Parenteral Nutrition Guidelines Research Articles

Interpretation of the 2023 "Guidelines for parenteral nutrition in preterm infants: the American Society for Parenteral and Enteral Nutrition"

The "Guidelines for parenteral nutrition in preterm infants: the American Society for parenteral and enteral nutrition" were developed by the American Society for Parenteral and Enteral Nutrition and published in the Journal of Parenteral and Enteral Nutrition in September 2023. The guidelines provide recommendations on 12 key clinical questions regarding parenteral nutrition (PN) for preterm infants. In comparison to similar guidelines, this set offers more detailed perspectives on PN for preterm infants. It presents evidence-based recommendations for the commencement time, nutrient dosage, and composition of PN, considering primary outcomes such as growth and development, as well as secondary outcomes like sepsis, retinopathy of prematurity, parenteral nutrition-related liver disease, and jaundice. This article aims to interpret the guidelines to provide a reference for colleagues in the field.

Commentary on guidelines for parenteral nutrition in preterm infants: Limitations reveal opportunities.

Commentary on guidelines for parenteral nutrition in preterm infants: Limitations reveal opportunities.

Multidisciplinary evidence-based tools for improving consistency of care and neonatal nutrition.

Extrauterine growth restriction from inadequate nutrition remains a significant morbidity in very low birth weight infants. Participants in the California Perinatal Quality Care Collaborative Quality Improvement Collaborative, Grow, Babies, Grow! developed or refined tools to improve nutrition and reduce practice variation. Five Neonatal Intensive Care Units describe the development and implementation of nutrition tools. Tools include Parenteral Nutrition Guidelines, Automated Feeding Protocol, electronic medical record Order Set, Nutrition Time-Out Rounding Tool, and a Discharge Nutrition Recommendations. 15 of 22 participant sites completed a survey regarding tool value and implementation. Reduced growth failure at discharge was observed in four of five NICUs, 11-32% improvement. Tools assisted with earlier TPN initiation (8 h) and reaching full feeds (2-5 days). TPN support decreased by 5 days. 80% of survey respondents rated the tools as valuable. Evidence and consensus-based nutrition tools help promote standardization, leading to improved and sustainable outcomes.

A Retrospective Study Evaluating Guideline Adherence of Neonatal Parenteral Nutrition in a Belgian Neonatal Intensive Care Unit.

Introduction Clinical nutrition for preterm and critically ill neonates remains a challenge. Preterms are often hemodynamically and metabolically compromised, which limits infusion volumes of nutrients and hinders achieving recommended nutrient intakes. While guidelines provide recommended ranges for parenteral nutrition (PN) intakes, they generally recommend enteral nutrition as soon as possible. Thus, in clinical practice, gradually increasing EN intakes complicates assessments of PN guideline adherence. Via a pragmatic approach, we assessed adherence to PN recommendations for macronutrients and energy as stated in the 2018 guidelines of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Methods In this retrospective study, we assessed the nutrition of preterm and critically ill term neonates from the neonatal intensive care unit of the University Hospital Brussels. We analyzed intakes for the first week of life, in which critically ill neonates at our center usually receive the majority of nutrients via PN. The PN-based provision of macronutrients and energy was analyzed descriptively in relation to the ESPGHAN 2018 recommendations. Results Macronutrients and energy provision gradually increased until they reached recommended or targeted values. Compared to term neonates, energy and lipid provision for preterms increased faster, while amino acid provision exceeded the ESPGHAN 2018 recommendations. Conclusions This study adds clinical practice data to the severely understudied field of the ESPGHAN 2018 PN guideline compliance. Using a pragmatic assessment of our nutrition protocols, we found the need to reduce the amount of amino acids per kg body weight per day to meet guideline recommendations.

Guidelines for parenteral nutrition in preterm infants: The American Society for Parenteral and Enteral Nutrition.

