Enhancing parenteral nutrition therapy for the neonate

Fatty acids from nutrition sources for preterm infants and their effect on plasma fatty acid profiles

BACKGROUND

In preterm infants, IV administration of fat is less well tolerated compared to intake via the enteral route, often resulting in hypertriglyceridemia. It is therefore recommended that parenteral fat intake should not exceed 3.5 to 4.0 g/kg/d whereas human milk can provide up to 8 g/kg/d. It is unknown whether such hypertriglyceridemic conditions are caused by a uniform increase of all fatty acids or it is linked to an elevation of distinct fatty acids due to an unbalanced intake. Obviously, both scenarios could potentially influence the formulation of novel lipid solutions for preterm infants. Objective of this exploratory study was to compare fatty acid profiles between a) different nutritional sources and corresponding plasma samples, b) plasma of infants fed breast milk versus those receiving lipid emulsion, and c) plasma of infants with normal versus elevated triglyceride levels.

METHODS

Forty-seven preterm infants < 36 weeks of gestation were included; fatty acid profiles were measured in serum samples and corresponding nutritional sources (breast milk and lipid emulsion) using gas chromatography/mass spectrometry.

RESULTS

Compared to breast milk levels, plasma contained significantly lower C8:0, C10:0, C12:0, C14:0, C19:1n9, C18:3n3 (p < 0.0001). In contrast, relative abundance of C16:0, C18:0 and C20:4n6 was higher in plasma than in corresponding breast milk samples (p < 0.001) and lipid emulsion (p < 0.01). Compared to the corresponding lipid emulsion, the abundance of C18:2n6 and C18:3n3 was significantly lower in plasma (p < 0.001). Fatty acid profiles in plasma of infants fed breast milk compared to lipid emulsion were not markedly different. Hypertriglyceridemic samples showed elevated levels for C18:1n9 and C16:0 when compared with normotriglyceridemic samples.

CONCLUSIONS

Our study reveals that lipid levels in plasma show both depletion and enrichment of distinct fatty acids which do not seem to be closely related to dietary intake. A more detailed understanding of fatty acid flux rates is needed, like the understanding of amino acid metabolism and is supported by the finding that hypertriglyceridemia might be a state of selective fatty acid accumulation. This would allow to develop more balanced diets for intensive care and potentially improve clinical outcomes.

Comparison Between Sodium Acetate and Sodium Chloride in Parenteral Nutrition for Very Preterm Infants on the Acid-Base Status and Neonatal Outcomes

PURPOSE

To compare between sodium acetate (SA) and sodium chloride (SC) in parenteral nutrition (PN) with associated metabolic acidosis and neonatal morbidities in preterm infants.

METHODS

Preterm infants below 33 weeks gestational age, and with a birth weight under 1,301 g were enrolled and further stratified into two groups: i) <1,000 g, or ii) ≥1,000 g in birth weight. The subjects were randomized to receive PN containing SA or SC within the first day of life. The results of routine blood investigations for the first 6 days of PN were collated, and the neonatal outcomes were recorded upon discharge or demise.

RESULTS

Fifty-two infants entered the study, with 26 in each group: 29 infants had extremely low birth weight (ELBW). There were no significant differences in birth weight, gestation, sex, exposure to chorioamnionitis and antenatal steroids, surfactant doses and duration of mechanical ventilation between groups. The SA group had significantly higher mean pH and base excess (BE) from days 4 to 6 than the SC (mean pH, 7.36 vs. 7.34; mean BE -1.6 vs. -3.5 [p<0.01]), with a two-fold increase in the mean BE among ELBW infants. Significantly fewer on SA required additional bicarbonate (n=4 vs. 13, p=0.01). The rate of bronchopulmonary dysplasia (BPD) was approximately four-fold lower in SA than SC (n=3 vs. 11, p<0.01). No significant differences were observed in necrotizing enterocolitis, patent ductus arteriosus, retinopathy of prematurity, cholestatic jaundice, and mortality between groups.

