Publications by authors named "Roberto José Negrão Nogueira"

25 Publications

  • Page 1 of 1

Hypophosphatemia in critically ill pediatric patients receiving enteral and oral nutrition.

JPEN J Parenter Enteral Nutr 2021 Jul 21. Epub 2021 Jul 21.

Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil.

Background: Hypophosphatemia(HP) is related to several comorbidities in pediatric intensive care units (PICUs). This study aimed to evaluate the incidence of HP in severely ill pediatric patients receiving oral and/or enteral nutrition. The secondary objectives were to investigate the association between HP and the inflammatory state, PICU length of stay, severity, mortality, nutrition status, and protein, energy, calcium, vitamin D, and phosphate intake.

Methods: A prospective, observational cohort study was conducted in a PICU of a quaternary hospital. Participants aged between 28 days and 14 years were included. Anthropometric and laboratory assessments were performed ≤72 h after PICU admission and repeated after 7 days for three consecutive times. Energy, protein, calcium, phosphate, and vitamin D intake per day of hospitalization were recorded individually. The Pediatric Index of Mortality 2 (PIM2) was used to determine each patient's severity score.

Results: A total of 103 participants were included in the study. Hypophosphatemic events ranged from 27.2% to 37.5% among the assessments. HP was associated with high C-reactive protein levels (P = .012) and lower energy adequacy (P = .037). Serum phosphorus was inversely correlated (weak correlation) with PIM2 (P = .017).

Conclusion: HP is common in critically ill pediatric patients, even when they are not receiving parenteral nutrition. It is necessary to monitor serum phosphorus levels and consider the possibility of early replacement, especially in patients showing high levels of inflammation. In addition to inflammation itself, low energy intake and illness severity were related to HP.
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July 2021

Extubation in the pediatric intensive care unit: predictive methods. An integrative literature review.

Rev Bras Ter Intensiva 2021 Apr-Jun;33(2):304-311

Universidade Estadual de Campinas - Campinas (SP), Brasil.

For extubation in pediatric patients, the evaluation of readiness is strongly recommended. However, a device or practice that is superior to clinical judgment has not yet been accurately determined. Thus, it is important to conduct a review on the techniques of choice in clinical practice to predict extubation failure in pediatric patients. Based on a search in the PubMed®, Biblioteca Virtual em Saúde, Cochrane Library and Scopus databases, we conducted a survey of the predictive variables of extubation failure most commonly used in clinical practice in pediatric patients. Of the eight predictors described, the three most commonly used were the spontaneous breathing test, the rapid shallow breathing index and maximum inspiratory pressure. Although the disparity of the data presented in the studies prevented statistical treatment, it was still possible to describe and analyze the performance of these tests.
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August 2020

Protein intake deficiency in critically ill children with respiratory insufficiency: A call to action?

Clin Nutr ESPEN 2020 06 17;37:69-74. Epub 2020 Apr 17.

University of Campinas, Unicamp, School of Medical Sciences, 126 Tessália Vieira de Camargo St., Cidade Universitária "Zeferino Vaz", Campinas, SP, 13083-887, Brazil; São Leopoldo Mandic College of Medicine and Dentistry, 13 Dr. José Rocha Junqueira St., Swift, Campinas, SP, 13045-755, Brazil. Electronic address:

Background & Aims: Adequate energy-protein intake is associated with improved clinical outcomes in critically ill children. The aim of this study was to evaluate the time of enteral nutrition (EN) onset and the energy-protein intake in critically ill pediatric patients admitted with respiratory insufficiency.

Methods: A single-center prospective cohort study, including children and adolescents, aged from 1 month to 14 years. All patients had been diagnosed with respiratory insufficiency and were exclusively enterally fed and had been admitted to a Pediatric Intensive Care Unit (PICU) of a public quaternary hospital in southeastern Brazil. Demographic, clinical, and nutritional therapy characteristics were recorded. Early EN (EEN) was considered when EN was initiated within the first 48 h of PICU admission.

Results: Seventy-one patients were included in this study, 64.79% were male with a median age of 6 months (2; 13) and a median PICU length of stay of 13.00 days (6.75; 23.00). PICU mortality was 4.23% and 78.87% of patients were under mechanical ventilation within the first 48 h of PICU admission with a median time of mechanical ventilation of 10 days (6.00; 16.50). The median energy adequacy was 74.97% (50.29; 93.94) and the median protein adequacy was 56.12% (40.72; 69.81). Only 7.25% of the patients achieved protein adequacy. Nutritional variables were compared between groups: EEN and late EN (LEN). EEN was utilized in 69.01% of patients who had increased energy (41.80 [34.07; 51.17] versus 23.60 [11.22; 35.17] kcal/kg/day; p < 0.0001) and protein intake (0.94 [0.78, 1.16] versus 0.53 [0.30, 0.79] g/kg/day, p < 0.0001) and better nutritional adequacies (p < 0.0001).

Conclusions: Patients who received EEN had increased energy-protein delivery and adequacies. However, protein inadequacy occurred throughout in all patients within this sample, regardless the onset of EN.
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June 2020

Nutritional Treatment of a Young Infant with Cystic Fibrosis Presenting with Severe Kwashiorkor Dermatosis.

