Parenteral Nutrition Exposure, Nutritional Trajectory, and Clinical Outcomes in Neonates with Surgical Gastrointestinal Conditions: A Retrospective Cohort Study

Background/Objectives: Neonates with surgical gastrointestinal conditions frequently require parenteral nutrition and are exposed to multiple overlapping risks for hepatobiliary, infectious, and nutritional complications. This study aimed to determine whether the timing and initial composition of parenteral nutrition (PN) were independently associated with hepatobiliary dysfunction, treatment-related complications, and nutritional outcomes. Methods: This retrospective cohort included 91 neonates hospitalized at the University Children’s Hospital between January 2024 and July 2026 who received parenteral nutrition (PN) for >5 consecutive days. Associations between PN timing, modality, duration, enteral progression, clinical severity, feeding type, and hepatobiliary, infectious, and growth outcomes were assessed using univariable and multivariable analyses. Results: Cholestasis occurred in 18 patients (19.8%) and intestinal failure-associated liver disease (IFALD) in 14 (15.4%). The interval from enteral feeding cessation to PN initiation and initial PN modality were not significantly associated with cholestasis or IFALD. Patients with IFALD had longer PN exposure than those without IFALD (21 vs. 12 days; p = 0.010). Each additional PN day increased the adjusted odds of catheter-related bloodstream infection by 9.7% (OR 1.097, 95% CI 1.032–1.167; p = 0.003). Simultaneous amino-acid and lipid initiation was associated with the highest unadjusted weight-gain velocity and numerically lowest cholestasis and IFALD rates, but no independent protective effect was established. Conclusions: Longer PN duration was associated with IFALD and CRBSI, although the IFALD association should be interpreted cautiously because PN duration contributes to its operational definition. Short delays in PN initiation and initial lipid timing were not independently associated with these outcomes. Management should remain individualized, with advancement of enteral nutrition when clinically feasible and minimization of unnecessary PN and central-line exposure.