CONCLUSION

The use of SA in PN was associated with reduced metabolic acidosis and fewer BPD.

Neonatal Parenteral Nutrition Containing Calcium Chloride and Sodium Phosphate

Objective. The authors’ objectives were to determine mineral as well as Al intakes for ≤1000 g birth weight (ELBW) infants supported with parenteral nutrition (PN) solutions containing calcium chloride (CaCl) and sodium phosphate (NaPhos). Study design. This study was a prospective cohort study of 32 ELBW infants. Nutrient and Al intakes were recorded based on actual fluid intakes and concentrations of nutrients and Al in PN solutions. Growth velocities and peak alkaline phosphatase (AP) levels during the hospital stay were recorded. Result. Mean (±standard deviation) weight, length, and head circumference gains and AP were 13.7 ± 1.8 g/kg/d, 1.0 ± 0.2 cm/wk, 0.7 ± 0.1 cm/wk, and 636 ± 227 U/L, respectively. Al intake was 0.27 ± 0.07 µmol/kg/d (7.2 ± 1.8 µg/kg/d) in infants receiving PN with low Al content. This study documented average parenteral Ca and P intakes of 1.15 to 1.20 and 1.19 to 1.29 mmol/kg/d, (46-48 and 37-40 mg/kg/d), respectively, with PN fluid intakes of 90 to 100 mL/kg/d. Conclusion. AP and growth in ELBW infants receiving PN solutions containing CaCl are comparable to those reported in the literature for ELBW infants. Ca and P intakes approaching those reported for preterm infants receiving PN containing calcium gluconate can be provided with PN solutions containing CaCl. Fluid restriction is a significant factor limiting mineral intakes. Al intake can be limited to near FDA recommended intakes in PN solutions containing CaCl.

Comparison of enteral feeding of preterm infants between two hospitals in China and United States

AIM

To compare the details of preterm infants enteral feeding between the two hospitals in China and in the United States, and to analyze the reason of the differences.

METHODS

A retrospective cohort study was conducted. Infants < 32 weeks were enrolled from Cincinnati University Hospital (CUH) during January 2011 to January 2012 and Peking Union Medical College Hospital (PUMCH) during January 2011 to May 2012. Basic data and enteral feeding data of the two groups were compared.

RESULTS

Eighty-two infants in CUH group and 74 infants in PUMCH group were enrolled, infants in CUH group were much smaller than PUMCH group (gestational age (29.1 ± 2.0) versus (30.6 ± 1.3) weeks, p = 0.000, birth weight (1204 ± 328) versus (1406 ± 320) g, p = 0.000). Significantly more infants in CUH group received human milk as the first enteral feeding (78/82 versus 7/74, p = 0.000). Human milk feeding rate in first 28 days in CUH group was much higher (77/82 versus 7/74, p = 0.000). The initial milk volume, and the milk volume on the 7th, 14th, 21st and 27th day of CUH group were significant larger [(15.9 versus 9.3 ml/kg·d, p = 0.000), (79.8 versus 35.2 ml/kg·d, p = 0.000), (133.2 versus 76.4 ml/kg·d, p = 0.000), (140.6 versus 108.6 ml/kg·d, p = 0.000), (142.2 versus 121.5 ml/kg·d, p = 0.002)]. CUH group achieved full enteral feeding sooner (12.0 versus 22.4 d, p = 0.000).

CONCLUSION

Preterm infants achieved full enteral feeding sooner at CUH compared to PUMCH. Human milk feeding may improve enteral feeding tolerance. We need more aggressive enteral feeding proposal in PUMCH.

Cholestasis in Preterm Infants

Cholestasis in preterm infants has a multifactorial etiology. Risk factors include degree of prematurity, lack of enteral feeding, intestinal injury, prolonged use of parenteral nutrition (PN), and sepsis. Soy-based parenteral lipid emulsions have been implicated in the pathophysiology of PN-associated liver injury. Inflammation plays an important role. Medical therapies are used; however, their effects have not consistently proven effective. Evaluation of cholestasis involves laboratory work; direct bilirubin levels are used for diagnosis and trending. Adverse outcomes include risk for hepatobiliary dysfunction, irreversible liver failure, and death. Early enteral feedings as tolerated is the best way to prevent and manage cholestasis.

