Complications of Parenteral Nutrition in Neonates

 

E.M.A. Mahmood Waffa¹, F. Islahudin²*, A.F.Shamsuddin²

¹Pharmacy Department, Sultanah Aminah Johor Bahru, Jalan Persiaran Abu Bakar, 80100 Johor Bahru, Malaysia

²Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia

 

ABSTRACT:

Parenteral nutrition allows preterm neonate’s nutritional requirement for growth and development to be met. This retrospective study was conducted to assess weight gain and complications of parenteral nutrition in low birth weight (LBW) neonates, very low birth weight (VLBW) neonates and extremely low birth weight (ELBW) neonates.A total of 82 patients received parenteral nutrition. Patients received parenteral nutrition at mean age of 4.63 ± 3.87 days. There were no significant difference in the weight gain between three different birth weight group (ELBW, VLBW and LBW) (p>0.05). There was a significant association between birth weight group and complications related to parenteral nutrition (p=0.00009). ELBW neonates had a higher percentage of parenteral nutrition complication (93.3%) compared to VLBW (85%) and LBW (33.3%). Complications observed were mostly electrolyte disturbances across all three groups. Findings from this study were able to provide information regarding parenteral nutrition in promoting weight gain and risks of complications in preterm neonates between ELBW, VLBW and LBW. Closer monitoring of effectiveness and safety of parenteral nutrition must be performed to ensure that complications can be reduced in the clinical setting.

 

 

 

INTRODUCTION:

Parenteral feeding has been a life-saving method in clinical practice. This is especially true for preterm neonates in order to produce reasonable rates of growth¹.Due to the immaturity of the gastrointestinal systems in very low birth weight premature neonates, enteral feeding cannot be established in the first few days of life. In view of this, parenteral nutrition allows neonate’s nutritional demands requirement for growth and development to be met when their size or condition prohibits enteral feeding².Preterm neonates have numerous physiologic differences with low carbohydrate and fat stores, elevated metabolic rates due to a higher percentage of metabolically active tissue, high evaporative losses, and immature gastrointestinal systems³. Therefore, parenteral nutrition which consists of protein, carbohydrate and fat infusion, should be started as soon as clinically possible. Parenteral nutrition should be started on the first day of life, if possible, to prevent a starvation state, to normalize serum glucose levels, and improve protein balance³.

 

The goal of nutrition management in very low birth weightneonates is the achievement of post-natal growth at a rate that approximates the intrauterine growth of a normal fetus at the same post-conceptional age³.However, the growth of very low birth weightneonates lags considerably after birth. Neonates weighing less than1000g at birth typically do not regain birth weight until 2 to 3 weeks of age. Additionally, it has been shown that the growth of most very low birth weightneonates proceeds at a slower rate than in utero by a large margin⁴.

 

The use of early nutrition support in low birth weight neonates has resulted in a significantly earlier regain of birthweight⁵. Furthermore, preterm neonates who were started on early nutrition support reached full enteral feedings significantly sooner than those who received delayed nutrition support⁵. Parenteral feeding may be more appropriate than enteral feeding in preterm neonates due to simulating intrauterine feeding⁶. Optimal nutrition of these neonates should meet the changing nutrient requirements and support growth that mimics normal fetal growth⁷. The period of 30 weeks’ gestation to 6months of life is critical for brain development. Moreover, nutritional compromise during the critical period of rapid brain growth could permanently impair cognitive function⁸, further suggesting the importance of early nutrition in preterm neonates.

 

Despite the need for parenteral nutrition, complications can occur from a catheter or metabolic origin. Those complications may involve the gastrointestinal, renal, bone, hepatic and biliary, and vascular target organs⁹. Although there are complications with parenteral feeding, most complications associated with parenteral nutrition are minor¹⁰. Catheter-related complications that occur are mechanical complications, line-related infections and venous thrombosis. On the other hand, metabolic complications that occur with parenteral nutrition are glucose metabolism, essential fatty acid deficiency, electrolyte abnormalities, hepatic and biliary dysfunction, gastrointestinal atrophy and metabolic bone dysfunction¹¹. However, despite the minor occurrence of these complications, failure to overcome these issues at an early stage could lead to severe problems.

 

The importance of parenteral nutrition allows preterm neonate’s nutritional requirement for growth and development to be met. However, despite positive results with parenteral nutrition in promoting weight gain, complications may still occur in the process. Although most complications that occur are minor, they can now be prevented or are much easily treatable due to advances in clinical practice. However, a few, most notably hyperglycemia and catheter-related problems remain a significant occurrence. To that end, this work was performed to identify factors associated with weight gain and complications during parenteral nutrition in preterm neonates.

