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Service design
Evidence review H
NICE Guideline, No. 154
National Guideline Alliance (UK).
Service Design
Review question
Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
Introduction
Due to the complexity of providing parenteral nutrition (PN) to babies, multidisciplinary care teams that have a special understanding of their nutritional requirements could offer added expertise in ensuring adequate nutrition to avoid deficits and promote growth, whilst reducing the risks associated with PN. The aim of this review is to determine whether multidisciplinary teams (MDTS) are effective, safe and decrease the risk of PN complications.
Summary of the protocol
Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol (PICO table).
For full details see the review protocol in appendix A.
Clinical evidence
Included studies
No randomised controlled trials (RCTs) were identified; therefore, observational studies were included to inform decision making.
Four observational studies (Furtado 2015, Gover 2014, Jeong 2016, Sneve 2008) were identified for this review.
One study (Furtado 2015) compared the outcomes of infants with intestinal failure who were managed by an MDT (professionals from gastroenterology, neonatology, general surgery, nursing, nutrition, pharmacy, social work, and occupational therapy) to infants from a historic cohort who had not been treated by an MDT.
One study (Gover 2014) compared the outcomes of infants with gastroschisis who were managed by an MDT (professionals from three or more disciplines, e.g. neonatology, gastroenterology, dietetics)) to a control group of babies who had not been treated by an MDT
One study (Jeong 2016) compared improvements in clinical and nutritional outcomes in preterm infants managed by a multidisciplinary nutritional support team to a historical cohort who had not received treatment from an MDT.
One study (Sneve 2008) compared the outcomes of neonates ≤1500g who were managed by an MDT, which included a registered dietitian, to a historical cohort of babies managed before the introduction of the MDT.
It was not considered appropriate to pool the data from the Furtado 2015 and Gover 2014 studies with the Jeong 2016 and Sneve 2008 studies (which were considered similar inough to combine where outcomes align) due to the heterogeneous nature of the populations. The babies included in the Furtado 2015 and Gover 2014 studies had different complex needs and were therefore also not combined with each other; intestinal failure and gastroschisis respectively.
The included studies are summarised in Table 2.
Table 2
Summary of included studies.
See the literature search strategy in appendix B, study selection flow chart in appendix C, study evidence tables in appendix D, forest plots in appendix E, and GRADE tables in appendix F.
Excluded studies
Studies not included in this review are listed, and reasons for their exclusions are provided in appendix K.
Summary of clinical studies included in the evidence review
Summaries of the studies that were included in this review are presented Table 2
See appendix D for the full evidence tables.
Quality assessment of clinical outcomes included in the evidence review
GRADE was conducted to assess the quality of outcomes. Evidence was identified for critical and important outcomes. The clinical evidence profiles can be found in appendix F.
Economic evidence
Included studies
A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question. A single economic search was undertaken for all topics included in the scope of this guideline. Please see supplementary material D for details.
Excluded studies
Studies not included in this review are listed, and reasons for their exclusions are provided in appendix K.
Summary of studies included in the economic evidence review
No economic evaluations were identified which were applicable to this review question.
Economic model
This topic was identified as a priority for economic modelling. However, the clinical evidence was of poor quality and insufficient to inform an economic model that would be useful for decision making in this area.
Clinical evidence statements
Weight z-score (discharge)
- Very low quality evidence from 1 observational study (n=229) showed no clinically important difference in weight at discharge of non-complex babies who received support from a nutrition support team as compared to those who did not have a nutrition support team; Mean difference (MD): 0.16 (95% CI −0.01 to 0.42).
Weight at discharge
- Very low quality evidence from 1 observational study (n=105) showed a clinically important difference in weight at discharge of non-complex babies who received support from a nutrition support team as compared to those who did not have a nutrition support team; with an MDT resulting in greater weight: MD 503g (95% CI 327.23 to 678.77).
Weight change z-score (during hospital stay)
- Very low quality evidence from 1 observational study (n=229) showed no clinically important difference in the weight change during hospital stay of non-complex babies who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team; MD 0.22 (95% CI −0.01 to 0.45).
Weight gained
- Very low quality evidence from 1 observational study (n=105) showed a clinically important difference in the weight gained between non-complex babies who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team, an MDT resulted in greater weight gain. However, there was uncertainty around the effect: MD 358g (95% CI 212.27 to 743.73).
