Indications for starting neonatal parenteral nutrition

1.1.1.

For preterm babies born before 31+0 weeks, start neonatal parenteral nutrition.

1.1.2.

For preterm babies born at or after 31+0 weeks, start parenteral nutrition if sufficient progress is not made with enteral feeding in the first 72 hours after birth.

1.1.3.

Start parenteral nutrition for preterm and term babies who are unlikely to establish sufficient enteral feeding, for example, babies with:

• a congenital gut disorder
• a critical illness such as sepsis.

Indications for starting neonatal parenteral nutrition if enteral feeds are stopped

1.1.4.

For preterm babies on enteral feeds, start parenteral nutrition if:

• enteral feeds have to be stopped and it is unlikely they will be restarted within 48 hours
• enteral feeds have been stopped for more than 24 hours and there is unlikely to be sufficient progress with enteral feeding within a further 48 hours.

1.1.5.

For term babies on enteral feeds, start parenteral nutrition if:

• enteral feeds have to be stopped and it is unlikely they will be restarted within 72 hours
• enteral feeds have been stopped for more than 48 hours and there is unlikely to be sufficient progress with enteral feeding within a further 48 hours.

Timing of starting neonatal parenteral nutrition

1.1.6.

When a preterm or term baby meets the indications for parenteral nutrition, start it as soon as possible, and within 8 hours at the latest.

Venous access

1.2.1.

Use a central venous catheter to give neonatal parenteral nutrition. Only consider using peripheral venous access to give neonatal parenteral nutrition if:

• it would avoid a delay in starting parenteral nutrition
• short-term use of peripheral venous access is anticipated, for example, less than 5 days
• it would avoid interruptions in giving parenteral nutrition
• central venous access is impractical.

1.2.2.

Only consider surgical insertion of a central venous catheter if:

• non-surgical insertion is not possible
• long-term parenteral nutrition is anticipated, for example, in short bowel syndrome.

Protection from light

1.2.3.

Protect the bags, syringes and infusion sets of both aqueous and lipid parenteral nutrition solutions from light.

Term babies who are critically ill or have just had surgery

1.3.3.

For term babies who are critically ill or have just had surgery, consider giving parenteral energy at the lower end of the starting range in recommendation 1.3.1, and gradually increase to the intended maintenance intake.

Glucose

1.5.1.

For preterm and term babies, give glucose as follows:

• If starting parenteral nutrition in the first 4 days after birth:

  –

  give a starting range of 6 to 9 g/kg/day

  –

  gradually increase (for example, over 4 days) to a maintenance range of 9 to 16 g/kg/day.

• If starting parenteral nutrition more than 4 days after birth:

  –

  give a range of 9 to 16 g/kg/day.

Amino acids

1.5.2.

For preterm babies, give amino acids as follows

• If starting parenteral nutrition in the first 4 days after birth:

  –

  give a starting range of 1.5 to 2 g/kg/day

  –

  gradually increase (for example, over 4 days) to a maintenance range of 3 to 4 g/kg/day.

• If starting parenteral nutrition more than 4 days after birth:

  –

  give a range of 3 to 4 g/kg/day.

1.5.3.

For term babies, give amino acids as follows:

• If starting parenteral nutrition in the first 4 days after birth:

  –

  give a starting range of 1 to 2 g/kg/day

  –

  gradually increase (for example, over 4 days) to a maintenance range of 2.5 to 3 g/kg/day.

• If starting parenteral nutrition more than 4 days after birth:

  –

  give a range of 2.5 to 3 g/kg/day.

Lipids and lipid emulsions

1.5.4.

For preterm and term babies, give lipids as follows:

• If starting parenteral nutrition in the first 4 days after birth:

  –

  give a starting range of 1 to 2 g/kg/day

  –

  gradually increase (for example, in daily increments of 0.5 to 1 g/kg/day) to a maintenance range of 3 to 4 g/kg/day.

• If starting parenteral nutrition more than 4 days after birth:

  –

  give a range of 3 to 4 g/kg/day.

1.5.5.

For preterm and term babies with parenteral nutrition-associated liver disease, consider giving a composite lipid emulsion rather than a pure soy lipid emulsion.

