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Invited Review
Department of Pediatrics, Baylor College of Medicine, USDA/ARS Children's Nutrition Research Center, Texas Children's Hospital, Houston, Texas, U.S.A.
JPGN 36:587–607, 2003. Key Words: Parenteral nutrition— acids—Lipid emulsion. © 2003 Lippincott Williams &Intravenous—Feeding—Neonates—Energy—Protein—Amino Wilkins, Inc.
TABLE 1. Equations for estimating basal metabolic exception is the preterm infant. PN is required after birth rate (MJ/day)* because of the premature infant's limited nutritional Age stores (21). A recent randomized controlled study com-(years) Male Female pared preterm infants (27 weeks gestational age, N ⳱ 125) receiving PN on the first day of life to those in<3 0.249 wt − 0.127 0.244 wt − 0.130<3 0.0007 wt + 6.349 L − 2.584 0.068 wt + 4.281 L − 1.730 whom it was started in the first few days of life and 3–10 0.095 wt + 2.110 0.085 wt + 2.033 advanced more slowly (22). Infants in the early PN group10–18 0.074 wt + 2.754 0.056 wt + 2.898 had fewer infections during hospitalization and were18–30 0.063 wt + 2.896 0.062 wt + 2.036 more likely to be above the 10th percentile for weight or * Notes height at the time of discharge (22). 1. To convert to kcal/day multiply by 239 2. Wt ⳱ weight in kilograms 3. L ⳱ Length in meters. Only predictions for children <3 years of Energy Sourcesage are improved by including length in the equation. From (9). There is controversy around the choice of nutrients to provide energy requirements via PN. There are glucose advocates, lipid believers, and argument as to whether Using indirect calorimetry and a number of covariates protein (i.e., amino acids) should be counted as part ofin a group of surgical infants, Pierro et al. developed the the total administered energy. At the expense of over-formula shown below to calculate energy expenditure simplification and wounding the true believers in each(15,16). camp (the authors are active participants in these contro-Resting energy expenditure (kcal/d) ⳱ versies), we submit that a few basic principles can be −74.436 +[34.661 x weight (kg)] agreed upon. 1) There is a minimum amount of glucose + [0.496 x heart rate (beats/min)] that must be provided in order to prevent hypoglycemia + [0.178 x age (days)] x [1.44] and a maximum that results in the production of exces- sive CO2 and/or hepatic steatosis (see below); 2) There is The prediction has an error of – 0.95 ± 3.65%; an R2 a minimum requirement (both dose and frequency) for⳱ 0.85; and a P < 0.00001) intravenous fat emulsion to prevent essential fatty acid White et al devised the following formula for estimat- deficiency but a maximum beyond which intravenous fating energy expenditure in intensive care patients (17): may have deleterious effects; and 3) Amino acids must be provided in adequate amounts to prevent hypoprotein-Energy expenditure (kcal/day) ⳱ emia but there are adverse consequences of giving an [(17 × age in months) + (48 × weight in kg) excess. Both the size and the age of the pediatric patient + (292 × body temperature in °C) – 9677] are important in determining the appropriate quantities of x [0.239] (R2 ⳱ 0.867) glucose, fat and amino acids administered in PN. Obese adolescents are an exception to the basal meta-bolic rate calculations provided in Table 1. The basal Glucosemetabolic rate for obese children can be calculated asfollows (18): Estimates of glucose utilization by the brain are shown in Table 2 (23). These estimates vary with age and, atFor Boys: BMR ⳱ first glance, reflect the minimum amount of glucose that [16.6 x weight (kg)] + [77 x height (meters)] + 572 must be provided to prevent hypoglycemia (23). Some investigators have argued that gluconeogenesis providesFor Girls: BMR ⳱ a significant amount of glucose (even in preterm infants) [7.4 x weight (kg)] + [482 x height (m)] + 217 and suggest that not all the glucose shown in Table 2 The clinical significance of energy expenditure, par- need be provided exogenously (24,25). However, theseticularly in the critically ill patient, also has an impact onthe timing of PN initiation. If very ill patients are going TABLE 2. Estimates of glucose consumption by the brainto be "hypermetabolic", available data suggest that it will Utilizationbe early in the disease process. PN administration itselfincreases metabolic rate (19,20). The more malnourished Age (mg ⭈ kg −1 ⭈ min ) −1 (g ⭈ kg−1 ⭈ d−1)the patient, the greater the stimulatory effect of PN on Newborn 8.0 11.5metabolic rate (20). Thus, administration of PN which 1 year 7.0 10.1provides all nutritional requirements should be avoided 5 years 4.7 6.8 Adolescent 1.9 2.7in the first couple of days of a patient's critical illness, as Adult 1.0 1.4it will further increase the metabolic rate and do little tostem the protein catabolic response to the illness. An From (23).
