Abstract
Background: High risk neonates hospitalized for surgical or cardiac complications, extremely premature neonates, or those with protracted diarrhea pose a particular nutrition support challenge. Low birth weight (LBW) neonates who need prolonged parenteral nutrition (PN) supplements are supposed to stay in the neonatal intensive care unit (NICU) for longer time due to severe underlying diseases or immature physical condition. However, there was few published literature described the relationship between short-term (≤ 5 days) PN use for neonates and length of NICU stay.
Methods: The charts of all neonates weighing between 1.5 and 2.5 kg upon admission to our NICU from Jan. 2010 through Apr. 2011 were studied. In total 184 LBW neonates have entered into this study.
Results: Their birth weights range from 1505 to 2490 g (2030.9±270 g). Seven out of 184 neonates used long-term (>5 days) PN, 10 neonates used short-term PN and the other 167 neonates did not. The average lengths of NICU stay of long-term, short-term PN users and non-users are 52.9±52.7, 27.6±11.7 and 15.5±8.5 days, respectively. Significant difference of length of NICU stay was observed not only in the long-term users but also between short-term PN users and non-users, P<0.001 (t-test), suggesting that malnutrition requiring short-term (≤ 5 days) PN use has an influential impact on the length of neonatal ICU stay.
Conclusion: LBW neonates are vulnerable to malnutrition-early evaluation of nutrition situation and use of PN if needed might be essential for this group of patients.
Key words: LBW neonate, PN, ICU stay
Introduction
High risk neonates hospitalized for surgical or cardiac complications, extremely premature neonates, or those with protracted diarrhea pose a particular nutrition support challenge.1 Postnatal growth deficit is the most commonly observed morbidity in very low birthweight infants and is due, at least in part, to inadequate early nutritional intake during hospitalization.2 In addition, neonates born at less than 37 weeks' gestation also have significantly increased fasting (NPO) days and longer length of stay when compared with neonates born at greater than 37 weeks.3
During their first weeks of life, very premature infants are at high risk of disturbed glucose homeostasis, which might result in increased morbidity and mortality. As these infants have a low tolerance to enteral feeding, they usually depend on parenteral nutrition (PN).4 Neonates with short gut or bowel atresia also have a long duration of PN 5 which offers the possibility of increasing or ensuring nutrient intake in patients in whom normal food intake is inadequate, enteral nutrition is not feasible or contraindicated.6 PN, a key therapeutic option in neonates whose clinical conditions require a period of bowel rest, is indicated as a lifesaving therapy in those with intestinal failure from any of several causes, including necrotizing enterocolitis, intestinal atresia, pseudo-obstruction, and other motility disorders,7 that is, early nutrition is associated with marked long-term benefits for certain premature neonates.8
In some situation, LBW neonates (birth weight <＝2500 g) require PN to help achieve adequate nutrition intakes for growth and development. LBW neonates who need prolonged PN supplements are supposed to stay in the NICU for longer time due to severe underlying diseases or immature physical condition. However, there was few published literature described the relationship between short-term (≤5 days) PN use for neonates and length of NICU stay, that's why this study has been undertaken to find out whether length of NICU stay of LBW neonates receiving short-term PN is longer than those who didn't due to malnutrition.
Methods
A retrospective chart review was conducted, and neonates weighing between 1.5 and 2.5 kg upon admission to our NICU from Jan. 2010 through Apr. 2011 were studied. Neonates born in other hospitals and sent to our NICU over 24 hours after birth were not enrolled due to incomplete data. Exclusion criteria were: those expired or those born with gastroschisis, tracheoesophageal fistula, and congenital diaphragmatic hernia. In total 184 LBW neonates of those admitted to this NICU have entered into this study. Definition of days of PN use is the use of parenteral nutrition for more than one hour a day.
Statistical analysis: the results are given as means with standard deviations. Independent T-test was chosen to compare the differences of Apgar scores, birth weights and gestational weeks between these two groups. Statistical significance was defined as a value <0.05.
In this NICU, PN is provided to neonates who cann't be fed orally or enterally, and minimal caloric requirements of 80 kcal/kg/day or protein intake of 2 g/kg/day can not be reached. All pediatricians use this similar rule for neonatal nutrition. Pediatricians making the decisions to use or delete PN, or to transfer a neonate to a common neonatal ward were not involved in the study, and the other members were blinded with respect to group.
