2. Total body water (TBW): the total intracellular and
extracellular fluids
Extracellular fluids (ECF): the total Intravascular and
Interstitial fluids
Insensible water loss (IWL): the evaporation of water
through the skin, respiratory tract and mucous
membranes
Definitions
R. Bissinger. D. Annibale, GOLDEN HOURS, Care of the VLBWI , Chicago Ill, 2014
3. General Principles
Water accounts for 75%-95% of an infant’s body
weight
TBW is inversely proportional to GE.
First week of life: physiologic weight loss due to
contraction of ECF.
VLBW infants – 10%-15%
Term infants – 10%
R. Bissinger. D. Annibale, GOLDEN HOURS, Care of the VLBWI , Chicago Ill, 2014
4. ELBW infants at lower GE have the highest Trans-
epidermal water loss (TEWL)
*Humidified incubator with Porthole sleeves ready
on admission for infants < 32weeks and/or <1,200
grams to decrease TEWL
R. Bissinger. D. Annibale, GOLDEN HOURS, Care of the VLBWI , Chicago Ill, 2014
5. FACTORS AFFECTING IWL
INCREASE DECREASE
Low maturity High maturity
Low relative humidity Increasing postnatal age
Ambient temperature exceeding
neutral thermal environment
High environmental relative
humidity
Skin defects (omphalocele,
gastroschisis)
High ventilator relative humidity
Phototherapy and use of radient
warmer
Oh W, Fluid and Electrolyte Management of VLBW Infants, Pediatrics and Neonatology 2012
6. IWL:
Intake – Output (mainly urine) - ∆ in weight
Oh W, Fluid and Electrolyte Management of VLBW Infants, Pediatrics and Neonatology 2012
7. Urine output: 1-3ml/kg/hr
Urine specific gravity: 1005-1012 is consistent with a balance
in TBW
Urine Osmolarity : (specific gravity – 1000) x 30
•Premature: 500mosm/l (spec. gravity 1020-1025)
•AT: 800 mosm/l (specific gravity 1030)
Serum electrolytes and Cr should be routinely monitored to
evaluate Renal Function and Fluid balance.
*Na+ / Cr / BUN
R. Bissinger. D. Annibale, GOLDEN HOURS, Care of the VLBWI , Chicago Ill, 2014
8. Maintenance Fluid Requirements During the first week of
Life
Birth Weight
(g)
IWL
(ml/kg/d)
Dextrose
(g/100ml)
Day 1-2
(ml/kg/day)
Day 3-7
(ml/kg/Day)
<750 100+ 5-10 100-200 120-200
750-1,000 60-70 10 80-150 100-150
1,001-1,500 30-65 10 60-100 80-150
>1,500 15-30 10 60-80 100-150
Fanaroff and Martin’s Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 10th Ed.
Elsevier, 2015
9. ESTIMATED ENERGY REQUIRMENTS FOR GROWING
PREMATURE INFANTS
Energy Expenditure Kcal/kg/d
Resting metabolic rate 40-60
Activity 0-5
Thermoregulation 0-5
Synthesis/energy cost of growth 15
Energy stored 20-30
Energy excreted 15
Total energy requirement
(estimated)
90-120
Fanaroff and Martin’s Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 10th Ed.
Elsevier, 2015
10. RECOMMENDED ENERGY INTAKE
American Academy of Pediatrics:
105-130 kcal/kg/day for preterm infants
ESPGHAN (Committee on Nutrition):
110-135 kcal/kg/day
Fanaroff and Martin’s Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 10th Ed.
Elsevier, 2015
11. FORMS OF ADMINISTRATION
PERIPHERAL: max osmolarity 900 mOsm/l
Limits increase of energy , Dext 12.5%.
Short term nutrition
Risk of infiltration, phlebitis, thrombosis
CENTRAL : osmolarity >1000mOsm/l
Prolonged Nutrition
Dext > 12.5%
ASPEN Nutrition Support Practice Manual 2nd Edition, 2005
14. OSMOLARITY DEPENDS MOSTLY ON:
• DEXTROSE 5mOsml/gr
• AMINO ACIDS 10mOsml/gr
• ELECTROLYTES 1mOsml/mEq
mOsm/L:
Total of Osmol x 1000
total volume in TPN
PLASMA OSMOLARITY: 280 -290 mosm/L
2x Na + Glucose mg/dl + BUN mg/dl
18 2,8
ASPEN Nutrition Support Practice Manual 2nd Edition, 2005
15. DEXTROSE
Normal Glucose Requirements
Glucose Infusion Rate (GIR):
• Preterm: 6-8mg/kg/min
• Term: 3-5mg/kg/min
Normal glucose level: 50-120 mg/dl
1 gram of glucose = 3,4 kcal
R. Bissinger. D. Annibale, GOLDEN HOURS, Care of the VLBWI , Chicago Ill, 2014
16. Infants who require high infusion rates
or a dextrose concentration (Tenor)
> 12.5% require placement of central venous catheter
(UVC, PICC)
Tenor: Total Glucose (g) x100
Total fluids in IV
Total grams of glucose= GIR (mg) x Weight (kg) x 1.44
R. Bissinger. D. Annibale, GOLDEN HOURS, Care of the VLBWI , Chicago Ill, 2014
18. AMINO ACIDS
Recommended Protein intake:
3 – 4 g/kg/day in VLBW infants
1g of aa = 4 kcal
This account for obligate protein loss of
(1.5 – 2.0 g/kg/day)
This will:
limits catabolism
improve protein balance
preserve endogenous protein stores
R. Bissinger. D. Annibale, GOLDEN HOURS, Care of the VLBWI , Chicago Ill, 2014
19. Parenteral Amino Acid Solutions
Aminosyn 10%
TrophAmine 10%
Primene 10%
* Presentation also available as 8,5%
Fanaroff and Martin’s Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 10th Ed.
