Days Of Parenteral Nutrition Research Articles

Using a WeChat mini-program-based lactation consultant intervention to increase the consumption of mother’s own milk by preterm infants in the neonatal intensive care unit: a study protocol for a cluster randomized controlled trial

BackgroundThe benefits of mother’s own milk (MOM) for preterm infants have been widely recognized. Many studies have shown that the rate of breastfeeding of premature infants remains very low. Although many studies use measures to promote breastfeeding, few high-quality cluster randomized controlled studies have evaluated the effectiveness of these measures. WeChat is an instant messaging software for smart terminals, and WeChat mini-programs have been widely used to promote health and self-management in China. Based on this background, we designed a randomized controlled study based on WeChat mini-programs to promote MOM feeding of premature infants in the neonatal intensive care unit (NICU).Methods/designThis study will evaluate the effectiveness of WeChat mini-programs to increase the consumption of MOM feeding in twelve NICUs in Jiangsu Province, namely, six “intervention” NICUs and six “control” NICUs. The study process is as follows: (1) design and preparation, (2) NICU recruitment and training, (3) interpretation and analysis of baseline data, (4) quality control implementation process, and (5) data analysis feedback and publication of study reports. The primary outcome is the proportion of MOM feeding of premature infants during NICU hospitalization. The secondary outcomes are as follows: (1) time to initiation of MOM feeding (hours) and proportion of first-time MOM feeding (%), (2) duration of parenteral nutrition (days), (3) time to total gastrointestinal feeding (days), (4) hospitalization time and hospitalization cost, and (5) incidence of complications (necrotizing enterocolitis, bronchopulmonary dysplasia, feeding intolerance, late-onset sepsis, retinopathy of prematurity).DiscussionThis study is the first cluster randomized controlled trial on the intervention of using a WeChat mini-program-based lactation consultant for premature infants in the NICU in China. We hope this study can improve the consumption of MOM by NICU premature infants during hospitalization through the intervention of WeChat mini-programs.Trial registrationClinicalTrials.gov NCT04383379. Registered on May 5, 2020.

60 Impact of sequential implementation of a standardized feeding protocol and donor breastmilk on necrotizing enterocolitis among preterm infants born <31 weeks gestation

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Necrotizing enterocolitis (NEC) is the leading cause of gastrointestinal morbidity and mortality among preterm infants born <31 weeks. Nutritional interventions such as a standardized feeding protocol (SFP) and donor breastmilk (DBM) are recommended to reduce NEC. Objectives Our objective was to assess the impact of implementing a feeding protocol and pasteurized donor breastmilk protocol on NEC among preterm infants born < 31 weeks GA. Design/Methods Retrospective cohort study including 682 infants born < 31 weeks, who survived ≥ 14 days and were admitted to two tertiary NICUs from 2009-2018. Data was obtained from the local Canadian Neonatal Network database. Infants were classified into epochs, based on the timing of interventions: Epoch 1, baseline (2009-2012); Epoch 2, SFP (2013-2015); Epoch 3, SFP + DBM (2016-2018). The primary outcome was NEC stage ≥ 2. Multivariable logistic regression models were used to assess associations between epochs and outcomes and were adjusted for confounders. Results Among 682 infants, 46 (7%) had NEC and 74 (11%) had mortality/NEC. Rates of NEC decreased with each epoch: 10% (25/246) Epoch 1 (baseline); 5% (8/163) Epoch 2 (SFP); and 5% (13/273) Epoch 3 (SFP+DBM), (p<0.01) (Table1). SFP alone was associated with significantly lower odds of NEC compared to baseline (Epoch 2 vs 1, AOR 0.42, 95% CI 0.17-0.93) (Table 2). Implementation of DBM was not associated with lower odds of NEC compared to SFP alone (Epoch 3 vs 2, AOR 0.94, 95% CI 0.38-2.42) (Table2). Number of NPO days prior to the initiation of enteric feeds after birth decreased in Epoch 3 (Epoch 1&2: 2 days versus Epoch 3: 1 day; p<0.01). Exclusive human breastmilk feeds during the first 3 weeks increased from 62% in Epoch 2 to 82% in Epoch 3 (p<0.01). A significant decrease in number of total parenteral nutrition and central venous line (CVL) days was observed from Epoch 1 to 3 (25 to 15 days and 26 to 15 days respectively; p<0.01) (Table 1), this was reflected in the decrease in late onset sepsis (Epoch 3 vs 1, AOR 0.55, 95% CI 0.35-0.86). Conclusion Implementation of SFP was associated with a significant decrease in NEC among infants born < 31 weeks. Combining the SFP and DBM did not further decrease NEC, but was associated with shorter NPO days, higher exclusive human breastmilk exposure, and significant decrease in number of central venous line (CVL) days.

