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Daily intakes of water soluble vitamins recommended by parenteral nutrition in term and preterm infants 35
Source publication
This update of guidelines for neonatal PN prescription is divided in two parts:
- Part I, included in the same issue of the journal, in which general aspects and criteria for fluids, energy, and macronutrients prescriptions, particularly for very and extremely preterm infants, are reviewed.
- Part II, herein included, in which criteria for micronu...
Contexts in source publication
Context 1
... Water-soluble vitamins (Table 6) Comments: -Although the optimal parenteral doses of most vitamins ...Context 2
... not yet been determined in newborn infants, Table 6 indicates the recommended doses for water soluble vitamins 35 -Vitamins should be administered daily (LoE 4, RG 0). 35 -Following the manufacturer's instructions, the content of one vial of Soluvit ® N (Fresenius Kabi) should be dissolved in 10 mL of water for injections or glucose solution for infusion (5%-50%). ...Similar publications
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Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes and water. PN should be provided via a central line because of its hypertonicity. However, pe...
Citations
... Fluid management and parenteral nutrition (PN) are vital in the management of extremely preterm neonates. Some practice guidelines available for PN in preterm population include NICE Guidelines 2020 [1], Portuguese Neonatal Society 2019 [2] and Australian Consensus Guidelines 2017 [3]. However, the practices vary across the settings according to the available resources and physician's discretion. ...
... Zinc supplementation is recommended from day one by NICE Guidelines [1] and Portuguese Guidelines [2]. However, other micronutrients/ trace elements are advised after two weeks of PN by Australian [3] and Portuguese Guidelines [2], whereas, since day one by NICE Guidelines [1]. ...
... Zinc supplementation is recommended from day one by NICE Guidelines [1] and Portuguese Guidelines [2]. However, other micronutrients/ trace elements are advised after two weeks of PN by Australian [3] and Portuguese Guidelines [2], whereas, since day one by NICE Guidelines [1]. In our survey, about half of the participants (53%) did not routinely add micronutrients in TPN (Total Parenteral Nutrition). ...
An online survey pertinent to fluid and parenteral nutrition practices in extreme preterm neonates was undertaken with responses from 123 neonatology practitioners across India. The initial fluid rate of 80 mL/kg/day was preferred by 67% neonatologists for 750–1000 g neonates. Half of them increased the fluid rates when weight loss per day was >2%. Practices vary widely across settings and guideline tailor made to clinical conditions is needed.
... The Portuguese guidelines for enteral nutrition in preterm neonates reported in this issue 5,6 are a fundamental element to enable such improvement. Used in conjunction with the previously published guidelines for parenteral nutrition 7,8 , and standardized postnatal growth monitoring 9,10 , these recommendations should allow for improved nutritional status during the acute stage of postnatal transition, as well as the convalescent stages preceding discharge from NICU. The guidelines underscore the importance of mother's own milk (MOM) as the optimal base for infant feeding, including preterm infants. ...
... As detailed elsewhere [33,34], the institutional neonatal nutrition protocol was followed considering the more recent international and national guidelines for parenteral and enteral nutrition [19,[36][37][38][39]. In brief, parenteral nutrition was initiated within the first 2 postnatal hours and early trophic feeding was initiated within the first 2 to 4 postnatal days preferentially using MOM, and DHM when MOM was insufficient. ...
The optimal method for human milk (HM) fortification has not yet been determined. This study assessed whether fortification relying on measured HM macronutrient content (Miris AB analyzer, Upsala, Sweden) composition is superior to fortification based on assumed HM macronutrient content, to optimize the nutrition support, growth, and body composition in infants born at <33 weeks’ gestation. In a mixed-cohort study, 57 infants fed fortified HM based on its measured content were compared with 58 infants fed fortified HM based on its assumed content, for a median of 28 and 23 exposure days, respectively. The ESPGHAN 2010 guidelines for preterm enteral nutrition were followed. Growth assessment was based on body weight, length, and head circumference Δ z-scores, and the respective growth velocities until discharge. Body composition was assessed using air displacement plethysmography. Fortification based on measured HM content provided significantly higher energy, fat, and carbohydrate intakes, although with a lower protein intake in infants weighing ≥ 1 kg and lower protein-to-energy ratio in infants weighing < 1 kg. Infants fed fortified HM based on its measured content were discharged with significantly better weight gain, length, and head growth. These infants had significantly lower adiposity and greater lean mass near term-equivalent age, despite receiving higher in-hospital energy and fat intakes, with a mean fat intake higher than the maximum recommended and a median protein-to-energy ratio intake (in infants weighing < 1 kg) lower than the minimum recommended.
