Abstract

BackgroundRecent nutrition guidelines for extremely-low-birth-weight infants (ELBWIs) recommend implementation of high initial amino acid (AA) supplementation in parenteral nutrition.ObjectiveWe sought to evaluate the influence of AA intake on refeeding syndrome–like electrolyte disturbances including hypophosphatemia in ELBWIs.Study designMedical records of 142 ELBWIs were reviewed. Demographic, nutritional, outcome, and electrolyte data were compared between ELBWIs with initial low (1.5 g/kg/day) and high (3 g/kg/day) AA intake. Multivariate analysis was conducted to determine the odds ratio of hypophosphatemia with high AA intake and small-for-gestational-age (SGA) ELBWIs.ResultsThe incidence of hypophosphatemia and severe hypophosphatemia increased from 51% and 8% in period I to 59% and 20% in period II, respectively (p = 0.36 and < 0.01). Specifically, SGA ELBWIs showed higher incidence of hypophosphatemia than appropriate-for-gestational age (AGA) ELBWIs in period II, whereas there was no difference in period I. For severe hypophosphatemia, SGA ELBWIs presented a 27% incidence versus a 2% incidence in AGA ELBWIs, even with low initial AA intake. Despite no difference in phosphate intake between infants with and without hypophosphatemia, serum phosphate level reached a nadir at the sixth postnatal day and gradually recovered over the second week in infants with hypophosphatemia. In multivariate analyses, the odds ratios for severe hypophosphatemia were 3.6 and 6.6 with high AA intake and SGA status, respectively, with the highest being 18.0 with combined high AA intake and SGA status.ConclusionsIn summary, high initial AA intake significantly increased the risk of refeeding syndrome–like electrolyte dysregulations including severe hypophosphatemia in ELBWIs. In SGA ELBWIs, the risk of electrolyte disturbance was significantly higher, even with low initial AA intake. Therefore, new tailored parenteral nutrition protocols starting with lower energy intake and a gradual increase over the first week may be warranted for application in high-risk SGA ELBWIs.

Highlights

  • Nutritional support including higher calories and greater protein intake in the first week of life for extremely-low-birthweight infants (ELBWIs) reduces mortality and the appearance of morbidities such as bronchopulmonary dysplasia and late-onset sepsis and improves neurodevelopmental outcome [1,2]

  • High initial amino acid (AA) intake significantly increased the risk of refeeding syndrome–like electrolyte dysregulations including severe hypophosphatemia in ELBWIs

  • New tailored parenteral nutrition protocols starting with lower energy intake and a gradual increase over the first week may be warranted for application in high-risk small for gestational age (SGA) ELBWIs

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Summary

Introduction

Nutritional support including higher calories and greater protein intake in the first week of life for extremely-low-birthweight infants (ELBWIs) reduces mortality and the appearance of morbidities such as bronchopulmonary dysplasia and late-onset sepsis and improves neurodevelopmental outcome [1,2]. Recent ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition (PN) and Cochrane Database of Systematic Reviews on amino acid intake on PN in newborns recommend implementation of early aggressive nutrition composed of a PN regimen with high initial amino acid (AA) supplementation (2–3 g/kg/day) and initiation of early enteral trophic feeding soon after birth to limit cellular catabolism and promote extrauterine growth [3,4,5,6,7]. Beginning in October 2013, we changed the PN protocol from low (1.5 g/kg/day) to high (3 g/kg/day) initial AA intake in ELBWIs. In the present retrospective observational study, we reviewed the medical records of ELBWIs with a 23- to 28-week gestational age to determine whether our PN protocol change from low to high initial AA intake was associated with improved or worsened adverse refeeding syndrome–like hypophosphatemia, especially in SGA ELBWIs. Recent nutrition guidelines for extremely-low-birth-weight infants (ELBWIs) recommend implementation of high initial amino acid (AA) supplementation in parenteral nutrition

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