuse in ten cases of psychosocial deprivation dwarfism

Ten children with a psychosocial deprivation syndrome had linear growth failure, retarded bone age, a voracious and bizarre appetite, and behavior abnormalities which were a consequence of maternal rejection. Direct and indirect evidence suggests that their food had been persistently restricted by mothers who abused the children physically and had personality traits characteristic of such mothers. Most of the children had a low IQ. Weight recovery occurred regularly in the hospital and in three cases in the home, providing food was not restricted. Diagnosis was difficult because ravenous appetites and abnormal stools suggested malabsorption in seven cases; however, histories, absorption tests, and weight recovery which occurred despite temporary persistence of abnormal stools indicated that malabsorption was not the primary cause of malnutrition. Deviant be havior and abnormal stools were used to rationalize frustration and food restriction. Intensive psychotherapy of the mother is necessary.

The influence of malnutrition on the postprandial metabolic rate and respiratory quotient

1. Pre- and post-prandial metabolic rates were measured in twelve malnourished Jamaican infants.

2. On admission to hospital, minimal increase in postprandial metabolic rate were found, whereas during the recovery phase when growth was rapid, inreases in postprandial metabolic rate of up to 38% occurred.

3. After recovery only the five children who were still gaining weight at a rate of more than 4 g/kg body-weigh. d continued to show a substantial increase in postprandial metabolism.

4. A highly significant correlation was found between growth rate and the increase in postprandial metabolic rate.

5. Marked differences existed in the respiratory quotient measured 4 h after the last meal, the values being low on admission and high during the phase of rapid growth.

6. After a test meal, the respiratory quotient rose sharply both innewly admitted and in recovered children, but fell slightly when the children were studied during the phase of rapid growth.