1. Guidelines on 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)
*Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Germany; †Hopital Necker-Enfants Malades, Paris, France, ‡Meyer Children's Hospital, Haifa, Israel
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BACKGROUNDThese Guidelines for Paediatric Parenteral Nutrition have been developed as a mutual project of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN; www.espghan.org) and the European Society for Clinical Nutrition and Metabolism (ESPEN; www.espen.org). The guidelines are addressed primarily to professionals involved in supplying and prescribing parenteral nutrition (PN) to infants, children and adolescents. Due to the scarcity of good quality clinical trials in children many of the recommendations are extrapolated from adult studies and are based on expert opinion. The document represents the consensus of view of a multidisciplinary working party of professionals, who are all actively involved in the management of children treated with PN.Guidelines are intended to serve as an aid to clinical judgement, not to replace it, as outlined by the Scottish Intercollegiate Guideline Network (http://www.sign.ac.uk/guidelines/fulltext/50/section1.html). Guidelines do not provide answers to every clinical question; nor does adherence to guidelines ensure a successful outcome in every case. The ultimate decision about clinical management of an individual patient will always depend on the clinical circumstances (and wishes) of the patient, and on the clinical judgement of the health care team. These guidelines are not intended to be construed or to serve as a standard of medical care.Parenteral Nutrition in ChildrenPN is used to treat children that cannot be fully fed by oral or enteral route, for example due to severe intestinal failure (1). Intestinal failure occurs when the gastrointestinal tract is unable to ingest, digest and absorb sufficient macronutrients and/or water and electrolytes to maintain health and growth. Children differ from adults in that their food intake must provide sufficient nutrients not only for the maintenance of body tissues but also for growth. This is particularly true in infancy and during adolescence when children grow extremely rapidly. At these times children are particularly sensitive to energy restriction because of high basal and anabolic requirements.The ability to provide sufficient nutrients parenterally to sustain growth in infants and children suffering from intestinal failure or severe functional intestinal immaturity represents one of the most important therapeutic advances in paediatrics over the last three decades. Improvements in techniques for artificial nutritional support now ensure that children in whom digestion and absorption are inadequate or who are unable to eat normally no longer need to suffer from the serious consequences of malnutrition including death. Since the 1960s, the wider availability of intravenous amino acid solutions and lipid emulsions resulted in successful prescription of PN in small infants, which was followed by the development of more appropriate solutions and delivery systems. PN can now be used not only for patients who require short-term parenteral feeding but also on a long-term basis for patients with chronic intestinal failure. With PN children with prolonged intestinal failure have the potential to grow and develop normally and to enjoy a good quality of life within the constraints of their underlying disease, and selected patients with irreversible intestinal failure may thus become candidates for intestinal transplantation (2). Whilst advances in knowledge of nutrient requirements, improved methods of nutrient delivery and understanding of the prevention and management of complications ensure that paediatric PN can generally be delivered safely and effectively, areas of uncertainty and controversy remain.PN is usually indicated when a sufficient nutrient supply cannot be provided orally or enterally to prevent or correct malnutrition or to sustain appropriate growth. Every effort should be made to avoid PN with the use of adequate care, specialised enteral feeds and artificial feeding devices as appropriate.