Post on 08-Aug-2020
By: Shihaam Cader
Chief Dietitian
Head of Department
RCWMCH
Update on Pediatric Parenteral
Nutrition Guidelines
Introduction
The goal of parenteral nutrition (PN) is to correct or prevent nutritional
deficiencies when unable to provide nutrients via enteral route
Usually considered when unable to feed for 3 – 5 days infants/children
Common conditions in children:
Intestinal failure ( SBS,atresia, NEC)
Enteropathies or malabsorption due to CGE
Choice of suitable parenteral solutions depends on the macronutrients &
micronutrients needs of children – not only quantity but quality of nutrients
Setting the scene….
6 month old girl Poor nutritional status (wt5.5kg,
stunted, wasted) Previous bowel resection (35cm SB)
due to NEC Ileostomy Initially TPN then weaned to enteral /
oral feeds
10 year old boy
Admitted to ICU with
complicated post
appendectomy, abdominal
sepsis
ventilation support
Poor nutritional status (25kg)
BMI 13.7 (Z score -2)
Patient A Patient B
Planned ileostomy closure due
to increased output
For recommencement of TPN
post surgery
Baseline bloods shows normal
electrolytes, CMP but raised
bilirubin levels
NPM for more than 5 days
post surgery
Baseline bloods normal
Guidelines on Pediatric PN
ESPGHAN/ESPEN/ESPR/CSPEN
1 •Guideline development process
2 •Energy
3 •Amino acids
4 •Lipids
5 •Carbohydrates
6 •Fluid & electrolytes
7 •Iron and trace elements
8 •Calcium, Phosphate, magnesium
9 •Vitamins
10 •Venous Access
11 •Organisational aspects
12 •Home parenteral nutrition
13 •Standard vs Individualized parenteral nutrition
14 •Complications
14
Ch
ap
ters
Key points from ESPGHAN 2018
1. Energy & Carbohydrate PN
2. Parenteral Nutrition in critically ill
3. Protein requirements
4. Lipid requirements & lipid emulsions
5. Micronutrients
6. Practical approach
Energy Needs
Hyperglycemia – may increase risk of infection
Hyperlipidemia
Excess fat deposition
Liver steatosis (impairing liver function)
- Hypoglycemia
- Impaired growth
- Tissue catabolism – LBM
- Poor cognitive/ behavioral development
- Impaired immunity
- Increasing risk of mortality/morbidity
Ris
k o
f e
xc
ess
en
erg
y
Risk
of in
ad
eq
ua
te e
ne
rgy
FINDING THE BALANCE
Energy recommendations
Schofield for REE (kcal/d) 0- 18 years is preferred – least to underestimate.
Add relevant PAL, disease factors & growth to get TOTAL PN requirments
Derived from 2004 FAO/WHO/UNU recommendations (previously 1985)
Lower as does not take into account 5-10% needed for enteral absorption.
