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Biological Impact of Recent Guidelines on Parenteral Nutrition in Preterm Infants
Isabelle Guellec1, Géraldine Gascoin, Alain Beuchee
1*Neonatal and Pediatric Intensive Care Unit, CHU Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Paris †Neonatal Intensive Care Unit, CHU Angers, Angers ‡Neonatal Intensive Care Unit, Pôle Médico-Chirurgical de Pédiatrie et de Génétique Clinique, CHU Rennes, Rennes §Division of Neonatology, AP-HM, Aix-Marseille University, Marseille ||Neonatal Intensive Care Unit, Pôle Femme Couple Enfant, CHU Amiens, Amiens ¶Neonatal and Pediatric Intensive Care Unit, CHU Félix Guyon, La Réunion #Neonatal Intensive Care Unit Port-Royal, Groupe Hospitalier Cochin-Broca-Hôtel Dieu, Assistance Publique-Hôpitaux de Paris, Paris **Neonatal Intensive Care Unit, Groupe Hospitalier Robert Debré, Assistance Publique-Hôpitaux de Paris, Paris, France.
Insights
New parenteral nutrition (PN) guidelines for preterm infants may disrupt ionic homeostasis, potentially causing metabolic acidosis and hypophosphatemia. Close monitoring is crucial for preventing adverse effects in these vulnerable neonates.
Area of Science:
- Neonatalogy
- Pediatric Nutrition
- Biochemistry
Background:
- Recent guidelines advocate for early parenteral nutrition (PN) with high protein and caloric intake in preterm neonates.
- This approach aims to optimize growth but may impact infant homeostasis during early postnatal weeks.
Purpose of the Study:
- To evaluate the potential influence of updated PN guidelines on the homeostasis of very preterm infants.
- To identify potential adverse effects associated with early high-protein and high-caloric PN in neonates.
Main Methods:
- Systematic review of relevant literature.
- Analysis of PubMed and recent clinical guidelines.
- Expert review by investigators from French perinatal centers.
Main Results:
- Updated PN recommendations may lead to metabolic acidosis (amino acid gap, hyperchloremic, ammonia acidosis).
- High amino acid intake can cause hypophosphatemia and hypercalcemia, mimicking 'repeat feeding-like syndrome', preventable with phosphorus.
- Early high-dose amino acid infusions appear safe for preterm infant renal function, but further research on protein intolerance markers is needed.
Conclusions:
- While beneficial for growth, optimal PN according to new guidelines may disrupt ionic homeostasis in very preterm infants.
- Clinicians must implement vigilant monitoring to prevent and manage potential adverse effects on homeostasis.
Objectives:
Recent guidelines for preterm neonates recommend early initiation of parenteral nutrition (PN) with high protein and relatively high caloric intake. This review considers whether these changes could influence homeostasis in very preterm infants during the first few postnatal weeks.
Methods:
This systematic review of relevant literature from searches of PubMed and recent guidelines was reviewed by investigators from several perinatal centers in France.
Results:
New recommendations for PN could be associated with metabolic acidosis via the increase in the amino acid ion gap, hyperchloremic acidosis, and ammonia acidosis. The introduction of high-intake amino acids soon after birth could induce hypophosphatemia and hypercalcemia, simulating a "repeat feeding-like syndrome" and could be prevented by the early intake of phosphorus, especially in preterm infants born after fetal growth restriction. Early high-dose amino acid infusions are relatively well tolerated in the preterm infant with regard to renal function. Additional studies, however, are warranted to determine markers of protein intolerance and to specify the optimal composition and amount of amino acid solutions.
Conclusions:
Optimal PN following new guidelines in very preterm infants, despite their demonstrated benefits on growth, may induce adverse effects on ionic homeostasis. Clinicians should implement appropriate monitoring to prevent and/or correct them.
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