Results
In total 184 LBW neonates of those admitted to this NICU have entered into this study. Their birth weights range from 1505 to 2490 g (2030.9±270 g). Seven out of 184 neonates used long-term (>5 days) PN, 10 neonates used short-term (≤5 days) PN and the other 167 neonates did not. The average Apgar scores, birth weights and gestational weeks of LBW neonates of short-term PN users versus non-users are 6.05±0.76: 5.84±0.59 (p=0.29), 1878.3±226.7 g: 2051.4±266.5 g (p=0.046), 32.4±2.5weeks: 31.1±2.2weeks (p=0.28), respectively. RDS (respiratory distress syndrome) rates at birth of both groups, regardless of using surfactant or not, are 0.300 (3/10 neonates): 0.299 (50/167 neonates), no significant difference.
The average lengths of NICU stay of long-term, short-term PN users and non-users are 52.9±52.7, 27.6±11.7 and 15.5±8.5 days, respectively. Significant difference of length of NICU stay was observed not only in the group of long-term users but also between short-term PN users and non-users, P<0.001(t-test), suggesting that malnutrition requiring short-term (≤5 days) PN use has an influential impact on the length of neonatal ICU stay.
Discussion
RDS rates at birth are used to evaluate the contributing factor leading to the development of bronchopulmonary dysplasia, a major cause of increased length of hospitalization,9 and results show no significant difference between these two groups.
APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) is a score to measure the health situation of a neonate within minutes after birth. The higher the score, the healthier a neonate is considered; scores ranging from 0 to 10. 0-3: critically ill, 4 to 6: less satisfying and 7 to 10: generally normal. Besides Apgar score, birth weights, and gestational weeks are also compared between these two groups, and results show the basis for comparison is roughly equal (p=0.29 for Apgar scor, and p=0.28 for gestational weeks) except for birth weights (p=0.046). Results show no conclusive equal background but similarity, and due to significant difference of length of NICU stay was observed between these two groups (P<0.001, t-test), that is why "tend to" is used in the title. Further studies with more neonates included are needed to have definitive conclusion.
In this NICU, neonates qualified to be transferred to a common neonatal ward are those who do not have any signs of infections, whose body weight is over 2000 g, those that are comfortable without the use of an oxygen hood or ventilator, and those with smooth feeding. Therefore, being able to be transferred to a common ward is equal to be generally healthy in this study so as to provide a relatively equal basis for comparison among LBW neonates.
LBW neonates require protein and energy for their growth,10 and the early provision of nutrients is an important determinant of postnatal growth.11 Use of PN may be associated with some problems, like precipitates during the administration of PN,10 liver dysfunction,12 infectious and metabolic complication,7 etc. However, neither precipitates since the use of inline filters nor infections due to malpractice of preparing PN solutions have occurred in this NICU in recent years, and liver dysfunction or fluctuation of sugar levels which are usually seen in long-term PN users is not significant in short-term PN users.12,13 Also, the short-term PN in critically ill patients does not exert a different influence on the serum concentrations of GI hormones compared to enteral nutrition,13 and no specific side effects were detected in this group of patients in former studies,14 suggesting that short-term PN use is feasible and appropriate for certain neonates.
PN offers the possibility of increasing or ensuring nutrient intake in patients in whom normal food intake or enteral nutrition is not feasible,6 and its initial goal is to provide sufficient nutrients to prevent negative energy and nitrogen balance and essential fatty acid deficiency. The average starting day of use of short-term PN is 3-4 days after birth in this NICU which is contradictory to some studies,15 i.e. they might have had a better outcome and discharged earlier if these neonates received PN earlier. Consequently, not only those suffering from malnutrition requiring long-term PN supplements are supposed to stay in the NICU for longer time due to severe underlying diseases or immature physical condition, but also these receiving short-term (≤5 days) PN. Therefore, how to manage to evaluate LBW neonates' nutrition situation within days after birth is essential for their health, and possibly shorten lengths of their NICU stay and reduce medical costs.
In total 17 LBW neonates born in other hospitals and sent to this NICU over 24 hours after birth were not enrolled due to incomplete data in this study. The reason why those born with gastroschisis, tracheoesophageal fistula, and congenital diaphragmatic hernia were excluded from this study is that it's obvious LBW neonates with any of these diseases stay longer in the NICU, and only three had the situations and were excluded during the study period.
PN solutions for neonates within days after birth vary in constituents. For example, no potassium is supposed to be added to a PN solution until after first urination for fear of hyperkalemia. In addition, calcium intake for a neonate is about 5 to 15 times higher than for an adult on the basis of body weight due to the increase in calcium demand to support the rapid growing skeleton. Moreover, amino acids requirements are also different in volume as well as varieties (rich in leucine, isoleucine and valine). Therefore, a customized PN solution is essential for an individual neonate's requirements.
Conclusion
PN is commonly used in the NICU for nutritional support of preterm neonates. LBW neonates are vulnerable to malnutrition and the age at which neonates first receive PN or are fed enteral feeds appear to influence their health and the length of NICU stay-early evaluation of nutrition situation and use of PN if needed might be essential for this group of patients.
