Search

Effective implementation of early parenteral feeding

Authors 

Koletzko B, Fewtrell MS, Domellöf M, Embleton ND, Grusfzeld D, McNulty A, Lapillonne A, Szitany P

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

Parenteral nutrition is commenced on the first day after birth, usually using standard solutions, and continued until sufficient enteral feeding is established.

Rationale

The goal is to provide appropriate nutrient supply and to prevent the early occurrence of nutrient deficits and growth faltering.

Very preterm infants have high nutritional requirements per kilogram body weight but only limited reserves to withstand the interruption of placental nutrient supply at delivery. Establishing full enteral feeding may take many days, especially if the infant is ill. Early commencement of parenteral nutrition (PN) was shown to shorten the time interval until birth weight was regained. PN should commence on the first day, as soon as the infant is admitted to the neonatal unit, to avoid interruption of nutrient supply and accumulation of nutrient deficits whilst enteral feeds are established. (1–3) PN should be continued until an adequate amount of enteral nutrition is established. (4)

PN with amino acids and glucose should be commenced in all very preterm infants. Intravenous lipid emulsions are a good source of energy. It is safe to start lipid emulsions on day one. (1,5,6) The delivery of adequate PN usually requires central venous access. (see TEG Patient safety & hygiene practice)

Standardised PN solutions prepared for preterm infants and most ill term infants were shown to be safe, to contribute to cost savings, and to help to broadly implement initiation of nutrition on the first day. (7–9)

Benefits

Short-term benefits

  • Reduced time of postnatal interruption of nutrient supply and negative nitrogen balance (1,3)
  • Reduced accumulation of nutrient deficits and growth faltering (1–3)
  • Facilitated gradual introduction and advancement of enteral feeds (consensus)
  • Reduced risk of prescription errors (1,10)

Long-term benefits

  • Possible improved growth and development with optimal provision of nutrients (11,12)

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents are informed by healthcare professionals about the benefits of early initiation of parenteral nutrition (PN). B (High quality) Patient information sheet1
       
For healthcare professionals    
2. A unit guideline on infant nutrition, including PN, is adhered to by all healthcare professionals. B (High quality) Guideline
       
3. PN is commenced on the first day, soon after admission. (4) A (Moderate quality) Audit report
       
4. Training on infant nutrition, including the importance of nutrient requirements and early PN, is attended by all healthcare professionals working in the NICU. B (High quality) Training documentation
       
5. PN is carried out in consultation with a specialised nutrition support team. B (Moderate quality) Audit report
       
For neonatal unit    
6. A unit guideline on infant nutrition, including PN, is available and regularly updated. B (High quality) Guideline
       
7. The availability of central (or peripheral) venous access is ensured. (see TEG Patient safety & hygiene practice) B (High quality) Audit report
       
For hospital    
8. Training on infant nutrition, including the importance of nutrient requirements and early PN, is ensured. B (High quality) Training documentation
       
9. Standardised PN solutions and lipid emulsions are available 24 hours per day 7 days a week, either from the pharmacy or via the use of stored bags kept in the neonatal unit. A (Low quality)
B (Moderate quality)
Audit report
       
10. A standardised procedure that ensures safe compounding practices and safe delivery of PN is established. B (High quality) Guideline
       
For health service    
11. A national guideline on infant nutrition, including PN, is available and regularly updated. B (High quality) Guideline
       

1 The TEG Nutrition very much supports the need of good communication with families and regular sharing of key information, but it is not in favour of sharing information on each standard by a „parent information sheet“, which is term chosen by the Chair Committee. In our view, sharing multiple parent information sheets bears the risk of overloading families with a plethora of written information during a stressful time period, which may not be very helpful. We suggest to consider other means of sharing information.

Where to go

Further development Grading of evidence
For parents and family  
N/A  
For healthcare professionals  
N/A  
For neonatal unit  
N/A  
For hospital  
N/A  
For health service  
  • Evaluate health econometrics of neonatal standard solutions produced by hospital pharmacies and by commercial providers. (8,9
A (Moderate quality)
  • Invest in research to improve knowledge in and practice of parenteral nutrition (PN).
B (Moderate quality)
   

Getting started

Initial steps
For parents and family
  • Parents are verbally informed by healthcare professionals about the benefits of early initiation of parenteral nutrition (PN).
For healthcare professionals
  • Attend training on infant nutrition, including the importance of nutrient requirements and early PN.
For neonatal unit
  • Develop and implement a unit guideline on infant nutrition, including PN.
  • Develop information material on PN for parents.
For hospital
  • Source suitable standard solutions
  • Support healthcare professionals to participate in training on infant nutrition, including the importance of nutrient requirements and early PN.
For health service
  • Develop and implement a national guideline on infant nutrition, including PN.
 

