Parenteral Nutrition in Preterm Infants

Publication Date: August 22, 2023
Last Updated: November 7, 2023

Summary of Recommendations

We recommend prompt initiation of PN after birth as soon as appropriate vascular access is obtained. However, few studies evaluated the timing of PN initiation (inclusive of dextrose, AA, and ILE) in preterm infants using growth outcomes that met definitions for inclusion. (S, VL)
620
We recommend against an initial dose of >3 g/kg/day given that a single trial found an increased rate of sepsis in infants who were prescribed an initiating AA dose of 3.5 g/kg/day. In considering the maximal target dose, we recommend providing parenteral AA at a minimum of 3 g/kg/day and not exceeding 3.5 g/kg/day. This guidance accounts for growth outcomes as well as neurodevelopmental outcomes associated with AA dose as addressed in question 3. Also, current evidence remains limited in distinguishing any benefit—namely, improved growth—comparing a maximum AA dose of 3.5 vs 4 g/kg/day. (S, L)
620
In considering the maximal target dose, we recommend providing parenteral AA doses at a minimum of 3 g/kg/day without increasing beyond 3.5 g/kg/day. The current evidence remains limited in distinguishing any benefit—namely, improved neurodevelopment—comparing a maximum AA dose of 3.5 vs 4 g/kg/day, and there is the suggestion that exceeding 3.5 g/kg/day may not be without harm. (S, L)
620
To improve growth, we recommend daily advancement of ILE to a dose of 3 g/kg/day if using SO-ILE or multicomponent ILE. We strongly emphasize the need for attention to ILE composition when making decisions on ILE dose to ensure the provision of sufficient fatty acids for the purposes of preventing an essential fatty acid deficiency (EFAD). Providing suboptimal ILE doses that are associated with a risk for an EFAD may impair growth and increase the risk for other adverse outcomes. (S, VL)
620
At this time, we do not recommend any specific ILE composition for enhanced growth, given there was no evidence of benefit from any particular ILE. (S, VL)
620
We do not recommend routinely reducing the dose of AA, dextrose, or ILE when providing PN or ILE when providing PN when providing PN to preterm infants for the purposes of preventing PNALD. (S, VL)
620
For the purpose of preventing PNALD in preterm infants, we do not recommend any specific ILE composition. We found no evidence of reduced PNALD risk with any specific ILE, whether it contains 100% SO as the sole oil source or a multicomponent-oil ILE with or without FO. (S, L)
620
For the purposes of preventing PNALD in preterm infants, we do not recommend the use of any specific ILE, whether it contains 100% SO as the sole oil source or a multicomponent-oil ILE that includes FO. As identified in secondary analyses, further study is needed to evaluate the potential for an ILE containing FO and its association with ROP severity. (S, L)
620
We are unable to recommend any specific ILE dose for the purpose of reducing unbound bilirubin levels. We suggest further research utilizing clinical trials is needed to address this question. (S, VL)
620
We recommend against a dose reduction of ILE to prevent sepsis. (S, VL)
620
Given the paucity of available data from clinical trials, we recommend that micronutrient provisions, including calcium and phosphate prescribing, be in accordance with doses advised in consensus guidelines such as those provided by ASPEN and ESPGHAN. (S, VL)
620
Given the absence of clinical trials to evaluate this question, we do not recommend use of standardized PN solutions for routine care of preterm infants. This recommendation does not address or dissuade use of premade PN solutions generally utilized for the first 24 h after birth (commonly referred to as “starter” or “stock” PN), which are useful given their immediate availability at all hours. (S, VL)
620
We recommend against the routine use of insulin for the purposes of improving growth outcomes in hospitalized preterm infants. (S, VL)
620

Recommendation Grading

Abbreviations

  • AA: Intravenous Amino Acids
  • BSID: Bayley Scales Of Infant Development
  • ILE: Injectable Lipid Emulsion
  • NEC: Necrotizing Enterocolitis
  • PN: Parenteral Nutrition
  • PNALD: PN-associated Liver Disease
  • ROP: Retinopathy Of Prematurity

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Parenteral Nutrition in Preterm Infants

Authoring Organization

American Society for Parenteral and Enteral Nutrition

Publication Month/Year

August 22, 2023

Last Updated Month/Year

April 1, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

The purpose of this guideline is to systematically evaluate the quality of relevant literature and provide recommendations on key clinical questions pertaining to the clinical practice of providing PN in preterm infants. The focus of this guideline is on preterm infants born without congenital diseases requiring surgery and does not address preterm infants who have been diagnosed with PN-associated liver disease (PNALD). This guideline's target population of preterm infants is expected to advance to full enteral nutrition without difficulty except in the event of necrotizing enterocolitis (NEC), an unpredictable complication associated with prematurity. The questions in this guideline address multiple aspects of PN, including the timing of PN initiation, nutrient dosing, and lipid injectable emulsion (ILE) composition. The a priori focus of the guideline was on the nutrients in PN; this guideline does not address aspects such as PN compounding and/or logistics of administration. This guideline serves as a foundation for future updates and systematic evaluation of additional relevant questions.

Target Patient Population

Infants born preterm (birth prior to 37 weeks of gestation) without congenital diseases requiring surgery

Target Provider Population

Providers involved in prescribing PN to preterm infants. These include: neonatal physicians, nurse practitioners, physician assistants, nurses, dietitians, pharmacists, and interdisciplinary nutrition support teams in neonatal intensive care units

Inclusion Criteria

Male, Female, Infant

Health Care Settings

Hospital, Outpatient

Intended Users

Dietician nutritionist, nurse, nurse midwife, nurse practitioner, health systems pharmacist, physician, physician assistant

Scope

Treatment, Management

Diseases/Conditions (MeSH)

D007224 - Infant Care, D007225 - Infant Food, D007228 - Infant Nutrition Disorders, D007223 - Infant, D010288 - Parenteral Nutrition

Keywords

parenteral nutrition, infant nutrition, Preterm Infants

Source Citation

Robinson, DT, Calkins, KL, Chen, Y, et al. Guidelines for parenteral nutrition in preterm infants: the American Society for Parenteral and Enteral Nutrition. J Parenter Enteral Nutr. 2023; 47: 830-858. doi:10.1002/jpen.2550

Supplemental Methodology Resources

Evidence Tables, Evidence Tables