References:
1. Christina JV, Teresa DP: Enhancing Parenteral Nutrition Therapy for the Neonate. Nutrition in Clinical Practice 2007; 22: 183-193.
2. Eleni-dit TS, Kermorvant DE, Huon C, et al: Early individualised parenteral nutrition for preterm infants. Archives of Disease in Childhood Fetal and Neonatal Edition 2009; 94(2): 152-153.
3. Puligandla PS, Janvier A, Flageole H, et al: The significance of intrauterine growth restriction is different from prematurity for the outcome of infants with gastroschisis. Journal of Pediatric Surgery 2004; 39(8): 1200-1204.
4. Chacko SK, Sunehag AL: Gluconeogenesis continues in premature infants receiving total parenteral nutrition. Archives of Disease in Childhood: Fetal and Neonatal Edition 2010; 95(6): 413-418.
5. Tawil KA, Gillam GL: Gastroschisis: 13 years' experience at RCH Melbourne. Journal of Paediatrics & Child Health 1995; 31(6): 553-556.
6. Bozzetti F, Arends J, Lundholm K, et al: ESPEN Guidelines on Parenteral Nutrition: non-surgical oncology. Clinical Nutrition 2009; 28(4): 445-454.
7. Pianese P, Salvia G, Campanozzi A, et al: Sterol Profiling in Red Blood Cell Membranes and Plasma of Newborns Receiving Total Parenteral Nutrition. Journal of Pediatric Gastroenterology and Nutrition 2008; 47(5): 645-651.
8. Khashu M, Harrison A, Lalari V, et al: Impact of shielding parenteral nutrition from light on routine monitoring of blood glucose and triglyceride levels in preterm neonates. Archives of Disease in Childhood Fetal and Neonatal Edition 2009; 94(2): 111-115.
9. Zon-Min L, Chiu-Ying W, Chi-Wen C, et al: Patent Ductus Arteriosus might be a contributing factor affecting on Length of ICU Stay of VLBW Neonates. The Journal of Taiwan Pharmacy 2010; 26(4): 3-8.
10. Chaieb SD, Chaumeil JC, Jebnoun S, et al: Effect of high calcium and phosphate concentrations on the physicochemical properties of two lipid emulsions used as total parenteral nutrition for neonates. Pda Journal of Pharmaceutical Science&Technology 2009; 63(1): 27-41.
11. Martin CR, Brown YF, Ehrenkranz RA, et al: Nutritional practices and growth velocity in the first month of life in extremely premature injfants. Pediatrics 2009; 124(2): 649-657.
12. Moreno Villares JM, Gomis Munoz P, Galiano Segovia MJ, et al: Liver complications associated with short-term parenteral nutrition in children. Anales Espanoles de pediatria 1999; 51(1): 22-26.
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摘要
需短期靜脈營養的低出生體重新生兒可能需住加護病房較久
背景：高風險新生兒因接受手術治療，或因心臟併發症、極度早產、長時間拉肚子等來住院均會造成營養需求的挑戰。需長期使用靜脈營養 (PN) 的低出生體重 (LBW) 新生兒常常會因有潛在疾病或不成熟的生理狀況，而需在新生兒加護病房 (NICU) 住較久的時間。然而，幾乎沒有已發表的文獻曾經探討使用短期 (≤5天) PN 與新生兒住 NICU 時間長短的相關性。
方法：於2010年1月至2011年4月所有住進我們 NICU 的新生兒，其體重介於1.5至2.5公斤的病歷都被查閱。此期間總共有184位 LBW 新生兒納入本研究。
結果：他們的出生體重範圍1505至2490克 (2030.9±270克)。此184個新生兒中有7名使用長期 (>5天) PN, 10名使用短期而其他167名不曾使用。此長期使用 PN、短期使用與不曾使用新生兒之平均住 NICU 天數分別為52.9± 52.7，27.6± 11.7 及15.5± 8.5天。不僅是長期使用 PN 新生兒的住 NICU 天數有顯著差別於其它兩組，連短期使用與不曾使用PN新生兒間也出現有意義的差別, P<0.001 (t-test)，意指營養不良到需使用短期 PN 支持對 NICU 住院天數是有影響的。
結論：LBW 新生兒的健康情形是很容易受到營養不良所影響-及早做新生兒的營養狀況評估和對有營養不良之新生兒及早使用 PN 或許是有利的。
作者
高雄長庚紀念醫院藥劑部藥師 王鵬翔、
李榮明、李炳鈺
行政院衛生署屏東醫院藥劑科藥師 江吉文