studies have used isotopic tracers to measure gluconeo- PN regimens were tested: 87:5:8 (glucose:fat:amino ac-genesis and it has been shown that this method underes- ids as percent of total energy), 60:32:8, and 34:58:8 Totaltimates the contribution of glucose to CO2 when com- energy intake was comparable to the recommended dailypared with data obtained from indirect calorimetry (23). allowance. The increase in resting energy expenditureThus, the data in Table 2 probably do reflect the amount (although reported as basal metabolic rate) induced byof exogenous glucose required to prevent hypoglycemia the high glucose regimen was nearly 5 times greater thanunder most circumstances (23). Kalhan and Kiliç re- that of the other two regimens (28). Bresson et al. alsoviewed the evidence that this amount of exogenous glu- noted increased energy expenditure in relationship to in-cose also is sufficient to minimize nitrogen loss (23). creasing glucose intake, albeit to a lesser extent, amount- What about the maximum rate of glucose oxidation? ing to 16% of the energy value of infused glucose (29).Lafeber et al. found a glucose oxidation rate of 6.6 ± 1.2 In the study by Nose et al. the respiratory quotient (RQmg ⭈ kg−1 ⭈ min−1 (9.5 g ⭈ kg−1 ⭈ d−1) in appropriate for ⳱ CO2 production/O2 consumption) was significantlygestational age preterm infants (birth weight: 1613 ± 151 greater on a high glucose regimen compared to lowerg, gestational age: 31.1 ± 1.5 wk; mean ± SD)(26). The glucose regimens (28). The data suggest that in thisrate was minimally greater than that found in small for population of stable patients on long-term PN, glucosegestational age infants (26). In contrast, in term surgical intakes in excess of 10 mg ⭈ kg−1 ⭈ min−1 result ininfants Jones et al. measured a maximal glucose oxida- conversion of glucose to fat (RQ >1) (28). As seen intion rate of 12.5 mg ⭈ kg−1 ⭈ min−1 (18 g ⭈ kg−1 ⭈ d−1) Figure 1, lipogenesis from glucose results in a large in-(27). This rate is comparable to that of stable patients crease CO2 production relative to O2 consumption (i.e.,both on long-term PN (N ⳱ 7, 30 ± 41 months of age) high RQ).or short-term PN (N ⳱ 36, 6 ± 4 months of age) (28,29). Talpers et al. (among others) examined the effect of Clinical status can modify glucose oxidative capacity different glucose/fat ratios on CO2 production in adultssignificantly. For example, Sheridan et al. noted that in (19,38). In contrast to the studies of Nose et al (and othercritically burned children the maximal rate of glucose investigators), they were unable to detect a change inoxidation was 5 mg ⭈ kg−1 ⭈ min−1 (30). CO2 production as a consequence of alterations in the glucose/fat ratios (19,38). It is possible that the discrep- ancy between these studies is a result of the higher pro- Consequences of Overfeeding with Glucose portion of total energy provided by amino acids in Talp- ers' study (20% of total energy) than in Nose's study (8% In critically ill individuals, glucose intakes above the of total energy) (28,38). Amino acids also can affectmaximal glucose oxidation rate will result in the non- ventilatory drive and the response to CO2. Increasingoxidative production of fat, hence, are unlikely to en- amino acid intake (with energy intake constant) leads tohance energy balance, or even reduce protein catabolism an increase in minute ventilation and more importantly,(23). On the other hand, glucose intakes above the maxi- an enhanced response to CO2 (i.e., minute ventilationmal oxidation rate promote fat deposition, which may be increases in a more responsive fashion to increasing lev-a nutritional goal in specific clinical situations (e.g., pre- els of CO2 (39,40). Thus, the higher percentage of aminoterm infants). We will use the term overfeeding to mean acids provided in the adult studies may have blunted theproviding calories in excess of the amount required for differences in CO2 production at different glucose/fatnormal weight gain. ratios. A number of recent reviews have addressed issues Another factor with an impact on CO2 production isrelated to carbohydrate overfeeding in the intensive care total energy intake. There is a linear relationship betweenunit patient (31–35). Unfortunately, the relationship be- energy intake and CO2 production and increased minutetween carbohydrate feeding and impaired pulmonary ventilation (presuming glucose is providing a portion offunction (in the form of increased CO2 production) as the energy) (38,40). Indeed, the patients reported to havewell as the development of fatty liver often is oversim- developed respiratory failure (i.e., CO2 retention and in-plified. creased minute ventilation) as a consequence of PN with When glucose is administered in excess of the amount high concentrations of glucose were receiving excessivethat can be directly oxidized for energy production and energy intakes (see reference 35 for a review). Underglycogen production, the excess is directed to fat syn- normal circumstances the increased CO2 production isthesis (lipogenesis) (Fig. 1) (36,37). This conversion is handled easily by increasing the respiratory rate and/orinefficient and probably accounts, in part, for the in- depth. Problems potentially arise in patients with respi-crease in energy expenditure seen with high rates of glu- ratory compromise. The respiratory response to enteralcose infusion (Fig. 1) (20). This inefficiency can have carbohydrate intake and enteral overfeeding mirrorsclinical consequences besides simply producing hyper- what is seen with PN (41).glycemia. In summary, the greater the proportion of glucose in Nose et al. studied energy expenditure and CO2 pro- the PN energy mix, the larger the increase in CO2 pro-duction in 7 infants receiving long term PN (28). Three duction and minute ventilation. Malnourished patients
FIG. 1. Respiratory quotient (CO2 production / O2 consumption) and caloric yield from the oxidation of glucose, fat, amino acids, and theconversion of glucose to fat. *Energy production values shown are theoretical. Actual energy produciton is less efficient. For conversionof palmitate it is about 41% (980/2398) whereas glucose conversion to fat is only about 20% efficient. Adapted from Flatt JP: Energeticsof intermediary metabolism. In Assessment of Energy Metabolism in Health and Disease, p. 77 (ed.) JM Kinney, Report of the First RossConference on Medical Research. Columbus, Ohio, Ross Laboratories, 1980.
are least and hypermetabolic individuals are most sus- used in combination (44). Steatosis was associated withceptible. Normally nourished and metabolically normal a rise in serum transaminases but no cholestasis waspatients have an intermediate response (42). The greater noted (44). Studies in normal adult volunteers suggestthe total energy intake, the greater the effect. that high carbohydrate feeding leads to an increase in In selected patient groups, giving glucose in amounts total VLDL triglyceride secretion rate from de novo syn-above the maximal oxidative rate may be appropriate thesis primarily due to stimulation of the secretion of(e.g., preterm infants who need to deposit fat). However, preformed fatty acids (45). The results imply that thethe greater the amount of glucose, the greater the risk of liver derives all its energy from carbohydrate oxidationadverse consequences. Unfortunately, the absolute intake as opposed to fatty acid oxidation such that fatty acidsat which the adverse consequences occur is poorly de- taken up by the liver are channeled into VLDL triglyc-fined. erides (45). Hepatic steatosis results when export of the Overfeeding of glucose also can affect liver function VLDL triglycerides does not keep pace with productionalthough its contribution to the development of cholesta- (34,45).sis in humans is unclear. Burke et al. observed a rela- Another potential complication of overfeeding withtionship between glucose infusion rate and the develop- glucose is an increase in infectious complications. PNment of fatty infiltration of the liver in necropsies of has been associated with an increased risk of infectiouschildren who died of severe burns (43). In a study in 37 complications compared with enteral feeding or no nu-catabolic adults, Tulikoura et al. administered PN using tritional support in adult studies (46–49). Recent dataglucose and glucose and fat as energy sources (44). suggest that this finding may actually be explained byThere was a significant increase in hepatic steatosis in overfeeding with glucose (50). Hyperglycemia is a riskthe glucose group but none when glucose and fat were factor for infection (51,52). Recently, hyperglycemia
