Practice ordering guidance for neonatal parenteral nutrition

Review of macronutrients in parenteral nutrition for neonatal intensive care population

Parenteral nutrition (PN) has become essential in the management of sick and growing newborn populations in the NICU. In the past few decades, PN has become fundamental in the nutritional management of the very low birth weight infant (<1,500 g).1 Although the components in PN are commonly determined and ordered by the physician or neonatal nurse practitioner provider, the NICU nurse is responsible for confirming the components in the daily PN prior to infusion and is responsible for maintaining the infusion of PN. Nurses should understand the nutritional components of PN as well as the indications, side effects, and infusion limitations of each component. The purpose of this article is to review the macronutrients in PN, including carbohydrates, protein, and fat. A subsequent article will review the micronutrients in PN, including electrolytes, minerals, and vitamins.

[Neonatal parenteral nutrition prescription practices in Portugal]

INTRODUCTION

The use of guidelines for neonatal parenteral nutrition (PN) improves its clinical efficiency and the safety of prescription.

OBJECTIVE

To evaluate the practices of neonatal parenteral nutrition prescription in Portugal, and the adherence to the National Consensus on neonatal PN (2008).

METHODS

A questionnaire based on a multiple choice response on parenteral nutrition prescription was conducted, and sent to the coordinators of the 50 public and private Portuguese neonatal special care units, 25 being level III and 25 level II.

RESULTS

Parenteral nutrition was prescribed in 32 neonatal units, 23 of which (71.9%) responded to the questionnaire. Of the respondents, 19 (82.6%) refer to follow the National Consensus, the remaining following local guidelines; 17 (73.9%) of units referred to using an electronic based system for prescription. In preterm neonates, most mentioned: administering judiciously the fluid intake during the first post-natal week; starting amino acids from the first post-natal day with 1.5-3g/kg/d, increasing up to 3-4g/kg/d; starting lipids from the first three post-natal days with 1g/kg/d, increasing up to 3g/kg/d; administering 40-70mg/kg/d of calcium and of phosphorus with the fixed calcium:phosphorus ratio of 1.7: 1 (mg:mg); and estimating the osmolality of the solutions, and weekly monitoring of serum triglycerides, blood urea, serum phosphorus and liver function.

CONCLUSIONS

The high response rate is probably representative of the practice of PN prescription in Portugal. Most of the units used the National Consensus on neonatal PN as a reference, thus contributing to better nutritional support for neonates.

Parenteral nutrition objectives for very low birth weight infants: results of a national survey

OBJECTIVES

The aim of the study was to evaluate parenteral nutrition objectives for very low birth weight (VLBW) infants in neonatal intensive care units (NICUs), and to compare nutritional protocol differences according to levels of care.

MATERIALS AND METHODS

A national survey was conducted in France through a questionnaire sent to 296 French neonatal departments to determine each team leader's nutritional objectives for parenteral nutrition of VLBW infants.

RESULTS

A total of 172 of the 296 French neonatal departments responded to the questionnaire. Protein administration was not started during the first day of life in half of the responding units. Furthermore, half of the units initiated protein administration with less than 1 g x kg(-1) x day(-1). The day of introduction of lipid emulsions varied considerably from one unit to another, but more than half of the units started the lipid emulsions after the third day of life. Twenty percent of the units reported a target energy intake of 100 kcal x kg(-1) x day(-1), whereas 14% reported a target intake above or equal to 130 kcal x kg(-1) x day(-1).

CONCLUSIONS

In comparison with recent guidelines for parenteral nutrition for VLBW infants, the results indicate that the majority of the departments are familiar with target macronutrient and energy intakes, but the time of introduction and the rate of progression of macronutrients, particularly proteins and lipids, are frequently lower than those defined by the guidelines. The large-scale publication of new nutritional guidelines for the parenteral nutrition of neonates and preterm infants as well as regular, specific training in the parenteral nutrition of preterm infants are needed.