J Trop Pediatr 2019 12;65(6):634-637

São LeopldoMandic School of Medicine, Clinical Coordin of the Multi-professional Team of Nutritional Therapy at Clinics Hospital - University of Campinas São Paulo, Brazil.

Kwashiorkor in infancy is typically associated to an underlying disease. Edema, a striking feature of this type of malnutrition, can be difficult to assess in this age group. The typical dermatosis of Kwashiorkor is not fully explained the deficiency of one isolated vitamin or micronutrient. This article presents an infant with cystic fibrosis, who developed Kwashiorkor in the third month of life with extensive cutaneous manifestations. An early, individualized and aggressive nutritional intervention with optimized supplementationof sulfur amino acids, vitamins and micronutrients was established, with impressively recovery of overall nutrition and skin manifestations in a relatively short period of time.
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December 2019

Inflammatory process of patients receiving parenteral nutrition is not exclusively responsible for low selenium and glutathione peroxidase levels.

Nutrition 2019 05 26;61:202-207. Epub 2018 Oct 26.

College of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil; São Leopoldo Mandic College of Medicine and Dentistry, Campinas, SP, Brazil.

Objective: The aim of this study was to verify if the selenium status of patients residing in locations with selenium-poor soil who receive parenteral nutrition (PN) without selenium supplementation is associated with the inflammatory process.

Methods: This was a prospective cohort study with hospitalized patients who started PN. The analyzed biochemical tests were plasma selenium, glutathione peroxidase (GPx), C-reactive protein, prealbumin, albumin, creatinine, lymphocytes, total cholesterol, high-density lipoprotein, and triglycerides.

Results: Seventy-seven patients with a mean age of 56.2 ± 15.7 y were studied. Most of them used PN as a result of clinical issues (70.1%) such as, gastric, renal, or hematologic neoplasia; gastrointestinal dysfunction; pancreatitis; sepsis; trauma without surgical needs; chylothorax; and fistula not related to surgical procedure. There were low levels of plasma selenium (98.7%) and GPx (60%) and elevated C-reactive protein (98.5%) in most cases. At the beginning of PN there was no correlation between selenium and laboratory tests (P > 0.05). At the second evaluation (seventh day of PN), there was a positive correlation of selenium levels with lymphocyte levels (r = 0.36; P = 0.04). After 2 wk of PN, there was a statistically significant correlation between selenium and GPx (r = 0.70; P = 0.02).

Conclusions: Very low values of selenium and GPx from the beginning of PN were identified. The correlation of selenium levels with GPx in only 14 d of PN, regardless of inflammation, may reflect a critical selenium status, mainly because the correlation was verified after the acute phase. Therefore it is important to emphasize that supplementation should be started from the beginning of PN, especially in regions with selenium-deficient soil.
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May 2019

Ultrasound Guidance for Pediatric Central Venous Catheterization: A Meta-analysis.

Pediatrics 2018 11;142(5)

Division of Pediatric Critical Care, Department of Pediatrics, University of Campinas, Campinas, São Paulo, Brazil; and.

: media-1vid110.1542/5828324804001PEDS-VA_2018-1719 CONTEXT: Central venous catheterization is routinely required in patients who are critically ill, and it carries an associated morbidity. In pediatric patients, the procedures can be difficult and challenging, predominantly because of their anatomic characteristics.

Objective: To determine whether ultrasound-guided techniques are associated with a reduced incidence of failures and complications when compared with the anatomic landmark technique.

Data Sources: We conducted a systematic search of PubMed and Embase.

Study Selection: We included randomized controlled trials and nonrandomized studies in which researchers compare ultrasound guidance with the anatomic landmark technique in children who underwent central venous catheterization.

Data Extraction: Study characteristics, sample sizes, participant characteristics, settings, descriptions of the ultrasound technique, puncture sites, and outcomes were analyzed. Pooled analyses were performed by using random-effects models.

Results: A total of 23 studies (3995 procedures) were included. Meta-analysis revealed that ultrasound guidance significantly reduced the risk of cannulation failure (odds ratio = 0.27; 95% confidence interval: 0.17-0.43), with significant heterogeneity seen among the studies. Ultrasound guidance also significantly reduced the incidence of arterial punctures (odds ratio = 0.34; 95% confidence interval: 0.21-0.55), without significant heterogeneity seen among the studies. Similar results were observed for femoral and internal jugular veins.

Limitations: Potential publication bias for cannulation failure and arterial puncture was detected among the studies. However, no publication bias was observed when analyzing only the subgroup of randomized clinical trials.

Conclusions: Ultrasound-guided techniques are associated with a reduced incidence of failures and inadvertent arterial punctures in pediatric central venous catheterization when compared with the anatomic landmark technique.
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November 2018


Rev Paul Pediatr 2019 Jan-Mar;37(1):126-129. Epub 2018 Aug 30.

Universidade Estadual de Campinas, Campinas, SP, Brasil.

Objective: To report a rare case of a child with invasive pneumococcal disease that presented meningitis associated with pericarditis.

Case Description: This report describes the unfavorable clinical course of a previously healthy 6-months-old female infant who initially presented symptoms of fever and respiratory problems. A chest X-ray revealed an increased cardiac area with no radiographic changes in the lungs. After identifying a pericardial effusion, the patient experienced seizures and went into coma. Pneumonia was excluded as a possibility during the clinical investigation. However, Streptococcus pneumoniae was identified in the cerebrospinal fluid and blood cultures. An initial neurological examination showed that the patient was brain dead, which was then later confirmed according to protocol.