Safety and efficacy of parenteral fish oil-containing lipid emulsions in premature neonates

OBJECTIVE

The aim of the study was to evaluate the safety and efficacy of fish oil-containing (FO) lipid emulsions that are rich in ω-3 fatty acids for parenteral nutrition in preterm neonates by using data retrieved from randomized controlled trials.

METHODS

We performed a meta-analysis of 8 randomized controlled trials representing 483 premature neonates to compare FO with control (CO) lipid emulsions.

RESULTS

This meta-analysis revealed that the levels of ω-3 fatty acids in the form of docosahexaenoic acid, eicosapentaenoic acid, and arachidonic acid (% of total fatty acids) in plasma were statistically higher in FO groups (mean difference [MD] -0.7%, 95% confidence interval [CI] -1.05 to -0.36, P < 0.001; MD -1.31%, 95% CI -1.40 to -1.21, P < 0.001). The differences were found in red blood cell (RBC) membranes. The levels of arachidonic acid (% of total fatty acids) as ω-6 fatty acid in plasma and red blood cell membranes were significantly lower in FO groups (MD 1.27%, 95% CI 1.12-1.42, P < 0.001) (MD 0.92%, 95% CI 0.12-1.72, P = 0.02). The mean body weight, serum level of bilirubin, triglycerides or C-reactive protein, all-cause mortality, and rate of lipid emulsion-associated complications were, however, not different between FO and CO groups.

CONCLUSIONS

The level of docosahexaenoic acid is efficiently improved by FO lipid emulsions. The changes observed in eicosapentaenoic acid and arachidonic acid, and the associated safety issue, however, remain to be clarified. Any clinical benefit or detrimental effect of using FO in premature neonates cannot be demonstrated by the present study.

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.

Management of renal dysfunction following term perinatal hypoxia-ischaemia

Acute kidney injury frequently develops following the term perinatal hypoxia-ischaemia. Quantifying the degree of acute kidney injury is difficult, however, as the methods currently in use are suboptimal. Acute kidney injury management is largely supportive with little evidence basis for many interventions. This review discusses management strategies and novel biomarkers that may improve diagnosis and management of renal injury following perinatal hypoxia-ischaemia.

CONCLUSION

Following perinatal hypoxia-ischaemia, acute kidney injury is common. Management of neonatal acute kidney injury is largely supportive. Novel acute kidney injury biomarkers may play a role in optimizing new categorical definitions of renal injury. Studies are needed to investigate the impact of neonatal acute kidney injury on long-term outcome.

The effect of two different parenteral nutrition regimens on parenteral nutrition-associated cholestasis

Exposure to parenteral nutrition (PN) is one major factor in the development of cholestasis. The aim of this retrospective study was to compare the effect of these two different PN regimens on PN-associated cholestasis (PNAC). The files of the patients who have received different PN regimens for >14 d in 2005 and 2009 were retrospectively reviewed. 133 patients have received PN more than 14 d. 22 (16.5%) patients had PNAC. 90 neonates were in Group low-dose parenteral (LDpn) and 43 neonates in Group high-dose parenteral. Mean gestational age and birth weight were statistically significantly lower in LDpn Group (p = 0.016, p = 0.434). Cholestasis rate was significantly higher in high dose group. (p = 0.023). Although several risk factors for PNAC are unavoidable, research is still needed to define the optimal parenteral amino acid solution for neonatal patients. Individualized PN may be more affective in allowing growth and minimizing side effects.

Efficacy and safety of a parenteral amino acid solution containing alanyl-glutamine versus standard solution in infants: a first-in-man randomized double-blind trial

BACKGROUND & AIMS

Efforts are directed at reaching the optimal composition of pediatric amino acids (AA) infusions. The goal was to demonstrate the safety and efficacy of a newly developed parenteral AA solution containing alanyl-glutamine (GLN-AA) compared to Standard-AA.

