2. Learning Objectives
Identify 5 common indications for PN in infants & children
Determine parenteral energy and protein requirements for
infants and children
Discuss 4 common complications of overfeeding.
Review how to begin and advance the following
macronutrients: % dextrose, protein and lipids.
Calculate glucose infusion rate (GIR) and discuss its
significance.
List 3 common signs of essential fatty acid deficiency
Given a TPN and lipid prescription and the child’s weight,
determine TPN calories.
Discuss laboratory monitoring for children on PN.
3. Indications for Parenteral Nutrition in
Infants and Children
Gastrointestinal Anomalies & Complications i.e.
NEC, gastroschesis, short bowel
Promotion of healing of TE fistula
Inflammatory bowel disease (severe cases)
Pediatric malignancies with severe GI problems
Preterm infants with severe respiratory distress,
immature gut motility & function
Critically ill (trauma, sepsis) patients with ileus
and/or abdominal trauma
5. Approach for the Critically
Ill Pediatric Patient
Begin with BEE for the first 1 – 3 days
Gradually advance energy delivery toward
above outlined goals, as status improves
(usually below RDA)
Indirect calorimetry still considered the
“gold standard” although not typically used
given financial and training considerations.
6. Complications of Overfeeding
Excess CO2 production & increased
minute ventilation
Pulmonary edema and respiratory failure
Hyperglycemia, which may lead to immuno-
suppression, and increased infection rates
Lipogenesis due to increased insulin
production
Generalized immunosuppression
Hepatic complications: fatty liver, intrahepatic
cholestasis, due to excess carbohydrate or
protein delivery.
7. Maintenance Fluid Requirements
for Children
Body Weight Amount Fluid/day
0.5 - 2.0 kg 120 -250 ml/kg
2 - 10 kg 100 ml/kg
11 - 20 kg 1000 ml + 50 ml/kg
for each kg>10 kg
> 20 kg 1500 ml + 20 ml/kg
for each kg>20 kg
8. Fluid Requirements
Skills Check
What are the maintenance fluid
requirements of a 17 kg child?
ANSWER: 1350 ml
What is this volume per kg?
ANSWER: 79 kcal/kg
9. Use of Carbohydrate in PN
Dextrose (D-Glucose) = 3.4 kcal/gm
Indications for peripheral vs. central PN:
1. Peripheral - max. of D10 - D12 % (PPN) Why?
- Indicated for short term PN < 2 weeks
2. Central - usual max of D20 - 25% (CPN)
- For periods > 2 weeks, or if infant has poor access
may use a surgical central line or a PICC-line
Small preterms: frequent hyperglycemia Why?
Initiation and advancement: Determine GIR
1. Preterms - advance by 0.5 - 2% q day
2. Older infants/children- adv. by 2.5 - 5% q day
10. Glucose Infusion Rate (GIR)
Calculating GIR:Calculating GIR: Rate X % Dextrose
Weight (kg) X 6
Units: mg glucose/kg/minuteUnits: mg glucose/kg/minute
GuidelinesGuidelines
Infants: Limit GIR to 12 – 14 mg/kg/min: Limit GIR to 12 – 14 mg/kg/min
Children: Limit GIR to 7 – 12 mg/kg/minChildren: Limit GIR to 7 – 12 mg/kg/min
11. GIR Calculation Problem
Infant in the PICU diagnosed with
neuroblastoma, receiving chemotherapy.
Weight: 6.8 kg
Infant’s TPN advanced over the weekend to:
D25% TPN with 20 gm TrophAmine/day
TPN Rate: 28 ml/hr
Calculate: GIR
13. Management of Hyperglycemia
in Infants & Children on PN
Initially may need to back down on % dextrose in PN
Hyperglycemia may be caused by decreased insulin
production, insulin resistance or stress response.
Insulin administration to preterm or critically ill infants is
controversial due to variable responses.
What are they?
Close monitoring is necessary to prevent episodes of
hypoglycemia, which may lead to brain damage.
