SAFETY AND QUALITY OF INTRAVENOUS LIPIDS FOR NEWBORNS: CURRENT KNOWLEDGE AND FUTURE PROSPECTS

. Premature birth leads to the developmentof "metabolic shock" in a newborn, the severity of whichis inversely opposite to the weight and gestational age.Infants lose the ability to receive nutrients naturally,transplacentally, and the ability to metabolize mother'smilk is limited due to immaturity. The growth up standardof a prematurely born child is intrauterine growth of thefetal brain and body, which requires not only a sufficientamount of essential nutrients, but also their qualitativecomposition. Nutritional support of premature newborns isa difficult task, especially if infants have perinatal diseasesor require mechanical ventilation, which makes theircatabolic state even worse. Stress limits the child's continuedphysical growth during the first few weeks after birth, andis associated with chronic morbidity and neurologicaldisability in the future. One, and sometimes the only way ofsupplying the main nutrients, is parenteral nutrition, highquality performance of which makes it possible to satisfymost of the nutritional needs of premature babies. In recentyears, high-quality parenteral nutrition protocols have beendeveloped, the adherence to which allows to achieve thegoal. They involve a rather aggressive approach to aminoacid and lipid infusion, but there is still concern about theuse of early parenteral nutrition. Especially restrictionsrelate to intravenous lipids, which are based on severaldogmas, indicating that lipid infusion can be associatedwith the damage of the lungs and liver tissues, as wellas the development of sepsis and thrombosis. There areseveral recent reviews that partially refute these dogmas.In our publication we would like to provide a short basicdata on the safety of lipid emulsions used in newborns, andalso to provide data on the positive effect of lipids on somebiochemical processes and conditions, with an emphasison their features, depending on the composition of the fatemulsion. The literature review can be used to view clinicalpractice, to search for optimal strategies of lipid emulsionsusage, taking into account their chemical components,which will improve the quality of nursing prematureinfants. The purpose of this work is to analyze scientificliterature sources to study and systematize data on modernaspects of the use of lipid emulsions in newborns.

Outcomes in relation to early parenteral nutrition use in preterm neonates born between 30 and 33 weeks’ gestation: a propensity score matched observational study

ObjectiveTo evaluate whether in preterm neonates parenteral nutrition use in the first 7 postnatal days, compared with no parenteral nutrition use, is associated with differences in survival and other important morbidities. Randomised trials in critically ill older children show that harms, such as nosocomial infection, outweigh benefits of early parenteral nutrition administration; there is a paucity of similar data in neonates.DesignRetrospective cohort study using propensity matching including 35 maternal, infant and organisational factors to minimise bias and confounding.SettingNational, population-level clinical data obtained for all National Health Service neonatal units in England and Wales.PatientsPreterm neonates born between 30+0 and 32+6 weeks+days.InterventionsThe exposure was parenteral nutrition administered in the first 7 days of postnatal life; the comparator was no parenteral nutrition.Main outcome measuresThe primary outcome was survival to discharge from neonatal care. Secondary outcomes comprised the neonatal core outcome set.Results16 292 neonates were compared in propensity score matched analyses. Compared with matched neonates not given parenteral nutrition in the first postnatal week, neonates who received parenteral nutrition had higher survival at discharge (absolute rate increase 0.91%; 95% CI 0.53% to 1.30%), but higher rates of necrotising enterocolitis (absolute rate increase 4.6%), bronchopulmonary dysplasia (absolute rate increase 3.9%), late-onset sepsis (absolute rate increase 1.5%) and need for surgical procedures (absolute rate increase 0.92%).ConclusionsIn neonates born between 30+0 and 32+6 weeks’ gestation, those given parenteral nutrition in the first postnatal week had a higher rate of survival but higher rates of important neonatal morbidities. Clinician equipoise in this area should be resolved by prospective randomised trials.Trial registration numberNCT03767634.

Optimizing Early Neonatal Nutrition and Dietary Pattern in Premature Infants

Providing adequate amounts of all essential macro- and micronutrients to preterm infants during the period of extraordinarily rapid growth from 24 to 34 weeks’ postmenstrual age to achieve growth as in utero is challenging yet important, since early growth restriction and suboptimal neonatal nutrition have been identified as risk factors for adverse long-term development. Along with now well-established early parenteral nutrition, this review emphasizes enteral nutrition, which should be started early and rapidly increased. To minimize the side effects of parenteral nutrition and improve outcomes, early full enteral nutrition based on expressed mothers’ own milk is an important goal. Although neonatal nutrition has improved in recent decades, existing knowledge about, for example, the optimal composition and duration of parenteral nutrition, practical aspects of the transition to full enteral nutrition or the need for breast milk fortification is limited and intensively discussed. Therefore, further prospective studies on various aspects of preterm infant feeding are needed, especially with regard to the effects on long-term outcomes. This narrative review will summarize currently available and still missing evidence regarding optimal preterm infant nutrition, with emphasis on enteral nutrition and early postnatal growth, and deduce a practical approach.

Fifteen-minute consultation: ABCDE approach to nutritional assessment in preterm infants

The last 20 years has seen dramatic improvements in the survival of preterm infants due to improved antenatal and neonatal care. Closer attention to nutrition means early parenteral nutrition and mother’s own milk are considered as standard of care. Many uncertainties remain however, such as optimal macronutrient intakes for longer term cognitive and metabolic outcomes, and the optimal probiotic regime to reduce the risk of necrotising enterocolitis. Nutrition involves macronutrients and micronutrients, immunonutrients, microbiomic aspects and nutrient delivery. It is also clear that there are behavioural and psychological aspects, and strongly held beliefs for parents and professionals that affect practice. While many healthcare professionals (HCPs) are aware of several key nutritional concepts on the neonatal intensive care unit (NICU), many HCPs lack a concise, systematic approach. This article provides a brief approach to nutritional assessment for use on the NICU summarised as ABCDE: A—anthropometry, B—biochemistry, C—clinical, D—dietary intakes, E—environment and evaluation.

