There are specific challenges in the direct implementation of both of these guidelines in our country. The main concerns are as follows:

TPN in term/late preterm: Most of the late preterm or term neonates are managed in public sector hospitals in Special newborn care units (SNCU). Starting TPN in these units will be a challenge due to understaffing, lack of training, and infrastructure for TPN prescription. Smaller units in the private sector also face similar challenges. Evidence shows that early initiation of TPN by seven days among critically sick term neonates is associated with an increased incidence of sepsis and decreased likelihood of earlier live discharge compared to TPN initiation after day 7 of ICU stay [7]. These adverse outcomes are likely to worsen in the absence of proper asepsis and standardized practices. However, neonates in the late TPN group experienced hypoglycemia more often. Notably early and late TPN groups had similar mortality rates. Therefore, it is challenging to recommend delayed initiation of TPN in late preterm and term neonates with the available evidence.

TPN formulation (Standardized TPN): Availability and cost is a significant concern for widespread usage. In most developed countries, TPN is prepared and dispensed by trained central pharmacists. Contrastingly, TPN is constituted in India by mixing the individual components by physicians and staff nurses. Manual mixing of various TPN constituents carries a risk of sepsis. There is an additional risk of errors in calculation or adding the right amount of TPN constituents with manual methods.

Micronutrients: Availability of phosphate, trace elements, and multi-vitamin solution in appropriate customized doses for neonates is a concern.

Venous access: Central line is preferred for delivery of TPN for long-term use. However, in most settings, maintenance of the central line and risk of sepsis are major limiting factors. Both guidelines allow peripheral line TPN for short-term use only.

Infections: Due to overcrowding, understaffing, and lack of laminar flow, the risk of infection is higher with TPN usage. The risk of infection can be reduced by strict asepsis during preparation and Quality improvement approaches for central line-associated bloodstream infection reduction.

Monitoring: Frequent monitoring can be a challenge, which can be overcome by using a standardized monitoring chart.

Stopping TPN: Maximal benefit of aggressive parenteral nutrition is achieved by continuing it until enteral feeds intake is above >120-140 mL/kg/day. However, to reduce the risk of sepsis-associated with central lines, TPN can be stopped once enteral nutrition delivers two-third of desired energy intake (roughly 100 mL/kg/day of oral feed).

Cost: Cost of central lines, TPN constituents, and frequent monitoring is an additional cost apart from the hospital stay for sickness and prematurity of the neonates, limiting TPN use across wider settings.

Due to the challenges mentioned above in limited-resource settings, we need to apply these guidelines cautiously in our setup. Moreover, there are no specific recommendations for TPN during cooling, volume, and infection control strategies.

In conclusion, early aggressive TPN ameliorates the risk of growth failure in premature neonates by providing calories and essential nutrients. Some of the best practices as per international guidelines may be contextual and restricted to developed nations. There is an urgent need to set up national guidelines on TPN’s standardized use of TPN in neonates in India to achieve its maximum benefits.

7. Fivez T, Kerklaan D, Mesotten D, et al. Early versus late parenteral nutrition in critically Ill children.　N Engl J Med. 2016;374:1111-22.