was associated with an increased risk of infection in 1.5 g/kg (approximately 500 mL of 20% intravenous fatchildren with burns (53). In a prospective randomized emulsion) twice a week in an adolescent, would be ad-trial in adults there was no difference between groups equate for all such patients. In patients receiving no in-receiving hypocaloric intravenous fluids and those re- travenous fat emulsion, some studies suggest that fattyceiving PN that did not overfeed the patients or induce acid deficiency develops faster when total energy intakehyperglycemia (54). These intriguing results require fur- is low than it does when total energy intake is highther verification but may have great implications for pa- (66,67).tient care. It often is suggested that intravenous fat emulsion be administered over less than 24 hours (e.g., 20 hours) to allow time for the fat to clear from the blood. In fact, Clinical Implications studies suggest that it is better to administer the daily dose over 24 hours in patients who have difficulty tol- Patients with respiratory compromise, particularly erating the infusion. Preterm infants should receive theCO2 retention (e.g., cystic fibrosis) are at risk for expe- infusion over 24 hours to avoid hypertriglyceridemia.riencing a worsening of their pulmonary status if glucose For patients without hypertriglyceridemia or other evi-provides a large proportion of their energy needs. The dence of intolerance to intravenous fat emulsion, a lessrisk increases as energy intake surpasses REE. Malnour- than 24-hour infusion schedule may be tolerated well.ished patients may not manifest this response until they One of the major determinants of the rate of clearance ofbegin to be nutritionally rehabilitated. A hypermetabolic fat from the blood is the amount of intravenous fat emul-patient will exhibit this reaction most quickly. Concerns sion infused per unit time (68). The longer the infusionabout overfeeding have been addressed recently in a con- time, the less likely the patient will develop hypertriglyc-sensus statement on the care of the adult intensive care eridemia (68,69). Intravenous fat emulsions with highunit patient (55). concentrations of phospholipids (i.e., 10% emulsions) should be avoided as they carry a higher risk of produc- Intravenous Fat Emulsion ing high serum levels of triglycerides, cholesterol, and phospholipids than other emulsions (i.e., 20% and 30% Unless otherwise noted, the term intravenous fat emul- emulsions) (70–72).sion refers to the currently available (in the United A number of other factors decrease the rate of clear-States) soy- or soy/safflower-based emulsions. A key ance of intravenous fat emulsions. The more malnour-role for intravenous fat emulsion is the prevention of ished the patient, the slower the rate of clearance will be.essential fatty acid deficiency. The usual preterm infant Slower clearance in malnourished patients is a result of(< 2 kg birthweight) on PN without intravenous fat emul- lower levels of lipoprotein lipase. This enzyme, which ission or on enteral feedings begins to demonstrate bio- responsible for releasing fatty acids from the fat emul-chemical evidence of essential fatty acid deficiency (in- sion, resides within the capillary system. The lower thecreased triene/tetraene ratio) within seven days of birth if capillary tissue mass (a situation found in preterm infantsnot provided with adequate intravenous fat emulsion and malnourished patients), the slower the rate of intra-(56). In the absence of intravenous fat emulsion, endog- venous fat emulsion clearance. Studies in adult volun-enous adipose tissue and the liver are probably the source teers have shown that the muscle, splanchnic, myocardi-of essential fatty acids (57). In order to prevent the mo- al, and subcutaneous fat capillary systems clear 47%,bilization of fatty acids for energy, essential fatty acids 25%, 14%, and 13% of the total amount of lipid infused,must be provided in amounts necessary to both replace respectively (73). Under normal circumstances the liverdeficits and supply ongoing needs for metabolism and clears less than 1% of infused lipid (73).growth. In other words, essential fatty acid deficiencies Another factor that alters the tolerance to intravenousare cumulative (58,59). Given that intravenous fat emul- fat emulsion is the concurrent administration of drugs.sions contain approximately 50% essential fatty acids by Because of their lipolytic effect, steroids are the proto-weight, about 0.5 g ⭈ kg−1 ⭈ d−1 of intravenous fat emul- type. Patients simultaneously receiving steroids and in-sion is required to prevent essential fatty acid deficiency travenous fat emulsions are prone to hypertriglyceride-in patients on total PN (56,60). However, there is con- mia (74). Additionally, a number of medications containtroversy regarding this figure, particularly in adults (and lipid or are microsomal formulations. Drugs such as pro-presumably adolescents) with some investigators sug- pofol and amphotericin B may contribute significantgesting the recommendation is more than adequate (e.g., amounts of (fat) energy to the total daily intake and1.5 g/kg twice weekly) and others stating it is too low which should be taken into account in nutritional calcu-(61–64). There appears to be a fair amount of inter- lations.individual variation in essential fatty acid requirements Patients who are metabolically stressed (i.e., sepsis,based upon age, disease, and nutritional status (56,61,62, trauma) or who have organ dysfunction (e.g., liver and/or65). Thus, one should not presume that giving the small- renal disease) also are likely to develop hypertriglyceri-est recommended amount of essential fatty acid, such as demia during intravenous fat emulsion infusion. These
