Parenteral Nutrition in Infants and Children

Parenteral nutrition in infants and children
Authors:
Robert D Baker, MD, PhD
Susan S Baker, MD, PhD
Jessica Briggs, RD
Georgina Bojczuk, RD, CSP
Section Editor:
Kathleen J Motil, MD, PhD
Deputy Editor:
Alison G Hoppin, MD
All topics are updated as new evidence becomes available and our peer review process
is complete.
Literature review current through: May 2019. | This topic last updated: Dec 16, 2018.
INTRODUCTIONSafe, long-term parenteral nutrition (PN) was first described in

infants in 1972 [1]. Since that time, it has contributed to the survival of many children.
Soon after the development of PN, however, it became clear that serious problems were
commonly associated with its use. Changes in the gastrointestinal (GI) luminal contents,
GI function, metabolic abnormalities, cholestasis, liver compromise, and blood stream
infections were reported. This dampened enthusiasm and led, in some instances, to
recommendations against its use [2]. The indication for pediatric PN is limited to those
children whose GI tract is inadequate to support normal growth and development.
Enteral nutrition should be used instead of or in addition to PN whenever possible. PN

should be used only when it is not possible to meet nutritional requirements via the GI
tract or when there is bowel dysfunction resulting in inability to tolerate enteral nutrition
for a prolonged time: 1 to 3 days in infants, 4 to 5 days for children and adolescents, and
7 to 10 days in adults. Enteral nutrition has several physiologic advantages as compared
with PN and generally has fewer complications. Indications and management of enteral
nutrition for infants and children are discussed in a separate topic review. (See
"Overview of enteral nutrition in infants and children".)
Premature infants have a number of unique characteristics that affect the

implementation and safety of PN. These considerations are discussed in a separate topic
review. (See "Parenteral nutrition in premature infants".)
PHYSIOLOGYPN is inherently nonphysiologic because nutrients are delivered directly

to the systemic circulation, bypassing the gastrointestinal (GI) tract and the portal
circulation, which are the usual routes of nutrient entry. Nutrients delivered
intravenously through PN avoid the "first pass" effect of passage through the liver. The
targets for nutrient intake administered via PN are designed to approximate the nutrient
content that reaches the systemic circulation in enterally fed patients.
The effect of PN on physiology can be placed into three broad categories:
●Absence of enteral nutrients – Consequences of bypassing the GI tract and portal

system, including lack of the direct effects of enteral nutrients on enterocytes, and loss
of the "first pass" effect.
●Missing nutrients – Sequelae from missing or deficient nutrients in the systemic
circulation.
●Abnormal or imbalanced nutrients – The effect of nutrients not ordinarily found in the
systemic circulation or, if present, in differing amounts or ratios.
Knowledge of which nutrients should be included or omitted in PN, and the optimal
nutrient ratios, is based largely on trial and error. Since PN is most frequently used in
severely ill and/or malnourished patients, it is not easy to distinguish among the effects
of PN, the underlying disease, and malnutrition. As an example, it is well known that
malnutrition results in profound changes in the GI tract, with thinning of the mucosa,
blunting of villi, and increased translocation. From animal studies, we know that many
of these same changes are seen in parenterally fed animals that are nutritionally replete,
indicating that some of these effects are due to under-use of the GI tract, rather than
direct effects of the PN itself [3].
One of the most profound effects of not using the GI tract is that infants do not learn
how to eat. Infants learn coordinated chewing and swallowing foods of different
textures and tastes during certain "critical periods" of their development [4]. Infants
who are not fed by mouth during these critical periods may fail to develop normal
interest in food and the ability to eat. Moreover, their parents may fail to develop
normal responses to the infant's cues for feeding. It may take years to overcome the oral
hypersensitivity and food aversion that results from a lack of feeding experience during
the critical periods. This often leads to a prolonged transition from parenteral feeding to
full oral feeds, which can be frustrating to parents and caregivers.
When the enteral route is bypassed, so are the physiologic consequences of eating. The
ingestion of food leads to a surge of hormones, neurotransmitters, and enzymes. These
mediators result in coordinated GI motility. Little is known about the alterations in GI
motility that are associated with PN. Animal data suggest that motility of the stomach,
duodenum, and gallbladder is reduced during PN. The decrease in gallbladder motility
may in part explain the increase in gallstones that is associated with PN. Interestingly,
PN does not affect motility in the jejunum in dogs [5].
The adverse effects of lack of enteral nutrition appear to be mediated in part by

glutamine deficiency, although the clinical implications of this observation remain
unclear. Glutamine is the major fuel of the enterocyte. The intestinal cell derives
glutamine both from the lumen of the GI tract and from the blood stream. If the GI tract
is not used, there is no glutamine in the intestinal lumen for the enterocytes to absorb
directly. Since standard PN solution has limited glutamine, the enterocyte may be
severely depleted of its main fuel source. In animal models of enterocolitis or intestinal
resection, supplemental glutamine promotes recovery [6]. However, clinical studies in
humans have generally failed to show benefits of enteral or parenteral glutamine
supplementation. As an example, a study in which glutamine was supplied both
intravenously and intraluminally to very ill adults with multiorgan failure in an
intensive care unit setting found no advantage to added glutamine, and mortality was
higher in the glutamine supplemented group [7]. (See "Nutrition support in critically ill
patients: Enteral nutrition", section on 'Glutamine' and "Management of short bowel
syndrome in children", section on 'Adaptive agents'.)
INITIATING PN
Indications and contraindications — If the gastrointestinal (GI) tract is partially

functional, the enteral route should be used even for a fraction of the required nutrients
[8]. Rarely, the GI tract cannot be accessed and all nutrients must be delivered via the
parenteral route; this is known as total parenteral nutrition (TPN). TPN is the last resort
when oral intake, enteral feeding, and the combination of partial PN and enteral feeds
are not possible. Examples of conditions in which PN or TPN is indicated are given in
the table (table 1). (See "Overview of enteral nutrition in infants and children".)
PN is indicated for infants and children who are unable to be fed enterally if nutritional
support is expected to be required for seven days or more. PN should not be used for
short periods of time, because the risks can outweigh benefits [9]. The appropriate time
for initiating PN depends on individual patient characteristics, including age, nutritional
status, underlying disease process, and expectations for future nutritional needs.
Well-nourished children or adolescents tolerate up to seven days without nutrition

support [10]. Patients in this age group who are unable to eat or tolerate enteral feeds
should be evaluated within three days to ensure that PN is initiated within four to five
days. Adults can tolerate 7 to 10 days without nutrition support [11]. There is no
evidence to support the use of PN to "prepare" a patient for surgery unless the patient is
severely malnourished [2].
PN is typically initiated earlier for neonates and premature infants. Premature and term
infants have limited nutritional reserves and are able to tolerate starvation or
semistarvation for only one to three days; if it is clear that the infant will not tolerate
enteral feeds, then PN usually should be initiated within the first two days of life.
However, the optimal timing of PN initiation remains unclear. As an example, early
versus late initiation of PN was evaluated in a randomized trial in critically ill, term
neonates admitted to the intensive care unit (ICU) [12]. The late initiation group had
fewer infections and a greater likelihood of live discharge from the ICU but also a
significant increase in episodes of hypoglycemia. Thus, the relative benefits and risks of
early versus late initiation of PN has not been established for this group of patients.
When caution should be used — PN, whether provided peripherally or centrally, should
only be used in patients who are hemodynamically stable and are able to tolerate the
necessary fluid. PN should be used with particular caution for children with electrolyte
imbalance, renal or hepatic compromise, metabolic acidosis, or alkalosis. Acid-base and
electrolyte abnormalities should be corrected prior to starting PN, or corrected by
infusions through a separate intravenous line. PN should not be used to correct
metabolic imbalances.
Children and adolescents undergoing treatment for cancers may or may not be
malnourished. Their nutritional status plays an important role in deciding on the
nutritional support necessary. PN is no more effective than enteral nutrition in children
undergoing chemotherapy, as suggested by a meta-analysis [13]. No meta-analysis is
available for malnourished children undergoing treatment, but several reviews in adults
raise concerns about the use of PN in patients undergoing chemotherapy, and the
American Gastroenterological Association (AGA) advises against its use [2]. No studies
have identified individual nutrients that have a positive effect on outcomes. These
studies reinforce the concept that PN should only be used when other methods of
nutrition support are not possible or have failed. If PN is deemed necessary in children
and adolescents undergoing treatment for cancer, then general principles should be
followed for the initiation and maintenance of PN in malnourished and non-
malnourished patients, as outlined below.
Central and peripheral venous access — PN can be administered through a peripheral or

a central vein. Central venous access is defined as a catheter whose distal tip lies in the
distal vena cava or right atrium [14]. To avoid cardiac tamponade, there is some
evidence that the catheter tip should lie outside of the pericardial sac, especially in
premature babies [15]. Any intravenous (IV) not fitting this definition is considered
peripheral. Generally, the choice of central versus peripheral venous access depends on
the anticipated duration of the nutrition therapy. The maximum osmolarity that can be
delivered via a peripheral vein is 900 mOsm/L, and this constraint limits the amount of
nutrients that can be provided by a peripheral IV.
The osmolarity of a PN solution can be determined with the following equation [16]:
mOsm/L = (grams amino acids/L x 10) + (grams dextrose/L x 5) + ([mEq Na + mEq K]