Failure to Thrive and Vomiting in a 32-day-old Girl.

Failure to Thrive and Vomiting in a 32-day-old Girl.

Long-term assessment of bilirubin and transaminase trends in pediatric intestinal failure patients during the era of hepatoprotective parenteral nutrition

PurposeThis study aimed to characterize the relationship between hepatoprotective parenteral nutrition (PN) dependence and long-term serum liver tests in children with intestinal failure (IF). MethodsA retrospective review was performed of children with severe IF (> 90 consecutive days of PN) who were followed from 2012 to 2019 at a multidisciplinary intestinal rehabilitation program. Patients were stratified into three groups based on level of PN dependence at most recent follow up: EN (achieved enteral autonomy), mixed (parenteral and enteral nutrition), and PN (> 75% of caloric intake from PN). PN at any point for this cohort was hepatoprotective, defined as soy-based lipids < 1.5 g/kg/day, combination (soy, medium chain fatty acid, olive and fish oil) lipid emulsion, or fish oil-based lipid emulsion. Kaplan-Meier analysis and a generalized estimating equation (GEE) model were utilized to estimate time to normalization and trends, respectively, of two serum markers of liver health: direct bilirubin (DB) and alanine aminotransferase (ALT). ResultsThe study included 123 patients (67 EN, 32 mixed, 24 PN). Median follow up time was 4 years. Based on the Kaplan Meier curve, 100% of EN and mixed group patients achieved normal DB levels by 3 years, while 32% of the PN group had elevated DB levels (Fig. 1). At 5 years, 16% of EN patients had elevated ALT levels compared to 73% of PN patients (p < 0.001, Fig. 2). The PN group's ALT levels were 1.76-fold above normal at 3 years (95%CI 1.48–2.03) and 1.65-fold above normal at 5 years (95%CI 1.33–1.97, Fig. 3). ConclusionsWhile serum bilirubin levels tend to normalize, long-term PN dependence in the era of hepatoprotective PN is associated with a persistent transaminase elevation in an overwhelming majority of patients. These data support continued vigilant monitoring of liver health in children with intestinal failure. Level of evidenceIII

NF-κB Regulation of LRH-1 and ABCG5/8 Potentiates Phytosterol Role in the Pathogenesis of Parenteral Nutrition-Associated Cholestasis.

Chronically administered parenteral nutrition (PN) in patients with intestinal failure carries the risk for developing PN-associated cholestasis (PNAC). We have demonstrated that farnesoid X receptor (FXR) and liver X receptor (LXR), proinflammatory interleukin-1 beta (IL-1β), and infused phytosterols are important in murine PNAC pathogenesis. In this study we examined the role of nuclear receptor liver receptor homolog 1 (LRH-1) and phytosterols in PNAC. In a C57BL/6 PNAC mouse model (dextran sulfate sodium [DSS] pretreatment followed by 14 days of PN; DSS-PN), hepatic nuclear receptor subfamily 5, group A, member 2/LRH-1 mRNA, LRH-1 protein expression, and binding of LRH-1 at the Abcg5/8 and Cyp7a1 promoter was reduced. Interleukin-1 receptor-deficient mice (Il-1r-/- /DSS-PN) were protected from PNAC and had significantly increased hepatic mRNA and protein expression of LRH-1. NF-κB activation and binding to the LRH-1 promoter were increased in DSS-PN PNAC mice and normalized in Il-1r-/- /DSS-PN mice. Knockdown of NF-κB in IL-1β-exposed HepG2 cells increased expression of LRH-1 and ABCG5. Treatment of HepG2 cells and primary mouse hepatocytes with an LRH-1 inverse agonist, ML179, significantly reduced mRNA expression of FXR targets ATP binding cassette subfamily C member 2/multidrug resistance associated protein 2 (ABCC2/MRP2), nuclear receptor subfamily 0, groupB, member 2/small heterodimer partner (NR0B2/SHP), and ATP binding cassette subfamily B member 11/bile salt export pump (ABCB11/BSEP). Co-incubation with phytosterols further reduced expression of these genes. Similar results were obtained by suppressing the LRH-1 targets ABCG5/8 by treatment with small interfering RNA, IL-1β, or LXR antagonist GSK2033. Liquid chromatography-mass spectrometry and chromatin immunoprecipitation experiments in HepG2 cells showed that ATP binding cassette subfamily G member 5/8 (ABCG5/8) suppression by GSK2033 increased the accumulation of phytosterols and reduced binding of FXR to the SHP promoter. Finally, treatment with LRH-1 agonist, dilauroyl phosphatidylcholine (DLPC) protected DSS-PN mice from PNAC. This study suggests that NF-κB regulation of LRH-1 and downstream genes may affect phytosterol-mediated antagonism of FXR signaling in the pathogenesis of PNAC. LRH-1 could be a potential therapeutic target for PNAC.

