Background: Parenteral nutrition (PN) is prescribed for preterm infants until nutrition needs are met via the enteral route, but unanswered questions remain regarding PN best practices in this population.Methods: An interdisciplinary committee was assembled to answer 12 questions concerning the provision of PN to preterm infants. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process was used. Questions addressed parenteral macronutrient doses, lipid injectable emulsion (ILE) composition, and clinically relevant outcomes, including PNALD, early childhood growth, and neurodevelopment. Preterm infants with congenital gastrointestinal disorders or infants already diagnosed with necrotizing enterocolitis or PN‐associated liver disease (PNALD) at study entry were excluded.Results: The committee reviewed 2460 citations published between 2001 and 2023 and evaluated 57 clinical trials. For most questions, quality of evidence was very low. Most analyses yielded no significant differences between comparison groups. A multicomponent oil ILE was associated with a reduction in stage 3 or higher retinopathy of prematurity (ROP) compared to an ILE containing 100% soybean oil. For all other questions, expert opinion was provided.Conclusion: Most clinical outcomes were not significantly different between comparison groups when evaluating timing of PN initiation, amino acid dose, and ILE composition. Future clinical trials should standardize outcome definitions to permit statistical conflation of data, thereby permitting more evidence based recommendations in future guidelines. This guideline has been approved by the ASPEN 2022‐2023 Board of Directors.

To evaluate the association between nutrition delivery practices and energy and protein intake during the transition from parenteral to enteral nutrition in infants of very low birth weight (VLBW). This was a retrospective analysis of 115 infants who were VLBW from a regional neonatal intensive care unit. Changes in energy and protein intake were estimated during transition phase 1 (0% enteral); phase 2 (>0, ≤33.3% enteral); phase 3 (>33.3, ≤66.7% enteral); phase 4 (>66.7, <100% enteral); and phase 5 (100% enteral). Associations between energy and protein intake were determined for each phase for parenteral nutrition, intravenous lipids, central line, feeding fortification, fluid restriction, and excess non-nutritive fluid intake. In phases 2 and 3, infants receiving feeding fortification received less protein than infants who were unfortified (-1.1 and -0.3 g/kg/d, respectively; P < .001). However, this negative association was not observed after adjusting for relevant nutrition delivery practices. Despite greater enteral protein intake during phases 2 and 3 (0.3 and 0.8 g/kg/d, respectively; P < .001), infants with early fortification received less parenteral protein than infants who were unfortified (-1.4 and -1.1 g/kg/d, respectively; P < .001). Similar patterns were observed for energy intake. Protein intake declined during phases 3 and 4. Infants paradoxically received less protein and energy on days with early fortification, suggesting that clinicians may lack easily accessible data to detect the association between nutrition delivery practices and overall nutrition in infants who are VLBW.

Background: Very low birth weight (VLBW) infants remain at risk for postnatal growth restriction. Clinicians may have difficulty identifying growth patterns resulting from nutrition interventions, impeding prompt management changes intended to increase growth velocity. This study aimed to quantify the association between growth and nutrition intake through 7-day moving averages (SDMAs). Methods: The first 6 weeks of daily nutrition intake and growth measurements were collected from VLBW infants admitted to a level 4 neonatal intensive care unit (2011-1014). The association between SDMA for energy and macronutrients and subsequent 7-day growth velocities for weight, length, and head circumference were determined using mixed effects linear regression. Analyses were adjusted for fluid intake, infant characteristics, and comorbid conditions. Results: Detailed enteral and parenteral caloric provisions were ascertained for 115 infants (n = 4643 patient-days). Each 10-kcal/kg/d increase over 7 days was independently associated with increased weight (1.7 g/kg/d), length (0.4 mm/wk), and head circumference (0.9 mm/wk; P < .001, for weight and head circumference; P = .041 for length). Each 1 g/kg/d macronutrient increase was also associated with increased weight (protein, P = .027; fat and carbohydrates, P < .001), increased length (fat, P = .032), and increased head circumference (fat and carbohydrates, P < .001). Conclusions: The SDMA identifies clinically meaningful associations among total energy, macronutrient dosing, arid growth in VLBW infants. Whether SDMA is a clinically useful tool for providing clinicians with prompt feedback to improve growth warrants further attention.

Background: Clinical decision support (CDS) improves nutrition delivery for infants in the neonatal intensive care unit (NICU), however, the prevalence of CDS to support nutrition is unknown.Methods: Online surveys, with telephone and email validation of responses, were administered to NICU clinicians in the Children’s Hospital Neonatal Consortium (CHNC). We determined and compared the availability of CDS to calculate calories and fluid received in the prior 24 h, stratified by enteral and parenteral intake, using McNemar’s test.Results: Clinicians at all 34 CHNC hospitals responded with 98 of 108 (91%) surveys completed. NICUs have considerably less CDS to calculate enteral calories received than enteral fluid received (32% vs. 82%,p < 0.001) and less CDS to calculate parenteral calories received than parenteral fluid received (29% vs. 82%,p < 0.001).Discussion: Most CHNC NICUs are unable to reliably and consistently monitor caloric intake delivered to critically ill infants at risk for growth failure.

Purpose: Few clinical decision support systems (CDSSs) are available to help clinicians calculate nutrition intake in infants in the neonatal intensive care unit (NICU) despite improvement in the accuracy of calculations and quality of nutrition delivered. The aim of this manuscript is to qualitatively define the barriers associated with the implementation of CDSSs to calculate fluid and nutrition intake. Methods: After defining the data necessary to calculate fluid and nutrition intake, multidisciplinary groups analyzed CDSS capabilities and barriers to implementation at two academically affiliated NICUs. They implemented CDSSs to calculate intake received in the past (retrospective) and to estimate future intake from orders (prospective). Barriers and measures to reduce them are reported. Results: Barriers to implementation include simultaneous enteral feeding orders, the use of free text in the electronic health record (EHR), and a large variety of enteral feeding types for clinical use. These barriers made implementation of prospective CDSSs more difficult. CDSSs reported values that were normalized by both the most recent measured weight (usually obtained daily) and a dosing weight, a weight updated less frequently and used by pharmacies to facilitate prescribing. Conclusion: Despite using an EHR from the same vendor, different solutions were implemented at each NICU. CDSSs improved access to individual infant data on fluid and nutrition intake; however, none of the CDSSs easily exported data to monitor the quality of intake for the entire NICU or specific populations (eg, infants with bronchopulmonary dysplasia). Comprehensive CDSSs that include prospective intake and monitor the quality of nutrition intake through standardized values will require continued investigation and resources.