Royal College of Paediatrics and Child Health A mixed bag: an enquiry into the care of hospital patients receiving parenteral nutrition Neena Modi Vice President, Science & Research Royal College of Paediatrics & Child Health Professor of Neonatal Medicine Imperial College London

Disclosures  Views of Expert Group members and advisors sought  Neonatal clinician in a tertiary centre  Lead a research programme involving newborn nutrition  Advised the Chief Pharmacist’s survey of neonatal PN in 2008/9

What we knew  Essential is the smallest, sickest babies  The target is growth, not correction of malnutrition  Standard regimens feasible  Often Partial (not Total) PN, bridging the gap to full milk feeds  Documentation poor and variable  Prescribing and dispensing processes variable  Complications common  Babies are neither small children nor adults  Some 1,500 to 3,000 babies receive PN in the UK each year

Confidential enquiries “ The purpose of a confidential enquiry is to detect areas of deficiency in clinical practice and devise recommendations to resolve them; enquiries can also make suggestions for future research programmes”

24% 12 babies

Documentation

Adequacy of first Parenteral Nutrition

Key findings  “Good practice”, defined as a “standard that you would accept from yourself, your trainees and your institution”, identified in 24% (62/264) of neonatal cases  Delay in recognising need for PN in 28%  Delay in starting PN once decision made in 17%  Poor documentation in 72%  First PN provided considered inadequate in 37%  Metabolic monitoring inadequate in 19%

Principal recommendations  Prompt consideration of need for PN, start without delay  First PN must be appropriate to neonate’s needs  Close monitoring essential  Neonatal units should have policies for documentation  Team approach  Consensus on best PN practice  Education, audit and training needed  NICE guidelines for nutritional support needed  Central hospital record of patients receiving PN  Attention to vascular line care

What was missing?  Details of prescribing and dispensing practice (Chief Pharmacist’s 2009 Study)  Denominators (how many babies should have received PN?)  Controls (were complications reliably attributable to PN?)  Details of concurrent milk feeds (was nutritional support really poor?)  A sense of what variation in practice there was among assessors (was the enquiry consistent?)  Acknowledgement that the evidence base is poor

Possible questions  Are process or outcome measures the best means for neonatal services to evaluate their practice?  What specific measures should be audited?  Is adequacy of PN the right question?  Which processes (prescribing, preparing, dispensing, delivering) require standardisation?  What is the research gap?

Optimal growth targets are not known Preterm nutrition is  Controversial  Variable  Poorly evidenced  Focused on growth outcomes even though the optimal pattern of growth is unknown

Optimal nutrient requirements for preterm babies are not known Intrauterine nutrient provision lipid - minimal glucose - moderate amino acid - high Postnatal nutrient provision lipid - high glucose - high protein - low

Other dangers Parenteral nutrition, (whether administered centrally or peripherally) (IRR 13.8, 95% CI 8.5 to 22.3, p<0.001) and gestational age < 26 weeks (IRR 2.4, 95% CI 1.7 to 3.5, p<0.001) are the highest significant independent risk factors for newborn late onset blood stream infection (Modi et al 2006)

The tightrope of preterm nutrition support  Not too much, not too little, but just right  NEON (Nutritional Evaluation and Optimisation in Neonates trial) commenced recruitment June 2010

Our conclusions  The call to improve practice is welcomed  The focus on the newborn and on children is applauded  The need for consistency of prescribing, dispensing, delivering and documenting is strongly supported  Preterm nutrition is experimental, research is needed  Beware the implementation of nutritional guidance that lacks an evidence base

Food for thought  Target methodology to specific patient group  Denominator capture  Appropriate controls  A priori definition of “best practice”  Links to other initiatives  Specific audit recommendations  Delineation of the research gap