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Review article
Parenteral nutrition in preterm newborns: proposal for a
practical protocol
Parenteral nutrition in preterm infants: proposal of a practical guideline
Fabiola Isabel S. de Souza1 , Marcia Teske2, Roseli Oselka S. Sarni3
Summary
Objective: To review the literature and concepts related
to parenteral nutritional therapy for preterm newborns and
propose a practical flowchart for indication, progression of
parameters and monitoring for use in neonatal units.
Data sources: Articles published in English and
Portuguese in the Medline, Embase, Lilacs and SciELO
databases in the last ten years, in addition to classic
references and international consensus. The keywords used
as a search source were preterm newborn, parenteral
nutrition, nutritional therapy and lipid emulsions.
Data synthesis: Parenteral nutrition is an essential
procedure in the in-hospital treatment of preterm newborns.
In addition to advances in knowledge and progress in
legislation, several factors have contributed to reducing the
morbidity and mortality of these newborns and increasing
the safety in the use of parenteral nutrition, such as the
quality of the catheters used, adequate training and
qualification of the professionals involved, the existence of parenteral nutrition formulations.
teams multidisciplinary teams and the development of new inputs. Conclusions: The practical parenteral nutrition guide
Conclusions: This practical protocol on parenteral
nutrition for premature newborns was developed based on
international recommendations from scientific societies and
on the critical analysis of scientific studies.
Keywords: parenteral nutrition; newborn; premature;
nutritional recommendations.
1 Master in Sciences from the Escola Paulista de Medicina of the Federal
University of São Paulo (Unifesp-EPM), collaborating physician in the
Nutrology Service of the Department of Pediatrics at the Faculdade de
Medicina do ABC (FMABC) and clinical coordinator of the Multidisciplinary
Team of Nutritional Therapy of the Mário Covas State Hospital and São
Bernardo do Campo University Hospital of the ABC Foundation. Santo
Andre, SP, Brazil
2 Collaborating physician at the Nutrology Service of the Department of
Pediatrics at FMABC. Santo Andre, SP, Brazil
3 PhD in Medicine and assistant physician at the Department of Pediatrics
at Unifesp-EPM, assistant professor at the Department of Pediatrics and
coordinator of the Nutrology Service at the Department of Pediatrics at
FMABC. Santo Andre, SP, Brazil
ABSTRACT
Objective: Review the literature regarding parenteral
nutrition of preterm infants in order to propose a practical
guideline for indication, increase of parameters and
monitoring of this nutritional therapy in neonatal units.
Data source: Studies in English and Portuguese from
the last ten years were retrieved from Medline, Embase,
Lilacs and SciELO using the following key-words: preterm
infants, parenteral nutrition, nutrition therapy and lipid
emulsions. Also classical studies and consensus on the theme
were manually searched.
Data synthesis: Parenteral nutrition is an essential
treatment strategy for preterm infants. Besides progress in
knowledge and legislation, several factors contribute to
reduce neonatal morbidity and mortality of newborns using
parenteral nutrition and to increase the security in its
prescription such as catheters' quality, training of the
multiprofessional team and development of new specific
line proposed here follows international guidelines and was
based on critical analysis of the studies published in the last
10 years.
Keywords: parenteral nutrition; infant newborn; infant
early; nutrition policy.
Mailing address:
Roseli Oselka Saccardo Sarni
Rua René Zamlutti, 94 – apt. 52 – Vila Mariana
CEP 04116 260 – São Paulo/SP
E-mail: rssarni@unifesp.br / rssarni@uol.com.br
Received on: 1/7/2008
Approved on: 4/10/2008
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Fabiola Isabel S. de Souza et al
Introduction
Parenteral nutrition (PN) is an essential therapeutic procedure
in the in-hospital treatment of preterm newborns (PTNB)(1). The
nutritional therapy of the PTNB represents an enormous
challenge, since the lower the weight and gestational age of the
newborn (NB), the greater their nutritional needs to achieve
adequate growth and development(2,3). PTNBs have reduced
reserves and greater immaturity of the gastrointestinal tract and