 

MATERIALS AND METHODS:

This is a retrospective cross-sectional study analyzing weight gain and complications identified during parenteral nutrition of low birth weight (LBW) neonates, very low birth weight (VLBW) neonates and extremely low birth weight (ELBW) neonates. Preterm neonates who were given total parenteral nutrition inthe neonatal intensive care unit within the past one year were included. Subjects were selected through parenteral nutrition entry records from the Aseptic Pharmacy Department. All selected patients’ notes were retrieved and reviewed. Patients included in the study were preterm neonates receiving parenteral nutrition for more than five days. This study was registered and ethics approval obtained from the local medical research and ethics committee.

 

Data collection:

Clinical data related to the complications, growth (weight gains) and nutrition were obtained from case notes and compared. The subjects were divided into three groups according to birth weight as previously described³, which are low birth weight (LBW) (weight 1501 to 2500 g), very low birth weight (VLBW) (weight 1000 to 1500 g) and extremely low birth weight (ELBW) (weight <1000 g). The complications identified and weight gains were compared between the three groups. Weight gains and complication were compared based on three nutrition groups; initial parenteral nutrition only, parenteral and enteral nutrition in combination and the overall nutrition period.

 

Statistical analyses:

Data collected were analysed in a descriptive manner using the Statistical Package for Social Sciences (SPSS version 19.0 software package for Macintosh, SPSS Inc., Chicago, IL). Numeric data were expressed as mean + standard deviation (SD). AChi-square test andmixed between-within subjects analysis of variance was conducted to compare data such as complications and weight gains in low birth weight (LBW) group, very low birth weight (VLBW) group and extremely low birth weight (ELBW) group. A p-value of less than 0.05 was considered significant.

 

RESULTS:

Patient demographics:

A total of 82 preterm neonates were included in the study (Table 1). The age range of all 82 subjects at which parenteral nutrition was started was between 1 to17 days of life with a mean age of 4.63 ± 3.87 days. There was no significant difference in mean age during initiation of parenteral nutrition. Most of the preterm neonates were male (52 patients; 63.4%). Female contributed to approximately 37% (n=30) of the study population. The duration of parenteral nutrition of all 82 subjects was between 5 to 45 days with a mean of 13.29 ± 7.54 days. The mean duration of parenteral nutrition management for ELBW neonates was 14.94 ± 8.86 days, VLBW neonates; 12.38 ± 6.5 days and LBW neonates; 11.33 ± 6.02 days. No significant difference in duration of parenteral nutrition was observed in all three groups.

 

Weight gain during parenteral nutrition:

All patients reviewed were premature with mild to severe respiratory distress syndrome. The preterm neonates had a birth weight of less than 2500g which fulfilled the criteria for parenteral nutrition indication. Appropriate indication for parenteral nutrition was observed in all patients included in the study. Parenteral nutrition energy requirements were given as recommended by ASPEN. The parenteral nutrition energy received by all 82 subjects included in this study was an average of 86.36 (±8.37) kcal/kg/day. There was a significant increase in weight gain in ELBW preterm neonates from baseline weight to the final weight achieved during overall parenteral management (p=0.012). No significant differences were observed in overall weight gain in the other groups from baseline. During the study, no significant differences were observed between weight gain of the three groups ELBW, VLWB and LBW neonates (Table 2).

 

Complications during parenteral nutrition:

Complication related to parenteral nutrition occurred in 68 patients (82.9%)(Table 3).  A total of 39 patients experienced more than one complication. Hypophosphataemia was the most common complication, which occurred in 36 patients (43.9%), followed by increase in liver enzyme (n=22, 26.8%). It was demonstrated that there was a significant difference in number of complications observed between the three birth weight groups (p=0.00009). Preterm neonates in the ELBW group were more likely to present with complications compared to other groups. However, there was no significant difference in 60-day mortality between the three groups in this present work (p>0.05).

