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Outcomes in relation to early parenteral nutrition use in preterm neonates born between 30 and 33 weeks' gestation: a propensity score matched observational study.
Webbe, JWH, Longford, N, Battersby, C, Oughham, K, Uthaya, SN, Modi, N, Gale, C
Archives of disease in childhood. Fetal and neonatal edition. 2022;(2):131-136
Abstract
OBJECTIVE To evaluate whether in preterm neonates parenteral nutrition use in the first 7 postnatal days, compared with no parenteral nutrition use, is associated with differences in survival and other important morbidities. Randomised trials in critically ill older children show that harms, such as nosocomial infection, outweigh benefits of early parenteral nutrition administration; there is a paucity of similar data in neonates. DESIGN Retrospective cohort study using propensity matching including 35 maternal, infant and organisational factors to minimise bias and confounding. SETTING National, population-level clinical data obtained for all National Health Service neonatal units in England and Wales. PATIENTS Preterm neonates born between 30+0 and 32+6 weeks+days. INTERVENTIONS The exposure was parenteral nutrition administered in the first 7 days of postnatal life; the comparator was no parenteral nutrition. MAIN OUTCOME MEASURES The primary outcome was survival to discharge from neonatal care. Secondary outcomes comprised the neonatal core outcome set. RESULTS 16 292 neonates were compared in propensity score matched analyses. Compared with matched neonates not given parenteral nutrition in the first postnatal week, neonates who received parenteral nutrition had higher survival at discharge (absolute rate increase 0.91%; 95% CI 0.53% to 1.30%), but higher rates of necrotising enterocolitis (absolute rate increase 4.6%), bronchopulmonary dysplasia (absolute rate increase 3.9%), late-onset sepsis (absolute rate increase 1.5%) and need for surgical procedures (absolute rate increase 0.92%). CONCLUSIONS In neonates born between 30+0 and 32+6 weeks' gestation, those given parenteral nutrition in the first postnatal week had a higher rate of survival but higher rates of important neonatal morbidities. Clinician equipoise in this area should be resolved by prospective randomised trials. TRIAL REGISTRATION NUMBER NCT03767634.
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Early versus later initiation of parenteral nutrition for very preterm infants: a propensity score-matched observational study.
Uthaya, S, Longford, N, Battersby, C, Oughham, K, Lanoue, J, Modi, N
Archives of disease in childhood. Fetal and neonatal edition. 2022;(2):137-142
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Abstract
OBJECTIVE To evaluate the impact of timing of initiation of parenteral nutrition (PN) after birth in very preterm infants. DESIGN Propensity-matched analysis of data from the UK National Neonatal Research Database. PATIENTS 65 033 babies <31 weeks gestation admitted to neonatal units in England and Wales between 2008 and 2019. INTERVENTIONS PN initiated in the first 2 days (early) versus after the second postnatal day (late). Babies who died in the first 2 days without receiving PN were analysed as 'late'. MAIN OUTCOME MEASURES The main outcome measure was morbidity-free survival to discharge. The secondary outcomes were survival to discharge, growth and other core neonatal outcomes. FINDINGS No difference was found in the primary outcome (absolute rate difference (ARD) between early and late 0.50%, 95% CI -0.45 to 1.45, p=0.29). The early group had higher rates of survival to discharge (ARD 3.3%, 95% CI 2.7 to 3.8, p<0.001), late-onset sepsis (ARD 0.84%, 95% CI 0.48 to 1.2, p<0.001), bronchopulmonary dysplasia (ARD 1.24%, 95% CI 0.30 to 2.17, p=0.01), treated retinopathy of prematurity (ARD 0.50%, 95% CI 0.17 to 0.84, p<0.001), surgical procedures (ARD 0.80%, 95% CI 0.20 to 1.40, p=0.01) and greater drop in weight z-score between birth and discharge (absolute difference 0.019, 95% CI 0.003 to 0.035, p=0.02). Of 4.9% of babies who died in the first 2 days, 3.4% were in the late group and not exposed to PN. CONCLUSIONS Residual confounding and survival bias cannot be excluded and justify the need for a randomised controlled trial powered to detect differences in important functional outcomes.
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Safety and Efficacy of Early High Parenteral Lipid Supplementation in Preterm Infants: A Systematic Review and Meta-Analysis.