Comments: Purulent pericarditis has become a rare complication of invasive pneumococcal disease since the advent of antibiotic therapy. Patients with extensive pneumonia are primarily predisposed and, even with early and adequate treatment, are prone to high mortality rates. The association of pneumococcal meningitis and pericarditis is uncommon, and therefore difficult to diagnose. As such, diagnostic suspicion must be high in order to institute early treatment and increase survival.
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August 2019

Lipid profile associated with the systemic inflammatory response syndrome and sepsis in critically ill patients.

Nutrition 2018 11 9;55-56:7-14. Epub 2018 May 9.

Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, São Paulo, Brazil; Center for Research in Pediatrics, Faculty of Medical Sciences, University of Campinas, São Paulo, Brazil; São Leopoldo Mandic Faculty, São Paulo, Brazil. Electronic address:

Objectives: Changes in lipid profiles occur in systemic inflammatory response syndrome (SIRS), whether due to sepsis or another cause. Hypocholesterolemia associated with hypertriacylglycerolemia can lead to disease severity and higher mortality. The aim of this systematic review was to describe the principal alterations in markers that participate in the alteration of the lipid profile.

Methods: We reviewed articles focused on alterations in the lipid profile in SIRS, sepsis, or both that were indexed in the Scientific Electronic Library Online from 2000 to 2017. The descriptors used were SIRS; sepsis; lipid profile; and lipoproteins. We focused in particular on the relationships among SIRS, sepsis, and lipid profiles.

Results: We included 29 studies that discussed decreased high-density lipoprotein (HDL), total cholesterol, and low-density lipoprotein, and elevated triacylglycerols concentrations in patients with SIRS, sepsis, or both. The variation in the lipid profile was proportional to the level of inflammation as evaluated by inflammatory markers, including C-reactive protein, interleukin-6 and interleukin-8, lipopolysaccharide-binding protein, and tumor necrosis factor. Additionally, there was a change in the composition of lipoproteins, especially HDL, triacylglycerols, and very low-density lipoprotein. HDL appears to be an inflammatory marker, as reduction of its levels reflects the intensity of the underlying inflammatory process.

Conclusion: Critically ill patients with SIRS, sepsis, or both presented with alterations in lipid metabolism.
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November 2018

Influence of AIDS antiretroviral therapy on the growth pattern.

J Pediatr (Rio J) 2019 Jan - Feb;95(1):7-17. Epub 2018 Apr 13.

Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Faculdade São Leopoldo Mandic, Campinas, SP, Brazil. Electronic address:

Objectives: Human immunodeficiency virus infection can result in the early impairment of anthropometric indicators in children and adolescents. However, combined antiretroviral therapy has improved, in addition to the immune response and viral infection, the weight and height development in infected individuals. Therefore, the objective was to evaluate the effect of combined antiretroviral on the growth development of human immunodeficiency virus infected children and adolescents.

Source Of Data: A systematic review was performed. In the study, the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) strategy was used as the eligibility criterion. The MEDLINE-PubMed and LILACS databases were searched using these descriptors: HIV, children, growth, antiretroviral therapy. The objective was defined by the population, intervention, comparison/control, and outcome (PICO) technique. Inclusion and exclusion criteria were applied for study selection.

Synthesis Of Data: Of the 549 studies indexed in MEDLINE-PubMed and LILACS, 73 were read in full, and 44 were included in the review (33 showed a positive impact of combined antiretroviral therapy on weight/height development, ten on weight gain, and one on height gain in children and adolescents infected with human immunodeficiency virus). However, the increase in growth was not enough to normalize the height of infected children when compared to children of the same age and gender without human immunodeficiency virus infection.

Conclusions: Combined antiretroviral therapy, which is known to play a role in the improvement of viral and immunological markers, may influence in the weight and height development in children infected with human immunodeficiency virus. The earlier the infection diagnosis and, concomitantly, of malnutrition and the start of combined antiretroviral therapy, the lower the growth impairment when compared to healthy children.
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October 2019

Selenium supplementation in pediatric patients using parenteral nutrition: Is it time to do something?

Rev Assoc Med Bras (1992) 2018 Mar;64(3):217-223

Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil.

Objective: To analyze the nutritional status of selenium and verify the effect of its supplementation in pediatric patients during 14 days of parenteral nutrition (PN).

Method: This is a series of cases with patients followed for two weeks while using PN. Data collection was performed at the beginning (T0), in the 7th (T1) and 14th days of PN (T2). The supplemented group received 2 µg/kg/day of selenous acid. Weight and height were measured for nutritional status assessment. Tests requested: plasma selenium, albumin, pre-albumin, C-reactive protein (CRP), total cholesterol and HDL-cholesterol.

Results: Fourteen (14) patients with inflammatory process and with low or very low weight for their ages were evaluated. In both groups (with and without supplementation), all patients had low selenium levels. Median plasma selenium concentrations were 17.4 µg/L (T0), 23.0 µg/L (T1) and 20.7 µg/L (T2). Increase and reduction of selenium occurred both in patients with high CRP and in those presenting normalization of this parameter.

Conclusion: Lower plasma selenium levels have been detected since the start of the research and supplementation (2 µg/kg/day of selenous acid) was not to enough to approach the reference values.
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March 2018

Ultrasound guidance for internal jugular vein cannulation in PICU: a randomised controlled trial.

