What are the guidelines for parenteral nutrition (PN) in a newborn with short gut syndrome?

Guidelines for Parenteral Nutrition in a Newborn with Short Gut Syndrome

Breast milk should be the enteral feed of first choice in newborns with short bowel syndrome, while parenteral nutrition should be tailored to support growth and minimize complications. 1

Initial Parenteral Nutrition Approach

• Individually tailored PN solutions should be used for newborns with short bowel syndrome as they cannot meet nutritional requirements with standard PN formulations due to abnormal fluid and electrolyte losses 1
• PN should be administered through a terminal filter: lipid emulsions through 1.2-1.5 μm filters and aqueous solutions through 0.22 μm filters 1
• PN solutions for premature newborns should be protected against light to prevent generation of oxidants 1
• Accurate flow control with infusion pumps is essential; the system should be under regular visual inspection 1

Fluid and Electrolyte Management

• For term neonates: 140-160 ml/kg/day of fluid with 2-3 mmol/kg/day of sodium, 1.5-3 mmol/kg/day of potassium, and 2-3 mmol/kg/day of chloride 1
• For preterm neonates >1500g: 140-160 ml/kg/day of fluid with 3-5 mmol/kg/day of sodium, 1-3 mmol/kg/day of potassium, and 3-5 mmol/kg/day of chloride 1
• For preterm neonates <1500g: 140-160 ml/kg/day of fluid with 3-5 mmol/kg/day of sodium, 2-5 mmol/kg/day of potassium, and 3-5 mmol/kg/day of chloride 1
• Tight assessment of body water balance and monitoring of serum electrolyte concentrations should be included in individualized protocols 1

Enteral Nutrition Introduction

• Complete enteral starvation should be avoided by giving some enteral feed whenever possible, even if only a minimal amount is tolerated 1
• In newborns with short bowel, expressed breast milk is the preferred option to optimize intestinal adaptation 1
• If breast milk is unavailable, start with elemental formula, then progress to extensively hydrolyzed and finally to polymeric feeds as tolerated 1
• Enteral feeds should be introduced as liquid feed infused continuously over 4-24 hours via feeding tube using a volumetric pump 1

Advancing Enteral Nutrition

• When increasing enteral feeds, only one change at a time should be made to assess tolerance 1
• Feed volumes must be increased cautiously according to tolerance, usually assessed by diarrheal stools/stoma output 1
• Enteral feeds should be given at normal concentrations (not diluted) 1
• PN should be reduced in proportion to, or slightly more than, the increase in enteral nutrition 1
• If a chosen weaning strategy fails, try again more slowly 1

Monitoring and Preventing Complications

• Risk of cholestasis is directly related to duration of PN 1
• The frequency of laboratory assessment should be based on patient's clinical condition (from once daily to 2-3 times per week) 1
• Small oral bolus feeds should be initiated as soon as possible to avoid oral hypersensitivity and feed aversion 1
• Continuous feeding improves enteral tolerance and weight gain in children with short bowel syndrome 1

Special Considerations

• Maternal expressed breast milk can be given either fresh (for small bolus feeds) or pasteurized (for continuous feeding) 1
• Donor milk may be available if maternal milk is not available 1
• There may be an increased incidence of cow milk or soya protein intolerance in newborns with short gut 1
• If vomiting or poor gastric emptying limits advancement of feed volumes, jejunal tube feeding can be considered, though this may worsen diarrhea in short bowel 1

Weaning from Parenteral Nutrition

• The overriding clinical priority is to establish enteral autonomy 1
• A reduction in PN may be attempted once the child is stabilized (intestinal losses minimized and optimal nutritional state reached) 1
• All children on PN should continue to have a minimum amount of enteral feed to maintain pancreatico-biliary secretion and promote gut mucosal integrity 1
• Solids should be started at the usual recommended age for healthy infants where possible, initially limiting to foods least likely to have allergenic effects 1