[Standardised parenteral nutrition in low birth weight preterm newborns: a case report.]

The aim of this study is to evaluate the possibility of increasing the use of standardised parenteral nutrition (PN) as a replacement of individualized parenteral nutrition in the neonatal intensive care unit (NICU). The standardisation of the PN formulations has the potential to improve nutrient intakes, quality control, cost effectiveness and reduce prescription errors. In our hospital the individualized PN solutions are made by Chemists for premature babies born during the working days. We have been using standardised PN formulations for about two years for the preterm infants born during the weekend. The use of SPN is currently limited to the weekend, until our Chemists can prepare the IPN.In this study we describe the case of a sick low birth weight baby for whom we used for the first time the bags of a standardised PN "ready to use" since the sixth day of life for thirteen consecutive days. The baby was not a very low birth weight, but he needed parenteral nutrition because he was relatively unstable and he had a poor feeding tolerance. As result of the study, the baby growth was regular and the SPN were well tolerated. No adverse effects were reported.

Early versus late parenteral nutrition for critically ill term and late preterm infants

BACKGROUND

Recently conducted randomised controlled trials (RCTs) suggest that late commencement of parenteral nutrition (PN) may have clinical benefits in critically ill adults and children. However, there is currently limited evidence regarding the optimal timing of commencement of PN in critically ill term and late preterm infants.

OBJECTIVES

To evaluate the benefits and safety of early versus late PN in critically ill term and late preterm infants.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (5 April 2019), MEDLINE Ovid (1966 to 5 April 2019), Embase Ovid (1980 to 5 April 2019), EMCare (1995 to 5 April 2019) and MEDLINE via PubMed (1966 to 5 April 2019). We searched for ongoing or recently completed clinical trials, and also searched the grey literature and reference lists of relevant publications.

SELECTION CRITERIA

We included RCTs comparing early versus late initiation of PN in term and late preterm infants. We defined early PN as commencing within 72 hours of admission, and late PN as commencing after 72 hours of admission. Infants born at 37 weeks' gestation or more were defined as term, and infants born between 34 and 36⁺⁶ weeks' gestation were defined as late preterm.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials, extracted the data and assessed the risk of bias. Treatment effects were expressed using risk ratio (RR) and risk difference (RD) for dichotomous outcomes and mean difference (MD) for continuous data. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

Two RCTs were eligible for inclusion. Data were only available from a subgroup (including 209 term infants) from one RCT in children (aged from birth to 17 years) conducted in Belgium, the Netherlands and Canada. In that RCT, children with medium to high risk of malnutrition were included if a stay of 24 hours or more in the paediatric intensive care unit (PICU) was expected. Early PN and late PN were defined as initiation of PN within 24 hours and after day 7 of admission to PICU, respectively. The risk of bias for the study was considered to be low for five domains and high for two domains. The subgroup of term infants that received late PN had significantly lower risk of in-hospital all-cause mortality (RR 0.35, 95% confidence interval (CI) 0.14 to 0.87; RD -0.10, 95% CI -0.18 to -0.02; number needed to treat for an additional beneficial outcome (NNTB) = 10; 1 trial, 209 participants) and neonatal mortality (death from any cause in the first 28 days since birth) (RR 0.29, 95% CI 0.10 to 0.88; RD -0.09, 95% CI -0.16 to -0.01; NNTB = 11; 1 trial, 209 participants). There were no significant differences in rates of healthcare-associated blood stream infections, growth parameters and duration of hospital stay between the two groups. Neurodevelopmental outcomes were not reported. The quality of evidence was considered to be low for all outcomes, due to imprecision (owing to the small sample size and wide confidence intervals) and high risk of bias in the included studies.

AUTHORS' CONCLUSIONS

Whilst late commencement of PN in term and late preterm infants may have some benefits, the quality of the evidence was low and hence our confidence in the results is limited. Adequately powered RCTs, which evaluate short-term as well as long-term neurodevelopmental outcomes, are needed.

Parenteral nutrition and oxidant stress in the newborn: A narrative review

There is strong evidence that oxidant molecules from various sources contaminate solutions of parenteral nutrition following interactions between the mixture of nutrients and some of the environmental conditions encountered in clinical practice. The continuous infusion of these organic and nonorganic peroxides provided us with a unique opportunity to study in cells, in vascular and animal models, the mechanisms involved in the deleterious reactions of oxidation in premature infants. Potential clinical impacts of peroxides infused with TPN include: a redox imbalance, vasoactive responses, thrombosis of intravenous catheters, TPN-related hepatobiliary complications, bronchopulmonary dysplasia and mortality. This is a narrative review of published data.

