Neonatology/Paediatrics - Guidelines on Parenteral Nutrition, Chapter 13

[Process for the Implementation of Evidence-Based Parenteral Nutrition in German Perinatal Centres - Outcomes of a Multidisciplinary Network]

INTRODUCTION

Parenteral nutrition, usually indicated for preterm infants with a birthweight<1500 g and sick newborns, enables the supply with critical nutrients. As a high degree of therapy safety is required, a European guideline provides recommendations for safe therapy procedures. The present project aimed to evaluate the implementation of the European guideline in German perinatal centers and to identify possible barriers that impede its implementation. A further goal was to develop solution approaches to overcome possible barriers.

METHODS AND RESULTS

A multidisciplinary cooperation conducted an online survey questioning the current implementation procedures of the European guideline among pediatricians and hospital pharmacists. Results show barriers in the provisioning process of parenteral nutrition that hinder a guideline-compliant implementation in practice. Based on results of this survey, an expert network developed an interactive toolkit with simplified guideline recommendations, guideline-compliant advice for practice, best-practice examples, forms, and handouts. It seeks to encourage critical reflection of routine processes and provides concrete solutions to overcome barriers in practice.

CONCLUSION

The current procedures related to parenteral nutrition deviate from guideline recommendations. The developed toolkit provides practice-oriented support aiming to enhance the guideline-compliant implementation of parenteral nutrition in perinatal centers.

Expert consensus on clinical management of metabolic bone disease of prematurity (2021)

Metabolic bone disease of prematurity (MBDP) is a systemic bone disease with a reduction in bone mineral content due to disorder of calcium and phosphorus metabolism. There is still a lack of in-depth research and systematic understanding of MBDP in China, and there are many irregularities in clinical management of this disease. Based on relevant studies in China and overseas, Grading of Recommendations Assessment, Development and Evaluation was used to develop the expert consensus on the clinical management of MBDP, which provides recommendations from the following five aspects: high-risk factors, screening/diagnosis, prevention, treatment, and post-discharge follow-up of MBDP, so as to provide relevant practitioners with recommendations on the clinical management of MBDP to reduce the incidence rate of MBDP and improve its short- and long-term prognosis.

A demonstration of using formal consensus methods within guideline development; a case study

BACKGROUND

Recommendations within guidelines are developed by synthesising the best available evidence; when limited evidence is identified recommendations are generally based on informal consensus. However, there are potential biases in group decision making, and formal consensus methods may help reduce these.

METHODS

We conducted a case study using formal consensus, to develop one set of recommendations within the Neonatal Parenteral Nutrition guideline being produced for the National Institute for Health and Care Excellence. Statements were generated through identification of published guidelines on several topics relating to neonatal parenteral nutrition. Ten high quality guidelines were included, and 28 statements were generated; these statements were rated by the committee via two rounds of voting. The statements which resulted in agreement were then used to develop the recommendations.

RESULTS

The approach was systematic and provided transparency. Additionally, a number of lessons were learnt; including the value of selecting the appropriate topic, giving adequate time to the process, and ensuring methodologies are understood by the committee for their value and relevance.

CONCLUSION

Formal consensus is a valuable option for use within guideline development when specific criteria are met. The approach provides transparent methodology, ensuring clarity on how recommendations are developed.

Turkish Neonatal Society guideline on parenteral nutrition in preterm infants

Postnatal growth failure due to inappropriate and insufficient nutrition is a risk for preterm infants, especially for very-low-birth-weight or extremely-low-birth-weight infants. This extrauterine growth failure causes negative effects on long-term neurodevelopment. Early initiation of intensive parenteral nutrition with appropriate protein and energy supply is a nutritional emergency when enteral feeding cannot be achieved. This approach prevents protein catabolism and helps achievement of positive protein balance and postnatal growth. Protein, lipid, and glucose initiation with appropriate doses that reach timely goals constitute the major elements of parenteral nutrition. The transition to enteral nutrition with the mother's milk at the earliest convenience must be targeted in parenteral nutrition.

