TOTAL PARENTERAL

NUTRITION
BY: Dr. ARUN AGGARWAL
GASTROENTEROLOGIST
⚫ Parenteral nutrition is a means of
providing either partially or completely the
nutritional requirements (fluid, calories
and vitamins) of renal metabolism and
growth to an infant incapable of tolerating
them enterally.

By: Dr. Arun Aggarwal Gastroenterologist

 INDICATIONS
⚫ 1. congenital GI anomalies preventing the
use of enteral feeds.
⚫ Post surgical patient unable to feed
enterally for an extended period of time.
⚫ Newborn with intractable diarrhea.
⚫ Preterm infants who are unable to tolerate
enteral feedings or unable to feed
adequate amount of enteral feedings.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Effective nutritional support of premature
and critically ill infants is largely
dependent on parenteral nutrition.
⚫ Initiate parenteral nutrition with in first 24
hrs, continue until enteral nutrition
supplies at least 75 % of total protein and
energy requirements.

By: Dr. Arun Aggarwal Gastroenterologist

 COMPONENTS OF PARENTERAL
NUTRITION
⚫ Proteins
⚫ Energy
⚫ Glucose
⚫ Lipids
⚫ Electrolytes, minerals, trace elements and
vitamins

By: Dr. Arun Aggarwal Gastroenterologist

 PROTEINS
⚫ Initial goal of TPN is to minimize losses and
preserve existing body stores.
⚫ 26 week gestation infant lose 1.5g/kg/day of
body protein; protein losses in term infants are
~0.7 g/kg/day.
⚫ If extremely premature infants are provided with
no AA (amino acid) supply, they lose over 1.5%
of their body protein per day when they should
be accumulating protein at a rate of 2% per
day.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ AA intakes of 1.1-2.3 g/kg/day at caloric
intakes of 30-50 kcal/kg/day change the
protein balance from significantly negative
to neutral or positive in sick VLBW infants.
⚫ In multiple controlled trials evaluating the
effect of early AA intake in premature
infants, no differences in ammonia
concentrations, acid base status or BUN
levels were observed b/w infants who recd
AA and those who did not.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Currently available data suggest that 70-
80 kcal/kg/day may be sufficient to
maximize protein accretion.
⚫ Based on a variety of studies measuring
protein losses and balance, 3.5-4.0
g/kg/day of AA is a reasonable estimate of
parenteral nutrition requirements in ELBW.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Cysteine is not included in the most AA solutions
because it is not stable for long periods.
⚫ A Cysteine supplement that can be added to the
PN solution just prior to delivery is commercially
available.
⚫ The addition of Cysteine also improves the
solubility of Ca and PO4 in PN solutions and also
may improve the status of antioxidant
glutathione.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ For above mentioned reasons, addition of
Cysteine (40 mg/g of AA, up to a max of
120 mg/kg) is recommended.
⚫ Cysteine can result in a metabolic acidosis,
but this possibility can be appropriately
countered by the use of acetate in the PN
solutions as a buffer.

By: Dr. Arun Aggarwal Gastroenterologist

 SUGGESTED DAILY PARENTERAL INTAKE FOR
ELBW
COMPONENTS DAY 0 TRANISITION GROWING
Energy (kcal) 40-50 75-85 105-115
Protein (g) 2 3.5 3.5-4
Glucose (g) 7-10 8-15 13-17
Fat (g) 1 1-3 3-4
Na (meq) 0-1 2-4 3-7
K (meq) 0 0-2 2-3
Cl (meq) 0-1 2-4 3-7
Ca (mg) 20-60 60 60-80
Phosphorus (mg) 0 45-60 45-60
Mg (mg) 0 3-7.2 3-7.2

By: Dr. Arun Aggarwal Gastroenterologist

 SUGGESTED DAILY PARENTERAL INTAKE FOR
VLBW
COMPONENTS DAY 0 TRANISITION GROWING
Energy (kcal) 40-50 70-80 90-100
Protein (g) 2 3.0-3.5 3.0-3.5
Glucose (g) 7-10 8-15 13-17
Fat (g) 1 1-3 3
Na (meq) 0-1 2-4 3-5
K (meq) 0 0-2 2-3
Cl (meq) 0-1 2-4 3-7
Ca (mg) 20-60 60 60-80
Phosphorus (mg) 0 45-60 45-60
Mg (mg) 0 3-7.2 3-7.2

By: Dr. Arun Aggarwal Gastroenterologist

 ENERGY
⚫ To support normal rates of growth, a
positive energy balance of 20-25
kcal/kg/day must be achieved.
⚫ Please see table on previous slide.
⚫ Most of the parenteral calories are best
supplied by a balanced caloric intake of
lipids and glucose.

