Use of parenteral nutrition in term and late preterm infants: an Australian and New Zealand survey

Early versus late parenteral nutrition in term and late preterm infants: a randomised controlled trial

BACKGROUND

There is limited evidence regarding the optimal time to commence parenteral nutrition (PN) in term and late preterm infants.

DESIGN

Single-centre, non-blinded, exploratory randomised controlled trial.

SETTING

A level-3 neonatal unit in a stand-alone paediatric hospital.

PATIENTS

Infants born ≥34 weeks of gestation and ≤28 days, who needed PN. Eligible infants were randomised on day 1 or day 2 of admission.

INTERVENTIONS

Early (day 1 or day 2 of admission, N=30) or late (day 6 of admission, N=30) PN.

MAIN OUTCOME MEASURES

Plasma phenylalanine and F2-isoprostane levels on day 4 and day 8 of admission. Secondary outcomes were amino-acid and fatty-acid profiles on day 4 and day 8, and clinical outcomes.

RESULTS

The postnatal age at randomisation was similar between the groups (2.3 (SD 0.8) vs 2.3 (0.7) days, p=0.90). On day 4, phenylalanine levels in early-PN infants were higher than in late-PN (mean (SD) 62.9 (26.7) vs 45.5 (15.3) µmol/L; baseline-adjusted percentage difference 25.8% (95% CI 11.6% to 39.9%), p<0.001). There was no significant difference in phenylalanine levels between the two groups on day 8. There was no significant difference between the groups for F2-isoprostane levels on day 4 (early-PN mean (SD) 389 (176) vs late-PN 419 (291) pg/mL; baseline-adjusted percentage difference: -4.4% (95% CI -21.5% to 12.8%) p=0.62) and day 8 (mean (SD) 305 (125) vs 354 (113) pg/mL; adjusted mean percentage difference -16.1 (95% CI -34.1 to 1.9) p=0.09).Postnatal growth restriction for weight was less severe in the early-PN group (change in weight z-score from baseline to discharge: -0.6 (0.6) vs -1.0 (0.6); p=0.02). The incidence of hyperglycaemia was greater in the early-PN group (20/30 (66.7%) vs 11/30 (36.7%), p=0.02).

CONCLUSIONS

The timing of the commencement of PN did not seem to affect the degree of oxidative stress in critically ill term and late preterm infants. The effect of transiently high plasma phenylalanine with early PN on clinical outcomes requires further investigation.

TRIAL REGISTRATION NUMBER

ACTRN12620000324910.

Administering Parenteral Nutrition in the Neonatal Intensive Care Unit: Logistics, Existing Challenges, and a Few Conundrums

Use of parenteral nutrition (PN) in the neonatal intensive care unit (NICU) requires evaluating the need for central venous catheters, potential drug incompatibilities, unintentional exposures, and suboptimal energy and nutrient intake during the transition to full enteral nutrition. Risks of photooxidation reactions in PN components, refeeding syndrome, and excess early amino acid intake should prompt the reevaluation of routine practices. The goal of this paper is to review the practicalities, challenges, and conundrums of administering PN in the NICU.

Early versus late parenteral nutrition in term and late preterm infants: study protocol for a randomised controlled trial

BACKGROUND

Despite the wide use of parenteral nutrition (PN) in neonatal intensive care units (NICU), there is limited evidence regarding the optimal time to commence PN in term and late preterm infants. The recommendations from the recently published ESPGHAN/ESPEN/ESPR/CPEN and NICE guidelines are substantially different in this area, and surveys have reported variations in clinical practice. The aim of this randomised controlled trial (RCT) is to evaluate the benefits and risks of early versus late PN in term and late preterm infants.

METHODS/DESIGN

This study is a single-centre, non-blinded RCT in the NICU of Perth Children's Hospital, Western Australia.A total of 60 infants born ≥34 weeks of gestation who have a high likelihood of intolerance to enteral nutrition (EN) for at least 3-5 days will be randomised to early (day 1 or day 2 of admission) or late commencement (day 6 of admission) of PN after informed parental consent. In both groups, EN will be commenced as early as clinically feasible. Primary outcomes are plasma phenylalanine and plasma F₂-isoprostane levels on Day 4 and Day 8 of admission. Secondary outcomes are total and individual plasma amino acid profiles, plasma and red blood cell fatty acid profiles, in-hospital all-cause mortality, hospital-acquired infections, length of hospital/NICU stay, z scores and changes in z scores at discharge for weight, height and head circumference, time to full EN, duration of respiratory (mechanical, non-invasive) support, duration of inotropic support, the incidence of hyper and hypoglycaemia, incidence of metabolic acidosis, liver function, blood urea nitrogen, and C-reactive protein (CRP).

DISCUSSION

This RCT will examine the effects of early versus late PN in term and late preterm infants by comparing key biochemical and clinical outcomes and has the potential to identify underlying pathways for beneficial or harmful effects related to the timing of commencement of PN in such infants.

TRIAL REGISTRATION

ANZCTR; ACTRN12620000324910 (3rd March 2020).

Status and Influencing Factors of Parenteral Nutrition Practice for Late Preterm Infants in China

OBJECTIVES

To explore the status of parental nutrition practice of hospitalized late preterm infants and the factors influencing the clinical prescription.

METHODS

A multi-center, prospective cohort study was conducted during October 2015 to October 2017. Infants born after 34 weeks and before 37 weeks were enrolled from twenty-five hospitals in the Beijing area of China. Data of enteral and parenteral nutrition were collected.

RESULTS

A total of 1,463 late preterm infants were enrolled in this study, 53.9% of infants were supported by parenteral nutrition. Over 60% of 34 weeks' infants were on parenteral nutrition during the 2nd to the 4th day. Logistic regression analysis showed that gestational age(GA) (OR = 0.69, 95%CI 0.58-0.81), birth weight (OR = 0.41, 95%CI 0.26-0.65), hypoglycemia (OR = 2.77, 95%CI 1.90-4.04), small for gestational age (SGA) (OR = 2.18, 95%CI 1.34-3.55), feeding intolerance (OR = 6.41, 95%CI 1.90-21.59), neonatal respiratory distress syndrome (NRDS) (OR = 2.16, 95%CI 1.12-4.18), neonatal infection(OR = 1.56 95%CI 1.16-2.10), and slow enteral nutrition advancement rate (OR = 0.92, 95%CI 0.90-0.95) were factors influencing the administration of parenteral nutrition.

CONCLUSION

Over half of hospitalized late preterm infants were prescribed with parenteral nutrition. Infants with lower GA, lower birth weight, diagnosed with hypoglycemia, SGA, feeding intolerance, NRDS, neonatal infection, or a slower rate of enteral nutrition advancement had a higher likelihood of receiving parenteral nutrition.