Using Machine Learning Algorithms to Predict Candidaemia in ICU Patients With New-Onset Systemic Inflammatory Response Syndrome.

Background: Distinguishing ICU patients with candidaemia can help with the precise prescription of antifungal drugs to create personalized guidelines. Previous prediction models of candidaemia have primarily used traditional logistic models and had some limitations. In this study, we developed a machine learning algorithm trained to predict candidaemia in patients with new-onset systemic inflammatory response syndrome (SIRS).Methods: This retrospective, observational study used clinical information collected between January 2013 and December 2017 from three hospitals. The ICU patient data were used to train 4 machine learning algorithms–XGBoost, Support Vector Machine (SVM), Random Forest (RF), ExtraTrees (ET)–and a logistic regression (LR) model to predict patients with candidaemia.Results: Of the 8,002 cases of new-onset SIRS (in 7,932 patients) included in the analysis, 137 new-onset SIRS cases (in 137 patients) were blood culture positive for candidaemia. Risk factors, such as fungal colonization, diabetes, acute kidney injury, the total number of parenteral nutrition days and renal replacement therapy, were important predictors of candidaemia. The XGBoost machine learning model outperformed the other models in distinguishing patients with candidaemia [XGBoost vs. SVM vs. RF vs. ET vs. LR; area under the curve (AUC): 0.92 vs. 0.86 vs. 0.91 vs. 0.90 vs. 0.52, respectively]. The XGBoost model had a sensitivity of 84%, specificity of 89% and negative predictive value of 99.6% at the best cut-off value.Conclusions: Machine learning algorithms can potentially predict candidaemia in the ICU and have better efficiency than previous models. These prediction models can be used to guide antifungal treatment for ICU patients when SIRS occurs.

Mucous Fistula Refeeding Promotes Earlier Enteral Autonomy in Infants With Small Bowel Resection.

Infants requiring intestinal resection because of necrotizing enterocolitis (NEC) or small bowel atresia (SBA) may benefit from mucous fistula refeeding (MFR) of enterostomy output to improve nutrition and bowel adaptation before reanastomosis. Previous series demonstrated improved outcomes with MFR but did not account for varied patient characteristics as potential sources of bias. We performed a cohort analysis using multivariable adjusted models to compare outcomes of patients with and without MFR. Retrospective chart review was performed for patients with NEC or SBA and small bowel resection with enterostomy and MF. Demographic and outcome data was compared between MFR and non-MFR groups using adjusted multivariable analysis for potential confounding variables. MFR was performed in 65 of 101 patients (64%), including 45 of 75 patients with NEC and 20 of 26 patients with SBA. Reasons for not receiving MFR included bowel stricture, technical limitation, or not otherwise specified. NEC patients receiving MFR had 14 fewer days to achieve full enteral feeds after intestinal reconnection, 22 fewer days of parenteral nutrition, lower peak direct bilirubin by 2.4 mg/dL, and 77% less odds of ursodiol use (all P < 0.01). SBA patients had similar trends not reaching statistical significance. Growth parameters were improved in MFR groups. There were no complications or increased infections from MFR. This study suggests that MFR safely improves nutritional outcomes in infants with intestinal resection, related to decreased total parenteral nutrition (TPN) dependence and earlier enteral autonomy.