By: Dr. Arun Aggarwal Gastroenterologist

 GLUCOSE
⚫ Maintaining glucose concentration of >40 mg/dL
and < 150-200 mg/dL is a reasonable clinical
goal.
⚫ GIR of 4-7 mg/kg/min is an appropriate starting
point for most infants.
⚫ For ELBW, a rate of 8-10 mg/kg/min is required
to match endogenous glucose production.
⚫ A gradual increase in glucose intake over 2-7
days, up to 13-17 g/kg/day, is usually tolerated
when the glucose is combined with amino acid
intake.

By: Dr. Arun Aggarwal Gastroenterologist

 LIPIDS
⚫ Lipids are made up of triglycerides,
phospholipids from egg yolk to emulsify and
glycerol, which is added to achieve isotonicity.
⚫ Iv lipids contain long chain triglycerides.
⚫ Essential fatty acid deficiency can be avoided if
0.5 -1.0 g/kg/day of iv lipids is provided.
⚫ Additional lipid is necessary if energy
requirements of preterm infants are to be met.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Meta analysis of studies confirmed that
early iv lipid administration (on day 1 of
life) is a recommended clinical practice.
⚫ Lipid infusion rates in excess of 0.25
g/kg/hr are associated with decrease in
PO2.
⚫ Triglyceride concentration are most often
used as an indication of lipid intolerance.
⚫ Maintaining triglycerides levels <150-200
mg/dL seems desirable.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Numerous studies have documented superiority
of 20% over 10% lipid emulsions.
⚫ At present, withholding iv lipids from jaundiced
premature infants does not seem warranted.
⚫ Carnitine facilitates transport of long chain fatty
acids through the myocardial membrane and
thereby plays an imp role in their oxidation.
⚫ At present, insufficient information is available to
support a recommendation for the routine
supplementation of parenterally fed neonates
with carnitine.

By: Dr. Arun Aggarwal Gastroenterologist

 ELECTROLYTES, MINERALS, TRACE
ELEMENTS AND VITAMINS
⚫ For ELBW infants, addition of Na to the PN
solution may not be necessary until about day 3
of life.
⚫ Frequently measure Na conc and water balance.
⚫ ELBW babies sometimes require > 2-4
meq/kg/day to compensate for larger renal
sodium losses.
⚫ Chloride requirements follow the same time
course as for Na requirements.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Once electrolytes are added to the PN
solution, Cl intake should not be less than
1 meq/kg/day and all Cl should not be
omitted when NaHCO3 or acetate is given
to correct metabolic acidosis.
⚫ K intakes of 2-3 meq/kg/day are usualle
adequate to maintain normal serum K
conc.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Current recommendations are to use PN
solutions containing 50-60 mg/dL of elemental
Ca and 40-47 mg/dL of phosphorus.
⚫ A Ca to phosphorus ratio of 1.7:1 by wt appears
to be optimal for bone mineralization.
⚫ PO4 is not usually provided to the premie during
the first 3 days when abnormalities of Ca
balance are most common.
⚫ Mg should be supplied at 3-7.2 mg/kg/day.

By: Dr. Arun Aggarwal Gastroenterologist

 Recommended parenteral intake of trace
elements for term and preterm infants
Trace element Term (µg/kg/day) Preterm
(µg/kg/day)
Chromium 0.20 0.2
Copper 20 20
Iron - -
Fluoride - -
Iodide 1 1
Manganese 1 1
Molybdenum 0.25 0.25
Selenium 2 2
zinc 250 400

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Zn should be included early in PN
solutions. Other trace elements probably
are not needed until after the first 2
weeks of life.
⚫ Pediatric trace metal solutions containing
Cu, Mn and Cr are usually provided at 0.2
ml/kg/day.
⚫ Supplementation with Se is suggested
after 2 weeks of age.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Parenteral iron is recommended only when
preterm infants are nourished exclusively
by parenteral solutions for the first 2
months of life.
⚫ Currently only one pediatric multivitamin
preparation is available and it is delivered
with a standard dosage of 2 ml/kg/day
(max 5 ml/day) in preterm infants and 5
ml/day in term infants.

By: Dr. Arun Aggarwal Gastroenterologist

 COMPLICATIONS OF PARENTERAL
NUTRITION
⚫ Cholestasis : ~ 50% of ELBW exhibits
cholestasis after 2 weeks of parenteral
nutrition.
⚫ Precise cause of cholestasis is unknown
and probably is multifactorial (hypoxia,
hemodynamic instability, infection).
⚫ Enteral feedings even at low caloric
intakes can reduce the incidence of
cholestasis.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Clinical manifestations of cholestasis are
hyperbilirubinemia and jaundice.
⚫ A sensitive but non specific indicator of early
cholestasis is an increase in GGT.
⚫ Elevation of AST and ALT occurs later.
⚫ Cholestasis most often resolves after
discontinuation of parenteral nutrition and
initiation of enteral feeds.
⚫ At present routine use of ursodeoxycholic acid or
Phenobarbital in PN associated cholestasis cant
be recommended.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Catheter related complications: infection.
⚫ Two of the most common bacterial
pathogens are Staph epidermidis and
Staph aureus. Fungal infections also occur
(Candida and Malassezia).
⚫ An association has been reported b/w the
use of iv lipids and CNS bacteremia and M.
furfur fungemia.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Hyperglycemia which can cause osmotic
diuresis and dehydration.
⚫ Hyperaminoacidemia.
⚫ Hyperammonemia.

