Clinical update

Parenteral feeding in neonatal care: best practice

New national guidance aims to tackle wide variation in practice, safety concerns and costs 
Picture of a Total Parenteral Nutrition fluids bag for feeding intravenously

New national guidance aims to tackle wide variation in practice, safety concerns and costs

Essential information

Parenteral nutrition is intravenous feeding that provides sustenance to those unable to receive adequate 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.

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.

About 95,000 babies born in the UK each year need neonatal care, according to the National Institute for Health and Care Excellence (NICE).

Whats new?

...

New national guidance aims to tackle wide variation in practice, safety concerns and costs

Picture of a Total Parenteral Nutrition fluids bag for feeding intravenously
Parenteral nutrition for feeding intravenously. Picture: Alamy

Essential information

Parenteral nutrition is intravenous feeding that provides sustenance to those unable to receive adequate 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.

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.

About 95,000 babies born in the UK each year need neonatal care, according to the National Institute for Health and Care Excellence (NICE).

What’s new?

 Neonatal parenteral nutrition is new guidance, published in February by NICE,  which is designed to improve standards on neonatal units by tackling the wide variation in practice, safety concerns and costs.

Background

In 2017, NHS Improvement issued a warning on the risk of harm and death from infusing total parenteral nutrition too rapidly in babies. It was aware of ten incidents that had caused severe harm.

Concerns had previously been raised by the 2010 National Confidential Enquiry into Patient Outcome and Death (NCEPOD), which 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.

Impact of inadequate nutrition

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, NICE says.

There is also evidence linking inappropriate nutritional management soon after birth to the development of metabolic syndrome in adults.

Reasons for starting parenteral nutrition

It is common practice to start parenteral nutrition in preterm babies within the first few hours of life, and also to support term babies who are critically ill.

In current practice, virtually all babies born before 31 weeks who weigh less than 1.5kg need parenteral nutrition for a period that depends on gestation, birth weight and other morbidities.

How you can help your patient

  • When a preterm or term baby meets the indications for parenteral nutrition, start it as soon as possible – within eight hours at most.
  • Use a central venous catheter to give neonatal parenteral nutrition if possible.
  • Protect the bags, syringes and infusion sets of aqueous and lipid parenteral nutrition solutions from light.
  • When starting neonatal parenteral nutrition for preterm and term babies, use a standardised neonatal parenteral nutrition formulation. Continue with a standardised bag unless an individualised parenteral nutrition formulation is indicated.
  • Provide regular opportunities and time for parents and carers of babies on parenteral nutrition to discuss their baby’s care, ask them about the information they have been given and discuss concerns.

Expert comment

Picture of Julia PettyJulia Petty is an executive member of the UK Neonatal Nurses Association

‘Parenteral feeding is such an important aspect of neonatal care, and one which many of the babies we look after need, particularly those who are preterm or have had major surgery.

‘Parenteral feeding involves accessing intravenous lines, often central lines, and it is associated with risk, particularly infection. As the guidance points out, getting nutrition right for these vulnerable babies is really important, having an impact on their growth and survival.

‘We needed national guidance to ensure standardised, consistent care, and this will be a valuable publication for neonatal nurses.

‘One of the benefits of this guideline is the recent evidence base that supports it to ensure best practice. It will be particularly useful for newly qualified nurses, as there is not always sufficient education on this type of feeding.’


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