If closely monitored, insulin administration can result in
increased energy intake and weight gain.
Initial dose = 0.05-0.1 U/kg/hour via a continuous infusion;
monitor blood glucose q hour initially.
14. Initiation and Advancement of
Protein in PN:
Preterm & term infants:
– Begin at 1.5 - 2.0 gm/kg q day and
– Advance by 1 gm/kg q day to endpoint
goal.
Older children: Begin at 1 – 2 gm/kg and
advance to goal by Day 2 of PN
Endpoint goals:
- Preterm & term infants: 3.5 - 4 gm/kg
- Older children: 1.5 - 2.5 gm/kg
15. Advantages of TrophAmine:
Provides essential amino acids (taurine,
tyrosine, histidine) 60% EAA
Promotes plasma amino acid profiles
within normal neonatal target range
Decreases tendency for cholestasis
Addition of cysteine HCl decreases pH of
PN: improves solubility of Ca & Phos
Recommended for infants < 2 years old
16. Initiation and Advancement of
Lipid in PN:
Preterm & term infants:
– Begin at 0.5 - 1.0 gm/kg q day and
– Advance by 0.5 - 1 gm/kg q day to
endpoint goal.
Older children: Begin at 1.0 gm/kg and
advance to goal by Day 2 of PN
Endpoint goals:
- Preterm & term infants: 2.5 – 4 gm/kg
- Older children: 1.0 – 2.5 gm/kg
17. Use of Lipids in PN
in Children
Minimal goals for provision of EFA:
0.5 - 1.0 gm/kg/day
Intralipid: 54% linoleic acid
1. 10% Intralipid - 1.1 kcal/ml
2. 20% Intralipid - 2.0 kcal/ml (Only at UVA-HS)
Intralipid provides 10 kcal/gm (due to glycerol)
Egg phospholipid may be allergy source
SGA infants are more susceptible to
hyperlipidemia Why?
18. Clinical Signs of EFA Deficiency
Reduced growth rate
Flaky dry skin
Poor hair growth
Thrombocytopenia ….What is this?
Increased susceptibility to infections
Impaired wound healing
19. Intralipid should be
used with caution:
Hyperbilirubinemia
Fatty acids may displace bilirubin from albumin binding
sites, increasing the risk of kernicterus.
Pulmonary hypertension or severe RDS
Excess lipid intake may decrease CO2 & O2 diffusion
capacity across the alveolar membranes.
Sepsis
Excess lipid increases arachidonic acid production, and
thus 2 series prostaglandins and 4 series leukotrienes.
These substances may cause increased risk of
immunosuppression.
20. The Use of Carnitine in PN
Preterm/SGA infants on long term PN may
become carnitine deficient due to lacking some
enzymes needed for biosynthesis.
Symptoms may include: cardiomyopathy,
increased triglycerides hypotonia, muscle
weakness, acidosis, failure to thrive.
Improvement in carnitine status can lead to:
Improved lipid tolerance
Improved nitrogen accretion
Improved growth.
22. Functions of Carnitine
Transports long-chain fatty acids into
the mitochondria for beta-oxidation
Regulates rate of fatty acid oxidation
Assists in ATP production
Scavenger of harmful acyl groups that
may lead to lipid membrane oxidation
Maintains pool of free CoA in
mitochondria
23. Recommended Dosages for Children
50-100 mg/kg/day level is used (may be
therapeutic)
Some negative effects reported at
greater than 50 mg/kg/day
May be prudent to use 10-20
mg/kg/day, especially in infants
Side effects: diarrhea, nausea, cramping;
risk for seizures
24. Pediatric Multivitamins
Vitamin C - 80 mg
Vitamin A - 2300 IU
Vitamin D - 400 IU
Vitamin E - 7 IU
Vitamin K - 0.2 mg
Biotin - 20 ug
5 ml for wt up to 40 kg
2 ml/kg Peds MVI for
wt through 2.5 kg
Vitamin B1 - 1.2 mg
Vitamin B2 - 1.4 mg
Vitamin B3 - 17 mg
Vitamin B6 - 1 mg
Vitamin B12- 1 ug
Folic Acid - 140 ug
Use 10 ml adult MVI for
children > 40 kg
25. Pediatric Trace Element Solution
Trace Element Content
Zinc 300 ug
Copper 20 ug
Chromium 0.17 ug
Manganese 5 ug
* Use 0.2 ml/kg/day for
children up to 5 kg.
