Neonatal parenteral nutrition

Context

Parenteral nutrition refers to intravenous feeding, a technique for providing nutrition to those who are unable to tolerate adequate enteral nutrition (orally or through an enteral tube). It is frequently needed by preterm babies while they establish enteral feeds, critically ill babies, and babies with gastrointestinal disorders who need surgery.

Inadequate nutrition, particularly in preterm babies, can have short-term and long-term health effects, including longer stays in the neonatal unit, an increased risk of infection, and worsened developmental outcomes. There is also evidence that inappropriate nutritional management soon after birth is linked to the development of metabolic syndrome in adults.

Approximately 95,000 babies born in the UK each year need neonatal care (National Neonatal Audit Programme 2016). Parenteral nutrition is widely used in neonatal care. It has become common practice to start it in preterm babies within the first few hours of life, and also to support term babies who are critically ill.

Parenteral nutrition contains nutrients such as glucose, electrolytes, amino acids, lipids, minerals, trace elements and vitamins. It may complement enteral feeding or, in some situations, replace it.

The National Confidential Enquiry into Patient Outcome and Death enquiry into the care of hospital patients receiving parenteral nutrition (2010) reviewed 264 cases of neonatal parenteral nutrition. It found that 73% of cases represented less than 'good practice', 40% had metabolic complications, 40% did not meet nutritional needs, and in 28% the start of parenteral nutrition was delayed. In 37%, the first parenteral nutrition provided was considered inadequate for the patient's needs.

Parenteral nutrition is normally formulated in an aseptic pharmacy unit. It can be in standardised or individualised forms. Prescribing is complex and open to error. Simplified, standardised regimens may reduce this risk, and may reduce costs.

In current practice, virtually all babies born before 31+0 weeks who weigh less than 1.5 kg need parenteral nutrition for a period that depends on gestation, birthweight and other morbidities. Postnatal growth failure is common in babies born before 31+0 weeks. It is associated with an increased need for respiratory support and increased risk of infection. It is also a risk factor for neurocognitive impairment. Optimal use of parenteral nutrition could potentially avoid postnatal growth failure.

Parenteral nutrition is expensive: for a large tertiary neonatal unit, it costs approximately £175,000 a year.

Given the wide variation in practice, safety concerns and costs, this guideline is needed to ensure that the provision of parenteral nutrition for babies is consistent across units and provides optimal care.