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Stopping parenteral nutrition
Evidence review G
NICE Guideline, No. 154
National Guideline Alliance (UK).
Stopping parenteral nutrition in preterm and term babies
Review question
What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to parenteral nutrition and enteral feeds) indicates that parenteral nutrition is no longer required?
Introduction
Determining when parenteral nutrition (PN) can be stopped is important; there is risk of malnutrition and associated complications to the baby if parenteral feeding is stopped too early. In contrast, the longer PN is continued, the greater the risk of line sepsis and PN associated liver disease. Guidance for clinicians on how to determine when it is safe to transition from combined parenteral and enteral nutrition to enteral nutrition (EN) alone is required.
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 further details see the review protocol in appendix A.
Clinical evidence
Included studies
As limited RCT evidence was available, we also included observational studies. Three studies were identified for inclusion in this review (Choi 2016, Dinerstein 2006, and Perrem 2019).
One randomised controlled trial (RCT) (n=137) compared stopping PN when EN reached 100ml/kg/day to stopping PN when EN reached 140ml/kg/day (Perrem 2019).
One observational study (n=87) compared stopping PN when EN reached 100ml/kg/day to stopping PN when EN reached 120ml/kg/day (Choi 2016).
One observational study (n=182compared stopping PN when EN reached 60kcal/kg/day to stopping PN when EN reached 100kcal/kg/day (Dinerstein 2006).
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 included in this review are presented in Table 2.
See the full evidence tables in appendix D and the forest plots in appendix E.
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
No studies were identified which were applicable to this review question.
Summary of studies included in the economic evidence review
No economic evaluations were identified which were applicable to this review question.
Economic model
This question was a medium priority for economic evaluation. However, the identified clinical data was very limited and insufficient to inform useful economic modelling in this area.
Evidence statements
Clinical evidence statements
Stopping PN when EN reached 100ml/kg/day versus stopping PN when EN reached 140ml/kg/day
Weight gain
- Moderate quality evidence from 1 RCT (n=137) showed no clinically important difference in time to regain birth weight in VLBW and ELBW babies who had PN stopped at 100ml/kg/day of EN compared with 140ml/kg/day of EN. However, there was uncertainty around the effect: Mean difference (MD) 1.50 days (95% CI 0.31 to 2.69).
- Moderate quality evidence from 1 RCT (n=83) showed no clinically important difference in time to regain birth weight in VLBW babies who had PN stopped at 100ml/kg/day of EN compared with 140ml/kg/day of EN. However, there was uncertainty around the effect: MD 0.60 days (95% CI −0.80 to 2.00).
- Moderate quality evidence from 1 RCT (n=54) showed a clinically important difference in time to regain birth weight in ELBW babies who had PN stopped at 100ml/kg/day of EN compared with 140ml/kg/day of EN with longer time to regain birthweight associated with stopping at the lower EN. However, there was uncertainty around the effect: MD 2.80 days (95% CI 0.80 to 4.80).
- High quality evidence from 1 RCT (n=137) showed no clinically important difference in weight at discharge in babies who had PN stopped at 100ml/kg/day of EN compared with 140ml/kg/day of EN, MD 13.00g (95% CI −191.05 to 217.05).
- Low quality evidence from 1 RCT (n=137) showed no clinically important difference in the number of babies whose weight was less than the 10th centile at discharge between those who had PN stopped at 100ml/kg/day of EN compared with 140ml/kg/day of EN. However, there was high uncertainty around the effect: Relative risk (RR) 1.09 (95% CI 0.70 to 1.68).
Linear growth
- High quality evidence from 1 RCT (n=137) showed no clinically important difference in length at discharge in babies who had PN stopped at 100ml/kg/day of EN compared with 140ml/kg/day of EN, MD 0.90cm (95% CI −0.54 to 2.34).
- Low quality evidence from 1 RCT (n=137) showed no clinically important difference in the number of babies whose length was less than the 10th centile at discharge between those who had PN stopped at 100ml/kg/day of EN compared with 140ml/kg/day of EN. However, there was high uncertainty around the effect: RR 1.07 (95% CI 0.78 to 1.48).