METHODS

This is a randomized (2:1), double-blind, multicentre clinical pilot trial. Infants after surgical interventions were allocated to receive GLN-AA or Standard-AA over a minimum of 5 days to maximum of 10 days. AA profiles in blood samples obtained at baseline, day 7, and end of treatment were compared to normal ranges. Data regarding safety, and efficacy were also collected.

RESULTS

Infants were comparable for (safety population) gestational age at birth (36 vs 38 weeks), birth weight (2460 vs 2955 g), and day of life during start intervention (1 vs 2 days). Plasma AA profiles in infants treated with GLN-AA (n = 13) were closer the normal ranges than those in infants treated with Standard-AA (n = 6). There were no clinical or statistical differences in adverse events, safety and efficacy parameters between both groups.

CONCLUSION

This first-in-man study shows that GLN-AA is safe in infants after surgical interventions, and is well tolerated. Compared to reference values, GLN-AA better reflects the amino acid requirements of the infant.

The metabolic effects of two different lipid emulsions used in parenterally fed premature infants--a randomized comparative study

OBJECTIVE

To compare the effects of two different lipid emulsions, based on soybean oil and olive oil respectively on plasma lipid concentrations and acylcarnitine profile of very low birth weight infants.

DESIGN

Randomized comparative study.

PATIENTS AND METHODS

Forty very low birth weight infants, ≤32 weeks of gestational age and receiving at least 40% of the calorie taken by parenteral nutrition from lipid solution at 14th day of life were evaluated. Group I (n=20) received soybean oil based lipid emulsion (Intralipid®) and Group II (n=20) received olive oil based lipid emulsion (Clinoleic®).

MAIN OUTCOME MEASURES

Plasma lipid concentrations and acylcarnitine profile were assessed.

RESULTS

Triglyceride, cholesterol, high and low density lipoprotein levels, liver function tests were similar between two groups whereas very low density lipoprotein level was statistically lower in Group I (p<0.05). Free carnitine levels were 15.73±10.67 in Group I and 34.25±22.18 μM in Group II (p=0.012) and hexanoyl carnitine levels 2.18±2.10 in Group I and 0.38±0.12 μM in Group II, respectively (p=0.005). Plasma medium chain acylcarnitine levels were significantly higher in Group I.

CONCLUSIONS

Low levels of very low density lipoprotein in Group I may be a way of hemostasis to keep the serum triglyceride within normal levels. Lower free carnitine levels in soybean oil-based group is the result of carnitine need during the mitochondrial transport of long chain fatty acids. In Group I, due to the inefficient transport of medium chain fatty acids into the mitochondria, medium chain acylcarnitines accumulate in plasma. This may be the reason of lower carnitine levels in Group I. We suggest that higher levels of hexanoyl carnitine, reflecting defective mitochondrial transport of hexanoyl which leads immunsupression, may be the cause of higher sepsis risk in Group I.

Maternal dietary DHA supplementation to improve inflammatory outcomes in the preterm infant

Dietary DHA (22:6n-3) is a long-chain PUFA that has provocative effects on inflammatory signal events that could potentially affect preterm infant health. It is well known that the essential fatty acid of the (n-3) series; α-linolenic acid (18:3n:3) can be desaturated and elongated in the liver endoplasmic reticulum and peroxisome to produce the 22-carbon DHA. Nevertheless, concern exists as to the efficiency of this mechanism in providing the preterm infant with adequate DHA. Activity of the δ-6-desaturase and the δ-5-desaturase necessary for DHA synthesis is decreased by protein deprivation. The combined effects of suboptimal intake of both DHA and protein in the preterm infants could have substantial clinical consequences.

Short-term use of parenteral nutrition with a lipid emulsion containing a mixture of soybean oil, olive oil, medium-chain triglycerides, and fish oil: a randomized double-blind study in preterm infants

BACKGROUND

For premature neonates needing parenteral nutrition (PN), a balanced lipid supply is crucial. The authors hypothesized that a lipid emulsion containing medium-chain triglycerides (MCTs) and soybean, olive, and fish oils would be as safe and well tolerated as a soybean emulsion while beneficially influencing the fatty acid profile.