other organs, systems and devices, which makes it impossible
to use the enteral route exclusively, especially in the first weeks
of life(4-6) . Thus, the advances in procedures related to PN,
such as the type of catheter used(7,8), the training and
qualification of the professionals involved(9) and the development
of new inputs, allied(10) to the progress in legislation(11 ,12),
have greatly contributed to increase safety in the use of this
form of nutritional therapy.
PN is a procedure that is part of the neonatal intensive care
routine, and it is important to develop practical protocols that
take into account the advances available in the literature and
proposals for international guidelines. In this context, the
objective of this article is, with an adequate review of the
literature, to present the concepts related to parenteral nutritional
therapy for PTNB and to propose a practical protocol for
indication, progression of parameters and monitoring, which can
be used in the training of professionals, such as pediatric
residents and multidisciplinary teams that work with neonatal
nutritional therapy.
To carry out the literature review, the guidelines proposed
by several international scientific societies such as the American
Academy of Pediatrics (APA)(13), American Society for
Parenteral and Enteral Nutrition (Aspen)(14) and European
Society for Clinical Nutrition were used. and Metabolism (Espen)
and European Society for Pediatric Gastroenterology, Hepatology
and Nutrition (ESPGHAN)(15) and for articles in English and
Portuguese related to parenteral nutritional therapy for PTNB,
published in Medline, Embase, Lilacs and SciELO databases, in
last ten years. The keywords used as a search source were:
preterm newborn, parenteral nutrition, nutritional therapy, lipid
emulsions.
Legislation
Brazil has had specific legislation since 1998. This is
Ordinance No. 272/MS/SNVS, of April 8, 1998(11), which
establishes the minimum requirements required for the therapy of
Rev Paul Pediatr 2008;26(3):278-89.
parenteral nutrition, regulating the indication, prescription,
pharmaceutical preparation (pharmaceutical evaluation,
manipulation, quality control, conservation and transport),
administration, clinical and laboratory control.
In 2005, the Ministry of Health published a series of
ordinances that instituted, within the scope of the Unified Health
System (SUS), the High Complexity in Nutritional Therapy
(Assistance Units and Reference Centers)(12). These ordinances
include several nutritional therapy procedures for adults and
children, including neonatal parenteral nutrition, which
represented a great advance in legislation in the recognition of
this therapeutic procedure.
Recommendation
The smaller the PTNB, the earlier the indication for PN should
be, since the energy reserves of these children are quite
limited(1,16). It is estimated that a 1,000g NB would have
enough energy reserves to survive, without nutritional therapy,
for just four days(17,18).
Children weighing less than 1000g should receive PN in the
first hours of life and, initially, a solution containing amino acids,
glucose and electrolytes is suggested(18,19). PTNB weighing
1000 to 1500g also deserve special attention, and the start of
PN should not be postponed for more than 48 hours. Even in
newborns weighing more than 1500g, they should not remain
for more than 72 hours without effective nutritional therapy(1) (Figure 1).
Enteral nutrition should preferably be administered with
human milk and as early as possible (in the first 48 hours of life),
even in small volumes (Figure 1), as it represents a potent
stimulus factor for the maturation of the gastrointestinal tract and
protection against infections, in addition to other advantages(20-22).
In Brazil, as well as in European countries, 3:1 solutions are
used (dextrose, lipids and proteins in the same container). In
some countries, such as the United States, lipids are supplied
separately from other nutrients, in order to reduce the risk of
incompatibilities and precipitation.
Next, the steps and different components of PN will be
discussed individually in order to formulate a practical protocol
for the use of PN in PTNB. Reading combined with observation
of Figure 1 is suggested.
venous access
PN solutions with osmolarity above 600mOsm/L
(Chart 1), used in peripheral accesses, can lead to
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Parenteral nutrition in preterm newborns: proposal for a practical protocol

