The Journal of Nutrition Supplement: Achieving Optimal Growth in Preterm Infants and Children Commercially Premixed 3-Chamber Bags for Pediatric Parenteral Nutrition Are Available for Hospitalized Children

Hospitalized children are vulnerable to malnutrition during serious illness or recovery from injury and are at subsequent risk of increased morbidity and growth retardation. In cases in which enteral nutrition is not possible, parenteral nutrition (PN) can be used to ensure that patients at nutritional risk receive appropriate amounts ofmacroandmicronutrients. Nutritional needs cannot be met by 1 standard PN formulation in pediatric patients (term to 18 y) because of the wide range of needs according to age, weight, degree of maturity, and disease state. Preparation of individualized PN is associatedwith several limitations, including prescribing errors, stability issues, and risk of infection. These risks may be avoided by the availability of a range of pediatric PN formulations provided as commercial premixed 3-chamber bags (3-CBs). These 3-CBs were developed in conjunction with experienced neonatologists and pediatricians in accordance with international guidelines. A prospective study has previously shown the practical handling and ease of use of 2 formulations of these 3-CBs, 1 designed for term infants and toddlers up to 2 y of age and 1 for children and adolescents aged 2–18 y. The majority of pharmacists and nurses described the 3-CB as easy to use and favored it over individual bottles, bags compounded on the ward, ready-to-use compounded bags, and premixes prepared by the pharmacy and tailored to patient needs. These formulations offer a means of improving the quality of care in hospital pediatric units, particularly in the absence of a nutrition support team. J. Nutr. 143: 2071S–2076S, 2013. Malnutrition in Hospitalized Infants and Children and the Need for Nutritional Support Despite advances in many areas of pediatric medicine, studies from Europe and the United States still demonstrate a malnutrition prevalence of 6–32% among hospitalized pediatric patients, with little change in rates over the past 2 decades (1–3). Nutritional status may deteriorate and malnutrition may develop in hospitalized patients, with potentially serious consequences, including increased risk of adverse clinical events and longer hospital stays, which lead to additional health care costs (4–6). Malnutrition in children can have a significant impact on growth, as well as increasing susceptibility to infection (6). Therefore, assessment of nutritional risk in addition to nutritional status at time of admission is important. A study investigating the use of a scoring system to evaluate the risk of nutritional depletion in hospitalized pediatric patients showed that nutritional risk is related to both the underlying disease (which may increase the protein-calorie demand) and other factors (e.g., pain) that impair oral feeding and digestive tolerance (6). Short-term goals for nutrition support in sick children include obtaining linear or catch-up growth and body composition similar to age-matched children as well as maximizing long-term growth and neurodevelopment (7). Critically ill children in pediatric intensive care units (PICUs) are at particularly high risk of developing malnutrition, which is 2 The cited studies by Colomb et al. 2012 (36) and Rigo et al. 2012 (25) were funded by Baxter Healthcare Corporation. Medical writing services from Gardiner-Caldwell Communications were funded by Baxter Healthcare Corporation. 3 Author disclosures: V. Colomb was a member of an advisory panel for Baxter Healthcare. 4 Abbreviations used: ESPGHAN, European Society of Paediatric Gastroenterology, Hepatology, and Nutrition; NST, nutrition support team; PICU, pediatric intensive care unit; PN, parenteral nutrition; 3-CB, 3-chamber bag. 1 Presented at the 4th Congress of the European Academy of Paediatric Societies (EAPS) conference, held in Istanbul, Turkey, 5 October 2012. The symposium was sponsored by Baxter Healthcare International. The views expressed in these papers are not necessarily those of the Supplement Coordinator or Guest Editors. The Supplement Coordinator for this supplement was Louise Profit, Gardiner-Caldwell Communications. Supplement Coordinator disclosures: Louise Profit is an employee of Gardiner-Caldwell Communications, a medical communications company that received financial remuneration from Baxter Healthcare for coordination of the supplement, medical editing, and medical writing support. This supplement is the responsibility of the Guest Editor to whom the Editor of The Journal of Nutrition has delegated supervision of both technical conformity to the published regulations of The Journal of Nutrition and general oversight of the scientific merit of each article. The Guest Editor for this supplement was Harry Dawson. Guest Editor disclosure: Harry Dawson had no conflicts to disclose. Publication costs for this supplement were defrayed in part by the payment of page charges. This publication must therefore be hereby marked "advertisement" in accordance with 18 USC section 1734 solely to indicate this fact. The opinions expressed in this publication are those of the authors and are not attributable to the sponsors or the publisher, Editor, or Editorial Board of The Journal of Nutrition. * To whom correspondence should be addressed. E-mail: [email protected]. ã 2013 American Society for Nutrition. Manuscript received March 6, 2013. Initial review completed May 17, 2013. Revision accepted September 11, 2013. 