* Add 100ug/kg zinc
for infants < 2.5 kg
* Add 50 ug/kg zinc
for post-op heart
infants or to aid in
wound healing.
27. General Guidelines for PN Solubility:
Protein, Calcium and Phosphorus
Per every 100 ml/kg of PN can add:
– 4 gm/kg TrophAmine
– 4 mEq/kg of Calcium
– 1.5 mMol/kg of Phosphorus
Can add only 40 gm of TrophAmine/L in TPN
Can add 45 - 50 gm of standard amino acids/L
Solubility Limits for Calcium & Phosphorus
– 5.2 mEq/100 ml of Ca + Phos for standard amino acids
– 7.2 mEq/100 ml of Ca + Phos for TrophAmine
28. Neonatal TPN
Practice Problem: Part I
2 month old infant s/p cardiac surgery for
Tetrology of Fallot (TOF)
Infant weight: 3.6 kg
Infant is to begin TPN and lipids on POD #1,
but given volume restriction and multiple I.V.
medications post-op, he can only receive 6
ml/hr of TPN.
What type of protein will you use? Why?
TrophAmine
29. Neonatal TPN
Practice Problem: Part II
How many ml/kg of TPN will the infant
receive?
6 ml/hr X 24 hr / 3.6 kg = 40 ml/kg
What is the maximum amount of Calcium you
can order in mEq/kg?
1.6 mEq/kg
What is the maximum amount of Phosphorus
you can order in mMol/kg?
0.6 mMol/kg
30. Use of H2 Blockers in TPN
Recommended for use in infants and
children on TPN for at least 1 week who
will not be enterally fed.
Prevents excess HCl acid production,
used for ulcer prophylaxis.
Pediatric dose for Famotidine:
0.8 – 1.0 mg/kg
31. Use of Parenteral Iron (Imferon)
Controversial due to concerns of increased
risk of gram negative sepsis
Infants with iron deficiency anemia with
decreased hemoglobin/hematocrit or serum
ferritin need iron in PN
Begin 0.5-0.8 mg/kg/day for 1-3 weeks
Monitor indices of iron status: HCT/HGB,
MCV, serum Fe, ferritin
32. Selenium Supplementation in PN:
Selenium deficiency:
cardiomyopathy
skeletal muscle
tenderness/pain
erythrocyte
macrocytosis
loss of pigmentation
of hair and skin
Selenium deficiency
may occur with long
term selenium free
PN
Supplementation:
1-2 ug/kg/day
Normal Selenium:
6.3-12.6 ug/dl
33. Calculation of Total Calories & Nutrients
from Parenteral Nutrition
PN volume = PN rate (ml/hr) X 24 hours
a. Calories from Dextrose
PN volume X % dextrose X 3.4 kcal/gm
b. Calories from Protein
Total grams protein/day X 4.0 kcal/gm
or gm/kg protein X wt (kg) X 4.0 kcal/gm
c. Calories from Fat
Intralipid volume X 1.1 kcal/cc (10% IL)
Intralipid volume X 2.0 kcal/cc (20% IL) @ UVA-HS
d. Kcal/kg = a + b + c / weight (kg)
34. Peds TPN Example
Infant with Short Bowel Syndrome
Weight: 5 kg
TPN Prescription: D 20% TPN with 3
gm/kg TrophAmine at 20 ml/hr X 24
hours.
Lipid order: 50 ml of 20% Intralipid
Calculate TPN total kcal and kcal/kg
35. TPN Calorie Calculations
TPN Volume?