Ratios of non-nitrogen energy to nitrogen, and carbohydrates to lipids

1.5.6.

When giving neonatal parenteral nutrition to preterm or term babies:

• use the values for each individual component in recommendations 1.5.1 to 1.5.4
• provide non-nitrogen energy as 60% to 75% carbohydrate and 25% to 40% lipid
• use a non-nitrogen energy to nitrogen ratio in a range of 20 to 30 kcal of non-nitrogen energy per gram of amino acids (this equates to 30 to 40 kcal of total energy per gram of amino acid).

1.5.7.

When altering the amount of neonatal parenteral nutrition, maintain the non-nitrogen energy to nitrogen ratio, and the carbohydrate to lipid ratio, to keep within the ranges of ratios specified in recommendation 1.5.6.

Iron

1.5.8.

Do not give intravenous parenteral iron supplements to preterm or term babies on neonatal parenteral nutrition who are younger than 28 days.

1.5.9.

For preterm babies on neonatal parenteral nutrition who are 28 days or older, monitor for iron deficiency and treat if necessary (see recommendation 1.7.11).

Acetate

Calcium

1.5.10.

For preterm and term babies, give calcium as follows:

• If starting parenteral nutrition in the first 48 hours after birth:

  –

  give a starting range of 0.8 to 1 mmol/kg/day

  –

  increase to a maintenance range of 1.5 to 2 mmol/kg/day after 48 hours.

• If starting parenteral nutrition more than 48 hours after birth, give a range of 1.5 to 2 mmol/kg/day.

Phosphate

1.5.11.

For preterm and term babies, give phosphate as follows:

• If starting parenteral nutrition in the first 48 hours after birth:

  –

  give 1 mmol/kg/day

  –

  increase to a maintenance dosage of 2 mmol/kg/day after 48 hours.

• If starting parenteral nutrition more than 48 hours after birth, give 2 mmol/kg/day.
• Give a higher dosage of phosphate if indicated by serum phosphate monitoring.

1.5.12.

Be aware that preterm babies may be at increased risk of phosphate deficit requiring additional phosphate supplementation.

Ratio of calcium to phosphate

1.5.13.

Use a calcium to phosphate ratio of between 0.75:1 and 1:1 for preterm and term babies on neonatal parenteral nutrition.

Other constituents of neonatal parenteral nutrition – general principles

Blood glucose

1.7.2.

Measure the blood glucose level:

• 1 to 2 hours after first starting parenteral nutrition
• 1 to 2 hours after each change of parenteral nutrition bag (usually every 24 or 48 hours).

1.7.3.

Measure blood glucose more frequently if:

• the preterm or term baby has previously had hypoglycaemia or hyperglycaemia
• the dosage of intravenous glucose has been changed
• there are clinical reasons for concern, for example, sepsis or seizures.

Blood pH, potassium, chloride and calcium

1.7.4.

Measure the blood pH, potassium, chloride and calcium levels:

• daily when starting and increasing parenteral nutrition
• twice weekly after reaching a maintenance parenteral nutrition.

1.7.5.

Measure blood pH, potassium, chloride or calcium more frequently if:

• the preterm or term baby has previously had levels of these components outside the normal range
• the dosages of intravenous potassium, chloride or calcium have been changed
• there are clinical reasons for concern, for example, in critically ill babies.

Serum triglycerides

1.7.6.

Measure serum triglycerides:

• daily while increasing the parenteral nutrition lipid dosage
• weekly after reaching a maintenance intravenous lipid dosage.

1.7.7.

Measure serum triglycerides more frequently, but not more than once a day, if:

• the level is elevated
• the preterm or term baby is at risk of hypertriglyceridaemia, for example, if the baby is critically ill or has a lipaemic blood sample.

1.7.8.

Be aware that ongoing serum triglyceride monitoring may not be needed for stable preterm or term babies transitioning from parenteral nutrition to enteral nutrition.

Serum or plasma phosphate

1.7.9.

Measure the serum or plasma phosphate level:

• daily while increasing the parenteral nutrition phosphate dosage
• weekly after reaching a maintenance intravenous phosphate dosage.

1.7.10.