preterm newborn

ÿ1000g 1000g¬1500g >1500g

Minimal enteral nutrition in Minimal enteral nutrition in Consider the exclusive use
24 hours or when stable 24 hours or when stable of enteral nutrition

Start NPP <24 hours of life 24¬48 hours of life 24¬72 hours of life

80mL/kg/day 70mL/kg/day 70mL/kg/day

initial volume
Progress daily: according to water needs, weight, clinical conditions, others
infused volumes and fluid balance. Generally, in 7 days it reachesÿ150mL/kg/day

Glucose (VIG) 4mg/kg/min 4mg/kg/min 4mg/kg/min

From the 1st day
*50% glucose solution

Progress VIG daily (4-12mg/kg/min) according to right-handedness (ideal: 70-120mg/dL)

amino acids 1.5g/kg/day 1.5g/kg/day 1.5g/kg/day

From the 1st day
*Amino acids with
10% taurine
Progress: 1g/kg/day (max: 3.5g/kg/day) Progress: 1g/kg/day (max:
3.0g/kg/day)

lipids
>24 hours of life 1g/kg/day 1g/kg/day 1g/kg/day
*20% emulsion with
TCL or TCL/TCM

Progress from 0.5-1g/kg/day to 3g/kg/day (maximum) and monitor triglyceride levels if: <150mg/dL
(progress), 200-250mg/dL (not progress) and >250mg/dL ( stop the infusion
of lipids for 24-48 hours and restart with 1g/kg/day if normalization)

Vitamins
®
>24 hours of life Pediatric Polivit A® : 4ml/kg (max: 10mL) + Pediatric Polivit B pediatric: 2ml/kg (max: 5mL)
MVI 12®: 2ml/kg (max: 5mL)
Frutovitan®: 2mL/kg
*Vitamin K (plus): 1 or 3mg (IM or IV) 1x/week or 1.5 or 0.5mg 2x/week

trace elements
>24 hours of life Oliped 4®: 1mL/kg Ped-Element® : 0.2mL/kg
Ad-Element® : 0.05mL/kg Tracitrans Plus ®: 0.3mL/kg
Politrace 4®: 0.1mL/kg
*Zinc: add 200-400ÿg/day to meet needs

Electrolytes
Electrolyte Onset Dose
Sodium ÿ72 hours 1-3mEq/kg
Potassium ÿ72 hours 1-2mEq/kg
Calcium <24 hours 1-2mEq/kg
Magnesium <24 hours 0.3-0.5mEq/kg
Phosphor >24 hours 1-2mmol/kg

Figure 1 – Algorithm for indication and follow-up of parenteral nutritional therapy in preterm newborns.

280 Rev Paul Pediatr 2008;26(3):278-89.

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Fabiola Isabel S. de Souza et al
to a series of complications (phlebitis, extravasation, etc.).
As, in most cases, the PN of the PTNB exceeds this value
and its use occurs for a prolonged period (>14 days), it is
preferable, initially, to have a central access.
The use of peripherally inserted central periphe rally
inserted central catheters (PICCs) represented a true revolution
in the choice of access route for PN due to its safety and ease
of insertion. Currently, such catheters are considered the first
option for PN infusion in neonates(7). PN infusion through
umbilical catheters is related to a greater number of mechanical
and infectious complications, and should be used only in
exceptional situations and for a short period (artery <5 days
and vein <14 days)(23) . Thus, the catheter in the umbilical
vein can be used in the first hours of life, while the insertion of
the PICC is provided.
amino acids
Studies show that the initial infusion of 1.5g/kg/day of
amino acids, followed by increases from 0.5 to 1g/kg/day up
to 3 to 3.5g/kg/day, is necessary to promote positive nitrogen
balance in PTNB (23.24). The infusion of higher rates of amino
acids (3 to 3.5g/kg/day) in the first hours of life, even in
newborns weighing <1000g, does not induce toxicity and
promotes a better immediate nitrogen balance when
compared to lower rates ( 1 to 1.5g/kg/day)(13,25,26),
however, there are still no studies evaluating adverse events
from this practice in the long term(27). In this protocol, it is
recommended to start with 1.5g/kg/day and promote rapid
increments (1g/kg/day and a maximum of 4g/kg/day), which
allows reaching the proposed supply in 72 hours (Figure 1) .
Protein supply in the early stages of PN in PTNB is much
higher than that recommended for older children in different
clinical situations. Therefore, the calculation of the ratio grams
of nitrogen/non-protein calories should not be taken into
account in this phase of PN planning(19,24). The energy
metabolism of PTNB is different, especially in those <1000g,
with glucose production from gluconeogenesis and use of
protein as an energy substrate, even in conditions of clinical stability(24,28).
levels are above 200mg/dL and suspend it if above 250mg/
Some amino acids are considered conditionally essential
for PTNBs and, therefore, the choice of pediatric solutions is
essential to ensure safety and meet specific nutritional needs.
Such solutions, specially adapted, contain taurine, tyrosine,
histidine, aspartic acid and glutamic acid in amounts similar to
those found in human milk, but contain lower concentrations
of methionine, glycine and phenylalanine(13,29) (Table 1) .
Rev Paul Pediatr 2008;26(3):278-89.
Cysteine is also a conditionally essential amino acid in the
neonatal period, especially for those younger than 32
weeks(30). This amino acid is the major substrate for the
synthesis of the tripeptide glutathione (an integral part of the
enzyme glutathione peroxidase, with an antioxidant function)
and is not part of amino acid solutions due to its low stability.
However, cysteine can be added to the PN solution (30 to
55mg/
kg/day or 200 to 350µmol/kg or 40mg/g protein in the solution)
to ensure the normalization of plasmatic levels, especially if
the child is not receiving enteral nutrition with human
milk(13,29).
Regarding glutamine, there is no current evidence of
benefits from its use in PTNB(13,14,30,31). If administered,
20% of the infused amount of amino acids should not be
exceeded (0.4 to 0.5g/kg/day)(14,29).
Carnitine, used in the transport of long-chain fatty acids
across the mitochondrial membrane, is also not present in
currently available amino acid solutions.
Its supplementation should be considered in children receiving
PN exclusively for a period longer than four weeks.
The suggested parenteral dose is 10mg/kg/day(29).
lipids
The infusion of lipids in the PN of the PTNB is important to
provide energy and essential fatty acids, with the
recommendation of linoleic acid for the PTNB of 0.25g/
day, and can be started early(32,33) and with improved
tolerance if the infusion occurs continuously, within 24
hours(34).
In practice, lipid infusion can be started from the second
day of life (>24 hours of life), with an initial infusion rate of 0.5
to 1g/kg/day (maximum 4g/kg/day) and increments of 0.5 to 1
g/kg/day. However, special attention should be paid to the
monitoring of serum triglycerides, requiring a new dosage at
each increase of 1g/kg(34) (Chart 2). It is suggested to
interrupt the progression of lipid infusion when triglyceride
dL, returning after 24 to 48 hours with 1g/kg, depending on
the clinical condition. Another important fact to be observed is
that the lipid infusion rate should not exceed 0.13 to 0.17g/kg/
h(34) (Figure 1).
Several factors, in addition to the lipid infusion rate, influence
triglyceridemia, including extreme prematurity, sepsis,
cholestasis, catabolism, renal failure and pancreatitis, among
others.
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Table 1 - Composition of crystalline amino acid solutions for parenteral use