Main source of fuel for brain cell metabolism & for
other body functions
Glucose metabolism is influenced by
1. Age
2. Acute illness
3. Nutritional status
4. Provision of other macronutrients
Use of glucose alone is not recommended
because of:
•Hyperglycemia
• fatty liver [steatosis] & increase VLDL
• excess CO2 production
• EFA deficiency [within 2-3 days]
Carbohydrate
Carbohydrate recommendations
Recognizing the different phases of critical ill
Phases of critical illness
Joosten etal Curr Opin Clin Nutr Metb Care 2019
Endogenous production irrespective of
exogenous energy provided
Gradual increase stepwise 2 -3 days
ACUTE phase
First hours – days
Resuscitation phase
- requires vital organ
support – such as
sedation,
mechanical
ventilation,
vasopressors, fluid
resuscitation
STABLE phase
When can be
weaned from
these vital
support
RECOVERY phase
When mobilising
More
Energy/CHO
required to
promote growth
and recovery
Phases of critical illness
Joosten etal Curr Opin Clin Nutr Metb Care 2019
Acute phase energy intake is equal or lower
Thereafter increased to promote tissue repair & growth
Energy : Different phases
Acute phase typically the first 1- 2 days
Recommendations for acute and stable phase can be applied to
critical care setting and recovery for all other patients
Carbohydrate needsNEW
Critical ill
Timing of supplemental PN
PEPaNIC trial : Early vs Late PN
Multicenter RCT in 1440 critically ill infants & children (0-17years)
Compared early initiation of supplemental PN (within 24 hrs) to
late PN (withholding for 8days) in addition to EN
Outcomes:
Reduced number of new infections, ventilation time, kidney
failure and LOS
Limitations:
PN may not have been indicated/needed
Timing of supplemental PN
A) Editorial response…
Mehta, N (2016 New England J Medicine) raised concerns
Appropriate PN indications
Equations used to determine energy requirements
Threshold of EN tolerance less than 80% of target calories
B ) Review article:
Koletzko, B et.al. (Curr Opin Clin Nutr Metab Care 2017)
Indications for PN – if gut works use it
Majority patients had normal BMI
Early PN group average ICU stay was ~4days
Supplemental PN can be delayed for 1 week in those with NORMAL
nutritional status or with low risk of nutritional deficiency
Overfeeding with glucose
During recovery insulin resistance will decrease and metabolism will improve
Lipogenesis & fat deposition
High CHO induces Insulin
resistence
Liver steatosis
Increased CO2
ACUTE phase
Management of Hyperglycaemia
Amino acid requirements
Preterm Infants Children Children Adolescents
2m - 3years 3-12 years >12years
g/kg/day
2005
1.5 - 4.01.5 - 3.0 1.0 - 2.5 1.0 - 2.0 1.0 - 2.0
2016
D1: 1.5 - 2.51.5 - 3.0 (max) 2.5 2.0 2.0
D2: 2.5 - 3.5 Accompanied by >65kcal/kg/d Min 1.0 min 1.0 min 1.0
Strong recommendation - Glutamine should not be supplemented
additionally in infants and children up to the age of two years
Taurine to be included in AA solutions (strong consensus)
AA requirements are lower in PN than EN because bypasses intestine
Pediatric suitable AA solutions
that includes Essential AA
ESPGHAN : Lipid requirements
Preterm Infants Children
g/kg/day
2005 3.0 - 4.0 3.0 - 4.0 1.0 - 3.0
2016 max 4.0 max 4.0 max 3.0
EFAs: 0.25g/kg Linoleic for preterm 0.1g/kg/day linoleic acid term infants and children
Integral part of pediatric PN
Providing high energy needs without CHO overload & increasing the osmolarity
EFAs – critical role in early development
Maximal lipid oxidation rate is
