Nutrition and fluid management at 1 week postnatally and the risk of bronchopulmonary dysplasia in preterm infants: A Meta-Analysis

doi:10.21203/rs.3.rs-3642938/v1

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Nutrition and fluid management at 1 week postnatally and the risk of bronchopulmonary dysplasia in preterm infants: A Meta-Analysis

https://doi.org/10.21203/rs.3.rs-3642938/v1

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OBJECTIVE

To explore the intricate interplay between nutritional status, fluid management in the early postnatal phase of preterm infants, and the susceptibility to bronchopulmonary dysplasia (BPD).

METHODS

A meticulous review encompassing PubMed, Embase, Cochrane Library, Web of Science, Chinese Biomedical Literature Database, China Knowledge Network, Wanfang Database, and Wipu Database was conducted. The search spanned up to October 7, 2023, focusing on case-control and cohort studies delving into the nexus of nutritional management and BPD. Meta-analysis, employing RevMan 5.3 and Stata 15.0 software, was carried out to synthesize the findings.

RESULTS

Incorporating 10 studies with a total of 1325 subjects (644 with BPD and 681 normal control), our meta-analysis revealed a significant reduction in calorie intake during the 1st week postnatally in the BPD group compared to the non-BPD group (MD = -5.94, 95% CI: -7.38 to -4.51, P < 0.05). Although fluid loading in both groups exhibited no statistical significance (MD = 5.83, 95% CI: -1.37-13.03, P = 0.11 > 0.05), macronutrient disparities were evident in the BPD group. Protein (MD = -0.13, 95% CI: -0.22 to -0.04, P < 0.05), lipids (MD = -0.39, 95% CI: -0.49 to -0.299,, P < 0.05), and carbohydrates (MD = -0.74, 95% CI: -0.95 to -0.54, P < 0.05) in the BPD group exhibited significantly lower intake during the initial postnatal week. Moreover, the BPD group experienced a prolonged time to achieve complete enteral nutrition compared to the non-BPD group (MD = 9.71, 95% CI: 7.78–11.63, P < 0.05).

CONCLUSION

Insufficient early nutritional intake may correlate with heightened BPD risk. Vigilant attention to nutritional and fluid management, coupled with optimization of respiratory support protocols, is imperative to mitigate BPD incidence.

bronchopulmonary dysplasia

nutritional management

fluid management

meta-analysis

Bronchopulmonary dysplasia (BPD) stands as a chronic respiratory sequelae, intricately woven by the interplay of multiple determinants, significantly impacting the prognosis and long-term quality of life for neonates [1]. Studies have shown [2] that preterm infants necessitate sufficient nutritional support for optimal growth and development during the initial postnatal phase. Inadequate nutritional intake, however, may precipitate diminished immune functionality in the lungs of preterm infants, and even simplify the structure of the alveoli in the lung tissue, as well as affect the morphology and function of the alveoli, which can make them more susceptible to the attack of infections. The judicious administration of appropriate nutrition during the initial postnatal period for preterm infants transcends mere growth facilitation. It emerges as a crucial catalyst in steering the comprehensive development and maturation of the respiratory system, offering essential fortification for lung development and thereby mitigating the vulnerability to BPD incidence. Despite the recognized significance of early nutritional support, a lingering controversy persists regarding its direct impact on BPD development in preterm infants [3]. This study employs a Meta-analysis framework, systematically gathering pertinent clinical research literature to scrutinize the intricate relationship between nutritional and fluid management and the propensity for BPD development in the first week of life among preterm infants. The ultimate goal is to furnish an evidence-based foundation for the nuanced nutritional management of neonates with BPD during their formative early stages of life.

1.1 Literature Search Strategy:

Computer search Wanfang, PubMed, Embase, China Knowledge Network, Web of Science, Weipu databases, Cochrane Library, China Biomedical Literature Database., the temporal scope of this search spanned from the inception of each respective database to 7 October 2023. The search strategy employed a judicious fusion of subject-specific terminology and unconstrained free terms to ensure an exhaustive and nuanced retrieval of pertinent literature. The Chinese search formula was (Bronchopulmonary dysplasia OR Bronchopulmonary dysplasia of prematurity OR Congenital pulmonary dysplasia OR Lung dysplasia OR Pulmonary bronchopulmonary dysplasia) AND (Nutrition OR Enteral nutrition OR Parenteral nutrition OR Liquid OR Calorie OR Calorie OR Energy); and the English search formula was (Bronchopulmonary Dysplasia OR Dysplasia, Bronchopulmonary) AND (Parenteral Nutrition OR Enteral Nutrition OR Energy Intake OR Fluid Intake).