Kim, K, Kim, NJ, Kim, SY
Nutrients. 2021;(5)
Abstract
The objective of this systematic review and meta-analysis was to summarize the effects of early initiation and achievement of a high dose of parenteral lipids (≥1.5 g/kg/day reached within the first 24 h of birth) on growth and adverse outcomes in preterm infants. PubMed, EMBASE, and Cochrane databases were utilized to search for publications for this meta-analysis. Randomized controlled trials were eligible if data on growth or clinical outcome was available. The search returned nine studies. The mean proportion of postnatal weight loss (%) was lower (mean difference [MD]: -2.73; 95% confidence interval [CI]: -3.69, -1.78), and the mean head circumference near the term equivalent age (cm) was higher in the early high lipid treatment group (MD: 0.67; 95% CI: 0.25, 1.09). There was a favorable association of early high lipid administration with the incidence of extrauterine growth restriction (relative risk [RR]: 0.27; 95% CI: 0.15, 0.48). Generally, there were no differences in morbidities or adverse outcomes with early high lipid administration. Early initiation of parenteral lipids and high dose achieved within the first 24 h of life appear to be safe and endurable and offer benefits in terms of growth.
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Effects of different lipid emulsions on serum adipokines, inflammatory markers and mortality in critically ill patients with sepsis: A prospective observational cohort study.
Ulusoy, H, Kangalgil, M, Küçük, AO, Özdemir, A, Karahan, SC, Yaman, SÖ, Yavuz, HB, Ok, Ü
Clinical nutrition (Edinburgh, Scotland). 2021;(7):4569-4578
Abstract
BACKGROUND & AIMS Intravenous lipid emulsions in parenteral nutrition may cause different metabolic responses and immune effects in critically ill patients with sepsis. The aim of this study is to investigate the effects of different lipid emulsions on changes in concentrations of adipokine and cytokine and their relationship with mortality in patients. METHODS Patients enrolled in this prospective, single-center, observational cohort study, were estimated to require more than ten days of parenteral nutrition. They were treated with soybean oil-based or olive oil-based parenteral lipid emulsions. Adipokine and cytokine concentrations of septic patients were determined at enrollment and ten days after, in accordance with the diagnostic criteria of SEPSIS-3. The concentrations levels were measured in an enzyme-linked immunosorbent assay. Mortality was analyzed using the Kaplan-Meier method and Cox regressions. RESULTS Over a 25-month period, 145 patients were assessed for eligibility and consequently, 40 patients were analyzed. On admission, both groups had comparable physiological scores, comorbidities, malnutrition risk, anthropometric measurements, metabolic/hematologic biomarkers and concentrations of adipokines and cytokines (p > .05). Serum leptin, resistin, and cytokines (IL-6, IL-10, IL-1β and TNF-α) decreased significantly in the entire cohort over ten days following sepsis (p < .05). Serum resistin decreased in both olive oil-based and soybean oil-based lipid emulsions groups. Serum adiponectin only decreased in soybean oil-based lipid emulsions group (p < .05). There was association between survival and percentage changes in adiponectin, resistin and visfatin concentrations (log rank test: p < .05). CONCLUSION Adipokine and cytokine responses are affected by medical nutritional therapy in the sepsis process and adipokines may represent functional prognostic biomarkers in critically ill patients with sepsis.
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High Early Parenteral Lipid in Very Preterm Infants: A Randomized-Controlled Trial.
Alburaki, W, Yusuf, K, Dobry, J, Sheinfeld, R, Alshaikh, B
The Journal of pediatrics. 2021;:16-23.e1
Abstract
OBJECTIVE To determine whether high early parenteral soybean oil lipid intake in very low birth weight (VLBW) infants in the first week after birth decreases the proportion of weight loss and subsequently the incidence of extrauterine growth restriction (EUGR). STUDY DESIGN This was a randomized controlled trial of appropriate for gestational- ge VLBW infants. Lipid intake in the control group started at 0.5-1 g/kg per day and increased daily by 0.5-1 g/kg per day till reaching 3 g/kg per day. The intervention group was started on 2 g/kg per day that increased to 3 g/kg per day the following day. RESULTS Of the 176 infants assessed for eligibility, 83 were included in the trial. Infants in the intervention group were started on lipid sooner (13.8 ± 7.8 vs 17.5 ± 7.8 hour; P = .03) and had higher cumulative lipid intake in the first 7 days of age (13.5 ± 4.2 vs 10.9 ± 3.5 g/kg per day; P = .03). Infants in the intervention group had a lower percentage of weight loss (10.4 vs 12.7%; P = .02). The mean triglyceride level was higher in the intervention group (1.91 ± 0.79 vs 1.49 ± 0.54 mmol/L; P = .01), however, hypertriglyceridemia was similar between the 2 groups. The incidence of EUGR was lower in the intervention group (38.6% vs 67.6%; P = .01). Head circumference z score was higher in the intervention group (-1.09 ± 0.96 vs -1.59 ± 0.98; P = .04). CONCLUSIONS In VLBW infants, provision of a high early dose of parenteral lipid in the first week of age results in less weight loss and lower incidence of EUGR. TRIAL REGISTRATION Clinicaltrials.gov: NCT03594474.
