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Trivedi A, Jatana V, Sinn JK. Early versus late administration of amino acids in preterm infants receiving parenteral nutrition. Cochrane Database Syst Rev 2024; 1:CD008771. [PMID: 38275196 PMCID: PMC10811752 DOI: 10.1002/14651858.cd008771.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND Observational studies in preterm newborns suggest that delay in administering amino acids (AA) could result in a protein catabolic state and impact on growth and development. OBJECTIVES The objective of this review was to compare the efficacy and safety of early versus late administration of intravenous AA in neonates born at < 37 weeks of gestation. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and trial registries in March 2023. We checked the reference lists of included studies and studies/systematic reviews where subject matter related to the intervention or population examined in this review. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing early administration of AA with late administration in premature newborn infants. We defined early administration of AA solution as the administration of AA in isolation or with total parenteral nutrition within the first 24 hours of birth, and late administration as the administration of AA in isolation or with total parenteral nutrition after the first 24 hours of birth. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS Nine studies (383 participants) were eligible for inclusion in the review. All study participants were born at < 37 weeks of gestation and were inpatients in neonatal intensive care units. No studies reported growth during the first months of life as assessed by difference in weight. Early administration of AA may have little or no effect on growth in the first month of life as measured by length (mean difference (MD) 0.00, 95% confidence interval (CI) -0.41 to 0.41; 1 study; 21 participants; low-certainty evidence) and head circumference (MD 0.05, 95% CI -0.03 to 0.14; 2 studies; 87 participants; low-certainty evidence). No studies reported the discharge weight outcome. Early administration of AA may result in little to no difference in neurodevelopmental outcome assessed by Mental Developmental Index (MDI) of < 70 at two years of age (odds ratio 0.83, 95% CI 0.21 to 3.28; 1 study; 111 participants; low-certainty evidence). No studies reported all-cause mortality at 28 days and before discharge. Early administration of AA may result in a large increase in positive nitrogen balance in the first three days of life (MD 250.42, 95% CI 224.91 to 275.93; 4 studies; 93 participants; low-certainty evidence). AUTHORS' CONCLUSIONS Low-certainty evidence suggests that there may be little to no difference between early and late administration of AA in growth (measured by length and head circumference during the first month after birth) and neurodevelopmental outcome (assessed by MDI of < 70). No RCTs reported on weight in the first month of life, mortality (all-cause mortality at 28 days and before discharge), or discharge weight. Low-certainty evidence suggests a large increase in positive nitrogen balance in preterm infants who received AA within 24 hours of birth. The clinical relevance of this observation is unknown. The number of infants in the RCTs included in the review was small, and there was clinical heterogeneity amongst trials. Adequately powered trials in infants < 37 weeks' gestation are required to determine optimal timing of initiation of AA. We identified two ongoing studies. Both studies will be recruiting infants ≥ 34 weeks of gestation and may or may not add to the outcome data for this review.
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Affiliation(s)
- Amit Trivedi
- Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Westmead, Australia
- The University of Sydney, Sydney, Australia
| | - Vishal Jatana
- Helen MacMillan Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Westmead, Australia
| | - John Kh Sinn
- Department of Neonatology, Royal North Shore Hospital, The University of Sydney, Sydney, Australia
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Liebau F, Sundström M, van Loon LJC, Wernerman J, Rooyackers O. Short-term amino acid infusion improves protein balance in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:106. [PMID: 25882298 PMCID: PMC4403712 DOI: 10.1186/s13054-015-0844-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 02/26/2015] [Indexed: 12/12/2022]
Abstract
Introduction Evidence behind the recommendations for protein feeding during critical illness is weak. Mechanistic studies are needed to elucidate the effects of amino acid and/or protein supplementation on protein metabolism before larger clinical trials with higher levels of protein feeding are initiated. Methods We studied the effects of parenteral amino acid supplementation (equivalent to 1 g/kg/day) over the course of 3 hours on whole-body protein turnover in critically ill patients in the intensive care unit (ICU) during the first week after admission. Patients were studied at baseline during ongoing nutrition and during extra amino acid supplementation. If the patient was still in the ICU 2 to 4 days later, these measurements were repeated. Protein kinetics were measured using continuous stable isotope-labeled phenylalanine and tyrosine infusions. Results Thirteen patients were studied on the first study occasion only, and seven were studied twice. Parenteral amino acid supplementation significantly improved protein balance on both occasions, from a median of −4 to +7 μmol phenylalanine/kg/hr (P =0.001) on the first study day and from a median of 0 to +12 μmol phenylalanine/kg/hr (P =0.018) on the second study day. The more positive protein balance was attributed to an increased protein synthesis rate, which reached statistical significance during the first measurement (from 58 to 65 μmol phenylalanine/kg/hr; n =13; P =0.007), but not during the second measurement (from 58 to 69 μmol phenylalanine/kg/hr; n =7; P =0.09). Amino acid oxidation rates, estimated by phenylalanine hydroxylation, did not increase during the 3-hour amino acid infusion. A positive correlation (r =0.80; P <0.0001) was observed between total amino acids and/or protein given to the patient and whole-body protein balance. Conclusion Extra parenteral amino acids infused over a 3-hour period improved whole-body protein balance and did not increase amino acid oxidation rates in critically ill patients during the early phase (first week) of critical illness. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0844-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Felix Liebau
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Hälsovägen 13, Huddinge, 14186, Sweden.