1.2 Literature Inclusion Criteria:

Study subjects: birth gestational age < 32 weeks and birth weight < 1500g;
Type of study: Ⅰ. The literature included case-control or cohort studies; Ⅱ. The observation and control groups were BPD and non-BPD preterm infants, respectively. Data can be provided as mean and standard deviation (SD), or can be converted to 95% CI of mean and standard deviation or interquartile Rang (IQR)
The literature describes the diagnostic criteria for BPD and unified as NICHD (National Institutes of Health Consensus Definition) diagnostic criteria;
Clear values of enteral and parenteral calorie, fluid, and macronutrient (protein, fat, and carbohydrates) intakes were required.

1.3 Literature Exclusion Criteria:

Repeated articles;
Incomplete raw data or no further information could be obtained;
Case reports, reviews, letters, dissertations, and unpublished articles.

1.4 Literature Screening and Data Extraction Methods:

Independently, the two researchers collected the database, scrutinizing titles and abstracts to eliminate literature not meeting the inclusion criteria. Those potentially meeting the criteria underwent a comprehensive reading. The two researchers meticulously cross-verified their screening outcomes, ensuring consensus on the inclusion of literature. Any disparities that emerged during this process were meticulously adjudicated by a third researcher. The gleaned information from the ultimately selected literature encompassed key details such as the primary author, publication date, sample size, gestational age, birth weight, feeding protocols, adherence to nutritional guidelines, and specific values pertaining to calorie, fluid, and macronutrient intake during the postnatal week.

1.5 Literature Quality Assessment

To assess the scholarly studies' quality, the Newcastle-Ottawa Scale (NOS) [4] was employed. The NOS incorporates three fundamental domains: selection, comparability, and outcomes, featuring eight criteria and a top score of nine. A study is deemed high quality if it scores above six on this scale. Throughout the quality evaluation of academic literature, any uncertainties were thoroughly deliberated with a third researcher for resolution.

1.6 Statistical Analysis

The statistical analysis encompassed a meta-analysis of data utilizing the statistical software versions RevMan 5.3 and Stata 15.0. Employing mean difference (MD) as the effect analysis statistic for continuous variables, we assessed the heterogeneity of the included data. In instances where P > 0.1 and I² ≤ 50%, signifying no notable heterogeneity among the studies, the fixed-effect model was employed for analysis. Conversely, if heterogeneity was present, the random-effect model was applied for meta-analysis. A significance level of p < 0.05 was deemed statistically significant.

2.1 Results of Literature Search

Out of a total of 3338 relevant articles identified, 10 articles were finally selected for this study through a step-by-step screening process, as visually depicted in Fig. 1.

2.2 Basic characteristics and quality assessment of included studies

The comprehensive assessment of the 10 incorporated research articles involved 1325 participants, encompassing 644 subjects diagnosed with BPD and 681 without BPD. The inclusive selection comprised four case-control studies [5–8] and six cohort studies [9–14]. Detailed information, including the essential characteristics and evaluation scores based on the NOS, is presented in Table 1.