Head circumference
- High quality evidence from 1 RCT (n=137) showed no clinically important difference in head circumference at discharge in babies who had PN stopped at 100ml/kg/day of EN compared with 140ml/kg/day of EN, MD 0.10cm (95% CI −0.87 to 0.67).
- Low quality evidence from 1 RCT (n=137) showed a clinically important difference in the number of babies whose head circumference was less than the 10th centile at discharge between those who had PN stopped at 100ml/kg/day of EN compared with 140ml/kg/day of EN with more babies below the 10th centile in the group of babies stopped at the lower EN. However, there was high uncertainty around the effect: RR 1.27 (95% CI 0.68 to 2.37).
Mortality
- Low quality evidence from 1 RCT (n=137) showed no clinically important difference in mortality in babies who had PN stopped at 100ml/kg/day of EN compared with 140ml/kg/day of EN. However, there was high uncertainty around the effect: RR 1.04 (95% CI 0.22 to 5.00).
Necrotising enterocolitis
- Low quality evidence from 1 RCT (n=137) showed a clinically important difference in the number of babies with necrotising enterocolitis between those who had PN stopped at 100ml/kg/day of EN compared with 140ml/kg/day of EN with more babies with necrotising enterocolitis associated with stopping at a higher EN. However, there was high uncertainty around the effect: RR 0.35 (95% CI 0.04 to 3.27).
Sepsis
- Low quality evidence from 1 RCT (n=137) showed a clinically important difference in the number of babies with central venous catheter-associated late onset sepsis between those who had PN stopped at 100ml/kg/day of EN compared with 140ml/kg/day of EN with more babies with central venous catheter-associated late onset sepsis associated with stopping at a higher EN. However, there was high uncertainty around the effect: RR 0.35 (95% CI 0.04 to 3.27).
Stopping PN when EN reached 100ml/kg/day versus stopping PN when EN reached 120ml/kg/day
Weight gain
- Very low quality evidence from 1 observational study (n=87) showed no clinically important difference in time to regain birth weight in babies who had PN stopped at 100ml/kg/day of EN compared with 120ml/kg/day of EN. However, there was uncertainty around the effect: MD −3.40 days (95% CI −6.45 to 0.35).
- Very low quality evidence from 1 observational study (n=87) showed a clinically important difference in the number of babies whose weight was less than the 10th centile at 36 weeks’ post conception between those who had PN stopped at 100ml/kg/day of EN compared with 120ml/kg/day of EN, with more babies below the 10th centile in the group of babies stopped at the higher EN. However, there was uncertainty around the effect: RR 0.72 (95% CI 0.58 to 0.90).
- Very low quality evidence from 1 observational study (n=87) showed a clinically important difference in the number of babies whose weight was less than the 10th centile at 40 weeks’ post conception between those who had PN stopped at 100ml/kg/day of EN compared with 120ml/kg/day of EN, with more babies below the 10th centile in the group of babies stopped at the higher EN. However, there was uncertainty around the effect: RR 0.56 (95% CI 0.39 to 0.80).
Linear growth
- Very low quality evidence from 1 observational study (n=87) showed a clinically important difference in the number of babies whose length was less than the 10th centile at 36 weeks’ post conception between those who had PN stopped at 100ml/kg/day of EN compared with 120ml/kg/day of EN, with more babies below the 10th centile in the group of babies stopped at the higher EN. However, there is uncertainty around the effect: RR 0.76 (95% CI 0.59 to 1.00).
- Very low quality evidence from 1 observational study (n=87) showed a clinically important difference in the number of babies whose length was less than the 10th centile at 40 weeks’ post conception between those who had PN stopped at 100ml/kg/day of EN compared with 120ml/kg/day of EN, with more babies below the 10th centile in the group of babies stopped at the higher EN. However, there is uncertainty around the effect: RR 0.79 (95% CI 0.63 to 0.99).