Evaluating Differences in Aluminum Exposure through Parenteral Nutrition in Neonatal Morbidities

Aluminum is a common contaminant in many components of parenteral nutrition, especially calcium and phosphate additives. Although long-term effects have been described in the literature, short-term effects are not well-known. Currently, the Food and Drug Administration recommends maintaining aluminum at <5 mcg/kg/day. This was a single center, retrospective case-control study of 102 neonatal intensive care unit patients. Patients were included if they had a diagnosis of necrotizing enterocolitis, rickets/osteopenia, or seizures and received at least 14 days of parenteral nutrition. Patients were matched 1:1 with control patients by gestational age and birth weight. Mean total aluminum exposure for the 14 days of parenteral nutrition was calculated using manufacturer label information. Differences in mean aluminum exposure between cases and controls, as well as subgroup analysis in those with renal impairment or cholestasis, was conducted. Aluminum exposure in patients meeting inclusion criteria closely mirrored the aluminum exposure of control patients. The difference in aluminum exposure was not found to be statistically significant, except in patients with cholestasis. Although the study found no difference in aluminum exposure in short-term complications with neonates, long-term complications are well established and may warrant the need to monitor and limit neonatal aluminum exposure.

Safety of parenteral nutrition in newborns: Results from a nationwide prospective cohort study

BACKGROUND & AIMS

Limited or delayed availability of parenteral nutrition (PN) solutions, as well as difficulties in ordering are often identified as reasons for non-compliance with international guidelines in newborns. This study aims at assessing the modality of use and safety of premixed standardized PN solutions in a nationwide prospective cohort of newborns treated in clinical practice.

METHODS

Two premixed fixed formulations with respective osmolarity of 715 and 790 mOsm/L specifically designed for neonates were made available throughout the country for clinical use from birth onwards. Descriptive data and modality of use were prospectively collected in a case report form, whereas all related and unrelated adverse events were recorded on a separate adverse event form.

RESULTS

A total of 14,167 infants were prospectively included and 16,640 parenteral nutrition periods were analyzed. Mean age was 33 weeks of gestation, and mean weight was 2086 g. The majority of infants (81%) started the parenteral nutrition the first day of life or the day after. The route of parenteral nutrition delivery was peripheral in 47% of the parenteral nutrition periods. During the whole study, a total of 72 adverse events occurring in 68 infants were reported. Of these adverse events, 59 (0.37% of the nutrition periods), among which 19 serious adverse events, were reported as related to the parenteral nutrition solutions. The events related to parenteral nutrition solutions were general disorders and administration site conditions (n = 42 including 9 cases of cutaneous necrosis), and nutrition and metabolism disorders (n = 17). There was no case of thrombophlebitis. Six of the 19 serious events related to the parenteral nutrition solutions (32%) were due to the misuse of the infusion bag.

CONCLUSIONS

These data support the concept that ready-to-use parenteral nutrition formulations can safely provide parenteral nutrition from birth onwards. They further support that parenteral solutions with an osmolarity up to 800 mOsm/L are well-tolerated when infused on a peripheral vein. Considering the potential risk of errors and misuses, this study also highlights the need for nutrition practice care guidelines for neonates and for regular campaigns providing information and strategies for a safe use of parenteral nutrition solutions.

The study of early intravenous nutrition therapy in very low birth weight infants

To analyze the clinical effect of early intravenous nutrition therapy for very low birth weight infants. 80 cases of very low birth weight infants referred to our hospital from June 2013 to June 2015 were randomly and evenly divided into two groups. The infants in group A were treated with early intravenous nutrition, while with late parenteral nutrition for those in group B. The intravenous nutrition time, proportion of body weight loss, time consumption for recovery to birth weight and full enteral nutrition and complication rate between the two groups were compared. We found that there were significant differences in the intravenous nutrition time, proportion of body weight loss, and time consumption for recovery to birth weight and full enteral nutrition between the two groups (P<0.05). Moreover, the complication rate of group A was 7.5%, which was 17.5% lower comparing with 25.0% in group B (P<0.05). Thus, we conclude that early intravenous nutrition therapy in very low birth weight infants is effective and safe and further promotion and application of this therapy is worthy.

Aluminum contamination in parenteral products

PURPOSE OF REVIEW

In 1986, the US Food and Drug Administration issued an aluminum mandate in hopes of minimizing patient exposure to aluminum contaminates contained in parenteral nutrition additives. The purpose of this article is to revisit the status of aluminum contamination as it relates to parenteral nutrition and to survey the recent literature to determine if any new findings have emerged. A special emphasis will be placed on the complications associated with aluminum toxicity.

