80 THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.3 Sep. 30 2012 臨 床 藥 物 治 療 學 Therapeutics of Clinical Drugs LBW Neonates Requiring Short-Term PN Tend to Prolong ICU Stay Peng-Hsiung Wang 1 , Zon-Min Lee 1 , Ping-Yu Lee 1 Chi-Wen Chiang 2 Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital 1 Department of Pharmacy, Pingtung Hospital, Department of Health, Executive Yuan, Pingtung 2 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
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80 THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.3 Sep. 30 2012
臨 床 藥 物 治 療 學 Therapeutics of Clinical Drugs
LBW Neonates Requiring Short-Term PN Tend to Prolong ICU Stay
Peng-Hsiung Wang1 , Zon-Min Lee1, Ping-Yu Lee1
Chi-Wen Chiang2
Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital1
Department of Pharmacy, Pingtung Hospital, Department of Health, Executive Yuan, Pingtung2
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
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藥學雜誌 第112冊 81
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 re t rospec t ive cha r t r ev iew 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
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
82 THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.3 Sep. 30 2012
臨 床 藥 物 治 療 學 Therapeutics of Clinical Drugs
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
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LBW Neonates Requiring Short-Term PN Tend to Prolong ICU Stay
藥學雜誌 第112冊 83
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 provis ion of nut r ients i s an impor tant 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
84 THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.3 Sep. 30 2012
臨 床 藥 物 治 療 學 Therapeutics of Clinical Drugs
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 in-dividualised parenteral nutrition for preterm infants. Archives of Disease in Childhood Fetal and Neonatal Edi-tion 2009; 94(2): 152-153.
3. Puligandla PS, Janvier A, Flageole H, et al: The signifi-cance 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. Ar-chives of Disease in Childhood: Fetal and Neonatal Edi-tion 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.
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 Edi-tion 2009; 94(2): 111-115.
9. Zon-Min L, Chiu-Ying W, Chi-Wen C, et al: Patent Duc-tus 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 physico-chemical properties of two lipid emulsions used as total parenteral nutrition for neonates. Pda Journal of Pharma-ceutical 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 pe-diatria 1999; 51(1): 22-26.
13. Mandragos C, Moukas M, Amygdalou A, et al: Gastroin-testinal hormones and short-term nutritional schedules in critically ill patients. Hepato-Gastroenterology 2003; 50 (53): 1442-1445.
14. Prinzler HJ, Weidler B, Lohmann B, et al: Routine post-operative parenteral feeding with a complete solution. Infusionstherapie (Basel) 1990; 17(2): 84-88.
15. Monroy TR, Macias AE, Ponce-de LS, et al: Weight gain and metabolic complications in preterm infants with nu-tritional support. Revista de Investigacion Clinica 2011; 63(3): 244-252.
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
第28卷第3期Sep. 30 2012
LBW Neonates Requiring Short-Term PN Tend to Prolong ICU Stay
藥學雜誌 第112冊 85
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。