REVIEW
Neonatal parenteral nutrition and the importance of the multidisciplinary team in delivery
Parenteral nutrition ( PN ) for neonates and its delivery is a complex process , with very specific requirements . A multi-disciplinary team can offer expertise to ensure adequate nutrition to avoid deficits and promote growth while reducing the risks associated with PN
Peter Mulholland MSc FRPharms Neonatal Pharmacist , Neonatal Intensive Care Unit , Royal Hospital for Children , Glasgow , UK
Providing parenteral nutrition ( PN ) to babies is a complex process . Multidisciplinary teams ( MDTs ) can have a unique understanding of the specific nutritional requirements and can offer added expertise in ensuring adequate nutrition to avoid deficits and promote growth , whilst reducing the risks associated with PN , including during the transition to full enteral feeding .
Parenteral nutrition : a background Appropriate nutrition is essential for growth and development . 1 – 3 Neonates who are unable to tolerate adequate enteral nutrition will require PN . Total parenteral nutrition ( TPN ) describes a situation whereby all nutrition is delivered intravenously ; however , PN is often used in the neonatal unit in conjunction with enteral feeds , either to maintain nutritional intake as milk feeds are increased or for babies in whom full enteral intake is not tolerated ( for example , in cases of short bowel ).
PN administration should be based on nationally agreed evidence-based guidelines , recognising that the evidence base for neonatal PN can be limited . 4 , 5 To date there has been no randomised controlled clinical trial of neonatal PN powered to examine longer-term outcomes including neurodevelopment and cardiovascular health . The 2020 National Institute for Health and Care Excellence ( NICE ) guideline for neonatal parenteral nutrition is the most comprehensive review of the current evidence . 6 This guideline covers PN for babies born preterm , up to 28 days after their due birth date and
TABLE 1
Absolute indications for PN in neonates
• < 31 completed weeks ’ gestation
• Congenital gastrointestinal defects ( for example , gastroschisis , intestinal atresia , congenital diaphragmatic hernia ( CDH ))
• Acquired gastrointestinal disease ( necrotising enterocolitis )
• Intestinal failure ( for example , short gut , pseudo-obstruction , enteropathy )
• Failure to establish enteral nutrition of > 100ml / kg / day by day 5 of life , regardless of gestation or birth weight
• Inability to tolerate enteral nutrition for a period likely to result in a significant nutritional deficit babies born at term , up to 28 days after their birth . The guideline provides recommendations on :
• indications for , and timing of , neonatal PN administration
• energy needs of babies on neonatal PN
• neonatal PN volume
• PN constituents
• standardised PN formulations
• monitoring neonatal PN
• stopping neonatal PN .
Indications for PN PN should be considered in any neonate who is unlikely to meet the nutritional requirements via the enteral route , either due to immaturity or illness . Premature infants , and especially those of extremely low birth weight , are particularly vulnerable due to their low nutritional reserves . 7 Early provision of nutrition for preterm infants is associated with improved weight gain and head growth . 8 When a baby meets the indications for PN , it is advised to start it as soon as possible , and within 8 hours at the latest . 6
The absolute indications are summarised in Table 1 .
The role of the multidisciplinary team in delivering neonatal PN The scope of the NICE guideline 6 only covered PN for babies born preterm , up to 28 days after their due birth date and babies born at term , up to 28 days after their birth . However , there will be babies who will require PN for longer periods due to factors that limit enteral intake . As part of the guideline development , NICE considered whether nutrition care / support teams are effective in providing parenteral nutrition in preterm and term babies . The literature review identified no randomised controlled trials ; therefore , observational studies were included to inform decisionmaking .
Four observational studies were identified by NICE . 9 – 12 Two involved cohorts of surgical patients , 9 , 10 whereas the others looked at cohorts of preterm infants . 11 , 12 The lack of robust trials in this area can be seen from the fact that in all categories considered , the NICE team found the evidence to be of very low quality ; however , experience has shown that the involvement of an MDT can improve outcomes .
Outcomes will potentially be influenced by the composition of the MDT which can include professionals from gastroenterology , neonatology , general surgery , nursing , nutrition , pharmacy , social work , and occupational therapy , depending on the individual patient . Not all disciplines will be involved in all patients . The current evidence does not enable the exact determination of an MDT to be detailed but
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