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1.
Cochrane Database Syst Rev ; 4: CD013141, 2020 04 08.
Artigo em Inglês | MEDLINE | ID: mdl-32266712

RESUMO

BACKGROUND: Recently conducted randomised controlled trials (RCTs) suggest that late commencement of parenteral nutrition (PN) may have clinical benefits in critically ill adults and children. However, there is currently limited evidence regarding the optimal timing of commencement of PN in critically ill term and late preterm infants. OBJECTIVES: To evaluate the benefits and safety of early versus late PN in critically ill term and late preterm infants. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (5 April 2019), MEDLINE Ovid (1966 to 5 April 2019), Embase Ovid (1980 to 5 April 2019), EMCare (1995 to 5 April 2019) and MEDLINE via PubMed (1966 to 5 April 2019). We searched for ongoing or recently completed clinical trials, and also searched the grey literature and reference lists of relevant publications. SELECTION CRITERIA: We included RCTs comparing early versus late initiation of PN in term and late preterm infants. We defined early PN as commencing within 72 hours of admission, and late PN as commencing after 72 hours of admission. Infants born at 37 weeks' gestation or more were defined as term, and infants born between 34 and 36+6 weeks' gestation were defined as late preterm. DATA COLLECTION AND ANALYSIS: Two review authors independently selected the trials, extracted the data and assessed the risk of bias. Treatment effects were expressed using risk ratio (RR) and risk difference (RD) for dichotomous outcomes and mean difference (MD) for continuous data. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: Two RCTs were eligible for inclusion. Data were only available from a subgroup (including 209 term infants) from one RCT in children (aged from birth to 17 years) conducted in Belgium, the Netherlands and Canada. In that RCT, children with medium to high risk of malnutrition were included if a stay of 24 hours or more in the paediatric intensive care unit (PICU) was expected. Early PN and late PN were defined as initiation of PN within 24 hours and after day 7 of admission to PICU, respectively. The risk of bias for the study was considered to be low for five domains and high for two domains. The subgroup of term infants that received late PN had significantly lower risk of in-hospital all-cause mortality (RR 0.35, 95% confidence interval (CI) 0.14 to 0.87; RD -0.10, 95% CI -0.18 to -0.02; number needed to treat for an additional beneficial outcome (NNTB) = 10; 1 trial, 209 participants) and neonatal mortality (death from any cause in the first 28 days since birth) (RR 0.29, 95% CI 0.10 to 0.88; RD -0.09, 95% CI -0.16 to -0.01; NNTB = 11; 1 trial, 209 participants). There were no significant differences in rates of healthcare-associated blood stream infections, growth parameters and duration of hospital stay between the two groups. Neurodevelopmental outcomes were not reported. The quality of evidence was considered to be low for all outcomes, due to imprecision (owing to the small sample size and wide confidence intervals) and high risk of bias in the included studies. AUTHORS' CONCLUSIONS: Whilst late commencement of PN in term and late preterm infants may have some benefits, the quality of the evidence was low and hence our confidence in the results is limited. Adequately powered RCTs, which evaluate short-term as well as long-term neurodevelopmental outcomes, are needed.


Assuntos
Estado Terminal/terapia , Nutrição Parenteral/estatística & dados numéricos , Aminoácidos/administração & dosagem , Aminoácidos/efeitos adversos , Viés , Infecção Hospitalar/epidemiologia , Emulsões Gordurosas Intravenosas/administração & dosagem , Emulsões Gordurosas Intravenosas/efeitos adversos , Mortalidade Hospitalar , Humanos , Hipoglicemia/epidemiologia , Lactente , Mortalidade Infantil , Recém-Nascido , Recém-Nascido Prematuro , Tempo de Internação , Lipídeos/administração & dosagem , Lipídeos/efeitos adversos , Nutrição Parenteral/efeitos adversos , Nutrição Parenteral/mortalidade , Soluções de Nutrição Parenteral/administração & dosagem , Soluções de Nutrição Parenteral/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial/estatística & dados numéricos , Nascimento a Termo , Fatores de Tempo
2.
Eur J Pediatr Surg ; 27(6): 503-515, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28114704

RESUMO

Introduction There are no evidence-based strategies to improve feed tolerance in gastroschisis. Early commencement of enteral feeds (CEF) is known to improve feed tolerance in preterm infants. It is possible that infants with gastroschisis may also benefit from early CEF. Objective To conduct a systematic review to evaluate the relationship between time of CEF, and time to reach full enteral feeds (FEF), duration of parenteral nutrition (PN), and duration of hospital stay (HS). Methods PubMed, EMBASE, Cochrane CENTRAL, and relevant conference abstracts were searched in December 2015. Studies of any design reporting on time to CEF and one or more of the outcomes of interest were included. Meta-regression analysis was conducted to find the association between time to CEF and the outcomes of interest. Results There were no randomized controlled trials (RCTs) comparing early (≤7 days from birth) versus delayed (>7 days) CEF. Forty-two observational studies on gastroschisis (4,835 infants) where feed-related information was available were included. Meta-regression results indicated that each day delay in CEF was associated with a delay of an additional 1.4 days (95% confidence interval [CI]: 0.95, 1.85) to FEF, 2.05 days (95% CI: 1.50, 2.59) to the duration of PN, and 1.91 days (95% CI: 1.37, 2.45) to the duration of HS. Sensitivity analysis after excluding studies that provided information exclusively on complex gastroschisis continued to show beneficial effects of early CEF. Conclusion Early CEF may be associated with early attainment of FEF in gastroschisis. RCTs comparing early versus delayed CEF are needed urgently.


Assuntos
Nutrição Enteral/métodos , Gastrosquise/terapia , Humanos , Recém-Nascido , Nutrição Parenteral/métodos , Fatores de Tempo , Resultado do Tratamento
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