Risks and Benefits of Prophylactic Cyclic Parenteral Nutrition in Surgical Neonates

Abstract

Background Cyclic parenteral nutrition (PN) is used for both the treatment and prevention of parenteral nutrition-associated liver disease (PNALD). Early initiation of prophylactic cyclic PN may not be well tolerated in young neonates. Our objective was to test the hypothesis that prophylactic cyclic PN initiated prior to the onset of hyperbilirubinemia is associated with younger age at initiation, lower bilirubin levels, and similar rates of adverse events compared to therapeutic cyclic PN initiated after established cholestasis in surgical neonates. Materials and Methods Retrospective review of infants with gastrointestinal disorders requiring surgical intervention who received cyclic PN from 2006 to 2011. Results Of the 43 infants eligible for analysis, 23 received prophylactic and 20 received therapeutic cyclic PN. Infants in both groups were comparable in demographics, surgical diagnoses, and illness severity. At initiation of cyclic PN, infants with prophylactic cyclic PN were significantly younger in chronologic (p = 0.003) and postmenstrual age (p = 0.029). Prophylactic cyclic PN was associated with a significantly lower incidence of hyperbilirubinemia (p = 0.001), lower maximum conjugated bilirubin (p < 0.0001), and lower last checked conjugated bilirubin (p = 0.032) compared to the therapeutic cyclic PN. The incidence of hypoglycemia, hyperglycemia, and hypertriglyceridemia was similar for the two groups. Conclusions There may be a potential benefit to initiating cyclic PN prior to the development of hyperbilirubinemia in surgical neonates. Early initiation of prophylactic cyclic PN does not appear to increase the risk for adverse events.

Effects of cyclic parenteral nutrition on parenteral-associated liver dysfunction parameters

“…Such difference might be explained by the fact that the PN initially administered in our hospital includes measures for the prevention of liver dysfunction, added to the fact that patients with a previous liver dysfunction were excluded from the study (15 patients). According to our protocol, these therapeutic measures must be adopted as soon as hepatic abnormalities are detected, which contradicts a recent study that suggests a benefit from early initiation of cPN [ 15 ]. Such measures include avoiding overfeeding, the early administration of enteral nutrition, the administration of cPN (8–12 h) [ 3 ], and the addition of taurine in PN.…”

ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Lipids

“…Besides, interruption of PN in neonates could result in higher infection rate, possibly due to increased line handling [91,92]. A retrospective analysis of PN cycling in both preterm and term neonates with gastrointestinal disorders requiring surgical intervention showed that prophylactic daily discontinuous PN infusion could not prevent a rise in conjugated bilirubin concentrations [93]. In another retrospective analysis of PN treated neonates with gastroschisis, prophylactic cycling of all PN components was associated with reduced cholestasis but the association disappeared after adjusting for confounders [92].…”

ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Organisational aspects

“…Children almost always tolerate night time infusion over 10e14 h [24]. The optimal time to initiate cyclical PN is unknown, and cycling may not be tolerated in young infants due to immature gluconeogenesis, limited glycogen stores, and large glucose demands [56]. However, there is evidence that cycling of PN is safe even in clinically stable newborns [56,57] (LoE 2À).…”