| | - Martin Sundström
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Hälsovägen 13, Huddinge, 14186, Sweden.
| | - Luc J C van Loon
- NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University, Universiteitssingel 40, Maastricht, 6229ER, The Netherlands.
| | - Jan Wernerman
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Hälsovägen 13, Huddinge, 14186, Sweden.
| | - Olav Rooyackers
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Hälsovägen 13, Huddinge, 14186, Sweden.
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Optimizing protein intake in premature infants: a neonatal quality improvement project. Adv Neonatal Care 2013; 13:E1-8. [PMID: 24300966 DOI: 10.1097/anc.0b013e3182a0a178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article examines a quality-improvement project to reduce clinical practice variation and measure growth outcomes by standardizing the process for the provision of protein intake for premature infants weighing 1250 g or less. Eighteen infants with a birth weight of 1250 g or less and gestational age of 32 weeks or less born between June and October 2010 were compared with 15 historical controls of the same birth weight and gestation born between January and May 2010 using a prospective cohort design. The prospective group followed a newly implemented standardized protein nutritional guideline. Independent t-tests and repeated measures of analyses of variance (between- and within-subjects) were performed on the difference between the intended and actual protein intakes between the 2 groups. A multivariate analysis of variance computed the difference between the birth and discharge gains. The prospective group showed statistically significant differences between the amount of intended and actual protein intakes (P = .023) when compared with historical controls. Growth outcomes were not significantly different (P = .67) between the 2 groups. Length of stay was not statistically significantly shorter (P = .06) in the prospective group. Reduction in clinical practice variation was associated with the implementation of a protein nutritional guideline. There was no statistical support for an improvement in the growth outcomes or reduction in length of stay.
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Yang S, Lee BS, Park HW, Choi YS, Jeong SH, Kim JH, Kim EAR, Kim KS. Effect of High vs Standard Early Parenteral Amino Acid Supplementation on the Growth Outcomes in Very Low Birth Weight Infants. JPEN J Parenter Enteral Nutr 2012; 37:327-34. [DOI: 10.1177/0148607112456400] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sami Yang
- Asan Medical Center, Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Sop Lee
- Asan Medical Center, Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Won Park
- Department of Pediatrics, Division of Neonatology, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Korea
| | - Yong-Sung Choi
- Asan Medical Center, Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong-Hun Jeong
- Asan Medical Center, Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji-Hee Kim
- Asan Medical Center, Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea
| | - Ellen Ai-Rhan Kim
- Asan Medical Center, Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Soo Kim
- Asan Medical Center, Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea
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Mok E, Hankard R. Glutamine supplementation in sick children: is it beneficial? J Nutr Metab 2011; 2011:617597. [PMID: 22175008 PMCID: PMC3228321 DOI: 10.1155/2011/617597] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 09/28/2011] [Indexed: 12/14/2022] Open
Abstract
The purpose of this review is to provide a critical appraisal of the literature on Glutamine (Gln) supplementation in various conditions or illnesses that affect children, from neonates to adolescents. First, a general overview of the proposed mechanisms for the beneficial effects of Gln is provided, and subsequently clinical studies are discussed. Despite safety, studies are conflicting, partly due to different effects of enteral and parenteral Gln supplementation. Further insufficient evidence is available on the benefits of Gln supplementation in pediatric patients. This includes premature infants, infants with gastrointestinal disease, children with Crohn's disease, short bowel syndrome, malnutrition/diarrhea, cancer, severe burns/trauma, Duchenne muscular dystrophy, sickle cell anemia, cystic fibrosis, and type 1 diabetes. Moreover, methodological issues have been noted in some studies. Further mechanistic data is needed along with large randomized controlled trials in select populations of sick children, who may eventually benefit from supplemental Gln.
