Koletzko B, Fewtrell MS, Domellöf M, Embleton ND, Gruszfeld D, McNulty A, Lapillonne A, Szitanyi P
Click on the image to read the standard in brief.
Target group
Very preterm term infants and parents
User group
Healthcare professionals, neonatal units, hospitals, and health services
Statement of standard
In very preterm infants (<32 weeks of gestation)/very low birthweight infants (<1500 g birthweight), parenteral nutrition should start on the first day after birth, usually using standard solutions, and should continue 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/very low birthweight 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. (1) PNshould 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. (1–5) PN should be continued until an adequate amount of enteral nutrition is established. (6)
PN with amino acids and glucose should be commenced in all very preterm infants and be complemented by intravenous lipid emulsions and micronutrients. (7–9) It is safe to start lipid emulsions on day one. (2,10,11) Attention should be paid to provide enough phosphorus and limit chloride delivery to prevent hypophosphatemia and metabolic acidosis, respectively. The delivery of adequate PN usually requires central venous access, although peripheral venous access may also be used, if a higher fluid intake is tolerated (see Patient safety & hygiene practice). (12)
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. (1,9,13–15)
Benefits
Short-term benefits
Reduced time of postnatal interruption of nutrient supply and negative nitrogen balance (2,4)
Reduced accumulation of nutrient deficits and growth faltering (2–4)
Facilitated gradual introduction and advancement of enteral feeds (consensus)
Reduced hypophosphataemia and metabolic acidosis (consensus)
Reduced risk of prescription errors (2,16)
Long-term benefits
Possible improved growth and development with optimal provision of nutrients (17,18)
Components of the standard
Component
Grading of evidence
Indicator of meeting the standard
For parents and family
Parents are informed by healthcare professionals about the benefits of early initiation of parenteral nutrition (PN).
A unit guideline on infant nutrition, including PN, is adhered to by all healthcare professionals.
B (High quality)
Guideline
PN is commenced on the first day, soon after admission. (6)
A (Moderate quality)
Audit report2
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
PN is carried out in consultation with a specialised nutrition support team.
B (Moderate quality)
Audit report2
For neonatal unit
A unit guideline on infant nutrition, including PN, is available and regularly updated.
Training on infant nutrition, including the importance of nutrient requirements and early PN, is ensured.
B (High quality)
Training documentation
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 report2
A standardised procedure that ensures safe compounding practices and safe delivery of PN is established.
B (High quality)
Guideline
For health service
A national guideline on infant nutrition, including PN, is available and regularly updated.
B (High quality)
Guideline
1The indicator ‘patient information sheet’ is an example for written, detailed information, in which digital solutions are included, such as web-based systems, apps, brochures, information leaflets, and booklets.
2The indicator ‘audit report” can also be defined as a benchmarking report.
*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 the 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. (14,19)
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.
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. (1,15) 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.
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September 2022 / 2nd edition / previous edition reviewed by van den Akker CHP / next revision: 2025
Recommended citation
EFCNI, Koletzko B, Fewtrell MS et al., European Standards of Care for Newborn Health: Effective implementation of early parenteral feeding. 2022.