Arch Dis Child 2018 10 4;103(10):952-956. Epub 2018 Apr 4.

Deparment of Pediatrics, University of Campinas (UNICAMP), Campinas, Brazil.

Objective: We investigated whether ultrasound guidance was advantageous over the anatomical landmark technique when performed by inexperienced paediatricians.

Design: Randomised controlled trial.

Setting: A paediatric intensive care unit of a teaching hospital.

Patients: 80 children (aged 28 days to <14 years).

Interventions: Internal jugular vein cannulation with ultrasound guidance in real time or the anatomical landmark technique.

Main Outcome Measures: Success rate, success rate on the first attempt, success rate within three attempts, puncture time, number of attempts required for success and occurrence of complications.

Results: We found a higher success rate in the ultrasound guidance than in the control group (95% vs 61%, respectively; p<0.001; relative risk (RR)=0.64, 95% CI (CI) 0.50 to 0.83). Success on the first attempt was seen in 95% and 34% of venous punctures in the US guidance and control groups, respectively (p<0.001; RR=0.35, 95% CI 0.23 to 0.54). Fewer than three attempts were required to achieve success in 95% of patients in the US guidance group but only 44% in the control group (p<0.001; RR=0.46, 95% CI 0.32 to 0.66). Haematomas, inadvertent arterial punctures, the number of attempts and the puncture time were all significantly lower in the ultrasound guidance than in the control group (p<0.015 for all).

Conclusions: Critically ill children may benefit from the ultrasound guidance for internal jugular cannulation, even when the procedure is performed by operators with limited experience.

Trial Registration Number: RBR-4t35tk.
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October 2018

Transthyretin levels: Potential biomarker for monitoring nutritional support efficacy and clinical complications risk in patients receiving parenteral nutrition.

Clin Nutr ESPEN 2018 04 3;24:134-139. Epub 2018 Feb 3.

College of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil; São Leopoldo Mandic College of Medicine and Dentistry, Campinas, SP, Brazil. Electronic address:

Nutritional support is an effective strategy to restore or maintain nutritional status, to reduce clinical complications, hospitalization period and the morbidity/mortality risk of hospitalized patients. So, a good marker is important to evaluate the nutritional support.

Objectives: This study aims to evaluate the evolution of transthyretin levels in patients receiving parenteral nutrition (PN) during 14 days.

Design & Methods: Longitudinal study of 88 hospitalized patients. The assessments and samples were taken during the first 72 h (T0), on the 7th day (T7) and 14th day (T14) of PN. This study was approved by the Ethics Committee of the School of Medical Sciences at UNICAMP (No 538/2011).

Results: The C-reactive protein (CRP) levels were high and albumin and transthyretin levels were low at baseline. From T0 to T14, only transthyretin increased (p = 0.03). According to the receiver operation characteristic (ROC) curve, we found that the transthyretin had some improvement when the CRP levels were less than 10.4 mg/dl (T7). According to the CRP/albumin ratio, all patients classified as without risk for complications were discharged from the hospital. In addition, we observed that patients with transthyretin reduction had a concomitant higher risk for complications according to their ratio CRP/albumin (p = 0.03).

Conclusions: CRP/albumin ratio was associated with the evolution of transthyretin levels. Transthyretin values showed significant improvement in the 14 days of PN. Especially, less inflamed patients (ie CRP less than 10.4 mg/dl) improved their transthyretin levels. So, CRP value at day 7 that predicts the transthyretin and transthyretin is a good biomarker for classification of nutritional support and clinical complications risk in patients receiving PN.
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April 2018

Hypercholesterolemia and hypertriglyceridemia as risk factors of liver dysfunction in children with inflammation receiving total parenteral nutrition.

Clin Nutr ESPEN 2018 02 20;23:148-155. Epub 2017 Nov 20.

Department of Pediatrics, State University of Campinas, Unicamp, Campinas, SP, Brazil; Department of Medicine, São Leopoldo Mandic Medicine Faculty, Campinas, Brazil.

Background And Aims: Hepatic dysfunction, due to parenteral nutrition, may become severe and lead to cirrhosis and hepatic failure, especially in newborns and infants. This study aimed to evaluate the association between the exclusive use of total parenteral nutrition (TPN) and changes in the hepatic profile, and to investigate the relationship between age, hypertriglyceridemia, and hypercholesterolemia, and the occurrence of laboratory liver dysfunction.

Methods: A descriptive and historical cohort study was conducted, evaluating 195 pediatric patients (age: 1 month to 19 years) who received TPN. The following hepatic and lipid profiles were assessed: alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, gamma-glutamyl transferase (GGT), bilirubin, triglycerides (TGs), cholesterol, high-density lipoprotein (HDL), albumin, and transthyretin. High C-reactive protein and/or low HDL were considered indicative of inflammatory process.

Results: The majority of patients presented normal values of AST (79.2%), ALT (74.9%), GGT (56.4%), and alkaline phosphatase (68.1%). Total bilirubin changed in 68.5% of patients, and transthyretin and albumin were low in 87.3% and 65.1% of the patients, respectively. Incidences of high GGT values were related to age (odds ratio [OR], 2.46; confidence interval [CI] 1.28-4.76; p = 0.007), hypercholesterolemia (OR, 3.00; 95% CI, 1.24-7.25; p = 0.015), and hypertriglyceridemia (OR, 2.39; 95% CI, 1.02-5.60; p = 0.046). Incidences of elevated ALT values were associated with hypercholesterolemia (OR, 4.57; 95% CI, 2.03-10.30; p < 0.001).