Physical stability of an all-in-one parenteral nutrition admixture for preterm infants upon mixing with micronutrients and drugs

Objectives

The main objective was to investigate Y-site compatibility of intravenous drugs with one standard total parenteral nutrition (TPN) admixture for preterm infants. Since micro-precipitation was observed in the water phase after addition of trace elements, the concentration effect on micro-precipitation formation developed as a sub-goal.

Methods

Seven drugs (ampicillin, ceftazidime, fluconazole, fosphenytoin, furosemide, metronidazole and paracetamol) were mixed in three mixing ratios with one preterm TPN admixture. Samples were investigated within 1 hour and again after 4 hours. Precipitation was studied in a lipid-free version called TPN_aq by light obscuration, turbidimetry and visual examination. Emulsion stability data were assessed by light obscuration and laser diffraction. pH was measured to assess the theoretical risk of precipitation and emulsion destabilisation. The influence of different concentrations of trace elements on precipitation was investigated by visual examination, turbidimetry and light obscuration.

Results

Ampicillin, ceftazidime, fosphenytoin and furosemide led to precipitation after mixing with TPN_aq. In some samples of TPN and fluconazole, metronidazole and paracetamol, the emulsion droplet size was above the acceptance limit, although this might also be inherent to the TPN admixture. An unexpected formation of micro-precipitate correlating with increasing amounts of added trace elements might be caused by an interaction of cysteine and copper, and complicated the compatibility assessment with drugs.

Conclusions

The micro-precipitate resulting from the addition of trace elements should be investigated further. This study did not provide sufficient evidence to recommend Y-site infusion of the tested drugs and the preterm admixture; however, it might offer some additional support to other compatibility data.

A Simple Method of Calculation in Excel for the Protein Requirements in Preterm New Borns

INTRODUCTION

The nutritional balance between the nutritional requirements of the organism and the intake is a very delicate thing to adjust especially when it comes to the premature new-born in whom often the oral feeding is very challenging and the need for parenteral feeding is very pressing.

PURPOSE

The goal of this article is to present a simple method of calculation for the amino acid parenteral intake in preterm infants using the Excel spreadsheet platform as a platform.

MATERIAL AND METHOD

Using Excel commands, we translate the algorithms for the protein requirements calculation into an electronic format. This will allow the creation of a template that quickly identifies the need for proteins according to the clinical and evolutional features of the premature new-born, significantly reducing the duration of the calculation.

RESULTS

This method is easy to perform, simple and efficient. The calculation template has significantly reduced the errors and the actual working time with the algorithms. These effects are very obvious in intensive care units that take care of a large number of premature babies.

CONCLUSIONS

Computerized calculation allows a decrease in calculation errors and also reduces the time actually allocated for the calculation, especially for the very complicated algorithms. Following this template in Excel, we can create separate modules for the algorithms necessary to calculate the needs for the intake of liquids, calories, lipids, and minerals.

Inpatient outcomes of preterm infants receiving ω-3 enriched lipid emulsion (SMOFlipid): an observational study

Neonatal units have started to switch from using conventional soy-based to alternate lipid emulsions, like SMOFlipid. SMOFlipid has been associated with an improvement in biochemical parameters and delays progression of parenteral nutrition-associated liver disease (PNALD). This retrospective epoch study aimed to compare clinically relevant neonatal outcomes in preterm infants (< 32 weeks), receiving SMOFlipid versus Intralipid. We compared clinical outcomes in two epochs-epoch 1 (Intralipid, October 2013-June 2015) versus epoch 2 (SMOFlipid, July 2015-March 2017). Primary outcome studied was mortality and rates of severe neonatal morbidities. Univariate and multivariate regression was conducted to determine risk for mortality and PNALD. A total of 222 infants (epoch 1, 123 versus epoch 2, 99) were included in the study. A higher incidence of late onset sepsis (56 versus 30%, p < 0.005) was observed in epoch 1. There was no significant difference in mortality or rates of any other severe neonatal morbidity. The type of lipid emulsion did not have a significant effect on mortality or PNALD on regression analysis.