METHODS

Double-blind, controlled study in 53 neonates (<34 weeks' gestation) randomized to receive at least 7 days of PN containing either an emulsion of MCTs and soybean, olive, and fish oils or a soybean oil emulsion. Target lipid dosage was 1.0 g fat/kg body weight [BW]/d on days 1-3, 2 g/kg BW/d on day 4, 3 g/kg BW/d on day 5, and 3.5 g/kg BW/d on days 6-14.

RESULTS

Test emulsion vs control, mean ± SD: baseline triglyceride concentrations were 0.52 ± 0.16 vs 0.54 ± 0.19 mmol/L and increased similarly in both groups to 0.69 ± 0.38 vs 0.67 ± 0.36 on day 8 of treatment (P = .781 for change). A significantly higher decrease in total and direct bilirubin vs baseline was seen in the test group compared with the control group P < .05 between groups). In plasma and red blood cell phospholipids, eicosapentaenoic acid and docosahexaenoic acid were higher, and the n-6/n-3 fatty acid ratio was lower in the test group (P < .05 vs control).

CONCLUSIONS

The lipid emulsion, based on a mixture of MCTs and soybean, olive, and fish oils, was safe and well tolerated by preterm infants while beneficially modulating the fatty acid profile.

Pre-treatment with an intravenous lipid emulsion containing fish oil (eicosapentaenoic and docosahexaenoic acid) decreases inflammatory markers after open-heart surgery in infants: a randomized, controlled trial

BACKGROUND & AIMS

This study assessed the effects of administering a lipid emulsion containing eicosapentaenoic and docosahexaenoic acid before and after open-heart surgery on cytokine production and length of hospital stay in infants.

METHODS

Thirty-two infants (40 ± 2.3 weeks gestational age; 10.6 days at time of surgery) undergoing open-heart surgery with cardiopulmonary bypass were randomized to receive an intravenous lipid emulsion with (treatment) or without (control) eicosapentaenoic and docosahexaenoic acid in this prospective, randomized, double-blind, controlled trial.

RESULTS

Mean plasma TNF-α concentration was significantly (p = 0.003) lower in the treatment (5.9 pg/mL) compared to the control group (14.8 pg/mL). In infants without sepsis, plasma TNF-α did not differ according to treatment, however when sepsis developed, mean plasma TNF-α was 21.1 pg/mL and 1.5 pg/mL (p = 0.0007) in control and treatment groups, respectively. Plasma TNF-α was positively correlated with length of hospital stay in the control group (p = 0.01), and negatively correlated with length of stay in the treatment group (p = 0.004), with a significant time by treatment interaction (p = 0.02).

CONCLUSIONS

Providing a lipid emulsion containing eicosapentaenoic and docosahexaenoic acid reduces TNF-α concentrations in infants undergoing open-heart surgery. Lipid emulsions containing eicosapentaenoic and docosahexaenoic acid may ameliorate the inflammatory response among critically ill infants.

Safety and efficacy of a lipid emulsion containing a mixture of soybean oil, medium-chain triglycerides, olive oil, and fish oil: a randomised, double-blind clinical trial in premature infants requiring parenteral nutrition

OBJECTIVES

Safety, tolerability, and efficacy of a novel lipid emulsion containing a mixture of soybean oil, medium-chain triglycerides, olive oil, and fish oil (SMOFlipid 20%) with reduced n-6 fatty acids (FA), increased monounsaturated and n-3 FA, and enriched in vitamin E were evaluated in premature infants compared with a soybean oil-based emulsion.