2071S First published online October 9, 2013; doi:10.3945/jn.113.176974. by gest on O cber 4, 2017 jn.nition.org D ow nladed fom considered a ‘‘second disease’’ and has been associated with increased morbidity and mortality (8–10). A study in infants undergoing cardiac surgery suggested that a low energy intake had an adverse effect on clinical outcomes, including increased duration of artificial ventilation, time to chest closure, and length of stay in the PICU and hospital (11). Nutritional support in critically ill children should aim to prevent catabolism as well as avoid overfeeding (3). Although optimizing nutritional condition in critically ill children may positively affect clinical outcomes (10), nutritional intake in this population is often inadequate and fails to meet target levels of protein and energy (3,10,12). However, the optimal form and timing of nutritional support for children in the PICU are still a matter of debate, with more research urgently needed (13), and there are no clear evidence-based guidelines on nutrition for this patient population. Indications for Parenteral Nutrition Parenteral nutrition (PN) is indicated for pediatric patients who cannot be fully fed by the oral or enteral route and are therefore at risk of malnutrition, in accordance with international guidelines for pediatric patients provided by the European Society for Clinical Nutrition and Metabolism and the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) (14). Common indications for pediatric PN include all causes of intestinal failure (e.g., small bowel syndrome), severe malnutrition or failure to thrive associated with an inability to tolerate oral or nasogastric feeds, as well as other clinical scenarios in which the child is expected to receive nothing enterally for > 5 to 7 days (e.g., some critically ill patients) (7). Although PN can be life-saving, its use is associated with complications, including infection, other catheter-related complications, metabolic disorders, essential fatty acid deficiency, metabolic bone disease, and PN-associated cholestasis (7). Use of Individualized PN in Pediatric Patients As in adults, PN in the pediatric population may be provided as individualized or standardized formulations. The need for individualized PN is theoretically greater in pediatric patients (term to 18 y) than in preterm infants and adult patients because of the wide range of weights, degree of maturity and related changes, as well as variation in the specific conditions warranting PN; a single standard formulation would therefore be inadequate for all children (15). Optimal individualized PN requires prescription by an experienced physician (16,17), compounding by trained pharmacy technicians following strict pharmaceutical rules (18), and delivery in the ward according to the expert guidelines. The ESPGHAN guidelines recommend the presence of a multidisciplinary nutritional support team (NST), including a senior pediatrician knowledgeable in nutrition, a dietician/nutritionist, a nurse, and, if possible, a pharmacist to improve the nutritional management of children in pediatric units (19). Individualized PN can be prepared either by automated or manual compounding in the hospital pharmacy (20). These resources are available in academic medical centers that specialize in children with rare digestive diseases such as short bowel syndrome, which is responsible for chronic intestinal failure (21). These patients receive long-term PN, often started at the hospital and then administered at home and are generally provided with a PN formulation prescribed according to individual needs by an expert physician and compounded in a specialized pharmacy unit (22,23). However, the majority of hospitals lack NSTs and pharmacies equipped for appropriate PN compounding. Therefore, nonexpert or junior physicians in Europe often prescribe PN admixtures that are manually prepared by the nurses in the ward without any pharmaceutical controls (e.g., glucose concentration, osmolarity, and calcium and phosphate ratio and concentrations). This can lead to quantitative errors due to poor estimation of the patient s needs (lack or excess) and to qualitative errors, such as inadequate ratios between glucose and lipids, energy and nitrogen, and calcium and phosphate (16). Such errors may impair the patient s nutritional and metabolic status. Other problems related to nonexpert prescription and compounding in the ward include the following: stability issues with the admixture (e.g., effect of storage temperature); risk of incompatibility with additions such as minerals, which may present clinical safety issues (e.g., presence of calcium phosphate precipitate) (24,25); microbial contamination and bloodstream infections (26,27); and mixing errors (28,29). Several recent retrospective studies showed that the rate of bloodstream infections was significantly lower in critically ill patients given standardized PN in the form of premixed multichamber bags than those given compounded PN (26,27,30). For these reasons, the American Society for Parenteral and Enteral Nutrition recommends using standardized processes for PN management, which may include the use of standardized PN formulations suitable for selected patient populations, prescribed by clinicians with expertise in nutrition support therapy (31). Preparation of PN also represents a major care burden to staff, with high costs. A cost analysis of neonatal and pediatric nutrition in Europe demonstrated that PN costs differed between countries, with a large proportion of total costs related to staff time; wages accounted for 20–43% of the cost of compounding PN in infants and children across 4 countries (32). A U.S.-based study in adults showed that multichamber bag PN was associated with significantly lower costs than compounded PN with regard to both PN acquisition and potential avoidance of bloodstream infections, resulting in substantial savings (;$770 per patient eligible for standardized premixed PN) (33). The use of standardized PN formulations therefore has advantages in efficiency, economy, and clinical appropriateness compared with individualized PN formulations in selected patient populations (34). Commercially Premixed Standardized PN Adult standardized formulations are not nutritionally adequate for children. Until recently, only a few standardized PN formulations were available for children and, to our knowledge, none as 3-chamber bags (3-CBs). The need for a range of pediatric standard formulations has been addressed by commercially premixed 3-CBs, which are available in 2 different formulations (Baxter Healthcare Numeta SmPc 2011): 1 designed for term infants and toddlers up to 2 y of age (G16%E) and another designed for children and adolescents from 2 to 18 y of age (G19%E). One formulation designed for preterm infants weighing <1500 g (G13%E) is currently unavailable (Table 1). These PN formulations were developed in conjunction with expert neonatologists and pediatricians in accordance with international (European Society for Clinical Nutrition and Metabolism and ESPGHAN) guidelines for pediatric patients (14). Each 3-CB, regardless of formulation, includes compartments for lipids, amino acids with electrolytes, and glucose, with optional activation of the lipid chamber. If lipid administration is undesirable, 2072S Supplement by gest on O cber 4, 2017 jn.nition.org D ow nladed fom