Parenteral nutrition (PN) is prescribed for preterm infants until nutrition needs are met via the enteral route, but unanswered questions remain regarding PN best practices in this population. An interdisciplinary committee was assembled to answer 12 questions concerning the provision of PN to preterm infants. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process was used. Questions addressed parenteral macronutrient doses, lipid injectable emulsion (ILE) composition, and clinically relevant outcomes, including PNALD, early childhood growth, and neurodevelopment. Preterm infants with congenital gastrointestinal disorders or infants already diagnosed with necrotizing enterocolitis or PN-associated liver disease (PNALD) at study entry were excluded. The committee reviewed 2460 citations published between 2001 and 2023 and evaluated 57 clinical trials. For most questions, quality of evidence was very low. Most analyses yielded no significant differences between comparison groups. A multicomponent oil ILE was associated with a reduction in stage 3 or higher retinopathy of prematurity (ROP) compared to an ILE containing 100% soybean oil. For all other questions, expert opinion was provided. Most clinical outcomes were not significantly different between comparison groups when evaluating timing of PN initiation, amino acid dose, and ILE composition. Future clinical trials should standardize outcome definitions to permit statistical conflation of data, thereby permitting more evidence based recommendations in future guidelines. This guideline has been approved by the ASPEN 2022-2023 Board of Directors.

Assessment of the Adherence to ESPGHAN 2018 Guidelines in the Neonatal Intensive Care Unit of the Ghent University Hospital: A Retrospective Study.

Parenteral nutrition (PN) is a standard of care for preterm infants in the first postnatal days. The European Society of Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) has updated their guideline recommendations on PN in 2018. However, data on actual 2018 guideline adherence in clinical practice are sparse. In this retrospective study, conducted at the neonatal intensive care unit (NICU) of Ghent University Hospital, we analyzed the ESPGHAN 2018 PN guideline adherence and growth for 86 neonates admitted to the NICU. Analyses were stratified by birth weight (<1000 g, 1000 to <1500 g, ≥1500 g). We documented the provisions for enteral nutrition (EN) and PN, and we tested the combined EN and PN provisions for ESPGHAN 2018 adherence. The nutrition protocols showed a high adherence to PN guidelines in terms of carbohydrate provisions, yet lipid provisions for EN and PN often exceeded the recommended maximum of 4 g/kg/d; although, PN lipid intakes maxed out at 3.6 g/kg/d. Protein provisions tended to fall below the recommended minimum of 2.5 g/kg/d for preterm infants and 1.5 g/kg/d for term neonates. The energy provisions also tended to fall below the minimum recommendations, especially for neonates with a birth weight (BW) < 1000 g. Over a mean PN duration of 17.1 ± 11.4 d, the median weekly Fenton Z-scores changes for length, weight, and head circumference were positive for all BW groups. Future studies have to assess how protocols adapt to current guidelines, and how this affects short- and long-term growth across different BW groups. In conclusion, the reported findings provide real-world evidence regarding the effect of ESPGHAN 2018 PN guideline adherence, and they demonstrate how standardized neonatal PN solutions can safeguard stable growth during NICU stays.

Impact of parenteral nutrition guideline implementation on growth of very low-birth-weight infants in a neonatal intensive care unit.

In preterm neonates, parenteral nutrition (PN) is utilized to provide adequate energy and maintain the expected growth rate of a fetus. To optimize growth, our institution implemented comprehensive guidelines for prescribing PN. This study compared the effect of this change on growth outcomes of very low-birth-weight (VLBW) infants at 28 days' postnatal age (PNA). Neonates <1250 g who received PN for >7 days were divided into preimplementation and postimplementation cohorts based on date of birth. The primary objective was to compare the average weight velocity (g/kg/day) of neonates at 28 days' PNA. Secondary objectives included identifying the average number of days to regain birth weight and comparing the percentage of infants above the 10th percentile for weight for age at 28 days with those at baseline. There were 204 neonates in cohort 1 (before implementation) and 176 neonates in cohort 2 (after). No difference in weight velocity was identified (12.9 ± 5.2 vs 12.1 ± 4.9 g/kg/day; P = .177). No difference was detected in days to regain birth weight (9.2 ± 4.6 vs 9.9 ± 4.7; P = .909) or in the percentage of patients above the 10th percentile for weight for age (birth: 85.3% vs 83.5% [P = .634]; 28 days: 73% vs 64.8% [P = .082]). No difference was observed in the weight velocity of VLBW neonates <1250 g at birth when using the implemented guideline for PN prescription writing at our institution.

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

BackgroundRecommendations 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.MethodsWe 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.ResultsThe 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.ConclusionFormal 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.

