Nutrition in Clinical Practice http://ncp.sagepub.com/
Evaluation of Parenteral Nutrition−Associated Liver Disease in Infants With Necrotizing Enterocolitis Before and After the Implementation of Feeding Guidelines Emma M. Tillman, Johanna L. Norman, Eunice Y. Huang, Linda F. Lazar and Catherine M. Crill Nutr Clin Pract 2014 29: 234 originally published online 25 February 2014 DOI: 10.1177/0884533614522834 The online version of this article can be found at: http://ncp.sagepub.com/content/29/2/234
Published by: http://www.sagepublications.com
On behalf of:
The American Society for Parenteral & Enteral Nutrition
Additional services and information for Nutrition in Clinical Practice can be found at: Email Alerts: http://ncp.sagepub.com/cgi/alerts Subscriptions: http://ncp.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
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522834
research-article2014
NCPXXX10.1177/0884533614522834Nutrition in Clinical PracticeTillman et al
Clinical Research
Evaluation of Parenteral Nutrition–Associated Liver Disease in Infants With Necrotizing Enterocolitis Before and After the Implementation of Feeding Guidelines
Nutrition in Clinical Practice Volume 29 Number 2 April 2014 234–237 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614522834 ncp.sagepub.com hosted at online.sagepub.com
Emma M. Tillman, PhD, PharmD1,2; Johanna L. Norman, PharmD1; Eunice Y. Huang, MD2,3; Linda F. Lazar, MD2,4; and Catherine M. Crill, PharmD1,2,4
Abstract Background: In 2009, an intestinal rehabilitation team implemented feeding guidelines for infants following gastrointestinal surgery at our institution. The purpose of this study was to determine the effect of enteral feeding guidelines on the incidence of parenteral nutrition (PN)–associated liver disease (PNALD) in infants with surgically managed necrotizing enterocolitis (NEC). Methods: This retrospective study included infants treated during 18-month time periods before and after the implementation of feeding guidelines. PNALD diagnosis was based on serum direct bilirubin >2 mg/dL after ≥14 days of PN exposure. Results: Of the 140 infants identified, 64 were surgically managed and included in the analysis. The duration of PN and the time nil per os (NPO) were significantly reduced after guideline implementation from a median of 106 days to 65 days (P = .03) and from 29 days to 16 days (P = .02), respectively. The incidence of PNALD decreased from 73% before guideline implementation to 42% after guideline implementation (P = .01). Conclusions: Implementation of feeding guidelines resulted in decreased time NPO and duration of PN support. Significantly fewer infants developed PNALD after guideline implementation. These data suggest that feeding guidelines may expedite the transition from PN to enteral nutrition and may improve outcomes. (Nutr Clin Pract. 2014;29:234-237)
Keywords parenteral nutrition; enteral nutrition; necrotizing enterocolitis; short bowel syndrome
Infants with intestinal failure often require prolonged parenteral nutrition (PN) to maintain their nutrition status and support growth. Although PN is lifesaving in these infants, it is also associated with complications such as PN-associated liver disease (PNALD) that contribute to morbidity and mortality. PNALD occurs in 40%–60% of children receiving long-term PN therapy due to intestinal failure.1,2 The cause of PNALD is not fully understood, but it has been associated with excessive calories or carbohydrates, the amino acid composition of the solution, lipid emulsions, nutrition deficiencies, sepsis, and inflammation or oxidative stress.3,4 Risk factors for PNALD include the duration of PN, lack of enteral nutrition (EN), short bowel syndrome (SBS), prematurity, and low birth weight.1,3,5–7 Although treatments such as administering ursodiol, cycling PN, restricting PN components, and using fish oil–based products have shown some benefit, resolution of PNALD normally requires advancement of EN with concomitant discontinuation of PN.8,9 Javid et al10 evaluated the role of EN in PNALD. The investigators reviewed bilirubin concentrations in 12 infants to determine whether they improved with increasing EN. Bilirubin and liver function did not normalize until several months after the infants were receiving full EN and PN had been discontinued. This highlights the significance of transitioning patients back to EN.10
Improved outcomes have been shown following the use of protocols to prevent PNALD in infants with intestinal failure by advancing EN and using other adjunctive strategies.11–13 Enteral feeding guidelines are used to transition patients from nil per os (NPO)/full PN to full EN. In 2009, a multidisciplinary intestinal rehabilitation team at our institution developed feeding guidelines for postsurgical infants in order to help them return to full EN more quickly. Infants are assigned to 1 of 4 guidelines based on degree of bowel resection, location of resection, and weight (Table 1).14 Although these are
From 1Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee; 2Le Bonheur Children’s Hospital, Memphis, Tennessee; 3Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee; and 4Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee. Financial disclosure: None declared. This article originally appeared online on February 25, 2014. Corresponding Author: Emma M. Tillman, PhD, PharmD, Le Bonheur Children’s Hospital, 50 N. Dunlap, Memphis, TN 38103, USA. Email: [email protected]
Downloaded from ncp.sagepub.com at Maastricht University on June 22, 2014
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Table 1. Enteral Feeding Guidelines. Guideline 1
Guideline 2
Guideline 3
Guideline 4
Residual small >40% residual small bowel bowela in continuity with colon
40% residual small bowel not 20%–40% residual small in continuity with colon bowel not in continuity with or colon 20%–40% residual small bowel or in continuity with colon
Evaluation of Parenteral Nutrition−Associated Liver Disease in Infants With Necrotizing Enterocolitis Before and After the Implementation of Feeding Guidelines Emma M. Tillman, Johanna L. Norman, Eunice Y. Huang, Linda F. Lazar and Catherine M. Crill Nutr Clin Pract 2014 29: 234 originally published online 25 February 2014 DOI: 10.1177/0884533614522834 The online version of this article can be found at: http://ncp.sagepub.com/content/29/2/234
Published by: http://www.sagepublications.com
On behalf of:
The American Society for Parenteral & Enteral Nutrition
Additional services and information for Nutrition in Clinical Practice can be found at: Email Alerts: http://ncp.sagepub.com/cgi/alerts Subscriptions: http://ncp.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Mar 13, 2014 OnlineFirst Version of Record - Feb 25, 2014 What is This?