~3g/kg/day in young children
1.7 – 2.5g/kg/day in adults
Excess stored in adipose tissue & increase risk of fat overload Sx and may impair the immune response
ESPGHAN : Types of Lipid emulsions
The choice of ILEs is influenced by:
composition of lipid emulsion ,
Duration of PN,
Clinical setting,
Age,
Disease conditions
NEW
ESPGHAN : Types of Lipid emulsions
Pediatric PN patients at high risk of IFALD – such as :
Premature infants
Long term bowel rest
Ileal resection / enterostomy (loss of hepatic-enteric cycle)
Sepsis
SBS
Use of lipid emulsions
Beneficial than pure SO lipid as less
proinflammatory effects, less
immunosuppression & more antioxidant
effects
Particularly in prems -
decreased LPL and
reduced fat oxidation
Use of Lipid emulsions
STRONG RECOMMENDATION
Management of IFALD
Common complication in long term PN
Is related to patients receiving long term PN [> 14 days]
It can be reversed if detected and monitored closely
It is clinically diagnosed with raised total bilirubin levels
[> 20mg/dL]
It can even persist 2 weeks after PN has stopped
The causes are multifactorial
Multifactorial
Absence of
enteral nutrition
Infection or
sepsis
Lipid
emulsions
Premature
infants
Short bowel
syndrome
reduced bile acid enterohepatic circulation, resulting in
reduce bile flow ----- hepatotoxic
OverfeedingCHO/Lipids
Prolonged PN>14days
Causes of IFALD / PNAC
Management strategies to include
1. Trophic feeding
2. Minimise the lipid dose [g/kg/day]
3. Ensure not overfeeding
4. Treat sepsis
5. Cyclical PN
6. And / Or altering Lipid emulsion
Management IFALD
Management IFALD
Several observational studies shown by changing dose or type of ILEs
has reversed IFALD – but limited RCT
These changes include:
1. Reduction in proinflammatory n6s
2. Reduction in phytosterol supply
3. Provision of alpha- tocopherol
4. Anti-inflammatory n3s
Pure Fish oil
Available studies shown the use of pure FO ILEs to benefit IFALD
However no long term studies (>15days)
Concern of EFA deficiency & aspects related to coagulation
Fish oil role in IFALD
1. ↓ inflammation
2. ↑ antioxidant activity
3. ↓ phytosterols
4. ↑biliary flow
1. ↑ inflammation
2. Provide EFAs
Having right balance between n6 and n3s
Ratio n6:n3
Soya Fish MCT Olive
o Rich in MUFA n9
o ↓ lipid
peroxidation
o Less PUFAs
o ↑ antioxidant
intake
o ↑ vitamin E
status
o Lacks omega3s
o Safe & well
tolerated
o Calorie rich
compound
o Rapidly
available source
of energy
o Not dependent
on carnitine for
mitochondrial
transport
o Safe & well
tolerated
o Rich in n3
o Source EPA/DHA
o Anti-inflammatory
properties
o Safe & well
tolerated
o Rich in n6
o Source of EFA
o Pro-inflammatory
properties
o Contains
Phytosterols
o Lack of
sufficient
antioxidants
o Concerns linked
with PNALD
Types of Lipid emulsions
Combination of lipid emulsions beneficial
List of lipid emulsions available [not all in SA]
Pure Soy*
Soya+MCT* Soya+Olive* Pure Fish
Soya+MCT+
FishSoy+MCT+ Olive+Fish*
Soybean (%) 100 50 20 0 40 30
Coconut(MCT) (%) 0 50 0 0 50 30
Olive (%) 0 0 80 0 0 25
Fish (%) 0 0 0 100 10 15
Phytosterols(mg/L) 348 ? 327 0 ~125 47.6
αtocopherol(µmol/L) 87 395 75 505 455 500
EPA 0 0 0 20.1 3 3
DHA 0 0 0 18.4 2 2
Ratio n6:n3 6.7:1 16:1 9.1:1 1:8.2 2.7:1 2.5:1
Pichler, J. Euro J Clin Nutr 2014;68:1161Seida, JPEN 2013; 37:44Vlaardingbroek Am J Clin Nutr 2012; 96:255
*Only available in SA
Mixed Lipid emulsions
ESPGHAN : Monitoring of lipids
ESPGHAN : Monitoring of lipids
Risk of hypertriglyceridemia:
CHO high
Lipid dose high