Composition Travasol® 10% Aminosteril® 10% Primene® 10% Aminoped® 10%
(g/100mL) baxter Fresenius Kabi baxter Fresenius Kabi
leucine 0.73 0.74 1.00 1.07
phenylalanine 0.56 0.51 0.42 0.46
lysine 0.58 0.66 1.10 0.71
Methionine 0.40 0.43 0.24 0.46
Isoleucine 0.60 0.50 0.67 0.64
Valine 0.58 0.62 0.76 0.71
histidine 0.48 0.30 0.38 0.41
threonine 0.42 0.44 0.37 0.52
tryptophan 0.18 0.20 0.20 0.18
Alanine 2.07 1.50 0.80 0.72
Glycine 1.03 1.40 0.40 --

Arginine 1.15 1.12 0.84 0.64

proline 0.68 1.50 0.30 1.61
serine 0.50 -- 0.40 0.90
tyrosine 0.04 -- 0.05 0.55
cysteine -- -- 0.19 0.04
Aspartic acid -- -- 0.60 --

Glutamic acid -- -- 1.00 --

ornithine -- -- 0.25 --

Taurine -- -- 0.06 --

Osmolarity-mOsm/L 998 939 790 848

Travasol® and Aminosteril®=are standard solutions; Primene® and Aminoped®= are pediatric solutions, the latter of which comes with taurine
(conditionally essential amino acid for PTNB).

Recent studies have shown that the use of heparin in PN
does not improve lipid clearance and therefore, currently, its
routine use in solutions for this purpose is not recommended. In
some situations, the use of heparin can be beneficial by
increasing the duration of the catheters and also by reducing the
risk of obstruction(35). The suggested dose is 0.5U/mL of the PN
solution, bearing in mind that its addition increases the risk of
instability in the 3:1 PN solution.
Huge advances have taken place in recent years regarding
the composition of lipid emulsions for PN. Currently, there are
emulsions with long-chain and medium-chain fatty acids on the
market, only long-chain (soybean oil), emulsions with olive oil,
fish oil and structured lipids (soybean, olive, fish and medium-
chain triglycerides ). However, there are few studies using these
new lipid emulsions in the PN of PTNB, which, unfortunately,
limits their current use(33)(Table 2).
In practice, prefer 20% lipid emulsions, since their lower ratio
between phospholipids and triglycerides promotes better
whitening and, consequently, lower risk of hypertriglyceridemia,
compared to 10% emulsions(34) . It is possible to use emulsions
containing only long chain triglycerides or half and half with
medium and long chain triglycerides. The latter, despite having a
lower content of essential fatty acids, are theoretically metabolized
more quickly because the medium-chain triglyceride is practically
independent of carnitine to enter the mitochondria and subsequent
oxidation(33,34) .
There is no obvious association between hyperbilirubinemia,
thrombocytopenia and cholestasis with the infusion of lipids,
however, if all other causes related to these diseases, which are
quite common in PTNBs, are ruled out, the triglyceride levels
should be more rigorously monitored. As a last resort, in
thrombocytopenia and cholestasis, one can temporarily reduce or suspend (2

