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Paediatric parenteral nutrition

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VOL: 96, ISSUE: 49, PAGE NO: 12

Louise MortoN, RSCN, is clinical nurse specialist in chronic granulomatous disease, Great Ormond Street Hospital for Children NHS Trust, London

Milla, P.J. [ed] (2000) Current Perspectives on Paediatric Parenteral Nutrition: A Report by a Working Party at the British Association for Parenteral and Enteral Nutrition. £10.00, BAPEN, PO Box 922, Maidenhead, Berks, SL6 4XE

Milla, P.J. [ed] (2000) Current Perspectives on Paediatric Parenteral Nutrition: A Report by a Working Party at the British Association for Parenteral and Enteral Nutrition. £10.00, BAPEN, PO Box 922, Maidenhead, Berks, SL6 4XE

This is a position paper on the practice of paediatric parenteral nutrition produced by a working party on behalf of BAPEN. It provides an introduction to the role of, and indications for, parenteral nutrition in childhood and a detailed discussion of constituents, micronutrient requirements and pharmaceutical considerations. This is followed by a brief review of the routes of delivery of nutrients and information on complications and monitoring, with particular reference to the role of the nutrition support team. An introduction to the organisation of home parenteral nutrition concludes the document.

These guidelines provide a useful review of parenteral nutrition in childhood, intended as they are for those without specialist knowledge in this area. It is worthy of note that the document acknowledges that it represents the view of a small group of professionals and that much of the recommendations are empirical.

As those with experience of paediatric parenteral nutrition will know, there is a dearth of hard evidence in many areas of practice. Guidelines such as these must rely heavily on expert practice and expert opinion. It is therefore somewhat surprising that the multidisciplinary working group responsible for this document has failed to count a dietitian among its members and that it relies so heavily on medical opinion.

Where this document is most helpful is in the detailed guide to the constituents of parenteral nutrition and micronutrient requirements. For nurses who are not specialists in nutrition, these guidelines may well prove a useful guide as to what is contained in the parenteral fluids they take such care to administer and how requirements for their patients are determined. It is important that nurses understand what it is they are administering and have an appreciation of the pertinent nutritional, pharmaceutical and practical considerations.

It is in reference to these practical issues that these guidelines may prove less useful. Brief consideration is given to the delivery of nutrients but readers would need to do their own research as to routes of delivery and appropriate devices. It is disappointing that the apparently detailed chapter on complications gives little advice on prevention.

A discussion of the thorny issue of blood-sampling from dedicated nutrition lines would have been most interesting. While, as acknowledged in the introduction, much practice in paediatric parenteral nutrition is, by necessity, empirical, the under-referencing of this section of the guidelines gives the misleading impression that there is less evidence available relating to the management of complications than perhaps might be found in a review of the literature.

For nurses seeking guidance on appropriate monitoring of patients on parenteral nutrition and the organisation of home parenteral nutrition this document will provide few answers. Information on monitoring lacks clarity and rationale for the investigations suggested.

The division of monitoring requirements into laboratory and nursing monitoring fails to acknowledge the multidisciplinary team approach, implying as it does that nursing staff have sole responsibility for these aspects of care and that medical staff can abdicate responsibility for, for instance, observation of the line site and fluid balance status. Critically, while attention is given to the monitoring of growth there is no mention of the assessment and monitoring of development and psychosocial sequelae. This is consistent with the approach throughout the document wherein the risk of delayed development, be it physical, psychological or social, and the consequences of failing to achieve growth potential are not explored.

The scant attention paid to the psychosocial aspects of caring for a child on parenteral nutrition belies the significance of this aspect of care in clinical practice.

In practice it is true that nurses pay a crucial role in the multidisciplinary team in identifying changes in clinical status and helping the child and family learn about, come to terms with and manage parenteral nutrition. That neither of these roles is reflected in this document is perhaps an oversight but one that is compounded by the failure to address the role of the specialist nutrition nurse in the nutrition team. Although this health care professional is listed as a team member, in the breakdown of roles that follows there is no mention of the nurse.

The working party was perhaps wise in not trying to incorporate a guideline for the provision of home parenteral nutrition in this document, choosing instead to highlight some salient points.

Emphasis is given to the need for home care to be coordinated by a specialist nutrition team in a specialist centre. While it is true that professional working outside these centres would neither need or wish for a detailed 'how to' guide to home parenteral nutrition, they would doubtlessly benefit from a better understanding of the process and what is involved. Perhaps this is an area that may be addressed in future document. In the meantime some explanation as to what a specific discharge plan might constitute and the requirements for teaching and home support may have been helpful.

In conclusion, Current Perspectives on Paediatric Parenteral Nutrition may provide just that - - a perspective. There is much useful information contained in the document which members of the several disciplines involved in the delivery of parenteral nutrition will find helpful, but some may also find that their particular perspective is lacking.

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