Consider measuring serum or plasma phosphate more frequently:

• if the level has been outside the normal range
• if there are clinical reasons for concern, for example, metabolic bone disease
• for preterm babies born at less than 32+0 weeks.

Iron status

1.7.11.

Measure ferritin, iron and transferrin saturation if a preterm baby is on parenteral nutrition for more than 28 days.

Liver function

1.7.12.

Measure liver function weekly in preterm and term babies on parenteral nutrition.

1.7.13.

Measure liver function more frequently than weekly if there are clinical concerns or previous liver function test levels outside the normal range.

1. Information and support

What are the information and support needs of parents and carers with babies on parenteral nutrition?

For a short explanation of why the committee made the research recommendation on information and support, see rationale and impact.

Full details of the research recommendation are in evidence review I: information and support.

2. Ratios of non-nitrogen energy to nitrogen

What is the optimal ratio of non-nitrogen energy to nitrogen in parenteral nutrition for preterm and term babies?

For a short explanation of why the committee made the research recommendation on the ratio of non-nitrogen energy to nitrogen in parenteral nutrition, see rationale and impact.

Full details of the research recommendation are in evidence review D7: ratio of non-nitrogen energy to nitrogen.

3. Timing of starting neonatal parenteral nutrition

What is the optimal timeframe for starting parenteral nutrition in term babies who are critically ill or require surgery?

For a short explanation of why the committee made the research recommendation on the timing of starting neonatal parenteral nutrition, see rationale and impact.

Full details of the research recommendation are in evidence review A2: optimal timeframe to start parenteral nutrition.

4. Venous access

What overall osmolality (or concentration of calcium and glucose/dextrose) in parenteral nutrition can determine whether to administer centrally or peripherally?

For a short explanation of why the committee made the research recommendation on using osmolality to determine whether to administer centrally or peripherally, see rationale and impact.

Full details of the research recommendation are in evidence review B: venous access.

Why the committee made the recommendations

How the recommendations might affect practice

The committee agreed that the recommendations would improve consistency of care across neonatal units, and ensure that the nutritional needs of vulnerable babies are met. Hospitals providing care for babies for whom parenteral nutrition is indicated would have to provide access to parenteral nutrition. If a hospital does not have access to neonatal parenteral nutrition, babies would need to be transferred to a unit that could provide it.

Early provision may be more costly because parenteral nutrition and staff would need to be available out-of-hours (including during weekends) to administer parenteral nutrition within the first 8 hours. However, costs can be reduced by using standardised parenteral nutrition bags, as recommended in the section on standardised neonatal parenteral nutrition formulations (‘standardised bags’), which can be stored and be readily accessible. The committee believe that there should be no reason why neonatal units cannot stock standardised bags because they have a long enough shelf life to enable storage, as long as a system of stock rotation is in place. The committee also agreed that the costs of early administration would be offset by the positive impact of early optimal nutrition.

Full details of the evidence and the committee’s discussion are in:

• evidence review A1: predictors of enteral feeding success
• evidence review A2: optimal timeframe to start parenteral nutrition.

Return to recommendations

Return to research recommendation

Why the committee made the recommendations

How the recommendations might affect practice

Why the committee made the recommendations

There was limited evidence on the energy needs for babies on parenteral nutrition, so the committee used their knowledge and experience to give a starting and maintenance range, and an example of how this should be increased gradually. The committee discussed the number of days over which energy intake should increase to reach the intended maintenance level, and agreed to align this with the recommendations on lipid, glucose and amino acid increases.

The committee agreed that babies who start parenteral nutrition in the first 4 days after birth should have a starting range and increase up to a maintenance range over approximately 4 days. This timeframe was primarily selected because neonatal metabolic adaptation occurs in the early days of life, enabling the baby to metabolise the nutrients delivered. In addition, fluid volume allowances are commonly increased over the first few days of life and this allows increasing amounts of nutrition to be given parenterally.

For babies who start parenteral nutrition more than 4 days after birth, early metabolic adaptation is likely to have taken place. The fluid allowances will have already increased, so this allows parenteral nutrition to be started using maintenance ranges.

