Parenteral Nutrition
`
` Many sick newborn infants cannot obtain adequate nutrition via the
`GI tract and, thus, require parenteral nutritional (PN) support. In some, GI function is
`adequate to allow some feedings. In others, the GI tract may not function for days to
`weeks (
`, necrotizing enterocolitis, bowel anomalies), so the infant receives all
`nutrition parenterally (Total Parenteral Nutrition, TPN).
`
`Sick newborns usually have increased caloric requirements.
`Minimal caloric requirements to prevent catabolism are at least 40 kcal/kg/d.
`For growth, minimal requirements are 80 kcal/kg/d and protein intake of >2
`gm/kg/d. For adequate growth, aim for 100 kcal/kg/d and protein intake of 3
`g/kg/d for term infants and 3.5 g/kg/d for preterm infants.
`Nutrition support should be initiated within 3 days of birth and should include
`protein. A "starter TPN" solution is available to start TPN at arrival to the unit.
`Start PN when at least 30 cc/kg/d can be used for this route.
`Although growth can be obtained with PN, enteral feedings should be initiated as
`soon as feasible, because of risks associated with PN.
`
`route is used for partial or supplemental PN. This route is usually used for
`short-term nutritional support. Peripheral PN solutions cannot exceed 12.5% dextrose
`(D12.5) or 3.5% amino acids due to the risk of thrombophlebitis and should not contain
`calcium because of the serious complications resulting from extravasation of calcium.
` PN is delivered by a venous catheter with the tip in a central location (see the
`section on Peripherally Inserted Central Catheters, P. 31). This route is used for patients
`who require long-term nutritional support, usually TPN.
`
`Neonatal nutrition support literature supports early and aggressive nutrition support for
`the VLBW infant. Clinical research shows that protein is well tolerated in the first hours
`of life and recent studies suggest starting that protein source as soon as possible after
`
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`birth with higher initial amounts is well tolerated. "Starter TPN" is now available on the
`unit to decrease the amount of time the infant is without a protein source.
`
`Parenteral Nutrition
`
`1. Target infants are <1200 grams or <30 weeks or those expected to require
`parental support based on diagnosis (eg. CDH, TEF, gastroschisis). The "starter"
`TPN may also be used if the patient specific prescribed TPN needs to be held for
`access issues (loss of PICC) or if the patient is made NPO and TPN needs to be
`started.
`2. 150 ml bags of D10AA3.5, no electrolytes are stocked in the ICN East
`refrigerator.
`3. The admitting MD/NNP writes the admit orders to initiate "starter" TPN as one of
`the IVF at 60-80 ml/kg/d. The starter TPN must be specified as D10WAA3.5 at
`__ml/hour.
`4. Maximum "starter" TPN amount is 100 ml/kg/day. Additional IVF will be
`ordered separately.
`5. For fluid restriction, the "starter" TPN can run at a lower rate but the protein
`intake will be lower than target.
`6. The admitting MD/NNP will also write the TPN order for the next bag, advancing
`as per ICN guidelines. An order to discontinue the "starter TPN" solution once the
`new TPN arrives will be written as well.
`
` include:
`
`1.
`
`is administered as a solution of amino acids, Premasol™, a preparation
`designed for pediatric patients. All infants in the ICN should receive Premasol™.
`Start amino acids at 2-3 g/kg/d, as much as possible depending on fluid
`allowance and access. The traditional step-wise advance of protein has not
`been found to be necessary and may be negatively affecting the infants'
`nutritional status. Advance by 0.5 gm/kg/d to goal as needed.
`Maximum is 3 g/kg/d in term infants and 3.5 g/kg/d in preterm infants.
`Include protein in you calorie count. Protein yields 4 kcal/g.
`
`Potential complications/risk include:
`Acidosis
`
`Elevated BUN
`
`
`Hyperammonemia
`Cholestasis with prolonged administration
`
`
`
`
`
` is administered as dextrose monohydrate.
`Start with 4-6 mg/kg/min or D10-D12.5. Alternatively, calculate the
`glucose infusion rate that the infant is already receiving and advance from
`there.
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`Parenteral Nutrition
`
`Very preterm infants may not tolerate that much dextrose and may even
`need insulin as an infusion to achieve adequate caloric intake without
`hyperglycemia.
`Advance by 1-3 mg/kg/min daily to a maximum of 12 mg/kg/min (up to
`15 mg/kg/min in selected cases).
`Dextrose yields 3.4 kcal/g.
`Consult reverse side of TPN order sheet for maximal allowable
`dextrose/amino acid concentrations.
`Potential complications/risks include:
`Hyperglycemia or hypoglycemia
`Glycosuria and potential osmotic diuresis
`Cholestasis and/or hepatic steatosis with high caloric intake usually
`from long-term high concentration infusion.