x 2)/L + (mEq Ca x 1.4)/L
Given this osmolarity restriction, it is usually impossible to supply all of the required
nutrients with peripheral PN, and central venous access will be required to meet the
child's full nutritional needs. Therefore, if an infant or child is likely to need parenteral
nutritional support for more than two weeks, a central venous catheter should be placed
to meet the nutrition needs of the patient.
A variety of catheters are used for PN which differ in how they are inserted, how they
are fixed in place, and where they terminate. These characteristics determine for what
purposes and for how long they can be used. For all catheters that are intended to end
centrally, imaging is required to confirm tip position. The main types of catheters and
their characteristics are:
●Percutaneous nontunneled central catheters – These catheters are usually inserted via
the subclavian, jugular, or femoral veins. This type of catheter is most appropriate for
short-term PN of one to two weeks. These catheters are easily removed and can be
replaced over a guide wire; however, they are associated with a high infection rate
especially those placed via the femoral vein.
●Tunneled cuffed central catheters – These catheters are placed surgically. The catheter
is tunneled subcutaneously before it enters the vein, commonly the jugular or cephalic
veins. This type of catheter is appropriate for long-term PN including home PN. It has a
lower infection rate than the nontunneled catheters. The major drawback of this type of
catheter is that a surgical procedure is required both for placement and for removal.
●Peripherally inserted central catheters (PICC) – These can be placed via any peripheral
vein but are typically placed via the antecubital vein. PICC lines are appropriate for
medium-term use, up to several months. With special care they can be used for home
PN. The major advantage of PICC lines is the ease with which they can be inserted.
PICC placement can occur anywhere in a hospital, from emergency room to the
patient's bedside with low risk. Because of errors in estimates of insertion length, it is
particularly important to confirm central positioning of a PICC line.
●Implanted ports – These are used only for long-term therapies including PN. They may
be of benefit when adequacy of catheter care is in question or when body image is
important. It also may be helpful if intermittent PN is planned. The subcutaneous port is
accessed via a percutaneous needle that can remain in place for hours or up to a week.
When not being used, the needle is removed, leaving nothing externally visible.
Implanted ports have a low rate of infection, but if an infection does develop, it is
difficult to clear, and treatment may require removal of the port. Placement and removal
of an implanted port require surgical or interventional radiology procedures.
●Peripheral catheters – Peripheral catheters are only appropriate for infusions of PN

with osmolarity of up to 900 mOsm/L, and they need to be replaced frequently. These
limitations mean that they can be used only for PN in conjunction with partial enteral
feeds, and only for a short time (days to one week). The main advantages to peripheral
catheters are the ease of insertion, the minimal infection rate, and the low rate of other
complications.
Lock therapy — Regardless of the type of catheter, catheter-related bloodstream

infections are a major complication of PN use. Many centers are employing daily
ethanol lock therapy in an attempt to decrease bloodstream infections. Typically,
enough 70% ethanol to completely fill the catheter is instilled during a time when the
catheter is not being used for PN. The ethanol is allowed to remain in the catheter for
four hours and then removed. The catheter is then flushed with PN solution. In some
circumstances (eg, PN associated liver disease and intestinal failure), there is weak
evidence that ethanol lock therapy reduces blood stream infections. However, ethanol
lock therapy also is associated with greater risk of thrombus and shortens the life of the
catheter [17-19]. At this time there is not enough evidence to recommend its use in all
situations. (See "Intestinal failure-associated liver disease in infants", section on
'Prevention of sepsis'.)
Taurolidine, an antibiotic, or taurolidine-citrate, have been used in place of ethanol to

prevent catheter-related bloodstream infections [20,21]. (See "Intravascular catheter-
related infection: Prevention", section on 'Antibiotic locks'.)
NUTRITIONAL ASSESSMENTThe need for PN is determined by a careful assessment

of the child's nutritional status and underlying disease. Hospitalized children are at high
risk for malnutrition. The nutritional assessment must be repeated at intervals as the
clinical situation changes. A complete nutritional assessment includes a dietary history,
anthropometrics, metabolic status, and an estimate of the nutritional requirements for
the individual patient. (See "Indications for nutritional assessment in childhood".)
Dietary history — The techniques for obtaining a dietary history are discussed in a
separate topic review (see "Dietary history and recommended dietary intake in
children"). Patients who require PN usually have a very limited diet, or have
experienced a catastrophic event that precludes or limits use of the gastrointestinal (GI)
route. As a result, the dietary history is abbreviated and generally limited to medical
foods (eg, formula feeds).
Anthropometrics — The most important components of a nutritional assessment are
accurate measurements of weight and length or height. For infants 0 to 24 months, these
are used to calculate weight for length, and for children 24 months and older, they are
used to calculate body mass index (BMI). These data are plotted on the appropriate
growth curves to determine percentiles and to compare with previous measurements,
when available. These data can also be used to calculate Z-scores, which are valuable
because they eliminate age as a variable and allow comparisons at the extremes of
ranges.
Using weight-for-height Z-scores in children younger than two years or BMI-for-age Z-

scores in older children, malnutrition can be categorized as follows [22,23]:
●Mild malnutrition – Z-score -1 to -1.9
●Moderate malnutrition – Z-score -2 to -2.9
●Severe malnutrition – Z-score ≤-3
The recommended growth curves and calculators for BMI and Z-scores are presented in
a separate topic review. (See "Measurement of growth in children", section on
'Recommended growth charts'.)
BMI is a good index of adiposity in most patients. In patients with edema or with
unusual ratios of lean tissue to fat, measurements of mid upper arm circumference and
skinfold thickness can be used to assess body composition. These measurements are
inexpensive and easily performed but have limited precision. (See "Measurement of
body composition in children".)
Overweight and obese children can have macro- and micronutrient deficiencies that are
masked by their over-nourished appearance. Overweight or obese patients are at risk for
hepatobiliary disease, respiratory distress, renal impairment, hyperglycemia,
hyperinsulinemia, and infection. These risks should be considered in the nutritional
planning for children with obesity. (See "Overview of enteral nutrition in infants and
children", section on 'Adjustments for children with obesity'.)
HOW TO PRESCRIBE PNIdeally, PN for pediatric patients is tailored to the needs of

the patient. This requires a series of calculations and an individualized PN prescription.
A step-by-step guide to prescribing PN can be found here (table 2). This is followed by
an example of PN calculations (figure 1). Target ranges for macronutrients when
initiating and advancing PN are found in another table (table 3). Following these is an
example of a PN order form (form 1). This order form can be converted to an order set
for electronic medical records.
Many hospitals and institutions have standard PN formulas available. These formulas
will often meet some needs of pediatric patients and can be used as starter formulas for
PN until an individualized prescription can be prepared. However, standard formulas
should not replace the individualized approach, which is detailed below.
Initiation and monitoring — Prior to initiating PN, goals for fluids, energy, protein,
carbohydrate, fat, electrolyte, mineral, and trace elements are set based on the patient's
individual needs. It is important to determine whether PN is to be used for maintenance,
normal growth, or nutritional repletion and catch-up growth. Anthropometric and
laboratory measures must be obtained at baseline, and repeated periodically after PN
treatment is begun to monitor the patient and adjust the PN prescription as needed (table
4).
Although the fluid and electrolyte content of PN can be customized to the individual
patient, PN should not be used as the sole fluid source in metabolically unstable
patients, nor should it be used to correct electrolyte abnormalities. Instead, any
significant fluid and electrolyte disturbance should be corrected with separate
intravenous fluids administered via separate venous access. If hypophosphatemia is
present, it should be corrected before PN is initiated because the dextrose in the PN
solution will cause an intracellular shift of phosphorus that will further decrease the
serum phosphorus level. Similarly, children with malnutrition typically require
phosphorus and calcium repletion in quantities that cannot be accommodated in a single
PN solution, so additional venous access usually is required. (See "Poor weight gain in
children younger than two years: Management", section on 'Nutritional recovery
syndrome (refeeding syndrome)'.)
Requirements — Recommended requirements for each nutrient, along with scientific