Description

PN can be delivered with solutions that are individually tailored for each infant, which may be necessary in infants with special requirements or those requiring long-term PN. Individual prescription and compounding of PN solutions has the major disadvantage that the start of PN is usually delayed by the additional time required to make solutions available, and frequently occurring limitations of availability on weekends and holidays. The use of standardised PN solutions tailored to the needs of most preterm or ill term infants that are prepared by hospital pharmacies or commercial providers can enable PN initiation through 24 hours every day and hence improves nutrient delivery and quality of care.

Components of standardised PN solutions are prepared by hospital pharmacies and commercial providers, and hence carry less risk of microbial contamination and infection than mixing PN solutions on the ward. They also reduce the risk of prescription errors.

Sources

  1. Koletzko B, Poindexter B, Uauy R, editors. Nutritional care of preterm infants: scientific basis and practical guidelines. Basel: Karger; 2014. 314 p. (World review of nutrition and dietetics).
  2. Moyses HE, Johnson MJ, Leaf AA, Cornelius VR. Early parenteral nutrition and growth outcomes in preterm infants: a systematic review and meta-analysis. Am J Clin Nutr. 2013 Apr 1;97(4):816–26.
  3. Wilson DC, Cairns P, Halliday HL, Reid M, McClure G, Dodge JA. Randomised controlled trial of an aggressive nutritional regimen in sick very low birthweight infants. Arch Dis Child Fetal Neonatal Ed. 1997 Jul;77(1):F4-11.
  4. Koletzko B, Goulet O, Hunt J, Krohn K, Shamir R, Group PNGW, et al. Guidelines on paediatric parenteral nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr. 2005;41:S1–87.
  5. Krohn K, Koletzko B. Parenteral lipid emulsions in paediatrics. Curr Opin Clin Nutr Metab Care. 2006 May;9(3):319–23.
  6. Drenckpohl D, McConnell C, Gaffney S, Niehaus M, Macwan KS. Randomized trial of very low birth weight infants receiving higher rates of infusion of intravenous fat emulsions during the first week of life. Pediatrics. 2008 Oct;122(4):743–51.
  7. Krohn K, Babl J, Reiter K, Koletzko B. Parenteral nutrition with standard solutions in paediatric intensive care patients. Clin Nutr Edinb Scotl. 2005 Apr;24(2):274–80.
  8. Lenclen R, Crauste-Manciet S, Narcy P, Boukhouna S, Geffray A, Guerrault M-N, et al. Assessment of implementation of a standardized parenteral formulation for early nutritional support of very preterm infants. Eur J Pediatr. 2006 Aug;165(8):512–8.
  9. Petros WP, Shank WA. A standardized parenteral nutrition solution: prescribing, use, processing, and material cost implications. Hosp Pharm. 1986 Jul;21(7):648–9, 654–6.
  10. Simmer K, Rakshasbhuvankar A, Deshpande G. Standardised parenteral nutrition. Nutrients. 2013 Apr;5(4):1058–70.
  11. Vlaardingerbroek H, van Goudoever JB. Intravenous lipids in preterm infants: impact on laboratory and clinical outcomes and long-term consequences. World Rev Nutr Diet. 2015;112:71–80.
  12. van den Akker CHP, te Braake FWJ, Weisglas-Kuperus N, van Goudoever JB. Observational outcome results following a randomized controlled trial of early amino acid administration in preterm infants. J Pediatr Gastroenterol Nutr. 2014 Dec;59(6):714–9.

November 2018 / 1st edition / next revision: 2021

Recommended citation

EFCNI, Koletzko B, Fewtrell MS et al., European Standards of Care for Newborn Health: Effective implementation of early parenteral feeding. 2018.

For the purpose of evaluation, we would be grateful if you could send us details on your profession and country. This information is optional, anonymous and the data processed will exclusively be used for the aforementioned purpose, in line with Article 6, Para. 1 lit. a GDPR (General Data Protection Regulation).

Thank you for your support!