The energy requirements were taken from the committee’s knowledge, informed (to a limited extent) by the evidence, and cross-referenced to the energy delivered by the combined constituent components (in the section on constituents of neonatal parenteral nutrition).

The committee agreed that giving energy at the lower range may be more appropriate for term babies who are critically ill or have just had surgery because the energy stores of term babies tend to be more replete. However, in critically ill preterm babies, who have limited nutritional stores, prioritising nutritional intake may be more important.

How the recommendations might affect practice

The committee agreed that the recommendations would improve consistency of care across neonatal units and would not incur extra costs or increase resource use. Providing the appropriate nutritional intake may avoid additional costs associated with nutritional deficit or providing excess energy.

Full details of the evidence and the committee’s discussion are in evidence review C: energy needs.

Return to recommendations

Why the committee made the recommendation

The recommendation on parenteral nutrition fluid volume was not developed by the usual NICE guideline systematic review process. The committee agreed the recommendation using a formal nominal group consensus method as well as their knowledge and experience.

The total fluid requirement for preterm and term babies is a complex topic, and was outside the scope of this guideline. Nevertheless, it is an important factor in providing neonatal parenteral nutrition. In some situations, the total fluid allowance may be restricted, or a significant proportion of the allowance might be required for other purposes (for example, other intravenous drug infusions). The committee recognised that this could result in difficulties in giving the required amount of parenteral nutrition. In order to minimise this risk, the committee agreed that standardised neonatal parenteral nutrition formulations (‘standardised bags’) should use the smallest fluid volume possible (see the section on standardised neonatal nutrition formulations). Concentrating parenteral nutrition in this way will facilitate the provision of nutritional requirements within the total fluid allowance.

How the recommendation might affect practice

The committee agreed that the recommendation will reinforce current best practice.

Full details of the evidence and the committee’s discussion are in evidence review J: general principles.

Return to recommendations

Why the committee made the recommendation

The evidence on glucose was difficult to interpret and draw any conclusions from. Only 1 study has been conducted that varied glucose intake without also varying other constituents (such as amino acids and lipids), so it is difficult to see what effect different levels of glucose intake have. Because of this, the committee used their knowledge and experience of physiological and metabolic requirements, and took into account the glucose doses used in the studies as well as current practice and international guidelines, when making their recommendation.

The committee decided that the maintenance range should be given for babies who start parenteral nutrition more than 4 days after birth. This is consistent with the approximate 4 days by which a maintenance dosage would be reached in babies starting parenteral nutrition from birth, because tolerance would increase during the first few days of life.

How the recommendation might affect practice

The committee agreed that the recommendation will reinforce current best practice.

Full details of the evidence and the committee’s discussion are in evidence review D1: glucose.

Return to recommendations

Why the committee made the recommendations

There was a lot of evidence related to amino acid intake. However, the evidence was uncertain, for example, because the studies involved small numbers of babies and the results were inconsistent, so the committee also used their knowledge and experience of current practice to make the recommendations.

For preterm babies, 1.5 g/kg/day was chosen as the lower starting dose threshold, because less than this can result in a negative nitrogen balance. The committee did not look for evidence on how different amino acid doses affect nitrogen balance, but used their knowledge of metabolic studies, which are widely used to estimate the minimum amount of amino acids needed to prevent negative nitrogen balance. The upper starting dose threshold of 2 g/kg/day was selected because there was evidence of better growth at a starting dose of 2 g/kg/day of amino acids compared with less than 2 g/kg/day, but these benefits did not persist at higher amino acid starting doses (3 g/kg/day).

Studies using different maximal amino acid intakes were considered in the evidence review, and informed the recommended maintenance range. There was some evidence that a maximal amino acid intake of 3 g/kg/day or more compared with less than 3 g/kg/day improved growth outcomes, but there was no evidence of reduced sepsis or neurodevelopmental problems. There was some evidence of appropriate growth at a maximal intake of 2.7 g/kg/day, but this was supported by early (within the first 24 hours) and progressive enteral feeding. Some babies receiving neonatal parenteral nutrition will be on no or minimal enteral feeds, or will be unable to increase enteral feeding in a timely manner. This, combined with the weak evidence of improved growth at 3 g/kg/day or more, meant that 3 g/kg/day was selected as the lower end of the maintenance range. However, the committee were split on this point so a majority decision was taken.

