Indications for TPN

A. Premature infants <30 weeks gestation and/or <1500g.

B. >30 weeks gestation but unlikely to achieve full enteral feeds by day 5.

C. Infants at high risk of NEC:1. <30 weeks gestation

2. >30 weeks with absent or reversed fetal umbilical artery flow.

3. Infants with perinatal asphyxia

D. Necrotising enterocolitis (NEC).

E. Gastro-intestinal tract anomalies.

Return to index

GOALS OF PN PN is initiated to correct in-utero growth

restriction PN to prevent subsequent growth failure. PN to provide

1. sufficient energy and nitrogen

2. to prevent catabolism and

3. to achieve positive nitrogen balance

Return to index

ADMINISTRATION

PN which include:

1. Route of administration

2. Content of PN based upon the timing of administration

3. Monitoring

Return to index

Components of TPN

1. Fluid

2. Calories (Energy)1. Carbohydrate

2. Protein

3. Lipid

3. Acetate

4. Minerals

5. Vitamins

Return to index

Energy

parenteral nutrition (PN) is calculated to provide percent of calories as

1. Carbohydrates………………………………….. 55%

2. Lipids ……………………………………………….. 30%

3. amino acids …………………………………….. 15%

Return to index

Fluid

Volumes are increased over the first 7 days in line with the feeding protocol with the aim of delivering 150 ml/kg/day by day 7.

Day 1 60 ml/kg/day Day 2-3 90 ml/kg /day Day 4-6 120 ml/kg /day Day 7 150 ml/kg /day

Return to index

Energy

Requirements; A. energy expenditure;

range of 50 to 60 kcal/kg per day

1. Basal metabolic rate2. Physical activity3. Specific dynamic action of food4. Thermoregulation

Return to index

Energy Requirements;

B. Growth;

about 5 kcal/g in utero weight gain of 14 g/kg per day energy intake of about 70 kcal/kg per day

Babies need at least 100-120 kcal/kg/day to grow.

Return to index

daily energy requirements for growing premature infants

Factor Kcal/kg CommentResting energy expenditure

50 Resting metabolic rate

Activity 15 30 percent above restingCold stress 10 ThermoregulationSynthetic effect of feeding 8 Dietary thermogenesisFecal loss 12 10 percent of intakeGrowth 25 Calories storedTotal caloric requirement

120  

Return to index

Caloric balance PN preterm

  Concentration, percent

g/kg/day kcal/kg/day

kcals, percent

Infusion rate at 135 mL/kg/dayGlucose 12.5 16.9 57.5 57Amino acids

2.5 3.4 13.6 13

Infusion rate at 15 mL/kg/dayLipid 20 3.0 30 30

energy sources in PN solutions based upon an assumed •Total Fluid Intake of 150 mL/kg per day and •Total Calorie Intake is 102 kcal/kg per day

Return to index

To calculate total daily calories,

use the following equation.

kcal/kg/ day =Total mL of formula x kcal/mL/Wt(kg)

Return to indexTPN CALCULATIONS

Calculate Proteins

% Amino acids = (Wt (kg) ×(g/kg/day) ×100) /

Vol in 24 h

Return to index

Calculate Fat emulsions

Fat emulsions. 10% fat emulsion (Intralipid) contains 1.1 kcal/mL 20% emulsion, 2 kcal/ mL.

Use the following formula to calculate daily caloric intake supplied by Intralipid 20%.

kcal / kq / day = (total lipid solution * 2) /wt

Return to index

CarbohydrateGLUCOSE

is administered as dextrose monohydrate.

Start with 4-6 mg/kg/min or D10-

D12.5.

Dextrose yields 3.4 kcal/g.

Return to index

Carbohydrate

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). The target plasma glucose level should

be 5.5 - 9.9 mmol/L.

Return to index

GlucoseReturn to index

Carbohydrate

Potential complications/risks include: 1. Hyperglycemia or hypoglycemia

2. Glycosuria and potential osmotic diuresis

3. Cholestasis and/or hepatic steatosis with high caloric intake usually from long-term high concentration infusion.

Return to index

AMINO ACIDS Start amino acids at 1.5-2 g/kg/d

step-wise advance of protein 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. Maximum peripheral concentration 3.5%

Include protein in you calorie count. Protein yields 4 kcal/g

Return to index

AMINO ACIDS optimal mixture of essential/nonessential amino acids required to achieve a positive nitrogen balance, which

results in protein accruement and growth

Return to index

Protein

Starting amino acid / protein intake:

Amino acid supply should start on the first

postnatal day.

A minimum amino acid intake of

1.5 g/kg per day is necessary to prevent a negative nitrogen balance.

Return to index

Protein

complications/risk include:

1. Acidosis

2. Elevated BUN ; rise in urea

3. Hyperammonemia ; rise ammonia

4. high levels of potentially toxic amino acids such as

phenylalanine.