patients have an outpouring of cortisol, catecholamines, polyunsaturated fatty acids in the emulsions to prosta-and cytokines that promote the lipolysis of endogenous glandins, which then can cause vasoconstriction or va-lipid stores (75–77). Liver and renal disease themselves sodilatation depending on the rate of infusion and theare associated with hypertriglyceridemia. However, adult clinical state of the lungs (85,86,93). Peroxides are an-(and presumably pediatric) patients with sepsis and liver other contaminant that can be found in the fat emulsiondisease can tolerate and utilize intravenous fat emulsions (94). Evidence suggests that they also promote increased(78,79). Infants with ventricular septal defects or trans- prostaglandin levels (95).position of the great vessels (i.e., cyanotic heart disease) Interpretation of the data linking intravenous fat emul-do not have inordinate increases in serum triglycerides in sions and pulmonary dysfunction is complicated. Theresponse to intravenous fat emulsion (80). adverse effects appear to depend on the dose and rate of Serum triglyceride levels should be measured four administration, presence of peroxides, and clinical statehours after starting an intravenous fat infusion or four of the lungs (89,90,93–95). Are the effects clinically rel-hours after any increase in infusion rate. It is at this time evant? In preterm infants the balance of data suggeststhat hypertriglyceridemia is most likely to occur (81–83). that administration of intravenous fat emulsion at normalIdeally the triglyceride level should be ⱕ100 mg/dL rates does not affect oxygenation (72). Studies to the(84). However, this upper limit varies depending on the contrary have usually used inappropriately rapid rates ofmethod used to measure serum triglycerides. For ex- infusion (96–98). Because intravenous fat emulsion canample, some common methods of measuring triglycer- induce vasoconstriction that is not limited to the pulmo-ides measure the free glycerol released from the triglyc- nary vasculature, observed decreases in transcutaneouseride molecule (85). Given that intravenous fat emul- pO2 may be related to local declines in subcutaneoussions contain free glycerol in addition to triglycerides, perfusion and not reflect systemic oxygenation (95,99).the serum triglyceride level measured by evaluating The effects of intravenous fat emulsion on the develop-glycerol will be an overestimation of the true serum tri- ment of chronic lung disease have been reviewed re-glyceride level. A value of 150 mg/dL may correspond to cently (72). The balance of the data suggests no adversean actual triglyceride level of only 100 mg/dL (Buffone impact and possibly a beneficial effect (72,100). How-and Shulman, unpublished data). Nephelometry should ever, much more work is needed in this area before wenot be used to monitor serum triglyceride levels as it is can be certain that there are no clinically significant ad-unreliable (85,86). Heparin administration lowers serum verse effects.triglyceride levels but does not affect the rate of fatty Even more confusing than the issue of pulmonaryacid oxidation (83,87,88). function is the controversy regarding the effect of intra- Clinicians frequently ask what level of hypertriglyc- venous fat (101–105) emulsions on immune function.eridemia is acceptable in a patient receiving PN. Given Some studies show a beneficial effect, some no effect,the need to provide essential fatty acids to patients who and some an adverse effect. A complete discussion ismay have hypertriglyceridemia for prolonged periods beyond the scope of the present article and the reader is(e.g., the critically ill patient), at what serum level do the referred to the supplied references. It should be pointedtriglycerides start having an adverse impact on the pa- out that reviews in this area sometimes give a prejudicedtient? Unfortunately, to our knowledge, there are no data view in that only selected publications are quoted. Inter-defining the level at which one should be concerned. pretation of publications often is blurred by the use of Many investigators have studied the impact of intra- inappropriate doses (both in vivo and in vitro), differ-venous fat emulsion on pulmonary function. Although an ences in patient groups or in vitro models (102). Similarin depth review of this topic is beyond the scope of this to the situation in pulmonary function studies, many ofarticle, a few points can be touched upon and the reader the effects of intravenous fat emulsions on immune func-is referred to two reviews (89,90). tion appear to be related to the generation of leukotrienes After a fatty meal, the serum triglyceride of normal and other polyunsaturates from the emulsions. There alsoadults may transiently approach 500 mg/dL (91). Even is evidence the long chain fats may alter cellular functionvalues above 1500 mg/dL do not appear to decrease the by changing membrane fluidity (104). Studies on pedi-carbon monoxide diffusing capacity in healthy adults atric patients and tissues have not revealed evidence sug-(91). This begs the question as to whether elevated tri- gesting an impairment of immune function by intrave-glycerides cause some of the adverse oxygenation effects nous fat emulsions (106–113).reported with intravenous fat emulsions that when severe Do intravenous fat emulsions promote infections?is referred to as the "fat overload syndrome" (92). It was Data are limited. A study in adult and pediatric bonefirst believed that the sometimes seen adverse effects of marrow transplant patients found no increase in the riskintravenous fat emulsions on pulmonary function (e.g., of bacteremia or fungemia in patients receiving intrave-decreased diffusion capacity, oxygenation, intrapulmo- nous fat emulsions (114). In contrast, a retrospectivenary shunting) were related to the serum triglyceride study of preterm infants identified intravenous fat emulsionlevel (89,90,93). It appears more likely that these as potentially contributing to the development of coagulase-changes, when seen, are due to the conversion of the negative staphylococcal infection (115). However,
Evidence suggests that amino acids contribute to the absorbed, even in patients with short bowel syndromedevelopment of PN-associated cholestasis (125,126). (128). Consequently, this is an option for many patientsEven enteral protein intake can decrease bile flow (127). receiving PN. Of course, whenever possible other nutri-If amino acids are removed from the PN when the patient ents should be provided enterally as well.develops cholestasis and no other source of protein is There are very limited data in pediatric patients re-provided, one then is faced with a patient who in addition garding the use of specialized amino acid solutions forto having liver disease has hypoproteinemia or even specific conditions such as critical illness and liver orkwashiorkor. There are some data to support the idea that renal failure. A crossover trial in children with end stageprovision of protein enterally while other nutrients (pri- liver disease suggested a benefit to a branched chainmarily carbohydrate) are provided intravenously can re- supplemented enteral formulation in that the special for-duce the risk of or lessen the severity of PN-associated mula promoted more rapid nutritional rehabilitationcholestasis (125). Protein is usually well digested and (129). Studies in adults with liver disease have been in-
consistent. Most studies indicate that if used at all, associated cholestasis the reader is referred to recent re-branched chain formulae should be reserved for patients views (139–141).who are malnourished and/or who are encephalopathic(130,131). The benefit of specialized amino acid solu-tions for patients with renal disease also is not clear REFEEDING SYNDROME(132,133). Similarly, the nutritional benefit of parenteralnutrition given during dialysis requires further study Refeeding syndrome is a potentially lethal condition(134,229). The two commercially available (in the characterized by severe electrolyte and fluid shifts asso-United States) pediatric amino acid solutions have con- ciated with metabolic abnormalities in malnourishedcentrations of essential amino acids, including branched patients undergoing refeeding orally, enterally, or paren-chain amino acids, which are fairly close to those in the terally (139). Clinical features include fluid-balance ab-specialized amino acids solutions. normalities, abnormal glucose metabolism, hypophos- phatemia, hypomagnesemia, hypokalemia, and some- Clinical Implications times thiamine deficiency (142). Refeeding syndrome can occur with either parenteral or enteral feeding. Because it is a preventable condition, Provision of amino acids should be a priority in cal- patients who are at risk should receive a PN prescriptionculation of PN