PATIENTS AND METHODS

Sixty (30/30) premature neonates (age 3-7 days, gestational age ≤ 34 weeks, birth weights 1000-2500 g) received parenteral nutrition (PN) with either SMOFlipid 20% (study group) or a conventional lipid emulsion (Intralipid 20%, control group) for a minimum of 7 up to 14 days. Lipid supply started at 0.5 g · kg body weight(-1) · day(-1) on day 1 and increased stepwise (by 0.5 g) up to 2 g · kg body weight(-1) · day(-1) on days 4 to 14. Safety and efficacy parameters were assessed on days 0, 8, and 15 if PN was continued.

RESULTS

Adverse events, serum triglycerides, vital signs, local tolerance, and clinical laboratory did not show noticeable group differences, confirming the safety of study treatment. At study end, γ-glutamyl transferase was lower in the study versus the control group (107.8 ± 81.7 vs 188.8 ± 176.7 IU/L, P < 0.05). The relative increase in body weight (day 8 vs baseline) was 5.0% ± 6.5% versus 5.1% ± 6.6% (study vs control, not significant). In the study group, an increase in n-3 FA in red blood cell phospholipids and n-3:n-6 FA ratio was observed. Plasma α-tocopherol (study vs control) was increased versus baseline on day 8 (26.35 ± 10.03 vs 3.67 ± 8.06 μmol/L, P < 0.05) and at study termination (26.97 ± 18.32 vs 8.73 ± 11.41 μmol/L, P < 0.05).

CONCLUSIONS

Parenteral infusion of SMOFlipid was safe and well tolerated and showed a potential beneficial influence on cholestasis, n-3 FA, and vitamin E status in premature infants requiring PN.

A double-blind, randomized clinical trial of the effect of omega-3 fatty acids on the oxidative stress of preterm neonates fed through parenteral nutrition

BACKGROUND/OBJECTIVES

The aim of this study was to research and draw conclusions about the effect of a parenteral nutrition (PN) fat emulsion, rich in omega-3 fatty acids, on the antioxidant markers of preterm infants, when compared with a standard fat emulsion. This was a double-blind, parallel-group study conducted in Athens, Greece, using an equal randomization method.

SUBJECTS/METHODS

Thirty-eight infants were selected using a double-blind method and a computer-generated randomization list. Both groups received PN, based on the same protocols. Group A received SMOFlipid fat emulsion, while group B received the standard fat emulsion (Intralipid). Serum levels of vitamin A, E and total antioxidant potential (TAP) were measured on days 0, 7 and 14 of PN support. Clinical and biochemical data were collected on days 0, 14 and on the day of discharge.

RESULTS

Serum levels of vitamin E and A were significantly increased in group A, while only vitamin A serum level was increased in group B on the fourteenth day (group A: vitamin E: P-value=0.002, vitamin A: P-value=0.000, group B: vitamin E: P-value=0.065, vitamin A: P-value=0.000). TAP was increased only in the intervention group (group A: P-value=0.000, group B: P-value=0.287). Mild anemia was developed in both groups, while no differences were detected in the infection rate, days of hospitalization, days of ventilator support and days of phototherapy.

CONCLUSIONS

Oxidative stress was significantly reduced in those neonates fed with omega-3 fatty acids, whereas no effect was observed in the neonates fed with standard lipids. Intervention had no effect on infants' growth and clinical outcome.

Neonatal nutrition: a brief review

BACKGROUND

With increasing survival of extremely premature infants, emphasis is now focused on the quality of these survivors' lives. Possibly the most important factor in the premature's ability to survive in the NICU and thrive is the ability to replicate in utero growth through enteral and parenteral nutrition.

DATA SOURCES

Current literature and review articles were retrieved from PubMed and personal files of the authors.

RESULTS

The use and complications of the various components of total parenteral nutrition (TPN) were reviewed. The composition of appropriate enteral feeds for the premature was reviewed as was the difficulties associated with the establishment of adequate enteral feeds in the premature infants.

CONCLUSIONS

Early initiation of amino acids in TPN and timely increases in the components of TPN can improve the caloric intake of prematures. Enteral feeds, particularly of breast milk, may be started within the first few days of life in all but hemodynamically unstable prematures. Newer lipid preparations show promise in reversing the hepatic damage of TPN associated cholestatic jaundice.