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Affiliation(s)
- Elise Mok
- INSERM Centre D'Investigation Clinique 802, Centre Hospitalier Universitaire de Poitiers, 86021 Poitiers Cedex, France
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Survival of exfoliated epithelial cells: a delicate balance between anoikis and apoptosis. J Biomed Biotechnol 2011; 2011:534139. [PMID: 22131811 PMCID: PMC3205804 DOI: 10.1155/2011/534139] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 08/22/2011] [Indexed: 01/21/2023] Open
Abstract
The recovery of exfoliated cells from biological fluids is a noninvasive technology which is in high demand in the field of translational research. Exfoliated epithelial cells can be isolated from several body fluids (i.e., breast milk, urines, and digestives fluids) as a cellular mixture (senescent, apoptotic, proliferative, or quiescent cells). The most intriguing are quiescent cells which can be used to derive primary cultures indicating that some phenotypes retain clonogenic potentials. Such exfoliated cells are believed to enter rapidly in anoikis after exfoliation. Anoikis can be considered as an autophagic state promoting epithelial cell survival after a timely loss of contact with extracellular matrix and cell neighbors. This paper presents current understanding of exfoliation along with the influence of methodology on the type of gastrointestinal epithelial cells isolated and, finally, speculates on the balance between anoikis and apoptosis to explain the survival of gastrointestinal epithelial cells in the environment.
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Blanco CL, Gong AK, Green BK, Falck A, Schoolfield J, Liechty EA. Early changes in plasma amino acid concentrations during aggressive nutritional therapy in extremely low birth weight infants. J Pediatr 2011; 158:543-548.e1. [PMID: 21129755 DOI: 10.1016/j.jpeds.2010.09.082] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 09/23/2010] [Accepted: 09/30/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To examine the changes in plasma amino acid (AA) concentrations over time when extremely low birth weight infants are provided either a standard intravenous AA supplementation (standard AA) or an early and high supplementation regimen (early and high AA). STUDY DESIGN Sixty-two infants were enrolled at birth in a randomized, double-masked, prospective fashion and treated for 7 days. The infants with standard AA concentrations received intravenous AA starting at 0.5 g/kg/d and increased by 0.5 g/kg every day to a maximum of 3 g/kg/d. Infants in the early and high AA group received 2 g/kg/d of intravenous AA soon after birth and advanced by 1 g/kg every day to 4 g/kg/d. Plasma AA concentrations were determined by high-pressure liquid chromatography on days 1, 3, and 7. RESULTS Total AA concentrations, total essential AA concentrations, and total nonessential AA concentrations were significantly higher in the infants in the early and high AA group; essential AA concentrations and total AA concentrations were higher at 1 and 3 days, and nonessential AA concentrations were different only on day 3. There were significant differences between standard AA and early and high AA groups for all AA concentrations except the nonessential AAs Glu, Asn, Gly, Gln, Ala, and Tyr and the conditionally essential AA Cys. CONCLUSION Infants who received early and higher parenteral AA had higher plasma AA concentrations.
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Affiliation(s)
- Cynthia Liudmilla Blanco
- Department of Pediatrics, University of Texas Health Science Center, San Antonio, TX 78229-3900, USA.
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Abstract
Birth and adaptation to extrauterine life involve major shifts in the protein and energy metabolism of the human newborn. These include a shift from a state of continuous supply of nutrients including amino acids from the mother to cyclic periodic oral intake, a change in the redox state of organs, thermogenesis, and a significant change in the mobilization and use of oxidative substrates. The development of safe, stable isotopic tracer methods has allowed the study of protein and amino acid metabolism not only in the healthy newborn but also in those born prematurely and of low birth weight. These studies have identified the unique and quantitative aspects of amino acid/protein metabolism in the neonate, thus contributing to rational nutritional care of these babies. The present review summarizes the contemporary data on some of the significant developments in essential and dispensable amino acids and their relationship to overall protein metabolism. Specifically, the recent data of kinetics of leucine, phenylalanine, glutamine, sulfur amino acid, and threonine and their relation to whole-body protein turnover are presented. Finally, the physiological rationale and the impact of nutrient (amino acids) interventions on the dynamics of protein metabolism are discussed.
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Affiliation(s)
- Satish C Kalhan
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio 44195, USA.