5. Cholestasis with prolonged administration

Return to index

Fat Energy source

Essential fatty acid source (intralipid)

Cell uptake and utilisation of free fatty acids is

deficient in preterm infants

Start at ; 1g/kg/day,

increasing gradually to 3g/kg/day (less if septic)

Return to index

Lipid

Daily increase in lipid starting at 1

g/kg/day, increasing by 1g/kg/day.

target of 3 g/kg per day

1 g = 6 ml from solution 20%

Return to index

Lipid

Monitor triglyceride levels with each

increase. If triglyceride levels >2.8 mmol/L, consider reducing

the lipid emulsions by 1 g/kg/day increments but aim to continue at least 0.5g/kg/day to prevent

essential fatty acid deficiency.

Return to index

Composition10 versus 20 percent IL 

A. 30 percent emulsion

has not been investigated in premature infants

B. 10 percent solution

1. requires a larger administered volume

2. associated with a poorer clearance of triglycerides due to

interference from lipoprotein X

3. accumulation of lipoprotein X appears to be due to the higher ratio

of phospholipids to triglycerides in the 10 percent solution

Return to index

Composition10 versus 20 percent IL C. 20 percent IL infused lipids

demonstrated by their lower serum concentrations of

triglyceride, cholesterol, and phospholipid

have lower phospholipid-to-triglyceride ratios and

liposomal content than the 10% solutions, resulting in

lower plasma triglyceride, cholesterol, and

phospholipid concentrations.

Return to index

Fat A lipid intake of 0.25-0.5 g/kg/d is required to prevent essential

fatty acid deficiency.

Include lipid emulsion in calculations of total fluid intake.

Lipids yield 10 kcal/g.

IV lipid preparations are available as a 20% soybean emulsion that yields 2 kcal/mL.

Return to index

Fat Deliver IV lipids over 24 hours.

Do not allow lipids to exceed 60% of total caloric intake.

Return to index

FatGestation Weight/

Diagnosis Initiate(0.5 g/kg/d)

Advance by0.5 g/kg/d

Goal is3 g/kg/d

byPreterm <1,500 g, stable DOL 3 DOL 7 DOL 11

>1,500 g, stable DOL 3 DOL 4 DOL 9

Very unstable (e.g.,

severe RDS, ↑ bilirubin)

DOL 3 When status

improves

Term No pulm. disease DOL 3 DOL 4 DOL 9

Severe pulm. disease,

PPHN, MAS

Consider DOL 7 When status

improves

Return to index

Complications

1. Hyperlipidemia

2. Potential risk of kernicterus at low levels of unconjugated bilirubin As a general rule, do not advance lipids beyond 0.5 g/kg/d until

bilirubin is below threshold for phototherapy

3. Potential increased risk or exacerbation of chronic lung disease

4. Potential exacerbation of Persistent Pulmonary Hypertension (PPHN)

5. Lipid overload syndrome with coagulopathy and liver failure

Return to index

Total Parenteral NutritionTotal Parenteral Nutrition

Calculate electrolytes to add to bag DOL#1: dextrose in water with no eletrolutes is usually appropriate

except in premies with low Ca stores who may require Ca DOL#2: add electrolytes to the bag based on estimated daily

requirements and BMP Estimated Needs:

NaCl = 2-4 mEq/kg/dayKCl = 1-2 mEq/kg/day (NOTE: Do not supplement K until UOP

>1cc/kg/hr, especially in premies)Ca Gluconate =200-400mg/kg/day (NOTE: mg not mEq and Ca

cannot be infused at >200mg/kg/day through a central line)

Return to index

Minerals Premature infants require high intakes of Ca and P to mimic fetal accretion

rates. Use of calcium gluconate 75mg/kg/day and inorganic phosphate 45mg/kg/day (glucose-l-phosphate) increases solubility and resulted in increased Ca and P retention and reduced PTH.11 However, there is concern regarding precipitation of Ca and P in TPN solutions preventing higher amounts being delivered. Low AA concentrations and high temperatures (in infusion tubing in the infant humidicrib) are significant risk factors for the precipitation of the insoluble dibasic calcium phosphate that may be fatal upon intravenous infusion. The AA concentration of the TPN formula should not be less than 15 g/L (and ideally >30 g/L) when high intakes of calcium (15

mmol/L) and phosphate (16.6 mmol/L) are prescribed.

Return to index

Vitamins

• Vitamins are supplied in the in lipid emulsion (soluvit N and vitalipid).

• The table below shows the amount of vitamins supplied to infants through the proposed lipid emulsion run at 3g/kg/day

Return to index

Parenteral Calcium and Phosphorus Doses

Calcium (mEq/kg) Phosphorus

(mmol/kg)

Initiate 2 mEq/kg 1 mmol/kg

Advance every 1-2

days

0.5 mEq/kg 0.3-0.5 mmol/kg

Goal 3mEq/kg preterm)

2 mEq/kg (term)

1.5 mmol/kg preterm)

1.2 mmol/kg (term)

Return to index

Route

A. peripheral IV catheters

B. central venous catheters, usually reserved for patients requiring long-term (>2 weeks) or

C. percutaneous central venous catheters

choice is dependent upon the expected duration of PN

Line infection is the most serious complication of PN.

