RANDOMISED CONTROLLED TRIAL OF AGGRESSIVE VS SLOW GRADING UP OF TOTAL PARENTERAL NUTRITION IN PRETERM NEONATES

1. Title: Randomised controlled trial comparing aggressive vs slow grading up of total parenteral nutrition in preterm neonates. 2. Department: Department of Neonatology, Christian Medical College, Vellore. 3. Name of the Candidate: Binu Govind 4. Degree and Subject: DM Neonatology 5. Name of Guide: Dr. Kurien Anil Kuruvilla 6. Word Count: 499 7. Background: Premature babies are not able to absorb the essential components of milk like their term counterparts because of immaturity of the gut. Hence, total parenteral nutrition is provided to meet their requirements. It is important to determine whether preterm babies can tolerate high amounts of lipid and amino acid from day 1 to improve the nutrition and whether the benefits outweigh the risks. 8. Objective: To compare the differences in the determinants of growth (weight, length and head circumference) following aggressive vs standard (slow grading up) TPN in preterm babies. 9. Setting: Tertiary care perinatal centre in south India 10. Methods: This was a double blind randomised control trial where preterm babies ≤1300g were given aggressive or standard TPN. Aggressive TPN group was started on 3.5g/kg of amino acid and 3 g/kg of lipid from day 1 of life. Standard TPN group was started on 1 g/kg of amino acid from day 1 and 1g/kg of lipid from day 2 of life; increasing by 0.5g/kg to a maximum of 3.5g/kg of amino acid and 3 g/kg of lipid over a period of 5-6 days. The two groups were compared for differences in gain in weight, length, head circumference; morbidity patterns, metabolic abnormalities, time to reach adequate enteral feeds and regain birth weight. 11. Results: Babies in the aggressive TPN group gained more weight compared to the standard group but the difference in rate of growth was not statistically significant (mean (SD) 10.06 (4.11) vs 9.61(3.91),p=0.66). Similarly, the gain in length and head circumference was also higher in the aggressive group (length in cm/week: 1.11(0.55) vs 0.98(0.62),p=0.40; head circumference in cm/week (0.80(0.19) vs 0.79(0.23),p=0.82). The time to regain birth weight was more in the standard group (14(5.62) vs 12.53(4.31), p=0.26) compared to the aggressive group. The time to reach nasogastric feeds of 100ml/kg/day was longer in the aggressive group, but the difference was not statistically significant (11.73 (4.60) vs 10.79 (3.86), p= 0.60). The duration of TPN administration was comparable between the aggressive and standard groups (7.86 (5.67) vs 7.57(3.33),p=0.75). 12. Conclusion: Providing increased amounts of amino acid and lipid from day one showed a trend towards a positive effect on weight, length and head circumference when compared to the standard method of TPN administration in preterm babies ≤1300g. However the difference did not reach statistical significance in this study. The number of days needed to attain full nasogastric feeds was longer in the aggressive group and days to regain birth weight was less in the aggressive group but the differences were not statistically significant. There was no significant difference in the morbidities and metabolic problems in babies in the aggressive and standard TPN groups.