Table 1

Characteristics of the included studies
Study	Methods	BPD/Non-BPD			Country	feeding methods	nutrition guidelines	NOS	Main outcomes
Study	Methods	Sample	Gestational age (x ± s, weeks)	Birth weight (x ± s, g)	Country	feeding methods	nutrition guidelines	NOS	Main outcomes
Xu 2023[5]	Retrospective case-control study	79/73	29.85 ± 1.48/ 29.94 ± 1.51	1173 ± 267 1275 ± 235	China	parenteral	Not available	7⭐	Calorie, fluid, and macronutrient intake values at 1 week postnatal period
Lin 2022[9]	retrospective cohort study	43/91	26 (25;27 + 2) 27 + 3 (26 + 5;28 + 4)	813 ± 120 936 ± 123	China	Enteral, parenteral	ESPHGAN	7⭐	Calorie, fluid, and macronutrient intake values at 2 week postnatal period
Li 2022[6]	retrospective case-control study	60/97	29.1(26.7∼31.7) 30.2(27.1∼31.9)	1215 (790∼1490) 1320 (1020∼1490)	China	Not available	Not available	8⭐	Fluid intake during the postnatal week
Milanesi 2021[10]	prospective cohort study	16/62	26.8 ± 2.5 29.4 ± 1.9	851 ± 244 1264 ± 343	Brazil	Enteral, parenteral	ESPHGAN	8⭐	Calorie, fluid, and macronutrient intake in the first month of life
Xu 2021[7]	Retrospective case-control study	86/68	28.35 ± 1.55 30.12 ± 1.23	1050.91 ± 190.6 1205.88 ± 195.83	China	Enteral, parenteral	2015 Canadian VLBWI Feeding Guidelines + 2013 Chinese Neonatal Nutritional Support Clinical Application Guidelines	7⭐	Calorie, fluid, and macronutrient intake values at 2 week postnatal period
Ding 2020[11]	prospective cohort study	30/42	29.76 ± 1.54 30.28 ± 1.2	1305.00 ± 315.76 1391.67 ± 231.81	China	Enteral, parenteral	Individualised management of enteral or parenteral nutrition on an individual basis	8⭐	Calorie and fluid intake on days 3, 7, 14, and 28 postnatally
Jebawi 2020[12]	retrospective cohort study	151/75	24.7 ± 1.7 26.8 ± 2.0	678 ± 154 837 ± 129	USA	Enteral, parenteral	NICU guidelines	8⭐	Calorie, fluid, and macronutrient intake values at 1 week postnatal period
Malikiwi 2019[8]	Retrospective case-control study	33/33	25.6 ± 1.1 26.4 ± 1.1	748.6 ± 127.1 831.0 ± 102.9	Australia	Enteral, parenteral	Not available	7⭐	Calorie, fluid, and macronutrient intake in the first month of life
Alshaikh 2017[13]	retrospective cohort study	125/108	25.9 ± 1.4 26.9 ± 1.2	832 ± 191 1028 ± 206	Canada	Enteral, parenteral	Not available	7⭐	Calorie, fluid, and protein intake values at 1 week postnatally
Lehtinen 2017[14]	prospective cohort study	21/32	28.6407 ± 7.1553 30.0683 ± 6.9843	1018.025 ± 663.8531 1095.9766 ± 636.3479	Finland	Enteral, parenteral	Not available	7⭐	Calorie, and fluid intake at 1-week postnatal period

2.3 Meta-Analysis Results

2.3.1 Calorie intake:

A collective of 8 papers incorporated in this analysis [5, 7–14] presented the total calorie intake data for children during the postnatal week, revealing heterogeneity (I² = 61%, p = 0.009). Consequently, a sensitivity analysis was conducted, revealing that Xu 2023 was the primary factor contributing to the heterogeneity, potentially attributed to the reliance on parenteral calorie intake as the predominant feeding method in this particular literature. Following the exclusion of the aforementioned literature, a subsequent meta-analysis was conducted, encompassing a cohort of 1016 children. The assessment for heterogeneity revealed an I² value of 28% and a P-value of 0.20, indicative of minimal heterogeneity within the selected studies, well within acceptable limits. Consequently, a fixed-effects model was employed. The meta-analysis results demonstrated a pooled MD of -5.94 with a 95% CI ranging from − 7.38 to -4.51. The statistical significance was affirmed with a z-score of 8.13 and P-value less than 0.05, signifying that the BPD group exhibited a diminished calorie intake in the initial week of life compared to the non-BPD group, as visually depicted in Fig. 2.

2.3.2 Fluid intake

9 publications [5–12, 14] were included, collectively presenting data on fluid intake throughout the initial postnatal week. The dataset encapsulated 1092 children and underwent heterogeneity testing, revealing an I² value of 94% and a P-value less than 0.01, indicative of notable heterogeneity among the selected papers. Consequently, a random-effects model was applied. The meta-analysis results unveiled a pooled MD of 5.83, accompanied by a 95% CI spanning from − 1.37 to 13.03. Despite a statistical significance with a z-score of 1.59, the P-value of 0.11 exceeded 0.05. None of the observed distinctions attained statistical significance, suggesting that infants with BPD did not exhibit elevated fluid intake during the initial week of life compared to their non-BPD counterparts, as illustrated in Fig. 3.