*O-29: Medical Predictors of Social-emotional and Adaptive Functioning in School-Age Pediatric Intestinal Failure

Introduction: Long-term survival in pediatric intestinal failure (IF) has improved over recent decades due to medical/surgical advances and the development of multi-disciplinary rehabilitation programs. Focus has shifted towards identifying neurodevelopmental morbidities and promoting optimal quality of life. There has been little exploration into social-emotional and adaptive functioning. Methods: Children (4-18 years) in our IF rehabilitation program underwent neuropsychological assessments (2012-2019) which included caregiver- and teacher-reported social-emotional (BRIEF/BRIEF-2, BASC-2/BASC-3) and adaptive (ABAS-II/ABAS-3, SIB-R, Vineland-II, BASC-2/BASC-3) functioning questionnaires. Results were compared to age-matched norms (mean=100; SD=15) using one-sample z-tests. Medical variables showing ≥3 significant correlations with social-emotional and adaptive functioning outcomes were included in linear regression analyses to explore medical factors independently associated with psychological outcomes. Results: Overall, 74 children (55% males) underwent assessments (median assessment age: 6.5 years, IQR:6.1-8.1). Most children (72%) were premature (median gestational age [GA]: 34 weeks, IQR:29-37; median birth weight [BW]: 2.1kg, IQR:1.1-2.6). The most frequent IF etiology was necrotizing enterocolitis (NEC; 32%). Although caregiver- and teacher-report indicated broadly average-range mean scores, given the standard deviations, the group performed significantly poorer than age-matched norms on executive functioning, internalizing emotional problems (i.e., anxiety, depression, somatization), and adaptive functioning (Figure). GA, NEC diagnosis, duration of first year hospitalization, and total ambulatory clinic appointments correlated with ≥3 social-emotional and adaptive functioning outcomes while BW, small and large bowel length, total septic episodes, and total parenteral nutrition days did not. In the regression, adjusted for GA, NEC diagnosis predicted internalizing emotional problems. Duration of first year hospitalization and total ambulatory clinic appointments were both non-significant. Conclusions: Relative to population norms, the group displayed executive dysfunctions, emotional issues, and poor adaptive functioning. NEC diagnosis and GA, rather than IF related factors, posed heightened risk for emotional issues. Future research should explore demographic risk factors to further inform clinical screening and targeted intervention.Figure.: Social-Emotional and Adaptive Functioning in School-Age Pediatric Intestinal Failure Compared to Age-Matched Population Norms.

Effects of different lipid emulsions on serum adipokines, inflammatory markers and mortality in critically ill patients with sepsis: A prospective observational cohort study

Intravenous lipid emulsions in parenteral nutrition may cause different metabolic responses and immune effects in critically ill patients with sepsis. The aim of this study is to investigate the effects of different lipid emulsions on changes in concentrations of adipokine and cytokine and their relationship with mortality in patients. Patients enrolled in this prospective, single-center, observational cohort study, were estimated to require more than ten days of parenteral nutrition. They were treated with soybean oil-based or olive oil-based parenteral lipid emulsions. Adipokine and cytokine concentrations of septic patients were determined at enrollment and ten days after, in accordance with the diagnostic criteria of SEPSIS-3. The concentrations levels were measured in an enzyme-linked immunosorbent assay. Mortality was analyzed using the Kaplan-Meier method and Cox regressions. Over a 25-month period, 145 patients were assessed for eligibility and consequently, 40 patients were analyzed. On admission, both groups had comparable physiological scores, comorbidities, malnutrition risk, anthropometric measurements, metabolic/hematologic biomarkers and concentrations of adipokines and cytokines (p>.05). Serum leptin, resistin, and cytokines (IL-6, IL-10, IL-1β and TNF-α) decreased significantly in the entire cohort over ten days following sepsis (p<.05). Serum resistin decreased in both olive oil-based and soybean oil-based lipid emulsions groups. Serum adiponectin only decreased in soybean oil-based lipid emulsions group (p<.05). There was association between survival and percentage changes in adiponectin, resistin and visfatin concentrations (log rank test: p<.05). Adipokine and cytokine responses are affected by medical nutritional therapy in the sepsis process and adipokines may represent functional prognostic biomarkers in critically ill patients with sepsis.