Nutrition support in acute cardiac care

Malnutrition in cardiac and critical illness is associated with a compromised clinical outcome. The aim of nutrition therapy is to prevent these complications and particularly to attenuate lean tissue wasting and the loss of muscle force and of physical function. During the last decade, several well-powered randomized controlled nutrition trials have been performed. Their results challenge the existing nutrition practices in critically ill patients. Enhancing the nutritional intake and the administration of specialized formulations failed to evoke clinical benefit. Some interventions even provoked an increased mortality or a delayed recovery. These unexpected new findings might be, in part, caused by an important leap forward in the methodological quality in the recent trials. Perhaps reversing early catabolism in the critically ill patient by nutrition or anabolic interventions is impossible or even inappropriate. Nutrients effectively suppress the catabolic intracellular autophagy pathway. But autophagy is crucial for cellular integrity and function during metabolic stress, and consequently its inhibition early in critical illness might be deleterious. Evidence from large nutrition trials, particularly in acute cardiac illness, is scarce. Full enteral feeding in vasopressor dependent patients recovering from hemodynamic shock increases the risk for bowel ischemia. Nutrition therapy is therefore focused on avoiding iatrogenic harm. Some enteral nutrition is administered if possible and eventually temporary hypocaloric feeding is tolerated. Above all, the refeeding syndrome and other nutrition-related complications should be prevented. There is no indication for early parenteral nutrition, increased protein doses, specific amino acids, or modified lipids in critical illness.

Time course of altered DNA methylation evoked by critical illness and by early administration of parenteral nutrition in the paediatric ICU

Background A genome-wide study identified de novo DNA methylation alterations in leukocytes of children at paediatric intensive care unit (PICU) discharge, offering a biological basis for their impaired long-term development. Early parenteral nutrition (early-PN) in PICU, compared with omitting PN in the first week (late-PN), explained differential methylation of 23% of the affected CpG-sites. We documented the time course of altered DNA methylation in PICU and the impact hereon of early nutritional management. Results We selected 36 early-PN and 36 late-PN matched patients, and 42 matched healthy children. We quantified DNA methylation on days 3, 5 and 7 for the 147 CpG-sites of which methylation was normal upon PICU admission in this subset and altered by critical illness at PICU discharge. Methylation in patients differed from healthy children for 64.6% of the 147 CpG-sites on day 3, for 72.8% on day 5 and for 90.5% on day 7 as revealed by ANOVA at each time point. Within-patients methylation time course analyses for each CpG-site identified different patterns based on paired t test p value and direction of change. Rapid demethylation from admission to day 3 occurred for 76.2% of the CpG-sites, of which 67.9% remained equally demethylated or partially remethylated and 32.1% further demethylated beyond day 3. From admission to day 3, 19.7% of the CpG-sites became hypermethylated, of which, beyond day 3, 34.5% remained equally hypermethylated or partially demethylated again and 65.5% further hypermethylated. For 4.1% of the CpG-sites, changes only appeared beyond day 3. Finally, for the CpG-sites affected by early-PN on the last PICU day, earlier changes in DNA methylation were compared for early-PN and late-PN patients, revealing that 38.9% were already differentially methylated by day 3, another 25.0% by day 5 and another 13.9% by day 7. Conclusions Critical illness- and early-PN-induced changes in DNA methylation occurred mainly within 3 days. Most abnormalities were at least partially maintained or got worse with longer time in PICU. Interventions targeting aberrant DNA methylation changes should be initiated early.

Early parenteral nutrition progression and nutritional parameters in critically ill patients

Introdução: A nutrição parenteral (NP) pode assegurar a vida de pacientes incapazes de atingir suas necessidades nutricionais via oral ou enteral. Este estudo teve como objetivo avaliar a progressão da NP nos primeiros 3 dias (72 h), em pacientes críticos admitidos em unidade de terapia intensiva (UTI) e verificar alguns de seus parâmetros nutricionais. Método: Neste estudo de coorte prospectivo observacional, foi realizada triagem e avaliação nutricional dos pacientes críticos recebendo NP precoce, usando os seguintes parâmetros: NUTRIC Score, espessura do músculo adutor do polegar (APMT), ângulo de fase (PA) e ângulo de fase padronizado (SPA). Além disso, avaliamos a adequação da NP durante os primeiros 3 dias, seguindo as recomendações da literatura. Resultados: Doze pacientes foram incluídos no estudo. Entre eles, 58% eram do sexo feminino e 75% tinham 60 anos ou mais. A maioria apresentava câncer e tinha sido submetida a tratamento cirúrgico. A NP foi recomendada devido a obstrução intestinal (50%), gastroparesia (33%) e fístulas gastrointestinais (17%). Antes do início da NP, o período médio de jejum foi 3 dias. Quase todos os pacientes apresentaram elevado risco nutricional, estado nutricional e prognóstico desfavoráveis. Este estudo demonstrou que as metas progressivas de energia e proteína não foram atingidas nos primeiros 3 dias (72 horas) na maioria dos pacientes com NP exclusiva. Conclusões: Os participantes deste estudo apresentavam alto risco nutricional, desnutrição leve e mau prognóstico. A maioria desses pacientes não atingiu a meta de suas necessidades nutricionais dentro de 72 horas após o início da terapia de NP. Além disso, não foi observada uma uniformidade da progressão da PN.