[en] Parenteral nutrition is used to treat children that cannot be fully fed by the enteral route. While the revised ESPGHAN/ESPEN/ESPR/CSPEN pediatric parenteral nutrition guidelines provide clear guidance on the use of parenteral nutrition in neonates, infants, and children based on current available evidence, they have helped to crystallize areas where research is lacking or more studies are needed in order to refine recommendations. This paper collates and discusses the research gaps identified by the authors of each section of the guidelines and considers each nutrient or group of nutrients in turn, together with aspects around delivery and organization. The 99 research priorities identified were then ranked in order of importance by clinicians and researchers working in the field using a survey methodology. The highest ranked priority was the need to understand the relationship between total energy intake, rapid catch-up growth, later metabolic function, and neurocognitive outcomes. Research into the optimal intakes of macronutrients needed in order to achieve optimal outcomes also featured prominently. Identifying research priorities in PN should enable research to be focussed on addressing key issues. Multicentre trials, better definition of exposure and outcome variables, and long-term metabolic and developmental follow-up will be key to achieving this. IMPACT: The recent ESPGHAN/ESPEN/ESPR/CSPEN guidelines for pediatric parenteral nutrition provided updated guidance for providing parenteral nutrition to infants and children, including recommendations for practice. However, in several areas there was a lack of evidence to guide practice, or research questions that remained unanswered. This paper summarizes the key priorities for research in pediatric parenteral nutrition, and ranks them in order of importance according to expert opinion.
Disciplines :
Pediatrics
Author, co-author :
Johnson, Mark J; Department of Neonatal Medicine, University Hospital Southampton NHS Trust, Southampton, UK. m.johnson@soton.ac.uk ; National Institute for Health Research Biomedical Research Centre Southampton, University Hospital Southampton NHS Trust and University of Southampton, Southampton, UK. m.johnson@soton.ac.uk
Lapillonne, Alexandre; Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, Paris University, Paris, France ; France and CNRC, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
Bronsky, Jiri; Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
Domellof, Magnus; Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
Embleton, Nicholas; Neonatal Unit, Newcastle University, Newcastle upon Tyne, UK ; Newcastle University, Newcastle Upon Tyne, UK
Iacobelli, Silvia; Department of Neonatal Intensive Care, CHU La Réunion, Saint Pierre, France
Joosten, Koen; Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
Kolacek, Sanja; Children's Hospital, University of Zagreb School of Medicine, Zagreb, Croatia
Mihatsch, Walter A; Department of Pediatrics Ulm University, Ulm, and Neu-Ulm University of Applies Sciences, Neu-Ulm, Germany
Moltu, Sissel J; Department of Neonatal Intensive Care, Oslo University Hospital, Oslo, Norway
Puntis, John W L; The General Infirmary at Leeds, Leeds, UK
Riskin, Arieh; Bnai Zion Medical Center, Rappaport Faculty of Medicine, Technion, Haifa, Israel
Shamir, Raanan; Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
Tabbers, Merit M; Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Emma Children's Hospital, Amsterdam, The Netherlands
Van Goudoever, Johannes B; Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Emma Children's Hospital, Amsterdam, The Netherlands
Saenz de Pipaon, Miguel; Department of Neonatology, La Paz University Hospital, Red De Salud Materno Infantil Y Desarrollo E Samid, Universidad Autonoma De Madrid, Madrid, Spain
ESPGHAN/ESPEN/ESPR/CSPEN Working Group on Pediatric Parenteral Nutrition
Senterre, Thibault ; Université de Liège - ULiège > Département des sciences de la santé publique
This study was supported by the Fundamental Research Funds of the State Key Laboratory of Ophthalmology, the National Nature Science Foundation in China (Grants No. 81300785; 81170865; 30901642).
Koletzko, B. et al. 1. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR). J. Pediatr. Gastroenterol. Nutr. 41(Suppl. 2), S1–87 (2005).
Mihatsch, W. A. et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition. Clin. Nutr. 37, 2303–2305 (2018). DOI: 10.1016/j.clnu.2018.05.029
Joosten, K. et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: energy. Clin. Nutr. 37, 2309–2314 (2018). DOI: 10.1016/j.clnu.2018.06.944
van Puffelen, E. et al. Early versus late parenteral nutrition in critically ill, term neonates: a preplanned secondary subgroup analysis of the PEPaNIC multicentre, randomised controlled trial. Lancet Child Adolesc. Health 2, 505–515 (2018). DOI: 10.1016/S2352-4642(18)30131-7
Vanhorebeek, I. et al. Effect of early supplemental parenteral nutrition in the paediatric ICU: a preplanned observational study of post-randomisation treatments in the PEPaNIC trial. Lancet Respir. Med 5, 475–483 (2017). DOI: 10.1016/S2213-2600(17)30186-8
Correani, A. et al. Oxygen saturation (SpO2) to fraction of inspired oxygen (FiO2) ratio in preterm infants on routine parenteral nutrition with conventional or fish oil containing lipid emulsions. Pediatr Pulmonol. 9, 2377-2382 (2020).
