Presented at the Neonatal Society 2012 Spring Meeting.
Mahaveer A, Grime C, Morgan C
Department of Neonatology, Liverpool Women’s Hospital
Background: We have previously shown (1) a modified standardised concentrated neonatal parenteral nutrition (scNPN2) regimen increased early protein intake when compared to a previous regimen (scNPN1). The difference in protein intake (3.5g/kg) occurred in the 72 hours following birth and was achieved by starting PN sooner (median 3 hours versus 23 hours of age). During this work it was revealed that the incidence of insulin-treated hyperglycaemia fell by 50% despite no changes in the hyperglycaemia protocol or daily carbohydrate intake. Although insulin use fell, the pattern of insulin use remained the same peaking on days 5-10 suggesting early protein may affect postnatal metabolic adaptation. Our aim was to compare mean daily blood glucoses in the patients receiving scNPN1 and scNPN2 in the previous study (1).
Methods: Local audit committee approval was obtained. The local electronic data management system was used to collect complete 14 day blood glucose data (analysis performed as part of blood gas measurement). Daily mean blood glucose for each patient was then estimated using every blood glucose measurement within each 24 hour period and the time between samples.
Results: There were no differences between the groups (both n=38) in median (range) birthweight scNPN2: 935 (440-1350)g versus scNPN1: 890 (470-1330)g or gestation scNPN2: 26 (23-28) weeks versus scNPN1 26 (23-28) weeks. Mean (95% confidence interval) first week protein intake was 15.3 (14.5-16.1)g versus 11.8 (11.0-12.6)g (p<0.001). Insulin use (p=0.03): scNPN2: 10/38 infants (47 insulin days, 155.3IU/kg total insulin used) versus scNPN1: 20/38 (79 insulin days, 335.5IU/kg total insulin used). Mean daily blood glucose for summarised in Table 1 (days1-2,12-14, p>0.4). Higher insulin use with scNPN1 (mainly day 5-10) does not abolish the difference in mean blood glucose.
Table 1: Mean (SE) daily blood glucose (mmol/l)
Conclusion: Increasing very early protein intake is associated with improved blood glucose control as measured by mean daily blood glucose and insulin treatment. We suggest interrupting amino acid supply for >24 hours after birth may increase the risk of postnatal metabolic maladaptation. Further investigation with a clinical randomised controlled trial is required.
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1. Mahaveer A, Grime C, Morgan C. Increasing early protein is associated with a reduction in insulin-treated hyperglycaemia in very preterm infants. Arch Dis Child 2011;96(Suppl1): A88