Conclusion: Monitoring the hepatic profile from the early stage of TPN is necessary. Changes in the plasma lipid and hepatic profiles were frequently observed during the infusion of TPN, in patients with inflammation. Patients >2 years old and those with high TG and HDL levels were more likely to have elevated GGT levels. Hypercholesterolemia was associated with ALT alterations. Strategies to attenuate these issues should be considered in the early stages, in patients with TPN.
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February 2018

Influence of selenium supplementation on patients with inflammation: A pilot double blind randomized study.

Nutrition 2017 Sep 4;41:32-36. Epub 2017 Apr 4.

College of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil.

Objective: The aim of the study was to analyze the effect of selenium supplementation on patients with inflammation receiving PN.

Methods: This double-blind randomized study included 20 hospitalized patients experiencing an inflammatory process while being fed by PN, who were monitored in three stages: first 72 h (0), day 7 (1), and day 14 (2) of PN. The supplemented patients group (G+S) received 60 μg/d (0.75 μmol) of selenium as selenious acid which was added to the PN bag. The nonsupplemented group (G-S) did not receive selenium. The concentration range of 84 to 100 μg/L (1.07-1.27 μmol/L) was used as a reference of plasma selenium.

Results: The study included 20 patients (8 G+S and 12 G-S) mainly diagnosed with cancer and/or sepsis. Most of them were hospitalized in the intensive care unit and were receiving PN for clinical reasons. Plasma selenium was greater in the G+S than in the G-S (P = 0.05) in two stages (0 and 1). Since the start of assessment, C-reactive protein (CRP) levels were elevated; however, there was no statistical difference in CRP values between groups (P > 0.05). There was no significant change of glutathione peroxidase over time or between groups (P > 0.05).

Conclusion: The selenium concentration was greater in the G+S than in the G-S, acting independently from CRP behavior. However, supplementation was not enough to reach the reference values.
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September 2017

[Is plasma selenium correlated to transthyretin levels in critically ill patients?]

Nutr Hosp 2017 06 5;34(3):540-547. Epub 2017 Jun 5.

College of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil.

Background: Selenium is an essential trace element, but critically ill patients using total parenteral nutrition (PN) do not receive selenium because this mineral is not commonly offered. Threfore, the eval uation of plasma selenium levels is very important for treating or preventing this deficiency. Recent studies have shown that transthyretin may reflect the selenium intake and could be considered a biomarker. However, this issue is still little explored in the literature.

Objective: This study aims to investigate the correlation of transthyretin with the plasma selenium of critically ill patients receiving PN.

Method: This was a prospective cohort study with 44 patients using PN without selenium. Blood samples were carried out in 3 stages: initial, 7th and 14th day of PN. In order to evaluate the clinical condition and the inflammatory process, albumin, C-reactive protein (CRP), transthyretin, creatinine and HDL cholesterol levels were observed. To assess the selenium status, plasma selenium and glutathione peroxidase (GPx) in whole blood were measured. Descriptive analyses were performed and the ANOVA, Mann-Whitney and Spearman's coefficient tests were conducted; we assumed a significance level of 5%.

Results: A positive correlation of selenium with the GPx levels (r = 0.46; p = 0.03) was identified. During two weeks, there was a positive correlation of transthyretin with plasma selenium (r = 0.71; p = 0.05) regardless of the CRP values.

Conclusion: Transthyretin may have reflected plasma selenium, mainly because the correlation was verified after the acute phase.
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June 2017

Quality of sweat test (ST) based on the proportion of sweat sodium (Na) and sweat chloride (Cl) as diagnostic parameter of cystic fibrosis: are we on the right way?

Diagn Pathol 2016 Oct 26;11(1):103. Epub 2016 Oct 26.

Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil.

Background: To assess the quality of sweat test (ST) based on the proportion of sweat sodium and sweat chloride as diagnostic parameter of cystic fibrosis (CF).

Methods: A retrospective study of 5,721 sweat samples and subsequent descriptive analysis were carried out. The test was considered "of good quality" (correct) when: (i) sweat chloride was lower than 60 mEq/L, and sweat sodium was higher than sweat chloride; (ii) sweat chloride was higher than 60 mEq/L, and sweat sodium was lower than sweat chloride.

