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Neonatal parenteral nutrition

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What is covered

This NICE Pathway covers parenteral nutrition (intravenous feeding) for babies born preterm, up to 28 days after their due birth date, and babies born at term, up to 28 days after their birth. Parenteral nutrition is often needed by preterm babies, critically ill babies and babies who need surgery.

Updates

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on parenteral nutrition (intravenous feeding) for newborn babies in an interactive flowchart.

What is covered

This NICE Pathway covers parenteral nutrition (intravenous feeding) for babies born preterm, up to 28 days after their due birth date, and babies born at term, up to 28 days after their birth. Parenteral nutrition is often needed by preterm babies, critically ill babies and babies who need surgery.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Neonatal parenteral nutrition (2020) NICE guideline NG154

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

A lipid emulsion that is derived from more than 1 source, for example, it might include 2 or more of soy oil, medium chain triglycerides, olive oil or fish oil.
Aqueous and lipid parenteral nutrition solutions that meet the nutritional requirements of an individual baby. The solutions are not pre-formulated and have to be prescribed and made up each time they are needed, on an individual basis for each baby. Electrolytes can be added, and macronutrients or micronutrients can be adjusted as necessary.
A baby born before 37+0 weeks. This can be subdivided further:
  • extremely preterm: babies born at less than 28+0 weeks
  • very preterm: babies born at between 28+0 and 31+6 weeks
  • moderate to late preterm: babies born at between 32+0 and 36+6 weeks.
A baby born before 37+0 weeks. This can be subdivided further:
  • extremely preterm: babies born at less than 28+0 weeks
  • very preterm: babies born at between 28+0 and 31+6 weeks
  • moderate to late preterm: babies born at between 32+0 and 36+6 weeks.
Babies born before 37+0 weeks. This can be subdivided further:
  • extremely preterm: babies born at less than 28+0 weeks
  • very preterm: babies born at between 28+0 and 31+6 weeks
  • moderate to late preterm: babies born at between 32+0 and 36+6 weeks.
Standardised bags contain pre-formulated aqueous and lipid parenteral nutrition solutions made to a set composition that is not varied. They are ready to use and aim to meet the nutritional and clinical needs of a defined group of babies. Additional intravenous infusions are sometimes used to meet more individualised fluid or electrolyte requirements.
Standardised bags are prescribed as part of a standardised parenteral nutrition regimen: a choice of standardised bags that are given at the appropriate volume to meet the nutritional and clinical needs of a defined group of babies.
Standardised bags contain pre-formulated aqueous and lipid parenteral nutrition solutions made to a set composition that is not varied. They are ready to use and aim to meet the nutritional and clinical needs of a defined group of babies. Additional intravenous infusions are sometimes used to meet more individualised fluid or electrolyte requirements.
Standardised bags are prescribed as part of a standardised parenteral nutrition regimen: a choice of standardised bags that are given at the appropriate volume to meet the nutritional and clinical needs of a defined group of babies.
Start parenteral nutrition for preterm and term babies who are unlikely to establish sufficient enteral feeding, for example, babies with:
  • a congenital gut disorder
  • a critical illness such as sepsis.
When a preterm or term baby meets the indications for parenteral nutrition, start it as soon as possible, and within 8 hours at the latest.
Use a central venous catheter to give neonatal parenteral nutrition. Only consider using peripheral venous access to give neonatal parenteral nutrition if:
  • it would avoid a delay in starting parenteral nutrition
  • short-term use of peripheral venous access is anticipated, for example, less than 5 days
  • it would avoid interruptions in giving parenteral nutrition
  • central venous access is impractical.
Only consider surgical insertion of a central venous catheter if:
  • non-surgical insertion is not possible
  • long-term parenteral nutrition is anticipated, for example, in short bowel syndrome.

