Optimal practice in neonatal parenteral nutrition

Neonatal parenteral nutrition at a glance: What is it? For whom is it? How is it applied?

  • What: injection of nutrition into the bloodstream
  • For whom: preterm and sick infants, who cannot suck-swallow at the same time and have an immature digestive tract
  • How: sterile, safe and according to European guidelines

Adequate nutritional intakes – especially during the first 1000 days of life – are essential for promoting growth and health, including long-term metabolic, cognitive and neurodevelopmental outcomes. For babies born preterm who take some time to establish enteral intakes, parenteral nutrition provides the only alternative method that allows meeting nutrient requirements. Parenteral nutrition is also needed in babies with illnesses affecting the digestive tract (e.g. congenital or acquired gut disorder like necrotising enterocolitis (NEC)). Parenteral nutrition is a feeding method that bypasses the digestive tract by delivering nutrients directly to the bloodstream. This is a bit similar to the feeding of the unborn through the umbilical cord. Although not the ideal source of nutrition for babies and including associated risks, parenteral nutrition is vital especially for very preterm and critically ill babies and allows for adequate growth and development.

More information on the administration and composition of parenteral nutrition as well as on associated benefits and risks can be found here and in our factsheet.

Over the last 10 years, several errors in the application of parenteral nutrition (PN) have been reported and in 2013 a European survey revealed that PN is frequently not applied according to guidelines. In 2018 European guidelines on PN have been updated based on new evidence in this field of research. EFCNI wants to raise awareness for PN in general and to promote the practical implementation of the guidelines with the help of supporters and partners

Roundtable and position paper

Several experts from various countries came together for the international EFCNI roundtable on parenteral nutrition in Munich on the 4th of July 2018. During this roundtable, the content of the position paper “Addressing the nutritional emergency of preterm birth – Optimal practice in neonatal parenteral nutrition” was developed highlighting the importance of parenteral nutrition as a life-saving treatment for very preterm and ill babies. Based on this fruitful discussion and constructive exchange of views and ideas, the position paper was developed by EFCNI together with the expert panel during the last months and is launched in Maastricht during the jENS congress this year! The position paper is intended to serve as a supplement to, and a driving force for the development and implementation of guidelines on a national level based on the newly revised European ESPGHAN/ESPEN/ESPR/CSPEN guidelines (see also our social media series below). It primarily targets policy makers and hospital administrators but can also be used as a tool by parent representatives and healthcare professionals to convince decision-making bodies to support the delivery of appropriate, high-quality parenteral nutrition.

Download position paper


Members of the expert project for the topic neonatal parenteral nutrition (in alphabetic order)

Professor Virgilio Carnielli, Professor Magnus Domellöf, Katarina Eglin, Professor Nicholas Embleton, Harald Erdmann, Professor Christoph Fusch, Professor Nadja Haiden, Professor Egbert Herting, Dr Martina Kohl, Professor Berthold Koletzko, Professor Alexandre Lapillonne, Dr Helen Mactier, Dr Sissel Moltu, Livia Nagy-Bonnard, Dr Mattias Paulsson, Dr Miguel Sáenz de Pipaón, Professor Manuel Sánchez Luna, Stephen Tomlin, Professor Hans van Goudoever

National roundtable and barrier analysis

Calling for implementation of the guidelines on the national level, EFCNI sought to first get a notion of how parenteral nutrition is implemented in Germany and whether health care professionals adhere to general standards and requirements as recommended by the guidelines.

Therefore, EFCNI formed a network with the Federal Association of German Hospital Pharmacists (ADKA) and the German Society for Neonatology and Paediatric Intensive Care (GNPI) and co-hosted a roundtable together with them. During this roundtable, an expert panel from German-speaking Universities and hospital pharmacies elaborated a survey to collect data on the implementation of the European guidelines in Germany.

In 2020, this survey was initiated in an online format. Invited for participation were all German hospital pharmacies and several clinics with neonatal intensive care units. The survey comprised mainly questions related to the details on the implementation of the guidelines, reasons for deviating from guidelines, but also organisational aspects such as the supply of parenteral nutrition on weekends and holidays. Moreover, the experts endeavoured to gather information on how and when parents are informed about PN as a required nutritional therapy for their baby.