Results: The study included 5,692/5,721 sweat samples of ST which had been requested due to clinical presentations compatible with CF and/or neonatal screenings with altered immunoreactive trypsinogen values. Considering the proportion of sweat sodium and sweat chloride as ST quality parameter, the test was performed correctly in 5,023/5,692 (88.2 %) sweat samples. The sweat chloride test results were grouped into four reference ranges for chloride (i) chloride < 30 mEq/L: 3,651/5,692 (64.1 %); (ii) chloride ≥ 30 mEq/L to < 40 mEq/L: 652/5,692 (11.5 %); (iii) ≥ 40 mEq/L to < 60 mEq/L: 673/5,692 (11.8 %); (iv) ≥ 60 mEq/L: 716/5,692 (12.6 %). In the comparative analysis, there was no association between ST quality and: (i) symptoms to indicate a ST [respiratory (p = 0.084), digestive (p = 0.753), nutritional (p = 0.824), and others (p = 0.136)], (ii) sweat weight (p = 0.416). However, there was a positive association with: (i) gender, (ii) results of ST (p < 0.001), (iii) chloride/sodium ratio (p < 0.001), (iv) subject's age at the time of ST [grouped according to category (p < 0.001) and numerical order (p < 0.001)]. For the subset of 169 patients with CF and two CFTR mutations Class I, II and/or III, in comparative analysis, there was a positive association with: (i) sweat chloride/sodium ratio (p < 0.001), (ii) sweat chloride values (p = 0.047), (iii) subject's age at the time of the ST grouped by numerical order (p = 0.001).

Conclusions: Considering that the quality of ST can be assessed by levels of sweat sodium and sweat chloride, an increasing number of low-quality tests could be observed in our sweat samples. The quality of the test was associated with important factors, such as gender, CF diagnosis, and subjects' age.
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October 2016

Hypophosphatemia, Hypomagnesemia, and Hypokalemia in Pediatric Patients Before and During Exclusive Individualized Parenteral Nutrition.

Nutr Clin Pract 2016 Apr 11;31(2):223-8. Epub 2016 Feb 11.

Department of Pediatrics, State University of Campinas, Unicamp, Brazil.

Background: Hypophosphatemia, hypomagnesemia, and hypokalemia occur in patients receiving parenteral nutrition (PN), mainly when the body's stores are depleted due to fasting or inflammation. Although these disorders are potentially fatal, few studies have reported the incidence in the pediatric population.

Methods: This study evaluated, in a historical cohort of pediatric patients, the prevalence of hypophosphatemia, hypokalemia, and hypomagnesaemia until 48 hours before initiation of PN infusion (P1) and from days 1-4 (P2) and days 5-7 (P3) of PN infusion and investigated if malnutrition, calories, and protein infusion were correlated to these disorders.

Results: Malnutrition was present in 32.8% (n = 119) of the subjects; 66.4% of the patients were in the pediatric intensive care unit. Survival rate was 86.6%. P1 had the highest prevalence of mineral disorders, with 54 events (58.1%; P2, n = 35, 37.6%; P3, n = 4, 4.3%). Hypokalemia events were related to malnutrition (odds ratio, 2.79; 95% confidence interval, 1.09-7.14; P = .045). In the first 7 days, infused calories were below the amount recommended by current guidelines in up to 84.9% of patients, and protein infused was adequate in up to 75.7%. Protein infused above the recommendation in the first 4 days was related to hypomagnesaemia (odds ratio, 5.66; 95% confidence interval, 1.24-25.79; P = .033).

Conclusion: Hypophosphatemia, hypokalemia, and hypomagnesemia were frequent in hospitalized pediatric patients before and during the first 4 days of PN infusion. Patients with malnutrition had more chances of having hypokalemia, and those who received high protein infusion had an increased chance of developing hypomagnesemia.
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April 2016

Changes in Home Parenteral Nutrition Practice Based on the Canadian Home Parenteral Nutrition Patient Registry.

JPEN J Parenter Enteral Nutr 2017 07 25;41(5):830-836. Epub 2015 Sep 25.

2 Toronto General Hospital, University Health Network, Toronto, Canada.

Background: Since 2005, the Canadian home parenteral nutrition (HPN) registry has collected data on patients' demography, outcomes, and HPN clinical practice. At annual meetings, Canadian HPN programs review and discuss results.

Aim: To evaluate changes over time in patient demography, outcomes, and HPN clinical practice using the registry data.

Methods: This retrospective study evaluated 369 patients who were prospectively entered in the registry. Two periods were compared for the first data entry: 2005-2008 (n = 182) and 2011-2014 (n = 187). Patient demography, indications for HPN, HPN regimen, nutrition assessment, vascular access, and number of line sepsis per 1000 catheter days were evaluated.

Results: For 2011-2014 compared with 2005-2008, indications for HPN changed significantly, with an increased proportion of patients with cancer (37.9% vs 16.7%) and with fewer cases of short bowel syndrome (32% vs 65.5%); line sepsis rate decreased from 1.58 to 0.97 per 1000 catheter days; and the use of tunneled catheters decreased from 64.3% to 38.0% and was no longer the most frequently chosen vascular access method. In contrast, the proportion of peripherally inserted central catheters increased from 21.6% to 52.9%. In addition, there was a reduction in number and days of hospitalizations related to HPN, and favorable changes were noted in the prescription of energy, proteins, and trace elements.

Conclusion: The Canadian HPN registry is useful in tracking trends in demography, outcomes, and clinical practice. Results suggest a shift in patient demography and line access with improvement in line sepsis, hospitalizations, and HPN prescriptions.
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July 2017


Nutr Hosp 2015 Jul 1;32(1):250-5. Epub 2015 Jul 1.

College of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP. Brazil..

Background: assess whether the current protein intake recommendations may improve the biochemical parameters of critical patients receiving parenteral nutrition.

Methods: longitudinal study with three evaluations made (during the first 72 hours, on the 7th and the 14th days of PN). The following tests were applied: albumin, C-reactive protein, prealbumin, total cholesterol, HDL, triglycerides, lymphocytes, and glutathione peroxidase. The severity was determined by SOFA. The statistical analysis included the Spearman and Mann-Whitney tests, as well as ANOVA (analysis of variance).

