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.

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, while 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 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 MDT in delivering neonatal PN

The scope of the NICE guideline⁶ 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 decision-making.

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 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.

Author

Peter Mulholland MSc FRPharms
Neonatal Pharmacist, Neonatal Intensive Care Unit, Royal Hospital for Children, Glasgow, UK

References

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