Head circumference
- Very low quality evidence from 1 observational study (n=87) showed a clinically important difference in the number of babies whose head circumference was less than the 10th centile at 36 weeks’ post conception between those who had PN stopped at 100ml/kg/day of EN compared with 120ml/kg/day of EN, with more babies below the 10th centile in the group of babies stopped at the higher EN: RR 0.54 (95% CI 0.37 to 0.77).
- Very low quality evidence from 1 observational study (n=87) showed a clinically important difference in the number of babies whose head circumference was less than the 10th centile at 40 weeks’ post conception between those who had PN stopped at 100ml/kg/day of EN compared with 120ml/kg/day of EN, with more babies below the 10th centile in the group of babies stopped at the higher EN. However, there is uncertainty around the effect: RR 0.60 (95% CI 0.41 to 0.88).
Duration of hospital stay
- Very low quality evidence from 1 observational study (n=87) showed no clinically important difference in duration of hospital stay in babies who had PN stopped at 100ml/kg/day of EN compared with 120ml/kg/day of EN. However, there is uncertainty around the effect: MD −7.90 days (95% CI −19.10 to 3.30).
Necrotising enterocolitis
- Very low quality evidence from 1 observational study (n=87) showed a clinically important difference in the number of babies with necrotising enterocolitis between those who had PN stopped at 100ml/kg/day of EN compared with 120ml/kg/day of EN, with more babies with necrotising enterocolitis associated with stopping at a lower EN. However, there is uncertainty around the effect: Peto odds ratio (POR) 5.82 (95% CI 0.35, 97.53).
Duration of PN
- Very low quality evidence from 1 observational study (n=87) showed no clinically important difference in duration of PN in babies who had PN stopped at 100ml/kg/day of EN compared with 120ml/kg/day of EN. However, there is uncertainty around the effect: MD −3.50 days (95% CI −9.88 to 2.88).
Sepsis
- Very low quality evidence from 1 observational study (n=87) showed a clinically important difference in the number of babies with sepsis between those who had PN stopped at 100ml/kg/day of EN compared with 120ml/kg/day of EN, with more babies with sepsis associated with stopping at a lower EN. However, there is high uncertainty around the effect: RR 0.79 (95% CI 0.46 to 1.34).
Stopping PN when EN reached 60kcal/kg/day versus stopping PN when EN reached 100kcal/kg/day
Weight gain
- Very low quality evidence from 1 observational study (n=182) showed a clinically important difference in the number of babies with postnatal growth failure at 40 weeks’ postmenstrual age between those who had PN stopped at 60kcal/kg/day of EN compared with 100kcal/kg/day of EN, with more babies with growth failure in the group of babies stopped at the lower EN. However, there is uncertainty around the effect: RR 1.45 (95% CI 1.17 to 1.80).
Linear growth
- Very low quality evidence from 1 observational study (n=182) showed no clinically important difference in length at 40 weeks’ postmenstrual age in babies who had PN stopped at 60kcal/kg/day of EN compared with 100kcal/kg/day of EN. However, there is uncertainty around the effect: MD −1.00cm (95% CI −1.81 to −0.19).
Head circumference
- Very low quality evidence from 1 observational study (n=182) showed a clinically important difference in head circumference at 40 weeks’ postmenstrual age in babies who had PN stopped at 60kcal/kg/day of EN compared with 100kcal/kg/day of EN, with greater head circumference in the group of babies stopped at the higher EN: MD −0.90cm (95% CI −0.96 to −0.84).
Necrotising enterocolitis
- Very low quality evidence from 1 observational study (n=182) showed a clinically important difference in the number of babies with necrotising enterocolitis between those who had PN stopped at 60kcal/kg/day of EN compared with 100kcal/kg/day of EN, with more babies with necrotising enterocolitis associated with stopping at a lower EN. However, there is high uncertainty around the effect: RR 2.70 (95% CI 0.46 to 15.75).
