Early versus late parenteral nutrition for preterm infants
Febrero 2022
Early versus late parenteral nutrition for preterm infants
Two studies from the same group investigate the balance of risks and benefits of early parenteral nutrition for preterm infants. Trials in older children and adults suggest that there may be harms from early use in critically ill patients, but preterm infants are in a very different nutritional position and are often not critically ill.
Both studies analysed routinely collected data from England and Wales, extracted from the UK National Neonatal Research Database. James Webbe et al looked at infants born at 30–32+6 weeks in 2012–17. With reasonable exclusion criteria they defined parenteral nutrition as early if any was given in the first 7 days. Infants who received early parenteral nutrition were compared using propensity matching to those who received no parenteral nutrition. There were around 35 000 infants included in matched pairs. Early parenteral nutrition was associated with slightly higher survival to hospital discharge (absolute difference 0.91%–95% CI 0.53% to 1.3%, but higher absolute rates of complications that might affect later outcome, such as NEC (4.6%), BPD (3.9)%, late onset sepsis (1.5%). Sabita Uthaya et al studied infants <31 weeks’ gestation, defining early parenteral nutrition as having been given in the first two postnatal days and later parenteral nutrition as having been given after this.
They too used propensity matching and studied around 16.000 infants born in 2008–19. They found no difference in their primary outcome of survival to discharge without major morbidity. As in the study by James Webbe et al, they found higher survival to discharge associated with earlier parenteral nutrition (absolute difference 3.25%, 95% CI 2.68% to 3.82%). Again, they found that early parenteral nutrition was associated with some small increases in absolute rates of morbidities that might affect later outcome, including BPD (1.24%), late onset sepsis (0.84%), ROP treatment 0.5%. These observational studies cannot direct practice, but they are helpful because they highlight an area where there is variation in practice that may have important effects on life outcomes. They show that differences between approaches are not so large as to be obvious anecdotally in day to day care and should support clinicians and families in having the equipoise to allow large scale randomised trials. There is an accompanying editorial by Mark Johnson that gives further explanation of the difference of this situation to that in older children and adults and the need for careful selection of the right comparisons for future studies.