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Early Enteral Feeding Improves Tolerance of Parenteral Nutrition in Preterm Newborns.
Boscarino, G, Conti, MG, Di Chiara, M, Bianchi, M, Onestà, E, Faccioli, F, Deli, G, Repole, P, Oliva, S, Cresi, F, et al
Nutrients. 2021;(11)
Abstract
(1) Background: The tolerance of preterm newborns for the high nutritional intakes given by parenteral nutrition (PN) is still debated because of the risk of metabolic complications. Despite enteral nutrition (EN) being the preferred route of nutrition, an exclusive enteral feeding is not always possible, as in preterm newborns, the gut is immature and less tolerant of EN. We aimed to study the impact of a minimal enteral feeding (MEF) on the possible early metabolic complications of PN in a cohort of preterms with gestational age at birth GA ≤ 29 + 6/7 weeks of postmenstrual age. (2) Methods: We divided the study sample in two cohorts: 1) Late-Feeding (cohort 1), newborns who received MEF starting from the 8th day of age, and (2) Early-Feeding (cohort 2), newborns who received MEF, consisting of the administration of at least 4-5 mL/kg/day by the enteral route, in the first 7 days of age. The primary outcome of the study was the rate of at least one metabolic complication, including hyperglycemia, hypertriglyceridemia, or metabolic acidosis. (3) Results: We enrolled 80 newborns (Late-Feeding cohort 51 vs. Early-Feeding cohort 29). The rate of all metabolic complications was statistically higher in the Late-Feeding cohort compared to the Early-Feeding cohort. Binary logistic regression analysis showed that late administration of MEF negatively influenced the rate of all metabolic complications. (4) Conclusions: Early minimal administration of EN is associated with less frequent PN-related metabolic side effects and a higher rate of survival in critically ill newborns.
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American Society for Parenteral and Enteral Nutrition Clinical Guidelines: The Validity of Body Composition Assessment in Clinical Populations.
Sheean, P, Gonzalez, MC, Prado, CM, McKeever, L, Hall, AM, Braunschweig, CA
JPEN. Journal of parenteral and enteral nutrition. 2020;(1):12-43
Abstract
On behalf of the American Society for Parenteral and Enteral Nutrition (ASPEN), a systematic review was conducted to evaluate the best available evidence regarding the validity of relevant body composition methods (eg, dual energy X-ray absorptiometry [DXA], ultrasound [US], and bioelectrical impedance analysis [BIA]) in clinical populations. The guidelines targeted adults >18 years of age with a potentially inflammatory condition or pathological end point associated with a specific disease or clinical condition. In total, 7375 studies were retrieved, and 15 DXA, 7 US, and 23 BIA studies provided applicable data. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used to assess the diagnostic accuracy of the test method against a "gold standard" reference. The Grading of Recommendations, Assessment, Development and Evaluation criteria were used to separate the evaluation of the body of evidence from the recommendations. Based on a limited number of studies and expert opinion, DXA is recommended for the assessment of fat mass in patients with a variety of disease states; however, the validity of DXA for lean mass assessment in any clinical population remains unknown. No recommendations can be made at this time to support the use of US or BIA in the clinical setting, as data to support its validity in any specific patient population are limited in scope or by the proprietary nature of manufacture-specific BIA regression models to procure body composition data, respectively. Directions for future research are provided. These clinical guidelines were approved by the ASPEN Board of Directors.
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Home medical nutrition during SARS-CoV-2 pandemic - A position paper.