RECENT FINDINGS

In addition to metabolic bone disease, patients with aluminum toxicity are also prone to other complications such as neurodevelopmental delays and cholestasis. Other potentially serious consequences, including osteoporosis, growth failure, and dementia, can arise years after the initial exposure to aluminum, showing that preventing toxicity is imperative.

SUMMARY

Unlike the rapid response to eliminating aluminum toxicity in the dialysis patient population, similar successes have not been realized in patients receiving parenteral nutrition solutions. Product formulation changes have been slow to emerge from manufacturers. It remains the responsibility of healthcare practitioners to recognize the patient populations at risk for toxicity and act accordingly. Monitoring aluminum status and purchasing products known to possess the least amount of aluminum are two such approaches.

[Secondary hemophagocytic syndrome: report of 5 cases]

Secondary hemophagocytic syndrome (HFS) is an uncommon entity with a high mortality rate in adults, if no therapy is given. It is characterized by a severe hipercytokinemia due to a highly stimulated but ineffective immune system. The principal causes are infections, malignancy or autoimmune diseases. It appears as a serious illness, similar to a multiorgan failure. Treatment is not well defined. We report five patients with HFS, aged 17 to 51 years (three females). The etiology was onco-hematological in three patients. In two patients, the diagnosis was performed during necropsy. One case was due to cytomegalovirus (CMV) infection in a hepatic transplant patient and the other, due to parenteral lipid administration. All presented fever, cytopenia, hepatosplenomegaly and hemophagocytosis. Four of them required admission in an Intensive Care Unit. All received different treatment modalities. Only one survived. Median survival time was 75 days. In conclusion, HFS has different etiologies and a high mortality in adults.

Standardised parenteral nutrition

Parenteral nutrition (PN) has become an integral part of clinical management of very low birth weight premature neonates. Traditionally different components of PN are prescribed individually considering requirements of an individual neonate (IPN). More recently, standardised PN formulations (SPN) for preterm neonates have been assessed and may have advantages including better provision of nutrients, less prescription and administration errors, decreased risk of infection, and cost savings. The recent introduction of triple-chamber bag that provides total nutrient admixture for neonates may have additional advantage of decreased risk of contamination and ease of administration.

Hypercalcemia and acute kidney injury caused by abuse of a parenteral veterinary compound containing vitamins A, D, and E

A previously healthy 19 year-old male presented to the hospital with anorexia, nausea, and vomiting. Laboratory studies were significant for hypercalcemia (peak calcium value of 14.8 mg/dL) and acute kidney injury (peak serum creatinine of 2.88 mg/dL). He admitted to using a parenteral formulation of vitamins A, D and E restricted for veterinary use containing 20,000,000 IU of vitamin A; 5,000,000 IU of vitamin D3; and 6,800 IU of vitamin E per 100 mL vial. The patient stated to have used close to 300 mL of the product over the preceding year. Interestingly, the young man was not interested in the massive amounts of vitamins that the product contained; he was only after the local effects of the oily vehicle. The swelling produced by the injection resulted in a silicone-like effect, which gave the impression of bigger muscles. Nevertheless, the product was absorbed and caused hypervitaminosis. The serum level of 25(OH) vitamin D was clearly elevated at 150 ng/mL (reference range from 30 to 60 ng/mL), but in most published cases of vitamin D toxicity, serum levels have been well above 200 ng/mL. His PTH level was undetectable and other potential causes of hypercalcemia were excluded. Therefore, we posit that the severity of the hypercalcemia observed in this case was the result of a synergistic effect of vitamins A and D. The patient was treated with normal saline, furosemide and zolendronic acid, with rapid normalization of calcium levels and renal function.

Fluid and electrolyte intake during the first week of life in preterm infants receiving parenteral nutrition according current guidelines

There is growing evidence that early water and electrolyte homeostasis may be influenced by energy balance in preterm infants. Some fluid and electrolyte disturbances of postnatal life could be in part promoted by the catabolism due to withheld amino acid and energy supply after birth. According to current guidelines parenteral nutrition with relatively high protein and lipid needs is commenced on day one. By turning the nitrogen balance from negative to zero or even positive, amino acid administration could also minimize the occurrence of water and ions disturbances after birth especially in extremely preterm infants. Future researches are needed in order to further investigate the impact of amino acid and energy intake on early fluid balance in preterm infants.