requirements. In situations where fluid from the outset that will decrease the likelihood of itsintake is significantly restricted, energy intake should be occurrence. A detailed review of the condition is beyondsacrificed at the expense of maintaining a greater amino the scope of this article but the reader is referred toacid intake, particularly when more than resting energy comprehensive reviews (142,143). The syndrome can beexpenditure can be provided. The PN concentration of prevented by adequate provision of phosphorus, and to aamino acids can be increased to 4%–8% (g/dL) depend- lesser extent magnesium and potassium at the time theing on the amino acid brand used (concentration of the patient begins to become anabolic. A common miscon-stock amino acid solutions range from 10%–20%). The ception is that additional phosphorus and potassium pro-BUN is a readily accessible and cheap method of titrat- vided at the onset of PN will prevent the syndrome. Thising amino acid intake if renal function and hydration are is true only if adequate nutrition is being provided to thenormal. Consideration of enteral (as much as possible) patient so that they are actually regaining lost tissue massrather than parenteral administration of protein should be (i.e., muscle and viscera). If the amount of nutrition (en-considered, particularly in patients at risk for cholestasis. ergy) being provided is less than that required to main-If not limited by intolerance (e.g., enteral carbohydrate in tain weight or promote catch-up weight gain, the syn-a patient with short bowel syndrome) other nutrients drome will not develop. Consequently, the patient mayshould be provided enterally as well. be at risk for hypophosphatemia and hypokalemia weeks after the initiation of PN (or whenever nutrient intake allows for catch-up weight gain). CYCLIC PARENTERAL NUTRITION Refeeding syndrome can be prevented by providing additional phosphorus and potassium (usually as KxPOx) The term cyclic PN refers to the administration of at the time PN is started. The amount of additional phos-intravenous fluids intermittently with regular breaks phorus and potassium required depends on the degree offrom infusion. Cyclic PN offers the advantage of increas- malnutrition and the adequacy of total energy intake. Aing the mobility of the patient and family. Much has been general rule of thumb in the authors' experience is thatwritten regarding its other presumed advantages but twice the recommended daily allowance (RDA) of phos-there are scant scientific data (135,136). One of the pro- phorus is a reasonable starting point. Usually the risk forposed benefits is a lower risk for the development of liver clinically significant declines in these minerals lasts fordisease although reports have been anecdotal (137). Re- 7–10 days. During this period, it is important to followcently, Hwang et al. carried out a prospective study in serum phosphorus and potassium closely (e.g., everyadults on PN exhibiting various degrees of presumed other day or more often if serum levels are tenuous).PN-associated liver disease (138). Patients who devel- After this time, supplementation above the RDA canoped hyperbilirubinemia were randomized to either re- gradually be reduced. Calcium and phosphorus shouldmain on continuous PN or were placed on cyclic PN. not be given independently as administering one withoutPatients with initial serum bilirubin less than 20 mg/dL, the other leads to renal wasting of the infused mineralwho remained on continuous PN, had a significant rise in (144).serum bilirubin compared with the cyclic PN groups A rate-limiting factor in providing additional phospho-(138). There was no apparent advantage of cyclic PN in rus is the risk of calcium/phosphorus precipitation. Tablepatients with serum bilirubin greater than 20 mg/dL 3 provides guidelines for the maximal amounts of cal-(138). These results are intriguing and beg for similar cium and phosphorus that can be administered in PNstudies in pediatric patients. For information on PN- (145–147). Note that the addition of cysteine (HCl) be-
TABLE 3. Maximal calcium and phosphorus concentrations teral Nutrition Packaging System, Fresenius Kabi, in parenteral nutrition solutions Uppsala, Sweden). The bag and components can be Without cysteine With cysteine# stored up to 24 months with the seals between the cham- bers intact. Seals are opened just before use. PN admix- g/dL (%) Calcium Phosphorus Calcium Phosphorus tures find their greatest usefulness in older patients, par-Amino acids mEq/L mmol/L mEq/L mmol/L ticularly those on cyclic PN and those at home (see be- 1.0 50 12 50 23 low). 2 50 2 50 Because the admixture is a physical mix of naturally 1.5 50 11 50 18 5 50 12 50 incompatible substances (oil and water, calcium and 2.0 50 12 50 25 phosphorus), their utilization requires strict attention to 7 50 12 50 pharmaceutical guidelines for preparation, storage, and 2.5 50 22 50 38 use (156). Particulate matter (mobile, undissolved sub- 6 50 28 50 stances that are unintentionally present in products) re- * Presumes the base amino acid solution has a pH of ⱕ5.5 sulting from inappropriate preparation or storage can be Administration of intravenous fat emulsion into the same intrave- life threatening. For example, deaths have been reportednous catheter may reduce solubility by 10%–20% (145, 146). Addition presumably as a result of precipitation of calcium andof acetate without the addition of cysteine also may reduce solubility by5–10% (147). # 40 mg/g of amino acids. phosphorus in admixtures (157,158). Table 5 lists poten- Note: This table is intended as a general guideline and is not to be tial areas of concern in the preparation and storage of PNused in lieu of pharmacist verification of the compatibility of the PN admixtures.solution. Modifications to the formulation and alterations in the method There have been multiple publications regarding howand order of preparation may result in different calcium/phosphorus PN admixtures should be prepared and their stability.solubilities. Preparation of an admixture requires exquisite attention to detail. The commercial product used, the sequence ofcause of its low pH enhances the solubility of the min- mixing, the type and concentration of additives, and stor-erals. Computer software is available to assist in assuring age conditions are critical for maintaining lipid dropletthat calcium and phosphorus solubilities are not ex- size and distribution and preventing the development ofceeded (148). In preterm infants and possibly other pa- particulate matter (159). For example, ideally all water-tients prone to acidosis, the addition of cysteine may soluble additions should be mixed together whereas li-require that the patient be supplemented with a source of pophilic additives (e.g., fat soluble vitamins) should bebase (e.g., acetate) (149). Calcium and phosphorus re- added to the intravenous fat emulsion (159). The last stepquirements for preterm infants have been fairly well de- should be mixing the intravenous fat emulsion (and itslineated in contrast to older children (150,151). components) with the water-soluble components (159). Undiluted hypertonic glucose solution should not be
TABLE 5. Three potential issues in the use of PN admixtures and contributing factors Chemical precipitation Intravenous fat stability Vitamin stability Calcium and phosphorus Low pH Thiamine reduction by metabisulphite Sulphur-containing amino acids Intravenous fat concentration Lack of exclusion of oxygen and copper during compounding Sulphur-containing amino acids Formation of peroxides Lack of use of and calcium oxygen-impermeable containers during storage Ascorbic acid and selenium Iron and phosphate Order of Mixing
From (159).