justification, can be found in the National Academy of Medicine's Dietary Reference
Intakes (DRIs) (www.nap.edu) and are summarized in UpToDate topic reviews.
Nutrients are absorbed from the gastrointestinal (GI) tract in varying degrees, and the
degree of absorption is affected by a number of factors such as simultaneously ingested
foods, motility of the GI tract, and function of the digestive process. Thus, parenteral
requirements are different and usually less than enteral requirements.
Fluids — Parenteral fluid guidelines are based on estimates of needs to maintain normal
hydration ("maintenance" needs), and adjusted for increased or decreased losses as
necessary. The Holliday-Segar method is most commonly used to calculate maintenance
needs (table 5) (calculator 1) [24]. (See "Maintenance fluid therapy in children", section
on 'Components of fluid therapy'.)
Many factors affect individual fluid requirements such as age, disease state, hydration
status, insensible water losses, and changes in metabolic rate and respiratory rate.
Infants and children generally require at least 115 mL of fluid per 100 kcal of energy
provided [25]. Conditions that may alter fluid requirements are outlined in the table
(table 6).
In many cases, PN is given in a volume of fluid that is considerably higher than the
maintenance fluid requirements in order to meet the child's nutritional needs. Most
patients can tolerate fluid administration at 30 to 50 percent above maintenance needs
[25].
Appropriate fluid management also requires ongoing monitoring and adjustment

according to the patient's fluid losses and level of hydration. Fluid losses should be
measured frequently and replaced, and the patient's weight should be measured daily to
assess the level of hydration. Specific issues that affect fluid needs include:
●GI losses through a stoma, fistula, or from short bowel syndrome, which can reach 1 to
3 liters daily. For most patients, this fluid should be measured and replaced separately
from the PN prescription, unless the fluid loss is small and consistent.
●Renal maturity will affect the extent of urinary fluid losses. At birth, urinary
concentrating ability is approximately 600 mOsm/kg of water, and increases to
approximately 1000 to 1200 mOsm/kg by one year of age. Periods of growth decrease
the renal solute load, whereas the renal solute load is higher during times of stress and
catabolism [25]. Thus, urinary fluid losses are relatively high during infancy and times
of stress and catabolism, and lower during times of rapid growth.
●Insensible fluid losses are higher in infants as compared with older patients, and the
maintenance fluid calculation compensates for these differences. Certain conditions can
increase insensible losses. For example, fever increases insensible losses by 5
mL/kg/day for each degree of temperature >38 degrees Centigrade [25]. Other
conditions that increase insensible loss are extensive burns, high respiratory rate, high
ambient temperature, and low humidity.
Fluid restriction may be necessary for patients who have cardiac disease,
bronchopulmonary dysplasia, head trauma, and renal failure. In such patients, PN
composition can be concentrated to optimize the provision of nutrients.
Energy — Accurate determination of a patient's energy needs for the PN prescription is

challenging. Energy requirements vary with age, weight, and numerous other individual
patient factors including fever, activity level, underlying disease, and ambient
temperature.
A practical approach to determining energy needs for the PN prescription is to estimate

the approximate range of energy needs, based on the patient's age and weight.
Guidelines from the American Society for Parenteral and Enteral Nutrition (ASPEN)
outline the following age- and weight-based energy requirements [26].
●Preterm neonate – 90 to 120 kcal/kg/day
●<6 months – 85 to 105 kcal/kg/day
●≥6 to 12 months – 80 to 100 kcal/kg/day
●≥1 to 7 years – 75 to 90 kcal/kg/day
After determining the approximate range for the patient's energy needs, the specific
target is selected from this range based on the individual patient's characteristics, such
as need for catch-up growth, factors that may alter energy requirements, and the
patient's tolerance of fluid. Factors that may alter energy requirements are listed in the
table (table 7). A number of alternative methods can be used to estimate energy needs
such as the Harris-Benedict Equation [27] or the Schofield Equation [28]. These
methods are estimates more appropriate for adults. For children and adolescents they
must be adjusted based on the weight and clinical status.
These approaches to estimating energy requirements are clinically practical, but have
only fair accuracy. As an example, a study that used indirect calorimetry to measure
resting energy expenditure found that the calculated estimates of energy requirements
using these and other frequently employed formulas are inaccurate and lead to the
prescription of overnutrition [29]. However, in most clinical settings, indirect
calorimetry is not available for routine use. Therefore, it is important to monitor the
patient's growth response to the PN with serial weights and adjust the energy input as
needed.
Protein — Targets for protein intake for pediatric patients with normal organ function
for age are as follows [26]:
●Preterm neonate – 3 to 4 g/kg/day
●Infants (1 to 12 months) – 2 to 3 g/kg/day
●Children (>10 kg, or age 1 to 10 years) – 1 to 2 g/kg/day
●Adolescents (11 to 17 years) – 0.8 to 1.5 g/kg/day
Protein needs also depend on severity of illness. Stress factors such as sepsis, thermal
injury, surgery, trauma, and stomal losses increase protein requirements. Urinary
excretion of nitrogen related to steroids, diuretics, or primary renal disease also can
increase the protein requirement. Protein may need to be reduced in conditions such as
renal disease, hepatic failure, and inborn errors of metabolism [30].
Once the protein target is determined, the caloric content of the amino acid solution is
calculated as a component of the total energy input (figure 1). PN solutions formulated
with crystalline amino acids provide 4 kcal/g and are assumed to be approximately 16
percent nitrogen. Available concentrations of stock solutions range from 3 percent to 15
percent, with 10 percent most frequently used.
Amino acids are categorized according to whether or not they can be synthesized by the
human body. Essential amino acids are those that cannot be synthesized by the human
body; nonessential amino acids are those that can be synthesized; and conditionally
essential amino acids are those that can be synthesized but, under certain conditions, are
synthesized in insufficient amounts. Both essential and nonessential amino acids are
provided in standard solutions. Cysteine is an amino acid that is conditionally essential
for premature and term neonates. It is not thought to be needed beyond the neonatal
period, but may be beneficial in some instances. Cysteine is not included in crystalline
amino acid solutions, because it is unstable. It can be added separately at the time of PN
infusion, in the form of L-cystine hydrochloride, which is converted to cysteine [25].
Special "pediatric" amino acid solutions contain a higher concentration of essential

amino acids and lower quantities of nonessential amino acids, so that the infants' plasma
amino acid patterns mimic those of healthy, breastfed neonates [31]. Whether these
solutions are beneficial to older infants and children is not known, but there is some
evidence that they are associated with a decreased risk of cholestatic liver disease [30].
(See "Intestinal failure-associated liver disease in infants", section on 'Amino acid dose
and composition'.)
Energy and protein are closely related. Within limits, the more energy supplied, the less
protein required to achieve nitrogen balance. One systematic review found that protein
intake of at least 1.5 g/kg/day and energy intake of at least 57 kcal/kg/day result in
positive protein balance in critically ill children who are mechanically ventilated [32].
Fat — Between 20 and 50 percent of energy needs in PN are provided as fat, in the form
of an intravenous fat emulsion (IVFE). For most patients, IVFE is initially prescribed to
provide fat at 1 g/kg per day. If tolerated, the fat dose can be advanced to 3 g/kg per day
(or 2 g/kg/day for older children) if needed to provide adequate energy intake (table 3).
The total calories supplied by fat are calculated using the factor 10 kcals/gram of lipid,
or 2 kcal/mL of 20 percent IVFE.
An IVFE emulsion has a high concentration of energy (2 kcal/mL for a 20 percent lipid
emulsion), and thus increases the caloric density of the PN solution. IVFE are sources
of essential fatty acids (EFAs: primarily linoleic and linolenic acids), which must
comprise at least four percent of total calories to prevent EFA deficiency. (See
"Micronutrient deficiencies associated with malnutrition in children", section on
'Essential fatty acid deficiency'.)
Soybean oil-based lipid emulsions (eg, Intralipid) are the most common form of IVFE
used in the United States and most other countries. They are rich in omega-6 fatty acids,
which have the advantage of supplying EFAs. However, accumulating evidence
suggests that soy-based IVFE also may be associated with increased inflammation and
liver injury, especially in infants on total parenteral nutrition (TPN), in a pattern known
as PN-associated liver disease, also known as intestinal failure-associated liver disease
(IFALD). Newer emulsions, such as a fish oil-based lipid emulsion (Omegaven),
contain omega-3 fatty acids, which have anti-inflammatory properties. Preliminary
evidence suggests that fish oil-based IVFE may be useful for treating infants with PN-
associated liver disease. However, fish oil-based IVFE provides minimal amounts of
EFA, so patients are at risk for developing EFA deficiency and should be monitored. A
mixed soybean, medium-chain triglyceride, olive, and fish oil lipid emulsion has been
developed, and preliminary evidence suggests that it may delay progression of IFALD
[33]. The available IVFE are summarized in the table, and their use for IFALD is
discussed separately (table 8). (See "Intestinal failure-associated liver disease in
infants", section on 'Fish oil-based lipid emulsions' and "Intestinal failure-associated
liver disease in infants", section on 'Mixed oil emulsions'.)
Other strategies to prevent or treat PN-associated liver disease include limiting the total
lipid dose to 1 g/kg per day, and avoidance of sepsis. (See "Intestinal failure-associated
liver disease in infants", section on 'Management'.)
Excessive doses of IVFE may cause hypertriglyceridemia, especially in malnourished

patients, as they have a reduced ability to clear triglycerides. Triglyceride levels as high
as 100 to 150 mg/dL are well tolerated. However, the dose of IVFE should be reduced if
the triglyceride levels are consistently in excess of 150 mg/dL. Carnitine is not present
in PN solutions, yet it is necessary for transport and metabolism of long-chain fatty
acids. Therefore, carnitine should be added to PN for patients on PN longer than two
months, at a dose of 2 to 5 mg/kg/day.
Carbohydrates — Glucose is the only source of carbohydrate in PN and provides 40 to

