Newborn Parenteral Nutrition

PARENTERAL NUTRITION IN NEWBORNS

Dr. Elsie Constanza

Paediatrician/Neonatologist

Karl Heusner Memorial Hospital

NEONATAL UNIT

Total body water (TBW): the total intracellular andextracellular fluids

Extracellular fluids (ECF): the total Intravascular andInterstitial fluids

Insensible water loss (IWL): the evaporation of waterthrough the skin, respiratory tract and mucousmembranes

Definitions

R. Bissinger. D. Annibale, GOLDEN HOURS, Care of the VLBWI , Chicago Ill, 2014

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%


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


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 radientwarmer

Oh W, Fluid and Electrolyte Management of VLBW Infants, Pediatrics and Neonatology 2012

IWL:

Intake – Output (mainly urine) - ∆ in weight

Oh W, Fluid and Electrolyte Management of VLBW Infants, Pediatrics and Neonatology 2012

Urine output: 1-3ml/kg/hr

Urine specific gravity: 1005-1012 is consistent with a balancein 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 toevaluate Renal Function and Fluid balance.

*Na+ / Cr / BUN


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

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


RECOMMENDED ENERGY INTAKE

American Academy of Pediatrics:

105-130 kcal/kg/day for preterm infants

ESPGHAN (Committee on Nutrition):

110-135 kcal/kg/day


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

COMPONENTS

Macronutrients

Amino acids

Carbohydrates

Lipids

Micronutrients:

Electrolytes: Mg, K, Na

Minerals

Vitamins

Calcium Gluconate


PREPARATION

Laminar flow hood

OSMOLARITY DEPENDS MOSTLY ON:

• DEXTROSE 5mOsml/gr• AMINO ACIDS 10mOsml/gr• ELECTROLYTES 1mOsml/mEq

mOsm/L:Total of Osmol x 1000total volume in TPN

PLASMA OSMOLARITY: 280 -290 mosm/L

2x Na + Glucose mg/dl + BUN mg/dl18 2,8


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


Infants who require high infusion ratesor a dextrose concentration (Tenor)

> 12.5% require placement of central venous catheter (UVC, PICC)

Tenor: Total Glucose (g) x100Total fluids in IV

Total grams of glucose= GIR (mg) x Weight (kg) x 1.44


Dextrose solutions and formulas:

D5W D30WD10W D50W

D10W: Glucose (g) - RV0,05

D5W: Remaining volume (RV) – D10W

D30W: Glucose (g) – RV0,2 2

D50W: Glucose (g) x 10 – RV4

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


Parenteral Amino Acid Solutions

Aminosyn 10%

TrophAmine 10%

Primene 10%

* Presentation also available as 8,5%


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/dayof IV lipids in the first 24 hrs of life.


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


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 thromboxanesand prostaglandins, and increased pulmonary vascular resistance

Infants with increased sepsis risk

Lipid intake should be limited to 40% - 50% of total calories


ELECTROLYTES: SODIO (NA+):

Initiate:48 hrs

Requirements:

PT: 2 to 5mEq/kg/day

AT: 2 a 4mEq/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


Can be adm. As KCLsalt or KH2PO4 salt.

Initiate: 48 hrs

Requirements:

RNPT y RNT:

1-4mEq/kg/day.

CLORURO DE POTASIO

7,5%®

Descripción:

Formula:


KCL USP 7,45 g.

Inyectable water c.s.

Every ml has:

1 mEq (K+);

1 mEq (Cl-);



ELECTROLYTES: Potassium (K+):

K2PO4 13,6%

1meq/ml

Initiate with aa.

Dosis:20-40mg/kg/day.

FOSFATO MONOBÁSICO DE

POTASIO

13,6%®

Formula:


Monobasic K2PO4

USP 13,61 g.


Every ml has:

1 mEq (K+)

1 mEq (H2PO4-)



ELECTROLYTES: PHOSPHUROS

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


Minerals: Calcium (Ca2+)

GLUCONATO DE CALCIO 10%®

Descripción:

Formula:


Calcium Gluconate USP 10,00 g


Each ml has:

0,5 mEq (Ca++)

0,5 mEq (Cl2H2O14)

Osmolarity: 1000 mOsm/l


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

Dosis: 0.25 - 0.5 mEq/kg/day

Serum Mg levels before adm.

Magnesium Sulphate 50% (4meq/ml)

Osmolarity 4057 mOsm/l


Minerals: Magnesium (Mg)

TRACE MINERALS

AT and PT: 0.4 – 0.6 ml/kg/day.

Discontinue:

Copper and manganese in hepaticcholestasis.

Selenium, chromium y molybdenum inAcute Renal Disease.

ASPEN Nutrition Support Practice Manual 2nd Edition, 2005 ASPEN Interdisciplinary Nutrition Support Review Course 2001

VITAMINS

WHEN TO DISCONTINUE PN?

Discontinue Parenteral Nutrition when patient has aEnteral Nutrition of 100cc/kg/d

Gradual omission if patient has 75% of total fluids asEnteral Nutrition and compliment with glucose at anadequate GIR.


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TO TAKE HOME:

1. Parenteral Nutrition should start as soon as possible2. GIR of 5-6 mg/kg/day; 1g of glucose = 3,4 kcal3. Amino Acids: 2-4g/kg/day; 1g of aa = 4 kcal4. Lipids: 2-4 g/kg/day; 1g of lipid = 9 kcal5. Recommended energy intake: 110 – 135 kcal/kg/day

Take in consideration IWL TBW is inversely proportional to GE Monitor electrolytes and renal function

Newborn Parenteral Nutrition

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