Head circumference growth
- Very low quality evidence from 1 observational study (n=105) showed a clinically important difference in the growth of non-complex babies head circumference between those who received support from a nutrition/care support team as compared to those who did not, the MDT resulted in better growth. However, there was uncertainty around the effect: MD 2cm (95% CI 0.91 to 3.09).
Head circumference at discharge
- Very low quality evidence from 1 observational study (n=105) showed a clinically important difference in the total head circumference between non-complex babies who received support from a nutrition/care support team as compared to those who did, an MDT resulted in greater head circumference at discharge: MD 2cm (95% CI 1.46 to 2.54).
Total length growth
- Very low quality evidence from 1 observational study (n=105) showed no clinically important difference in the length of non-complex babies between those who received support from a nutrition/care support team as compared to those who did not; MD 1cm (95% CI −1.08 to 3.08).
Length at discharge
- Very low quality evidence from 1 observational study (n=105) showed a clinically important difference in the length of non-complex babies at discharge between those who received support from a nutrition/care support team as compared to those who did not, an MDT resulted in greater length of babies at discharge. However, there was uncertainty around the effect; MD 2cm (95% CI 0.77 to 3.23).
Length of stay in NICU
- Very low quality evidence from 1 observational study (n=55) showed no clinically important difference in the mean number of days spent in NICU of babies with intestinal failure who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team. However, there was uncertainty around the effect; MD −10.00 (95% CI −49.73 to 29.73).
- Very low quality evidence from 1 observational study (n=396) showed no clinically important difference in the mean number of days spent in NICU of babies with gastroschisis who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team; MD 13.00 (95% CI 2.34 to 23.66).
- Very low quality evidence from 2 observational studies (n=334 ) showed no clinically important difference in the mean number of days spent in NICU of non-complex babies who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team. However, there was uncertainty around the effect; MD −1.57 days (95% CI −17.74 to 14.60).
Achievement of 80kcal/kg on day 7
- Very low quality evidence from 1 observational study (n=229) showed a clinically important difference in the number of non-complex babies who achieved 80kcal/kg on day 7 in those who received support from a nutrition support team as compared to those who did not have a nutrition support team, with more babies cared for by an MDT achieving this target. However, there was uncertainty around the effect: Relative risk (RR) 1.5 (95% CI 1.16 to 1.95).
PN duration
- Very low quality evidence from 1 observational study (n=55) showed a clinically important difference in the duration that babies with intestinal failure were on PN between those who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team, those babies cared for by an MDT were on PN for a longer duration. However, there was uncertainty around the effect: MD 63.70 (95%CI 20.34 to 107.06).
- Very low quality evidence from 1 observational study (n=396) showed no clinically important difference in the duration that babies with gastroschisis were on PN between babies who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team. However, there was uncertainty around the effect; MD 13.00 (95%CI 4.59 to 21.41).
- Very low quality evidence from 1 observational study (n=229) showed no clinically important difference in duration of PN between non-complex babies who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team; MD −4.4 (95%CI −9.31 to 0.51)
Mortality
- Very low quality evidence from 1 observational study (n=55) showed a clinically important difference in mortality of babies with intestinal failure who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team, fewer occurrences of mortality were observed in those babies cared for by an MDT. However, there was high uncertainty around the effect: RR 0.48 (95% CI 0.10 to 2.42).
- Very low quality evidence from 1 observational study (n=396) showed a clinically important difference in mortality of babies with gastroschisis who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team, fewer occurrences of mortality were observed in those babies cared for by an MDT. However, there was high uncertainty around the effect: RR 0.47 (95% CI 0.16 to 1.35).
- Very low quality evidence from 2 observational studies (n=334) showed a clinically important difference in mortality of non-complex babies who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team, greater occurrences of mortality were observed with an MDT. However, there was high uncertainty around the effect: RR 1.94 (95%CI 0.47 to 8.09).
Necrotising enterocolitis (NEC)
- Very low quality evidence from 2 observational studies (n=334) showed no clinically important difference in the number of non-complex babies with NEC between those who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team. However, there was high uncertainty around the effect; RR 1.20 (95% CI 0.53 to 2.72).
Sepsis
- Very low quality evidence from 1 observational study (n=229) showed no clinically important difference in the number of non-complex babies with sepsis between those who received support from a nutrition/care support team as compared to those who did not have a nutrition support/care team. However, there was high uncertainty around the effect; RR 1.21 (95%CI 0.79 to 1.87).