60 percent of total calories, or 60 to 75 percent of nonprotein calories. It is provided in a
monohydrous form (dextrose monohydrate), which has a caloric concentration of 3.4
kcal/g, somewhat less than the concentration of carbohydrate calories in food (4 kcal/g).
For the PN prescription, the target carbohydrate dose is determined by calculating the
energy (caloric) needs that are not provided by fat or protein. The doses of protein and
fat may vary depending on patient needs:
Energy from carbohydrates = Total energy needs – Energy from protein – Energy from
fats
The result is then converted into grams of glucose:
Grams glucose = Energy (kcals) from carbohydrates ÷ 3.4 kcal/g
After calculating the target carbohydrate dose, the glucose infusion rate (GIR) should
also be calculated, to ensure that the hourly carbohydrate dose is in an appropriate range
(table 9).
The acceptable GIR varies with the patient's age and clinical condition (table 3).
Adequate quantities of glucose are important because at glucose infusions <2
mg/kg/min, body fat is mobilized for energy and ketosis occurs. Moreover, the brain
uses glucose as the primary source of energy. The brain represents 12 percent of body
weight in infants, but only 2 percent in adults. Because of this difference in relative
brain size, glucose utilization by infants (6 to 8 mg/kg/min) is far more than adults (2
mg/kg/min) [25,34]. It is also important to avoid excessive glucose; an excessive GIR
can cause hyperglycemia, hyperosmolarity, and osmotic diuresis. Excessive glucose can
increase the risk of hepatic steatosis. A healthy child can tolerate a GIR of 12 to 14
mg/kg/min, but an ill or malnourished child may not. Thus, the glucose concentration
must be carefully advanced in a malnourished patient to reduce the risk of refeeding
syndrome, and serum phosphorus, potassium, calcium, and magnesium should be
closely monitored. Lower GIR targets are used for ventilated patients, and patients with
hyperglycemia, sepsis, and cholestasis or liver disease.
Glucose is available in stock solutions of 5 to 70 percent, as dextrose monohydrate.

Concentrations greater than 12.5 percent must not be used in a peripheral vein, because
the high osmolarity can damage veins. Central lines can accommodate a maximum
concentration of 25 percent glucose. Glucose should be initiated in an incremental
fashion while monitoring for hyperglycemia (blood glucose >200 mg/dL) and
glucosuria.
Electrolytes — Electrolytes are essential and must be provided in PN. Requirements for
sodium, potassium, calcium, magnesium and phosphorus are included as a separate
component of the PN prescription (table 10). The chloride content of the PN solution is
determined by the patient's acid-base status: patients who are acidotic should be given a
chloride/acetate ratio of 1:2 or less. The maximum and minimum chloride/acetate ratios
are determined by the overall composition of the PN solution. The electrolyte additives
typically provide approximately 30 mL fluid per liter of PN.
Calcium and phosphorus — Calcium to phosphorus ratio in PN should be close to a 1:1

molar ratio. Ratios lower than 1:1 result in elevated serum and urine phosphorus,
possibly due to inadequate calcium and hence decreased utilization of phosphorus [35].
Premature infants have high requirements for calcium and phosphorus, which must be
balanced against limited solubility of these nutrients in the PN solution. (See "Parenteral
nutrition in premature infants", section on 'Calcium and phosphate'.)
Trace elements and minerals — Trace elements are prepared in standard packages of
four, five, or six essential elements. Individual needs vary and, at times, supplements
beyond what is provided in the solution or other adjustments are necessary. Key
considerations are:
●Zinc is frequently supplemented in patients who have excessive GI fluid losses via
ostomy output or diarrhea. There is no good parameter to monitor for zinc status, but
serum zinc levels and alkaline phosphatase are used clinically.
●Selenium is an essential nutrient so patients who require PN for two months or more
must receive selenium. Selenium is not included in some standard packages of trace
elements, so patients on long-term PN need a trace element preparation that includes
selenium.
●For copper and manganese, decreased doses may be required for patients with
cholestasis. However, in this case, serum levels should be monitored. Manganese can
accumulate in patients with liver disease because it is normally excreted in bile. It is
speculated that manganese accumulation can contribute to the development of PN
cholestasis. Levels should be checked in patients receiving PN for greater than 30 days.
If high levels are found, the amount of manganese should be decreased and levels
monitored.
●Chromium is a contaminant in PN solutions. Serum and urine levels should be

monitored in patients on long-term PN with renal impairment.
●Aluminum is a contaminant of PN solutions. Since crystalline amino acids have

replaced protein hydrolysates, aluminum contamination has decreased. However, it
remains a concern. The US Food and Drug Administration (FDA) requires disclosure of
aluminum content and concentration on labels of parenteral compounding supplies.
Some components of PN including calcium gluconate and phosphate salts, still include
significant amounts of aluminum. There is no consensus to define "safe" levels of
parenteral aluminum intake. Intakes of less than 4 to 5 micrograms/kg/day were
recommended by the FDA in 2004 [36]. However, it is often difficult to achieve
exposures under these limits using available products, particularly for preterm infants
who typically have high calcium needs. (See "Intestinal failure-associated liver disease
in infants", section on 'Other parenteral nutrition components'.)
●Iodine is generally not included in PN; it is not provided in most trace element
solutions or added to the PN. As a result, infants and children on chronic exclusive PN
may develop iodine deficiency. In one report, nearly one-half of children on chronic PN
had severe iodine deficiency, and one-third developed hypothyroidism [37]. Children
for whom parenteral nutrition is their sole source of nutrition should undergo periodic
monitoring of iodine status by checking serum thyroid-stimulating hormone (TSH)
every six months. If serum TSH is elevated, then iodine status can be evaluated by
measurement of either 24-hour urinary iodine or spot urinary iodine (and creatinine).
(See "Acquired hypothyroidism in childhood and adolescence", section on 'Iodine
deficiency'.)
Iron is not added to PN solutions. Instead, it must be administered orally,

intramuscularly or intravenously. Iron status should be monitored every three to four
months while on PN, by measuring hemoglobin, hematocrit, and iron indices (eg, serum
iron, total iron binding capacity, ferritin, and/or soluble transferrin receptor levels).
Because ferritin is an acute phase reactant, it is not a reliable index of iron stores in
patients with inflammation. A measure of inflammation, such as C-reactive protein, can
be used to exclude inflammation and validate the results of serum ferritin. Patients on
long-term PN are at risk for iron deficiency.
Multivitamin — Multivitamins should be routinely included in the PN prescription.

Pediatric preparations are commercially available in the United States under the brand
names MVI Pediatric and Infuvite Pediatric. Both preparations contain the same
quantities of 13 vitamins listed in the table (table 11).
For children 3 kg body weight to 11 years of age, the recommended daily dose of the
pediatric parenteral multivitamin preparation is 5 mL. For infants weighing less than 3
kg, a fraction of the 5 mL dose is given. Adult intravenous multivitamin preparations
and doses are given to children and adolescents over 11 years of age. Because of
recurring national shortages of intravenous vitamin preparations, neither MVI Pediatric
nor Infuvite Pediatric may be available. Websites that offer alternatives are given in the
section below.
PHARMACYPreparing a PN solution for pediatric patients presents special challenges

for the pharmacist because infants and children cannot tolerate high fluid volumes, and
they need high concentrations of calcium and phosphorus that are not necessarily
compatible. Nationwide shortages of sterile injectable ingredients used for
compounding PN have confronted pharmacists and nutritionists. Since 2010, important
and sustained shortages have included amino acids, intravenous fat emulsions (IVFE),
electrolytes and minerals including phosphate, potassium magnesium and calcium,
multivitamins for infusion (particularly pediatric preparations), trace elements, and zinc
[38].
These frequent shortages require each institution or hospital to assess their supplies and
develop a strategy for their institution. Prescribing providers should consider whether a
nutrient can be safely administered by the oral or enteral route for an individual patient.
If a shortage necessitates rationing, patients should be monitored to detect deficiencies.
A current list of updated drug shortages can be found at the following websites along
with recommendations for PN management during times of shortage.
●American Society for Parenteral and Enteral Nutrition (ASPEN):

http://www.nutritioncare.org/
●The US Food and Drug Administration (FDA), Drug Shortage Program, Current Drug
Shortages: http://www.accessdata.fda.gov/scripts/drugshortages/default.cfm (note that
this information does not track regional allocation of drugs, so there may be regional
shortages even if a supply is listed as available)
●American Society of Health-System Pharmacists (ASHP), Drug Shortages Resource