 

 

Table 1: Demographic of preterm neonates included in the study based on their body weights

ELBW < 1000g; VLBW 1000g-1500g; LBW 1501g-2500g

 

Table 2: Weight gain of preterm neonates on parenteral nutrition during the study duration

Weight gain	ELBW (n=33)	VLBW (n=40)	LBW (n=9)	ap-value
Initial PN only (g)	18.0 ± 70.2	6.6 ± 158.4	69.7 ±156.6	0.424
PN/EN combination (g)	64.1 ±101.5	38.2 ± 74.7	45.4 ±115.9	0.480
Overall (g)	70.8 ±114.1	40.2 ±159.0	101.1 ±119.3	0.409

ELBW < 1000g; VLBW 1000g-1500g; LBW 1501g-2500g

^a One-way ANOVA, p<0.05 considered significant

 

Table 3: Complications during parenteral nutrition in preterm neonates

	ELBW (n=33)	VLBW (n=40)	LBW (n=9)	bp-value
Complication of PN	31 (93.9%)	34 (85%)	3 (33.3%)	0.00009
Hyperglycaemia	9 (27.3%)	8 (20%)	-
Hypernatraemia	1 (3%)	-	-
Hyponatraemia	10 (30.3%)	11 (27.5%)	-
Hyperkalaemia	1 (3%)	1 (2.5%)	1 (11.1%)
Hypokalaemia	5 (15.2%)	4 (10%)	2 (22.2%)
Hypophosphataemia	20 (60.6%)	15 (37.5%)	1 (11.1%)
Hypocalcaemia	5 (15.2%)	4 (10%)	1 (11.1%)
Hypermagnaesia	1 (3%)	2 (5%)	-
Increased liver enzyme	7 (21.2%)	13 (32.5%)	2 (22.2%)
Sepsis	2 (6.1%)	2 (5%)	-

ELBW < 1000g; VLBW 1000g-1500g; LBW 1501g-2500g

^b Chi-squared test, p<0.05 considered significant

 

DISCUSSION:

The nutritional needs of preterm neonates are dependent on parenteral nutrition during early postnatal life. Current management of preterm neonates include staring parenteral nutrition on the first few days of life¹², which was similarly observed in this present work. Parenteral nutrition should be complete in order to cover fluid intake and nutritional needs during the first days of life, particularly in premature neonates for who enteral feeding is gradually started¹³. Due to the multiple components of parenteral nutrition admixtures, nutritional needs should be tailored to suit each preterm neonate^13,14.Interestingly, current methods include parenteral nutrition as a pre-prepared standard formulation or alternatively, an individualized parenteral nutrition compound adapted to the patient’s needs and prepared on a daily basis^13,14. For this particular work, the preterm neonates were managed using individualised packs based on requirements of the patient.

 

During the present work, it was demonstrated that all patients were prescribed parenteral nutrition in accordance to recommendations³. It was also noted that all patients received the recommended amount of energy as recommended. Previous work has demonstrated that preterm neonates receiving amino acids from day one develop a positive nitrogen balance earlier with a higher protein synthesis when compared to those receiving the same caloric intake based on glucose only¹⁵. Appropriate lipids in parenteral nutrition has also allowed calories and essential fatty acids to be given without increasing carbon dioxide production when compared to neonates receiving the same caloric intake based on glucose infusion only¹².  It is essential for preterm neonates to received adequate caloric intake as they need the energy for metabolism and growth. Interestingly, despite receiving appropriate parenteral management, it was noted that only preterm neonates of ELBW recorded a significant increase in body weight from the first day of treatment until full enteral feeding was reached. Previous work has shown otherwise, with neonates weighing less than 2g lagging behind in terms of weight gain compared to those weighing more¹⁶. When comparing weight gains between the three main groups, findings however were similar to previous data¹²with no significant difference in overall weight gain between ELBW, VLBW and LBW. Indeed, it is important to note that the weight in neonates with low birth weight is not linear and is attributed to four main phases: weight loss, fetal weight curve, growth acceleration and stability along the individual centile^{17, 18}. Nutritional management do not contribute to the initial weight loss, instead is caused by a reduction of extracellular water^{12, 19}.  

 

Findings from this study demonstrated that there was a higher incidence of complications in ELBW infants than any other group, in line with previous work²⁰. Greater incidence of complication was found in neonates weighing less than 1000g when compared to neonates weighing between 1001 to 1250g²⁰. Common complications observed during parenteral nutrition are related to electrolyte imbalances^{21, 22}, similarly observed in this present study.Mechanical and infectious complications were less frequently noted. Electrolyte homeostasis is affected by changes in intake, losses, redistribution, and physiologic and pathophysiologic regulatory mechanisms. The treatment of electrolyte disorders relies on the identification of the etiology and is guided by the acuity and the presence or absence of symptoms. Parenteral nutrition solutions should not be primarily used to manage fluid and electrolyte imbalances. However, adjustments in parenteral nutrition solutions can avoid or improve potential complications³. Another complication which was observed frequently was hyperglycaemia. Premature infants are more likely to develop hyperglycemia with incidences increasing with prematurity. It is also seen more frequently in patients requiring mechanical ventilation^{21, 22}.

