Abstract
BackgroundParenteral nutrition associated cholestasis (PNAC) is a frequently observed pathology in extremely low birth weight (ELBW) infants. Its pathogenesis is determined by the composition and duration of parenteral nutrition (PN) as well as the tolerance of enteral feeds (EF). “Aggressive” nutrition is increasingly used in ELBW infants to improve postnatal growth. Little is known about the effect of “aggressive” nutrition on the incidence of PNAC. We analyzed the influence of implementing an “aggressive” nutritional regimen on the incidence of PNAC and growth in a cohort of ELBW infants.MethodsELBW infants were nourished using a “conservative” (2005–6; n = 77) or “aggressive” (2007–9; n = 85) nutritional regimen that differed in the composition of PN after birth as well as the composition and timing of advancement of EFs. We analyzed the incidence of PNAC (conjugated bilirubin > 1.5 mg/dl (25 µmol/l)) corrected for confounders of cholestasis (i.e., NEC and/or gastrointestinal surgery, sepsis, birth weight, Z-score of birth weight, time on PN and male sex), growth until discharge (as the most important secondary outcome) and neonatal morbidities.ResultsThe incidence of PNAC was significantly lower during the period of “aggressive” vs. “conservative “nutrition (27% vs. 46%, P < 0.05; adjusted OR 0.275 [0.116–0.651], P < 0.01). Body weight (+411g), head circumference (+1 cm) and length (+1 cm) at discharge were significantly higher. Extra-uterine growth failure (defined as a Z-score difference from birth to discharge lower than −1) was significantly reduced for body weight (85% vs. 35%), head circumference (77% vs. 45%) and length (85% vs. 65%) (P < 0.05). The body mass index (BMI) at discharge was significantly higher (11.1 vs. 12.4) using “aggressive” nutrition and growth became more proportionate with significantly less infants being discharged below the 10th BMI percentile (44% vs. 9%), while the percentage of infants discharged over the 90th BMI percentile (3% vs. 5%) did not significantly increase.Discussion“Aggressive” nutrition of ELBW infants was associated with a significant decrease of PNAC and marked improvement of postnatal growth.
Highlights
Parenteral nutrition associated cholestasis (PNAC) is the most common form of liver damage in neonates while receiving parenteral nutrition (PN) (Kelly, 1998)
To avoid PNAC and other complications associated with PN, parenteral proteins and lipids were frequently withheld right after birth unless ‘‘metabolic tolerance’’ was assumed (Pereira, 1995) and enteral feeds (EF) were only cautiously introduced in fear of necrotizing enterocolitis (NEC) (Morgan, Young & Mcguire, 2011)
With ‘‘conservative’’ nutrition, PN was started after birth with glucose only, while protein and fat were slowly introduced during the first week of life
Summary
Parenteral nutrition associated cholestasis (PNAC) is the most common form of liver damage in neonates while receiving parenteral nutrition (PN) (Kelly, 1998). To avoid PNAC and other complications associated with PN, parenteral proteins and lipids were frequently withheld right after birth unless ‘‘metabolic tolerance’’ was assumed (Pereira, 1995) and EFs were only cautiously introduced in fear of necrotizing enterocolitis (NEC) (Morgan, Young & Mcguire, 2011) This ‘‘conservative’’ approach of nutrition caused a deficit in protein and energy supply (Embleton, Pang & Cooke, 2001) leading to postnatal growth failure—a common phenomenon in ELBW infants (Fanaroff et al, 2007). ELBW infants were nourished using a ‘‘conservative’’ (2005–6; n = 77) or ‘‘aggressive’’ (2007–9; n = 85) nutritional regimen that differed in the composition of PN after birth as well as the composition and timing of advancement of EFs. We analyzed the incidence of PNAC (conjugated bilirubin > 1.5 mg/dl (25 μmol/l)) corrected for confounders of cholestasis (i.e., NEC and/or gastrointestinal surgery, sepsis, birth weight, Z-score of birth weight, time on PN and male sex), growth until discharge (as the most important secondary outcome) and neonatal morbidities. Discussion. ‘‘Aggressive’’ nutrition of ELBW infants was associated with a significant decrease of PNAC and marked improvement of postnatal growth
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