Downloaded from ncp.sagepub.com at Maastricht University on June 22, 2014
522834
research-article2014
NCPXXX10.1177/0884533614522834Nutrition in Clinical PracticeTillman et al
Clinical Research
Evaluation of Parenteral Nutrition–Associated Liver Disease in Infants With Necrotizing Enterocolitis Before and After the Implementation of Feeding Guidelines
Nutrition in Clinical Practice Volume 29 Number 2 April 2014 234–237 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614522834 ncp.sagepub.com hosted at online.sagepub.com
Emma M. Tillman, PhD, PharmD1,2; Johanna L. Norman, PharmD1; Eunice Y. Huang, MD2,3; Linda F. Lazar, MD2,4; and Catherine M. Crill, PharmD1,2,4
Abstract Background: In 2009, an intestinal rehabilitation team implemented feeding guidelines for infants following gastrointestinal surgery at our institution. The purpose of this study was to determine the effect of enteral feeding guidelines on the incidence of parenteral nutrition (PN)–associated liver disease (PNALD) in infants with surgically managed necrotizing enterocolitis (NEC). Methods: This retrospective study included infants treated during 18-month time periods before and after the implementation of feeding guidelines. PNALD diagnosis was based on serum direct bilirubin >2 mg/dL after ≥14 days of PN exposure. Results: Of the 140 infants identified, 64 were surgically managed and included in the analysis. The duration of PN and the time nil per os (NPO) were significantly reduced after guideline implementation from a median of 106 days to 65 days (P = .03) and from 29 days to 16 days (P = .02), respectively. The incidence of PNALD decreased from 73% before guideline implementation to 42% after guideline implementation (P = .01). Conclusions: Implementation of feeding guidelines resulted in decreased time NPO and duration of PN support. Significantly fewer infants developed PNALD after guideline implementation. These data suggest that feeding guidelines may expedite the transition from PN to enteral nutrition and may improve outcomes. (Nutr Clin Pract. 2014;29:234-237)
Keywords parenteral nutrition; enteral nutrition; necrotizing enterocolitis; short bowel syndrome
Infants with intestinal failure often require prolonged parenteral nutrition (PN) to maintain their nutrition status and support growth. Although PN is lifesaving in these infants, it is also associated with complications such as PN-associated liver disease (PNALD) that contribute to morbidity and mortality. PNALD occurs in 40%–60% of children receiving long-term PN therapy due to intestinal failure.1,2 The cause of PNALD is not fully understood, but it has been associated with excessive calories or carbohydrates, the amino acid composition of the solution, lipid emulsions, nutrition deficiencies, sepsis, and inflammation or oxidative stress.3,4 Risk factors for PNALD include the duration of PN, lack of enteral nutrition (EN), short bowel syndrome (SBS), prematurity, and low birth weight.1,3,5–7 Although treatments such as administering ursodiol, cycling PN, restricting PN components, and using fish oil–based products have shown some benefit, resolution of PNALD normally requires advancement of EN with concomitant discontinuation of PN.8,9 Javid et al10 evaluated the role of EN in PNALD. The investigators reviewed bilirubin concentrations in 12 infants to determine whether they improved with increasing EN. Bilirubin and liver function did not normalize until several months after the infants were receiving full EN and PN had been discontinued. This highlights the significance of transitioning patients back to EN.10
Improved outcomes have been shown following the use of protocols to prevent PNALD in infants with intestinal failure by advancing EN and using other adjunctive strategies.11–13 Enteral feeding guidelines are used to transition patients from nil per os (NPO)/full PN to full EN. In 2009, a multidisciplinary intestinal rehabilitation team at our institution developed feeding guidelines for postsurgical infants in order to help them return to full EN more quickly. Infants are assigned to 1 of 4 guidelines based on degree of bowel resection, location of resection, and weight (Table 1).14 Although these are
From 1Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee; 2Le Bonheur Children’s Hospital, Memphis, Tennessee; 3Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee; and 4Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee. Financial disclosure: None declared. This article originally appeared online on February 25, 2014. Corresponding Author: Emma M. Tillman, PhD, PharmD, Le Bonheur Children’s Hospital, 50 N. Dunlap, Memphis, TN 38103, USA. Email: [email protected]
Downloaded from ncp.sagepub.com at Maastricht University on June 22, 2014
Tillman et al
235
Table 1. Enteral Feeding Guidelines. Guideline 1
Guideline 2
Guideline 3
Guideline 4
Residual small >40% residual small bowel bowela in continuity with colon
40% residual small bowel not 20%–40% residual small in continuity with colon bowel not in continuity with or colon 20%–40% residual small bowel or in continuity with colon