Elsevier, 2015
20. LIPIDS
Intravenous lipids:
Prevents essential fatty acids deficiency (EFAD)
(linoleic/linolenic acids)
Provides a significant source of non-protein energy.
Requirments 1-4 g/kg/day
1g of lipid = 9 kcal
EFAD can be avoided with 0.5 – 1.0 g/kg/day
of IV lipids in the first 24 hrs of life.
R. Bissinger. D. Annibale, GOLDEN HOURS, Care of the VLBWI , Chicago Ill, 2014
21. Intralipids are available as 10% and 20%
20% solutions are preferred due to lower cholesterol and
plasma triglyceride levels.
IV lipid solutions have LCT (>12C)
Maintain serum glucose levels
Monitor Triglycerides: <200 mg/dl and < 140mg/dl with
hyperbilirubinemia
R. Bissinger. D. Annibale, GOLDEN HOURS, Care of the VLBWI , Chicago Ill, 2014
22. Care should be taken in:
Infants with unconjugated hyperbilirubinemia to
avoid bilirubin toxicity as a result of free fatty acids
displacing bilirubin from albumin binding sites.
Infants with BPD due to release of thromboxanes
and prostaglandins, and increased pulmonary
vascular resistance
Infants with increased sepsis risk
Lipid intake should be limited to 40% - 50% of total
calories
R. Bissinger. D. Annibale, GOLDEN HOURS, Care of the VLBWI , Chicago Ill, 2014
23. ELECTROLYTES: SODIO (NA+):
Initiate:48 hrs
Requirements:
PT: 2 to 5
mEq/kg/day
AT: 2 a 4
mEq/kg/day.
CLORURO DE SODIO 20%®
Descripción:
Formula
Every 100 ml contains:
Sodium Chloride USP 20,00 g
Inyectable Water c.s.
Each ml has:
3,4 mEq Sodium ion (Na+)
3,4 mEq Cloride ion (Cl-)
Osmolarity: 6.844 mOsm/l
1mOsm/l = 1mEq
(3.4x1000) x 2= 6.800 mOsm/l
ASPEN Nutrition Support Practice Manual 2nd Edition, 2005
24. Can be adm. As KCL
salt or KH2PO4 salt.
Initiate: 48 hrs
Requirements:
RNPT y RNT:
1-4
mEq/kg/day.
CLORURO DE POTASIO
7,5%®
Descripción:
Formula:
Every 100 ml contains:
KCL USP 7,45 g.
Inyectable water c.s.
Every ml has:
1 mEq (K+);
1 mEq (Cl-);
Osmolarity: 2.000 mOsm/l
ASPEN Nutrition Support Practice Manual 2nd Edition, 2005
ELECTROLYTES: Potassium (K+):
25. K2PO4 13,6%
1meq/ml
Initiate with aa.
Dosis:20-40
mg/kg/day.
FOSFATO MONOBÁSICO DE
POTASIO
13,6%®
Formula:
Every 100 ml contains:
Monobasic K2PO4
USP 13,61 g.
Inyectable water c.s.
Every ml has:
1 mEq (K+)
1 mEq (H2PO4-)
Osmolarity: 2.000 mOsm/l
ASPEN Nutrition Support Practice Manual 2nd Edition, 2005
ELECTROLYTES: PHOSPHUROS
26. Mostly found in bone tissue
Initiate at birth
Dosis: 1.5 – 4 mEq/kg/day.
Adjustment to increase dose:
Asphyxia
NB of Diabetic mother
PT and SGE
ASPEN Nutrition Support Practice Manual 2nd Edition, 2005
Minerals: Calcium (Ca2+)
27. GLUCONATO DE CALCIO 10%®
Descripción:
Formula:
Every 100 ml contains:
Calcium Gluconate USP 10,00 g
Inyectable water c.s.
Each ml has:
0,5 mEq (Ca++)
0,5 mEq (Cl2H2O14)
Osmolarity: 1000 mOsm/l
ASPEN Nutrition Support Practice Manual 2nd Edition, 2005
28. INCOMPATIBILITY Ca-P
RELATION CALCIUM/PHOSPHORUS =
Ca mEq/L X (P MMOL X 1.8)
Ca/P Relationship < 300 to be considered safe
Contemporary Nutritional Support Practice: a clinical guide. Saunder 2003
30. TRACE MINERALS
AT and PT: 0.4 – 0.6 ml/kg/day.
Discontinue:
Copper and manganese in hepatic
cholestasis.
Selenium, chromium y molybdenum in
Acute Renal Disease.
ASPEN Nutrition Support Practice Manual 2nd Edition, 2005
ASPEN Interdisciplinary Nutrition Support Review Course 2001
34. ASPEN Nutrition Support Practice Manual 2nd Edition, 2005
ASPEN Interdisciplinary Nutrition Support Review Course 2001
35. WHEN TO DISCONTINUE PN?
Discontinue Parenteral Nutrition when patient has a
Enteral Nutrition of 100cc/kg/d
Gradual omission if patient has 75% of total fluids as
Enteral Nutrition and compliment with glucose at an
adequate GIR.
ASPEN Nutrition Support Practice Manual 2nd Edition, 2005
36. TO TAKE HOME:
1. Parenteral Nutrition should start as soon as possible
2. GIR of 5-6 mg/kg/day; 1g of glucose = 3,4 kcal
3. Amino Acids: 2-4g/kg/day; 1g of aa = 4 kcal
4. Lipids: 2-4 g/kg/day; 1g of lipid = 9 kcal
5. Recommended energy intake: 110 – 135 kcal/kg/day
Take in consideration IWL
TBW is inversely proportional to GE
Monitor electrolytes and renal function