Newsletter

[ Vol. 10 No. 1 ] (January - April 2009 )
The ESPEN/ESPGHAN paediatric PN guidelones and their relevance to asia

Patrick A. Ball
Professor of Pharmacy, Charles Sturt University, Wagga Wagga NSW, Australia

The pan-European guidelines for pediatric parenteral nutrition were jointly sponsored by the European Society for Paediatric Gastroenterology and Nutrition and the European Society for Parenteral and Enteral Nutrition. The concept arose out of growing concerns that practices varied widely across Europe and that the differences were a consequence of reasons other than scientific evidence or the best interests of the child.

Parenteral Nutrition is a therapy which can be life-saving, safe, effective and cost effective when done properly. Further, a number of other therapies such as neonatal surgery, neonatal intensive care, cancer chemotherapy and organ transplantation are severely compromised, and the cost of these therapies may be wasted, if adequate nutrition support is not available to help the patient through the course of treatment. Even if carried out sub-optimally, it is generally better than starving the patient, but it has the risk of severe and expensive complications if carried out badly.

The concept was to produce a document that would providesufficient information for someone starting out to put together all the necessary pieces for a service, based upon the best available evidence, or where evidence is lacking, a strong international consensus of a multidisciplinary team of experienced experts.

The process was supported by unconditional financial support from Baxter Healthcare, B.Braun Melsungen, Fresenius-Kabi and the Child Health Foundation of Germany. All members of the team completed a disclosure of potential conflicts of interest.

The process is summarized in the table below. A steering committee was formed, forking groups were identified, a literature review was undertaken, the evidence summarized and circulated for comment. A plenary session was held to develop consensus where evidence was lacking. The guidelines were developed, circulated for consultation and comments, and then published in the Journal of Paediatric Gastroenterology and Nutrition.

The guidelines are divided into the following sections:

1. Introduction
2. Energy.
3. Amino Acids.
4. Lipids.
5. Carbohydrates.
6. Fluid and Electrolytes (Na, Cl and K)
7. Iron, Minerals and Trace Elements.
8. Vitamins.
9. Venous Access.
10. Organisational Aspects of Hospital PN.
11. Home Parenteral Nutrition in Children.
12. Complications.
13. Annex: List of Products.

Each section presents, a review of published evidence, specific recommendations with levels of evidence and grade of recommendation, and a comprehensive bibliography.

The guidelines have relevance to Asia in that they currently provide; the strongest evidence or broadest consensus on best practice that is currently available. Like Europe, standards vary widely across the membership of PENSA. For those who appear to be at or beyond the standards set out, the guidelines enable users to benchmark their services with ‘best practice’ across all aspects of nutrition support and ensure they are in line. They also provide an opportunity to protect services and facilities against cut-backs and cost-savings.

For those apparently behind the standards, they provide a target to aim for and justification of the need to aim for these standards. They also provide sufficient information to allow these services to be built from scratch.

For Asia, the guidelines may need adaptation. The number and skill level of allied health professionals available to supporta team may vary from country to country, but the guidelines clearly indicate the skills needed and it may be appropriate for some of these skills to be acquired by professionals other than those traditionally used in Europe owing to availability and training level constraints.

The guidelines provide a strong basis on the science of admixture stability, and this is important in matters such as generic substitution of solutions and components within a nutrition support service. The evidence is clear that substitution of alternative amino acid mixtures, lipid emulsions, additives etc requires full validation. These cannot be considered interchangeable items of commerce. The guidelines are having a profound influence on practice across Europe and beyond.

2005 Koletzko, B., Goulet, O., Hunt, J., Krohn, K., Shamir, R. for the Parenteral Nutrition Guidelines Working Group. Guidelines in Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), supported by the European Society of Paediatric Research (ESPR). Journal of Pediatric Gastroenterology and Nutrition 2005:41:S1-S87

From  
The 12^th PENSA Congress
October 18-20 2007, Century Park Hotel. Manila, Philippines 
Page: 38-39