Late onset sepsis
- Very low quality evidence from 1 observational study (n=182) showed no clinically important difference in the number of babies with late onset sepsis between those who had PN stopped at 60kcal/kg/day of EN compared with 100kcal/kg/day of EN. However, there is high uncertainty around the effect: RR 0.90 (95% CI 0.52 to 1.55).
Economic evidence statements
No economic evidence was identified which was applicable to this review question.
The committee’s discussion of the evidence
Interpreting the evidence
The outcomes that matter most
EN is less energy dense than PN, which is designed to provide an ideal energy composition. Additionally, EN must be digested in order to release energy, as opposed to PN which is delivered ‘ready to use’. Therefore, the committee prioritised total nutritional intake, growth and body composition measures as critical outcomes, as nutritional intake has a direct impact on growth and body composition.
Mortality and neurodevelopmental outcomes were selected as important outcomes as these are also likely to be affected by differences in nutrition. Sepsis was selected as an important outcome as there is an increased risk of sepsis with longer duration of PN due to the presence of inserted lines. For this reason, duration of PN was also selected as an important outcome to help quantify the risk or benefit associated with stopping PN at different thresholds. Finally, duration of hospital stay and necrotising enterocolitis were selected as important outcomes as these may be affected by EN, nutritional intake and duration of PN.
The quality of the evidence
The quality of the evidence for this review was assessed using GRADE methodology. The observational evidence was very low quality due to risk of bias in the included studies and uncertainty around the effects. The RCT evidence ranged from low to high quality and was downgraded due to uncertainty around the effects.
The committee noted that the evidence from the observational studies was confounded due to differences in the PN regimens used between arms, which were in addition to the difference in the point at which PN was stopped. For example, in one study (Choi 2016), the nutritional intake from PN was higher in the arm that stopped PN at a smaller volume of EN compared with the arm that stopped at a higher volume of EN. It was therefore often difficult to interpretdifferences in the outcomes between groups. The committee were also concerned that the duration of PN in one of the observational studies (Choi 2016) was much longer than they would expect based on their knowledge, so may not be representative of practice. The committee also acknowledged that it was difficult to make comparisons across the studies due to the overlap in doses administered to babies in the low and high energy arms of the studies. Therefore, the committee agreed that it was not possible to draw firm conclusions about the point at which PN should be stopped from the observational evidence.
There was no RCT evidence available for nutritional intake, body composition or neurodevelopmental outcomes and duration of PN and hospital stay were not reported sufficiently for analysis.
Benefits and harms
The committee discussed that, based on their expertise, there are a number of factors that need to be considered when making the decision to stop PN, beyond the volume of EN that has been reached. How well enteral feeds are being tolerated should be considered as further PN may be required if babies stop tolerating enteral feeds. Further, the nutritional composition of different types of EN is not equivalent and consideration should therefore be given to the composition of EN before PN is stopped to avoid nutritional deficits. Consideration should also be given to the relative benefit of additional nutritional intake from maintaining PN and the risk of venous catheter sepsis, which may be dependent on the gestational age and size of the baby. Finally, the committee discussed the need to consider the individual baby’s circumstances as the decision to stop PN for babies with complex or surgical conditions is more complicated. The committee discussed that clinicians may want to wait until increasing volumes of EN have been tolerated for a longer period of time before stopping PN, and to consider how difficult it may have been to obtain venous access, and how many venous access sites are remaining before PN is stopped. However, there was no evidence for this group so the committee could not make specific recommendations.
The RCT evidence showed that it took longer for extremely low birth weight babies to regain their birthweight if PN was stopped at a smaller volume of EN (100ml/kg/day) compared with a larger volume of EN (140ml/kg/day). There were no clinically important differences based on the stopping point of PN for any of the growth outcomes in extremely low and very low birth weight babies combined, with the exception of head circumference which was more likely to be in the bottom 10th centile when PN was stopped at a smaller volume of EN. There were no clinically important differences in mortality rates between groups.