Malnourished ( slower rate of clearance)
Sepsis
Prem/ELBW – limited muscle/fat mass &
reduced hydrolytic capacity
When to monitor:
1- 2days after initiation or adjustment of lipid infusion
Thereafter weekly to monthly depending on the
patient
LIPIDS TO BE LOWERED – NEVER STOPPED
Micronutrients
Limited data for last 30 years
However infants and children are at risk of deficiencies
Therefore recommendations are that all children receive micronutrients
daily infusions as part of their PN solution
Water and lipid solutions should be added to lipid emulsions increase
vitamin stability
Fat soluble vitamins
•Adequate supply essential for growth and development
• Vitamin A & E exposure to sunlight is detrimental and can cause degradation
•Administering with lipid helps reduce this risk and at same time protecting the
lipids from peroxidation – antioxidant properties
Vitamins & Trace elements 2005 2018
Infants[per kg] Children [per day] Infants(per kg) Children (per day)
Vitamin C [mg] 15-25 80 same same
Thiamine[B1] [mg] 0.35-0.50 1 same 1.2mg/day
Riboflavin [mg] 0.15-0.2 1.4 same same
Pyridoxine [mg] 0.15- 0.2 1 same same
Niacin [mg] 4 - 6.8 17 same same
B12 [ug] 0.3 1 same same
Pantothenic [mg] 1-2 5 2.5mg/kg same
Biotin [ug] 5 - 8 20 same same
Folic acid [ug] 56 140 same same
Vitamin A[ug] 150-300 150 same same
Vitamin D2[ug] 32 IU 400 IU 40 - 150IU/kg/day 400 - 600IU/day
Vitamin E[mg] 2.8-3.5 7 same 11mg/day
Vitamin K[ug]
10µg/kg -recommended but not
possible 200 same same
copper[ug] 20 20ug/kg upto 0.5mg/day same
Iodine[ug] 1 same same
Selenium[ug] 2-32 - 3ug/kg max
100ug/day same
Zinc[ug]250 for <3m 50µg/kg same same
100 for >3m max 5mg/d
Mn [ug] low dose 1µg/kg 50 max 50ug/daysame
Mo [ug]0.25µg/kg[max
5µg/d]
Vitamin D
Several reports of vitamin D deficiency and decreased bone
mineral disease among pediatric during and after PN
Therefore needs to be monitored
Minerals (Ca/P/Mg)
Parenteral mineral supply :
Ca cations may precipitate with inorganic phosphate
(calcium chloride) anions
To some degree this can be avoided by mixing Ca and
phosphate with amino-acid and glucose solutions
before diluting the solution and by adding phosphate
salt at the end of the process
Energy metabolism & optimal bone mineralization
Malnourished patients – hypoP has been result of refeeding Sx
Extreme hypoP can result in muscle weakness, respiratory
failure, cardiac dysfunction & death
Children on long term PN are at high risk of metabolic bone
disease (MBD)
Therefore close monitoring of Ca, P, vitamin D & bone
mineral status is required
Phosphate needs in long term PN
Added in PN solutions in
different variations as:
CaCl
MgSo4
KPO4
mg /kg / day (mmol/kg/day)
Calcium Preterm 0 - 6months 7 -12months 1 - 13 years 14 - 18 years
2005 32 (0.8) 20 (0.5) 11 ( 0.2) 7 ( 0.2)
2016
First days: 32 – 80
(0.8 - 2.0 ) 30 - 60 (0.8 - 1.5) 20 (0.5) 10 - 16 (0.25 -0.4)
growing: 100 – 140
(1.6 - 3.5)
Phosphate Preterm 0 - 6months 7 -12months 1 - 13 years 14 - 18 years
2005 14 (0.5) 15 (0.5) 6 (0.2) 6 (0.2)
2016 31 - 62 (1.0 -2.0) 20 - 40 (0.7 - 1.3) 15 (0.5) 6 - 22 (0.2 -0.7)
6 - 22
(0.2 -0.7)
77 - 108 (1.6 -3.5)
Magnesium Preterm 0 - 6months 7 -12months 1 - 13 years 14 - 18 years
2005 5 (0.2) 4.2 (0.2) 2.4 (0.1) 2.4 (0.1)
2016 2.5 - 5.0 (0.1 - 0.2) 2.4 - 5 (0.1 - 0.2) 4 (0.15) 2.4 (0.1) 2.4 (0.1)
5.0 - 7.5 (0.2 - 0.3)
Calcium, Phosphorus, Magnesium
PRACTICAL APPROACH
SA perspective
Choice of PN bags based on :
Standardised solutions that has both macro and micronutrients