By: Dr. Arun Aggarwal Gastroenterologist

CONTRAINDICATION TO LIPID USE:

⚫ Infants with liver disease.

⚫ Blood coagulopathies.
⚫ Hyperbilirubinemia.
⚫ Use with caution in very low birth weight
infants with severe pulmonary disease<1
wk old because of pulmonary deposition
and transitory lower PO2 levels.

By: Dr. Arun Aggarwal Gastroenterologist

 PRACTICAL APPROACH
⚫ Urgent need to initiate iv AA shortly after birth.
⚫ Goal of early PN should be to limit catabolism
and preserve endogenous protein loss.
⚫ Start with a min of 1.5-2.0 g/kg/day of AA on
day 1 of life.
⚫ Advance AA intake by 1g/kg/day until the goal is
reached.
⚫ Add cysteine to the AA solution @ 40mg/g of
AA.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Glucose should be supplied in a quantity
sufficient to maintain normal plasma
glucose concentrations.
⚫ Need of premature infants are in the
range of 6-8 mg/kg/min.
⚫ Giving D10 @ 100 ml/kg/day provides a
GIR of 7mg/kg/min.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Lipids should be started with in the first 24
hr of life, usually at 1g/kg/day.
⚫ Advance by 0.5-1.0 g/kg/day to a usual
maximum of 3 g/kg/day while monitoring
and maintaining the serum triglyceride
< 200mg/dL.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Caloric goals during PN are lower than
enteral feeds.
⚫ To achieve optimal protein retention,
~ 80- 90 kcal/kg/day is a reasonable goal.
⚫ To optimize growth, somewhat higher
caloric intake may be necessary.
⚫ Non protein balance b/w carbohydrate and
lipid should be ~ 60:40

By: Dr. Arun Aggarwal Gastroenterologist

⚫ PN should be continued until enteral
feedings are well established and
providing ~ 100-110 kcal/kg/day.
⚫ As enteral feeds are advanced, the protein
and lipid contents of the PN can be
gradually decreased.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Carbohydrates: start at 6-9 g/kg/day (4.2-6.2
mg/kg/min) and advance by 1-3 g/kg/day till 17-
21 g/kg/day, until they account for 605 of total
calories or presence of glucose intolerance.
⚫ AA: started on 1st day of life at 1.5g/kg/day and
advance by 1g/kg/day to a max of 3.5g/kg/day
for babies <1500 g and 3 g/kg/day for babies
>1500 g. monitor BUN and NH3 levels.
⚫ Intralipid: (20%) started on day 1-2 @0.5-
1.0g/kg/day and advance by 0.5-1.0g/kg/day to
a max of 3g/kg/day.
⚫ Hold intralipids at 1-2 g/kg/day if S. bili is
elevated to near exchange transfusion level,
baby has severe respiratory compromise or
severe sepsis.

By: Dr. Arun Aggarwal Gastroenterologist

 HOLD ENTERAL FEEDS IF:
⚫ Abdominal distention with increased
abdominal girth >2 cm from baseline.
⚫ Blood in stools or guiac positive stools in
the absence of anal fissure, bloody oro or
nasopharyngeal secretions or gastric
residuals.
⚫ Persistent bilious residuals or vomiting.0
⚫ X ray findings suggestive of NEC.

By: Dr. Arun Aggarwal Gastroenterologist

 STOCK SOLUTION
⚫ To be started immediately after birth for babies
<1500g and for sick babies >1500g
⚫ For babies <1000g stock solution proportion will
be 80 ccD5W +1.5 g AA +1.5 mEq (30 mg)
elemental calcium.
⚫ For babies >1000g stock solution proportion will
be 80 ccD10W +1.5 g AA +1.5 mEq (30 mg)
elemental calcium.
⚫ Solution should be given @ 80cc/kg/day
⚫ Any extra vol should be given separetely.

By: Dr. Arun Aggarwal Gastroenterologist

⚫ Exact vol prepared by pharmacy will be:
⚫ 100ccD5W +1.875 g of protein + cal
gluconate 375 mg +25unit of heparin
Or
⚫ 100ccD10W +1.875 g of protein + cal
gluconate 375 mg +25unit of heparin
⚫ No addition to be made to stock solution
bag.

By: Dr. Arun Aggarwal Gastroenterologist