added to intravenous fat emulsion (160). Solutions may mixtures that are inappropriate for certain patients. Be-be stable when refrigerated and become unstable at room cause of the limitations in the amount of calcium andtemperature. Another example, heparin stability, has phosphorus that can be used in PN admixtures (evenbeen a subject of great debate. Contradictions regarding more severe than in non- admixture PN), their use mayits risk of precipitating with calcium probably are re- be inappropriate in young infants. One report has sug-lated to differences in the studied heparin prepara- gested that PN admixtures can be used in former pretermtions and the other additives and their concentrations infants and newborns, however, in this study it was notin the admixtures (159). The reader is referred to com- clear that the PN admixtures had been validated as stableprehensive reviews regarding the factors related to PN nor was there stability testing reported after the admix-admixture stability as well as methodologies used to tures were prepared (169). Because the emulsion istest stability (159–163). In general, final concentra- opaque (as a result of fat emulsion) a precipitate may betions range from 2% to 5% for amino acids, 5% to 23% invisible to the naked eye. The calcium and phosphorusfor glucose, and 1.5% to 5% for intravenous fat emul- requirements for neonates is 3–4 mEq ⭈ kg−1 ⭈ d−1 andsion (161). 1–2 mmol ⭈ kg−1 ⭈ d−1, respectively (162). Based upon In order to see through the morass of information it is studies using a commonly employed pediatric aminobest to follow a simple rule: after identifying a PN ad- acid solution (TrophAmine, B. Braun Medical, Inc., Mel-mixtures whose stability has been well documented, use sungen, Germany) the PN admixture would provide in-them exactly as described. Unlike standard PN solutions, adequate amounts of these minerals (170). As an infantalterations of components, volumes, and/or concentra- approached 4–6 months of age it is conceivable that theirtions should not be made. A case in point is a recent calcium and phosphorus needs could be met using a PNreport of episodes of respiratory distress and death pos- admixture (161,162,170). However, it must be stressedsibly related to changing from one commercial amino that this is dependent upon the amino acid, glucose, in-acid brand to another despite (or it should be said, be- travenous fat emulsion, calcium, and phosphorus prod-cause of) not modifying any other aspect of the admix- ucts (as well as the other components) used as well as theture (164). A Food and Drug Administration (FDA) alert mixing protocol. If a PN admixture is to be used in anwas issued in 1994 regarding the hazards of precipitation infant less than a year of age, it should be done with(165). It is recommended that information on the proper particularly careful consideration regarding mineral re-preparation of a PN admixture be obtained directly from quirements.the manufacturer(s) of the amino acids and intravenous PN admixtures only should be used in patients who arefat emulsion that are to be used. As a general rule, the clinically stable. Changes in the formulation of PN ad-amino acids, glucose, and intravenous lipid are added in mixtures are more costly than changes in traditionalfixed ratios by volume (e.g., 2:1:1, 1:1:1, 1:1:0.5, etc.) (two-in-one) PN because of the wastage of both the(166). To reduce the risk of precipitates reaching the dextrose/amino acid and its components, and the intra-patient an inline filter should be used. This should be a venous fat emulsion.1.2 micron air-eliminating filter (in contrast to the 0.22 A number of questions remain about PN admixtures.micron air-eliminating filter recommended for nonlipid- These include the appropriate dosing of some vitamins,containing PN) (165). The importance of filtration re- the true risks related to particulate matter and fat dropletcently has been reviewed and revalidated (167,168). A size, and drug compatibilities. For example, there is lessPN admixture is considered inappropriate for adminis- loss of fat-soluble vitamins such as vitamin A than intration if > 0.4% of the total fat contains particles > 5 traditional (two-in-one) PN because the intravenous fatmicrons in size (162,163). emulsion is protective (see below) (171). Some drugs are What patients are candidates for PN admixtures? It compatible with PN admixtures but not with traditionalmay be more important to ask whether there are PN PN and visa versa (172).
TABLE 6. Adult and children (>11 years of age) parenteral (162). In April 2000, the Food and Drug Administration multivitamin preparations amended the adult multivitamin formulation to bring it Infuvite™* M.V.I.-12™ into accordance with the 1988 recommendations of the Vitamin (Sabex) (aaiPharma) American Medical Association-FDA Public Workshop Committee (Table 6) (176). To date, the optimal paren-A (IU) 3300 IU 3300D IU (g) 200 (5) 200 (5) teral vitamin and mineral requirements for children andE (IU) 10 10 neonates have not been determined and a parenteral mul-K (g) 150 — tivitamin formulation specifically for preterm infants hasC (mg) 200 200 not been developed.Thiamin (mg) 6 3Riboflavin (mg) 3.6 3.6 While there are several parenteral vitamin prepara-Niacin (mg) 40 40 tions available for older children (> 11 years) and adultsPyridoxine (mg) 6 4 (Table 6), few are available for neonates and children.Folate (g) 600 400 InFuvite Pediatric™ (Sabex, Inc., Boucherville, Canada)B12 (g) 5 5 and M.V.I. Pediatric™ (aaiPharma, Inc., Wilmington,Pantothenic Acid (mg) 15 15Biotin (g) 60 60 NC) are approved for use in prematures, infants, and children < 11 years (Table 7). The adult formulations are * Conforms to the FDA amended formula for adult multivitamin not recommended for use in low birth weight infants lesspreparations (165). than 1500 grams because of concerns about the toxicity of the propylene glycol and polysorbate additives (177,178). Limitations in the availability of the pediatric VITAMINS products have made children vulnerable to shortages (179). Table 7 gives the doses of vitamins recommended Guidelines for pediatric parenteral vitamin and min- for infants by the American Society of Clinical Nutritioneral supplementation have been previously reviewed, al- Subcommittee on Pediatric Parenteral Nutrient Require-beit quite some time ago (173). Despite subsequent pub- ments (). This recommendation differs from the packagelications that have provided additional support for these inserts (180).recommendations, there has not been a recent significant Clearly, there are patients whose needs do not fit theevaluation or reformulation of parenteral vitamin prod- current vitamin formulations. For example, preterm in-ucts for premature infants, infants, or children (less than fants, children with liver or renal disease or short bowel11 years of age) (174,175). syndrome, or who are severely malnourished require Recommendations from the 1998 National Advisory close attention to vitamin nutriture. Some adult parenter-Group on Standards and Practice Guidelines emphasized al vitamin products that are used for children >11 yearsthe need for establishing optimal trace element and vita- of age may put younger patients on long term PN at riskmin formulations for both adult and pediatric patients for excessive vitamin intakes (see Table 6).
* Infuvite Pediatric™/MVI-Pediatric™. # See reference (180). ** 500 g ⳱ 1643 IU. ## 1 mg ⳱ 1 IU.