Matras, P, Klek, S, Folwarski, M, Zmarzly, A, Bartoszewska, L, Cebulski, W, Jakubczyk, M, Kamocki, Z, Klepczyk, K, Kunecki, M, et al
Clinical nutrition ESPEN. 2020;:196-200
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Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a worldwide rapidly spreading illness, Coronavirus Disease 2019 (COVID-19). Patients fed enterally and parenterally at home are exposed to the same risk of infection as the general population, but more prone to complications than others. Therefore the guidance for care-givers and care-takers of these patients is needed. METHODS The literature search identified no relevant systematic reviews or studies on the subject. Therefore a panel of 21 experts from 13 home medical nutrition (HMN) centres in Poland was formed. Twenty-three key issues relevant to the management of SARS-CoV-2 infection or COVID-19 in the HMN settings were identified and discussed. Some statements diverge from the available nutrition, surgical or ICU guidelines, some are based on the best available experience. Each topic was discussed and assessed during two Delphi rounds subsequently. Statements were graded strong or weak based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. RESULTS the panel issued 23 statements, all of them were graded strong. Two scored 85.71% agreement, eleven 95.23%, and ten 100%. The topics were: infection control, enrolment to HMN, logistics and patient information. CONCLUSIONS the position paper present pragmatic statements for HMN to be implemented in places without existing protocols for SARS-CoV-2 pandemic. They represent the state of knowledge available at the moment and may change should new evidence occurs.
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Effects of Probiotics on Intestinal Failure-Associated Liver Disease in Adult Patients Receiving Prolonged Parenteral Support: A Tertiary Care Center Experience.
Alomari, M, Nusairat, L, Al Momani, L, Chadalavada, P, Covut, F, Olayan, M, Young, M, Romero-Marrero, C
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2020;(3):454-463
Abstract
BACKGROUND It has been hypothesized that dysbiosis plays a significant role in the pathogenesis of intestinal failure-associated liver disease (IFALD). Therefore, we aimed to investigate the effect of probiotics on IFALD in patients receiving parenteral support, namely home parenteral nutrition (HPN) and home intravenous fluids (HIVFs). METHODS We retrospectively reviewed charts of patients with intestinal failure who received HPN or HIVF for >2 weeks at our tertiary center between January 2005 and August 2016. We excluded patients <18 years of age, patients with other causes of liver disease, patients who used probiotics for <30 days, patients with <6 months' follow-up, and those who had long-term antibiotic use (>30 days). Bivariable and multivariable logistic regression analyses were used in this study. RESULTS A total of 282 patients who received parenteral support were included. Eighty-five percent of our sample received PN. A total of 78 (27.7%) patients used probiotics. The prevalence of IFALD in patients who used probiotics was 35.9% vs 54.4% in patients who did not use probiotics, P = .005. In multivariable analysis, only small-bowel length of 10-90 cm and HPN use showed a significant impact on IFALD, odds ratio (OR) = 4.394 (95% confidence interval [CI], 1.635-11.814; P = .003) and OR = 4.502 (95% CI 1.412-14.351; P = .011), respectively. CONCLUSION Our study revealed that the prevalence of IFALD was comparable among the probiotic users and nonusers. Only small bowel length of 1090 cm and HPN use showed a significant impact on IFALD.
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Predictive factors of hyperglycaemia in patients with parenteral nutrition.
Sangrador Pelluz, C, Pardo Pastor, J, Navas Moya, E, Nicolás Picó, J, Quintana, S
Medicina clinica. 2020;(5):157-162
Abstract
OBJECTIVE To identify the predictive factors of hyperglycaemia in patients receiving parenteral nutrition (PN). MATERIAL AND METHODS Retrospective observational study (January 2016-December 2016) conducted in a 450-bed university hospital. Adult hospitalized patients who received total PN through a central line for at least 48hours were included. The required variables to characterize patients, and those related to the PN received were collected and hyperglycaemia was defined as 3 consecutive glycaemias greater than 150mg/dl or 2 greater than 180mg/dl. A descriptive, comparative bivariate statistical analysis was carried out, as well as a multivariate analysis using binary logistic regression (SPSS.v.24.) RESULTS 234 patients were included. The prevalence of hyperglycaemia in the population under study was 44.0%. The main differences observed in the bivariate analysis between hyperglycaemic and normoglycemic patients were related to age, previous comorbidities, medical department, presence of sepsis, duration and glucose contribution in PN, as well as blood glucose levels and corticosteroids. The predictors of hyperglycaemia obtained after the multivariate analysis were: renal clearance (OR=.982, 95% CI .968-.996, P=.010), pre-PN glycaemia (OR=1.039, 95% CI 1.026-1.051, P<.001), diabetes mellitus (OR=11.016, 95% CI 3.028-31.697, P<.001), intensive medicine (OR=3.303, 95% CI 1.183-9.219, P=.023), corticosteroids (OR=3.155, 95% CI 1.179-8.226, P=.022). CONCLUSIONS Decreased renal clearance, high blood glucose levels, diabetes, corticosteroid use, and critical patients are predictors of hyperglycaemia, therefore it would be advisable to consider them in the design of PN start formula.