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Pediatric parenteral nutritionM.safarian,MSc,MD, PhDMashhad University of Medical Sciences,Nutrition Department

Indication:Unsafe or non functional GIMalnurished childrenIncreased risk of malnutrition: They include infants who have gone: 2-3 days without adequate intakeolder children who have gone 4-5 daysPeripheral parenteral nutrition:

the patient is not fluid-restricted nutrient needs can be met, and central PN is not feasible.Central parenteral nutrition:

the patient is fluid-restricted peripheral access is limited, and nutritional needs cannot be met by peripheral PN.PPN vs. TPNPPNPeripheral access 38C Simple Trauma 0.2 Multiple Injuries 0.4 Burns 0.5-1 Sepsis0.4 Growth 0.5 Nutritional requirementsProtein:AA in parenteral nutrition

Parenteral AA GuidelinesAgeInitiateAdvanceMaximum10yr (adolescents)1g/kg/day1g/kg/day0.8-2.5g/kg/day***Goal aa correspond to ASPEN protein guidelines for critical illness ***4kcal/g aaASPEN (2010)Nutritional requirementsProtein:Assessment:There is no good markerNutritional requirementsCarbohydrate: Solutions greater than 12.5% dextrose should not be infusedshould be initiated in a stepwise fashion

Assessment:evaluation of serum glucose levels

GIR/Dextrose GuidelinesAgeInitiateAdvanceMaximum10yr (adolescents)1-2mg/kg/min 1-2mg/kg/minMax: 5-6mg/kg/minASPEN (2010)Nutritional requirementsFat:

Assessment:Tolerance is measured by an Intralipid level, a measure of unmetabolized intravenous fat or artificial chylomicrons. A level 50kgNa2-5meq/kg2-5meq/kg1-2meq/kgK2-4meq/kg2-4meq/kg1-2meq/kgCa2-4meq/kg0.5-4meq/kg10-20meq/dayPhos1-2mmol/kg0.5-2mmol/kg10-40mmol/dayMg0.3-0.5meq/kg0.3-0.5meq/kg10-30meq/dayAcetateAs needed to maintain acid-base balanceChlorideAs needed to maintain acid-base balance26Assuming normal organ function and lossesPNALDPNALDAvoid macronutrient overfeeding in generalDecrease lipidsGIR 12.5mg/kg/minCholestatic trace elementsDecreased Cu; no MnCycle TPN as ableInitiate EN asap (even trophic feeds)

Btaiche and Khalidi (2002), Kaufman (2002)IL: build up of excess phytosterols therby increasing the lithogenesis of bile; omega-6 FA pro-inflammatoryCu and Mn are excreted in bileTrophic feeds to stimulate Cholecystokinin27PN-suggested guidelines for Initiation and Maintenance Substrate InitiationAdvancementGoalsCommentsDextrose10%2-5%/day25%Increase as tolerated.Consider insulin if hyperglycemic Amino acids1 g/kg/day 0.5-1 g/kg/day 2-3 g/kg/day Maintain calorie:nitrogen ratio at approximately 200:1 20% Lipids1 g/kg/day 0.5-1 g/kg/day 2-3 g/kg/day Only use 20%

MonitoringInitial: weight, height, Total protein/Albumin (TP/Alb), Transthyretin (TTR);Daily Chem until stableStable: weekly Chem and bimonthly TG, LFTs, TB/DBChronic: bimonthly Chem and monthly TG, LFTs, TP/Alb/TTR Suggested monitoring Protocol

WeightUrine dip for glucose Bedside glucoseLabsFirst weekDailyQ shiftQ shift

Daily SMA-7, Ca, Mg, Phos, triglyceridesQ OD LFTsSubsequentlyDailyQ shiftQ shift

SMA-7, Ca, Mg, Phos 2x/wk CBC, LFTs weekly Triglycerides 2x/wkCalculationsDextrose____g/100ml Dextrose ____ml/day = ____grams/day_____g/day (weight 1.44) = _____mg/kg/min_____g/kg/day 3.4 kcal/g = _____ kcal/kg/dayCalculationsFat 20 grams/100ml Fat _____ml/day = _____grams/day_____g/kg/day 9 kcal/g = _____ kcal/kg/day

Calculationsgrams Protein 6.25 = _____ NitrogenNon-protein calories Nitrogen = Calorie:Nitrogen ratio 33Keep Cal/N ratio 150-200:1Key pointsThere may not exhibit significant hyper catabolism post-injury

Their energy need may be decreased due to: Decreased physical activity, Transient absence of growth during the acute illness34Agus and Jaksic (2002)Key pointsOverfeeding: Impair liver function by inducing steatosis/cholestasisIncrease risk of infectionHyperglycemiaProlonged mechanical ventilationProlonged icu LOSNo benefit to the maintenance of lean body mass (LBM)

Overfeeding complicationsHyperglycemia glycosuria dehydration Lipogenesis fatty liver liver dysfunctionElectrolyte abnormalities: PO4 , K, MgVolume overload, CHF CO2 production- ventilatory demand O2 consumptionIncreased mortality (in adult studies)MONITORINGPrevent OverfeedingCarbohydrate: High RQ indicates CHO excess, stool reducing substancesProtein: Nitrogen balanceFat: triglycerideVisceral protein monitoringElectrolytes, vitamin levels

37Nitrogen balance=(dietary protein/6.25)-(Urine urea nitrogen/0.8 +4)Positive balance in the range of 2-4 g nitrogen/day is desirable

Other complications CHOLESTASISelevated conjugated bilirubin and other liver function tests.Patients most at risk to develop cholestasis: overfeeding lack enteral nutrition long-term parenteral nutrition gastrointestinal surgery were preterm a history of recurrent sepsis peak conjugated bilirubin may occur up to one month after cessation of PNOther complications Chylothorax Elevated serum ureaHyperglycemia GlycosuriaHyperbilirobinemia Hyperlipidemia Hypoglycemia

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Thank you