practices that seem clear (i.e., based on science), often cally ill surgical neonates have increased energy expenditure? Jturn out to be wrong or not so clear. We now realize that Pediatr Surg 2001;36:63–7. 6. Garza JJ, Shew SB, Keshen TH, Dzakovic A, Jahoor F, Jaksic T.aggressive nutritional support carries risks. The risk of Energy expenditure in ill premature neonates. J Pediatr Surginfection may be related more to hyperglycemia (or hy- 2002;37:289–93.pertriglyceridemia) than to PN per se, and essential fatty 7. Lloyd DA. Energy requirements of surgical newborn infants re-acid requirements may not be as well defined as previ- ceiving parenteral nutrition. Nutrition 1998;14:101–04. 8. Coss-Bu JA, Klish WJ, Walding D, Stein F, Smith EO, and Jef-ously thought. When it seems as if knowledge is for ferson LS. Energy metabolism, nitrogen balance, and substratenaught, the following quote comes to mind: "I reserve utilization in critically ill children 1-3. Am J Clin Nutr 2001;74:the right to be smarter tomorrow than I am today" 664–69.(227,228). 9. Schofield W. Predicting basal metabolic rate, new standards and In a way, we are victims of our own success. PN can review of previous work. Hum Nutr Clin Nutr 1985;39C S1;5–41. 10. Koen FM, Joosten KFM, Verhoeven JJ, and Hazelzet JA. Energyprovide effective nutritional support but, as is evident Expenditure and Substrate Utilization in Mechanically Ventilatedfrom this review, there are large holes in our knowledge Children. Nutrition 1999;15:444–48.and little likelihood of abundant future research to fill 11. Turi RA, Petros AJ, Eaton S, Fasoli L, Powis M, Basu R, Spitz L,them. For the most part, these deficiencies in knowledge Pierro A. Energy metabolism of infants and children with sys-are more problematic for pediatric patients than for temic inflammatory response syndrome and sepsis. Annals of Sur- gery 2001; 233: 581–87.adults. Unfortunately, because pediatric PN makes up 12. Duro D, Rising R, Cole C, Valois S, Cedillo M, Lifshitz F. Newsuch a small share of the market, manufacturers are re- equations for calculating the components of energy expenditure inluctant to spend the resources to carry out the studies infants. J Pediatr 2002;140:534–9.needed to define the child-specific impact of new lipid 13. http://www.nal.usda.gov/fnic/dga/rda.pdfemulsions, reformulated vitamins, etc. Money spent on 14. White MS, Shepherd RW, McEniery JA. Energy expenditure measurements in ventilated critically ill children: within- andthese questions would not be recouped quickly. The re- between-day variability. J Parenter Enteral Nutr 1999;23:300–4.sponsibility for improving PN safety and efficacy lies 15. Pierro A, Jpnes MO, Hammond P, Donnell SC, Lloyd DA. A newwith all concerned: industry, funding agencies, physi- equation to predict the resting energy expenditure of surgicalcians, pharmacists, nurses, and nutritionists. infants. J Pediatr Surg 1994;29:1103–8. 16. Pierro A, Jones MO, Donnell SC. Total parenteral nutrition in PN is still the life-saving, far-from-perfect therapy it surgical infants. Biochem Soc Trans 1998;26:131–6.has been for over 40 years. Like all therapies it must be 17. White MS, Shepherd RW, McEniery JA. Energy expenditure inused and monitored appropriately. Using it means more 100 ventilated, critically ill children: Improving the accuracy ofthan just checking the patient's weight, and monitoring predictive equations. Crit Care Med 2000; 28: 2307-2312.now means more than checking the serum electrolytes. 18. Dietz WH, Bandini LG, Schoeller DA. Estimates of metabolic rate in obese and nonobese adolescents. J Pediatr 1991;118:Checking the box on the order sheet will never be 146–49.enough. 19. Mondejar EF, Duro Lombardo M, Perez de la Cruz AJ, Merida Morales A, Torres Ruiz JM, Ferron Orihuela JA. Variations in Acknowledgments: The authors thank Dr. W.C. Heird for oxygen consumption and carbon dioxide production during par-his very helpful comments. This study was supported by the enteral nutrition. Intensive Care Med 1982;8:169–72.National Institute of Child Health and Human Development, 20. Elwyn DH, Askanazi J, Kinney JM, Gump FE. Kinetics of energyGrant No. RO1 NR05337-01A2, the Daffy's and Henriksen substrates. Acta Chir Scand Suppl 1981;507:209–19.Foundations, and the USDA/ARS under Cooperative Agree- 21. Koretz RL, Lipman TO, Klein S. AGA Technical Review on Parenteral Nutrition. Gastroenterology 2001;121:970–1001.ment No. 58-6250-1-003. This work is a publication of the 22. Wilson DC, Cairns P, Halliday HL, Reid M, McClure G, DodgeUSDA/ARS Children's Nutrition Research Center, Department JA. Randomised controlled trial of an aggressive nutritional regi-of Pediatrics, Baylor College of Medicine and Texas Children's men in sick very low birthweight infants. Arch Dis Child FetalHospital, Houston, TX. 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Key Largo
Key Largo, American film noir, released in 1948, that is widely considered a classic of the genre. It was directed by John Huston, stars married actors Humphrey Bogart and Lauren Bacall, and was loosely based on a 1939 play by Maxwell Anderson.
Bogart played against type as Frank McCloud, a cynical army veteran who visits a hotel on Florida's Key Largo owned by the father (played by Lionel Barrymore) and young widow (Bacall) of one of his military comrades. McCloud finds himself among the captives in the hotel when it is taken over by notorious gangster Johnny Rocco (Edward G. Robinson) and his gang of thugs, who are hoping to hide out until they can escape to Cuba. Although he initially seems nonheroic and maintains a stance of noninvolvement, McCloud comes to despise Rocco for his cruelty, and he decides to fight back. The drama is heightened by the violent hurricane battering the island.
Though the plot and characters are hardly original, the interactions between Rocco and the eclectic group of hotel residents held against their will generate suspense. John Huston directed an impressive cast, highlighted by Robinson's brutal on-the-lam crime kingpin and Claire Trevor in an Academy Award-winning role as his abused and humiliated mistress. A scene in which Robinson forces Trevor's character, an alcoholic and former nightclub entertainer, to sing for a drink is memorable for its heartbreaking pathos.
Production notes and credits
- Studio: Warner Brothers
- Director: John Huston
- Writer: Richard Brooks and John Huston
- Music: Max Steiner
- Running time: 100 minutes
- Humphrey Bogart (Frank McCloud)
- Edward G. Robinson (Johnny Rocco)
- Lauren Bacall (Nora Temple)
- Lionel Barrymore (James Temple)
- Claire Trevor (Gaye Dawn)
Academy Award nominations (* denotes win)
- Supporting actress* (Claire Trevor)
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film noir: Lighting
…Indemnity, 1944), Karl Freund ( Key Largo, 1948), and Sid Hickox ( The Big Sleep, 1948) to heighten the sombre tone of films in the genre. Classic images of noir included rain-soaked streets in the early morning hours; street lamps with shimmering halos; flashing neon signs on seedy taverns, diners, and…
Humphrey Bogart
Humphrey Bogart, American actor who became a preeminent motion picture "tough guy" and was a top box-office attraction during the 1940s and '50s. In his performances he projected the image of…


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Well being, Nutrition, And Training
All about fitness including energy coaching, cardio, yoga and pilates. My 4 years studying drugs trained me really well for working as a doctor, in terms of medical method and information, and also in skilful interpersonal communication with patients and colleagues. My training at Flinders prepared me effectively for my work as a junior physician and for specialist and sub-specialist coaching in paediatric ophthalmology. Wilderness drugs entails the follow of medication in the wild, where conventional medical facilities might not be available. Sekarang giliran anda. Kami akan membantu anda untuk mencapai tujuan health anda dan melakukan lebih dari yang anda bayangkan.