Center: http://www.ashp.org/shortages?WT.ac=hp%5FPopLinks%5FDrug
%5FShortages
CYCLINGThe term "cycling" is used when the PN solution is infused at a higher rate
for less than 24 hours, followed by several hours without a PN infusion. Cycling can be
initiated when a patient has been stable on PN for at least one week. Generally the time
off PN is increased and the infusion rate is increased to compensate, so that the total
daily volume of PN is unchanged (table 12).
Cycling PN has psychological, developmental, and physiologic benefits. For children,

time off the pump allows them freedom of movement and the ability to participate in
activities such as attending school and social events. For infants and toddlers, freedom
of movement is important as they develop large motor skills. In addition, continuous
infusion of PN usually suppresses appetite, and cycling off of PN may allow children to
experience hunger, which is helpful when transitioning to oral feeds. Cycling allows the
rise and fall of hormones associated with meals. Finally, continuous infusion of glucose
can be associated with high levels of insulin secretion, which may contribute to hepatic
steatosis and increase hepatic lipogenesis [16]. These effects can often be lessened by
cycling of PN.
Cycling requires careful planning and monitoring because sudden discontinuation of a

high glucose infusion can cause hypoglycemia, especially in children younger than three
years of age [39]. Blood glucose levels should be closely monitored when implementing
a cycling regimen. To prevent hypoglycemia, the rate of PN delivery should be tapered
during the final one to two hours of the infusion. A standard practice is to decrease the
infusion rate to one-half for an hour and then one-half again for a second hour, prior to
stopping the infusion entirely. The patient's blood sugar should then be checked 30 to 60
minutes after PN cessation to assure tolerance. Once the patient is on a stable, cycled
schedule and has shown that she/he can tolerate the drop in glucose infusion, frequent
monitoring of blood sugars is no longer necessary. This practice of tapering the infusion
rate and monitoring blood sugar should be employed whenever initiating cycling or
discontinuing PN.
HOME PNProviding PN outside of the hospital setting ("home PN") promotes a normal
lifestyle and decreases complications and medical costs. Home PN allows continuation
of nutrition support in a more normal environment, facilitates the child's development
and permits participation in family and social activities. Home PN is associated with
fewer infections when compared with PN in the hospital, if the caretakers are
appropriately trained to use sterile technique when accessing the central venous line.
Home PN decreases length of the hospital stay, thus reducing the cost [40].
Indications for home PN include all those for the hospitalized patient, with the
additional provisos of an adequate home environment and support in the home. Home
PN should be considered when the duration of PN therapy is anticipated to be prolonged
and the patient is medically stable, no longer requiring hospitalization. For infants and
children, it is prudent to initiate PN in the hospital. As an inpatient the child can be
monitored more closely, the family adequately trained to provide care, and the PN
tailored and adjusted to the patient's specific needs prior to discharge. The suitability of
the home should be evaluated including assessment of the family members and the
safety of the home environment [41]. Planning should include contingencies for times
when the primary caretaker is not available, when the child becomes ill, when
mechanical problems occur, and for such events as power failure. Federal and state
health care programs, along with private medical insurances, have strict guidelines that
must be met for reimbursement for home PN [42].
Home PN solutions are frequently compounded as "three-in-one" solutions. That means

carbohydrates, fats, and amino acids along with minerals, electrolytes, and vitamins are
combined as one emulsion (rather than administering the fat emulsion as a separate
component, as is typically done in hospitals). Having everything in one solution allows
easy administration, but adds complexity to the job of the pharmacy to ensure a stable
emulsion.
Home PN should be managed with a multidisciplinary approach including clinicians,

home nurses, pharmacists, dietitians, and social workers. A reliable home care company
needs to be selected that has adequate mixing, storage, and delivery systems as well as
staff that are trained and experienced in the management of pediatric patients. Strict
monitoring of the patient, with frequent nursing and clinic visits, combined with
communication with the family are key factors to achieve successful management of
home PN. Suggested follow-up and monitoring protocols are outlined in the table (table
4).
PSYCHOLOGICAL ASPECTS OF PEDIATRIC PNThe effect of PN on the

psychological health and well-being of the child and the family is often overlooked, but
is critically important. PN requires a high level of care that affects quality-of-life for the
patient and family over and above the issues surrounding the child's underlying medical
problem. Administering PN is time consuming, expensive, and intrusive into daily
routines. Patients receiving PN are often troubled by the inconvenience of high
intestinal output, presence of a stoma, altered body image, and fear of complications
[43]. The patient may also need to remain nil per os (NPO) or have a very restricted oral
diet, which can be extremely challenging for a child who may not understand the
rationale behind this part of their medical treatment. Our society focuses on food and
sharing meals with others especially during social and school activities, sporting events,
family holiday gatherings, religious traditions, and various day to day activities. For
families with children receiving PN who are not able to consume food orally, these
seemingly innocent and celebratory times can cause added emotional stress.
It is important for health care providers to recognize and facilitate treatment of the
potential psychosocial problems that may arise with the use of PN. Some common
problems identified in the literature are anxiety, parent-child conflict, sibling rivalry,
peer difficulty, marital discord, loss of employment (due to time away from work
required for medical appointments), financial concerns, physical and emotional fatigue,
social isolation, disruption of family routines, and food refusal/aversion upon
reintroduction of food [8]. Some of these difficulties are amenable to treatment through
psychological counseling and support. Early referral to a qualified pediatric
psychologist or counselor may be helpful for many PN patients and their family
members [16].
SOCIETY GUIDELINE LINKSLinks to society and government-sponsored guidelines

from selected countries and regions around the world are provided separately. (See
"Society guideline links: Nutrition support (parenteral and enteral nutrition) in infants
and children".)
SUMMARY AND RECOMMENDATIONS
●Parenteral nutrition (PN) is indicated for infants and children whose gastrointestinal
(GI) tract function is inadequate to support normal growth and development if
nutritional support is required for seven days or more, except in premature infants and
neonates, who may require earlier intervention. If the GI tract is partially functional, the
enteral route should be used even if it is only able to supply a fraction of the required
nutrients. A wide variety of underlying conditions may lead to a need for PN (table 1).
(See 'Indications and contraindications' above.)
●PN almost always requires central venous access, which is defined as a catheter tip in
the proximal vena cava or right atrium. This is because a PN solution must have high
osmolarity in order to meet most or all of the child's nutritional needs, and solutions
with high osmolarity cannot be infused through a peripheral vein. (See 'Central and
peripheral venous access' above.)
●The assessment prior to prescribing PN includes anthropometrics (primarily height,

weight, and body mass index [BMI]) and determination of whether acute or chronic
malnutrition is present. These measures are used to determine the child's protein and
energy requirements for the PN prescription. A panel of laboratory tests is performed at
baseline (table 4), and the results are used to adjust the fluid and electrolyte content of
the PN prescription. An understanding of the child's underlying disease and
comorbidities is also important because these determine choices for the PN prescription
including macronutrient balance, fluid, and electrolytes. Anthropometrics and
laboratory measures must be repeated periodically after PN treatment has begun to
monitor the patient and adjust the PN prescription as needed. (See 'Nutritional
assessment' above.)
●PN is tailored to the needs of the patient, requiring a series of calculations and an
individualized PN prescription. The prescription for PN is created from a series of
stepwise calculations (table 2 and figure 1). The ranges for macronutrients when
initiating and advancing PN are based on the child's age (table 3), then modified by
individual clinical considerations. (See 'How to prescribe PN' above.)
•Fluid supplied in PN is based on estimates of needs to maintain normal hydration

("maintenance" needs), and adjusted for increased or decreased losses as necessary. The
Holliday-Segar method is most commonly used to calculate maintenance needs (table 5)
(calculator 1). The fluid requirement may be increased or decreased by a variety of
underlying conditions (table 6). In many cases, PN is given in a volume of fluid that is
30 to 50 percent higher than the maintenance fluid requirements, in order to meet the
child's nutritional needs. Any large fluid losses through the GI tract (eg, in children with
short bowel syndrome) should be measured and replaced separately from the PN. (See
'Fluids' above.)
•Energy needs are estimated based on the patient's age and weight, then modified by
individual patient's characteristics, such as need for catch-up growth, the patient's
tolerance of fluid, and factors that may alter energy requirements (table 7). (See 'Energy'
above.)
•Protein needs are also based primarily on the patient's age and weight. These estimates
are used to calculate the total protein dose per day, and the energy supplied by that
protein (using the factor 4 kcal/g protein). (See 'Protein' above.)
•Fat is supplied by an intravenous fat emulsion (IVFE), and provides between 20 and 50
percent of energy needs for PN. For most patients, IVFE is initially prescribed to
provide fat at 1 g/kg per day. If tolerated, the fat dose can be advanced to 3 g/kg per day
(or 2 g/kg/day for older children). Excessive doses of fat may cause
hypertriglyceridemia, and also may contribute to PN-associated liver disease, especially
in young infants. (See 'Fat' above.)
•Carbohydrates in PN are supplied by glucose (in the form of dextrose monohydrate),