ANALYSIS OF THE USE OF FAT EMULSIONS IN NEONATAL PARENTAL `NUTRITION IN UKRAINE

Fat emulsions are extremely important for newborns, especially for seriously ill, premature babies with very low and extremely low body weight (congenital or acquired pathology that causes gastrointestinal failure), if routine enteral feeding is problematic and sometimes impossible. All current updated data on the quality, efficacy and feasibility of using lipid emulsions in parenteral nutrition for medical reasons were published in the 2019 Cochrane Review “Systematic review of lipid emulsions for intravenous nutrition in term and late preterm infants”. More recently, fatty emulsions obtained from several sources have become available for clinical use. SMOFLipid is one of such fat emulsion. It`s a mixture of soybean oil, medium-chain triglycerides, olive oil and fish oil in a 30: 30: 25: 15 ratio that has certain benefits. Due to the content of medium-chain triglycerides, it`s rapidly metabolized; soybean oil - a source of polyunsaturated fatty acids; olive oil - less immune effects; and fish oil - the antiinflammatory effect is enhanced, and a decrease in the frequency of bronchopulmonary dysplasia and infection in premature infants is noted. Today in Ukraine, to cover the needs for energy, calories, and essential fatty acids in term and premature babies, when oral or enteral nutrition is not possible, insufficient or contraindicated, lipid emulsion SMOFLipid is actively used as part of total parenteral nutrition. The general dynamics of prescribing lipid emulsions in Ukraine are regressive due to certain regions, where the practice of parenteral nutrition for newborns differs from other areas in sporadicity and less priority due to objective and subjective circumstances. One of the key ways to solve the problem of improving the quality of medical care for newborns in neonatal hospitals should be the introduction of a training system (seminars, practical training, etc.) for neonatologists in modern principles of conducting and international clinical guidelines for parenteral nutrition of newborns at all levels in all regions. Ukraine.

Long-term effects on growth of an energy-enhanced parenteral nutrition in preterm newborn: A quasi-experimental study.

AimTo assess the best energy intake in Parenteral Nutrition (PN) for preterm newborns, considering both possible benefits for growth and risk of complications.MethodsQuasi-experimental study comparing two cohorts of newborns, receiving Energy-Enhanced vs. Standard PN (Cohort A, from 1st January 2015 to 31 January 2016 and Cohort B from 1st February 2016 to 31 March 2017; respectively) after implementation of a change in the PN protocol. The primary outcome measure was growth at 24 months of life. The PN associated complications were also measured.ResultsWe enrolled 132 newborns in two Cohorts, similar for prenatal and postnatal clinical characteristics. Although, body weight and length at 24 months of life were significantly higher (p<0.05) in the Cohort A (11.1, 95% CI 10.6 to 11.6 Kg; 85.0 95% CI 83.8 to 86.2 cm) compared with Cohort B (10.4, 95% CI 9.9 to 10.9 Kg; 81.3 95% CI 79.7 to 82.8 cm), body weight and length Z-Score in the first 24 months of life were similar between the two Cohorts. The rate of PN associated complications was very high in both study Cohorts (up to 98% of enrolments). Multivariate analysis showed that length at 24 months was significantly associated with receiving standard PN (cohort A) in the first week of life and on the energy intake in the first week of life. We also found a marginally insignificant association between Cohort A assignment and body weight at 24 months of life (p = 0.060).ConclusionsEnergy-enhanced PN in early life has not significant effects on long-term growth in preterm newborns. The high prevalence of PN associated complications, poses concerns about the utility of high energy intake recommended by current guidelines for PN.

Summary of Proceedings and Expert Consensus Statements From the International Summit "Lipids in Parenteral Nutrition".

