28 Questions
What was the range of initial AA doses studied in the clinical trials?
0.5-1 g/kg/day
Which measurement tool was most commonly used in trials to evaluate neurodevelopment?
BSID, 2nd and 3rd editions
What is the recommended daily advancement of ILE to improve growth outcomes?
3 g/kg/day
What is the primary concern regarding ILE composition?
Providing sufficient fatty acids
What was the maximum target dose range studied for AA?
3-4 g/kg/day
What was the outcome of the single trial that showed an association between higher AA doses and lower BSID scores?
Lower scores at 18 months' corrected age
What is the quality of evidence for the recommendation on ILE dose?
Very low
What is the strength of recommendation for parenteral AA dosing?
Strong
What is the highest maximum dose of ILE studied in the clinical trials?
3.8 g/kg/day
What was the outcome of the single study that showed an association between higher starting ILE dose and postnatal weight loss?
Smaller postnatal weight loss
What is the main objective of parenteral nutrition in preterm infants?
To provide nutrition until enteral nutrition can meet their needs
How many questions about parenteral nutrition did the interdisciplinary committee aim to answer?
12
What was the time frame for the citations reviewed by the committee?
2001-2023
What was the primary outcome of interest in the clinical trials evaluated by the committee?
PNALD and early childhood growth
What was the finding regarding multicomponent oil ILE compared to ILE containing 100% soybean oil?
A reduction in stage 3 or higher retinopathy of prematurity
What was the quality of evidence for most questions evaluated by the committee?
Very low
What is the recommended next step to improve future guidelines on PN in preterm infants?
Standardize outcome definitions to permit statistical conflation of data
Which of the following groups of preterm infants were excluded from the study?
All of the above
What is the primary rationale for recommending prompt initiation of PN in preterm infants?
To account for the endogenous capacity to metabolize parenteral nutrients
What is the recommended maximum initial dose of parenteral AA in preterm infants?
3.5 g/kg/day
What is the main concern regarding higher doses of parenteral AA in preterm infants?
Increased risk of sepsis
What is the recommended minimum target dose of parenteral AA in preterm infants?
3 g/kg/day
What is the primary reason for not recommending AA doses exceeding 3.5 g/kg/day?
Lack of improvement in growth outcomes
According to the recommendation, what is the goal of providing parenteral AA in preterm infants?
To promote growth outcomes
What is the quality of evidence for the recommendation on the timing of PN initiation in preterm infants?
Very low
What is the strength of recommendation for the prompt initiation of PN in preterm infants?
Strong
What is the primary concern regarding the delay in PN initiation in preterm infants?
Protein and total energy deficits
Why is it recommended to initiate PN promptly after birth in preterm infants?
To account for the rapid accrual of protein and total energy deficits
Study Notes
Parenteral Nutrition in Preterm Infants
- Parenteral nutrition (PN) is prescribed for preterm infants until nutrition needs are met via the enteral route, but there are unanswered questions regarding PN best practices in this population.
- An interdisciplinary committee was assembled to answer 12 questions concerning the provision of PN to preterm infants, using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process.
Timing of PN Initiation
- The committee recommends prompt initiation of PN after birth as soon as appropriate vascular access is obtained, despite the very low quality of evidence.
- The rationale for this recommendation is based on the endogenous capacity to metabolize parenteral nutrients and the rapid accrual of protein and total energy deficits after birth in preterm infants.
Parenteral Amino Acid (AA) Doses
- The committee recommends against an initial dose of >3 g/kg/day of parenteral AA, due to the increased rate of sepsis in infants who were prescribed an initiating AA dose of 3.5 g/kg/day.
- The committee recommends providing parenteral AA at a minimum of 3 g/kg/day and not exceeding 3.5 g/kg/day, considering growth outcomes as well as neurodevelopmental outcomes associated with AA dose.
Parenteral AA Doses and Neurodevelopmental Outcomes
- The committee recommends providing parenteral AA doses at a minimum of 3 g/kg/day without increasing beyond 3.5 g/kg/day, due to the limited evidence distinguishing any benefit in neurodevelopmental outcomes.
- There is a suggestion that exceeding 3.5 g/kg/day may not be without harm, based on the risk difference (RD) of cerebral palsy and the directional consistency between study outcomes in favor of lower AA doses.
Lipid Injectable Emulsion (ILE) Composition and Doses
- The committee recommends daily advancement of ILE to a dose of 3 g/kg/day if using SO-ILE or multicomponent ILE, to improve growth outcomes.
- The committee strongly emphasizes the need for attention to ILE composition when making decisions on ILE dose to ensure the provision of sufficient fatty acids for the prevention of essential fatty acid deficiency (EFAD).
Multicomponent Oil ILE and Retinopathy of Prematurity (ROP)
- A multicomponent oil ILE was associated with a reduction in stage 3 or higher retinopathy of prematurity (ROP) compared to an ILE containing 100% soybean oil.
This quiz assesses knowledge of amino acid doses and their impact on neurodevelopment in clinical trials. Questions cover dose ranges, measurement tools, and growth outcomes.
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