2.3.3 Macronutrient Intake

(1) Protein Intake: a total of 5 studies [5, 7–10] reported the value of protein intake during the postpartum week, and a total of 584 children were included. The heterogeneity examination, with an I² value of 52.9% and a P-value of 0.075, indicated a mild heterogeneity among the compiled literature, staying within an acceptable range. Consequently, a random effects model was implemented. The meta-analysis outcomes demonstrated a statistically significant MD of -0.13, accompanied by a 95% CI ranging from − 0.22 to -0.04. With a z-score of -2.706 and a P-value less than 0.05, the results were deemed statistically significant. This implies that, during the initial week of life, the protein intake of infants with BPD was markedly lower than that of their non-BPD counterparts. A detailed depiction is presented in Fig. 4.

(2) Lipid Intake: Four distinct studies [7, 8, 10, 12] reported on lipid intake during the postnatal week, encompassing a total of 584 infants. Post heterogeneity assessment, yielding an I² value of 0% and a P-value of 0.957, indicating an absence of substantial heterogeneity within the selected literature, a fixed-effect model was employed. The meta-analysis results revealed a MD value of -0.39, with a 95% CI ranging from − 0.49 to -0.299. With a z-score of -7.427 and a P-value below 0.05, the outcomes were deemed statistically significant. This underscores that, in the initial week of life, infants diagnosed with BPD exhibited significantly lower lipid intake compared to their non-BPD counterparts, as illustrated in Fig. 5.

(3) Carbohydrate Intake: The cumulative data from five studies [5, 7, 8, 10, 12] detailing carbohydrate intake in the postnatal week included a total of 676 children. Following the heterogeneity examination, with an I² value of 42.3% and a P-value of 0.139, indicating an absence of notable heterogeneity within the chosen literature, a fixed-effect model was employed. The Meta-analysis outcomes revealed a MD value of -0.74, accompanied by a 95% CI ranging from − 0.95 to -0.54. With a z-score of -7.013 and a P-value below 0.05, the results were considered statistically significant. This underscores that, during the initial week of life, children diagnosed with BPD exhibited significantly lower carbohydrate intake compared to their non-BPD counterparts, as depicted in Fig. 6.

2.3.4 Time to reach complete enteral:

A total of 5 kinds of literature [5, 7, 9, 10, 13] all reported the time to reach complete enteral feeding in preterm infants, after the heterogeneity test, (I² = 55%, p = 0.06), signifying heterogeneity among the chosen literature, a sensitivity analysis was conducted. This analysis identified the study by Xu in 2023 as the primary source of heterogeneity. After the exclusion of this literature a total of 599 children, the heterogeneity test was performed again (I² = 0, p = 0.54). Consequently, a fixed-effect model was applied. The Meta-analysis results revealed a MD value of 9.71, accompanied by a 95% CI ranging from 7.78 to 11.63. With a z-score of 9.88 and a p-value below 0.05, the outcomes were deemed statistically significant. This suggests that, in comparison to the non-BPD group, infants diagnosed with BPD exhibited a significantly shorter duration to achieve complete enteral feeding, as depicted in Fig. 7.

2.3.5 Subgroup analysis of fluid intake:

Meta-analysis result presented high heterogeneity in fluid intake for the primary outcome indicators, and subgroup analyses based on birth weight, study area, study method, and different fluid loads did not reveal any source of heterogeneity, and none of the differences in the results of the subgroups were with statistical significance (all P-values > 0.05), is presented in Table 2.

Table 2

Fluid intake subgroup analysis
Group	Sample size	heterogeneity test			Effect model	OR(95%CI)	P
Group	Sample size	I²	P		Effect model	OR(95%CI)	P
Birth weight
< 1000g	4	95.5%		< 0.01	Random	5.09(-5.51,15.69)	0.346
> 1000g	5	93.1%		< 0.01	Random	6.55(-5.34, 18.45)	0.280
Country
China	5	86.9%		< 0.01	Random	0.02(-5.79, 5.82)	0.995
Other	4	95.9%		< 0.01	Random	13.75(-3.39, 30.89)	0.116
Methods
case-control study	4	89.5%		< 0.01	Random	0.92(-6.47,8.32)	0.807
cohort study	5	95.4%		< 0.01	Random	10.02(-3.63,23.67)	0.150
Fluid intake (mL/kg·d)
> 150	3	94.2%	< 0.01		Random	7.23(-11.41,25.88)	0.447
120–150	5	95.3%	< 0.01		Random	6.05(-3.16, 15.26)	0.198
< 120	1	0%	< 0.01		Random	0.000(-6.33, 6.33)	1.000