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Blanco CL, Falck A, Green BK, Cornell JE, Gong AK. Metabolic responses to early and high protein supplementation in a randomized trial evaluating the prevention of hyperkalemia in extremely low birth weight infants. J Pediatr 2008; 153:535-40. [PMID: 18589451 DOI: 10.1016/j.jpeds.2008.04.059] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 03/06/2008] [Accepted: 04/24/2008] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine whether early and higher intravenous amino acid (EHAA) supplementation decreases hyperkalemia in extremely low birth weight (ELBW) infants (<1000 g). STUDY DESIGN Infants were enrolled at birth in a randomized, double-masked, prospective fashion and treated for 7 days. The standard group (SAA) infants received intravenous amino acid (AA) starting at 0.5 g x kg(-1) x d(-1) and increased by 0.5 g x kg(-1) every day to a maximum of 3 g x kg(-1) x d(-1). EHAA group infants received 2 g x kg(-1) x d(-1) of AA soon after birth and advanced by 1 g x kg(-1) every day to 4 g x kg(-1) x d(-1). Data analysis was by SPSS 11.5, with statistical significance at alpha = 0.05 and 90% power to determine a difference in mean K(+) level of 2. RESULTS Sixty-two patients, mean gestational age of 26.0 +/- 2.0 weeks and birth weight of 775 +/- 136 g, were enrolled. Hyperkalemia (K(+) > or =6.5 mEq/L) occurred in 13% of the studied population; no difference in incidence of hyperkalemia was found between the SAA and EHAA groups (16% vs 10%, respectively, P = .70). Serum blood urea nitrogen was higher in the EHAA group. AA infusion was stopped early in 6 patients for high blood urea nitrogen or elevated ammonia level. CONCLUSIONS During the study period, hyperkalemia decreased significantly and was not affected by EHAA supplementation in the first week of life.
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Affiliation(s)
- Cynthia Liudmilla Blanco
- Department of Pediatrics, University of Texas Health Science Center, San Antonio, TX 78229-3900, USA.
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Sadiq F, Crompton LA, Scaife JR, Lomax MA. Effect of prolonged intravenous glucose and essential amino acid infusion on nitrogen balance, muscle protein degradation and ubiquitin-conjugating enzyme gene expression in calves. Nutr Metab (Lond) 2008; 5:5. [PMID: 18269762 PMCID: PMC2263059 DOI: 10.1186/1743-7075-5-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 02/12/2008] [Indexed: 12/02/2022] Open
Abstract
Background Intravenous infusions of glucose and amino acids increase both nitrogen balance and muscle accretion. We hypothesised that co-infusion of glucose (to stimulate insulin) and essential amino acids (EAA) would act additively to improve nitrogen balance by decreasing muscle protein degradation in association with alterations in muscle expression of components of the ubiquitin-proteasome proteolytic pathway. Methods We examined the effect of a 5 day intravenous infusions of saline, glucose, EAA and glucose + EAA, on urinary nitrogen excretion and muscle protein degradation. We carried out the study in 6 restrained calves since ruminants offer the advantage that muscle protein degradation can be assessed by excretion of 3 methyl-histidine and multiple muscle biopsies can be taken from the same animal. On the final day of infusion blood samples were taken for hormone and metabolite measurement and muscle biopsies for expression of ubiquitin, the 14-kDa E2 ubiquitin conjugating enzyme, and proteasome sub-units C2 and C8. Results On day 5 of glucose infusion, plasma glucose, insulin and IGF-1 concentrations were increased while urea nitrogen excretion and myofibrillar protein degradation was decreased. Co-infusion of glucose + EAA prevented the loss of urinary nitrogen observed with EAA infusions alone and enhanced the increase in plasma IGF-1 concentration but there was no synergistic effect of glucose + EAA on the decrease in myofibrillar protein degradation. Muscle mRNA expression of the ubiquitin conjugating enzyme, 14-kDa E2 and proteasome sub-unit C2 were significantly decreased, after glucose but not amino acid infusions, and there was no further response to the combined infusions of glucose + EAA. Conclusion Prolonged glucose infusion decreases myofibrillar protein degradation, prevents the excretion of infused EAA, and acts additively with EAA to increase plasma IGF-1 and improve net nitrogen balance. There was no evidence of synergistic effects between glucose + EAA infusion on muscle protein degradation or expression of components of the ubiquitin-proteasome proteolytic pathway.
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Affiliation(s)
- Fouzia Sadiq
- Division of Nutritional Sciences, University of Nottingham, Sutton Bonington Campus, LE12 5RD, UK.
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Zhou J, Li Y, Liu F, Cao Y, Li J. Tumor necrosis factor α attenuates glutamine-enhanced skeletal muscle protein synthesis in rats. Nutr Res 2007. [DOI: 10.1016/j.nutres.2007.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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