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Table 2 - Composition of traditional lipid emulsions for parenteral use

Composition (g/100mL) Lipovenos® Lipovenos® Lipovenos® Lipovenos® Lipovenos®
TCL 10% TCL 20% MCT 10% MCT 20% PLR
Fresenius Fresenius Fresenius Fresenius Fresenius
kabi kabi kabi kabi kabi
Soy oil 10 20 5 10 10
TCM --- --- 5 10 ---
Glycerol 2.5 2.5 2.5 2.5 2.5
egg phospholipid 1.2 1.2 0.6 1.2 ---
egg lecithin --- --- --- --- 0.6
alpha tocopherol --- --- --- --- ---

Osmolarity (mOsm/L) 273 273 272 273 272

Composition (g/100mL) Lipofundin® Lipofundin® Ivelip® TCL10% Ivelip®

TCM 10% TCM 20% TCL20%

B.Braun B.Braun baxter baxter

Soy oil 5 10 10 20
TCM 5 10 --- ---
Glycerol 2.5 2.5 2.5 2.5
egg phospholipid --- --- --- ---
egg lecithin 0.8 1.2 1.2 1.2
alpha tocopherol 10 20 --- ---

Osmolarity (mOsm/L) 345 380 265 270

48s) the infusion and observe if there is improvement in the greater number of complications, especially of an infectious
condition(14,34). Regarding cholestasis, fasting is one of the most nature, and increased risk of mortality(39).
important risk factors for its development. Thus, the administration
of enteral nutrition, even with small volumes, is fundamental(36). Vitamins

Glucose The vitamins are added in combination, in ampoules, in the

D-glucose (dextrose) is the carbohydrate used in PN solutions
and provides 3.4kcal/g. Solutions with 5, 10, 25 and 50%
concentration are available. Glucose plays a fundamental role in
the metabolism of the central nervous system. To calculate the
amount to be added to the PN, the infusion rate or glucose
infusion rate (TIG or VIG) is used, expressed in mg/kg/min.
Generally, it starts with a VIG of 4mg/kg/min, progressing to 12
and 14mg/kg/min, depending on the neonate's needs and clinical
condition (Charts 1 and 2). In this progression, it is essential to
monitor blood glucose, ideally values between 70 and 120mg/
dL(13,28,37). Episodes of hypoglycemia are associated with
worse future neuropsychomotor development(38) and episodes
of hyperglycemia are related to the
PN solution. It is important to know the recommendation and
composition of the multivitamins available to offer adequate
amounts(40), bearing in mind that there are no specific products
for PTNBs. An approximate calculation, taking into account the
recommendations for this age group and the solutions most
commonly used in our country, is available in the algorithm
proposed at the end of this chapter (Table 3, Figure 1).
Special emphasis can be given to vitamin A, as the solutions
available on the market often do not meet the needs of the
neonate, without leading to an excess supply of other vitamins.
A recent meta-analysis
concluded that vitamin A supplementation (intramuscular,
intravenous or oral) in PTNB weighing <1500g is associated with
reduced mortality and the need for oxygen therapy at one month
of life. For neonates <1000g,

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Parenteral nutrition in preterm newborns: proposal for a practical protocol

Chart 1 – Parameters for monitoring parenteral nutritional therapy in preterm newborns.

Expected Meaning

a) Calcium concentration <10mEq/L This is the [Ca] in mEq/L in the PN solution.