and provide 40 to 60 percent of total calories. The energy to be supplied by glucose is
determined by subtracting the energy supplied by protein and fats from the patient's
estimated total energy needs. The dose of glucose is then determined in grams (using
the factor 3.4 kcal/g dextrose). The glucose infusion rate (GIR, in mg/kg/minute) is then
calculated from the glucose dose and planned rate of infusion; the acceptable GIR varies
with the patient's age and clinical condition (table 3). (See 'Carbohydrates' above.)
•Supplements of electrolytes and minerals (sodium, potassium, calcium, magnesium,

and phosphorus (table 10)), trace elements, and multivitamins are required in PN and
are included as a separate component in the prescription. Patients should be monitored
for nutrient deficiencies (table 4); iodine deficiency is common in patients on long-term
PN and may result in hypothyroidism. The electrolyte doses can be adjusted to some
degree according to the patient's needs, but PN should not be used to correct significant
electrolyte abnormalities. (See 'Electrolytes' above and 'Trace elements and minerals'
above and 'Multivitamin' above.)
●Cycling PN (infusing the PN solution for less than 24 hours daily) has psychological,
developmental, and physiological benefits, and should be implemented when possible.
Patients are candidates for cycling when they have been stable on a 24-hour infusion
schedule for at least one week, and are able to tolerate higher infusion rates of fluid and
glucose. Cycling requires care and planning to avoid hypoglycemia, which may be
caused by a sudden discontinuation of a high glucose infusion, especially in children
younger than three years of age. To prevent hypoglycemia, the rate of PN delivery
should be tapered during the final one to two hours of the infusion, and blood glucose
levels monitored. (See 'Cycling' above.)
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Topic 15634 Version 22.0
GRAPHICS
Indications for parenteral nutrition (PN) in children
Partially functioning gastrointestinal tract
Cannot meet nutritional requirements after maximizing enteral support
Burns
Multi-organ failure
Malabsorption
Short bowel syndrome
Chronic intractable diarrhea
Congenital small bowel malabsorptive syndromes such as congenital chloride diarrhea,
tufting enteropathy, or microvillus inclusion disease
Pseudo-obstruction
Severe malnutrition with hypoproteinemia and bowel edema
Non-functional gastrointestinal tract
Paralytic ileus
Small bowel ischemia
Necrotizing enterocolitis
Gastrointestinal surgery
Gastroschisis, omphalocele, gastrointestinal atresias (parenteral nutrition is indicated
until the enteral route is functional and accessible)
Reproduced with permission from: Pediatric Parenteral Nutrition, Baker RD, Baker SS,
Davis AM (Eds), Aspen Publishers, Inc, Gaithersburg 2001. Copyright © 2001 Robert
D Baker, MD, PhD; Susan S Baker, MD, PhD; and Anne M Davis, RD, CNSD.
Graphic 90425 Version 2.0
Initiating parenteral nutrition (PN)
Step Calculations and considerations
Does the patient meet indications for parenteral
nutrition (PN)?
1. Assess medical status and
Is anticipated duration of PN >2 weeks?
determine nutrition goals
Will PN be used to provide full or partial nutritional
requirements?
Does the patient require central venous access to
meet nutritional needs (as for most patients
requiring PN)?
2. Assess venous access If central venous access is necessary, consider type

of catheter and number of lumens needed to
accommodate PN and any other therapies. Verify
that catheter is centrally placed prior to starting PN,
using radiography.
Consider which weight measure will be used to
determine the patient's nutritional targets (eg, actual
3. Determine weight
body weight, dry weight, ideal body weight, usual
body weight, or an adjusted body weight).
Review patient's fluid status, intake/output balance,
gastrointestinal losses, etc.
Use Holliday-Segar formula to estimate initial fluid

4. Calculate fluid requirements, and then adjust as needed based on
requirements/volume of PN to be the patient's individual needs.
provided
The estimated fluid requirement determines the
approximate total volume available for PN. Most
patients can tolerate fluid administration at 30 to 50
percent above maintenance needs.
Estimate energy (caloric) needs for PN at ~80
percent of enteral requirements.
5. Assess total energy requirements
and approximate targets for
Provide 40 to 60 percent of calories from dextrose,
carbohydrate, fat and protein intake
20 to 50 percent of calories from fat, and 10 to 20
percent of calories from protein/amino acid.
Assess whether the patient has increased protein
needs (eg, due to gastrointestinal protein losses,
wound healing, etc).
6. Assess protein requirements
Calculate total grams of protein in g/kg, g/day, and
g/L.
20 percent lipid emulsion provides 20 g fat per 100
mL solution, or 2 kcal/mL.
7. Calculate grams of fat or mL of
lipid
Energy from fat (kcal/day) ÷ 2 kcal/mL = mL/day
of lipid.
Energy to be provided from dextrose ÷ 3.4 kcal/g of
8. Calculate grams of dextrose
dextrose = g dextrose.
GIR (mg/kg/min) = grams dextrose/kg x 1000 mg/g
÷ minutes of infusion
9. Calculate glucose infusion rate
(GIR)
(minutes of infusion = 1440 min. if given for 24
hours).
Determine mEq per kilogram and total mEq/L.
10. Assess electrolyte requirements
Refer to table describing electrolyte requirements.
11. Assess vitamin/mineral and Check with pharmacist to see which products are
trace element requirements available and what concentrations are compatible.
mOsm/L = (g amino acid/L x 10) + (g dextrose x 5)
12. Calculate osmolality of + [(mEq Na + K + Ca/L) x 2].
solution (if intravenous access is
peripheral) Solution must be <900 mOsm/L for peripheral
administration.
Total volume to be infused in mL ÷ hours of
infusion time = rate mL/hour.
13. Determine rate of infusion
Refer to section on "cycling" if infusion <24 hours.
mEq: milliequivalents; mOsm: milliosmoles.
Modified with permission from: Pediatric Parenteral Nutrition, Baker RD, Baker SS,
Pediatric parenteral nutrition calculation
PN: parenteral nutrition; NPO: nil per os (nothing by mouth); PICC: peripherally
inserted central catheter; CHO: carbohydrate; AAS: amino acid solution; IVFE:
intravenous fat emulsion; D50: 50 percent dextrose in water (500 mg dextrose/mL).
Courtesy of Susan Baker, MD, PhD, and Robert Baker, MD, PhD.
Macronutrient guidelines for initiation and advancement of parenteral nutrition in
children
Age
Carbohydrate/dextrose* Protein/amino acid¶ Fat/lipid
group
Initial: 2 to 3 Initial: 1
g/kg/day g/kg/day
Initial: 6 to 8 mg/kg/min
Daily increase: 1 Daily increase: 1
<1 year
g/kg/day g/kg/day
Goal: 10 to 14 mg/kg/min
Maximum: 3 Maximum: 3
g/kg/day g/kg/day
Initial: 1 to 2 Initial: 1
g/kg/day g/kg/day
Initial: 10 to 12.5 percent
1 to 10 Daily increase: 1 Daily increase: 1
years Daily increase: 5 percent increments g/kg/day g/kg/day
(maximum 15 mg/kg/min)
Maximum: 2.5 to 3 Maximum: 3
g/kg/day g/kg/day
Initial: 1 to 1.5 Initial: 1
g/kg/day g/kg/day
Initial: 10 to 15 percent
>10 Daily increase: 1 Daily increase: 1
years Daily increase: 5 percent increments g/kg/day g/kg/day
(maximum 8.5 mg/kg/min)
Maximum: 1.5 to 2 Maximum: 2
g/kg/day g/kg/day
* Carbohydrate intake is given as the glucose infusion rate (GIR), in mg/kg/minute. See
topic text for explanation of how to calculate the GIR.
¶ Starting protein intake at the low end of the range then advancing is generally
recommended. This is out of caution, because there is no good evidence suggesting the
need to limit initial protein to less than calculated needs.
Example of pediatric total parenteral nutrition (PN) orders
DBILI: direct bilirubin; PED MVI: pediatric multivitamin solution; WCHOB: Women
and Children's Hospital of Buffalo.
* WCHOB TES is a solution of trace elements made specifically for young infants by
the WCHOB pharmacy.
• DBILI TES is a solution of trace elements designed for infants with cholestasis, which
does not contain copper or manganese.
Courtesy of Drs. Robert and Susan Baker and Women and Children's Hospital of
Buffalo (WCHOB). Reproduced with permission from: Kaleida Health.
Suggested monitoring parameters and schedule for parenteral nutrition in children
Suggested frequency
Parameter
Initial/hospitalized Follow up/home
Growth
Weight Daily Daily to monthly
Weekly to
Height Weekly
monthly
Weekly to
Head circumference Weekly
monthly
Monthly to
Triceps skin fold Monthly
annually
Monthly to
Mid arm muscle circumference Monthly
annually
Serum*
Weekly to
Electrolytes Daily to weekly
monthly
BUN, creatinine Weekly Monthly
Weekly to
Calcium, phosphorus, magnesium Twice weekly
monthly
Weekly to
Acid-base status (venous bicarbonate) Until stable
monthly
Weekly to
Albumin Weekly
monthly
¶
Prealbumin Weekly Monthly
Weekly to
Glucose Daily to weekly
monthly
Daily while increasing Weekly to
Triglycerides
lipid monthly
Liver function tests (AST, ALT, GGTP and Weekly to
Weekly
alkaline phosphatase) monthly
Weekly to
CBC and differential Weekly
monthly
Weekly to
Platelets Weekly
monthly
Weekly to
PT, PTT, INR Weekly
monthly
Δ
TSH As indicated Every 6 months
Biannually to
Iron indices◊ As indicated
annually
Biannually to
Trace elements§ As indicated
annually
Biannually to
Fat soluble vitamins¥ As indicated
annually
Carnitine As indicated As indicated
Biannually to
Ammonia As indicated
annually
Biannually to
Blood culture from central venous catheter As indicated
annually
CRP or ESR As indicated As indicated
Urine
Glucose 2 to 6 times/day Daily to weekly
Ketones 2 to 6 times/day Daily to weekly
Iodine and creatinine (spot or 24-hour If TSH is
As indicated
collection)Δ elevated
Urine specific gravity As indicated As indicated
Urea nitrogen As indicated As indicated
Clinical observations
Daily, or as
Vital signs‡ Daily, or as indicated
indicated
Intake and output Daily Daily
Check administration system 6 to 12 times/day 2 to 6 times/day
Catheter site/dressing 6 to 12 times/day 2 to 6 times/day
Developmental milestones As indicated As indicated
Frequency depends on clinical condition.
BUN: blood urea nitrogen; AST: aspartate aminotransferase; ALT: alanine
aminotransferase; GGTP: gamma glutamyl transpeptidase; CBC: complete blood count;
PT: prothrombin time; PTT: partial thromboplastin time; INR: international normalized
ratio; TSH: thyroid stimulating hormone; CRP: C-reactive protein; ESR: erythrocyte
sedimentation rate.
* Metabolically unstable patients may need more frequent checks.
¶ Prealbumin is also known as thyroxine-binding prealbumin (TBA) or transthyretin. It
is an index of the short-term adequacy of protein intake. However, prealbumin is also
suppressed by the acute phase response, so it is not useful as a measure of adequate
protein intake in the setting of inflammatory disease.
Δ Iodine deficiency can cause hypothyroidism. If parenteral nutrition is the sole source
of nutrition, the child should be screened periodically for hypothyroidism by measuring
serum TSH. If TSH is elevated, then iodine status should be evaluated by measuring 24
hour urinary iodine or spot urinary iodine and creatinine. Spot urinary iodine
concentrations can be interpreted as follows: Severe deficiency <20
micrograms/L; Moderate deficiency 20 to 50 micrograms/L; Mild deficiency 51 to 99
micrograms/L.
◊ Iron indices are serum iron (Fe), total iron binding capacity (TIBC), ferritin, and/or
soluble transferrin receptor levels.
§ Adequacy of trace elements is monitored by measuring whole-blood or erythrocyte
manganese (Mn), copper (Cu); serum zinc (Zn) and alkaline phosphatase; and plasma
selenium (Se). Chromium (Cr) concentrations should be monitored periodically in
patients on long-term PN with renal impairment.
¥ Fat soluble vitamins are measured as serum retinol (for vitamin A); 25-
hydroxyvitamin D (for vitamin D); and alpha-tocopherol (for vitamin E). Serum
concentrations of alpha-tocopherol are strongly influenced by concentrations of serum
lipids, so the effective vitamin E levels are calculated as the ratio of
alpha-tocopherol/(cholesterol + triglycerides), where a normal ratio is >0.8. For vitamin
K, measurements of PT and PTT are used to screen for deficiency.
‡ Vital signs include respiratory rate, heart rate, temperature, and blood pressure.
References:
1. Ikomi C, Cole CR, Vale E, et al. Hypothyroidism and Iodine Deficiency in
Children on Chronic Parenteral Nutrition. Pediatrics 2018; 141.
Other content reproduced with permission from: Pediatric Parenteral Nutrition, Baker
RD, Baker SS, Davis AM (Eds), Aspen Publishers, Inc, Gaithersburg 2001. Copyright
© 2001 Robert D Baker, MD, PhD; Susan S Baker, MD, PhD; and Anne M Davis, RD,
CNSD.
Fluid requirements in parenteral nutrition (PN)
Body
Amount of fluid per day
weight
1 to 10 kg 100 mL/kg
11 to 20 kg 1000 mL + 50 mL/kg for each kg >10 kg
>20 kg 1500 mL + 20 mL/kg for each kg >20 kg
Based on the Holliday-Segar method for calculating maintenance fluid requirements in
children.
References:
1. Meyers RS. Pediatric fluid and electrolyte therapy. Pediatr Pharmacol Ther
2009; 14:204.
2. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid
therapy. Pediatrics 1957; 19:823.

