Transplantation of the heart has become an accepted means of treating end stage heart disease during the twenty years of its clinical application. One year survival rates have improved from 22% in 1968 to 87% at present, with 85% of patients now expected to live more than five years. (Figure 1). Nevertheless, relatively few children have had heart transplants. Of the 2, 200 patients having this procedure in 1987 only 300-400 were children. In part this is no doubt due to the reluctance of pediatricians to refer young patients for a procedure with uncertain long term results. Yet there remain many diseases and congentital anomalies affecting the hearts of children for which there is either no effective therapy or "conventional" therapy which, at best, is only palliative and which subjects the child to an equally uncertain long term result. As more information is becoming available about the really long term results (i. e. beyond 10 years) of some of these operations, it is clear that in many instances they are suboptimal. Thus, as the results of transplantation have improved there has naturally developed an increasing interest in transplanting children.
The foundation of the University of Louvain Medical School liver transplantation program was laid in 1969. This early initiation of the clinical program was the outcome of training of the first author with Professor T. E. Starzl in Denver (USA) as well as training in the surgical research laboratory during the preceeding 10 years (1, 2). Among the 3 patients who received a liver transplant during that early period, there was a child transplanted at 17 months for biliary atresia who survived 59 days. In the mid-seventies, our medical school was transferred from the city of Louvain to a new campus in the outskirts of Brussels. The dramatic improvement of the results obtained in Pittsburgh since the introduction of Ciclosporine has triggered the second start of our liver transplantation program in 1984.
Nutritional support of the critically ill or injured patient has become a routine practice in most medical centers. Until recently, generic administration of protein and carolies, along with vitamins, trace elements, and electrolytes, was felt to meet the needs of these patients. It is now recognized that there may be "conditionally essential nutrients" that may be important in preserving the gut mucosal barrier and also in modulating the immune response. In addition, enteral feeding appears to offer better gut preservation and immune stimulation than parenteral feeding. Glutamine is one such amino acid nutrient which appears to be an important energy source for the small intestine. This amino acid may offer gut mucosal preservation during stress and chemo or radiotherapy. Several nutrients may be important as immunostimulants. Arginine and nucleotides stimulate the immune response. The administration of omega-3 or omega-6 fatty acids may also influence immune function. These micro and macronutrients may play a significant role in the incidence and severity of sepsis. Recent laboratory and clinical investigations regarding these nutrients are presented. Comparisons between enteral and parenteral nutrition are discussed and the clinical significance reviewed.