Results: among the 53 patients evaluated, 20 (37.74%) died. The mean calorie was 24.68 ± 9.78 kcal/kg (beginning of PN), 26.49 ± 8.89 kcal/kg (3rd to 7th days of PN), and 30.9 ± 12.19 kcal/kg (7th to 14th days of PN). The mean protein was 1.19 ± 0.44 g/kcal/kg (first 72 hours of PN), 1.29 ± 0.44 g/kcal/kg (3rd to 7th days of PN) and 1.49 ± 0.69 g/kcal/kg (7th to 14th days of PN). Prealbumin, albumin, total cholesterol and HDL were below the reference values, while the CRP levels were high. Throughout the three evaluation times, there was no a significant improvement on the levels of laboratory examinations. A strong and negative correlation was found between SOFA and prealbumin (r = -0.64, p = 0.05).

Conclusions: the protein offer, according to the traditional recommendations, was not enough to improve the biochemical parameters of critical patients undergoing parenteral nutrition.
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July 2015

[Factors impacting the growth and nutritional status of cystic fibrosis patients younger than 10 years of age who did not undergo neonatal screening].

Rev Paul Pediatr 2015 Jan-Mar;33(1):3-11. Epub 2015 Feb 11.

Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil.

Objective: The aim of this study was to evaluate by clinical and laboratory parameters how cystic fibrosis (CF) affects growth and nutritional status of children who were undergoing CF treatment but did not receive newborn screening.

Methods: A historical cohort study of 52 CF patients younger than 10 years of age were followed in a reference center in Campinas, Southeast Brazil. Anthropometric measurements were abstracted from medical records until March/2010, when neonatal screening program was implemented. Between September/2009 and March/2010, parental height of the 52 CF patients were also measured.

Results: Regarding nutritional status, four patients had Z-scores ≤ -2 for height/age (H/A) and body mass index/age (BMI/A). The following variables were associated with improved H/A ratio: fewer hospitalizations, longer time from first appointment to diagnosis, longer time from birth to diagnosis and later onset of respiratory disease. Forced vital capacity [FVC(%)], forced expiratory flow between 25-75% of FVC [FEF25-75(%)], forced expiratory volume in the first second [FEV1(%)], gestational age, birth weight and early respiratory symptoms were associated with IMC/A.

Conclusions: Greater number of hospitalizations, diagnosis delay and early onset of respiratory disease had a negative impact on growth. Lower spirometric values, lower gestational age, lower birth weight, and early onset of respiratory symptoms had negative impact on nutritional status. Malnutrition was observed in 7.7% of cases, but 23% of children had nutritional risk.
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June 2017

[Should pediatric parenteral nutrition be individualized?].

Rev Paul Pediatr 2014 Dec;32(4):326-32

Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brasil.

Introduction: Parenteral nutrition (PN) formulations are commonly individualized, since their standardization seem inadequate for the pediatric population. This study aimed to evaluate the nutritional state and the reasons for PN individualization in pediatric patients using PN hospitalized in a tertiary hospital in Campinas, São Paulo.

Methods: This longitudinal study comprised patients using PN followed by up to 67 days. Nutritional status was classified according to the criteria established by the World Health Organization (WHO) (2006) and WHO (2007). The levels of the following elements on blood were analyzed: sodium, potassium, ionized calcium, chloride, magnesium, inorganic phosphorus and triglycerides (TGL). Among the criteria for individualization, were considered undeniable: significant reduction in blood levels of potassium (<3 mEq/L), sodium (<125 mEq/)L, magnesium (<1 mEq/L), phosphorus (<1.5 mEq/L), ionic calcium (<1 mmol) and chloride (<90 mEq/L) or any value above the references.

Results: Twelve pediatric patients aged 1 month to 15 years were studied (49 individualizations). Most patients were classified as malnourished. It was observed that 74/254 (29.2%) of examinations demanded individualized PN by indubitable reasons.

Conclusion: The nutritional state of patients was considered critical in most cases. Thus, the individualization performed in the beginning of PN for energy protein adequacy was indispensable. In addition, the individualized PN was indispensable in at least 29.2% of PN for correction of alterations found in biochemical parameters.
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December 2014

Anthropometric and body-mass composition suggests an intrinsic feature in Williams-Beuren syndrome.

Rev Assoc Med Bras (1992) 2011 Nov-Dec;57(6):681-5

Department of Medical Genetics, Faculdade de Ciências Médicas, Universidade de Campinas (FCM–UNICAMP), Campinas, São Paulo, SP, Brazil

Objective: Although considered a well-known condition, there is only one study describing the body composition among individuals with Williams-Beuren syndrome. The aim was to characterize the nutritional status in Brazilian individuals with this condition.

Methods: Cross-sectional study was designed to evaluate clinical and nutritional data of 17 Brazilian patients. Z-scores for height, weight, body mass index, triceps and subscapular skinfold thickness, arm circumference, arm muscle area, arm fat area were calculated. Wilcoxon's test was used to investigate differences between the z-scores of the anthropometrical measures and zero.