Anastomosis near to the ileocecal valve in neonates with focal intestinal perforation, is it safe

Background Anastomosis near the ileocecal valve (ICV) are controversial due to the increased pressure on the suture; in this situation, the valve could be removed at a first stage or at the moment of stoma closure. However, preservation of the ICV has proved important benefits in the long term. The aim of this study is to evaluate its feasibility in neonates with focal intestinal perforation (FIP). Methods Retrospective study (2010–2019) of neonates with FIP who underwent intestinal resection and primary anastomosis. Patients were divided into group A (anastomosis less than 5 cm from ICV) and group B (more than 5 cm). Results Forty patients were treated. Patients ostomized or with resection of ICV were excluded. Finally, 24 patients (birth weight 1043 ± 594 g (520–3000), age 8.8 ± 7.8 days (2–39)) were included for analysis. Patent ductus arteriosus was present in 75%. There were 6 patients in group A (25%) and 18 in group B (75%). Groups were comparable in terms of gestational age, birth weight, and age at the time of surgery (p > .05). There were no cases of dehiscence nor stenosis of the anastomosis. There were no differences in reoperation rate, infectious complications, time to enteral feeding, days of parenteral nutrition, hospital stay nor survival (p > .05). Conclusion Ileo-ileal anastomosis closer to the ileocecal junction, in neonates with focal intestinal perforation, is an effective and safe option which also allows the preservation of the ICV avoiding the complications derived from its absence in a group of patients with high morbidity.

Outcome of primary peritoneal drainage in perforated necrotizing enterocolitis: an experience with 96 infants

Background: Necrotizing enterocolitis is a life-threatening inflammation of neonatal intestine of multifactorial etiology. In early stages, medical management is considered; while as a transmural disease with pneumatosis or perforation needs surgical attention. Primary peritoneal drainage has evolved as an alternative to classic exploratory laparotomy especially in sick preterm and very low birth weight infants.Methods: In our study, we tried to employ primary peritoneal drainage as an initial intervention in all surgical necrotizing enterocolitis patients and analyzed the results and final outcome in terms of total days in neonatal intensive care unit, total parenteral nutrition days, days to start oral feeds, need for laparotomy, mortality and other complications.Results: Around one-third patients were either very low or extremely low birth weight and 80% patients were preterm. Primary peritoneal drainage was successful without need for laparotomy in around 65% of patients. In the rest 34 patients, 24 were subjected to rescue laparotomy, while 10 could not be stabilized for major surgery. Overall mortality was 29.16%.Conclusions: Early bedside primary peritoneal drainage can be employed in all cases of NEC with perforation with rescue laparotomy to be determined by subsequent monitoring. This strategy seems to be safe and cost-effective in a resource challenged set up and lifesaving in sick and extremely low birth weight infants.

Routine prefeed gastric aspiration in preterm infants: a systematic review and meta-analysis.

Despite lack of evidence, the practice of routine prefeed gastric residue aspiration before the next feed is common. Recent studies suggest that this practice might be even harmful. Therefore, we aimed to evaluate the effect of avoiding routine prefeed gastric residue aspiration as compared to routine aspiration, on various clinical outcomes in preterm infants. We searched five different electronic databases (MEDLINE, EMBASE, Web of Science, CINAHL, and Cochrane Library) until March 8, 2021. Only randomized controlled trials comparing the practice of routine prefeed gastric aspiration with no routine aspiration in preterm infants were considered eligible. The random-effects meta-analysis was done using RevMan 5.3 software. Of the 894 unique records identified by our search, we included 6 studies (451 participants) in the review. There was no significant difference in the incidence of necrotizing enterocolitis (RR 0.80; 95% CI 0.31 to 2.08; 421 participants in 5 trials). Avoiding routine prefeed aspiration was associated with achieving full enteral feeds earlier (MD - 3.19 days, 95% CI - 4.22 to - 2.16), shorter duration of hospitalization (MD - 5.32 days; 95% CI - 10.25 to - 0.38), and lower incidence of late-onset sepsis (RR 0.77; 95% CI 0.60 to 0.99). Time to regain birth weight, days of total parenteral nutrition or central venous line usage, culture-positive sepsis, and all-cause mortality did not differ between the two groups.Conclusion: In the absence of other signs of feed intolerance, routine prefeed gastric residue aspiration should be avoided in preterm infants.Prospero registration number: CRD42020197657 What is Known: • Though, routine prefeed aspiration before next feed is a common practice in preterm gavage-fed infants. • Recent study suggests that the omission of routine gastric residual evaluation led to improved weight gain and earlier hospital discharge. What is New: • Low- to moderate-quality evidence suggest that avoiding routine prefeed gastric residue monitoring helps in the reduction of late-onset sepsis, achieving full enteral feeds earlier, and earlier discharge from the hospital. • Abandoning the practice of routine prefeed aspiration in absence of other signs of feed intolerance in preterm low birthweight neonates is safe.

