Presented at the Neonatal Society 2012 Autumn Meeting.
Johnson MJ1,2, Moyses HE1, Leaf AA1,2, Cornelius VR3
1 National Institute for Health Research, Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
2 Department of Neonatal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
3 Department of Primary Care and Public Health Sciences, Kings College London, UK
Background: Achieving adequate nutritional intakes in preterm infants is challenging, and may explain poor growth often seen in this group. The use of early parenteral nutrition (PN) has been proposed as one way of addressing this issue, although the benefit and harms are unknown. We carried out a systematic review to assess the effect of timing of commencement of PN on growth and risk of morbidity and mortality in preterm infants.
Methods: The databases MEDLINE, EMBASE, CINAHL, ‘Web of Science’ and ‘CSA-Conference Papers Index’ were searched between 1947 and July 2012, with selective citation and reference searching. Studies were eligible if they were RCTs or observational studies comparing ‘early’ versus ‘late’ PN or intravenous amino acids in preterm infants, and had at least one growth outcome. The definition of ‘early’ was within 48 hours of birth, and studies where the ‘early’ feeding intervention was later than 48 hours were excluded. There was no restriction on language.
Results: Eight RCTs and 13 observational studies met inclusion criteria (n=553 and 1796 infants). Meta-analysis was limited by disparate growth outcome measures. Assessment of potential bias was difficult to gauge due to inadequate reporting. Results are given as mean difference (95% Confidence Interval). Early PN reduced time to regain birth weight by 2.2 days (1.1-3.2) for RCTs and 3.2 days (2.0-4.4) in observational studies. Maximum percentage weight loss was lower with early PN by 3.1% (1.7-4.5) for RCTs and 3.5% (2.6-4.3) for observational studies. Early PN improved weight at discharge/36 weeks by 14.9g (5.3-24.5, observational studies only). No benefit was found for length or head circumference at discharge/36 weeks. There was no significant difference in the risk of mortality, necrotising enterocolitis, sepsis, chronic lung disease, VH or cholestasis between the early and late groups.
Conclusion: The results of this review whilst subject to some limitations, demonstrates that the use of early PN provides benefit for short term growth outcomes, with some evidence of benefit for growth outcomes at discharge or 36 weeks. No evidence that early PN causes harm was found. Growth measures in neonatal research would benefit from the development of a set of core outcome measures.
Corresponding author: m.johnson@soton.ac.uk
References
1. Embleton NE, Pang N, Cooke RJ. Postnatal malnutrition and growth retardation: an inevitable consequence of current recommendations in preterm infants? Pediatrics 2001;107(2):270
2. Ehrenkranz RA. Early, aggressive nutritional management for very low birth weight infants: what is the evidence? Semin Perinatol 2007;31(2):48-55.