CONCLUSION

Use of SMOFlipid as the primary lipid emulsion seems to have minimal effect on rates of clinically important neonatal outcomes; however, long-term effects need to be further evaluated. What is Known: • Many neonatal units have started replacing traditional soy-based lipid formulations with SMOFlipid (ω-3 enriched lipid emulsion), as the primary lipid component in parenteral nutrition for preterm infants. • While there is evidence associating improved liver function and balanced essential fatty acid levels in infants receiving SMOFlipid, there is a lack of evidence evaluating relevant clinical outcomes in infants receiving SMOFlipid versus traditional lipid formulations. What is New: • The influence of SMOFlipid on a series of clinical outcomes in an at-risk preterm population is presented. • SMOFlipid appears to be well tolerated in preterm infants with minimal side effects, and some growth benefits seen.

Higher versus lower amino acid intake in parenteral nutrition for newborn infants

BACKGROUND

Sick newborn and preterm infants frequently are not able to be fed enterally, necessitating parenteral fluid and nutrition. Potential benefits of higher parenteral amino acid (AA) intake for improved nitrogen balance, growth, and infant health may be outweighed by the infant's ability to utilise high intake of parenteral AA, especially in the days after birth.

OBJECTIVES

The primary objective is to determine whether higher versus lower intake of parenteral AA is associated with improved growth and disability-free survival in newborn infants receiving parenteral nutrition.Secondary objectives include determining whether:• higher versus lower starting or initial intake of amino acids is associated with improved growth and disability-free survival without side effects;• higher versus lower intake of amino acids at maximal intake is associated with improved growth and disability-free survival without side effects; and• increased amino acid intake should replace non-protein energy intake (glucose and lipid), should be added to non-protein energy intake, or should be provided simultaneously with non-protein energy intake.We conducted subgroup analyses to look for any differences in the effects of higher versus lower intake of amino acids according to gestational age, birth weight, age at commencement, and condition of the infant, or concomitant increases in fluid intake.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (2 June 2017), MEDLINE (1966 to 2 June 2017), Embase (1980 to 2 June 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 2 June 2017). We also searched clinical trials databases, conference proceedings, and citations of articles.

SELECTION CRITERIA

Randomised controlled trials of higher versus lower intake of AAs as parenteral nutrition in newborn infants. Comparisons of higher intake at commencement, at maximal intake, and at both commencement and maximal intake were performed.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trial quality, and extracted data from included studies. We performed fixed-effect analyses and expressed treatment effects as mean difference (MD), risk ratio (RR), and risk difference (RD) with 95% confidence intervals (CIs) and assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

Thirty-two studies were eligible for inclusion. Six were short-term biochemical tolerance studies, one was in infants at > 35 weeks' gestation, one in term surgical newborns, and three yielding no usable data. The 21 remaining studies reported clinical outcomes in very preterm or low birth weight infants for inclusion in meta-analysis for this review.Higher AA intake had no effect on mortality before hospital discharge (typical RR 0.90, 95% CI 0.69 to 1.17; participants = 1407; studies = 14; I² = 0%; quality of evidence: low). Evidence was insufficient to show an effect on neurodevelopment and suggest no reported benefit (quality of evidence: very low). Higher AA intake was associated with a reduction in postnatal growth failure (< 10th centile) at discharge (typical RR 0.74, 95% CI 0.56 to 0.97; participants = 203; studies = 3; I² = 22%; typical RD -0.15, 95% CI -0.27 to -0.02; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 4 to 50; quality of evidence: very low). Subgroup analyses found reduced postnatal growth failure in infants that commenced on high amino acid intake (> 2 to ≤ 3 g/kg/day); that occurred with increased amino acid and non-protein caloric intake; that commenced on intake at < 24 hours' age; and that occurred with early lipid infusion.Higher AA intake was associated with a reduction in days needed to regain birth weight (MD -1.14, 95% CI -1.73 to -0.56; participants = 950; studies = 13; I² = 77%). Data show varying effects on growth parameters and no consistent effects on anthropometric z-scores at any time point, as well as increased growth in head circumference at discharge (MD 0.09 cm/week, 95% CI 0.06 to 0.13; participants = 315; studies = 4; I² = 90%; quality of evidence: very low).Higher AA intake was not associated with effects on days to full enteral feeds, late-onset sepsis, necrotising enterocolitis, chronic lung disease, any or severe intraventricular haemorrhage, or periventricular leukomalacia. Data show a reduction in retinopathy of prematurity (typical RR 0.44, 95% CI 0.21 to 0.93; participants = 269; studies = 4; I² = 31%; quality of evidence: very low) but no difference in severe retinopathy of prematurity.Higher AA intake was associated with an increase in positive protein balance and nitrogen balance. Potential biochemical intolerances were reported, including risk of abnormal blood urea nitrogen (typical RR 2.77, 95% CI 2.13 to 3.61; participants = 688; studies = 7; I² = 6%; typical RD 0.26, 95% CI 0.20 to 0.32; number needed to treat for an additional harmful outcome (NNTH) 4; 95% CI 3 to 5; quality of evidence: high). Higher amino acid intake in parenteral nutrition was associated with a reduction in hyperglycaemia (> 8.3 mmol/L) (typical RR 0.69, 95% CI 0.49 to 0.96; participants = 505; studies = 5; I² = 68%), although the incidence of hyperglycaemia treated with insulin was not different.