Ca (mEq) -------- volume in PN If >10mEq/L, it may destabilize the solution.

x (mEq) -------- 1000 mL

b) Sum of cations [Mg+Ca]<16 mEq/L It is the sum of the mEq of the cations (bi and
Ca (mEq)+Mg (mEq) ---- volume in PN trivalent) in the solution. If >16mEq/L, it may
destabilize the solution.
x (mEq) ------------------------- 1000 mL

c) Ca/P ratio (mg)
Ca (mg) in PN -------------1.3¬2
P (mg) in PN --------------- 1
1.3:1 to 2:1 (mg) This is the ratio of the amount of Ca and P to
1.1:1 to 1.3:1 (molar) maintain solution stability when inorganic
phosphorus salts are used. A level close to 2:1
(mg) is best for bone incorporation.

d) Osmolarity (mOsm/L) <600mOsm/L It is the best parameter to define the route of PN

Osm=(AX8)+(GX7)+(Nax2)+(Px0.2)-50 (peripheral) use: if <600, it is safe to use the peripheral route;
>600mOsm/L 600-900, you can use the peripheral route with
G=Glucose (g/L); A=amino acids (g/L);
care; and >900, it is mandatory to use the central
Na=sodium (mEq/L; P=phosphorus (mg/L) (central) route .

e) Non-protein Kcal/gram N (C/N) 100/1-150/1 Characterization of nutrient distribution.

N/C=g N/kcal Lipid+kcal (glucose) (metabolic stress) Hypercatabolic NBs or under metabolic
150/1-250/1 stress benefit from the 100/1-150/1 ratio. RN in
1g protein=0.16g nitrogen (4kcal)
anabolism need ratios of 150/1-250/1. This
(for anabolism)
1g lipid=9kcal relationship is not so important in PTNB.
1g glucose=3.4kcal

f) Glucose concentration >12.5% It cannot be the only parameter to define whether

[Glucose]=g (glucose)/total volume the solution will be used in the peripheral or central
route.

g) Caloric offer PN calories/weight Calculation to verify that the necessary

OC=kcal (lipids)+kcal (proteins)+kcal (glucose)/ calories are being offered for synthesis/
weight (kg) maintenance of organs, tissues and systems.

such findings were also observed after 36 weeks of corrected
gestational age(14,41).
In situations where there is a need for exclusive use of PN,
without using the enteral route or in the presence of cholestasis
or sepsis, intravenous or intramuscular supplementation with
vitamin K at a dose of 1 to
3mg/week.
Another important care that reduces vitamin losses is the use
of vials and equipment with photoprotection. Exposure to light
leads to the degradation of photosensitive vitamins and to a
greater production of lipid peroxides in PN(42). a recent work
suggests that the photoprotection of the PN solution would reduce
by 30% the incidence of chronic lung disease in PTNB(43).
trace elements
Similar to vitamins, oligoelements are added to the PN solution
in combination, in ampoules, and there are no specific products
for PTNB(40,44)
(Table 4). An offer suggestion, based on the recommendations
and composition of the solutions available on the market, is shown
in Figure 1. There are solutions available only

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Chart 2 – Suggested clinical and laboratory controls in nutritional therapy for preterm newborns.
parameters First period stable period

Clinical (activity, diuresis, blood pressure, heart rate, Daily Daily

respiratory rate, temperature, fluid balance)

Electrolytes and pH (Na, K, Ca, P, Mg) 3-4x week Weekly

urea and creatinine 2-3x week Weekly

Glycemia (dextro) Daily (3 times) Daily (1 time)

glycosuria Daily (3 times) Daily (1 time)

Albumin Weekly Weekly

Liver enzymes (TGO, TGP, Gamma-GT) Weekly Weekly

Hemoglobin and hematocrit Weekly Weekly

glycosuria Daily Daily

Urinary density Daily Daily

Leukogram when indicated when indicated

cultures when indicated when indicated

Triglycerides (total cholesterol and fractions not required) 4 hours after ÿ lipid infusion Weekly

Table 3 - Lipo and water-soluble vitamin requirements kg/day in preterm newborns and composition for each mL of solutions
Daily MVI 12 Polivit ® A Polivit® B frutovitam®
Opoplex®
recommendation (kg/day) Pediatric Pediatric ampoule 10mL
Pediatric ampoule 10mL ampoule 5mL
ampoule 5mL
grossman Inpharma Inpharma crystallia