Results: Four children were considered stunted and two severely malnourished. The z-score mean value for height was -1.14 ± 1.00 (p-value = 0.004), for weight, -0.67 ± 1.19 (p-value = 0.0443), for arm circumference, -0.94 ± 1.14 (p-value = 0.0222), for triceps skinfold thickness, -0.59 ± 0.63 (p-value = 0.0042) and for arm fat area -0.67 ± 0.67 (p-value = 0.0061).

Conclusion: Short stature seen in this series confirms a previous study describing this feature in a German population, which would suggest it as an intrinsic feature in Williams-Beuren syndrome. In addition, skinfold thickness measures have not been previously performed in this syndrome and detected abnormalities in fat stores in this sample. Considering this method a fast and low-cost way to evaluate body composition, similar studies could be performed in other populations in order to better characterize this issue. Morbidity related with this genetics condition and information for clinical investigation and clinical follow-up are also discussed.
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October 2012

Malnutrition causing neonatal dyslipidemia.

Nutr Clin Pract 2011 Aug 3;26(4):440-4. Epub 2011 Jun 3.

Department of Pediatrics, Faculty of Medical Sciences, State University of Campinas (Unicamp), Brazil.

Lipid abnormalities in children have become more common in recent decades. This trend is related to the increase in overweight and obesity. The 2002 National Health and Nutrition Examination Survey reported that the percentage of risk for overweight and overweight in children aged > 6 years is 31%, higher than the previous surveys. Serum lipids tend to increase quickly up to 6 months of age and reach values very close to adult values by age 2. As suggested by the American Heart Association, serum lipid values for children and adolescents (2-19 years old) are considered abnormal when total cholesterol is >200 mg/dL, high-density lipoprotein is <35 mg/dL, low-density lipoprotein is >130 mg/dL, and triglycerides are >150 mg/dL. Dyslipidemia can be found in patients with malnutrition, a severe condition that needs prompt nutrition intervention. This report describes a case of malnutrition causing severe dyslipidemia in a newborn. Primary dyslipidemia was excluded by the presence of primary malnutrition, normal response to a postheparin lipoprotein lipase activity test, a favorable clinical course after nutrition intervention, and relatives' blood lipid levels close to normal that did not indicate familial dyslipidemia. The child was fed fat-free milk formula supplemented with medium-chain triglycerides and had adequate weight gain with a decrease in blood lipids. Subsequently the formula was changed to regular milk-based formula, and the child maintained adequate growth rate. Although blood lipids never returned to normal values for age and sex, they were lower than before treatment.
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August 2011

Growth evaluation in infants with neonatal cholestasis.

Arq Gastroenterol 2006 Oct-Dec;43(4):305-9

Department of Pediatrics, State University of Campinas, SP, Brazil.

Background: [corrected] Chronic liver diseases in childhood often cause undernutrition and growth failure. To our knowledge, growth parameters in infants with neonatal cholestasis are not available

Aim: To evaluate the nutritional status and growth pattern in infants with intrahepatic cholestasis and extrahepatic cholestasis.

Patients And Methods: One hundred forty-four patients with neonatal cholestasis were followed up at the Pediatric Gastroenterology Service of the Teaching Hospital, State University of Campinas, Campinas, SP, Brazil, in a 23-year period, from 1980 to 2003. The records of these patients were reviewed and patients were classified into two groups, according to their anatomical diagnosis: patients with intrahepatic cholestasis - group 1, and patients with extrahepatic cholestasis - group 2. Records of weight and height measurements were collected at 4 age stages of growth, in the first year of life: 1) from the time of the first medical visit to the age of 4 months (T1); 2) from the 5th to the 7th month (T2); 3) from the 8th to the 10th month (T3); and 4) from the 11th to the 13th month (T4). The weight-by-age and height-by-age Z-scores were calculated for each patient at each stage. In order for the patient to be included in the study it was necessary to have the weight and/or height measurements at the 4 stages. Analyses of variance and Tukey's tests were used for statistical analysis. Repeated measurement analyses of variance of the weight-by-age Z-score were performed in a 60-patient sample, including 29 patients from group 1 and 31 patients from group 2. The height-by-age data of 33 patients were recorded, 15 from group 1 and 18 from group 2

Results: The mean weight-by-age Z-scores of group 1 patients at the 4 age stages were: T1=-1.54; T2=-1.40; T3=-0.94; T4=-0.78. There was a significant difference between T2 X T3 and T1 X T4. The weight-by-age Z-scores for group 2 patients were :T1=-1.04; T2=-1.67; T3=-1.93 and T4=-1.77, with a significant difference between T1 X T2 and T1 X T4. The mean weight-by-age Z-scores also showed a significant difference between group 1 and group 2 at stages T3 and T4. The mean height-by-age Z-scores at the four stages in group 1 were: T1=-1.27; T2=-1.16; T3=-0.92 and T4=-0.22, with a significant difference between T3XT4 and T1XT4. The scores for group 2 patients were: T1=-0.93; T2=-1.89; T3=-2.26 and T4=-2.03, with a significant difference between T1XT2 and T1XT4. The mean height-by-age Z-scores also showed a significant difference between group 1 and group 2 at T3 and T4

Conclusion: The weight and height differences between the groups became significant from the 3rd measurement onward, with the most substantial deficit found in the extrahepatic group. In this group, there is evidence that the onset of weight and height deficit occurs between the first and second evaluation stages.
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December 2007