` Intravenous lipid emulsions are essential components of TPN. They provide
`essential fatty acids and are a concentrated energy source critical for growth and
`development of infants not receiving enteral feedings. There are potential safety
`concerns regarding administration of lipid emulsions to very low birth weight infants and
`infants with hyperbilirubinemia, pulmonary hypertension and serious pulmonary disease.
`To maximize benefits of lipids and minimize their adverse effects, use the following
`guidelines: (a) provide sufficient lipids to prevent essential fatty acid deficiency; (b)
`monitor for evidence of lipid intolerance; (c) adjust lipid dose based on clinical status.
`
`A lipid intake of 0.25-0.5 g/kg/d is required to prevent essential fatty acid
`deficiency.
`
`ations of total fluid intake.
`
`Lipids yield 10 kcal/g.
`IV lipid preparations are available as a 20% soybean emulsion that yields 2
`kcal/mL.
`See Table below for starting and advancing lipids.
`Deliver IV lipids over 24 hours.
`Do not allow lipids to exceed 60% of total caloric intake.
`Potential complications/risks include:
`
`Hyperlipidemia
`Potential risk of kernicterus at low levels of unconjugated bilirubin because of
`displacement of bilirubin from albumin binding sites by free fatty
`acids. As a general rule, do not advance lipids beyond 0.5 g/kg/d until
`bilirubin is below threshold for phototherapy
`Potential increased risk or exacerbation of chronic lung disease
`Potential exacerbation of Persistent Pulmonary Hypertension (PPHN)
`Lipid overload syndrome with coagulopathy and liver failure
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`Parenteral Nutrition
`
`
`
`DOL 3
`DOL 3
`DOL 3
`
` DOL 7
`DOL 4
`When status improves
`
`DOL 11
`DOL 9
`
`
`Preterm
`
`Term
`
`<1,500 g, stable
`1,500 g, stable
`.,
`Very unstable (
` bilirubin)
`severe RDS,
`No pulm. disease
`Severe pulm. disease,
`PPHN, MAS
`(DOL, day of life; pulm., pulmonary; PPHN, persistent pulmonary hypertension of newborn; MAS
`meconium aspiration syndrome)
`
`DOL 4
`DOL 3
`Consider DOL 7 When status improves
`
`DOL 9
`
`
`4.
` are stated on the parenteral nutrition order form and must be
`adjusted according to serum values and clinical condition. (See section of Fluids and
`Electrolytes, p. 56) Initial PN solutions may be started without added electrolytes. Add
`electrolytes gradually as the patient becomes more stable. Acetate is metabolized to
`- and is added to adjust acid-base status. It can be ordered maximize, minimize, or
`HCO3
`balance with chloride depending upon an infant's acid-base status.
`
` Preterm infants and term infants receiving long-term parenteral nutrition are
`at increased risk for bone demineralization and fractures. Calcium (Ca) and phosphorus
`(P) delivery should be maximized for all infants receiving PN.
`
`Calcium is only allowed if the TPN if the line is central. If only a peripheral line is
`available, add phosphorus to the TPN and give Ca gluconate separately.
`Only 1 mineral may be added if the solution also contains sodium or potassium. The
`maximum P=Total Cation X 0.6.
`Mark Premasol box.
`Determine current dose of calcium prescribed in mEq of elemental calcium/kg.
`(approximately 1 mEq Ca=2mg Calcium gluconate)
`If the current calcium gluconate dose significantly exceeds the goal amount, start calcium
`in the TPN at goal (as solubility allows) and give additional Ca gluconate boluses as
`needed monitoring ionized calcium. Wean off the boluses as tolerated.
`See table below for advancement. Try to keep a Ca (mEq) to P (mmol) ratio of 2:1.
`
`Check Premasol solubility table on back of TPN form.
`Advance as long as Ca <1.4. To treat a high Ca , increase the P. Be sure the
`patient isn’t receiving too much calcium (eg.Ca in the TPN and concurrent Ca
`gluconate boluses)
`Follow ionized calcium and weekly pediatric TPN panels.
`Do not start magnesium until the serum level is <2.5 mg/dL.
`
`Initiate
`Advance every 1-2 days
`Goal
`
`2 mEq/kg
`0.5 mEq/kg
`3 mEq/kg (preterm)
`2 mEq/kg (term)
`
`1 mmol/kg
`0.3-0.5 mmol/kg
`1.5 mmol/kg (preterm)
`1.2 mmol/kg (term)
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`Parenteral Nutrition
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`Preterm
`
`Term
`
`1.2-1.4
`
`1.2-1.3
`
`(mg/dL)
`8-11
`
`8-12
`
`6-8
`
`5-9.5
`
`2-2.5
`
`1.8-2.3
`
`include:
` are recommended as 0.2 mL/kg/d of trace element solution
`containing zinc, manganese, copper, and chromium.
`Preterm infants need additional zinc (300 mcg/kg/d) and selenium (2
`mcg/kg/d).
