HPE 101 – July 2022 | Page 30

indicates that there is a role for this team . The composition will likely be determined by the clinical condition of the baby and its severity . The report in 2011 by the Paediatric Chief Pharmacists Group recommended that all children have access to a competent MDT , with a minimum composition of a doctor , pharmacist , nurse and dietitian . 4 The exact structure of an MDT will depend on the caseload and the patients that are seen . An MDT can be network-based .
Not all babies will require longer-term management by an MDT . A lot of babies , particularly those not in Level 3 units , will only be on PN for a short period and standard bags are appropriate for these patients . For others , for example , in cases of CDH , there might be fluid restrictions , which together with multiple drug infusions limit the volume for nutrition . In these cases , the MDT has a significant role to play in optimising nutrition .
Suggested roles within the MDT Clinicians The neonatal consultant will generally be the team member with an overall view of the patient ’ s condition and will , generally , be the one to make the decision for commencing PN for patients who fall outside the absolute criteria above . For babies falling under surgical conditions , for example in CDH , then a surgeon will have a major input into the nutrition regime , particularly regarding the introduction of enteral feeds . For babies on long-term PN at risk of PN-associated liver disease ( PNALD ), then a gastroenterologist will also be required .
Nurse The nurse will be the healthcare professional who will be spending the most time with the patient and will be monitoring associated items like fluid balance and line condition . The NICE guideline has given ranges for the osmolality of solutions that can be run peripherally . This will be a change in practice for some units and might require more stringent line management , particularly for peripheral cannulae .
Pharmacist Following the introduction of non-medical prescribing in 2004 , prescribing of PN was seen as a natural progression for pharmacists as they had been involved in the formulation of PN for many years . Having a pharmacist as a member of the MDT , particularly attending ward rounds for babies on PN , will help to reduce prescribing errors , 6 and ensure suitability , from a chemical compatibility view , of the proposed regimen . This would be done in liaison with a pharmacist in the pharmacy aseptic unit , to discuss the validation and clinical appropriateness of any amendments to the formulation with the prescribing pharmacist .
Dietitian Enteral feeding was outside the scope of the NICE guideline so there were no recommendations around the transition to enteral feeds from PN . However , nearly all babies on PN will transition to full enteral feeding at some point , and this crossover as feeds increase and PN reduces can lead to a nutritional gap . Dietitians play an important role in recommending optimal enteral nutrition for these patients .
The MDT will not be the only factor influencing PN provision and duration of treatment ; for example , gestational age is also a factor . Critical outcomes identified by NICE were anthropometric outcomes , prescribing errors , and achievement of target intake . The latter two , in particular , can be influenced by the MDT . Although the evidence around the benefit of an MDT is low quality , knowledge and experience have shown these teams to be effective , particularly for babies with complex needs .
Conclusion Access to these core professionals , with access to other fields of expertise where needed , for example , surgeons or gastroenterologists as listed above , to provide additional clinical support , will help to provide optimum PN for neonates . This additional expertise can be network-based as not all units will have this additional support on site , and would be called upon as required for specific patients
So , the question is not whether an MDT is required for neonatal PN – experience has shown that it is beneficial – but what is the ideal composition for such a team . However , further research is required in this field to continue improvement in the provision of PN to neonates .
KEY POINTS
• Neonatal parenteral nutrition ( PN ) is a complex intervention that requires the involvement of multiple members of the clinical team and a multidisciplinary approach .
• The composition of the team will often be patient-specific ; for example , a baby with PN-associated liver disease will require the input of a gastroenterologist .
• Core members of the team will be consultant neonatologists , pharmacists , dietitians and neonatal nurses .
• The multidisciplinary team can be network-based where additional support is required as not all units will have all specialties onsite .
• Further research is required in this field to continue improvement in the provision of PN to neonates .
References 1 Ehrekranz RA et al . Longitudinal growth of hospitalised very low birth weight infants . Pediatrics 1999 ; 104 : 280 – 9 . 2 Morgan C . Optimising parenteral nutrition for the very preterm infant . Infant 2011 ; 7:2:42 – 6 . 3 Stewart JAD et al . A Mixed Bag . An enquiry into the care of hospital patients receiving parenteral nutrition . National Confidential Enquiry into Patient Outcome and Death 2010 . www . ncepod . org . uk / 2010report1 / downloads / PN _ report . pdf ( accessed July 2022 ). 4 Improving Practice and Reducing Risk in the Provision of Parenteral Nutrition for Neonates and Children . Report
of the Paediatric Chief Pharmacists Group . November 2011 . www . rpharms . com / Portals / 0 / RPS % 20document % 20 library / Open % 20access / Hospital % 20 Pharmacy % 20Hub / minimising-risk-pnchildren- % 286 % 29 . pdf ( accessed July 2022 ). 5 British Association of Perinatal Medicine . The Provision of Parenteral Nutrition within Neonatal Services - A Framework for Practice . April 2016 . www . bapm . org / resources / 42-theprovision-of-parenteral-nutrition-withinneonatal-services-a-framework-forpractice-2016 ( accessed July 2022 ). 6 National Institute for Health and Care Excellence . Neonatal parenteral nutrition . NG154 www . nice . org . uk /
guidance / NG154 ( accessed July 2022 ). 7 Georgieff MK , Innis SM . Controversial nutrients that potentially affect preterm neurodevelopment : essential fatty acids and iron . Pediatr Res 2005 ; 57:99R – 103R . 8 Tam MJ , Cooke RWI . Improving head growth in very preterm infants – I . A randomised control trial : neonatal outcomes . Arch Dis Child 2008 ; 93 : F337 – 41 . 9 Furtado S et al . Outcomes of patients with intestinal failure after the development and implementation of a multidisciplinary team . Can J Gastroenterol Hepatol 2016 ; 2016:9132134 . 10 Gover A et al . Outcome of patients with gastroschisis managed with
and without multidisciplinary teams in Canada . Paediatr Child Health 2014 ; 19 ( 3 ): 128 – 32 . 11 Jeong E et al . The successful accomplishment of nutritional and clinical outcomes via the implementation of a multidisciplinary nutrition support team in the neonatal intensive care unit . BMC Paediatrics 2016 ; 16:113 . 12 Sneve J et al . Implementation of a multidisciplinary team that includes a registered dietitian in a neonatal intensive care unit improved nutrition outcomes . Nutr Clin Pract 2008 ; 23 ( 6 ): 630 – 4 .
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