For each 1mL For each 1mL For each 1mL For each 1mL

fat soluble vitamins

700 122 70 --- 304
A (µg)
2.8 1.4 0.7 --- 5
In G)
80 40 --- --- ---
K (µg)
4 1 1 ---
D (µg) two

water soluble vitamins

25 16 8 --- 50
Ascorbic acid (mg)
0.35 0.3 0.12 --- ---
Thiamine (mg)
0.15 0.35 0.14 --- 0.5
Riboflavin (mg)
0.18 0.25 0.10 --- 1.5
Pyridoxine (mg)
6.8 4.25 1.7 --- 10
Niacin (mg)
2.0 1.25 0.5 --- 2.5
Pathothenic Acid (mg)
6.0 4 --- 4 ---
Biotin (µg)
56.0 28 --- 35 ---
Folate (µg)
0.3 0.2 --- 0.2 ---
Vitamin B12 (µg)
dose/day 2mL/kg 4mL/kg 2mL/kg 2mL/kg

*Conversions: vitamin A, 700µg=2300UI; vitamin E, 7mg of ÿ-tocopherol=7UI; vitamin D, 10µg=400UI.

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Table 4 – Trace element requirements (kg/day) in preterm newborns and composition for each mL of trace element solutions

Nutrient Recommendation Ped-Element® Oliped 4® Ad-Element® Polytrace®4 Tracitrans® Plus*

(µg/kg/day) (5mL ampoule) (5mL ampoule) (2mL ampoule) (5mL ampoule) (10mL vial)
Manufacturer Darrow Inpharma Darrow Inpharma Fresenius
(µg/mL) (µg/mL) (µg/mL) (µg/mL) (µg/mL)
Zinc (µg) 400 500 100 1250 1000 660

Copper (µg) 20 100 20 400 200 127

2.0 --- --- --- --- 3.2
Selenium (µg)
Chromium (µg) 0.20 1 0.17 5 two 1

Manganese (µg) 1.0 10 6 200 100 27

0.25 --- --- --- ---
Molybdenum (µg) two

1.0 --- --- --- --- 13

Iodine (µg)
dose/day& 0.2mL/kg 1mL/kg 0.05mL/kg# 0.1mL/kg 0.3mL/kg
*Tracitrans® plus: also contains iron 112µg/mL and fluoride 95µg/mL; #Even with the dose adjustment, the supply of manganese is ten times higher
than recommended per day; &The calculation was based on the recommendation for copper and, therefore, some trace elements are above and
others below the recommended level, since an individualized calculation is not possible. In the case of zinc, there is an individualized solution and it
is necessary to add 200 to 400µg in addition to that offered by the trace elements solution to adjust needs.

with zinc in its composition (200µg/mL and 1,000µg/mL),
which can be used in combination with trace element solutions
to meet the extra zinc needs in this age group.
Some precautions are important: manganese and copper
are excreted by the liver. In conditions where there is impaired
bile excretion (cholestasis), the addition of these oligoelements
to PN can be reduced or even excluded. It is possible, even
with exclusive PN, to use only the zinc solution for a period of
two weeks, without prejudice to the PTNB(14,44).
Recent studies indicate that selenium is an important trace
element in the nutritional therapy of preterm infants from the
first days of life, especially to reduce episodes of sepsis(45,46).
Unfortunately, commercially available pediatric trace element
solutions do not contain selenium. An option to supplement
selenium is to administer the solution of trace elements for
adults (adapting the amounts to be offered by Tracitrans®
Plus) or the supplementary feeding via enteral route.
Minerals
One of the great challenges of PTNB nutritional therapy is
to offer large amounts of calcium and phosphorus, with
adequate ratio for bone mineralization (calcium:phosphorus
ratio from 1.3:1 to 2:1mg or from 1.1:1 to 1, 3:1 in molar ratio)
and without leading to precipitation of the solution. To facilitate
administration, it is preferred to use phosphorus in organic
form (Table 5). Parenteral needs range from 80 to 100mg/kg/
day of calcium and 43 to 62mg/kg/day of phosphorus(40).
The other electrolytes (sodium, potassium, magnesium) are
added to the solution according to the days of life and the
recommended amounts (Figure 1). Some care should be
taken into account when offering electrolytes in 3:1
solutions(44): the amount of calcium in the solution should not
exceed 10mEq/L and the sum of di- or trivalent cations (calcium
and magnesium) should remain below 16mEq /L (Table 1).
The initial water supply should be 80mL/kg/day for NB
<1,000g and 70mL/kg for the others(13). Volume progression
should take into account the water balance and other fluids
infused enterally or parenterally, and at the end of the first
week of life, it should be around 130 to 150mL/kg/day. It is
also important to consider, for water supply, the presence of
diseases that lead to the need for water restriction, such as
patent ductus arteriosus.
enteral nutrition
Enteral nutrition should be introduced early, preferably
within the first 48 hours of life, in small amounts, with raw
human milk (1st option) or pasteurized (2nd option). The
progression is made, depending on the clinical condition and
the tolerance of the diet by the PTNB, with increments of 20 to
30mL/kg/day(4,17), however, it should be remembered that
the use of human milk is associated with better tolerance and ,
therefore, a faster progression of the enteral diet can be
performed. When it is not possible to use breast milk, the most
appropriate option is the use of specific infant formulas for
preterm infants.