20 ml/hr X 24 hours = 480 ml
Dextrose Calories?
= 480 ml X .20 X 3.4 = 326 kcal (a)
Protein Calories?
= 3 gm/kg X 5.0 kg X 4 kcal/gm = 60 kcal (b)
Fat Calories?
= 50 ml X 2.0 kcal/ml = 100 kcal (c)
Total Calories = a + b + c/wt (kg)
= 486 kcal/5.0 kg = 97 kcal/kg
36. Pediatric Cyclic Parenteral
Nutrition
Recommended for children on long term PN, who will
benefit from a nocturnal PN schedule
Advantages: Provides a “window” or break when no
PN is given, allows for normal activities during the
day: ambulation, therapies, school etc..
Provides a physiological “break” from PN, which has
been shown to decrease incidence of cholestasis and
hepatic toxicity
PN must be tapered on and off, to help prevent
episodes of hyper & hypoglycemia
– Example: 10 ml/hr X 1 hr, 20 ml/hr X 10 hr, 10 ml/hr X 1 hr
37. Monitoring Growth & Tolerance
of Pediatric PN
Anthropometrics: daily weights in infants,
weekly in older children, length & head
circumference for assessment of linear growth
Laboratory Monitoring:
1. Initial Monitoring: Basic Metabolic Panel to
include: Na, K, Cl, CO2, BUN, Cr, Glucose, Ca, Mg,
and Phos
2. Weekly PN Monitoring: TPN Profile (NICU) or
Hepatic Panel A + triglycerides, prealbumin
Need: Albumin, AST/ALT, Alkaline phosphatase,
triglycerides, and conjugated bilirubin
38. Complications of PN in Children
Metabolic Complications: electrolyte disturbances,
hyperglycemia, hyperammonemia, metabolic
alkalosis
Complications with Intralipids: hyperlipidemia in
SGA infants and during sepsis, decreased activity of
lipoprotein lipase. Use lipids with caution with:
1. Hyperbilirubinemia
2. Infection/sepsis
3. Severe or chronic lung disease
Liver Dysfunction
1. Cholestasis: caused by excess kcal or protein
2. Fatty liver: related to excess calories, including
CHO calories
39. Role of the Nutritionist in Managing
Pediatric Parenteral Nutrition
Work closely with physicians or residents
ordering the PN to make appropriate
recommendations, so that PN order changes
can be entered in a timely manner.
Educate physicians and pediatric residents on
the “how-to’s” of pediatric PN on regular basis
Whenever possible work to obtain “verbal” or
“pended” order privileges on PN. The R.D.
would then be able to enter PN orders.
40. Role of the Nutritionist in Monitoring
Pediatric Parenteral Nutrition
Work closely with physicians, nurses and
computer specialists to make changes to PN
ordering forms or be part of team to develop
order screens when using the electronic
medical record (EMR) ordering process.
Work closely with nurse practitioners and
home health companies to facilitate transition
from hospital to home and to ensure that
patient receives the appropriate PN
formulation in the home setting.
41. Pediatric PN Case Study
5 year old girl admitted to PICU following an MVA.
She has experienced:
– Significant abdominal trauma, perforation of duodenum
– Splenic laceration
– Right femur fracture
Admission weight: 18 kg (50th
%-ile) NCHS curves
Post-operative Day 1: Receiving D5% ¼ NS at 50
ml/hr. She had central line placed in the OR.
Consult: Begin PN and lipids, TPN rate to start at 50
ml/hr to replace above IV fluids.
42. Questions to Consider ….
What are this child’s calorie, protein and fluid
requirements?
How would you start TPN and lipids on Day 1?
Calculate calorie, protein and fat intake (in gm/kg)
based on your first TPN order.
How would you advance the TPN macronutrients to
meet this child’s nutritional needs?
What amino acid solution would you use and why?
What labs should be checked on a daily basis?
Which ones on a weekly basis?
