PARENTERAL NUTRITION OF PREMATURE INFANTS IN AFRICA: A CHALLENGE?

Dr Ndèye Ramatoulaye Diagne Guèye, MCA in Pediatrics

Unit of training and research in Health Sciences, University of Thiès.

In developing countries, neonatal health is a public health concern. The leading causes of neonatal death are dominated by low birth weight (37%), infections and perinatal asphyxia [1]. Low-birth-weight babies (LBW) (<2500 g) require optimal nutritional and caloric intakes to avoid the development of ectopic growth retardation (EGR) observed in 40-90% of premature infants [2]. Postnatal growth restriction is associated with long-term deleterious effects on growth, cerebral development and cognitive functions [3-5], but also on chronic lung disease [6]. Similarly, inadequate diet in this early period of life is associated with a risk of metabolic and cardiovascular disease occurring in adulthood [7].

The nutrition objective of the premature child is therefore to pursue growth and development in a manner similar to that of the fetus of the same age and thus to avoid ectopic growth retardation (EGR) [8]. For this, nutrition should be optimal from the first days of life, which is difficult with the enteral pathway which is usually started towards the third day of life with low amounts because of the frequent problems of digestive tolerance [9]. Therefore, it seems often indispensable or even impossible to circumvent the use of parenteral nutrition (PN) in the first weeks of life to avoid the risk of ectopic growth retardation. In a study by Faye et al in Senegal, the risk of developing EGR was associated with low lipid and protein intake at day 3 (p = 0.004).
However, this PN is not often available or accessible in developing countries. Even if the solutions were available, many other constraints would make it difficult or even unrealistic to use them routinely: the need for a secure central channel, strict aseptic conditions, monitoring of side effects, etc. Preparation would require, for example, Neonatology of laminar air flow hoods to prepare solutions, which involves architectural modifications; unless you opt for standard NP preparations that do not always meet the specific needs of each preterm infant. Even in countries with long experience in neonatal PN, some shortcomings are still observed: procedural difficulties such as pharmaceutical validation of the manufacturing process, preparation of mixtures outside a controlled atmosphere zone, or failure of control of parenteral nutrition mixtures [10].

In spite of these difficulties, it seems necessary to gradually reflect on the conditions for practicing parenteral nutrition in our neonatal units, considering the deleterious effects in the short and long term of postnatal malnutrition. This reflection should be multidisciplinary, including pharmacists, pediatricians, pediatric gastroenterologists and paramedical teams.

References
1- Lawn JE, Blencowe H, Oza S, You D, Lee CA, Waiswa P et al. Every newborn: progress, priorities and potential beyond survival. Lancet Every Newborn Study Group. Lancet 2014; 384 (9938): 189-205.

2- Cooke RJ, Ainsworth SB, Fenton AC. Postnatal growth retardation: a universal problem in preterm infants. Arch Dis Child Fetal Neonatal Ed 2004; 89: F428-30.

3- Georgieff MK. Nutrition and the developing brain: nutrient priorities and measurement. Am J Clin Nutr 2007; 85: 614S-20S.

4- Isaacs EB, Gadian DG, Sabatini S, et al. The effect of early human diet on caudate volumes and IQ. Pediatr Res 2008; 63: 308-14.

5- Stephens BE, Walden RV, Gargus RA, et al. First-week protein and energy intakes are associated with 18-month developmental outcomes in extremely low birth weight infants. Pediatrics 2009; 123: 1337-43.

6-Ho MY, Yen YH, Hsieh MC, et al. Early versus late nutrition support in premature neonates with respiratory distress syndrome. Nutrition; 19: 257-60.

7- Barker DJ. The fetal and infant origins of adult diseases. Br Med J 1990; 301: 1111.

8- American Academy of Pediatrics on Nutrition: Nutritional needs of low-birth weight infants. Pediatrics 1985; 76: 976-986.

9- Faye PM, Diagne-Guèye NR, Paraiso IL, et al. Postnatal weight gain of low birth weight babies in the neonatal department of the Albert Royer Children's Hospital: incidence of ectopic growth retardation. Journal of Pediatrics and Childcare 2016; 29: 20-7

10- S. Bahri, I Jmour, I Maoudoud, S Sfar, O Corriol. / Clinical and metabolic nutrition 29 (2015) 77–87.