AUTHORS' CONCLUSIONS

Low-quality evidence suggests that higher AA intake in parenteral nutrition does not affect mortality. Very low-quality evidence suggests that higher AA intake reduces the incidence of postnatal growth failure. Evidence was insufficient to show an effect on neurodevelopment. Very low-quality evidence suggests that higher AA intake reduces retinopathy of prematurity but not severe retinopathy of prematurity. Higher AA intake was associated with potentially adverse biochemical effects resulting from excess amino acid load, including azotaemia. Adequately powered trials in very preterm infants are required to determine the optimal intake of AA and effects of caloric balance in parenteral nutrition on the brain and on neurodevelopment.

[Parenteral nutrition in premature babies with a birth weight <1500g: a systematic single-center analysis and comparison with current guidelines]

BACKGROUND

Parenteral and enteral nutrition are essential for both growth and development of preterm infants. Based on the results of many studies, the rate of nutritional growth and the amount of substrate delivered parenterally are under debate.

OBJECTIVE

The main aim of this study was to assess parenteral nutrition in very and extremely immature preterm infants, i.e. very low birth weight (VLBW, birth weight <1500g) and extremely low birth weight (ELBW, birth weight <1000g) neonates, and to compare the amount of parenterally delivered substrate in our neonatal intensive care unit (NICU) to current German guidelines.

METHODS

Retrospective audit at our tertiary NICU at the University Children's Hospital of Saarland, Homburg, Germany between 1 January 2009 and 31 December 2010.

RESULTS

In total, 100 premature neonates were included. The mean gestational age was 29.6 weeks (range 24.4-34.1 weeks) and the mean birth weight was 1119 g ± 260 g (range 570 g-1490 g). Comparing the amount of fluids, glucose, amino acids, lipids and kcals with the current guidelines of the German Society for Nutritional Medicine in preterm infants, only glucose was adequately given; however, a substantial number of weight-dependent (more often in ELBW neonates) episodes of hyperglycemia requiring insulin treatment were also seen. During the first 3 weeks of life a substantial drop in body weight, length and head circumference occurred in our study cohort. In contrast, at 2 years corrected age, catch-up growth was seen in our cohort with anthropometric data now comparable to healthy term infants. Using the Bayley II test for developmental outcome assessment, at 2 years corrected age 78.6% (33/42) of infants demonstrated normal development.

CONCLUSIONS

This retrospective data analysis demonstrated inadequate provision of parenteral nutrition in our NICU, which was often not in line with current German guidelines. This was associated with inadequate growth in our cohort, most notably during the first 3 weeks of life; however, implementation of current guidelines is impeded by metabolic disturbances in this cohort, most notably in ELBW neonates. Whether adherence to published guidelines will result in better early ex utero growth, and whether this normalized growth pattern will translate into better long-term outcome on a metabolic and neurological level, remains unclear.

Soy and phytoestrogens: possible side effects

Phytoestrogens are present in certain edible plants being most abundant in soy; they are structurally and functionally analogous to the estrogens. Phytoestrogens have been applied for compensation of hormone deficiency in the menopause. At the same time, soy products are used in infant food and other foodstuffs. Furthermore, soy is applied as animal fodder, so that residual phytoestrogens and their active metabolites such as equol can remain in meat and influence the hormonal balance of the consumers. There have been only singular reports on modified gender-related behavior or feminization in humans in consequence of soy consumption. In animals, the intake of phytoestrogens was reported to impact fertility, sexual development and behavior. Feminizing effects in humans can be subtle and identifiable only statistically in large populations.