The role of feeding advancement strategy on length of stay and hospital costs in newborns with gastroschisis

Background: Infants with gastroschisis require prolonged hospitalization for surgical repair and gradual advancement of feeds. The present study explores the effect of a change in a protocolized enteral feeding regimen with length of hospital stay (LOS) and total costs in newborns with gastroschisis. Methods: A retrospective review was performed in neonates with uncomplicated gastroschisis at a free-standing pediatric institution from 2012 to 2020. The effect of two different enteral feed advancement protocols on clinical outcomes and hospital costs was analyzed. Results: Seventy-four patients were identified, of which 50 (68%) underwent 10 ml/kg/day feeding advancements, and 24 (32%) underwent 20 ml/kg/day feeding advancements. Compared to neonates who underwent 10 ml/kg/day enteral advancements, neonates receiving 20 ml/kg/day advancements reached goal feeds faster (14 vs 20 days, p<0.001), were younger at goal feeds (26 vs 34 days, p = 0.001), required fewer days of parenteral nutrition (22 vs 29 days, p = 0.001), and had shorter LOS (30 vs 36 days, p = 0.001). On multivariable analysis, total costs decreased by 9.77% in the 20 ml/kg/day advancement cohort (p = 0.071). Conclusion: In neonates with uncomplicated gastroschisis who underwent primary repair, a nutritional protocol that incorporated 20 ml/kg/day feeding advancements was safe and resulted in faster attainment of goal feeds and shorter LOS. Level of evidence: II/III.

A real-world study to evaluate a peptidic oral supplement in adults with altered intestinal function after parenteral nutrition

Objectives: in routine clinical practice many disorders are found that can disrupt the sequence of reactions in digestion and absorption, leading to malnutrition and requiring the use of oral nutritional supplements (ONS). The objective of our study was to evaluate in a real world setting the use of and compliance with a peptide-based ONS in malnourished adult patients with intestinal compromise after more than 14 days of parenteral nutrition. Material and methods: the study was carried out in 44 malnourished patients who required total parenteral nutrition for at least 14 days without using the oral route during their hospital stay. All patients were administered, on an outpatient basis, 1 brick per day of Vital 1.5® for 12 weeks. At the beginning of treatment and after the intervention period evaluated, the following variables were collected: weight, height, body mass index (BMI), global subjective assessment test, nutritional biochemistry, 3-day nutritional survey, adverse effects generated by the formula, and completion rate. Results: 44 patients were enrolled. Mean age was 70.4 ± 10.4 years (20 women & 24 men). After the intervention the following parameters had increased: BMI (0.51 ± 0.1 kg/m2; p = 0.02), weight (1.4 ± 0.3 kg; p = 0.03), prealbumin (3.5 ± 4.1 mg/dl; p = 0.01), albumin (1.3 ± 0.1 mg/dl; p = 0.03), and transferrin (71.5 ± 24.1 mg/dl; p = 0.02). Dietary intake of the ONS represented 14.4 % of the diet's total caloric intake at 3 months, 17.5 % of carbohydrates, 12.9 % of proteins, and 12.3 % of fats. Mean compliance was 87.7 ± 7.2 % of the prescribed intakes. In relation to the nutritional situation, at the beginning of the study, 52.3 % (n = 23) of patients were in the global subjective assessment test in category B (moderate malnutrition or nutritional risk), and 47.7 % (n = 21) in category C (severe malnutrition). After the intervention, 75 % of patients were in category A (n = 33), 13.6 % (n = 6) in category B, and 11.4 % (n = 5) in category C. Conclusions: the use of a peptide-based ONS with short-chain triglycerides in outpatients showed a beneficial effect on biochemical and anthropometric parameters, and improved the nutritional status of patients with high compliance and good tolerance rates.

