Guidelines for making the process of ordering Parenteral Nutrition

in NICU easier.

Second edition 2007

NEONATAL TPN

Edit by:

Dr. Fahad Al- Aql

Consultant neonatologist
Head of NICU department

Dr. Fahad Al-Harbi

Consultant Neonatologist

Dr. Abdulrahman Al-Matary

Consultant Neonatologist
Chairman of Education Committee

Dr. Atiyah Al-Zahrani

Consultant Neonatologist

Dr. Samih AboZaid

Consultant Neonatologist

Prepared by:

Edit by:

Ph. Wafaa O. Cafege

Dr. Fahad Al-Aql

Children Pharmacy
TPN/IV Supervisor

Head of NICU Department

Consultant Neonatologist

Typed & designed by: Suad A. Al-Abdan

INTRODUCTION

Contents
Introduction and Indecations ----------------------- 2
Section 1----------------------------------------------------- 3
Daily Energy and Calories Requirements
Daily Fluid Requirements
Section 2----------------------------------------------------- 6
Daily Dextrose Requirements.
Section 3 ------------------------------------------------- 7
Daily Amino Acid Requirements
Why do we give protein?
Section 4 ---------------------------------------------------- 9
Lipid Requirements
Monitoring lipid
Why do we give lipid?
Section 5 ---------------------------------------------------- 11
Daily Electrolyte and Minerals Requirements
Calcium and phosphate Maximum Ratio in PN
Section 6 ---------------------------------------------------- 14
Vitamins
Trace elements
Heparin
Guideline for Metabolic Monitoring During
Parenteral Nutrition.
References ------------------------------------------------- 18

Nutrition support by parenteral route is

commonly seen in NICU and its plays an
important role in the management of sick
neonates.
It
can
reduce
metabolic
complications and minimize the interruption to
normal growth until the infants can tolerate
enteral / oral feeding.
This pocket book is designed to provide
straight forward, accurate, authoritative and
up to date information on neonatal parenteral
nutrition. It's meant to be used by doctors,
residents, nurses and students at the bedside
and to make prescribing and monitoring PN in
the unit easier and safer.

INDECATION
Parenteral nutrition can be used as the sole

source of complete nutrition support for infants

who cannot be fed enterally or as an adjunct
to enteral feeding. In sick infant, PN allows
prompt resumption of growth and expedites
the transition to full-volume enteral feeding by
providing supplemental nutrition while enteral
tolerance is reduced.
1. Any infant unable to tolerate adequate
enteral feeding for more than 2-3 days
should receive PN support.
2. PN and/or enteral nutrition should begin
within 24 hours after birth.

FLUID REQUIREMENTS

SECTION 1

ENERGY AND CALORIES

Goal: 100-120 kcal/kg/day
The resting metabolic rate (MR) in
ventilated infants in the first few days of life is
around 40 kcal/kg/day. Energy intake to cover
protein accretion over resting MR should be at
minimum of 10 kcal/gm proteins. For relatively
stable ventilated infant, this gives a minimum
energy requirement of approximately 50
kcal/kg/ day at an amino acid intake of 2
gm/kg/day.
Dextrose = 3.4 kcal/gm
Protein = 4 kcal/gm
20% IL = 10 kcal/gm (2 cal/ml)

NEONATE

INITIAL

INCREASE BY

MAXIMUM

Full-Term
(>= 37 wks)

60-80
ml/kg/day

10 ml/kg/day

150 ml/kg/day

Pre-Term
(28-36 wks
>= 1000 gm)

70-80
ml/kg/day

10 ml/kg/day

150 ml/kg/day

10 ml/kg/day

200ml/kg/day to
maintain
Output/Input
Ratio.
Usually will level
out

ELBW
(23-27wks
<1000gm)

80-100
ml/kg/day

Infants are born with high water content and will lose
about 10% of body weight. If weight loss is extreme,
more fluids may be required.
Urine output (UOP) usually 2-5ml/kg/hr. however,
preterm infants may have urine output as high as 1012ml/kg/hr. output/Input ratio is usually about 0.7
if the output is high the ratio will be higher and infant
may need more fluids.
The electrolytes panel can be helpful in determining
fluid requirements. Na and Cl are good indicators of
fluid status in the first few days of life. When Na and
Cl levels are high, more fluids are required.

SECTION 2
FACTORS AFFECTING FLUID REQUIREMENTS

DEXTROSE REQUIREMENTS
NEONATE

INITIAL

ADVANCEMENT

GOAL

Factors increasing fluid

requirements

Factor decreasing fluid

requirements

1kg

8 mg/kg/min

1-3 mg/kg/min

12-14
mg/kg/min*

Phototherapy

Humidified incubator

< 1 kg

6 mg/kg/min

1-3 mg/kg/min

12-14
mg/kg/min

Increase permeability of the skin

Humidified ventilation

Larger body surface area relative

to body weight

respiratory distress Syndrome

(RDS)

Increase respiratory distress

Renal oliguria

Elevated body temperature

Patent Ductus Arteriosus (PDA)

Glycosuria with osmotic diuresis

Broncho Pulmonary Disorder

(BPD)

Gastric or intestinal losses

* maximum recommended upper limit for glucose intake.

