Total Parenteral

Nutrition
Mohamed Khashaba
Professor of
Pediatrics/Neonatology
Head of NICU, MUCH

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 Parenteral Nutrition

Learning Objectives
 Know the indications of parenteral
nutrition.
 Recognize the complications of
parenteral feeding.

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Learning Objectives
 Know the components of parenteral
nutrition.
 Fluid volume
 Calories
 Glucose
 Proteins
 Lipids
 Electrolytes, minerals and vitamins
 Monitor infants on parenteral nutrition.
 Proceed to oral feeding.
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INTRODUCTION
 Nutritional management of the
neonate in health and disease states
is one the most important parts of the
general management of these babies
during hospitalization and after their
discharge.
 The nutritional status of the newborn
interferes positively or negatively
with the outcome of many disorders
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 This nutritional
management should be
thought of on daily basis
during hospitalization and
assessed at regular intervals
on subsequent outpatient
follow up.

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 Parenteral Nutrition
Intravenous delivery of energy
and nutrients required for the
infant’s growth.
 Partially
 Completely

Infants incapable of tolerating

enteral feeding
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Parenteral Nutrition
 Central line

 Peripheral vein

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 Parenteral Nutrition
 Indications:
• Preterm infants: not expected to
tolerate enteral feeds within 3-7
days.
• NEC (suspected or confirmed):
NPO for an extended
period.
• Post-Surgical infants: unable to
feed for an extended period.
Congenital GI anomalies.
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•
 practical hints for TPN
 Do not starve babies! The ones who don’t
complain are the ones who need it the
most.
 Use birthweight to calculate intake till
birthweight regained, then use daily wt
 Start TPN on 2nd or 3rd day if the baby will
not be on full feeds by a week
 Start with proteins (1 g/kg/d) and increase
slowly.
 After a few days (3rd or 4th day), add lipids
(0.5 kg/kg/d)
 Aim for 90-100 Cal/kg/day with 2.5-3 g/kg/d
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 Parenteral Nutrition
 Complications:
1. Catheter related:
Local skin infection
Sloughs
Sepsis
Thrombosis

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1. Metabolic complications:
Hyperglycemia
Electrolyte imbalance
Acidosis
Liver damage and cholestasis
Osteopenia

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 Parenteral Nutrition
 Components:
 Fluid volume
 Calories
 Glucose
 Protein
 Lipids
 Electrolytes
 Minerals & Vitamins

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 Parenteral Nutrition
Fluid Volume

Depends upon the daily fluid

requirements at different days of life
in different days of life in different
birth weights groups.

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 Fluid requirements day of
Life # 1-3
IV Fluid requirements ( cc /kg/day )

Birth 1000g 1000- 1500- >2500g

weight 1500g 2500g
Day # 1 120 D5 W 100 D7.5 80 D10 W 80 D10 W
W

Day # 2 140 D5 W 120 D7.5 100 D10 W 90 D10 W

W

Day # 3 170 D5 W 130 D7.5 110 D10 W 100 D10 W

W

N.B. Subtract 20 CC/kg/day if the infant suffers from

R.D.
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 Parenteral Nutrition
 Calories

-The ultimate goal:

90-100 K Cal./Kg/day

-For the VLBW infants should be

advanced slowly:

Day of life 1-3 = 50-55 k cal./kg/day

Day of life 3-5 = 65-75 k cal./kg/day
Day of life 5-7 = 85-90 k cal./kg/day 15
Parenteral Nutrition
 Calories

 From PROTEIN not to exceed 15%

 From LIPIDS not to exceed 50%

of the total calories

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 Parenteral Nutrition
 Glucose
 I gm. 3.4 k cal.
 Start with:

4-6 mg./kg./min. (in VLBW)

8-10 mg./kg./min. (in full term)

 Advance in daily increments of

1-2 mg./kg./min.
(to ↓ risk of Hyperglycemia)

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 Glucose
 IV:
 Dextrose 3.4 Cal/g = 34 Cal/100 cc of
D10W.
 Tiny babies are less able to tolerate
dextrose. If < 1 kg, start at 6
mg/kg/min. If 1-1.5 kg, start at 8
mg/kg/min.
 If blood levels >150-180 mg/dL,
glucosuria=> osmotic diuresis,
dehydration
 Insulin can control hyperglycemia
 Hyper- or hypo-glycemia => early sign 18
GIR (mg/ kg /min) =
Fluid rate (cc/hr) x Dextrose
Concentration
6 x weight (kg)
 

