NICE Guidelines on Neonatal parenteral nutrition

,has released its latest 2020 guidelines on Neonatal parenteral nutrition. This guideline covers parenteral nutrition (intravenous feeding) for babies born preterm, up to 28 days after their due birth date and babies born at term, up to 28 days after their birth. Parenteral nutrition is often needed by preterm babies, critically ill babies, and babies who need surgery.

Following are the major recommendations: 

1. Indications for, and timing of, neonatal parenteral nutrition

Indications for starting neonatal parenteral nutrition

• For preterm babies born before 31+0 weeks, start neonatal parenteral nutrition.
• For preterm babies born at or after 31+0 weeks, start parenteral nutrition if sufficient progress is not made with enteral feeding in the first 72 hours after birth.
• Start parenteral nutrition for preterm and term babies who are unlikely to establish sufficient enteral feeding, for example, babies with:
• a congenital gut disorder
• a critical illness such as sepsis.

Indications for starting neonatal parenteral nutrition if enteral feeds are stopped

• For preterm babies on enteral feeds, start parenteral nutrition if:
• enteral feeds have to be stopped and it is unlikely they will be restarted within 48 hours
• enteral feeds have been stopped for more than 24 hours and there is unlikely to be sufficient progress with enteral feeding within a further 48 hours.

• For term babies on enteral feeds, start parenteral nutrition if:
• enteral feeds have to be stopped and it is unlikely they will be restarted within 72 hours
• enteral feeds have been stopped for more than 48 hours and there is unlikely to be sufficient progress with enteral feeding within a further 48 hours.

Timing of starting neonatal parenteral nutrition

• When a preterm or term baby meets the indications for parenteral nutrition, start it as soon as possible, and within 8 hours at the latest.

2. Administration of neonatal parenteral nutrition

Venous access

• Use a central venous catheter to give neonatal parenteral nutrition. Only consider using peripheral venous access to give neonatal parenteral nutrition if:
• it would avoid a delay in starting parenteral nutrition
• short-term use of peripheral venous access is anticipated, for example, less than 5 days
• it would avoid interruptions in giving parenteral nutrition
• central venous access is impractical.

• Only consider surgical insertion of a central venous catheter if:
• non-surgical insertion is not possible
• long-term parenteral nutrition is anticipated, for example, in short bowel syndrome.

Protection from light

• Protect the bags, syringes and infusion sets of both aqueous and lipid parenteral nutrition solutions from light.

3. Energy needs of babies on neonatal parenteral nutrition

• For preterm and term babies who need total neonatal parenteral nutrition, deliver energy as follows:

• If starting parenteral nutrition in the first 4 days after birth:

• give a starting range of 40 to 60 kcal/kg/day
• gradually increase (for example, over 4 days) to a maintenance range of 75 to 120 kcal/kg/day.

• If starting parenteral nutrition more than 4 days after birth:

• give a range of 75 to 120 kcal/kg/day.
• For preterm and term babies who are on enteral feeds in addition to neonatal parenteral nutrition, reduce the amount of energy that is given parenterally as enteral feeds increase.

Term babies who are critically ill or have just had surgery

• For term babies who are critically ill or have just had surgery, consider giving parenteral energy at the lower end of the starting range in recommendation 1.3.1, and gradually increase to the intended maintenance intake.

4. Neonatal parenteral nutrition volume

• Standardised neonatal parenteral nutrition ('standardised bags') should be formulated in concentrated solutions to help ensure that the nutritive element of intravenous fluids is included within the total fluid allowance.

5. Constituents of neonatal parenteral nutrition

Glucose

• For preterm and term babies, give glucose as follows:
• If starting parenteral nutrition in the first 4 days after birth:

• give a starting range of 6 to 9 g/kg/day
• gradually increase (for example, over 4 days) to a maintenance range of 9 to 16 g/kg/day.

• If starting parenteral nutrition more than 4 days after birth:

• give a range of 9 to 16 g/kg/day.

Amino acids

• For preterm babies, give amino acids as follows:

• If starting parenteral nutrition in the first 4 days after birth:
• give a starting range of 1.5 to 2 g/kg/day
• gradually increase (for example, over 4 days) to a maintenance range of 3 to 4 g/kg/day.

• If starting parenteral nutrition more than 4 days after birth:

• give a range of 3 to 4 g/kg/day.

• For term babies, give amino acids as follows:
• If starting parenteral nutrition in the first 4 days after birth:

• give a starting range of 1 to 2 g/kg/day
• gradually increase (for example, over 4 days) to a maintenance range of 2.5 to 3 g/kg/day.

• If starting parenteral nutrition more than 4 days after birth:

• give a range of 2.5 to 3 g/kg/day.