The 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology, to assess the current state of knowledge and develop expert consensus statements regarding the use of intravenous lipid emulsions in various patient populations and clinical settings. The main purpose of the consensus statements is to assist healthcare professionals by providing practical guidance on common clinical questions related to the provision of lipid emulsions as part of parenteral nutrition (PN). The summit was designed to allow interactive discussion and consensus development. The resulting consensus statements represent the collective opinion of the members of the expert panel, which was informed and supported by scientific evidence and clinical experience. The current article summarizes the key discussion topics from the summit and provides a set of consensus statements designed to complement existing evidence-based guidelines. Lipid emulsions are a major component of PN, serving as a condensed source of energy and essential fatty acids. In addition, lipids modulate a variety of biologic functions, including inflammatory and immune responses, coagulation, and cell signaling. A growing body of evidence suggests that lipid emulsions containing ω-3 fatty acids from fish oil confer important clinical benefits via suppression of inflammatory mediators and activation of pathways involved in the resolution of inflammation. This article provides a set of expert consensus statements to complement formal PN guideline recommendations.

Outcomes in Relation to Early Parenteral Nutrition Use in Preterm Neonates Born between 30 and 33 Weeks Gestation: A Propensity Score Matched Observational Study

Importance: Preterm neonates are among the highest users of parenteral nutrition (PN). Randomised trials in critically ill older children show that harms, such as nosocomial infection, outweigh benefits of early PN administration; there is a paucity of similar randomised trial data in neonates. Objective: To evaluate whether in preterm neonates born between 30+0 and 32+6 weeks+days, PN use in the first seven postnatal days, compared with no PN use, is associated with differences in survival and other important morbidities. Design: Retrospective cohort study using propensity matching including 35 maternal, infant and organisational factors to minimise bias and confounding. Routinely recorded clinical data obtained from the UK National Neonatal Research Database. Setting: National population-level data from all National Health Service neonatal units in England and Wales. Participants: 35,362 neonates born over the period January 2012 to December 2017 and admitted to a neonatal unit; 16,292 neonates were compared in propensity score matched analyses. Exposure: The exposure was PN administered in the first seven days of postnatal life; the comparator was no PN in the first seven days. Main Outcome and Measure: The primary outcome was survival to discharge from neonatal care. Secondary outcomes comprised the neonatal core outcome set (including necrotising enterocolitis, bronchopulmonary dysplasia and late-onset sepsis). Results: Compared with matched neonates not given PN in the first postnatal week, neonates who received PN had higher survival to discharge (absolute rate increase 0.91%; 95% CI 0.53% to 1.30%), but higher rates of necrotising enterocolitis (absolute rate increase 4.6%; 95% CI 3.9% to 5.3%), bronchopulmonary dysplasia (absolute rate increase 3.9%; 95% CI 3.2% to 4.7%), late-onset sepsis (absolute rate increase 1.5%; 95% CI 1.1% to 1.8%) and need for surgical procedures (absolute rate increase 0.92%; 95% CI 0.57% to 1.3%). Conclusions and Relevance: In neonates born between 30+0 and 32+6 weeks gestation, those given PN in the first postnatal week had higher rates of survival but higher rates of important neonatal morbidities. Prospective, randomised trials powered for important outcomes are needed to identify in which neonates the benefits of early PN use outweigh the harms. Trial Registration: ClinicalTrials.gov: NCT03767634, Prospectively Registered: 06/12/2018. Funding Statement: The NNRD is funded and maintained from awards to NM. These include costs for data transfer, storage, cleaning, merging, administration and regulatory approvals. The extraction of study data from the NNRD and analysis for this study was funded through a Mason Medical Research Fellowship awarded to JW. CG was funded by the United Kingdom Medical Research Council (MRC) through a Clinician Scientist Fellowship award. Declaration of Interests: JW has received support from Chiesi Pharmaceuticals to attend an educational conference and has received a research grant from Mason Medical Research Foundation. SU has received funding from the National Institute of Health Research, the Department of Health and Prolacta Life Sciences. SU has been on the Advisory Board of Fresenius Kabi and received honoraria and travel expenses for speaking at study days organised by Fresenius Kabi. SU is a member of the National Institute for Health and Care Excellence Parenteral Nutrition Guideline Development Committee. NM is the Chief Investigator for the National Neonatal Research Database and Director of the Neonatal Data Analysis Unit at Imperial College London. In the last five years NM has served on the Board of Trustees of the Royal College of Paediatrics and Child Health, David Harvey Trust, Medical Women’s Federation and Medact; and is a member of the Nestle Scientific Advisory Board. NM has received research grants from the British Heart Foundation, Medical Research Council, National Institute of Health Research, Westminster Research Fund, Collaboration for Leadership in Applied Health and Care Northwest London, Healthcare Quality Improvement Partnership, Bliss, Prolacta Life Sciences, Chiesi, Shire and HCA International; travel and accommodation expenses from, Nutricia, Prolacta, Nestle and Chiesi; honoraria from Ferring Pharmaceuticals and Alexion Pharmaceuticals for contributions to expert advisory boards, and Chiesi for contributing to a lecture programme. CG is part of an international team developing reporting guidance (a CONSORT extension) for clinical trials using cohorts and routinely collected health data. He has received support from Chiesi Pharmaceuticals to attend an educational conference; in the past 5 years he been investigator on received research grants from Medical Research Council, National Institute of Health Research, Canadian Institute of Health Research, Department of Health in England, Mason Medical Research Foundation, Westminster Medical School Research Trust and Chiesi Pharmaceuticals, and has been an unremunerated member of the Neonatal Data Analysis Unit Board, which oversees the NNRD. The authors declare no other competing interests. Ethics Approval Statement: Obtained study-specific research ethics committee, Health Research Authority and Health and Care Research Wales approval (18/NI/0214).