The committee agreed, based on their expertise, that it was important to provide an upper limit for amino acid intake because of possible adverse events such as acidosis, high serum urea, hypercalcaemia or hypophosphatemia, hypokalaemia and re-feeding syndrome. The maximal amino acid intake in the studies reviewed was 4 g/kg/day. The committee looked for adverse effects across all the studies in the evidence review, including those using maximal amounts of over 3.5 g/kg/day, and found no evidence of harm. However, the committee were concerned that the absence of evidence of harm is not the same as evidence of absence. It was noted that higher amino acid intakes need to be supported by sufficient non-nitrogen energy. The committee followed the evidence in agreeing an upper maintenance range limit of 4 g/kg/day. They suggested being more vigilant for adverse effects when using the top half of this maintenance range.

Babies on enteral feeds will receive macronutrients from milk in addition to those from parenteral nutrition. The committee acknowledged that for those babies on enteral feeds, the proportional decrease in parenteral nutrition as enteral intake increases will decrease the delivery of amino acids from parenteral nutrition, thus alleviating risks of excessive amino acid delivery. However, they noted that the enteral feeding regimen was outside the scope of this guideline, so did not recommend different ratios for babies on enteral feeds.

Most of the studies gradually increased amino acid intake over a number of days to reach a target dose. However, there was not enough consistent evidence to specify the number of days over which intake should be increased. The committee recommended 4 days, based on informal consensus agreement, using their knowledge and experience. In addition, the committee agreed that this is approximately how long it would take to reach the maintenance range if incrementing from the starting range at rates similar to those used in the included studies. This also matched the recommendations made for glucose and lipids, which is important because nitrogen to non-nitrogen ratios need to be maintained within the range specified in the guideline.

There was no evidence about amino acids for term babies, so the committee recommended a lower starting and maintenance dose based on their own expert consensus and knowledge of nitrogen balance studies. These studies show that term babies lose less protein than preterm babies, and suggest the amount of amino acids needed to achieve similar weight gain to term babies on milk feeds.

There was no evidence for babies who did not start parenteral nutrition from birth. The committee agreed, based on their expertise, that babies starting parental nutrition more than 4 days after birth would be able to tolerate the maintenance dosage of amino acids.

How the recommendations might affect practice

The committee noted that the recommendations will reduce variation in practice.

Full details of the evidence and the committee’s discussion are in evidence review D2: amino acids.

Return to recommendations

Why the committee made the recommendations

The evidence was uncertain (there was an inconsistent pattern of benefit and harm), so the committee also used their knowledge and experience of current practice to make the recommendations by informal consensus.

There was evidence of both benefit and harm when giving lipids compared with no lipids, but the committee agreed that the benefits of giving lipids outweighed possible risks. There was evidence that giving lipids in the ranges provided in the studies was not associated with any harm in the short term. In addition, there was evidence that higher doses may reduce retinopathy of prematurity and necrotising enterocolitis compared with lower doses. The committee concluded that the ranges in the studies were safe and effective.

In relation to how the target dose is reached, the evidence showed that slowly increasing lipids from a low starting dose to a target dose may be associated with a reduced risk of retinopathy of prematurity and hypertriglyceridaemia, compared with starting at a higher dose and rapidly increasing to the same target dose. The committee agreed to use similar parameters in the recommendations. Based on their knowledge of doses of lipids exceeding those used in the studies and the risk of problems such as hypertriglyceridemia, the committee recommended an upper limit for the maintenance dose.

The committee recommended that in babies with parenteral nutrition-associated liver disease, consideration be given to changing from a pure soy lipid emulsion (if that is being used) to a composite lipid emulsion. The committee discussed some evidence suggesting that there was more resolution of parenteral nutrition-associated liver disease or cholestasis with fish oil-containing lipid emulsions compared with pure soy lipid emulsions. However, the committee noted that there were limitations in the design of some studies and uncertainty in the measurement, which made this evidence very weak. There was also some evidence of a benefit with pure fish oil, but the committee were aware that there is a risk of essential fatty acid deficiency with pure fish oil. They therefore decided that even though this evidence to support the efficacy of composite lipid emulsions is not compelling, it could be trialled because these babies are at risk of developing progressive liver disease and liver failure. The available evidence was from preterm and late preterm babies. However, the recommendation was extended to cover term babies based on expertise from the committee that late preterm and term babies often have the same treatment, and similar benefits would be likely for term babies.