- Very low quality evidence from 1 observational study (n=55) showed a clinically-important difference in the occurrence of sepsis in babies with intestinal failure, with greater occurrences in babies who received support from a nutrition/care support team as compared to those who did not have a nutrition/care support team. However, there was uncertainty around the effect; RR 1.29 (95%CI 0.95 to 1.75).
Mean number of septic episodes per baby
- Very low quality evidence from 1 observational study (n=55) showed no clinically important difference in the number of septic episodes in babies with intestinal failure who received support from a nutrition/care support team as compared to those who did have a nutrition/care support team. However, there was high uncertainty around the effect, MD 0.00 (95%CI −1.35 to 1.35).
Economic evidence statements
No studies were identified which were applicable to this review question.
The committee’s discussion of the evidence
Interpreting the evidence
The outcomes that matter most
The committee agreed that anthropometric outcomes, prescribing errors and achievement of target intake were the critical outcomes for this review. These outcomes are potentially influenced by the makeup of the team members who determine PN, for instance good oversight from a pharmacist with expertise should reduce prescribing errors. Important outcomes included alteration to PN provision, adherence to monitoring, duration of PN, adverse events, duration of hospital stay and parental satisfaction. These outcomes may all be influenced by an MDT, but would also be influenced by other factors within the NICU (for instance duration of PN may be due to the gestational age of the baby rather than due to the constituency of the MDT).
The quality of the evidence
The included outcomes were assessed using GRADE methodology, and all evidence presented was considered very low quality, indicating the data is unreliable. The included studies were all retrospective in design, and were downgraded due to serious risk of bias from confounding, deviations from the intended interventions, and unclear bias in measurement of outcomes. There was a high level of heterogeneity in the studies, and as such not all studies were combined (where populations varied considerably), analysis using a random effects model was undertaken to take this heterogeneity into account. In addition, data was considered imprecise; in sum the evidence should be interpreted with caution. None of the studies were from the UK, which also makes the services less generalisable to an NHS setting.
Benefits and harms
The committee agreed that overall the evidence was very low quality; however the evidence supported their knowledge and experience of when an MDT is likely more effective, for example babies with complex needs. Therefore, the committee considered the evidence and used it to support their clinical experience to make the recommendations by informal consensus.
Overall the evidence demonstrated that babies had a greater weight gain, greater weight at discharge and greater increase in head circumference when cared for by an MDT. However, some of the data (for example weight z-score at discharge and weight z-score during hospital stay and total length at discharge) showed no difference between groups in these outcomes, and this may be due to high levels of imprecision, making it difficult to draw firm conclusions.
In general, the included studies did not describe the composition of the non-MDT arm, so it was difficult to determine what effect the newly introduced MDT may be having on overall care. One study showed a significantly greater number of babies who were cared for by an MDT achieved a specific target of intake (80kcal/kg on day 7 [Jeong 2016]), and another study showed clinical benefits in weight and head circumference for babies who were cared for by an MDT [Sneve 2008]).
Two of the included studies (Furtado 2016 and Gover 2014) included babies with short gut syndrome and intestinal failure respectively; these are not the most frequent indications for PN in neonates, and only account for a small number of babies receiving PN; therefore, these studies were considered in isolation. The studies showed that fewer of these babies died when an MDT provided care. The presence of the MDT also resulted in babies receiving PN for longer. The committee discussed how it is difficult to determine whether it is more beneficial or not for babies to be on PN for longer or shorter time-periods; if a baby stays on PN for longer they may be receiving better nutrition, but they are at risk of line infections; however, the data did not clearly show this; therefore, the longer duration of PN did not appear to be detrimental. The committee agreed that with complex babies more regular MDT team meetings are likely required, and a wider range of specialist should be included (for example a gastroenterologist, who may not normally be included in the MDT).