These macronutrients profile suitable for pediatric such as
appropriate amino acids solutions with essential amino acids
Availability of alternative lipid emulsions – combination of
different types of lipids
Additional micronutrients suited for pediatric population given for
long term PN ( > 2-4 weeks)
Standardised bags is recommended as it minimizes the risk of
compounding errors, reduced cost, reduced wastage
Practical approach
6 month girl Poor nutritional status (wt
5.5kg, stunted and wasted
Previous bowel resection
(35cm SB) due to NEC
Ileostomy
Initially TPN then weaned to
enteral / oral feeds
Planned ileostomy closure
due to increased output
For recommencement of TPN
post surgery
Baseline bloods shows normal
electrolytes, CMP but raised
bilirubin levels
Patient A Energy RQ: Recovery: 75 – 85kcal/kgProtein: 2g/kg/dayLipid: 1-4g/kg/dayCHO: 8.6 – 14g/kg/dayFluid: 120 – 150ml/kg
Pediatric bag 3m-3years (750ml bag)
Fluid 120ml/kg 130ml/kg 150ml/kg
Total Fluid 660ml 715ml 825ml
Energy(per kg)
85kcal 92kcal 107kcal
Protein(per kg
2.5g 2.8g 3.2g
Lipid(per kg)
2.5g 2.8g 3.2g
CHO(per kg)
12.7g 13.8g 16g
Electrolytes met with all volumes
Essential amino acids met
EFAs met
Practical approach
6 month girl Poor nutritional status (wt
5.5kg, stunted and wasted
Previous bowel resection
(35cm SB) due to NEC
Ileostomy
Initially TPN then weaned to
enteral / oral feeds
Planned ileostomy closure
due to increased output
For recommencement of TPN
post surgery
Baseline bloods shows normal
electrolytes, CMP but raised
bilirubin levels
Patient A Administration:
Day 1: half rate i.e 60ml/kg
Day 2: Full 120ml/kg
Due to increase bilirubin
levels and expected long
term use of PN
Complex lipid
emulsion with
soya,MCT,olive,Fish
Maintain same lipid
dose
Trophic feeding
Reassess – if not gaining
adequate weight increase PN
volume to 130 – 140ml/kg
Practical approach
10 year old boy
Admitted to ICU with
complicated post
appendectomy,
abdominal sepsis
ventilation support
Poor nutritional status with
weight of 25kg
BMI 13.7 (Z score -2)
NPM for more than 5 days
post surgery
Patient B
Energy RQ: Acute phase: 30 – 40kcal/kgStable phase: 40 – 55kcal/kgRecovery: 55 – 65kcal/kg Protein: 1- 2g/kgLipid: 1-3g/kgCHO: Acute: 2.9 – 3.6g/kgStable: 2.8 – 5.8g/kgRecovery: 4.3 – 8.6 g/kgFluid: 60 – 80ml/kg
Pediatric bag 6- 12years (1400ml bag)
Fluid 60ml/kg 65ml/kg 70ml/kg
Total Fluid 1500ml 1625ml 1750ml
Energy(per kg)
52kcal 56kcal 60kcal
Protein(per kg)
1.6g 1.7g 1.8
Lipid(per kg)
2.1g 2.3g 2.45g
CHO(per kg)
6.3g 6.8g 7.3g
Practical approach
10 year old boy
Admitted to ICU with
complicated post
appendectomy,
abdominal sepsis
ventilation support
Poor nutritional status with
weight of 25kg
BMI 13.7 (Z score -2)
NPM for more than 5 days
post surgery
Patient B Administration:
D1-D2 (Acute): Rate 36ml/hr
3.6g CHO and 30kcal/kg
D2 – D3 (Stable): Rate 46ml/hr
4.8g CHO and 38kcal/kg
Recovery: Full rate 68ml/hr
Fluid 65ml/kg
Limitation:
To meet this fluid volume – 2
bags required
Early change of PN bag
Summary
New guidelines emphasizes the importance of
recognizing energy requirements during the 3 phases of
critical illness
Encourage the use of composite lipid emulsions as
oppose to pure soya lipid emulsion
Monitoring micronutrients such as Vitamin D as pediatric
population at risk of deficiency
When choosing appropriate PN solutions ensure that
they are suitable for needs of the pediatric patient
THANK YOU
Contact details:
Shihaam.Cader@westerncape.gov.za