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Early versus late parenteral nutrition for critically ill term and late preterm infants.
Cochrane Database Syst Rev. 2020 04 08; 4:CD013141.CD

Abstract

BACKGROUND

Recently conducted randomised controlled trials (RCTs) suggest that late commencement of parenteral nutrition (PN) may have clinical benefits in critically ill adults and children. However, there is currently limited evidence regarding the optimal timing of commencement of PN in critically ill term and late preterm infants.

OBJECTIVES

To evaluate the benefits and safety of early versus late PN in critically ill term and late preterm infants.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (5 April 2019), MEDLINE Ovid (1966 to 5 April 2019), Embase Ovid (1980 to 5 April 2019), EMCare (1995 to 5 April 2019) and MEDLINE via PubMed (1966 to 5 April 2019). We searched for ongoing or recently completed clinical trials, and also searched the grey literature and reference lists of relevant publications.

SELECTION CRITERIA

We included RCTs comparing early versus late initiation of PN in term and late preterm infants. We defined early PN as commencing within 72 hours of admission, and late PN as commencing after 72 hours of admission. Infants born at 37 weeks' gestation or more were defined as term, and infants born between 34 and 36+6 weeks' gestation were defined as late preterm.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials, extracted the data and assessed the risk of bias. Treatment effects were expressed using risk ratio (RR) and risk difference (RD) for dichotomous outcomes and mean difference (MD) for continuous data. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

Two RCTs were eligible for inclusion. Data were only available from a subgroup (including 209 term infants) from one RCT in children (aged from birth to 17 years) conducted in Belgium, the Netherlands and Canada. In that RCT, children with medium to high risk of malnutrition were included if a stay of 24 hours or more in the paediatric intensive care unit (PICU) was expected. Early PN and late PN were defined as initiation of PN within 24 hours and after day 7 of admission to PICU, respectively. The risk of bias for the study was considered to be low for five domains and high for two domains. The subgroup of term infants that received late PN had significantly lower risk of in-hospital all-cause mortality (RR 0.35, 95% confidence interval (CI) 0.14 to 0.87; RD -0.10, 95% CI -0.18 to -0.02; number needed to treat for an additional beneficial outcome (NNTB) = 10; 1 trial, 209 participants) and neonatal mortality (death from any cause in the first 28 days since birth) (RR 0.29, 95% CI 0.10 to 0.88; RD -0.09, 95% CI -0.16 to -0.01; NNTB = 11; 1 trial, 209 participants). There were no significant differences in rates of healthcare-associated blood stream infections, growth parameters and duration of hospital stay between the two groups. Neurodevelopmental outcomes were not reported. The quality of evidence was considered to be low for all outcomes, due to imprecision (owing to the small sample size and wide confidence intervals) and high risk of bias in the included studies.

AUTHORS' CONCLUSIONS

Whilst late commencement of PN in term and late preterm infants may have some benefits, the quality of the evidence was low and hence our confidence in the results is limited. Adequately powered RCTs, which evaluate short-term as well as long-term neurodevelopmental outcomes, are needed.

Authors+Show Affiliations

Perth Children's Hospital, Pharmacy Department, Perth, Australia. The University of Western Australia, Centre for Neonatal Research and Education, Medical School, Perth, Australia.The University of Western Australia, Centre for Neonatal Research and Education, Medical School, Perth, Australia. Perth Children's Hospital and King Edward Memorial Hospital for Women, Department of Neonatology, Subiaco, Australia.University of Newcastle, Newcastle Upon Tyne, UK.The University of Western Australia, Centre for Neonatal Research and Education, Medical School, Perth, Australia. Perth Children's Hospital and King Edward Memorial Hospital for Women, Department of Neonatology, Subiaco, Australia.

