By George W. Holcomb III MD, J. Patrick Murphy MD
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Extra info for Ashcraft's Pediatric Surgery, 5th Edition
Here, the amino groups are removed from glutamine and detoxified to urea through the urea cycle. The amino acid carbon skeleton can then enter the gluconeogenesis pathway. Alternatively, in skeletal muscle, the amino group can be transferred to pyruvate, thereby forming the amino acid alanine. When alanine is transported to the liver and detoxified, pyruvate is re-formed and can be converted to glucose through gluconeogenesis. 59 Hence the transport amino acid systems involving glutamine and alanine provide carbon backbones for gluconeogenesis while facilitating the hepatic detoxification of ammonia by the urea cycle.
14 Neonates and children also share much higher baseline energy requirements. 13,15,16 Clearly, the child’s need for rapid growth and development is a large component of this increase in energy requirement. Moreover, the relatively large body surface area of the young child may increase heat loss and further contributes to elevations in energy expenditure. 17 As illustrated, the recommended protein provision for the neonate is almost three times that of the adult. 18 The increased metabolic demand and limited nutrient reserves of the infant mandates early nutritional support in times of traumatic injury and critical illness in order to avoid untoward nutritional consequences.
81 Therefore, a surplus of carbohydrate may increase the ventilatory burden on the critically ill patient. 83 In addition, excessive carbohydrate provision may play a role in the genesis of TPN-associated cholestatic liver injury. 84 When designing a nutritional regimen for the critically ill child, excessive carbohydrate calories should be avoided. A mixed fuel system, with both glucose and lipid substrates, should be used to meet the patient’s caloric requirements. 86 This approach will provide the child with full nutritional supplementation while alleviating an increased ventilatory burden and difficulties with hyperglycemia.
Ashcraft's Pediatric Surgery, 5th Edition by George W. Holcomb III MD, J. Patrick Murphy MD