If possible, the continuity of PN infusion should not be interrupted to reduce the risk of infection

Return to index

Total Parenteral NutritionTotal Parenteral Nutrition

Central TPN1. Easy to meet nutrition needs2. No limits on osmolarity3. Little risk of phlebitis4. Long term use5. May require general anesthesia6. Greater risk of infection7. Increased cost8. Greater risk of mechanical injury,

air embolism, venous obstruction

Peripheral TPN1. Unable to meet needs for

Ca/Phos needs2. Maximum rate of Calcium

gluconate is 200mg/kg/d3. Maximum % dextrose is 12.5%4. Short term use5. Less risk for catheter related

infections6. Lower cost ?7. Less risk of mechanical injury, air

embolism, venous obstruction

Return to index

Constituents of PN

1. Solution A (ie amino acid solution)

2. Solution B (ie lipid)

Return to index

Solution A (ie amino acid solution)1. amino acids: Vaminolact® for children under 15kg Vamin 18 EF® for children over one year, who are fluid restricted

2. glucose and electrolytes

3. zinc, copper, selenium, manganese, fluoride, iodine and chloride: Peditrace® for children under 15kg Additrace® for those over 15kg

4. Solivito N®: water-soluble vitamins if a non lipid containing regimen

Return to index

Solution B (ie lipid)

1. lipid emulsions: Intralipid® 20 per cent SMOF® 20 per cent

2. Vitlipid N infant®: fat-soluble vitamins

3. Solivito N®: water-soluble vitamins if a lipid containing regime

Return to index

METABOLIC MONITORING Test Initial When stableElectrolytes,BUN/creatinine

Daily 2-3x/week

Chemstrip/glucose q6hr-daily Daily, more frequently when changing CHO

Calcium, ionized ,total calcium, phosphorus,magnesium, bilirubin (T/D),ALT, alkaline phosphatase, GGT,albumin

dailyBaseline

2-3x/weekweekly

Triglycerides When lipid infusion reaches 1.5 gfat/kg/d and3 g fat/kg/d

weekly

CBC/Diff and platelets weekly

Return to index

Laboratory monitoring of infants receiving parenteral nutrition (PN)

Laboratory test Frequency

Blood

Electrolytes: sodium, potassium, chloride, bicarbonate

Daily till stable, then serially as indicated

Glucose Daily till stable, then serially as indicated

BUN, creatinine, calcium, phosphorus, magnesium, alkaline phosphatase, liver function studies (bilirubin, alanine and aspartate aminotransferases)

After the first week and then serially on a alternate week schedule as indicated

Urine dipstick Daily till stable then as indicated

Return to index

MONITORING GROWTH Weekly measurements of head circumference. Measurements

(weight, length and headcircumference) should be plotted on standard post-natal growth charts.

Return to index

Risks of PN

Line associated sepsis

Line related complications (eg thrombosis)

Hyperammonaemia

Hyperchloraemic acidosis

Cholestatic jaundice

Trace element deficiency

Return to index

TPN WEANING GUIDELINES guidelines may be used for both the preterm and term infant, although the term

infant may not need the concentrated breast milk/formula

When the patient is tolerating >50 ml/kg/day of feedings, the TPN should be gradually tapered off

Return to index

TPN WEANING GUIDELINES

maintains a minimum calorie intake of 100 kcal/kg/day and >2 grams

protein/kg/day.

Return to index

Table 5. TPN Weaning Guidelines:

Feed

Volume

(cc/kg)

PN Substrate

(CHO/prot/f

at)1

IV+po

Volume

(cc/kg)

Total TPN

Volume

(cc/kg)2,3

Ca/P

(mEq/

mmol)5

MBM/formula

concentration

(kcal/oz)

0-49 12/3.5/3 100-140 100-140 3/1.5 20

50-74 10/2.5/2 120-140 70-90 2.45/1.2 20

75-99 8/2/1.5 130-140 55-654 1.75/0.85 20

100-120 8/2/1 130-150 554 1.75/0.85 22

120-150 None NA None N/A 22-24

150-160 None NA None N/A 241. mg CHO/kg/min, g prot/kg, g fat/kg2. Total TPN volume= (IV+po goal)-(lower end of indicated feed volume

range)3. Total TPN volume includes lipids4. Keep the minimum dextrose/amino acid volume at 50 cc/kg for ordering

purposes5. Amount per kg as ordered on the TPN form

Return to index

DISCONTINUING PARENTERAL NUTRITIONinfant 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.

Return to index

DISCONTINUING PARENTERAL NUTRITIONLipids 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" (D10W,AA3.5) may also be used to

maintain protein intake until a new bag arrives.

Return to index

Transitional Feeds

Reduce IV lipid by 50% when infant tolerates

100ml/kg/day of enteral feed.

Cease lipids when infant tolerates 120ml/kg/day

of enteral feeds

Return to index