286 Rev Paul Pediatr 2008;26(3):278-89.

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Fabiola Isabel S. de Souza et al

Table 5 - Composition of electrolyte solutions

Product Cation anion
mEq/mL mg/mL mEq/mL mg/mL
10% sodium acetate 0.7 16.9 0.7 43.4
Sodium acetate 2mEq/mL 2.0 46.0 2.0 118.1
Potassium acetate 2mEq/mL 2.0 78.2 2.0 117.9
10% sodium bicarbonate 1.2 27.4 1.2 72.6
Sodium chloride 3% 0.5 13.1 0.5 20.2
Sodium chloride 10% 1.7 39.3 1.7 60.7
Sodium chloride 20% 3.4 78.6 3.4 121.4
Sodium chloride 4mEq/mL 4.0 92 4.0 141.8
Potassium chloride 19.1% 2.6 100.1 2.6 90.9
Potassium chloride 2mEq/mL 2.0 78.2 2.0 70.9
Potassium diacid phosphate 25% 1.8 71.8 1.8 57.0
Potassium Monoacid Phosphate 25% 2.9 112.3 1.9 44.5
Sodium Phosphate 2mEq/mL 2.0 46.0 1.1* 34.2
Potassium phosphate 2mEq/mL 2.0 96 1.1* 34.2
Sodium glycerophosphate 1Mmol/mL 2.0* (Na) 46 1.0* 31.0
Sodium glycerophosphate 0.33Mmol/mL 0.66* (Na) 15.3 0.33* 10.2
Calcium Gluconate 10% 0.5 8.9 0.5 87.0
Magnesium sulfate 10% 0.8 9.9 0.8 39
Magnesium sulfate 20% 1.6 19.8 1.6 78.0
Magnesium sulfate 50% 4.0 49.5 4.0 195.0
Magnesium sulfate 1mEq/mL 1.0 12.2 1.0 48.1
*Mmol/L.

Monitoring Proper maintenance of catheters greatly reduces infectious

The implementation of a follow-up and monitoring strategy for
the use of PN is essential to prevent and treat early complications
related to its use. The participation of a multidisciplinary team in
the institution of care protocols with catheter, manipulation, drug-
nutrient interaction, installation, photoprotection, nutritional
assessment and metabolic and laboratory follow-up increase the
safety and effectiveness of the use of PN in PTNB (Chart 1 and
two).
Complications
complications related to PN.
For PTNB-associated cholestasis of PN, the most important
risk factors are enteral fasting time, time of use of PN and sepsis.
Once cholestasis is installed, for its treatment, the use of enteral
nutrition (even in small volumes), the reduction in the supply of
amino acids and the supply of glucose, maintenance of circulating
triglyceride levels below 200mg/ dL (if necessary, suspend the
lipid infusion for 24 to 48 hours), temporary suspension (seven
to 14 days) of the oligoelement solution, since copper and
manganese are excreted by the liver. In more advanced cases,
cyclic PN can be used (14,47).

The most serious complications associated with the use of

PN in PTNB are hepatobiliary complications (cholestasis) and Final considerations
sepsis(47). Protocols of care and monitoring of the use of PN,
with the involvement of the multidisciplinary team, prevent and This practical protocol on PN for PTNB was developed based
significantly reduce the complications associated with PN(9). on international recommendations from scientific societies and
theand
Measures such as care with the preparation of the solution, positioning critical analysis of scientific papers.

Rev Paul Pediatr 2008;26(3):278-89. 287

Machine Translated by Google
Parenteral nutrition in preterm newborns: proposal for a practical protocol
with appropriate methodology approaching the theme. The
article intends to facilitate the training of pediatric residents
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