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Impact of a standardised parenteral nutrition protocol: a quality improvement experience from a NICU of a developing country
  1. Gul Ambreen1,
  2. Vikram Kumar2,
  3. Syed Rehan Ali2,
  4. Uswa Jiwani3,
  5. Waqar Khowaja4,
  6. Ali Shabbir Hussain4,
  7. Kashif Hussain1,
  8. Syed Shamim Raza1,
  9. Arjumand Rizvi4,
  10. Uzair Ansari4,
  11. Khalil Ahmad4,
  12. Simon Demas4,
  13. Shabina Ariff4
  1. 1 Department of Pharmacy, Aga Khan University Hospital, Karachi, Pakistan
  2. 2 Neonatology, Indus Hospital and Health Network, Karachi, Sindh, Pakistan
  3. 3 Center of Excellence in Women and Child Health, Aga Khan University Hospital, Karachi, Pakistan
  4. 4 Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
  1. Correspondence to Dr Shabina Ariff, Department of Paediatrics & Child Health, Aga Khan University Hospital, Karachi 74800, Pakistan; shabina.ariff{at}


Objective Nutrition societies recommend using standardised parenteral nutrition (SPN) solutions. We designed evidence-based SPN formulations for neonates admitted to our neonatal intensive care unit (NICU) and evaluated their outcomes.

Design This was a quality improvement initiative. Data were collected retrospectively before and after the intervention.

Setting A tertiary-care level 3 NICU at the Aga Khan University in Karachi, Pakistan.

Patients All NICU patients who received individualised PN (IPN) from December 2016 to August 2017 and SPN from October 2017 to June 2018.

Interventions A team of neonatologists and nutrition pharmacists collaborated to design two evidence-based SPN solutions for preterm neonates admitted to the NICU.

Main outcome measures We recorded mean weight gain velocity from days 7 to 14 of life. The other outcomes were change in weight expressed as z-scores, metabolic abnormalities, PN-associated liver disease (PNALD), length of NICU stay and episodes of sepsis during hospital stay.

Results Neonates on SPN had greater rate of change in weight compared with IPN (β=13.40, 95% CI: 12.02 to 14.79) and a smaller decrease in z-scores (p<0.001). Neonates in the SPN group had fewer hyperglycemic episodes (IPN: 37.5%, SPN: 6.2%) (p<0.001), electrolyte abnormalities (IPN: 56.3%, SPN: 21%) (p<0.001), PNALD (IPN: 52.5%, SPN: 18.5%) (p<0.001) and sepsis (IPN: 26%, SPN: 20%) (p<0.05). The median length of stay in NICU was 14.0 (IQR 12.0–21.0) for the IPN and 8.0 (IQR 5.0–13.0) days for the SPN group.

Conclusions We found that SPN was associated with shorter NICU stay and greater weight gain. In-house preparation of SPN can be used to address the nutritional needs in resource-limited settings where commercially prepared SPN is not available.

  • nutrition
  • neonatology

Data availability statement

Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as suplementary information.

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Data availability statement

Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as suplementary information.

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  • GA and VK contributed equally.

  • Contributors SA, RA and AH conceptualised the design. GA, VKK and KA contributed to instrument development. WK, GA, VKK and SD carried out data collection. KH and SSR facilitated from pharmacy perspective for approvals and data retrieval. GA and UJ wrote the first draft. AR and UA carried out the analysis. SA critically revised the subsequent drafts. All authors contributed to the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.