Factors that may require increased or decreased fluid administration
Increased fluids Decreased fluids
Fever Congestive heart failure
Polyuria Head trauma
Losses through gastrointestinal tract (eg, short bowel
Renal insufficiency
syndrome, or a stoma)
Bronchopulmonary
Vomiting
dysplasia
Diarrhea
Nasogastric suctioning
Ostomy output
Prematurity
Increased insensible losses through the skin (eg, extensive
burns)
Reasons for alteration in energy requirements
Increased energy requirements Decreased energy requirements
Trauma Immobility
Surgery Mechanical ventilation
Sepsis Extracorporeal membrane oxygenation (ECMO)
Burns Medical sedation/paralysis
Tumors
Seizures
Hypertonia
Spinal cord injury
Comparison of different intravenous lipid emulsion formulations used in infants and
children
Intralipid(Freseni Nutrilipid( Omegaven*(Freseni Smoflipid(Freseni
us Kabi) B. Braun) us Kabi) us Kabi)
Concentration
10, 20 20 10 20
s (percent)
Oil source Soybean 100 Soybean Fish 100
(percent) 100 Soybean 30
MCT 30
Olive 25
Fish 15
Fatty acids (percent)¶
Linoleic (C
44 to 62 48 to 58 1 to 7 18.7
18:2 ω-6)
Linolenic (C
4 to 11 4 to 11 2 2.4
18:3 ω-3)
Palmitic (C
7 to 14 9 to 13 2.5 to 10 9.2
16:0)
Oleic (C 18:1
19 to 30 17 to 30 6 to 13 27.8
ω-9)
Stearic (C
1.4 to 5.5 2.5 to 5 0.5 to 2 2.7
18:0)
EPA (C 20:5
0 0 12.5 to 28.2 2.4
ω-3)
DHA (C 22:6
0 0 14.4 to 30.9 2.2
ω-3)
Caprylic acid
0 0 0 16.3
(C 8:0)
Caproic acid
0 0 0 11.4
(C 10:0)
Ratio (ω-6:ω- Not
7:1 1:7 2.5:1
3) available
Egg yolk
phospholipids 1.2 1.2 1.2 1.2
(percent)
Glycerin
2.25, 2.25 2.5 2.5 2.5
(percent)
Energy
density 1.1, 2 2 1.1 2
(kcal/mL)
Osmolarity
260, 260 390Δ 308 to 376Δ 380Δ
(mOsm/L)
Approved product labeling in the United States and other countries warns of risks
of hyperlipidemia, fat accumulation in lungs, and potential aluminum toxicity with use
of intravenous fat emulsions in preterm and very low birth weight infants. Refer to
accompanying text and local product information.
Smoflipid is not approved by US Food & Drug Administration for use in pediatric
patients.
PUFA: long-chain n-3 polyunsaturated fatty acids; MCT: medium chain triglycerides;
DHA: docosahexaenoic acid; EPA: eicosapentaenoic acid.
* Omegaven fish oil contains several other n-3 PUFAs and arachidonic acid in addition
to those shown in this table. Additional information is available from the oley.org
website.
¶ For fatty acids the percentages shown are based on the lipid component of emulsion
only. Thus, for a 10 percent lipid emulsion, the final concentration (ie, grams per 100
mL) is obtained by dividing each fatty acid percent shown in the table by 10. The
chemical structure is noted as: length of hydrocarbon chain (C atoms): number of
double bonds; and position of first double bond (ω).
Δ mOsm/kg.
Data from:
1. Gura KM, Duggan CP, Collier SB, et al. Reversal of parenteral nutrition -
associated liver disease in two infants with short bowel syndrome using
parenteral fish oil: implications for future management. Pediatrics 2006;
118:197.
2. Nordenstrom J, Thorne A. Comparative studies on a new concentrated fat
emulsion: intralipid 30 percent vs. 20 percent. Clin Nutr 1993; 12:160.
3. Smoflipid (lipid injectable emulsion) US product information; May, 2016
(available at:
http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/207648lbl.pdf)
4. Rayvan M, Devliger H, Jochum F et al. Short-term use of parenteral nutrition
with a lipid emulsion containing a mixture of soybean oil, olive oil, medium-
chain triglycerides and fish oil: A randomized double-blind study in preterm
infants. J Parenter Enteral Nutr 2012; 36:81S.

