Royal College of Paediatrics and Child Health
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
children nor adults
 Some 1,500 to 3,000 babies
receive 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%
12 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