Protection from light

Protect the bags, syringes and infusion sets of both aqueous and lipid parenteral nutrition solutions from light.
For preterm and term babies who need total neonatal parenteral nutrition, deliver energy as follows:
  • If starting parenteral nutrition in the first 4 days after birth:
    • give a starting range of 40 to 60 kcal/kg/day
    • gradually increase (for example, over 4 days) to a maintenance range of 75 to 120 kcal/kg/day.
  • If starting parenteral nutrition more than 4 days after birth:
    • give a range of 75 to 120 kcal/kg/day.
For preterm and term babies who are on enteral feeds in addition to neonatal parenteral nutrition, reduce the amount of energy that is given parenterally as enteral feeds increase.
Standardised neonatal parenteral nutrition ('standardised bags') should be formulated in concentrated solutions to help ensure that the nutritive element of intravenous fluids is included within the total fluid allowance.

Glucose

For preterm and term babies, give glucose as follows:
  • If starting parenteral nutrition in the first 4 days after birth:
    • give a starting range of 6 to 9 g/kg/day
    • gradually increase (for example, over 4 days) to a maintenance range of 9 to 16 g/kg/day.
  • If starting parenteral nutrition more than 4 days after birth:
    • give a range of 9 to 16 g/kg/day.
For preterm and term babies, give lipids as follows:
  • If starting parenteral nutrition in the first 4 days after birth:
    • give a starting range of 1 to 2 g/kg/day
    • gradually increase (for example, in daily increments of 0.5 to 1 g/kg/day) to a maintenance range of 3 to 4 g/kg/day.
  • If starting parenteral nutrition more than 4 days after birth:
    • give a range of 3 to 4 g/kg/day.
For pre-term and term babies with parenteral nutrition-associated liver disease, consider giving a composite lipid emulsion rather than a pure soy lipid emulsion.
When giving neonatal parenteral nutrition to preterm or term babies:
  • use the values for each individual component in the recommendations on glucose and amino acids (see above)
  • provide non-nitrogen energy as 60% to 75% carbohydrate and 25% to 40% lipid
  • use a non-nitrogen energy to nitrogen ratio in a range of 20 to 30 kcal of non-nitrogen energy per gram of amino acids (this equates to 23 to 34 kcal of total energy per gram of amino acid).
When altering the amount of neonatal parenteral nutrition, maintain the non-nitrogen energy to nitrogen ratio and the carbohydrate to lipid ratio, to keep within the ranges of ratios specified in the recommendation immediately above.
Do not give intravenous parenteral iron supplements to preterm or term babies on neonatal parenteral nutrition who are younger than 28 days.
See the NICE guideline to find out why we did not make recommendations about acetate.

Calcium

For preterm and term babies, give calcium as follows:
  • If starting parenteral nutrition in the first 48 hours after birth:
    • give a starting range of 0.8 to 1 mmol/kg/day
    • increase to a maintenance range of 1.5 to 2 mmol/kg/day after 48 hours.
  • If starting parenteral nutrition more than 48 hours after birth, give a range of 1.5 to 2 mmol/kg/day.

Phosphate

For preterm and term babies, give phosphate as follows:
  • If starting parenteral nutrition in the first 48 hours after birth:
    • give 1 mmol/kg/day
    • increase to a maintenance dosage of 2 mmol/kg/day after 48 hours.
  • If starting parenteral nutrition more than 48 hours after birth, give 2 mmol/kg/day.
  • Give a higher dosage of phosphate if indicated by serum phosphate monitoring.

