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Early Versus Later Initiation of Parenteral Nutrition for Very Preterm Infants: A Propensity Score Matched Observational Study

24 Pages Posted: 27 Apr 2021

See all articles by Sabita Uthaya

Sabita Uthaya

Imperial College London - Neonatal Medicine

Nicholas T. Longford

Imperial College London - Neonatal Medicine

Cheryl Battersby

Imperial College London - Neonatal Medicine

Kayleigh Ougham

Imperial College London - Neonatal Medicine

Julia Lanoue

Imperial College London - Neonatal Medicine

Neena Modi

Imperial College London - Neonatal Medicine

More...

Abstract

Background: A current standard of care based on expert opinion is to commence parenteral nutrition (PN) within hours of birth in very preterm infants. Trials in critically ill adults and children, including term infants have found short and long-term harms from early initiation of PN.  

Methods: We included all infants born below 31 weeks gestation between January 2008 and December 2019 and admitted to National Health Service neonatal units in England and Wales. The source of data was the National Neonatal Research Database. The exposure was PN initiated within the first two days after birth (early) versus after the second postnatal day (late). We used propensity matched analysis to balance the two groups on background variables. The primary outcome was survival to discharge without major morbidity. 

Findings: Of 65,033 infants included, 16,294 infants formed the matched cohort, 8147 in each group. There was no evidence of a difference in survival to discharge without major morbidity (absolute rate difference (ARD) between early versus late 0·50%; 95% Confidence Interval (CI), -1·45, 0·45; p=0·29). Survival to discharge was higher in the early group (ARD -3·25%; 95% CI, -3·82 to -2·68; p<0·001) but they also had higher rates of late-onset sepsis (ARD -0·84%; 95% CI, -1·20 to -0·48; p<0·001), bronchopulmonary dysplasia (ARD -1·24%; 95% CI, -2·17 to -0·30; p=0·01), treatment for retinopathy of prematurity (ARD (-0·5%; 95% CI, -0·84 to -0.17; p<0·001), surgical procedures (ARD -0·8%; 95% CI, -1·40 to -0·20; p=0·01) and greater drop in weight z-score between birth and discharge (absolute difference 0·019; 95% CI, 0·003 to 0·039; p=0·02). Among infants that died the median age (days) at death was shorter in the late group (ARD 6; 95% CI, 6; p<0.001).   

Interpretation: These observational data justify the need for a randomised controlled trial of early versus late PN powered to detect differences in long-term functional outcomes.  

Funding Information: No specific funding.

Declaration of Interests: NM is the Chief Investigator for the National Neonatal Research Database at Imperial College London. SU, NL, CB, KO, JL declare no conflict of interest involving the work under consideration for publication.

Ethics Approval Statement: The Health Research Authority, and Health and Care Research Wales, approved the study (ID 273001). All neonatal units agreed to the inclusion of their data in the study.

Keywords: Neonatal, parenteral nutrition, preterm, propensity score

Suggested Citation

Uthaya, Sabita and Longford, Nicholas T. and Battersby, Cheryl and Ougham, Kayleigh and Lanoue, Julia and Modi, Neena, Early Versus Later Initiation of Parenteral Nutrition for Very Preterm Infants: A Propensity Score Matched Observational Study. Available at SSRN: https://ssrn.com/abstract=3835131 or http://dx.doi.org/10.2139/ssrn.3835131

Sabita Uthaya (Contact Author)

Imperial College London - Neonatal Medicine ( email )

London
United Kingdom

Nicholas T. Longford

Imperial College London - Neonatal Medicine ( email )

London
United Kingdom

Cheryl Battersby

Imperial College London - Neonatal Medicine ( email )

London
United Kingdom

Kayleigh Ougham

Imperial College London - Neonatal Medicine ( email )

London
United Kingdom

Julia Lanoue

Imperial College London - Neonatal Medicine

South Kensington Campus
Exhibition Road
London, SW7 2AZ
United Kingdom

Neena Modi

Imperial College London - Neonatal Medicine ( email )

Chelsea and Westminster Hospital Campus
369 Fulham Road
London, SW10 9NH
United Kingdom
+44 (0) 203 315 5101 (Phone)

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