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A mixed bag: an enquiry into the care of hospital patients receiving parenteral nutrition

Neena Modi

Vice President, Science & Research

Royal College of Paediatrics & Child Health

Professor of Neonatal Medicine

Imperial College London

Disclosures

Views of Expert Group members and advisors

sought

Neonatal clinician in a tertiary centre

Lead a research programme involving newborn

nutrition

Advised the Chief Pharmacist’s survey of neonatal

PN in 2008/9

What we knew

Essential is the smallest, sickest

babies

The target is growth, not

correction of malnutrition

Standard regimens feasible

Often Partial (not Total) PN,

bridging the gap to full milk feeds

Documentation poor and

variable

Prescribing and dispensing

processes variable

Complications common

Babies are neither small Babies are neither small

children nor adultschildren nor adults

Some 1,500 to 3,000 babies Some 1,500 to 3,000 babies

receive PN in the UK each yearreceive PN in the UK each year

Confidential enquiries

“The purpose of a confidential enquiry is to

detect areas of deficiency in clinical practice

and devise recommendations to resolve

them; enquiries can also make suggestions

for future research programmes”

24%24%

12 babies12 babies

Documentation

Adequacy of first Parenteral Nutrition

Key findings

“Good practice”, defined as a “standard that you would

accept from yourself, your trainees and your institution”,

identified in 24% (62/264) of neonatal cases

Delay in recognising need for PN in 28%

Delay in starting PN once decision made in 17%

Poor documentation in 72%

First PN provided considered inadequate in 37%

Metabolic monitoring inadequate in 19%

Principal recommendations

Prompt consideration of need for PN, start without delay

First PN must be appropriate to neonate’s needs

Close monitoring essential

Neonatal units should have policies for documentation

Team approach

Consensus on best PN practice

Education, audit and training needed

NICE guidelines for nutritional support needed

Central hospital record of patients receiving PN

Attention to vascular line care

What was missing?

Details of prescribing and dispensing practice (Chief Pharmacist’s 2009 Study)

Denominators (how many babies should have received PN?)

Controls (were complications reliably attributable to PN?)

Details of concurrent milk feeds (was nutritional support really poor?)

A sense of what variation in practice there was among assessors (was the enquiry consistent?)

Acknowledgement that the evidence base is poor

Possible questions

Are process or outcome measures the best means for

neonatal services to evaluate their practice?

What specific measures should be audited?

Is adequacy of PN the right question?

Which processes (prescribing, preparing, dispensing,

delivering) require standardisation?

What is the research gap?

Optimal growth targets are not known

Preterm nutrition is

Controversial

Variable

Poorly evidenced

Focused on growth outcomes even though the

optimal pattern of growth is unknown

Optimal nutrient requirements for preterm babies are not known

• Intrauterine nutrient provision

• lipid - minimal

• glucose - moderate

• amino acid - high

• Postnatal nutrient provision

• lipid - high

• glucose - high

• protein - low

Other dangers

Parenteral nutrition, (whether administered

centrally or peripherally) (IRR 13.8, 95% CI 8.5

to 22.3, p<0.001) and

gestational age < 26 weeks (IRR 2.4, 95% CI

1.7 to 3.5, p<0.001) are the highest significant

independent risk factors for newborn late onset

blood stream infection

(Modi et al 2006)

The tightrope of preterm nutrition support

Not too much, not too

little, but just right

NEON (Nutritional

Evaluation and

Optimisation in

Neonates trial)

commenced recruitment

June 2010

Our conclusions

The call to improve practice is welcomed

The focus on the newborn and on children is applauded

The need for consistency of prescribing, dispensing,

delivering and documenting is strongly supported

Preterm nutrition is experimental, research is needed

Beware the implementation of nutritional guidance that

lacks an evidence base

Food for thought

Target methodology to specific patient group

Denominator capture

Appropriate controls

A priori definition of “best practice”

Links to other initiatives

Specific audit recommendations

Delineation of the research gap