... The samples studied by phase did not differ except in terms of weight. The comparison concerning PN nutrients intakes between the two groups is presented in Table 2 where maximal recommended daily intakes are also given [12,13]. For the first phase of the study, mean nutrient intakes respected the maximal recommended intakes for all nutrients except sodium and potassium intakes. ...
Objectives: Parenteral nutrition (PN) offers a quality therapeutic option when enteral feeding is non-tolerated or impossible. However, it can be associated with an increased risk of medical errors, especially in sensitive populations such as newborns. This study aimed at determining the impact of the implementation of a computerized physician order entry (CPOE) system on PN medication errors in the neonatology department in the largest teaching hospital in Tunisia.
Materiel & Methods: The frequency of medication errors in PN, in a teaching neonatal intensive care unit, was prospectively reviewed by a pharmacist between December 2018 and March 2019 in a two-phase interventional study (pre and post locally developed CPOE System implementation).
Results: Implementation of CPOE system decreased PN order errors from 379 to 147 representing a 61.1% reduction. The decreases on PN order errors per stage, i.e. prescribing and preparation, were form 207 to 22 (89.4%), and from 117 to 66 (43.6%) respectively. Mean nutrients intakes were in conformity to the recommended daily intakes during the CPOE phase of the study. CPOE is a protective tool against prescription and preparation errors. It significantly impacted all items of the ordering process.
Conclusions: In addition to the rigorous application of the recommendations, the CPOE system allows to reduce the risk of PN medication errors. This improves the safety and quality of medicines in newborns.
... For healthy preterm infants, 90-120 kcal/kg/day of energy is recommended through exclusive parenteral nutrition, after the first postnatal week [75,76]. BPD infants are a special subset of preterm infants who were found to receive a lower energy intake than those without BPD in the first month of life [77]. ...
... Hydrochlorothiazide is preferred due to its calcium-sparing effect compared with furosemide [84,85]. Recently, doses of calcium and phosphate provided through PN were reviewed and much higher doses were recommended than previously: in the first postnatal week Ca 32-80 mg/kg/day and P 31-62 mg/kg/day; subsequently, Ca 100-140 mg/kg/day and P 77-108 mg/kg/day, with a Ca/P ratio of 1.3 (mass) or 1 (molar) [76,86]. These very high doses are difficult to achieve in infants with BPD due to fluid restriction and the inherent risk of calcium phosphate precipitation in parenteral nutrition solutions [87,88]. ...
... Adequate doses of vitamins should be provided through parenteral nutrition, since preterm infants are especially prone to vitamin deficits due to their limited stores and rapid growth rate [76,90]. As mentioned before, a deficit of some vitamins in preterm infants was associated with the risk of BPD [33,51,62]. ...
Bronchopulmonary dysplasia (BPD) remains the most common severe complication of preterm birth, and nutrition plays a crucial role in lung growth and repair. A practical nutritional approach for infants at risk of BPD or with established BPD is provided based on a comprehensive literature review. Ideally, infants with BPD should receive a fluid intake of not more than 135‒150 mL/kg/day and an energy intake of 120‒150 kcal/kg/day. Providing high energy in low volume remains a challenge and is the main cause of growth restriction in these infants. They need a nutritional strategy that encompasses early aggressive parenteral nutrition and the initiation of concentrated feedings of energy and nutrients. The order of priority is fortified mother’s own milk, followed by fortified donor milk and preterm enriched formulas. Functional nutrient supplements with a potential protective role against BPD are revisited, despite the limited evidence of their efficacy. Specialized nutritional strategies may be necessary to overcome difficulties common in BPD infants, such as gastroesophageal reflux and poorly coordinated feeding. Planning nutrition support after discharge requires a multidisciplinary approach to deal with multiple potential problems. Regular monitoring based on anthropometry and biochemical markers is needed to guide the nutritional intervention.
... Infants will be managed according to the NICU nutrition protocol, taking into account international and national guidelines for parenteral and enteral nutrition [25,[39][40][41][42][43]. Parenteral nutrition is initiated within the first 2 postnatal hours and early trophic feeding within the first 2 to 4 postnatal days using, preferentially, their mother's own milk, and when this is insufficient, using donor's milk. ...
Objective The study aimed to assess the association between intrauterine growth of preterm infants and energy and macronutrient contents in their mothers' milk.
Study Design A historical cohort of mothers of preterm infants was assessed according to offspring's intrauterine growth. Fetal growth restriction (FGR) was defined as small-for-gestational age or appropriate for gestational age with fetal growth deceleration. During the first 4 weeks after delivery, the composition of daily pool samples of mothers' milk was measured by using a mid-infrared human milk analyzer. Explanatory models for milk energy, true protein, total carbohydrate, and fat contents were obtained by generalized additive mixed effects regression models.