In the contemporary era, marked by advancements in perinatal medicine, the survival rates of infants afflicted by BPD have witnessed an upward trajectory. Nonetheless, BPD persists as a pervasive challenge, standing out as one of the most prevalent and consequential sequelae affecting preterm infants. The ramifications extend beyond the individual to cast a substantial burden on both families and society at large. A burgeoning body of research underscores the pivotal role of early nutritional support in mitigating the risk of BPD among preterm infants. This investigation seeks to unravel the intricate interplay between BPD occurrence and the nuanced domains of nutritional and fluid management. The overarching aim is to refine and elevate the standards of nutritional and fluid management for the betterment of preterm infants.

Calories:

This investigation reveals a noteworthy distinction in caloric provisioning between the non-BPD and BPD groups during the initial postnatal week. The findings underscore the protective role of heightened caloric intake in preterm infants against BPD development. Notably, children grappling with BPD exhibit an augmented demand for calories attributable to heightened metabolic requisites and increased respiratory workload. Consequently, a keen focus on caloric supply is imperative. Experimental animal models have corroborated that caloric restriction diminishes alveolar count and reduces the effective alveolar surface area [15]. Additionally, Ehrenkranz et al. [16] established a correlation wherein a 2% reduction in BPD prevalence per 1 Kca/kg-d increase in weekly total energy intake was observed in neonates. National expert consensus advocates a tailored approach, suggesting an initial daily energy intake of 80–100 kcal/kg in the first week, progressively scaling to 120–150 kcal/kg daily over the initial four weeks, thereby mitigating the BPD risk [17].

Fluids

Body fluids, integral conveyors of nutrients and metabolites, wield significant influence on postpartum BPD genesis. Deviations in fluid supply during this critical period can precipitate abnormal fluid status, contributing to BPD onset. Striking a balance is paramount; fluid restriction impairs energy intake, fostering malnutrition and stunted growth [18]. Conversely, elevated fluid volume may culminate in pulmonary edema, compromised lung compliance, heightened airway resistance, impaired gas exchange, and escalated reliance on mechanical ventilation [19–21]. Intriguingly, our study renders fluid loading and BPD development statistically non-significant. This may stem from inherent heterogeneity within our study cohort. The expert consensus urges caution, recommending a capped initiation of postnatal fluid in high-risk BPD infants at 80–100 mL/kg daily, with a stringent fluid volume ceiling of 120–150 mL/kg daily for the initial week [17].

Protein

Emerging research posits that protein deficiency in preterm infants intensifies lung tissue oxidation, precipitating alveolar thinning and hastening BPD progression [22]. Our study corroborates a statistically significant difference in protein provisioning during the first postnatal week between BPD and non-BPD groups. Augmented protein supply emerges as a protective factor against BPD development in preterm infants, underscoring the imperative of prioritizing heightened protein intake during early postnatal stages.

Lipid

The salutary role of fat in providing ample calories, curbing oxidative stress, and bolstering tissue growth is underscored in our study. Clinical trials demonstrate that neonates administered parenteral nutrition infused with fish oil fat emulsion manifest a reduced likelihood of severe BPD [23]. Furthermore, fat emulsions exhibit potential in attenuating inflammatory responses and enhancing immune function [24]. Ensuring adequate calorie intake to diminish BPD risk mandates the early incorporation of lipids into intravenous nutritional solutions [25]. Our study echoes this sentiment, elucidating that fat milk supply in the non-BPD group significantly surpasses that in the BPD group during the postnatal week. This observation reinforces the pivotal role of fat milk in furnishing preterm infants with requisite calories and reducing BPD susceptibility. Consequently, vigilant attention to fat milk intake in intravenous nutrition is advocated.