Developing and implementing all-in-one standard paediatric parenteral nutrition

Parenteral nutrition (PN) is a feeding mode suitable for children that do not achieve requirements via the enteral route. For this intervention to be successful, healthcare professionals require: knowledge on nutrient requirements; access to an aseptic compounding facility; and a system that ensures adequate and safe delivery of PN. Previously, it was thought that individualised PN was the "gold standard" for delivering nutrients to children; however, studies have highlighted concerns regarding inadequate delivery of nutrients, prescribing and compounding errors. We, therefore, set out to develop and implement all-in-one (AIO) paediatric PN solutions. Through a systematic approach, four AIO PN solutions were developed: birth-two months of age (Ped 1); two months-10 kg (Ped 2); 11-15 kg (Ped 3); and 16-30 kg (Ped 4). We implemented them with the help of a teaching pack, over a one month time period, and reviewed usage at six months. At that time, five children initially received standard PN without electrolyte changes; but after a few days, electrolytes needed amendments, and three required individualised PN. A change to AIO PN is feasible and safe; however, some may require electrolyte changes, and there will always be those that will require individualised PN.

SCAMP: standardised, concentrated, additional macronutrients, parenteral nutrition in very preterm infants: a phase IV randomised, controlled exploratory study of macronutrient intake, growth and other aspects of neonatal care

Background

Infants born <29 weeks gestation are at high risk of neurocognitive disability. Early postnatal growth failure, particularly head growth, is an important and potentially reversible risk factor for impaired neurodevelopmental outcome. Inadequate nutrition is a major factor in this postnatal growth failure, optimal protein and calorie (macronutrient) intakes are rarely achieved, especially in the first week. Infants <29 weeks are dependent on parenteral nutrition for the bulk of their nutrient needs for the first 2-3 weeks of life to allow gut adaptation to milk digestion. The prescription, formulation and administration of neonatal parenteral nutrition is critical to achieving optimal protein and calorie intake but has received little scientific evaluation. Current neonatal parenteral nutrition regimens often rely on individualised prescription to manage the labile, unpredictable biochemical and metabolic control characteristic of the early neonatal period. Individualised prescription frequently fails to translate into optimal macronutrient delivery. We have previously shown that a standardised, concentrated neonatal parenteral nutrition regimen can optimise macronutrient intake.

Methods

We propose a single centre, randomised controlled exploratory trial of two standardised, concentrated neonatal parenteral nutrition regimens comparing a standard macronutrient content (maximum protein 2.8 g/kg/day; lipid 2.8 g/kg/day, dextrose 10%) with a higher macronutrient content (maximum protein 3.8 g/kg/day; lipid 3.8 g/kg/day, dextrose 12%) over the first 28 days of life. 150 infants 24-28 completed weeks gestation and birthweight <1200 g will be recruited. The primary outcome will be head growth velocity in the first 28 days of life. Secondary outcomes will include a) auxological data between birth and 36 weeks corrected gestational age b) actual macronutrient intake in first 28 days c) biomarkers of biochemical and metabolic tolerance d) infection biomarkers and other intravascular line complications e) incidence of major complications of prematurity including mortality f) neurodevelopmental outcome at 2 years corrected gestational age

Trial registration

Current controlled trials: ISRCTN76597892; EudraCT Number: 2008-008899-14

Important aspects of nutrition in children with cancer

Adequate nutrition during cancer plays a decisive role in several clinical outcome measures, such as treatment response, quality of life, and cost of care. However, the importance of nutrition in children and young adults with malignancies is still an underestimated topic within pediatric oncology. The importance of our work is to reinforce and indicate that malnutrition in children with cancer should not be accepted at any stage of the disease or tolerated as an inevitable process. Unique to our manuscript is the close collaboration, the exchange of knowledge and expertise between pediatric oncologists and a nutritional specialist, as well as the comprehension of the mechanisms during cancer cachexia and malnutrition. We provide a critical review of the current state of research and new knowledge related to nutritional management in childhood cancer.