Effect of Implementing Total Parenteral Nutrition Nursing Guidelines on Adult Critically Ill Patients’ Outcomes

Total parenteral nutrition for hospitalized critically ill patients is essential for improving outcomes, insufficient nutritional support lead to occurrences of complications, increased morbidity and mortality rates, increased length of hospital stay. Critical care nurses are the cornerstone in preventing theses complications. Aim: To investigate the effect of implementing total parenteral nutrition nursing guidelines on adult critically ill patients’ outcomes. Design: Non randomized prospective research design was used to utilize this study Subjects: convenience samples of 60 patients were assigned equally to study and control group at intensive care units at Assiut University hospitals. The control group received routine hospital care during TPN administration while, the study group received the developed guidelines for TPN during a period from January 2018 to December 2018. Methods Each patient in both groups were assessed by taking history, clinical examination, nutritional assessment laboratory investigation. Patients in study groups were received care according to developed total parenteral nutrition guidelines to determine outcome and complications in both groups. Results Finding of the present study revealed that significant improvement in study group with values of less than p=001 compared to control group Conclusion : implementing of total parenteral nutrition guidelines improve the outcomes and reduce the occurrence of complications among critically ill patients. Keywords : total parenteral nutrition, nursing guidelines, critically ill patient, outcomes DOI : 10.7176/JHMN/61-04 Publication date : April 30 th 2019

Central Line in Long-term Parenteral Nutrition in Children: A European Survey.

The guidelines for the insertion and maintenance of the central venous catheter (CVC) in children on long-term parenteral nutrition (PN) were published 12 years ago and studies evaluating the outcomes are limited. Therefore, the aim of the present study was to perform a survey about criteria for CVC insertion and maintenance in intestinal failure/rehabilitation centers treating children on home PN. An online cross-sectional survey based on previous European Society of Paediatric Gastroenterology, Hepatology and Nutrition PN guidelines was distributed electronically to the members of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition networking group, Network for Intestinal Failure and Transplantation in Europe and tertiary pediatric gastroenterology centers in Europe. Overall, 55 responses from 49 centers in 18 European countries and Israel were collected. The majority of respondents were from the United Kingdom (10, 19%), followed by Germany (7, 13%) and France (6, 11%). Eleven centers (21%) cared for >30 patients, 8 (15%) centers between 20 and 30 patients, 18 (34%) centers between 10 and 20 patients, and 16 (30%) <10 patients on home PN. There was a high variability in the majority of answers to the cross-sectional survey. CVC insertion and maintenance in children on home PN varies largely amongst centers in Europe. These differences could be at least partially explained by the lack of updated guidelines and limited evidence. There is an urgent need for collaborative research to make recommendations about the best possible practice.

SUN-P223: Adherence to Prescription Clinical Guidelines for Parenteral Nutrition in Pediatric Patients Have Not Valued by Nutritional Support Unit from Juarez Hospital of Mexico

SUN-P223: Adherence to Prescription Clinical Guidelines for Parenteral Nutrition in Pediatric Patients Have Not Valued by Nutritional Support Unit from Juarez Hospital of Mexico

Anticoagulants for the prevention and treatment of catheter-related thrombosis in adults and children on parenteral nutrition: a systematic review and critical appraisal.