Lapillonne, A. et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Lipids. Clin. Nutr. 37, 2324–2336 (2018). DOI: 10.1016/j.clnu.2018.06.946
Jochum, F. et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: fluid and electrolytes. Clin. Nutr. 37, 2344–2353 (2018). DOI: 10.1016/j.clnu.2018.06.948
Sulyok, E. Physical water compartments: a revised concept of perinatal body water physiology. Physiol. Res. 55, 133–138 (2006).
Hartnoll, G., Betremieux, P. & Modi, N. Body water content of extremely preterm infants at birth. Arch. Dis. Child Fetal Neonatal Ed. 83, F56–59 (2000). DOI: 10.1136/fn.83.1.F56
Foster, B. A., Tom, D. & Hill, V. Hypotonic versus isotonic fluids in hospitalized children: a systematic review and meta-analysis. J. Pediatr. 165, 163–169 (2014). e162. DOI: 10.1016/j.jpeds.2014.01.040
McNab, S. et al. 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial. Lancet 385, 1190–1197 (2015). DOI: 10.1016/S0140-6736(14)61459-8
McNab, S. et al. Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children. Cochrane Database Syst. Rev. 18, CD009457 (2014).
Ingvaldsen B. Væske, elektrolytter, blodgasser og infusjonsterapi (2019).
Bronsky, J. et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Vitamins. Clin. Nutr. 37, 2366–2378 (2018). DOI: 10.1016/j.clnu.2018.06.951
Marino, L. V., Valla, F. V., Beattie, R. M. & Verbruggen, S. C. A. T. Micronutrient status during paediatric critical illness: a scoping review. Clin. Nutr. 39, 3571-3593(2020).
Hartman, C. et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: complications. Clin. Nutr. 37, 2418–2429 (2018). DOI: 10.1016/j.clnu.2018.06.956
Stout, S. M. & Cober, M. P. Metabolic effects of cyclic parenteral nutrition infusion in adults and children. Nutr. Clin. Pr. 25, 277–281 (2010). DOI: 10.1177/0884533610368701
Nghiem-Rao, T. H. et al. Risks and benefits of prophylactic cyclic parenteral nutrition in surgical neonates. Nutr. Clin. Pract. 28, 745–752 (2013). DOI: 10.1177/0884533613502813
Lacaille, F. et al. Intestinal failure-associated liver disease: a position paper of the ESPGHAN Working Group of Intestinal Failure and Intestinal Transplantation. J. Pediatr. Gastroenterol. Nutr. 60, 272–283 (2015). DOI: 10.1097/MPG.0000000000000586
Mutanen, A. et al. Persistent abnormal liver fibrosis after weaning off parenteral nutrition in pediatric intestinal failure. Hepatology 58, 729–738 (2013). DOI: 10.1002/hep.26360
Burroughs, A. K. & Thalheimer, U. Hepatic venous pressure gradient in 2010: optimal measurement is key. Hepatology 51, 1894–1896 (2010). DOI: 10.1002/hep.23710
Castera, L., Pinzani, M. & Bosch, J. Non invasive evaluation of portal hypertension using transient elastography. J. Hepatol. 56, 696–703 (2012). DOI: 10.1016/j.jhep.2011.07.005
Gutierrez, I. M. et al. Risk factors for small bowel bacterial overgrowth and diagnostic yield of duodenal aspirates in children with intestinal failure: a retrospective review. J. Pediatr. Surg. 47, 1150–1154 (2012). DOI: 10.1016/j.jpedsurg.2012.03.019
Wang, R. F., Cao, W. W. & Cerniglia, C. E. PCR detection and quantitation of predominant anaerobic bacteria in human and animal fecal samples. Appl. Environ. Microbiol. 62, 1242–1247 (1996). DOI: 10.1128/aem.62.4.1242-1247.1996
Parker, P., Stroop, S. & Greene, H. A controlled comparison of continuous versus intermittent feeding in the treatment of infants with intestinal disease. J. Pediatr. 99, 360–364 (1981). DOI: 10.1016/S0022-3476(81)80318-6
Nagelkerke, S. C. J. et al. Standardized and individualized parenteral nutrition mixtures in a pediatric home parenteral nutrition population. J. Pediatr. Gastroenterol. Nutr. 70, 269–274 (2020). DOI: 10.1097/MPG.0000000000002528
Hay, W. W. & Thureen, P. Protein for preterm infants: how much is needed? How much is enough? How much is too much? Pediatr. Neonatol. 51, 198–207 (2010). DOI: 10.1016/S1875-9572(10)60039-3
Morgan, C. & Burgess, L. High protein intake does not prevent low plasma levels of conditionally essential amino acids in very preterm infants receiving parenteral nutrition. JPEN J. Parenter. Enter. Nutr. 41, 455–462 (2017). DOI: 10.1177/0148607115594009
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