This action might not be possible to undo. Are you sure you want to continue?
Mohamed Khashaba Professor of Pediatrics/Neonatology Head of NICU, MUCH
Know the indications of parenteral nutrition. Recognize the complications of parenteral feeding.
Know the components of parenteral nutrition.
Fluid volume Calories Glucose Proteins Lipids Electrolytes, minerals and vitamins
Monitor infants on parenteral nutrition. Proceed to oral feeding.
Nutritional management of the neonate in health and disease states is one the most important parts of the general management of these babies during hospitalization and after their discharge. The nutritional status of the newborn interferes positively or negatively with the outcome of many disorders
This nutritional management should be thought of on daily basis during hospitalization and assessed at regular intervals on subsequent outpatient follow up.
Intravenous delivery of energy and nutrients required for the infant’s growth.
Infants incapable of tolerating enteral feeding
Preterm infants: not expected to tolerate enteral feeds within 3-7 days. NEC (suspected or confirmed): NPO for an extended period. Post-Surgical infants: unable to feed for an extended period. Congenital GI anomalies.
practical hints for TPN
Do not starve babies! The ones who don’t complain are the ones who need it the most. Use birthweight to calculate intake till birthweight regained, then use daily wt Start TPN on 2nd or 3rd day if the baby will not be on full feeds by a week Start with proteins (1 g/kg/d) and increase slowly. After a few days (3rd or 4th day), add lipids (0.5 kg/kg/d) Aim for 90-100 Cal/kg/day with 2.5-3 g/kg/d 9
Local skin infection Sloughs Sepsis Thrombosis
Hyperglycemia Electrolyte imbalance Acidosis Liver damage and cholestasis Osteopenia
Fluid volume Calories Glucose Protein Lipids Electrolytes Minerals & Vitamins
Depends upon the daily fluid requirements at different days of life in different days of life in different birth weights groups.
Fluid requirements day of Life # 1-3
IV Fluid requirements ( cc /kg/day )
Day # 1 Day # 2 Day # 3
120 D5 W 140 D5 W 170 D5 W
100 D7.5 W 120 D7.5 W 130 D7.5 W
80 D10 W 100 D10 W
80 D10 W 90 D10 W
110 D10 W 100 D10 W
N.B. Subtract 20 CC/kg/day if the infant suffers from R.D.
-The ultimate goal: 90-100 K Cal./Kg/day -For the VLBW infants should be advanced slowly: Day Day Day of of of life life life 1-3 = 50-55 3-5 = 65-75 5-7 = 85-90 k k k cal./kg/day cal./kg/day cal./kg/day
From PROTEIN not to exceed 15% From LIPIDS not to exceed 50%
of the total calories
3.4 k cal.
I gm. Start with:
4-6 mg./kg./min. (in VLBW) 8-10 mg./kg./min. (in full term)
Advance in daily increments of
1-2 mg./kg./min. (to ↓ risk of Hyperglycemia)
Dextrose 3.4 Cal/g = 34 Cal/100 cc of D10W. Tiny babies are less able to tolerate dextrose. If < 1 kg, start at 6 mg/kg/min. If 1-1.5 kg, start at 8 mg/kg/min. If blood levels >150-180 mg/dL, glucosuria=> osmotic diuresis, dehydration Insulin can control hyperglycemia Hyper- or hypo-glycemia => early sign 18
GIR (mg/ kg /min) = Fluid rate (cc/hr) x Dextrose Concentration 6 x weight (kg)
is the GIR in an infant weighting 2 kg on a total fluid of 120 cc/kg/day using the D10W solution? Hourly rate is:
2 (kg) x 120 (cc /kg /day) ÷ 24 = 10 cc/hr GIR = 10 x 10% ( D W) ÷ (6x2) = 10 8.3 mg/kg/min
(6% Amino acid solution containing taurine)
Start with : 0.5 – 1 gm./kg./day Advance in daily increments of 1.5 – 1gm./kg./day
Reduce the protein load, if serum BUN is raising, or with metabolic acidosis. The ratio of protein (gm.) : nonprotein calories.
Should not exceed 1 : 25
Intralipid 20% (soybean oil, egg phosphlipid and 2.25 % glycerol) 1 gm. 10 kcal (2 kcal/ml.) Start with : 0.5 – 1 gm./kg./day Advance in daily increments of 0.5gm./kg./day
Maximum of 3.0 – 4.0 gm./kg./day
serum Triglycerid level is: > 200 mg stop Intralipids. > 150 mg decrease the infusion rate.
should be used at minimum rate (0.5 – 1 gm./kg./day) in: Sepsis Severe lung disease Hepatic disease Jaundice Thrombocytopenia
Start Glucose (3.4 kcal.) Protein (4.0 kcal.) Lipids (10 kcal.)
4-6 mg./kg./min. 0.5-1 gm./kg./day 0.5-1 gm./kg./day
1-2 mg./kg./min. 0.5-1 gm./kg./day 0.5 gm./kg./day
12.5% solution in peripheral vein 3.0-3.5 gm./kg./day (6% solution) 3.0-4.0 gm./kg./day (20% solution)
Fat soluble vitamins: A, D, E, K Water soluble vitamins: Vitamins B1,B2, B6, B12, Biotin, Niacin, Pantothenate, Folic acid, Vitamin C All neonates should get vit K at birth Term neonates: No vitamin supplement required, except perhaps vit D Preterm: Start vitamin supplements once full feeds established if on human milk without HMF. No need if on human milk with HMF, or preterm 27
IV Electrolytes and minerals requirements
Sodium* (mEq/kg/da y) Potassium* (mEq/kg/da y) Calcium (elemental) (mg/kg/day)
Day # 1 Day # 2 Day # 3
0 2-3 2-3
0 1-2 1-2
45 45 45
*Do not add sodium if it > 140 mEq/1 *Do not add potassium until urine output is established.
Electrolytes, Minerals & Vitamins Maintain Ca: P ratio at 2:1 1 mmol of P = 31 mg
Zinc, Copper, Selenium, Chromium, manganese, Molybdenum, Iodine Trace elements (except for zinc) should be deleted if direct bilirubin is > 3 mg/dl
Assessment of hydration status of the neonate
Daily, twice a day if <1000g Daily, Every 8 hr if <1000g Daily, Every 8-12 hr if <1000g Each diaper change
Daily weight loss should not exceed 1-3% Look for evidence of dehydration Restrict fluids if <130 Liberalize fluids if >145 N. Volume 2-3 cc/kg/hr N. Sp. Gr. 1005-1010
Skin and fontanel
Serum sodium Urine Volume Specific gravity Glycosuria*
Suggested monitoring schedule during parenteral nutrition:
Monitoring variable last period
Weight Length, Head circumference Weekly Serum Electrolytes, Ca, P, CO2 Weekly Serum BUN, albumin, LFTs
Daily Daily Weekly 2/week Weekly