 

CONCLUSION:

In conclusion, this study was able to demonstrate the risk of complications arising during parenteral nutrition. Furthermore, the higher incidence of complication in ELBW infants allows us to provide necessary steps in order to prevent further issues during parenteral nutrition management. Despite this, as with all retrospective studies, generalization of results should be performed with caution due to the limited amount of data retrieved from medical records. Furthermore, the small sample size should also be noted. Nevertheless, this present work allows us initial insight into better management of preterm neonates on parenteral nutrition management and calls for more research to be performed in this area.

 

REFERENCES:

1.        Thureen PJ, Hay WW Jr. Intravenous nutrition and postnatal growth of the micropremie. Clinics in Perinatology. 27; 2000: 197–234.

2.        Chaudhari S, Kadam S. Total parenteral nutrition in neonates. Indian Pediatrics. 43;2006:953 – 964.

3.        ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. Journal of Parenteral Enteral and Nutrition.26; 2002:1SA-138SA.

4.        Adamkin DH. Nutrition management of the very low-birthweight infant. NeoReviews.7(12);2006:e602.

5.        Donovan R, et al. Outcomes of early nutrition support in extremely low-birth-weight infants. Nutrition in Clinical Practice.21(4);2006:395 – 400.

6.        MorganJB, Kovar IZ. The low birth weight infant and parenteral nutrition. Nutrition Research Reviews.5;1992:115-129.

7.        Hay WW Jr. Assessing the effect of disease on nutrition of the preterm infant. Clinical Biochemistry. 29; 1996:399 – 417.

8.        Lucas A, Morley R, Cole TJ. Randomised trial of early diet in preterm babies and later intelligence quotient. British Medical Journal.317; 1998:1481-1487. 

9.        Montalvo-Jave EE et al. Specific topics and complications of parenteral nutrition. Langenbeck’s Archives Surgery. 392; 2007:119–126.

10.     Al-Batani R, AbdKadir N, Bahari B. Evaluation of the parenteral nutrition services in Hospital Pulau Pinang. Malaysian Journal of Pharmaceutical Sciences.4(2);2006:25-32.

11.     Maroulis J, Kalfarentzos F. Complications of parenteral nutrition at the end of the century. Clinical Nutrition.19 (5); 2000:295-304.

12.     Pauls J, Bauer K, Versmold H. Postnatal body weight curves for infants below 1000 g birth weight receiving early enteral and parenteral nutrition. European Journal of Pediatrics.157;1998: 416 – 421.

13.     Lenclen R et al. Assessment of implementation of a standardized parenteral formulation for early nutritional support of very preterm infants.European Journal of Pediatrics.165;2006:512–518.

14.     Riskin A, Shiff Y, Shamir R. Parenteral Nutrition in Neonatology –To Standardize or Individualize? The Israel Medical Association Journal.8;2006:641–645.

15.     Anderson TL et al. A controlled trial of glucose versus glucose and amino acids in premature infants.Journal of Pediatrics.94; 1979:947 – 951.

16.     Hirai Y et al.Total parenteral nutrition in low-birth-weight neonates with complicated surgical disorders; effects and difficulties. The Japanese Journal of Surgery.1 (3); 1981:175-183.

17.     Ozkan H, Uguz A, Haberal S. Postnatal weight velocity patterns in very low birth weight infants. Indian Journal of Pediatrics.64; 1997:383-388.

18.     Gairdner D, Pearson J. A growth chart for premature and other infants. Archives of Disease in Childhood.46; 1971:783-787.

19.     Bauer K et al. Efect of intrauterine growth retardation on postnatal weight change in preterm infants. Journal of Pediatrics. 123;1993:301-306.

20.     Guzman JM et al. Parenteral nutrition and immature neonates. Comparative study of neonates weighing under 1000 and 1000-1250 g at birth. Early Human Development.65;2001:S133 – S144.

21.     Vaidya UV, Bhave SA, Pandit AN. Parenteral nutrition (PN) in the management of very low birth weight (VLBW) babies-A randomized controlled trial. Indian Pediatrics.32;1995:165 – 170.

22.     Al-Batani R, Che Abdullah D, Bahari MB. Evaluation of the total parenteral nutrition service at Universiti Sains Malaysia Hospital. The European e-Journal of Clinical Nutrition and Metabolism. 2 (6); 2007:e111– e115.

 

 

 

Received on 28.05.2014          Modified on 06.06.2014

Accepted on 10.06.2014          © RJPT All right reserved