`Term infants need additional zinc (200 mcg/kg/d) and selenium (2
`mcg/kg/d).
`,. direct bilirubin >2.5 mg/dL),
`For infants with cholestasis (
`discontinue the trace element solution and give:
`Zinc 400 mcg/kg/d TOTAL (preterm infants)
`300 mcg/kg/d TOTAL (term infants)
`Chromium 0.2 mcg/kg/d
`Selenium 2 mcg/kg/d
`Discontinue selenium with patients on renal dialysis.
`Pediatric multivitamins are recommended as 2.0 mL/kg/d up to a
`maximum of 5 mL/kg/d. Components are listed on the PN order form.
`(1 unit/mL) is added to all central venous lines and to all peripheral
`infusions running at <2 mL/hr in order to maintain catheter patency.
` of infants receiving parenteral nutrition should include:
`
`Test
`Electrolytes,
`BUN/creatinine
`Chemstrip/glucose
`
`Calcium, ionized
`Total calcium, phosphorus,
`magnesium, bilirubin (T/D),
`ALT, alkaline phosphatase, GGT,
`albumin
`Triglycerides
`
`Initial
`Daily
`
`q6hr-daily
`
`daily
`Baseline
`
`When stable
`2-3x/week
`
`Daily, more frequently when
`changing CHO
`2-3x/week
`weekly
`
`When lipid infusion reaches 1.5 g
`fat/kg/d and
`3 g fat/kg/d
`CBC/Diff and platelets
`
`weekly
`Note: The Pediatric TPN panel includes all of the above laboratory tests except the CBC/diff, platelets and
`glucose. It requires 0.4 cc of blood in each of 2 microtainer tubes (i.e., 0.8 cc total). It is usually drawn on
`Mondays with additional individual labs as needed or suggested above.
`
`weekly
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` of infants receiving PN is essential, including weekly
`measurements of head circumference. Measurements (weight, length and head
`circumference) should be plotted on standard post-natal growth charts.
`
`Parenteral Nutrition
`
`When the patient is tolerating >50 ml/kg/day of feedings, the TPN should be gradually
`tapered off. The table below maintains a minimum calorie intake of 100 kcal/kg/day and
`>2 grams protein/kg/day. These guidelines may be used for both the preterm and term
`infant, although the term infant may not need the concentrated breastmilk/formula.
`
`Directions: Determine total fluid allowance for the day. Write the TPN for the suggested
`volume and substrate amounts as indicated by the feeding volume. Use the lower end of
`the feeding volume range specified for your calculations. The suggested amounts of the
`CHO/protein/fat should be compatible except if the patient is significantly fluid
`restricted. The calcium and phosphorus must also be decreased for solubility reasons.
`Specify an IV+po order to keep total fluid intake at the prescribed amount.
`
`Feed
`Volume
`(cc/kg)
`0-49
`50-74
`75-99
`100-120
`120-150
`150-160
`
`PN Substrate
`(CHO/prot/fat)1
`
`12/3.5/3
`10/2.5/2
`8/2/1.5
`8/2/1
`None
`None
`
`IV+po
`Volume
`(cc/kg)
`100-140
`120-140
`130-140
`130-150
`NA
`NA
`
`Total TPN
`Volume
`(cc/kg)2,3
`100-140
`70-90
`55-654
`554
`None
`None
`
`MBM/formula
`Ca/P
`concentration
`(mEq/
`mmol)5
`(kcal/oz)
`20
`3/1.5
`20
`2.45/1.2
`1.75/0.85 20
`1.75/0.85 22
`N/A
`22-24
`N/A
`24
`
`1. mg CHO/kg/min, g prot/kg, g fat/kg
`2. Total TPN volume= (IV+po goal)-(lower end of indicated feed volume range)
`3.
`4. Keep the minimum dextrose/amino acid volume at 50 cc/kg for ordering purposes
`5. Amount per kg as ordered on the TPN form
`
`: PN may be stopped when the
`infant is tolerating 100-120 cc/kg of enteral feedings or is receiving 25 cc/kg/d of PN.
`The rate of dextrose administration should be tapered to prevent rebound hypoglycemia.
`Chemstrips should be done q6h. Newborns need a slower tapering than older children
`and require continued monitoring of glucose after the solution has been stopped. Lipids
`may be stopped without tapering. If the PN catheter clots or infiltrates, start another IV
`with dextrose concentration 12.5% depending on the current glucose concentration. The
`“Starter TPN” (D10WAA3.5) may also be used to maintain protein intake until a new
`bag arrives.
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`Parenteral Nutrition
`
`For additional information regarding PN:
`Please see the following web site:
`http://yew.ucsf.edu/DIAS/parenteral_nutr_guide_Neo_ped.htm
`Request consult from Nutrition Services: 353-1461 or 353-1814, Ext. 1; on
`weekends, page the Nutritionist on call at 443-4822.
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