Ratio of calcium to phosphate

Use a calcium to phosphate ratio of between 0.75:1 and 1:1 for preterm and term babies on neonatal parenteral nutrition.
Give magnesium in parenteral nutrition ideally from the outset, but as soon as possible after starting parenteral nutrition.
Give sodium and potassium in parenteral nutrition to maintain standard daily requirements, adjusted as necessary for the individual baby.
Be aware that even if the parenteral nutrition solution contains sodium and potassium, additional supplements of these electrolytes can be given using a separate intravenous infusion.
Give daily intravenous trace elements ideally from the outset, but as soon as possible after starting parenteral nutrition.
Give daily intravenous fat-soluble and water-soluble vitamins ideally from the outset, but as soon as possible after starting parenteral nutrition, to maintain standard daily requirements.
Give fat-soluble and water-soluble vitamins in the intravenous lipid emulsion to improve their stability.
When starting neonatal parenteral nutrition for preterm and term babies, use a standardised neonatal parenteral nutrition formulation ('standardised bag'). Note that this might be an off-label use as not all parenteral nutrition formulations have a UK marketing authorisation for this indication. See prescribing medicines at NICE website for more information.
Standardised bags should:
  • be formulated to allow delivery of parenteral nutrition (see recommendations on neonatal parenteral nutrition volume and constituents ).
  • be prepared following nationally agreed quality standards.
Continue with a standardised bag unless an individualised parenteral nutrition formulation is indicated, for example, if the baby has:
  • complex disorders associated with a fluid and electrolyte imbalance
  • renal failure.

Blood samples

When taking blood samples to monitor neonatal parenteral nutrition:
  • collect the minimum blood volume needed for the tests
  • use a protocol agreed with the local clinical laboratory to retrieve as much information as possible from the sample
  • coordinate the timing of blood tests to minimise the number of blood samples needed.

Blood glucose

Measure the blood glucose level:
  • 1 to 2 hours after first starting parenteral nutrition
  • 1 to 2 hours after each change of parenteral nutrition bag (usually every 24 or 48 hours).
Measure blood glucose more frequently if:
  • the preterm or term baby has previously had hypoglycaemia or hyperglycaemia
  • the dosage of intravenous glucose has been changed
  • there are clinical reasons for concern, for example, sepsis or seizures.

Blood pH, potassium, chloride and calcium

Measure the blood pH, potassium, chloride and calcium levels:
  • daily when starting and increasing parenteral nutrition
  • twice weekly after reaching a maintenance parenteral nutrition.
Measure blood pH, potassium, chloride or calcium more frequently if:
  • the preterm or term baby has previously had levels of these components outside the normal range
  • the dosages of intravenous potassium, chloride or calcium have been changed
  • there are clinical reasons for concern, for example, in critically ill babies.

Serum triglycerides

Measure serum triglycerides:
  • daily while increasing the parenteral nutrition lipid dosage
  • weekly after reaching a maintenance intravenous lipid dosage.
Measure serum triglycerides more frequently, but not more than once a day, if:
  • the level is elevated
  • the preterm or term baby is at risk of hypertriglyceridaemia, for example, if the baby is critically ill or has a lipaemic blood sample.
Be aware that ongoing serum triglyceride monitoring may not be needed for stable babies transitioning from parenteral nutrition to enteral nutrition.

Serum or plasma phosphate

Measure the serum or plasma phosphate level:
  • daily while increasing the parenteral nutrition phosphate dosage
  • weekly after reaching a maintenance intravenous phosphate dosage.
Measure liver function weekly in preterm and term babies on parenteral nutrition.
Measure liver function more frequently than weekly if there are clinical concerns or previous liver function test levels outside the normal range.
For all babies, take into account the following when deciding when to stop parenteral nutrition:
  • the baby's tolerance of enteral feeds
  • the amount of nutrition being delivered by enteral feeds (volume and composition)
  • the relative contribution of parenteral nutrition and enteral nutrition to the baby's total nutritional requirement
  • the likely benefit of the nutritional intake compared with the risk of venous catheter sepsis
  • the individual baby's particular circumstances, for example, a baby with complex needs such as short bowel syndrome, increased stoma losses or slow growth, may need long-term parenteral nutrition.
For preterm babies born at or after 28+0 weeks and term babies, consider stopping parenteral nutrition within 24 hours if the enteral feed volume tolerated is 120 to 140 ml/kg/day, taking into account the factors in the list above.

Glossary

Paths in this pathway

Pathway created: February 2020 Last updated: July 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

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