Estimating Length of Stay for Simple Gastroschisis

BackgroundLength of stay (LOS) is an important measure of quality; however, estimating LOS for rare populations such as gastroschisis is problematic. Our objective was to identify explanatory variables for LOS and build a model to estimate LOS in neonates with simple gastroschisis. MethodsIn 73 neonates with simple gastroschisis (47% female, 67% White), statistical correlations for 31 potential explanatory variables for LOS were evaluated using multivariate linear regression. Poisson regression was used to estimate LOS in predetermined subpopulations, and a life table model was developed to estimate LOS for simple gastroschisis. ResultsFemale sex (−2.4 d), “time to silo placement” (0.9 d), total parenteral nutrition days (0.6 d), need for any nasogastric feedings (11.4 d) and at discharge (−7 d), “feeding tolerance” (0.4 d), days to first postoperative stool (−0.3 d), and human milk exposure (−3.4 d) associated with LOS in simple gastroschisis. Estimated LOS for preterm neonates was longer than term infants (5.4 versus 4.6 wk) but similar for estimates based on sex and race. Based on these associations, we estimate that >50% of neonates with simple gastroschisis will be discharged by hospital day 35. ConclusionsWe identified several associations that explained variations in LOS and developed a novel model to estimate LOS in simple gastroschisis, which may be applied to other rare populations.

Severe hypomagnesaemia and severe hypophosphatemia in adults icu patients receiving total parenteral nutrition

Rationale: Severe mineral disorders are significantly associated with increased need for mechanical ventilation, prolonged ICU stay and increased mortality. The purpose of this study is to evaluate the prevalence of severe hypophosphatemia and hypomagnesaemia prior and within the first 7 days of total parenteral nutrition (TPN) infusion in ICU patients.

A Prevention Initiative to Reduce Healthcare-Associated Bloodstream Infections in a Spanish University Hospital

Background: Bloodstream infections are one of the main adverse effects of healthcare in Spain. In our hospital, we have reported that the mean incremental cost of patients who develop bacteremia during admission was €15,526 (US$18,314.62) per discharge, representing an annual increment in hospital cost of €1,108,190 (US$1,307,232) in 2005–2012. Moreover, we have also observed that only 15.4% of episodes of our bacteremia occur in intensive care units, with most of these infections (67%) occurring in conventional units.1 Therefore, we started several initiatives to reduce healthcare-associated bloodstream infections. Herein, we describe one of these initiatives, which is the implementation of the intravascular therapy team (ITT) and its effect on the observed healthcare-associated bloodstream infections. Methods: This retrospective analysis evaluated the incidence of healthcare-associated bloodstream infections in a University Hospital of 520 beds from January 2014 to June 2019. The ITT was implemented in 2017. This is a multidisciplinary team with 2 specialists in infection control and 2 specialists in intravascular therapy. We evaluated the annual incidence rate of healthcare-associated bloodstream infections (number of bacteremia episodes per 1,000 days of hospital stay) and its relation with the interventions carried out by the multidisciplinary team. Results: The annual incidences of healthcare-associated bloodstream infections (episodes per 1,000 days of hospital stay) were 0.50 (2014), 0.46 (2015), 0.58 (2016), 0.69 (2017), 0.60 (2018), 0.51 (first quarter 2019), and 0.38 (second quarter 2019, 0.38), respectively. The highest incidence of bacteremia was observed in 2017 when the ITT started the following actions: (1) following a clinical protocol to improve the appropriateness in the utilization of new devices such as a peripherally inserted central catheter (PICC) and Medline; (2) continuous training of healthcare professionals, particularly young staff; (3) feedback with hospitalization units; and (4) proactive surveillance of venous access manipulation and maintenance. The interventions were designed, implemented, and evaluated by the ITT and were well accepted by healthcare professionals. After the implementation of the ITT, the incidence of healthcare-associated bloodstream infections decreased. This trend was particularly relevant for parenteral nutrition catheters (episodes per 1,000 days of parenteral nutrition) (Fig. 1). Conclusions: The implementation of the ITT in our center has allowed us to considerably reduce the incidence of healthcare-associated bloodstream infections. From our experience, the interventions related to systematic evaluation, education, and feedback are key to obtain and maintain this improvement.Funding: NoneDisclosures: Carlota Hidalgo-Lopez reports that this study was partly funded by Diversey. The authors did not receive direct Funding: from the sponsor, Juan Pablo Horcajada reports consulting fees from MSD, Pfizerand, and Menarini, as well as speaker fees from MSD, Pfizer, and Zambon.

