Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes
Abstract
:1. Introduction
2. Before Surgery
3. At Surgery
3.1. Variability in Metabolic Demand
3.2. Hyperglycemia
3.3. A positive Immunological Response
4. After Surgery
4.1. Fluid Balance
4.2. Energy and Macronutrients Needs
4.2.1. Glucose
4.2.2. Amino Acids
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- Glutamine is the most abundant free amino acid in the body and it is the preferred respiratory fuel for rapidly proliferating cells. In case of metabolic stress, the endogenous production of glutamine could be insufficient, becoming a “conditionally essential amino acid”. Meta-analyses do not provide evidence that glutamine supplementation gives advantage for preterm infants [55]. Furthermore, studies focusing on surgical newborns also showed no benefit from glutamine supplementation during PN [56,57].
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- Taurine (synthesized from methionine and cysteine) deficiency may increase glyco-conjugates of bile acids resulting in cholestasis [58]. Studies showed that prolonged PN with a taurine-free parenteral solution resulted in reduced plasma taurine levels [59]. Although the cause of neonatal cholestasis and PNALD is probably multifactorial, there are few data indicating that adequate taurine may prevent cholestasis, in particular in patients with NEC [60]. The right dose of taurine supplementation is not yet known [58]: Spenser et al. demonstrated some benefits from taurine integration with a dose ranging from 6 to 21.6 mg/kg/day depending on the total protein delivery and formulation [60].
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4.2.3. Lipids
4.3. Micronutrients
4.3.1. Vitamins and Electrolytes
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- A total of 200–1000 IU/day (or 80–400 IU/kg/day) of vitamin D for preterm infants and 400 IU/day (or 40–150 IU/kg/day) for term infants up to 12 months of age;
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- A minimum of 0.8 mmol/kg/day up to 3.5 mmol/kg/day of calcium in preterm infants;
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- A minimum of 1 mmol/kg/day up to 3.5 mmol/kg/day of phosphorus in preterm infants.
4.3.2. Trace Elements
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- Manganese should be supplied at a dose of no more than 1 μg/kg/day, however with blood levels regularly monitored as there is high risk of accumulation with neurotoxicity [130,131]. This risk is increased in neonates due to the evidence of significant quantities of Mn in neonatal PN as a contaminant [132,133]. Patients who develop PNALD are at a higher risk of Mn accumulation [79,134]: In case of PNALD whole blood manganese should be determined and if >220 nmol/L, parenteral supplementation should be discontinued [79,80].
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- Anemia often occurs during the acute phase due to several causes, especially bleeding and blood test monitoring. During this phase, no evidence suggests iron deficiency since multiple transfusions are needed and might give iron support. However, prolonged PN (particularly > 3 weeks) without iron supplementation may induce iron deficiency and anemia [22,101]. For this reason, it is important to plan iron supplementation that should preferentially be given enterally rather than with intermittent infusions due to adverse drug reactions, in particular anaphylaxis [80]. If patients develop SBS, the incidence of anemia is controversial [22,77,101,105,106] and it can be explained by blood draws, iron, or vitamin B12 deficiency, recurrent infection and intestinal anastomotic ulcers that can cause refractory anemia [77,81]. Therefore, the iron status, comprising serum ferritin and hemoglobin, should be regularly monitored in patients on long-term PN in order to prevent iron deficiency and iron overload [80].
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- Salivary, gastric, pancreatic, and intestinal juices contain a significant amount of zinc that normally is reabsorbed in the proximal small intestine, more specifically in the distal duodenum and proximal jejunum [135]. Newborns with elevated enteral fluid losses (diarrhea, steatorrhea, or stoma losses) are at a high risk for zinc deficiency [136]. Many case series document zinc deficiency in newborns with bowel damage, especially with jejunostomy or ileostomy [22,79,101,106,137]. Symptoms of zinc deficiency are well known, ranging from weight loss, failure to thrive, periorificial dermatitis, glossitis, and increased susceptibility to infections [138,139,140,141,142,143]. Intravenous zinc supplementation of 400 to 500 μg/kg/day in preterm infants is recommended, however no specific recommendations in infants with small intestinal stoma are available [80]. A monocentric study by D’Aniello et al. showed that a zinc deficit is prevented in newborns with a small bowel stoma if supplementation is 500 μg/kg/day parenterally [82]. Therefore, higher parenteral zinc supplementation should be planned early in infants after surgical NEC with jejunostomy or ileostomy.
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- Similarly, copper deficiency can be found in infants with jejunostomy or ileostomy or long-term PN [22,77,106,142]. Copper is primarily absorbed via the small intestine and patients who have increased copper losses through stool or ostomy require additional supplementation in PN solutions by 10–15 μg/kg [137]. However, there is no agreement on the best parenteral copper dose: The American Society for Clinical Nutrition and the ASPEN recommend 20 μg/kg/day [107,108], while the ESPGHAN guideline recommends 40 μg/kg/day in preterm infants and 20 μg/kg/day in term infants [80]. Additionally, there are no specific indications for surgical patients. Adler et al. found that 20 μg/kg/day of copper in PN of neonates with ostomies is insufficient to prevent Cu deficiency [83]. Moreover, the predominant pathway of copper excretion is through bile and it remains common practice to reduce or eliminate copper in the PN solutions of infants with PNALD because of the risk of hepatic toxicity.
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
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Guiducci, S.; Duci, M.; Moschino, L.; Meneghelli, M.; Fascetti Leon, F.; Bonadies, L.; Cavicchiolo, M.E.; Verlato, G. Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes. Nutrients 2022, 14, 919. https://doi.org/10.3390/nu14050919
Guiducci S, Duci M, Moschino L, Meneghelli M, Fascetti Leon F, Bonadies L, Cavicchiolo ME, Verlato G. Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes. Nutrients. 2022; 14(5):919. https://doi.org/10.3390/nu14050919
Chicago/Turabian StyleGuiducci, Silvia, Miriam Duci, Laura Moschino, Marta Meneghelli, Francesco Fascetti Leon, Luca Bonadies, Maria Elena Cavicchiolo, and Giovanna Verlato. 2022. "Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes" Nutrients 14, no. 5: 919. https://doi.org/10.3390/nu14050919