The committee did not make recommendations for babies with surgical conditions because there was no evidence of advantage of any type of lipid emulsion over other lipid formulations. Recommendations were not made for babies without parenteral nutrition-associated liver disease, including those at high risk, because there was not conclusive evidence of either benefit or harm.

How the recommendations might affect practice

The committee agreed that the recommendations will reinforce and standardise current best practice.

Full details of the evidence and the committee’s discussion are in:

• evidence review D3: lipids
• evidence review D4: lipid emulsions.

Return to recommendations

Why the committee made the recommendations

Why the committee did not make a recommendation on ratios of phosphate to amino acids

The evidence on the relative amounts of amino acids and phosphate to be given in parenteral nutrition was limited.

The committee agreed that the phosphate to amino acid ratios derived from following the phosphate and amino acid recommendations (1.5.11, 1.5.2 and 1.5.3) in this guideline are appropriate. However, because the evidence was limited and did not provide enough detail on the exact amount of phosphate needed per gram of amino acid, the committee decided not to make a recommendation on specific relative amounts.

How the recommendations might affect practice

The committee agreed that the recommendations reflect current best practice and should have little impact on practice. They should reduce any variation across units.

Full details of the evidence and the committee’s discussion are in:

• evidence review D7: ratio of non-nitrogen energy to nitrogen
• evidence review D8: ratio of carbohydrates to lipids
• evidence review D10: ratio of phosphate to amino acids

Return to recommendations

Return to research recommendation

Why the committee made the recommendations

There was limited evidence about intravenous iron supplementation for babies younger than 28 days. The evidence did not show a substantial benefit or harm. The committee recognised that usual clinical practice in the UK is not to include intravenous iron in the parenteral nutrition regimen for babies younger than 28 days, and agreed that there was not enough new evidence to change current practice. In addition, preterm babies often have blood transfusions that can result in unpredictable amounts of iron. The committee discussed the potential for iron overload and toxicity, and used their expertise and experience to recommend that early supplementation should not be used.

The committee agreed that healthcare professionals may need to reconsider iron supplementation for preterm babies who are 28 days or older based on monitoring for iron deficiency.

How the recommendations might affect practice

The recommendations reflect current practice, so should not result in any changes.

Full details of the evidence and the committee’s discussion are in evidence review D5: iron.

Return to recommendations

Why the committee decided not to make a recommendation

There was some evidence that using acetate in parenteral nutrition reduces the risk of hyperchloraemia, but there was no evidence about the amount of acetate needed. The evidence did not explain how chloride had been provided and the committee were unconvinced that the interventions used in the studies reflect current practice. The committee agreed that using the right balance of parenteral nutrition components and the use of standardised bags would avoid an excess of chloride and the need to add acetate.

The committee acknowledged that parenteral nutrition is not the only source of chloride (for example, some trace elements are in the form of chloride salts), so an imbalance may need to be addressed by adding acetate to reduce the risk of metabolic acidosis secondary to hyperchloraemia. The committee discussed that there is variation in clinical practice about the use of acetate but agreed that the evidence was not strong enough to make any recommendations about acetate.

Full details of the evidence and the committee’s discussion are in evidence review D6: acetate.

Return to recommendations

Why the committee made the recommendations

How the recommendations might affect practice

The recommendations on phosphate and calcium are largely in line with existing guidance and reflect current best practice. There is variation in practice so the recommendations should ensure consistency of care across different care settings.

Full details of the evidence and the committee’s discussion are in evidence review D9: ratio of calcium to phosphate.

Return to recommendations

Why the committee made the recommendations

The recommendations were not developed by the usual NICE guideline systematic review process. The committee agreed the recommendations’ evidence statements using a formal nominal group consensus method, and based the recommendations on their knowledge and experience.

How the recommendations might affect practice

The committee agreed that the recommendation will reinforce current best practice.