Lipids and lipid emulsions

• For preterm and term babies, give lipids as follows:
• If starting parenteral nutrition in the first 4 days after birth:

• give a starting range of 1 to 2 g/kg/day
• gradually increase (for example, in daily increments of 0.5 to 1 g/kg/day) to a maintenance range of 3 to 4 g/kg/day.

• If starting parenteral nutrition more than 4 days after birth:

• give a range of 3 to 4 g/kg/day.

• For preterm and term babies with parenteral nutrition-associated liver disease, consider giving a composite lipid emulsion rather than a pure soy lipid emulsion.

Ratios of non-nitrogen energy to nitrogen, and carbohydrates to lipids

• When giving neonatal parenteral nutrition to preterm or term babies:

• use the values for each individual component in recommendations 1.5.1 to 1.5.4
• provide non-nitrogen energy as 60% to 75% carbohydrate and 25% to 40% lipid
• use a non-nitrogen energy to nitrogen ratio in a range of 20 to 30 kcal of non-nitrogen energy per gram of amino acids (this equates to 30 to 40 kcal of total energy per gram of amino acid).
• When altering the amount of neonatal parenteral nutrition, maintain the non-nitrogen energy to nitrogen ratio, and the carbohydrate to lipid ratio, to keep within the ranges of ratios specified in recommendation 1.5.6.

Iron

• Do not give intravenous parenteral iron supplements to preterm or term babies on neonatal parenteral nutrition who are younger than 28 days.
• For preterm babies on neonatal parenteral nutrition who are 28 days or older, monitor for iron deficiency and treat if necessary (see recommendation 1.7.11).

Calcium

• For preterm and term babies, give calcium as follows:

• If starting parenteral nutrition in the first 48 hours after birth:

• give a starting range of 0.8 to 1 mmol/kg/day
• increase to a maintenance range of 1.5 to 2 mmol/kg/day after 48 hours.

• If starting parenteral nutrition more than 48 hours after birth, give a range of 1.5 to 2 mmol/kg/day.

Phosphate

• For preterm and term babies, give phosphate as follows:

• If starting parenteral nutrition in the first 48 hours after birth:

• give 1 mmol/kg/day
• increase to a maintenance dosage of 2 mmol/kg/day after 48 hours.

• If starting parenteral nutrition more than 48 hours after birth, give 2 mmol/kg/day.
• Give a higher dosage of phosphate if indicated by serum phosphate monitoring.

• Be aware that preterm babies may be at increased risk of phosphate deficit requiring additional phosphate supplementation.

Ratio of calcium to phosphate

• Use a calcium to phosphate ratio of between 0.75:1 and 1:1 for preterm and term babies on neonatal parenteral nutrition.

Other constituents of neonatal parenteral nutrition – general principles

Vitamins

• Give daily intravenous fat-soluble and water-soluble vitamins ideally from the outset, but as soon as possible after starting parenteral nutrition, to maintain standard daily requirements.
• Give fat-soluble and water-soluble vitamins in the intravenous lipid emulsion to improve their stability.

Electrolytes

• Give sodium and potassium in parenteral nutrition to maintain standard daily requirements, adjusted as necessary for the individual baby.
• Be aware that even if the parenteral nutrition solution contains sodium and potassium, additional supplements of these electrolytes can be given using a separate intravenous infusion.

Magnesium

• Give magnesium in parenteral nutrition ideally from the outset, but as soon as possible after starting parenteral nutrition.

Trace elements

• Give daily intravenous trace elements ideally from the outset, but as soon as possible after starting parenteral nutrition.

6. Standardised neonatal parenteral nutrition formulations ('standardised bags')

• When starting neonatal parenteral nutrition for preterm and term babies, use a standardised neonatal parenteral nutrition formulation ('standardised bag')[1].
• Standardised bags should:

• be formulated to allow delivery of parenteral nutrition as recommended in the sections on neonatal parenteral nutrition volume and constituents of neonatal parenteral nutrition
• be prepared following nationally agreed quality standards.

• Continue with a standardised bag unless an individualised parenteral nutrition formulation is indicated, for example, if the baby has:
• complex disorders associated with a fluid and electrolyte imbalance
• renal failure.

7. Monitoring neonatal parenteral nutrition

• When taking blood samples to monitor the preterm or term baby's neonatal parenteral nutrition:

• collect the minimum blood volume needed for the tests
• use a protocol agreed with the local clinical laboratory to retrieve as much information as possible from the sample
• coordinate the timing of blood tests to minimise the number of blood samples needed.

Blood glucose

• Measure the blood glucose level:

• 1 to 2 hours after first starting parenteral nutrition
• 1 to 2 hours after each change of parenteral nutrition bag (usually every 24 or 48 hours).

• Measure blood glucose more frequently if:

• the preterm or term baby has previously had hypoglycemia or hyperglycemia
• the dosage of intravenous glucose has been changed
• there are clinical reasons for concern, for example, sepsis or seizures.

