Guidelines for the use of vitamins, trace elements, calcium, magnesium, and phosphorus in infants and children receiving total parenteral nutrition: report of the Subcommittee on Pediatric Parenteral Nutrient Requirements from the Committee on Clinical Practice Issues of the American Society for Clinical Nutrition.

Over the last decade, tracheostomy has been increasingly performed in children, aligned with the improvements in neonatal and pediatric ICU care Nowadays, the majority of children with tracheostomy represent a very complex cohort of patients with sustained reliance on tracheostomy and related medical technology for long-term survival Tracheostomy is one of the most commonly performed procedures in the adult ICU Contrary to adult practice, tracheostomy is a much less common procedure in the pediatric ICU, being performed in < 3% of patients There is no definite consensus about the length of time a child should remain endotracheally intubated before the placement of a tracheostomy Tracheostomy in children also continues to remain a predominantly surgical procedure, with percutaneous tracheostomy being performed infrequently and only considered feasible in older children The indications, preoperative considerations, and procedure types for tracheostomy in children are reviewed There is also a lack of consensus on an optimal pediatric decannulation protocol The literature discusses a myriad of protocols that use varying combinations of in-patient/out-patient resources, specialized tests, and procedures An ideal decannulation protocol is presented, as well as review of recently published decannulation algorithms Finally, children with tracheostomy have a higher risk of adverse events and mortality, which are largely secondary to their comorbidities rather than the tracheostomy The majority of the tracheostomy-related events are in fact potentially preventable There is a recognized need for improvement and coordination of care of pediatric patients with tracheostomy A multidisciplinary coordinated approach to tracheostomy care has already shown promising results This paper seeks to review the pertinent literature regarding quality improvement initiatives for tracheostomy care, including review of the recently established Global Tracheostomy Collaborative

http://rc.rcjournal.com/content/respcare/62/6/799.full.pdf

Tracheostomy in Infants and Children

Plasma vitamin A and retinol-binding protein in premature and term neonates

Vitamin A is essential for growth and differentiation of a number of cells and tissues. Notably during pregnancy and throughout the breastfeeding period, vitamin A has an important role in the healthy development of the fetus and the newborn, with lung development and maturation being particularly important. The German Nutrition Society (DGE) recommends a 40% increase in vitamin A intake for pregnant women and a 90% increase for breastfeeding women. However, pregnant women or those considering becoming pregnant are generally advised to avoid the intake of vitamin A rich liver and liver foods, based upon unsupported scientific findings. As a result, the provitamin A carotenoid β-carotene remains their essential source of vitamin A. Basic sources of provitamin A are orange and dark green vegetables, followed by fortified beverages which represent between 20% and 40% of the daily supply. The average intake of β-carotene in Germany is about 1.5–2 mg a day. Assuming a vitamin A conversion rate for β-carotene for juices of 4:1, and fruit and vegetables between 12:1 and 26:1; the total vitamin A contribution from β-carotene intake represents 10–15% of the RDA. The American Pediatrics Association cites vitamin A as one of the most critical vitamins during pregnancy and the breastfeeding period, especially in terms of lung function and maturation. If the vitamin A supply of the mother is inadequate, her supply to the fetus will also be inadequate, as will later be her milk. These inadequacies cannot be compensated by postnatal supplementation. A clinical study in pregnant women with short birth intervals or multiple births showed that almost 1/3 of the women had plasma retinol levels below 1.4 µmol/l corresponding to a borderline deficiency. Despite the fact that vitamin A and beta-carotene rich food is generally available, risk groups for low vitamin A supply exist in the western world. It is therefore highly critical to restrict the β-carotene supply from diet, particularly from sources of β-carotene with high consumer acceptance such as fortified juices (e.g. “ACE juices”) or dietary supplements (e.g. multivitamins for pregnant women). For the part of the population unable to meet vitamin A requirements according to the DACH recommendations, sufficient intake of β-carotene may be crucial to help improve and maintain adequate vitamin A status and prevention of developmental disorders. At this time it has to be urgently advised against restricting the β-carotene supply or putting warning labels on β-carotene fortified products. It is, however, highly recommended to improve the available data on nutrient intakes in Germany, especially for pregnant and breastfeeding women. For them, recommendations to be aware of potential nutrient intake inadequacies might prove useful.

The importance of beta-carotene as a source of vitamin a with special regard to pregnant and breastfeeding women

OBJECTIVE: Genetic analyses in humans suggest a role for retinoid-related genes in the pathogenesis of congenital diaphragmatic hernia (CDH). The goal of this study was to investigate the vitamin A status of mothers and their newborns in association with CDH. METHODS: We conducted a hospital-based, case-control study with 22 case and 34 control mothers and their newborns. In maternal and cord blood samples, retinol and retinol-binding protein (RBP) levels were measured with high-performance liquid chromatography and an enzyme-linked immunosorbent assay, respectively. Univariate and multivariate logistic regression analyses were performed to determine crude and adjusted risk estimates. RESULTS: Case newborns had significantly lower levels of retinol (0.60 vs 0.76 μmol/L; P = .003) and RBP (5.42 vs 7.11 mg/L; P = .02) than did control newborns. The multivariate logistic regression analysis showed lower levels of retinol and RBP in association with CDH risk; the odds ratio for retinol levels of <15th percentile (<0.61 μmol/L) was 11.11 (95% confidence interval: 2.54-48.66; P = .001), and that for RBP levels of <15th percentile (<4.54 mg/L) was 4.00 (95% confidence interval: 1.00-15.99; P= .05). Retinol and RBP levels were not different between case and control mothers. CONCLUSIONS: CDH is strongly associated with low retinol and RBP levels in newborns, independent of maternal retinol status. This is an important finding supporting the idea that human CDH is linked with abnormal retinoid homeostasis.

Retinol status of newborn infants is associated with congenital diaphragmatic hernia.

Serum vitamin A in premature and term neonates

The effect of tracheostomy incisions on tracheal growth.

Late results of ureteroureterostomy in puppies

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Serum vitamin A in premature and term neonates

The effect of tracheostomy incisions on tracheal growth.

Late results of ureteroureterostomy in puppies