Full details of the evidence and the committee’s discussion are in evidence review J: general principles.

Return to recommendations

Why the committee made the recommendations

There was limited evidence on whether healthcare professionals should use parenteral nutrition formulations that are standardised (‘standardised bags’) or individualised. The committee used the limited evidence, and their knowledge and experience, to make the recommendations.

The committee agreed that healthcare professionals should use standardised bags routinely because:

• standardised bags are immediately available when needed, and suitable for most babies
• they help to minimise prescribing errors and clinical variation
• they can improve compliance with national recommendations on quality control of parenteral nutrition manufacturing, dispensing, prescribing and administration, because they must comply with nationally agreed quality standards (in line with the Royal Pharmaceutical Society and NHS Pharmaceutical Quality Assurance Committee standards for the quality assurance of aseptic preparation services)
• they have lower acquisition costs.

Individualised bags are not immediately available on a neonatal unit and are more complex to prescribe. The committee agreed that without good evidence to support the use of individualised bags, the additional complexity and cost is not justified.

Although the committee agreed that standardised bags should be used routinely and continued once started, individualised parenteral nutrition may be needed for babies with complex needs, for example, babies with a fluid imbalance.

Standardisation of parenteral nutrition is a concept which means that its effectiveness depends on optimal content for the average baby and its safety is related to the process of standardisation. Although there was some evidence suggesting that growth-related outcomes favoured an individualised approach, these findings were largely dependent on the specifics of what was in the standardised bag being trialled (which for most studies was not what would currently be recommended). The committee therefore agreed that, to be effective formulations, the standardised bags would be made up using the constituents outlined in the section on constituents of neonatal parenteral nutrition to provide optimal nutrition.

How the recommendations might affect practice

The committee agreed that the recommendations will lead to greater consistency in clinical practice and improve safety through compliance with national recommendations for parenteral nutrition manufacturing, dispensing, prescribing and administration.

Full details of the evidence and the committee’s discussion are in evidence review E: standardised neonatal parenteral nutrition formulations.

Return to recommendations

Why the committee made the recommendations

There was no evidence so the committee used their knowledge and experience to make the recommendations.

How the recommendations might affect practice

Because there is no current consensus on the monitoring of lipids, these recommendations may change clinical practice. All other recommendations reflect current practice, so the committee agreed there would be no change in practice.

Full details of the evidence and the committee’s discussion are in evidence review F: monitoring neonatal parenteral nutrition.

Return to recommendations

Why the committee made the recommendations

There was some evidence indicating better growth with stopping parenteral nutrition at a higher volume of enteral feeds (140 ml/kg/day). However, there were some inconsistencies between different studies, so the committee also used their knowledge and experience to make the recommendations. The committee based the ranges on the baby’s age because the balance between prioritising nutritional intake and minimising the risk of line sepsis may differ depending on the size of the baby. The committee agreed that there were other factors apart from the volume of enteral feeds that should be considered for all babies before stopping parenteral nutrition (for example, tolerance and amount of enteral feeds delivered as well as the clinical situation).

The lower limit for stopping parenteral nutrition in extremely preterm babies was taken from the evidence, but the upper limit was based on the committee’s knowledge and experience. In clinical practice, enteral feeds are not normally fortified at 140 ml/kg/day (as was done in the available evidence), so stopping at this point may risk nutritional deficits, so the committee recommended an upper threshold of 150 ml/kg/day. This may be considered the threshold at which the risks of continuing parenteral nutrition outweigh the benefits. The thresholds for stopping parental nutrition in babies born at or after 28+0 weeks were based on the committee’s expertise. The energy stores of older preterm babies and term babies are more replete than those of extremely preterm babies, allowing parenteral nutrition to be stopped at a lower volume.

However, the committee highlighted that stopping parenteral nutrition, even when these ranges are reached, should only be made once the other considerations (in recommendation 1.8.1) have been taken into account.