Work out the way you need, and get probably the most from the latest health tools, group workouts and devoted support from our licensed consultants. Your membership contains all the pieces you should make health a part of your life. Saat latihan di health club, kita bisa melakukan aktivitas apapun sesuai dengan goal kesehatan dan kebugaran yang ingin dicapai. Sama halnya dengan berolahraga di rumah atau di luar ruangan, Anda bisa menggabung berbagai bidang olahraga yang Anda. Jadi dalam satu hari, jangan cuma melakukan satu hal yang sama, tapi lakukan bergantian dengan aktivitas lain.
A bodily workout which contains boxing and aerobic drills based on the coaching methods boxers interact in to stay super match. The exercise doesn't involve truly hitting anyone (or being hit). A typical class will contain hitting pads, punching baggage, skipping, push ups, sit ups and sprints. This class gives individuals with little to no boxing skill to expertise the benefits from the health the sport can bring. You can be educated on punching methods and footwork and improve your punching power, hand-eye coordination, cardiovascular fitness, and depart feeling powerful.
The company has an analogous take care of no-frills German grocer Aldi, opening the grocery shops next door to Kohl's. Planet Health said its Kohl's-adjacent gyms can be between 20,000 sq. ft and 25,000 sq. feet. But do not anticipate gym tie-ins at other stores: Target's CEO not too long ago nixed the concept when a reporter asked about the Kohl's and Planet Health deal at an event in New York. Mental and bodily health are the two most commonly discussed types of health. We also speak about "non secular well being," "emotional well being," and "monetary well being," among others. These have additionally been linked to decrease stress levels and psychological and bodily wellbeing.
Sweat your way to a more healthy body and mind in our sizzling yoga studios, or learn to train your muscle groups successfully in a pilates class. Thoughts and Body exercises are suitable for all health levels. The scope and sciences underpinning human drugs overlap many other fields. Dentistry , whereas considered by some a separate discipline from drugs, is a medical area. Faculty of Medical Drugs – The web site for the College of Clinical Medicine. Good for individuals who want to get some critical (core) work performed. Pull up a chair and tone your whole body. Zumba Sentao® combines energy and resistance coaching with modern dance strikes, using a chair as your dance companion. A high depth workout that focuses on defining your muscles, enhancing total cardiovascular health and burning main calories. A singular technique to challenge the muscle mass of your body.


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This topic contains 4 replies, has 5 voices, and was last updated by askins 1 year, 2 months ago.
April 3, 2017 at 7:32 am #10786021
Hi all, I am here to get some suggestions. I am 4 months pregnant. I used to spend a lot of time in the pool before since it helped me a lot to reduce stress. But now while consulting the doctor he told me that my pressure levels were high and advised me to do some exercises. While surfing online I came across this article http://www.soldapools.com/blog/swimming/advantages-swimming-pregnancy/ and I found it interesting. Is it safe to swim while you are pregnant? Please chime in with some good suggestions. Also, it would be great if you could suggest some tips for reducing stress. Thanks in advance.May 5, 2017 at 7:14 am #10786052
I think that swimming is a great and healthy idea. When I was pregnant I was in a swimming pool 3-4 times a week and this helps me to have a better and painless birth.
Also, to feel more comfortable when I was pregnant, I changed my bed. The old one was too old and not so comfortable. I found http://www.comfortmeble.pl/meble-do-sypialni/italia-style.html in this page many interesting propositions not only for my bed but and for baby furniture 🙂May 31, 2017 at 6:55 am #10786076
It helps in strengthening your muscles.September 24, 2017 at 5:08 pm #10786334
Hello my dear friend, congratulations on your pregnancy and you are going through such beautiful time in your life. It is always a dream of ladies to get pregnant and to get happiness of a beautiful baby in life. I hope you are enjoying your beautiful period. Pregnancy is beautiful but it is also challenging period for any woman. Your body will go through many physical as well as hormonal changes during this time of pregnancy. I can understand that you want to live healthy and active Lifestyle. It is very important to stay active and healthy during pregnancy. If you want to use swimming during pregnancy, it will be very helpful for you. Swimming is considered as all in one exercise and it will help you to stay fit and active. It is also very helpful to reduce stress and anxiety problem that you may feel during pregnancy. If you want to go for swimming, you have to be careful and you have to take complete care of your body in it. I will suggest you consult with any health expert who can provide good information according to your Physical health and condition. It is very important for you to be careful when you are going for swimming because you will also find slippery surface at any swimming pool. You can also get help to stay fit with other relaxing exercises and yoga during pregnancy. Yoga will be very helpful for your physical as well as psychological condition during pregnancy. I hope you will be able to take care with good exercises and you will be able to give birth to healthy and beautiful baby. Best of luck for such happiness in your life my dear.July 22, 2018 at 6:03 pm #10788479
I am here from Adelaide Australia and I am also here to share this point of swimming for relaxation and I am 4 months pregnant. I am also planning to design the nursery for my baby. Do you think that Oeuf https://www.aushoppinghub.com/brand/oeuf/ is good one to go with like for chest of drawers and bed etc.
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Articles from the May 10, 2019 edition
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Red Bull 400 returns Saturday
By BRYAN HELLIOS email@example.com IRONWOOD TOWNSHIP — The Red Bull 400 will return to Copper Peak on Saturday. Kassi Huotari, marketing director for Copper Peak, said the second annual ev...
Bessemer DDA hires filmmaker to market city
By P.J. GLISSON firstname.lastname@example.com BESSEMER - The Downtown Development Authority in Bessemer voted Thursday afternoon to hire a filmmaker from Ontonagon County to create four videos to market...
Illinois man charged with attempted escape
By RICHARD JENKINS email@example.com BESSEMER — An Illinois man is facing local charges after he tried to escape from the custody of the Iron County Sheriff's Department in late April. Devin Jacob Snow, 29, is charged with escape while...
Community calendar
Friday, May 10 Mercer Cribbage, 9:30-11:30 a.m., Mercer Senior Center. Double Trouble, 11 a.m.-12:30 p.m., Serenity Center, Ironwood. Mercer Food Pantry, noon-1 p.m., Railroad Street, Mercer, Wis. Emergencies: 715-476-7655. Alcoholics Anonymous/... Full story
Jean Ann Broemer
IRONWOOD, Mich. — Jean Ann Broemer 85, of Ironwood, passed away at Westgate Nursing Center in Ironwood on May 8, 2019. She was born to Walter and Irene (Sereno) Lapachin on June 17, 1933, in... Full story