Pub Type(s)

Journal Article
Meta-Analysis
Research Support, Non-U.S. Gov't
Systematic Review

Language

eng

PubMed ID

32266712

Citation

Moon, Kwi, et al. "Early Versus Late Parenteral Nutrition for Critically Ill Term and Late Preterm Infants." The Cochrane Database of Systematic Reviews, vol. 4, 2020, p. CD013141.
Moon K, Athalye-Jape GK, Rao U, et al. Early versus late parenteral nutrition for critically ill term and late preterm infants. Cochrane Database Syst Rev. 2020;4:CD013141.
Moon, K., Athalye-Jape, G. K., Rao, U., & Rao, S. C. (2020). Early versus late parenteral nutrition for critically ill term and late preterm infants. The Cochrane Database of Systematic Reviews, 4, CD013141. https://doi.org/10.1002/14651858.CD013141.pub2
Moon K, et al. Early Versus Late Parenteral Nutrition for Critically Ill Term and Late Preterm Infants. Cochrane Database Syst Rev. 2020 04 8;4:CD013141. PubMed PMID: 32266712.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Early versus late parenteral nutrition for critically ill term and late preterm infants. AU - Moon,Kwi, AU - Athalye-Jape,Gayatri K, AU - Rao,Uday, AU - Rao,Shripada C, Y1 - 2020/04/08/ PY - 2020/4/9/entrez PY - 2020/4/9/pubmed PY - 2020/8/21/medline SP - CD013141 EP - CD013141 JF - The Cochrane database of systematic reviews JO - Cochrane Database Syst Rev VL - 4 N2 - BACKGROUND: Recently conducted randomised controlled trials (RCTs) suggest that late commencement of parenteral nutrition (PN) may have clinical benefits in critically ill adults and children. However, there is currently limited evidence regarding the optimal timing of commencement of PN in critically ill term and late preterm infants. OBJECTIVES: To evaluate the benefits and safety of early versus late PN in critically ill term and late preterm infants. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (5 April 2019), MEDLINE Ovid (1966 to 5 April 2019), Embase Ovid (1980 to 5 April 2019), EMCare (1995 to 5 April 2019) and MEDLINE via PubMed (1966 to 5 April 2019). We searched for ongoing or recently completed clinical trials, and also searched the grey literature and reference lists of relevant publications. SELECTION CRITERIA: We included RCTs comparing early versus late initiation of PN in term and late preterm infants. We defined early PN as commencing within 72 hours of admission, and late PN as commencing after 72 hours of admission. Infants born at 37 weeks' gestation or more were defined as term, and infants born between 34 and 36+6 weeks' gestation were defined as late preterm. DATA COLLECTION AND ANALYSIS: Two review authors independently selected the trials, extracted the data and assessed the risk of bias. Treatment effects were expressed using risk ratio (RR) and risk difference (RD) for dichotomous outcomes and mean difference (MD) for continuous data. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: Two RCTs were eligible for inclusion. Data were only available from a subgroup (including 209 term infants) from one RCT in children (aged from birth to 17 years) conducted in Belgium, the Netherlands and Canada. In that RCT, children with medium to high risk of malnutrition were included if a stay of 24 hours or more in the paediatric intensive care unit (PICU) was expected. Early PN and late PN were defined as initiation of PN within 24 hours and after day 7 of admission to PICU, respectively. The risk of bias for the study was considered to be low for five domains and high for two domains. The subgroup of term infants that received late PN had significantly lower risk of in-hospital all-cause mortality (RR 0.35, 95% confidence interval (CI) 0.14 to 0.87; RD -0.10, 95% CI -0.18 to -0.02; number needed to treat for an additional beneficial outcome (NNTB) = 10; 1 trial, 209 participants) and neonatal mortality (death from any cause in the first 28 days since birth) (RR 0.29, 95% CI 0.10 to 0.88; RD -0.09, 95% CI -0.16 to -0.01; NNTB = 11; 1 trial, 209 participants). There were no significant differences in rates of healthcare-associated blood stream infections, growth parameters and duration of hospital stay between the two groups. Neurodevelopmental outcomes were not reported. The quality of evidence was considered to be low for all outcomes, due to imprecision (owing to the small sample size and wide confidence intervals) and high risk of bias in the included studies. AUTHORS' CONCLUSIONS: Whilst late commencement of PN in term and late preterm infants may have some benefits, the quality of the evidence was low and hence our confidence in the results is limited. Adequately powered RCTs, which evaluate short-term as well as long-term neurodevelopmental outcomes, are needed. SN - 1469-493X UR - https://www.unboundmedicine.com/medline/citation/32266712/Early_versus_late_parenteral_nutrition_for_critically_ill_term_and_late_preterm_infants_ L2 - https://doi.org/10.1002/14651858.CD013141.pub2 DB - PRIME DP - Unbound Medicine ER -