Low quality evidence showed an increased risk of sepsis and necrotising enterocolitis when PN was stopped at a larger volume of EN compared with a smaller volume of EN. The committee agreed this was consistent with their expectation of increased risk of sepsis with longer duration of PN and that the decision to stop PN requires a balance between optimising nutritional intake and minimising the risk of sepsis. However, the committee acknowledged that the study was powered to detect differences in time taken to regain birthweight, not adverse events.
The committee agreed that for extremely low birth weight babies, prioritising nutrition, and therefore growth, was most critical and that PN should be stopped at a larger volume of EN. Whilst the evidence related to extremely low birth weight the committee decided to make recommendations based on gestational age (extremely preterm babies <28+0 weeks’ gestation) rather than birthweight to be consistent with other recommendations made in this guideline and because extremely preterm babies would be more likely to have extremely low birth weight than babies born at a later gestational age. The committee noted that EN was fortified at 140ml/kg/day in the RCT, which is not common in clinical practice so there was concern from the committee that nutrition may be inadequate if PN was stopped at 140ml/kg/day when EN was not fortified. Therefore, the committee recommended that clinicians consider stopping PN when EN reached 140-150ml/kg/day. The upper limit of 150ml/kg/day was recommended as the committee agreed that this was the threshold at which the potential benefits of continuing PN would not outweigh the risks and, therefore, the balance favoured discontinuing PN.
The committee discussed that it is important to maintain nutritional intake when transitioning from parenteral to enteral nutrition. However, the committee discussed that clinicians may consider stopping PN at a lower volume of enteral feeds for babies born from 28+0 weeks’ gestation onwards than for extremely preterm babies, as the balance between the risk from nutritional shortfall and the risk of sepsis may be different in this population. The committee acknowledged that this balance may be different for growth restricted babies but did not have evidence to support a specific recommendation for this group. The committee discussed the lower threshold for stopping PN in babies born from 28+0 weeks’ gestation at length. Whilst there was little evidence of growth deficits for very low birthweight babies in the RCT when PN was stopped at 100ml/kg/day, the committee were concerned that this threshold was too low and would result in stopping PN before adequate nutritional intake had been achieved. Therefore, the committee recommended by informal consensus that clinicians consider stopping PN when EN reached 120-140ml/kg/day for these babies.
The committee agreed that the thresholds specified in these recommendations should be the point at which PN is no longer prescribed, but that any existing PN which is still in place should be finished. In practical terms, the committee agreed this would mean stopping PN within 24 hours of EN volume reaching the specified volumes.
Cost effectiveness and resource use
No economic studies were identified which were applicable to this review question.
The committee discussed that these recommendations would reduce variation in practice as the point at which parental nutrition is stopped is inconsistent across services. For some services, these recommendations will result in providing PN for a longer duration, which would have increased costs associated with additional PN and nurse time required to administer PN. However, for other services, these recommendations would result in providing PN for a shorter duration and may produce cost savings.
The volume of PN is decreased as the volume of EN is increased during the transition from PN to EN. Therefore, the committee were concerned that stopping PN at larger volumes of EN may result in very small volumes of PN being prescribed, which would not be practical or economically viable i.e. due to a high wastage of PN. As a result, the committee discussed whether there should be a minimum volume of parental nutrition that is prescribed, such as 30ml/kg/day. This could mean that PN is stopped at this point, or that this volume is maintained, rather than decreased further, until the threshold of EN is reached. However, the minimal volume of parental nutrition was outside the scope of this review question, so no evidence was reviewed to support a minimal volume.
The committee noted that there is a need to balance the risk and benefits of PN including optimising nutritional intake and minimising the risk of sepsis and necrotising enterocolitis i.e. there was evidence of an increased risk of sepsis and necrotising enterocolitis when PN is stopped at a larger volume of EN compared with a smaller volume of EN. However, the committee questioned the finding for necrotising enterocolitis due to the studies being underpowered to detect a difference in this outcome. The recommendations in this area will mean that PN is stopped at an optimal time and will potentially result in fewer cases of sepsis. Sepsis incurs substantial costs to the NHS. According to the Hospital Episode Statistics 2016/17 the mean duration of stay at NICU was 8 days for babies with sepsis. The mean cost of stay at NICU is £1,445 per day. Any strategy that reduces the risk of sepsis is likely to represent a cost effective use of NHS resources.