How the recommendations might affect practice

The committee agreed that the recommendations would reduce variation in clinical practice. For some services, these recommendations may result in a longer duration of parenteral nutrition, which would have associated costs. However, for other services, these recommendations would result in providing parenteral nutrition for a shorter duration and may produce cost savings. The committee discussed whether the recommendations could result in smaller volumes of parenteral nutrition being prescribed during the transition from parenteral to enteral nutrition, and that these small volumes would not be an efficient use of costs or resources. However, the committee agreed this could be mitigated by giving consideration to residual prescribed volumes of parenteral nutrition when making the decision to stop parenteral nutrition.

Full details of the evidence and the committee’s discussion are in evidence review G: stopping parenteral nutrition.

Return to recommendations

Why the committee made the recommendations

There was some evidence that multidisciplinary team services improve outcomes in newborn babies. However, there were many limitations relating to the evidence, and none of the studies were conducted in the UK. The committee made recommendations that they considered would provide optimum care for babies on parenteral nutrition, using the limited evidence (relating to the clinical role of multidisciplinary teams), and their knowledge of current clinical practice reports in the public domain (particularly related to the team’s role in service governance).

The committee acknowledged that inadequacies in the provision of neonatal parenteral nutrition had been highlighted in a 2011 report from the Paediatric Chief Pharmacists Group, Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children, which highlighted the need for improvements in practice

To address these shortcomings and ensure the safety of babies receiving parenteral nutrition, the committee agreed that neonatal parenteral nutrition services should be overseen and supported by a multidisciplinary team with expertise in neonatal parenteral nutrition. The committee specified the membership of the team to ensure that there is expertise in the clinical, prescribing and nutritional core components of neonatal parenteral nutrition (a consultant neonatologist or paediatrician with a special interest in neonatology, as well as a neonatal pharmacist and dietitian). The committee also recognised that access to other roles may be required, such as neonatal nursing, paediatric gastroenterology or expertise in clinical biochemistry to cover specific clinical or specialist areas of parenteral nutrition. The committee listed these different professionals, but agreed that all those listed would not need to see every baby routinely within the unit. The committee decided that an oversight or support team could be available at a local level or within a clinical network to ensure that every unit has access to these professionals when needed.

The committee agreed that enhanced multidisciplinary team input (for assessment and management) may be needed for preterm and term babies with complex needs, for example, babies with short gut who need parenteral nutrition for long time periods and who therefore have an increased risk of complications. This may involve more frequent meetings between multidisciplinary team members, and may also mean that other specialists are included in the multidisciplinary team, for example, a gastroenterologist. The committee did not want to be prescriptive about which professionals should be in the ‘enhanced’ multidisciplinary team because this would depend on the needs of each baby.

How the recommendations might affect services

The committee noted that there is currently variation in practice regarding the availability of specialists who are included within multidisciplinary teams, but agreed that these professionals would be available somewhere within a network of care. Arranging and formalising this access may require extra resources. However, babies with complex needs would invariably be seen by professionals from multiple disciplines, so this would not be a change in practice. The recommendations therefore would reduce variation and reinforce current best practice.

Full details of the evidence and the committee’s discussion are in evidence review H: service design.

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Why the committee made the recommendations

There was no evidence so the committee used their knowledge and experience to make the recommendations.

Good nutrition underpins good neonatal care, so the committee agreed that giving parents and carers information about parenteral nutrition is important.

The committee recognised that having a baby in a neonatal unit is a challenging and stressful situation, and agreed that the best approach to working with parents and carers is a collaborative one. This should involve giving parents and carers information tailored to their needs, and helping them to feel involved in their baby’s care.

The committee noted that principles of good information sharing and communication, as well as encouraging shared decision making, are covered in the NICE clinical guideline on patient experience in adult NHS services.

Given that there was no evidence, the committee made a recommendation for further research. This is important because having a baby in a neonatal unit can be a stressful and difficult time for parents and carers. Information and support can help parents manage these circumstances and help them feel involved and part of their baby’s care, which can improve outcomes. Given that the number of babies needing parenteral nutrition is likely to increase as prematurity survival rates improve, understanding what information and support parents need will help to support good outcomes.

How the recommendations might affect practice

The committee agreed there is variation in practice. These recommendations should improve consistency in how healthcare professionals support parents and carers, and ensure that they are given timely, consistent and appropriate information about parenteral nutrition.

Full details of the evidence and the committee’s discussion are in evidence review I: information and support.

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