Effective implementation of early parenteral feeding

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Authors

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

Long-term benefits


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)

Clinical records, parent information sheet1*

(see example)

For healthcare professionals

  1. A unit guideline on infant nutrition, including PN, is adhered to by all healthcare professionals.

B (High quality)

Guideline

  1. PN is commenced on the first day, soon after admission. (6)

A (Moderate quality)

Audit report2

  1. 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

  1. PN is carried out in consultation with a specialised nutrition support team.

B (Moderate quality)

Audit report2

For neonatal unit

  1. A unit guideline on infant nutrition, including PN, is available and regularly updated.

B (High quality)

Guideline

  1. The availability of central (or peripheral) venous access is ensured. (see Patient safety & hygiene practice)

B (High quality)

Audit report2

For hospital

  1. Training on infant nutrition, including the importance of nutrient requirements and early PN, is ensured.

B (High quality)

Training documentation

  1. 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

  1. A standardised procedure that ensures safe compounding practices and safe delivery of PN is established.

B (High quality)

Guideline

For health service

  1. 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.

  1. Carnielli VP, Correani A, Giretti I, D Apos Ascenzo R, Bellagamba MP, Burattini I, et al. Practice of Parenteral Nutrition in Preterm Infants. World Rev Nutr Diet. 2021;122:198–211.
  2. 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).
  3. 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.
  4. 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.
  5. van Goudoever JB, Carnielli V, Darmaun D, Sainz de Pipaon M, ESPGHAN/ESPEN/ESPR/CSPEN working group on pediatric parenteral nutrition. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Amino acids. Clin Nutr Edinb Scotl. 2018 Dec;37(6 Pt B):2315–23.
  6. 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.
  7. Bronský J, Campoy C, Braegger C. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Vitamins. Clin Nutr. 2018;
  8. Domellöf M, Szitanyi P, Simchowitz V, Franz A, Mimouni F, ESPGHAN/ESPEN/ESPR/CSPEN working group on pediatric parenteral nutrition. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Iron and trace minerals. Clin Nutr Edinb Scotl. 2018 Dec;37(6 Pt B):2354–9.
  9. Lapillonne A, Fidler Mis N, Goulet O, van den Akker CHP, Wu J, Koletzko B, et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Lipids. Clin Nutr. 2018 Dec;37(6):2324–36.
  10. Krohn K, Koletzko B. Parenteral lipid emulsions in paediatrics. Curr Opin Clin Nutr Metab Care. 2006 May;9(3):319–23.
  11. 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.
  12. Kolaček S, Puntis JWL, Hojsak I, Braegger C, Bronsky J, Cai W, et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Venous access. Clin Nutr. 2018 Dec;37(6):2379–91.
  13. 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.
  14. Lenclen R, Crauste-Manciet S, Narcy P, Boukhouna S, Geffray A, Guerrault MN, 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.
  15. Riskin A, Picaud JC, Shamir R, Braegger C, Bronsky J, Cai W, et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Standard versus individualized parenteral nutrition. Clin Nutr. 2018 Dec;37(6):2409–17.
  16. Simmer K, Rakshasbhuvankar A, Deshpande G. Standardised parenteral nutrition. Nutrients. 2013 Apr;5(4):1058–70.
  17. 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.
  18. 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.
  19. 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.

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.