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Metabolism and nutritional support in the surgical neonate.

Various factors can influence the metabolism of surgical neonates. These include prematurity, operative stress, critical illness, and sepsis. The nutritional management of surgical infants with congenital or acquired intestinal abnormalities has improved after the introduction of parenteral nutrition. This article is focused on the energy and protein metabolism of surgical neonates with particular reference to the metabolic response to operative trauma and sepsis. The metabolic utilization of intravenous nutrients also is discussed. The metabolic response to operative trauma is different between neonates and adults. Infants have high rates of protein turnover and are avid retainers of nitrogen. Energy expenditure increases only transiently (4 to 6 hours) after major surgery in neonates. Protein turnover and catabolism seems not to be affected by major operative procedures in neonates. In neonates on parenteral nutrition, carbohydrate and fat have an equivalent effect on protein metabolism. The main determinants of fat utilization are carbohydrate intake and resting energy expenditure. Parenteral nutrition in surgical neonates is associated with increased production of oxygen-free radicals. This seems to be related to intravenous fat administration. Promoting fat utilization by reducing the carbohydrate to fat ratio in the intravenous diet reduces free radical activity to a similar extent as fat exclusion. Glutamine appears to be safe for use in neonates and infants and is "conditionally essential" in very-low birth weight infants and in septic neonates. Enteral glutamine supplementation in very-low birth weight infants reduces the risk of sepsis. The metabolism of surgical neonates is affected by operative trauma, critical illness, and sepsis. Nutritional support in surgical neonates has a profound impact on outcome. Exogenous glutamine can modulate immune, metabolic, and inflammatory responses. Further investigations are needed to clarify the clinical benefit of parenteral or enteral glutamine administration in surgical neonates.