The committee agreed that the included evidence, despite the limitations discussed above, demonstrated some benefits related to the clinical MDT. They noted that the evidence did not allow them to exactly determine which health care professionals should make up the MDT, and they agreed that details of the daily work of the MDT could not be defined because that would depend on the case load and the type of babies that are seen in the services that they would oversee or support. Even though the evidence did not directly address this, based on their knowledge of current practice and national reports related to shortcomings of current PN provision (see other considerations below) the committee also recognised that the team should not only provide clinical input but should also provide oversight of services. The committee agreed that policies and protocols are needed as well as the auditing of outcomes to ensure the safety of PN provision. The committee decided that a team of specialists should be accessible to all services providing PN. Such teams should always contain a consultant neonatologist or paediatrician with a special interest in nutrition, pharmacist and dietitian to ensure there is expertise in the clinical, prescribing and nutritional core components of neonatal PN. The committee also recognised that access to other roles may be required, such as neonatal nursing, paediatric gastroenterology or expertise in clinical biochemistry to cover specific clinical or specialist areas of PN. The committee noted that if all core professionals listed in the recommendation and access to additional expertise where needed, to provide governance or clinical support, this would likely result in the provision of optimum PN for neonates. The committee are aware that not all units have all the listed professionals present on their units all the time. They discussed that most babies would not require daily bed-side assessments by all members listed within the MDT but that services need to be set up so that an MDT would have oversight of PN provision. This could mean access to them within a clinical network rather than availability to all of them locally.
The committee agreed that it is important that all members of the MDT have responsibility for PN governance and supporting delivery of PN. The committee discussed the importance of these professionals having their role within the MDT clearly recognised, and each member of the team would have clear and specific roles and responsibilities defined; however, they agreed this would be aspirational, but hope that these recommendations result in MDT members having dedicated time allocated for them to fulfil this role.
The committee, based on the evidence which demonstrated better outcomes associated with MDT involvement for babies with short gut syndrome or intestinal failure, agreed by informal consensus that babies with complex needs may require input from professionals other than those they listed for the oversight team. This ‘enhanced’ team could require the expertise of a gastroenterologist or a surgeon but the committee did not want to be prescriptive about these additional specialists. They agreed that the composition of an enhanced team would need to be tailored to each individual baby.
Cost effectiveness and resource use
No economic studies were identified which were applicable to this review question.
The committee explained that the question is not whether MDT should be provided or not. MDT input is necessary and the real question is as to the best composition and structure of the MDT. The committee noted that the clinical evidence was poor and insufficient to guide the committee as to the best composition of MDT and how the expertise of the team is used in service provision.
The committee discussed the role of the MDT i.e. to oversee and support the service to ensure that clinicians involved in the day to day care of the baby adhere to the guidelines and standards. They would also give a steer in the management of complicated cases. The committee also discussed key individuals required for this oversight MDT including consultant paediatrician or neonatologist, pharmacist, dietitian, neonatal nurse, and in some complicated cases a paediatric gastroenterologist. The committee noted that there may be a lack of certain experts in some centres and that there may be procurement issues. The committee explained that the network or regional centres should have such expertise available and individual centres within a network can draw on this expertise to support their local needs. The committee highlighted that these professionals already exist within the NHS and are funded for being part of the paediatric team and so the recommendations in this area would not incur additional resources to the NHS.
The committee explained that the MDT input would increase with the severity of the baby’s condition. However, this is standard clinical practice and the recommendation pertaining to the enhanced MDT would not incur additional resources to the NHS.
Other factors the committee took into account
The committee took into account national reports that highlight inadequacies and safety concerns in the provision of neonatal PN (such as the National Confidential Enquiry into Patient Outcome and Death – PN from 2010 and the report from the Paediatric Chief Pharmacists Group in 2011 - improving practice and reducing risk in the provision of PN for neonates and children). They agreed that strong recommendations in favour of MDT input would help to address the concerns raised in these reports.