Other factors the committee took into account
Whilst the focus of this review question was the point at which PN should be stopped, the committee agreed that it was also important to ensure that adequate nutritional intake has been reached before weaning from PN is started. However, they could not make recommendations in this area as it was outside the scope of the review question.
References
Choi 2016
Choi, A. Y., Lee, Y. W., Chang, M. Y., Modification of nutrition strategy for improvement of postnatal growth in very low birth weight infants, Korean Journal of Pediatrics, 59, 165–173, 2016 [PMC free article: PMC4865639] [PubMed: 27186226]Dinerstein 2006
Dinerstein, A., Nieto, R. M., Solana, C. L., Perez, G. P., Otheguy, L. E., Larguia, A. M., Early and aggressive nutritional strategy (parenteral and enteral) decreases postnatal growth failure in very low birth weight infants, Journal of Perinatology, 26, 436–42, 2006 [PubMed: 16801958]Perrem 2019
Perrem, L., Semberova, J., O’Sullivan, A., Kieran, E. A., O’Donnel, C. P. F., White, M. J., Miletin, J., Effect of early parenteral nutrition discontinuation on time to regain birth weight in very low birth weight infants: a randomized controlled trial, Journal of Parenteral and Enteral Nutrition, 2019 [PubMed: 30613992]
Appendices
Appendix A. Review protocols
Review protocol for review question: What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to PN and enteral feeds) indicates that parenteral nutrition is no longer required?
Table 3. Review protocol – stopping parenteral nutrition in preterm and term babies
Appendix B. Literature search strategies
Literature search strategies for review question: What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to PN and enteral feeds) indicates that parenteral nutrition is no longer required?
Appendix C. Clinical evidence study selection
Clinical study selection for: What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to PN and enteral feeds) indicates that parenteral nutrition is no longer required?
Appendix D. Clinical evidence tables
Clinical evidence tables for review question: What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to PN and enteral feeds) indicates that parenteral nutrition is no longer required?
Table 4. Clinical evidence tables (PDF, 282K)
Appendix E. Forest plots
Forest plots for review question: What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to PN and enteral feeds) indicates that parenteral nutrition is no longer required?
No meta-analysis was conducted for this review; therefore there are no forest plots.
Appendix F. GRADE tables
GRADE tables for review question: What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to PN and enteral feeds) indicates that parenteral nutrition is no longer required?
Appendix G. Economic evidence study selection
Economic evidence study selection for review question: What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to PN and enteral feeds) indicates that parenteral nutrition is no longer required?
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: What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to PN and enteral feeds) indicates that parenteral nutrition is no longer required?
No economic studies were identified which was applicable to this review question.
Appendix I. Economic evidence profiles
Economic evidence profiles for review question: What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to PN and enteral feeds) indicates that parenteral nutrition is no longer required?
No economic studies were identified which was applicable to this review question.
Appendix J. Economic analysis
Economic evidence analysis for review question: What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to PN and enteral feeds) indicates that parenteral nutrition is no longer required?
No economic analysis was undertaken for this review question.
Appendix K. Excluded studies
Excluded clinical and economic studies for review question: What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to PN and enteral feeds) indicates that parenteral nutrition is no longer required?
Clinical studies
Economic studies
No economic evidence was identified for this review. See supplementary material D for further information.
Appendix L. Research recommendations
Research recommendations for review question: What amount of enteral feed (measured in terms of ml/kg/d, or kcal/kg/d, or ratios in relation to PN and enteral feeds) indicates that parenteral nutrition is no longer required?
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)
- Stopping parenteral nutritionStopping parenteral nutrition
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