Improving neonatal parenteral nutrition in line with European Society of Paediatric Gastroenterology, Hepatology nutrition guidelines
Many neonatal units’ parenteral nutrition (PN) protocols fall short of achieving the requirements of the pre-term infant (Grover et al., 2008). The European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines (Koletzko et al., 2005) recommend a minimum of 1.5 g amino acid per kg per day and a minimum of 1 g lipid per kg per day be administered on day one of life. The primary aim of the audit was to determine how much amino acid and lipid were being prescribed from day one of life and how this compared to ESPGHAN. The secondary aim was to determine if growth charts were being used appropriately. Methods:
Pharmacy PN prescription records were used to identify the medical charts of all the babies who received PN for 7 days or longer from April 2009 to November 2009. Fifteen babies met the inclusion criteria; only 10 charts were available for review. The dose of lipid and amino acid prescribed from day 1 to day 7 of life was recorded along with the gestational age and weight of the infant. It was also noted whether growth charts were maintained weekly. Results:
Fifty percent (n = 5) of this group were <1 kg, 30% (n = 3) were <1.5 kg, and 20% (n = 2) were >1.5 kg birth weight. The infants’ daily weight gain was documented in all cases however a growth charts was completed for only one baby. Only two infants started amino acids and lipids on day 1 of life. Fifty per cent (n = 5) of infants received <1.5 g amino acid per kg per day initially and 70% (n = 7) of all infants received 0.5 g lipid per kg per day initially. Discussion:
There is emerging evidence that inadequate early nutrition affects normal growth patterns and neuro-cognitive and motor outcomes. An infant weighing <1 kg contains only 1% fat and 8% protein and has a non-caloric reserve of only 110 kcal kg−1 day−1 body weight, therefore early nutrient delivery is of vital importance (Koletzko et al., 2005). The results showed that half of this audit group were <1 kg and therefore were at greatest risk of malnutrition related complications. The importance of starting lipids early ensures sufficient non-protein calories for utilisation of the amino acid supply. At least 1 g lipid per kg per day is required to prevent essential fatty acid deficiency (EFA). The results showed that lipids were not prescribed early enough for all infants or at a dose necessary to prevent EFA deficiency. Although 1.5 g amino acid per kg per day is needed to prevent negative nitrogen balance only half of the audit group received this dose. It was also evident that amino acids were not delivered early enough in most cases. It should be noted that this audit predates the National Confidential Enquiry into Patient Outcome and Death (NCEPOD, 2010) but our observations concur with the report's findings. Conclusion:
It is clear that the PN guideline fell short of the ESPGHAN recommendations. New guidelines have therefore been introduced and will be re-audited on a six monthly basis. References:
Grover, A., Khashu, M., Mukherjee, A. & Kairamkonda, V. (2008) Iatrogenic Malnutrtion in Neonatal Intensive Care Units: Urgent Need to Modify Practice. JPEN. J. Parenter. Enteral. Nutr. 32,140–144.
Koletzko, B., Goulet, O., Hunt, J., Krohn, K. & Shamir, R. (2005) Guidelines on Paediatric Parenteral Nutrtion of the European Society of Paediatric Gastroenterology, Hepatology and Nutrtion (ESPGHAN) and the European Society for Clinical Nutrtion and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR). J. Pediatr. Gastroenterol. Nutr. 41, S1-S4.
The National Confidential Enquiry into Patient Outcome and Death NCEPOD (2010) A mixed bag. An Enquiry into the Care of Hospital Patients Receiving Parenteral Nutrition. (ISBN 978-0-9560882-3).
Document Type: Research Article
Affiliations: 1: Pharmacy Department, Belfast, UK; 2: Department of Nutrition and Dietetics, Belfast, UK and 3: Neonatal Unit, Ulster Hospital, Belfast, South Eastern HSC Trust, Belfast, UK, Email: [email protected]
Publication date: 2011-06-01