Results In total, 127 milk samples were analyzed from 73 mothers who delivered 92 neonates. Energy content was significantly higher in mothers with chronic hypertension (average: +6.28 kcal/dL; 95% confidence interval [CI]: 0.54–12.01; p = 0.034) and for extremely preterm compared with very preterm infants (average: +5.95 kcal/dL; 95% CI: 2.16–9.73; p = 0.003), and weakly associated with single pregnancies (average: +3.38 kcal/dL; 95% CI: 0.07–6.83; p = 0.057). True protein content was significantly higher in mothers with chronic hypertension (average: +0.91 g/dL; 95% CI: 0.63–1.19; p < 0.001) and with hypertension induced by pregnancy (average: +0.25 g/dL, 95% CI: 0.07–0.44; p = 0.007), and for extremely preterm compared with very and moderate preterm infants (average: +0.19; 95% CI: 0.01–0.38; p = 0.043 and +0.28 g/dL; 95% CI: 0.05–0.51; p = 0.017, respectively). Fat content was weakly and negatively associated with FGR, both in SGA infants and AGA infants with fetal growth deceleration (average: −0.44 g/dL; 95% CI: −0.92 to −0.05; p = 0.079 and average: −0.36 g/dL; 95% CI: −0.74 to −0.02; p = 0.066, respectively).
Conclusion Energy and macronutrient contents in mothers' milk of preterm infants was significantly and positively associated with the degree of prematurity and hypertension. The hypothesis that the composition of milk is associated with FGR was not demonstrated.
Key Points
... Infants will be managed according to the NICU nutrition protocol, taking into account international and national guidelines for parenteral and enteral nutrition [25,[39][40][41][42][43]. Parenteral nutrition is initiated within the first 2 postnatal hours and early trophic feeding within the first 2 to 4 postnatal days using, preferentially, their mother's own milk, and when this is insufficient, using donor's milk. ...
Adequate nutrition of very preterm infants comprises fortification of human milk (HM), which helps to improve their nutrition and health. Standard HM fortification involves a fixed dose of a multi-nutrient HM fortifier, regardless of the composition of HM. This fortification method requires regular measurements of HM composition and has been suggested to be a more accurate fortification method. This observational study protocol is designed to assess whether the target HM fortification method (contemporary cohort) improves the energy and macronutrient intakes and the quality of growth of very preterm infants, compared with the previously used standard HM fortification (historical cohorts). In the contemporary cohort, a HM multi-nutrient fortifier and modular supplements of protein and fat are used for HM fortification, and the enteral nutrition recommendations of the European Society for Paediatric Gastroenterology Hepatology and Nutrition for preterm infants will be considered. For both cohorts, the composition of HM is assessed using the Miris Human Milk analyzer (Uppsala, Sweden). The quality of growth will be assessed by in-hospital weight, length, and head circumference growth velocities and a single measurement of adiposity (fat mass percentage and fat mass index) performed just after discharge, using the air displacement plethysmography method (Pea Pod, Cosmed, Italy). ClinicalTrials.gov registration number: NCT04400396.
Background
There is no consensus on optimal nutrition for preterm infants, leading to substantial practice variation. We aimed to assess the quality of nutritional guidelines for preterm infants, the consistency of recommendations, and the gaps in recommendations.
Methods
We searched databases and websites for nutritional guidelines for preterm infants before first hospital discharge, which were endorsed, prepared, or authorised by a regional, national, or international body, written in English, and published between 2012‐2023. Two reviewers independently screened articles and extracted the recommendations. Four reviewers appraised the included guidelines using AGREE II.
Results
7051 records were identified, and 27 guidelines included, 26% of which were high in quality. Most guidelines lacked stakeholder involvement and rigour of development. We found considerable variation in recommendations, many of which lacked details of certainty of evidence and strength of recommendation. Recommendations for type of feed and breastmilk fortification were consistent among high quality guidelines, but recommendations varied for intakes of almost all nutrients and monitoring of nutritional adequacy. Different guidelines gave different certainty of evidence for the same recommendations. Most gaps in recommendations were due to very low certainty of evidence.
Conclusions
Future development of nutritional guidelines for preterm infants should follow the standard guideline development method and ensure the rigorous process including stakeholders involvement to improve the reporting of strength of recommendation, certainty of evidence, and gaps in recommendation. Evidence is needed to support recommendations about macro and micronutrient intakes, breastmilk fortification, and markers on adequacy of intake of different nutrients.
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Mesmo que as estratégias ventilatória e antimicrobiana praticadas numa unidade de cuidados intensivos neonatais sejam de excelência, a qualidade assistencial praticada nestas pode considerar-se de citária se não for dada a devida atenção ao suporte nutricional. MENU
