Assessment of the Adherence to ESPGHAN 2018 Guidelines in the Neonatal Intensive Care Unit of the Ghent University Hospital: A Retrospective Study

Abstract

Parenteral nutrition (PN) is a standard of care for preterm infants in the first postnatal days. The European Society of Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) has updated their guideline recommendations on PN in 2018. However, data on actual 2018 guideline adherence in clinical practice are sparse. In this retrospective study, conducted at the neonatal intensive care unit (NICU) of Ghent University Hospital, we analyzed the ESPGHAN 2018 PN guideline adherence and growth for 86 neonates admitted to the NICU. Analyses were stratified by birth weight (<1000 g, 1000 to <1500 g, ≥1500 g). We documented the provisions for enteral nutrition (EN) and PN, and we tested the combined EN and PN provisions for ESPGHAN 2018 adherence. The nutrition protocols showed a high adherence to PN guidelines in terms of carbohydrate provisions, yet lipid provisions for EN and PN often exceeded the recommended maximum of 4 g/kg/d; although, PN lipid intakes maxed out at 3.6 g/kg/d. Protein provisions tended to fall below the recommended minimum of 2.5 g/kg/d for preterm infants and 1.5 g/kg/d for term neonates. The energy provisions also tended to fall below the minimum recommendations, especially for neonates with a birth weight (BW) < 1000 g. Over a mean PN duration of 17.1 ± 11.4 d, the median weekly Fenton Z-scores changes for length, weight, and head circumference were positive for all BW groups. Future studies have to assess how protocols adapt to current guidelines, and how this affects short- and long-term growth across different BW groups. In conclusion, the reported findings provide real-world evidence regarding the effect of ESPGHAN 2018 PN guideline adherence, and they demonstrate how standardized neonatal PN solutions can safeguard stable growth during NICU stays.

Keywords: enteral nutrition; guideline recommendations; neonates; parenteral nutrition; practice patterns; premature birth.

Figure 1

Reason for initiation of parenteral nutrition. Patient numbers are shown on the right.

Figure 2

Weekly changes in Z-scores. Z-scores for (A) weight and age, (B) length and age, and (C) head circumference and age were calculated using Fenton growth charts [25]. * p < 0.05.

Figure 3

Adherence to ESPGHAN 2018 guideline recommendations, with regard to carbohydrate provisions [14], over time. The total carbohydrate provisions, both for enteral and parenteral nutrition (PN), were used to assess adherence; the mean volume percentage for PN, with regard to glucose provisions, is shown on top. The colors indicate if the provisions fell below the recommended minimum intake, exceeded the maximum intake, or if they were in range. The numbers inside the bars show patient numbers. Adherence was assessed for three birth weight groups: (A) <1000 g, (B) 1000 to <1500 g, and (C) ≥1500 g.

Figure 4

Adherence to ESPGHAN 2018 guideline recommendations, with regard to lipid provisions, [15] over time. The total lipid provisions, for both enteral and parenteral nutrition (PN), were used to assess adherence; the mean volume percentage of PN, with regard to lipid provisions, is shown on top. The colors indicate if the provisions exceeded the recommended maximum intake or if they were in range of 0–4 g/kg/d. Numbers inside the bars show patient numbers. Adherence was assessed for three birth weight groups: (A) <1000 g, (B) 1000 to <1500 g, and (C) ≥1500 g.

Figure 5

Adherence to ESPGHAN 2018 guideline recommendations, with regard to amino acid provisions [16], over time. The total amino acid provisions, for both enteral and parenteral nutrition (PN), were used to assess adherence; the mean volume percentage of PN, with regard to amino acid provisions, is shown on top. The colors indicate if the provisions fell below the recommended minimum intake, exceeded the maximum, or if they were in range. Insufficient and sufficient energy refers to the intake of non-protein energy. Numbers inside the bars show patient numbers. Adherence was assessed for three birth weight groups: (A) <1000 g, (B) 1000 to <1500 g, and (C) ≥1500 g.

Figure 6

Adherence to ESPGHAN 2018 guideline recommendations, with regard to energy provisions [13], over time. The total energy provisions, for both enteral and parenteral nutrition (PN), were used to assess adherence; the mean volume percentage of PN, with regard to energy provisions, is shown on top. The colors indicate if the provision fell below the recommended minimum intake, exceeded the maximum, or if they were in range. Numbers inside the bars show patient numbers. Adherence was assessed for three birth weight groups: (A) <1000 g, (B) 1000 to <1500 g, and (C) ≥1500 g.