Survey findings in brief:

The survey reveals that a majority of the respondents were aware of the guidelines and indicated to implement them. However, some findings are of major concern, for instance: Respondents stated that the supply with parenteral solutions on weekends is challenging, leading to deviations from hygiene standards. Moreover, only a third of respondents have access to software that is necessary to calculate the nutrient requirements. Although the European guideline recommends preferring standardised solutions over individualised solutions, only half of the respondents use standardised solutions regularly. Moreover, the way of how parents are usually informed is insufficient. Parents are mainly informed orally and directly after birth.  This is a format that does not always respect their situation and needs. All in all, the survey provided evidence that practice of parenteral nutrition partly differs from guideline recommendations which calls for activities to promote a safe and recommended implementation of parenteral nutrition.

Download the publication

Overcoming barriers in Germany-speaking countries: Digital roundtable and development of a toolkit to improve the application of parenteral nutrition

In January 2021, together with the ADKA, GNPI and under the support of the Bundesverbandes „Das frühgeborene Kind“ e.V. (BVDfK) and the Berufsverbandes Kinderkrankenpflege e.V. (BeDK), EFCNI hosted two digital roundtables. During these roundtables, well-known German-speaking experts discussed how identified barriers can be avoided and overcome in future. Based on these fruitful discussions and constructive exchange of perspectives, they elaborated solutions, advice and best-practice recommendations to support health care professionals in the implementation of the European guidelines on parenteral nutrition in their daily practice. In order to share their solutions with all healthcare professionals, the expert panel developed the toolkit “Toolkit für die parenterale Ernährung von Früh- und kranken Neugeborenen – Von der Leitlinie in die multidisziplinäre Anwendung“ (Toolkit for parenteral nutrition of preterm and sick newborns – From guideline to multidisciplinary application) in German language and launched it at the virtual GNPI congress in June 2021. Its intention is to support all healthcare professionals that work in the field of parenteral nutrition in adhering to the guidelines and in providing high-quality parenteral nutrition.

 
Download Toolkit

Professor Nicholas Embleton on Quality Improvement and Risk Management

Professor Nicholas Embleton

Professor Nicholas Embleton is Consultant Neonatal Paediatrician at the Newcastle-upon-Tyne hospital and a member of the expert panel for the topic of neonatal parenteral nutrition.

In our interview he explains:

  • Reporting practices in Quality Improvement (QI) and Risk Management (RM)
  • The Briefing in a minute (BIM) as a method of QI and RM
  • The importance of a blame-free culture

Read full interview

Factsheet “Parenteral nutrition”: All you need to know about parenteral nutrition (PN) at a glance

For a quick overview and insights on parenteral nutrition, download our factsheet! Here you can learn e.g. which group of children require parenteral nutrition, how it is administered, how parenteral nutrition is composed and which benefits and risks may come with parenteral feeding. The factsheet is available in English and German.

Go to download section

Common Call to Action

Parenteral nutrition is a life-saving feeding method in infants who cannot be fed enterally. Parenteral nutrition does however carry certain risks, especially if it is not performed according to evidenced-based guidelines.

The panel therefore calls on all stakeholders involved in parenteral nutrition to:

  • Implement the Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), the European Society for Clinical Nutrition and Metabolism (ESPEN), the European Society of Paediatric Research (ESPR), and the Chinese Society of Parenteral and Enteral Nutrition (CSPEN) into daily practice by translating them to national and hospital level guidelines
  • Develop and implement a warning system for the early detection of errors and adaptation of processes
  • Develop and implement an evidence-based computerised order entry system according to current guidelines with appropriate interfaces with the compounding units in hospitals adapted to the special needs of neonatal parenteral nutrition
  • Increase research into optimal formulations and the long-term outcomes of infants treated with parenteral nutrition
  • Develop and implement a benchmarking system to measure and compare the use of parenteral nutrition
  • Implement antenatal preparatory conversations with mothers at high risk of having a preterm birth and include information about parenteral nutrition as well as counselling on breast milk expression in these conversations
  • Provide accurate and reliable information to parents and families on parenteral nutrition

We warmly thank the following healthcare societies and organisations for supporting the position paper on parenteral nutrition (in alphabetical order):

We warmly thank the following parent organisations for supporting the position paper on parenteral nutrition (in alphabetical order):

The roundtable, the position paper, the barrier analysis and the corresponding toolkit are kindly supported by an educational grant by Baxter.