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Example:
What is the GIR in an infant
weighting 2 kg on a total fluid of
120 cc/kg/day using the D10W
solution?
Hourly rate is:
 2 (kg) x 120 (cc /kg /day) ÷ 24 =
10 cc/hr
  GIR = 10 x 10% ( D W) ÷ (6x2) =
10
8.3 mg/kg/min
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 Parenteral Nutrition
 Protein
(6% Amino acid solution containing
taurine)

 1 gm 4.0 kcal
 Start with : 0.5 – 1 gm./kg./day
 Advance in daily increments of 1.5 –
1gm./kg./day

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 Parenteral Nutrition
 Protein

 Reduce the protein load, if serum

BUN is raising, or with metabolic
acidosis.

 The ratio of protein (gm.) : non-

protein calories.

Should not exceed 1 : 25 22

 Parenteral Nutrition
Lipids

Intralipid 20% (soybean oil, egg

phosphlipid and 2.25 % glycerol)

 1 gm. 10 kcal (2 kcal/ml.)

 Start with : 0.5 – 1 gm./kg./day
 Advance in daily increments of
0.5gm./kg./day

Maximum of 3.0 – 4.0 gm./kg./day 23

 Parenteral Nutrition
 Lipids

 If
serum Triglycerid level is:
> 200 mg stop Intralipids.
> 150 mg decrease the
infusion rate.

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 Intralipidsshould be used at
minimum rate (0.5 – 1
gm./kg./day) in:
 Sepsis

 Severe lung disease

 Hepatic disease

 Jaundice

 Thrombocytopenia

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 Parenteral Nutrition
Macro nutrients

Start Daily Maximum

Advance
Glucose 4-6 1-2 12.5% solution
mg./kg./min. mg./kg./min. in peripheral
(3.4 vein
kcal.)
Protein 0.5-1 0.5-1 3.0-3.5
gm./kg./day gm./kg./day gm./kg./day
(4.0 (6% solution)
kcal.)
Lipids 0.5-1 0.5 3.0-4.0
gm./kg./day gm./kg./day gm./kg./day
(10 (20% solution)
kcal.)
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 Vitamins
 Fat soluble vitamins: A, D, E, K
 Water soluble vitamins: Vitamins B1,B2,
B6, B12, Biotin, Niacin, Pantothenate,
Folic acid, Vitamin C
 All neonates should get vit K at birth
 Term neonates: No vitamin supplement
required, except perhaps vit D
 Preterm: Start vitamin supplements
once full feeds established if on human
milk without HMF. No need if on
human milk with HMF, or preterm 27
IV Electrolytes and minerals
requirements
Sodium* Potassium* Calcium
(mEq/kg/da (mEq/kg/da (elemental)
y) y) (mg/kg/day)
Day # 1 0 0 45

Day # 2 2-3 1-2 45

Day # 3 2-3 1-2 45

*Do not add sodium if it > 140 mEq/1

*Do not add potassium until urine output is

established. 28
 Parenteral Nutrition
Electrolytes, Minerals & Vitamins

Maintain Ca: P ratio at 2:1

1 mmol of P = 31 mg

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 Trace elements

Zinc, Copper, Selenium,

Chromium, manganese,
Molybdenum, Iodine

Trace elements (except for zinc)

should be deleted if direct
bilirubin is > 3 mg/dl 30
 Assessment of hydration
status of the neonate
Parameter Frequency Comments

Weight Daily, twice a day if Daily weight loss

<1000g should not exceed
1-3%
Skin and fontanel Daily, Every 8 hr Look for evidence of
if <1000g dehydration

Serum sodium Daily, Every 8-12 hr if Restrict fluids if

<1000g <130
Liberalize fluids if
Urine
>145
Volume Each diaper change N. Volume 2-3
cc/kg/hr
Specific
N. Sp. Gr. 1005-1010
gravity
Glycosuria* 31
 Parenteral Nutrition
Monitoring
Suggested monitoring schedule during
parenteral nutrition:

Monitoring variable First week

last period
Weight Daily Daily
Length, Head circumference Weekly
Weekly
Serum Electrolytes, Ca, P, CO2 2/week
Weekly
Serum BUN, albumin, LFTs Weekly
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