Postsurgical Intestinal Rehabilitation Using Semisynthetic Glucagon‐Like Peptide‐2 Analogue (sGLP‐2) at a Referral Center: Can Patients Achieve Parenteral Nutrition and sGLP‐2 Independency?

Teduglutide, a semisynthetic analogue of glucagon-like peptide-2 (sGLP-2), increases intestinal absorption of fluids and nutrients, reducing the need for parenteral nutrition (PN). This report aims to describe our experience with sGLP-2 in a cohort of adult patients with short-bowel syndrome. This is a prospective observational study on adult patients initially evaluated in our specialized intestinal rehabilitation program that received sGLP-2 from June 2014 to March 2020. Autologous gastrointestinal reconstruction surgery (AGIRS) was performed in 108 patients; 68.5% (74 of 108) achieved intestinal sufficiency with standard medical therapy. Seventeen patients were treated with sGLP-2; 66.5% (8 of 12) received treatment for a mean time of 25.8 weeks (3.4-54.0) and could suspend PN. One patient reinitiated treatment due to renal lithiasis and acute renal failure. Currently, 7 of 12 patients (53.8%) continue without PN for a mean time of 165.6 weeks. Volume, energy, and days of PN were reduced in all patients. No serious adverse events were registered. Four of 7 patients (57.1%) who discontinued PN could also discontinue sGLP-2. Therefore, the use of sGLP-2 increased the overall success rate of PN independency after AGIRS to 76% (82 of 108). This study confirmed that sGLP-2 should be considered as part of the standard therapy for postsurgical medical rehabilitation treatment in patients with chronic intestinal failure. We add to the current knowledge that some patients can discontinue both PN and sGLP-2 in the long term, achieving complete recovery of their quality of life.

Parenteral Nutrition–Associated Liver Disease in Adult Inpatients Receiving Commercial Premixed Parenteral Nutrition for More Than 2 Weeks

AbstractBackgroundLong‐term use of parenteral nutrition (PN) may elicit complications, including PN‐associated liver disease (PNALD), which may yield critical outcomes. This study intended to investigate the development of complications associated with commercial premixed PN in adult patients.MethodsAdult patients who received nutrition support with commercial PN without enteral intake for &gt;14 consecutive admission days were included in the analysis.ResultsSeventy‐two adults, from 2001 to 2016, were reviewed. Mean length of hospital stay was 43.0 days. A mean of 27.3 days of PN was given. Mean energy supplied by PN was 29 kcal/kg/d. Ten patients (13.8%) developed PNALD. Length of stay was significantly longer (P = .034), and duration of PN administration was significantly longer (P = .022) in patients who developed PNALD. The proportion of PN products with soybean oil–based lipids was significantly higher, and fish oil– or medium‐chain triglyceride–containing combination lipids were significantly lower in the patient group with PNALD (P = .02). Multivariate logistic regression analysis showed that longer duration of days receiving PN support was an independent risk factor for PNALD (odds ratio, 1.052; P = .029).Conclusion: The incidence of PNALD in hospitalized adult patients who received daily PN support with commercial premixed 3‐in‐1 products for &gt;2 weeks was 13.8%. Longer duration of days receiving PN support was an independent risk factor for PNALD.

Factors in Early Feeding Practices That May Influence Growth and the Challenges that Arise in Growth Outcomes Research.

Growth in preterm infants is associated with improved outcomes during both the initial hospitalization and long-term. A single center investigation evaluated preterm infant in-hospital growth trajectory and how it related to early nutritional practices as a way to identify areas for quality improvement. Infants born <34 weeks’ gestational age and with discharge at or prior to 40 weeks’ gestational age were included and were divided into quartiles based on their change in weight z-score through hospitalization. Early nutritional factors were compared between the lowest and highest growth quartiles. Although the highest growth quartile experienced less days of parenteral nutrition and higher enteral caloric density in the first week, as the data was analyzed, potential statistical pitfalls became apparent. Therefore, the aim of this study was to investigate selection bias and cohort effect related to both the inclusion criteria for this cohort as well as the inherent challenges in comparison of preterm infant growth trajectories by standard fetal growth charts.