Does early initiation of parenteral nutrition improve the outcomes of critically ill neonates?

Posted March 17th, 2008 by giacconea

Author Name(s):

Annie Giaccone, MD, Tawia Apenteng, MD

Reviewer Name:

Samir S. Shah, MD, MSCE

Clinical Question:

Are there benefits to starting TPN early in critically ill neonates?

Background:

Traditionally, parenteral nutrition (TPN) for critically ill neonates is not initiated for several days following birth. During this time, dextrose is typically the only source of nutrition the neonate receives. However, postnatal growth in neonates lags far behind intrauterine growth. Furthermore, in utero there is a constant supply of amino acids. Several studies have attempted to evaluate the benefits and harms of initiating TPN early in the postnatal course.

Clinical Bottom Line:

1. There is mixed evidence that early intiation of TPN improves postnatal growth.
2. Early initiation of TPN results in a decrease in negative nitrogen balance and higher levels of amino acids in the blood.
3. There is no apparent clinical benefit to early intiation of TPN in regards to mortality or the incidence of intraventricular hemorrhage, patent ductus arteriosus, retinopathy of prematurity, necrotizing enterocolitis, or chronic lung disease of prematurity.
4. Early initiation of TPN appears to be safe.

Summary of Key Evidence:

Van Goudoever (1995, randomized controlled, N=18) found that the treated group had improved nitrogen balance and no increase in acidosis or other negative effects. However, clinical outcomes were not studied.
Ibrahim (2004, randomized controlled, N=32) found that the treated group had increased nitrogen retention and caloric intake, but also increased bilirubin. There was no difference in clinical outcomes.
Wilson (1997, randomized controlled, N=125) found that the treated group had better growth outcomes and higher caloric intake. However, there was no difference in clinical outcomes between the two groups.
Te Braake (2005, randomized controlled, N=135) found that the treated group had a positive nitrogen balance and improved amino acid levels but also that the treated group had more acidosis and higher BUN.
Dinerstein (2006, matched case control with historical controls, N=189) found that the treated group had a reduction of postnatal growth failure, and less caloric and protein deficit. However, no difference in clinical outcomes was detected.
Poindexter (2006, prospective observational study, N=1018) found improved growth in treated group but no difference in clinical outcomes.
Donovan (2006, observational chart review, N=93) found that while birth weight was regained earlier in treatment group, there was no difference in length of stay or NEC.

Search Strategy:

MeSH search with "TPN" and "neonatal". PubMed search with "Early AND TPN AND neonate"

References:

1) Donovan R, Puppala B, Angst D, Coyle BW. Outcomes of early nutrition support in extremely low-birth-weight infants. Nutr Clin Pract. 2006 Aug;21(4):395-400. [Penn Proxy]

2) Ibrahim HM, Jeroudi MA, Baier RJ, Dhanireddy R, Krouskop RW. Aggressive early total parental nutrition in low-birth-weight infants. J Perinatol. 2004 Aug;24(8):482-6. [Penn Proxy]

3) Van Goudoever JB, Colen T, Wattimena JL, Huijmans JG, Carnielli VP, Sauer PJ. Immediate commencement of amino acid supplementation in preterm infants: effect on serum amino acid concentrations and protein kinetics on the first day of life. J Pediatr. 1995 Sep;127(3):458-65. [Penn Proxy]

4) Poindexter BB, Langer JC, Dusick AM, Ehrenkranz RA. Early provision of parenteral amino acids in extremely low birth weight infants: relation to growth and neurodevelopmental outcome. J Pediatr. 2006 Mar;148(3):300-305. [Penn Proxy]

5) Dinerstein A, Nieto RM, Solana CL, Perez GP, Otheguy LE, Larguia AM. Early and aggressive nutritional strategy (parenteral and enteral) decreases postnatal growth failure in very low birth weight infants. J Perinatol. 2006 Jul;26(7):436-42. [Penn Proxy]

6) Wilson DC, Cairns P, Halliday HL, Reid M, McClure G, Dodge JA. Randomised controlled trial of an aggressive nutritional regimen in sick very low birthweight infants. Arch Dis Child Fetal Neonatal Ed. 1997 Jul;77(1):F4-11. [Penn Proxy]

7) te Braake FW, van den Akker CH, Wattimena DJ, Huijmans JG, van Goudoever JB. Amino acid administration to premature infants directly after birth. J Pediatr. 2005 Oct;147(4):457-61. [Penn Proxy]