Blood pH, potassium, chloride and calcium

• Measure the blood pH, potassium, chloride and calcium levels:

• daily when starting and increasing parenteral nutrition
• twice weekly after reaching a maintenance parenteral nutrition.

• Measure blood pH, potassium, chloride or calcium more frequently if:

• the preterm or term baby has previously had levels of these components outside the normal range
• the dosages of intravenous potassium, chloride or calcium have been changed
• there are clinical reasons for concern, for example, in critically ill babies.

Serum triglycerides

• Measure serum triglycerides:

• daily while increasing the parenteral nutrition lipid dosage
• weekly after reaching a maintenance intravenous lipid dosage.

• Measure serum triglycerides more frequently, but not more than once a day, if:

• the level is elevated
• the preterm or term baby is at risk of hypertriglyceridaemia, for example, if the baby is critically ill or has a lipaemic blood sample.

• Be aware that ongoing serum triglyceride monitoring may not be needed for stable preterm or term babies transitioning from parenteral nutrition to enteral nutrition.

Serum or plasma phosphate

• Measure the serum or plasma phosphate level:

• daily while increasing the parenteral nutrition phosphate dosage
• weekly after reaching a maintenance intravenous phosphate dosage.

• Consider measuring serum or plasma phosphate more frequently:

• if the level has been outside the normal range
• if there are clinical reasons for concern, for example, metabolic bone disease
• for preterm babies born at less than 32+0 weeks.

Iron status

• Measure ferritin, iron and transferrin saturation if a preterm baby is on parenteral nutrition for more than 28 days.

Liver function

• Measure liver function weekly in preterm and term babies on parenteral nutrition.
• Measure liver function more frequently than weekly if there are clinical concerns or previous liver function test levels outside the normal range.

8. Stopping neonatal parenteral nutrition

• For all babies, take into account the following when deciding when to stop parenteral nutrition:

• the baby's tolerance of enteral feeds
• the amount of nutrition being delivered by enteral feeds (volume and composition)
• the relative contribution of parenteral nutrition and enteral nutrition to the baby's total nutritional requirement
• the likely benefit of the nutritional intake compared with the risk of venous catheter sepsis
• the individual baby's particular circumstances, for example, a baby with complex needs such as short bowel syndrome, increased stoma losses or slow growth, may need long-term parenteral nutrition.

• For preterm babies born before 28+0 weeks, consider stopping parenteral nutrition within 24 hours once the enteral feed volume is 140 to 150 ml/kg/day, taking into account the factors in recommendation 1.8.1.
• For preterm babies born at or after 28+0 weeks and term babies, consider stopping parenteral nutrition within 24 hours if the enteral feed volume tolerated is 120 to 140 ml/kg/day, taking into account the factors in recommendation 1.8.1.

9. Service design

• Neonatal parenteral nutrition services should be supported by a specialist multidisciplinary team. Such teams could be based locally or within a clinical network.
• The neonatal parenteral nutrition multidisciplinary team should include a consultant neonatologist or paediatrician with a special interest in neonatology, a neonatal pharmacist and a neonatal dietitian, and should have access to the following:

• a neonatal nurse
• a pediatric gastroenterologist
• an expert in clinical biochemistry.

• The neonatal parenteral nutrition multidisciplinary team should be responsible for:
• governance, including:

• agreeing policies and protocols for the neonatal parenteral nutrition service
• ensuring that policies and protocols for neonatal parenteral nutrition are followed and audited
• monitoring clinical outcomes

• supporting delivery of parenteral nutrition, including:

• providing clinical advice
• providing enhanced multidisciplinary team input for preterm and term babies with complex needs, for example, babies with short bowel syndrome who may need long-term parenteral nutrition.

Information and support for parents and carers

• Ask parents and carers of babies on parenteral nutrition how and when they would like to receive information and updates, and how much information they would like about their baby's care.

• Topics to discuss with parents or carers include:

• why their baby needs parenteral nutrition
• what parenteral nutrition involves
• the importance of good nutrition for newborn babies
• how long their baby is likely to need parenteral nutrition for
• common concerns, for example, central venous catheter placement, the risk of catheter-related infections, taking blood samples, and whether they can hold and care for their baby
• simultaneous enteral feeding, unless this is not possible
• how their baby's progress will be monitored
• how their baby will be weaned off parenteral nutrition.

• Give information to parents or carers that:

• is tailored to their baby's circumstances
• meets their needs and preferences
• is up to date, relevant and consistent between healthcare professionals
• is available in suitable formats (written and spoken, with information available to take away).

For more guidance on communication (including different formats and languages), providing information, and shared decision making, see the NICE clinical guideline on patient experience in adult NHS services.

• Provide regular opportunities and time for parents and carers of babies on parenteral nutrition to discuss their baby's care, ask questions about the information they have been given, and discuss concerns.

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