Patients on parenteral nutrition require a central venous access and are at risk of catheter-related thrombosis, pulmonary embolism, and vena cava syndrome. Parenteral nutrition guidelines suggest anticoagulation for the primary prevention of catheter-related thrombosis during long-term parenteral nutrition. We conducted a systematic review of the efficacy, safety and feasibility of anticoagulant use for preventing and treating catheter-related thrombosis during parenteral nutrition. We searched for interventional and observational studies on adults and children receiving systemic anticoagulants during either short- or long-term parenteral nutrition delivered via central venous access. Primary outcomes were: objectively-confirmed catheter-related thrombosis, pulmonary embolism and bleeding. Secondary outcomes were: heparin-induced thrombocytopenia, prevalence of anticoagulation, and quality of International Normalised Ratio management in vitamin K antagonist-treated patients. We identified 1,199 studies, of which 23 were included. Seven interventional studies of short-term parenteral nutrition (adult population, n=5) were classified as low-quality: in those, intravenous unfractionated heparin did not prevent catheter-related thrombosis if compared to saline. No interventional studies were conducted in patients on long-term parenteral nutrition. Observational data were sparse, rarely focusing on anticoagulation, and overall of low quality. The reported use of anticoagulants was between 22 and 66% in recent multicentre cohorts. The amount and quality of data in this area are very suboptimal: most studies are outdated and involved heterogeneous populations. Currently, there is insufficient evidence to allow conclusions to be reached regarding the efficacy and safety of anticoagulants in this setting.

Early versus Delayed Human Milk Fortification in Very Low Birth Weight Infants–A Randomized Controlled Trial

To compare the effect of initiating human milk fortification at 2 different feeding volumes on feeding intolerance and the time to reach full feeding volume. Very low birth weight infants (n=100) were prospectively randomized to early fortification (EF) (beginning at a feeding volume of 20mL/kg/d) or delayed fortification (at a feeding volume of 100mL/kg/d). We employed a standardized feeding protocol and parenteral nutrition guidelines for the nutritional management of all study infants. The median days to reach full feeding volumes were equivalent in the 2 groups (20 vs 20, P=.45). No significant difference was observed in the total number of episodes of feeding intolerance (58 vs 57). Two cases of necrotizing enterocolitis (Bell stage ≥2) and deaths occurred in each group. Median daily protein intake (g/kg/d) was higher in EF group in week 1 (3.3 [3.2, 3.5] vs 3.1 [2.9, 3.3], P<.001), week 2 (3.6 [3.5, 3.8] vs 3.2 [2.9, 3.4], P<.001), and week 3 (3.7 [3.4, 3.9] vs 3.5 [2.8, 3.8], P=.006). Cumulative protein intake (g/kg) in the first 4weeks of life was higher in EF group (98.6 [93.8, 104] vs 89.6 [84.2, 96.4], P<.001). Very early human milk fortification may improve early protein intake in very low birth weight infants without increasing frequencies of adverse events. ClinicalTrials.gov: NCT01988792.

Electrolyte and Mineral Homeostasis After Optimizing Early Macronutrient Intakes in VLBW Infants on Parenteral Nutrition.

The aim of the present study was to evaluate electrolyte and mineral homeostasis in very-low-birth-weight (VLBW) infants who received high protein and energy intakes with a unique standardized parenteral nutrition solution containing electrolytes and minerals from birth onward. Prospective cohort study in 102 infants with birth weight <1250 g. The evolution of plasma biochemical parameters was described during the first 2 weeks of life. During the first 3 days of life, mean parenteral intakes were 51 ± 8 kcal · kg · day with 2.7 ± 0.4 g · kg · day of protein, 1.1 ± 0.2 mmol · kg · day of sodium and potassium, and 1.3 ± 0.2 mmol · kg · day of calcium and phosphorus. Afterwards, most nutritional intakes (parenteral and enteral) met growth requirements. No infant developed a hyperkalemia >7 mmol/L, and a hypernatremia >150 mmol/L occurred only in 15.7% of the infants. In contrast, hyponatremia <130 mmol/L and hypokalemia <3 mmol/L occurred in 30.4% and 8.8% of the infants, respectively. The initial neonatal metabolic acidosis rapidly resolved in most infants and only 2.0% developed a base deficit >10 mmol/L after day 3 of life. Early hypocalcemia <1.8 mmol/L occurred in 13.7% of the infants. In contrast, hypophosphatemia <1.6 mmol/L occurred in 37.3% and hypercalcemia >2.8 mmol/L occurred in 12.7% of the infants. Increasing early protein and energy intakes in VLBW infants in the first week of life improves electrolyte homeostasis. It also increases the phosphorus requirements with a calcium-to-phosphorus ratio ≤1.0 (mmol/mmol) and the potassium and sodium requirements to avoid the development of a refeeding-like syndrome. These data suggest that the parenteral nutrition guidelines for VLBW infants for the first week of life need to be revised.

Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children's Hospital After Implementation of Electronic Ordering and Compounding.

The Institute for Safe Medication Practices has stated that parenteral nutrition (PN) is considered a high-risk medication and has the potential of causing harm. Three organizations--American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), American Society of Health-System Pharmacists, and National Advisory Group--have published guidelines for ordering, transcribing, compounding and administering PN. These national organizations have published data on compliance to the guidelines and the risk of errors. The purpose of this article is to compare total compliance with ordering, transcription, compounding, administration, and error rate with a large pediatric institution. A computerized prescriber order entry (CPOE) program was developed that incorporates dosing with soft and hard stop recommendations and simultaneously eliminating the need for paper transcription. A CPOE team prioritized and identified issues, then developed solutions and integrated innovative CPOE and automated compounding device (ACD) technologies and practice changes to minimize opportunities for medication errors in PN prescription, transcription, preparation, and administration. Thirty developmental processes were identified and integrated in the CPOE program, resulting in practices that were compliant with A.S.P.E.N. safety consensus recommendations. Data from 7 years of development and implementation were analyzed and compared with published literature comparing error, harm rates, and cost reductions to determine if our process showed lower error rates compared with national outcomes. The CPOE program developed was in total compliance with the A.S.P.E.N. guidelines for PN. The frequency of PN medication errors at our hospital over the 7 years was 230 errors/84,503 PN prescriptions, or 0.27% compared with national data that determined that 74 of 4730 (1.6%) of prescriptions over 1.5 years were associated with a medication error. Errors were categorized by steps in the PN process: prescribing, transcription, preparation, and administration. There were no transcription errors, and most (95%) errors occurred during administration. We conclude that PN practices that conferred a meaningful cost reduction and a lower error rate (2.7/1000 PN) than reported in the literature (15.6/1000 PN) were ascribed to the development and implementation of practices that conform to national PN guidelines and recommendations. Electronic ordering and compounding programs eliminated all transcription and related opportunities for errors.

Do aggressive feeding guidelines eliminate first week nutrition deficits in very low birth weight infants fed exclusively mother’s own milk? (247.2)

Background: Hospitalized VLBW infants fed human milk are reported to have lower growth rates compared to those fed nutrient‐enriched formulas. Aggressive parenteral nutrition guidelines for VLBW infants have been adopted in many neonatal intensive care units (NICUs) in response to data confirming short‐term safety of this approach and potential long‐term neurocognitive benefits. However, actual intakes during the first week of life have not been extensively evaluated since adoption of these guidelines.Objective: To describe the parenteral and enteral energy and macronutrient intakes in human milk‐fed VLBW infants from NICUs with aggressive nutrition guidelines.Design: Daily parenteral and enteral intakes were prospectively collected for 96 VLBW infants fed only MOM enterally during the first week. Feeding goals included provision of protein (&gt;2.0) and lipids (1.0 g/kg/day) on the day of birth, advancing to 3.5 (protein) and 3.0 (lipid) g/kg/day within the first few days.Results: We found that 34% and 70% of infants did not meet protein and energy goals (of 3.5 g/kg/day and 90‐100 kcal/kg/day), respectively, at the end of the first week.Conclusions: Despite the adoption of more aggressive nutrition guidelines, most MOM‐fed VLBW infants remain undernourished at the end of the first week of life. Strategies to address these deficits may significantly impact the health outcomes of this vulnerable population.Grant Funding Source: Supported by CIHR (MOP#210093).