Calculation of the glucose infusion rate (GIR) for parenteral nutrition
1. Calculate grams of glucose in the Energy (kcals) from carbohydrates ÷ 3.4
parenteral nutrition (PN) prescription kcal/g = grams glucose
2. Convert to milligrams of glucose Grams glucose x 1000 = mg glucose
3. Calculate milligrams of glucose per Mg glucose ÷ body weight (kg) = mg
kilogram glucose/kg
Mg glucose/kg ÷ minutes of infusion = mg

4. Calculate milligrams of glucose per
glucose/kg/minute
kilogram per minute
(where minutes of infusion = 1440 if infusion
= glucose infusion rate (GIR)
is continuous over 24 hours)
Courtesy of Susan Baker, MD, and Robert Baker, MD.
Daily electrolyte and mineral requirements for parenteral nutrition in pediatric patients
Electrolyte Preterm neonates Infants/children Adolescent
Sodium 2 to 5 mEq/kg 2 to 5 mEq/kg 1 to 2 mEq/kg
Potassium 2 to 4 mEq/kg 2 to 4 mEq/kg 1 to 2 mEq/kg
2 to 4 mEq/kg 0.5 to 4 mEq/kg 10 to 20 mEq total daily dose

Calcium
(= 1 to 2 mmol/kg)*¶ (= 0.25 to 2 mmol/kg)*¶ (= 5 to 10 mmol)*¶
Phosphorus 1 to 2 mmol/kg 0.5 to 2 mmol/kg 10 to 40 mmol
Magnesium 0.3 to 0.5 mEq/kg 0.3 to 0.5 mEq/kg 10 to 30 mEq
Δ
Acetate As needed As needed As needed
Δ
Chloride As needed As needed As needed
These estimated requirements assume normal age-related organ function and normal
loss.
* For young infants (especially premature infants), calcium and phosphorus should be
added in a molar ratio that is close to 1:1, to optimize phosphorus utilization. Refer to
the UpToDate topic review on Parenteral nutrition in premature infants.
¶ Conversions: 1 mEq elemental calcium (20 mg) = 0.5 mmol = 215 mg calcium
gluconate salt. The molecular weight of calcium gluconate is 430.373 g/mol.
Δ The ratio of acetate and chloride is adjusted as needed to maintain acid-base balance.
From: Mirtallo J, Canada T, Johnson D, et al. Journal of parenteral and enteral nutrition
(Volume 28, Issue 6). pp.S39-70, Copyright © 2004 by the American Society for
Parenteral and Enteral Nutrition. Reprinted by permission of SAGE Publications.
Intravenous multivitamin preparation for pediatric use
Each 5 mL solution contains:
Vitamin C (ascorbic acid) 80 mg
Vitamin A (palmitate) 2300 IU
Vitamin D (cholecalciferol) 400 IU
Vitamin B1 (thiamine) 1.2 mg
Vitamin B2 (riboflavin) 1.4 mg
Vitamin B6 (pyridoxine) 1 mg
Niacinamide 17 mg
Dexpanthenol 5 mg
Vitamin E 7 IU
Vitamin K1 (phytonadione) 0.2 mg
Folic acid 140 mcg
Biotin 20 mcg
Vitamin B12 (cyanocobalamin) 1 mcg
IU: international units.
Data from: Product information - Infuvite Pediatric (Baxter Healthcare Corporation).
Example of a step-wise approach to cycling parenteral nutrition
Continuous Continuous 24 hour PN 1000 mL infusing at 42 mL/hr for 24 hours
48 mL/hr x 20 hours
22 hours on, 2 hours 24 mL/hr x 1 hour (Cycle down)

Start of cycling
off
12 mL/hr x 1 hour (Cycle down)
Off 2 hours
25 mL/hr x 1 hour (Cycle up)
55 mL/hr x 17 hours
20 hours on, 4 hours
Step 2
off 25 mL/hr x 1 hour (Cycle down)
Off 4 hours
Step 3 18 hours on, 6 hours
off 35 mL/hr x 1 hour (Cycle up)
61 mL/hr x 15 hours
Off 6 hours
36 mL/hr x 1 hour (Cycle up)
70 mL/hr x 13 hours
16 hours on, 8 hours
Step 4
off 36 mL/hr x 1 hour (Cycle down)
Off 8 hours
Example of a step-wise approach to cycling parenteral nutrition. The cycle length
achieved will be dependent on the glucose infusion rate (GIR) and the glucose tolerance
of the individual patient.
Courtesy of Susan Baker, MD, Robert Baker, MD, Jessica Briggs, RD, and Georgina
Bojczuk, RD, CSP.

Parenteral Nutrition in Infants and Children

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Parenteral Nutrition in Infants and Children

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Parenteral nutrition in infants and children

INTRODUCTIONSafe, long-term parenteral nutrition (PN) was first described in

Enteral nutrition should be used instead of or in addition to PN whenever possible. PN

Premature infants have a number of unique characteristics that affect the

PHYSIOLOGYPN is inherently nonphysiologic because nutrients are delivered directly

The effect of PN on physiology can be placed into three broad categories:

●Absence of enteral nutrients – Consequences of bypassing the GI tract and portal

The adverse effects of lack of enteral nutrition appear to be mediated in part by

Indications and contraindications — If the gastrointestinal (GI) tract is partially

Well-nourished children or adolescents tolerate up to seven days without nutrition

Central and peripheral venous access — PN can be administered through a peripheral or

mOsm/L = (grams amino acids/L x 10) + (grams dextrose/L x 5) + ([mEq Na + mEq K]

●Peripheral catheters – Peripheral catheters are only appropriate for infusions of PN

Lock therapy — Regardless of the type of catheter, catheter-related bloodstream

Taurolidine, an antibiotic, or taurolidine-citrate, have been used in place of ethanol to

NUTRITIONAL ASSESSMENTThe need for PN is determined by a careful assessment

Using weight-for-height Z-scores in children younger than two years or BMI-for-age Z-

●Mild malnutrition – Z-score -1 to -1.9

●Moderate malnutrition – Z-score -2 to -2.9

●Severe malnutrition – Z-score ≤-3

HOW TO PRESCRIBE PNIdeally, PN for pediatric patients is tailored to the needs of

Requirements — Recommended requirements for each nutrient, along with scientific

Appropriate fluid management also requires ongoing monitoring and adjustment

Energy — Accurate determination of a patient's energy needs for the PN prescription is

A practical approach to determining energy needs for the PN prescription is to estimate

●Preterm neonate – 90 to 120 kcal/kg/day

●<6 months – 85 to 105 kcal/kg/day

●≥6 to 12 months – 80 to 100 kcal/kg/day

●≥1 to 7 years – 75 to 90 kcal/kg/day

●≥7 to 12 years – 50 to 75 kcal/kg/day

●≥12 to 18 years – 30 to 50 kcal/kg/day

●Preterm neonate – 3 to 4 g/kg/day

●Infants (1 to 12 months) – 2 to 3 g/kg/day

●Children (>10 kg, or age 1 to 10 years) – 1 to 2 g/kg/day

●Adolescents (11 to 17 years) – 0.8 to 1.5 g/kg/day

Special "pediatric" amino acid solutions contain a higher concentration of essential

Excessive doses of IVFE may cause hypertriglyceridemia, especially in malnourished

Carbohydrates — Glucose is the only source of carbohydrate in PN and provides 40 to

The result is then converted into grams of glucose:

Grams glucose = Energy (kcals) from carbohydrates ÷ 3.4 kcal/g

Glucose is available in stock solutions of 5 to 70 percent, as dextrose monohydrate.

Calcium and phosphorus — Calcium to phosphorus ratio in PN should be close to a 1:1

●Chromium is a contaminant in PN solutions. Serum and urine levels should be

●Aluminum is a contaminant of PN solutions. Since crystalline amino acids have

Iron is not added to PN solutions. Instead, it must be administered orally,

Multivitamin — Multivitamins should be routinely included in the PN prescription.

PHARMACYPreparing a PN solution for pediatric patients presents special challenges

●American Society for Parenteral and Enteral Nutrition (ASPEN):

●American Society of Health-System Pharmacists (ASHP), Drug Shortages Resource

Cycling PN has psychological, developmental, and physiologic benefits. For children,

Cycling requires careful planning and monitoring because sudden discontinuation of a

Home PN solutions are frequently compounded as "three-in-one" solutions. That means

Home PN should be managed with a multidisciplinary approach including clinicians,

PSYCHOLOGICAL ASPECTS OF PEDIATRIC PNThe effect of PN on the

SOCIETY GUIDELINE LINKSLinks to society and government-sponsored guidelines

SUMMARY AND RECOMMENDATIONS

●The assessment prior to prescribing PN includes anthropometrics (primarily height,

•Fluid supplied in PN is based on estimates of needs to maintain normal hydration

•Carbohydrates in PN are supplied by glucose (in the form of dextrose monohydrate),

•Supplements of electrolytes and minerals (sodium, potassium, calcium, magnesium,

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Topic 15634 Version 22.0

2. Assess venous access If central venous access is necessary, consider type