References
Furtado 2016
Furtado S., Ahmed N., Forget S., Sant’ Anna A., Outcomes of patients with intestinal failure after the development and implementation of a multidisciplinary team. Canadian Journal of Gastroenterology and Hepatology, ID 9132134, 2016. [PMC free article: PMC4904660] [PubMed: 27446876]Gover 2014
Gover A., Albersheim S., Sherlock R., Claydon J., Butterworth S., Kuzeljevic B., Outcome of patients with gastroschisis managed with and without multidisciplinary teams in Canada. Paediatric Child Health 19 (3), 128–132, 2014. [PMC free article: PMC3959971] [PubMed: 24665222]Jeong 2016
Jeong E., Jung YH., Shin SH., Kim MJ., Bae HJ., Cho YS., Kim KS., Kim HS., Moon JS., Kim e-K., Kim H-S., Ko JS., The successful accomplishment of nutritional and clinical outcomes via the implementation of a multidisciplinary nutrition support team in the neonatal intensive care unit. BMC Paediatrics 16: 113, 2016. [PMC free article: PMC4963950] [PubMed: 27465214]Sneve 2008
Sneve J., Kattelmann K., Ren C., Stevens DC., Implementation of a Multidisciplinary team that includes a registered dietitian in a neonatal intensive care unit improved nutrition outcomes. Nutrition in Clinical Practice 23 (6), 630–634, 2008. [PubMed: 19033222]
Appendices
Appendix A. Review protocols
Review protocol for review question: Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
Appendix B. Literature search strategies
Literature search strategy for review question: Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
Appendix C. Clinical evidence study selection
Clinical study selection for review question: Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
Appendix D. Clinical evidence tables
Clinical evidence tables for review question: Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
Table 4. Clinical evidence tables for included studies (PDF, 665K)
Appendix E. Forest plots
Forest plots for review question: Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
Figure 2. MDT versus no MDT; length of stay in NICU
Appendix F. GRADE tables
GRADE tables for review question: Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
Appendix G. Economic evidence study selection
Economic evidence study selection for review question: Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
One global search was conducted for all review questions. See supplementary material D for further information.
Appendix H. Economic evidence tables
Economic evidence tables for review question: Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
No evidence was identified which was applicable to this review question.
Appendix I. Economic evidence profiles
Economic evidence profiles for review question: Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
No economic studies were identified which were applicable to this review question.
Appendix J. Economic analysis
Economic analysis for review question: Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
No economic analysis was undertaken for this review question.
Appendix K. Excluded studies
Excluded studies for review question: Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
Clinical studies
Economic studies
No economic evidence was identified for this review question. See supplementary material D for further information.
Appendix L. Research recommendations
Research recommendations for review question: Are nutrition care/support teams effective in providing parenteral nutrition in preterm and term babies?
No research recommendations were made for this review question.
Final
Evidence reviews
These evidence reviews were developed by the National Guideline Alliance which is part of the Royal College of Obstetricians and Gynaecologists
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
- Supplementary material A - National Guideline Alliance technical team list (PDF)
- Supplementary material B - Glossary and abbreviations (PDF)
- Supplementary material C - Methods (PDF)
- Supplementary material D - Health economic literature (PDF)
- Equality impact assessment (PDF)
- Membership of Neonatal Parenteral Nutrition Guideline Committee (PDF)
- Declarations of interests register (PDF)
- Effectiveness of a multidisciplinary total parenteral nutrition team in the hospital setting.[JBI Libr Syst Rev. 2003]Effectiveness of a multidisciplinary total parenteral nutrition team in the hospital setting.Fernandez R, Griffiths R, Naylor CJ. JBI Libr Syst Rev. 2003; 1(2):1-45.
- Review Practice of parenteral nutrition in VLBW and ELBW infants.[World Rev Nutr Diet. 2014]Review Practice of parenteral nutrition in VLBW and ELBW infants.Embleton ND, Simmer K. World Rev Nutr Diet. 2014; 110:177-89. Epub 2014 Apr 11.
- Review Management of parenteral nutrition in critically ill patients.[World J Crit Care Med. 2017]Review Management of parenteral nutrition in critically ill patients.Cotogni P. World J Crit Care Med. 2017 Feb 4; 6(1):13-20. Epub 2017 Feb 4.
- [Impact of the creation of a nutritional support team on the quality, safety and effectiveness of total parenteral nutrition].[Nutr Hosp. 2012][Impact of the creation of a nutritional support team on the quality, safety and effectiveness of total parenteral nutrition].López-Martín C, Abilés J, Garrido Siles M, Faus Felipe V. Nutr Hosp. 2012 May-Jun; 27(3):871-8.
- Reducing the inappropriate use of parenteral nutrition in an acute care teaching hospital.[JPEN J Parenter Enteral Nutr. ...]Reducing the inappropriate use of parenteral nutrition in an acute care teaching hospital.Maurer J, Weinbaum F, Turner J, Brady T, Pistone B, D'Addario V, Lun W, Ghazali B. JPEN J Parenter Enteral Nutr. 1996 Jul-Aug; 20(4):272-4.
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