Carbohydrate:

Carbohydrates stand as the primary energy source for preterm infants during the early postnatal phase, with glucose serving as the principal substrate for carbohydrate utilization. Glucose, a ubiquitous metabolic fuel, caters to the energy demands of vital organs. Al-Jebawi et al. discerned a significant reduction in carbohydrate intake within the moderate to severe BPD cohort during the initial week of life compared to the non-BPD and mild BPD groups [12]. Thiess [26] further affirms that carbohydrate intake fosters pulmonary development, aligning with our study's findings. Emphasis on meticulous attention to carbohydrate intake in preterm infants is warranted. Simultaneously, a heightened carbohydrate load may elevate basal oxygen consumption and carbon dioxide production, posing pulmonary stress risks [27]. Careful control of glucose supply rate is crucial, ensuring a per-minute glucose administration of less than 12 mg/kg to avert undue speed-associated complications.

Transition to Full Enteral Feeding

Prolonged reliance on intravenous nutrition may precipitate atrophy of intestinal mucosal villi, rendering children susceptible to cholestasis and related ailments. Our study reveals a markedly abbreviated duration of parenteral nutrition in the non-BPD group and a significantly prolonged period of total enteral feeding in the BPD group in comparison to the non-BPD group. This underscores the protective role of expeditious realization of total enteral feeding against BPD development. Hence, early implementation of enteral nutrition, contingent on conducive conditions, and expeditious removal of central venous catheters assume paramount significance in BPD prevention and management.

Compared to preceding meta-analyses [28], our study encompasses a more extensive array of pertinent research, integrating additional macronutrient impact indicators while imposing more stringent inclusion criteria and undertaking further subgroup analyses. Nevertheless, inherent limitations persist: 1. Discrepancies exist in prevailing clinical guidelines and consensuses on nutritional management of bronchopulmonary dysplasia in preterm infants both domestically and internationally. Divergent nutritional guidelines among the incorporated literature may yield clinical heterogeneity, potentially compromising systematic evaluation efficacy. 2. Adequacy of study effect indicators is not uniformly realized, necessitating statistical transformations for certain analyses.

Caloric and macronutrient intake modulation, and timely initiation of enteral nutrition exhibit correlation with bronchopulmonary dysplasia incidence in preterm infants. Proactive enteral and parenteral nutrition during the early postnatal period constitutes a pivotal facet in BPD prevention and treatment. Robust nutritional and fluid management, coupled with optimized respiratory support strategies, represent imperative measures to curtail BPD incidence.

Ethics approval and consent to participate：Not applicable

Consent for publication：All authors approved the final manuscript and the submission to this journal

Availability of data and materials：The datasets generated during and analyzed during the current study are publicly available

Competing interests： The authors declare that they have No competing financial interests exist.

Funding: This work was supported by the Inner Mongolia Natural Science Foundation（Grant NO. 2020MS08034）and the Inner Mongolia Autonomous Region Science and Technology Programme(Grant NO. 2022YFSH0088)

Authors' contributions：Jiayi Yang：Writing-Original Draft, Validation, Formal analysis, Visualization, Software, Methodology

Corresponding author：Hua Mei:Methodology, Writing-Review&Editing, Funding acquisition, Resources, Supervision, Project administration

Mengyue Huo:Resources,Data Curation

Yuheng Zhang:Visualization, Investigation

Yanbo Zhang: Formal analysis

Chun Xin:Validation, Software

Acknowledgements: We thank participants at the Conferences you have attended for valuable discussions and comments.

Additional Information：

1. the review was not registered （The manuscript has been registered, but it is still under review, if it passes, we will submit the registration number in time, thank you！）

2. a protocol was not prepared

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No competing interests reported.

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Nutrition and fluid management at 1 week postnatally and the risk of bronchopulmonary dysplasia in preterm infants: A Meta-Analysis

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Abstract

OBJECTIVE

METHODS

RESULTS

CONCLUSION

Figures

INTRODUCTION

DATA AND METHODS

1.1 Literature Search Strategy:

1.2 Literature Inclusion Criteria:

1.3 Literature Exclusion Criteria:

1.4 Literature Screening and Data Extraction Methods:

1.5 Literature Quality Assessment

1.6 Statistical Analysis

RESULTS

2.1 Results of Literature Search

2.2 Basic characteristics and quality assessment of included studies

2.3 Meta-Analysis Results

2.3.1 Calorie intake:

2.3.2 Fluid intake

2.3.3 Macronutrient Intake

2.3.4 Time to reach complete enteral:

2.3.5 Subgroup analysis of fluid intake:

DISCUSSION

Calories:

Fluids

Protein

Lipid

Carbohydrate:

Transition to Full Enteral Feeding

CONCLUSION

Declarations

References

Additional Declarations

Supplementary Files

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