Glucose is the main energy substrate of the

infant.
You can give up to 12.5% dextrose in
peripheral lines.

How to calculate the dextrose in mg/kg/min

from concentration:
% of glucose x rate (ml/hr) 0.167
Weight (kg)

WHY DO WE GIVE PROTEINS?

SECTION 3

Proteins are the key components of

every organs : bones, muscles, skin, and

AMINO ACID REQUIREMENTS

brain.
Neonate

Initial

Advancement

Goal

Term*

1.5-2 g/kg/d

0.5-1 g/kg/d

2-3 g/kg/d

ELBW
(Extremely low
birth weight)

1.5-2 g/kg/d

0.5-1 g/kg/d

3.5-4 g/kg/d

1 g/kg/d

0.25-0.5
g/kg/d

Septic,
Hypoxic**

Infants who receive only glucose, lose 1%

of their proteins store each day.

3-4 g/kg/d

* (BUN) Blood Urea Nitrogen, ammonia, arterial pH (Blood or plasma monitoring).

** Lactate concentration (blood or plasma monitoring).

Proteins yield amino acid up on

hydrolysis.
Pediatric essential amino acids over
adults amino acid are cysteine (enhance
Calcium, Phosphate solubility) Taurine

25-30 non-protein calories are needed for

each gram of proteins to avoid catabolism.

(prevents cholastasis, vital for brain and

retinal development).

1.5-2 g/kg/d is sufficient to avoid

catabolism in most infants.

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MONITORING LIPID

SECTION 4

1. Check triglyceride daily until full intralipid rate

given.

LIPID REQUIREMENTS
Neonate

Initial

Advancement

Goal

Term

1-2 g/kg/d

0.5-1 g/kg/d

3 g/kg/d*

Preterm

0.5 -1 g/kg/d

0.25-1 g/kg/d

3 g/kg/d

Severe respiratory
distress

3. Contraindication to IV fat when triglycerides

more than 4.5 mmol/l.
4. To check the triglyceride level you need to stop
the intralipid infusion for 4 hrs. then take the

Hyperbilirubinemic
Sepsis

2. Acceptable triglycerides < 200 mg/dl (2mMol/L).

0.5 g/kg/d**

0-0.5 g/kg/d

1-2
g/kg/d

sample.

WHY DO WE GIVE LIPIDS?

* may consider slightly higher dose in growth failure.

** minimum fat needed to prevent essential fatty acid deficiency.

IV fat emulsion infusion over 24 hrs

maximizes clearance.
IV lipid dose can be increased to normal
range when bilirubin is below 50% of
exchange level and when sepsis and
respiratory distress is under adequate
control.

Lipids are needed for brain development.

Lipids are used for :

Myelin formation

Neuronal growth

Retinal development

Cell membrane formation

20% lipid is recommended. The 10% have

higher phospholipids content that impedes
plasma triglyceride and cholesterol
clearance.

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12

chloride-acetate ratio may need to be

adjusted. For example, if metabolic
acidosis is present, maximum acetate
and minimum chloride should be used in
the PN admixture. Conversely, if
metabolic alkalosis is present, maximum
chloride and minimum acetate should
be used.

SECTION 5
ELECTROLYTES REQUIREMENTS
For the first 12-24 hrs; sodium, potassium,
and chloride usually are not required.

Later in the first week, needs are:

1-2mEq/kg/day for potassium and 2-4

Supplementation of sodium and

potassium is usually started on the

mEq/kg/day for sodium and chloride.

During the active growth period after the

second or 3rd day after establishing

1st wk, needs for potassium increase to

good urine output and checking

2-3 mEq/kg/day and for sodium and

electrolytes.

chloride to 3-5 mEq/kg/day.

Some of the smallest preterm infants

Sodium and potassium are available as

chloride, acetate, and phosphate salts,
the choice of the chloride versus acetate
salt of sodium and potassium depends
on the patient's acid-base status.
Generally, acid-base balance can be
maintained by using approximately
equal amounts of chloride and acetate
(ie, a 1:1 ratio). Acetate and chloride are
also present in the base amino acid
solutions in various amounts. If a patient
has altered acid-base status, the

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have sodium requirements as high as 6-8

mEq/kg/day or even higher, because of
the decreased capacity of the kidney to
retain sodium.
These are just guidelines and you may need
to readjust electrolytes according to the serum
levels.

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MAXIMUM CALCIUM AND PHOSPHATE ON

CENTRAL TPN
The recommended ratio of calcium to
phosphorus is 1.3 mg Cal:
1mg phos in infants > 28 wks and infants >
1000 gm.
The ratio is 1.7 mg Cal: 1mg phos in ELBW
infants.
Precipitation of crystals is much more likely
when the concentration of both calcium
and phosphorus is high or the pH of the TPN
solution is high.
The pH is mostly dependant on 2 factors:

Primene concentration: the amino acid

solution has a low pH. The more
concentration of the AA solution, the
lower the pH (allowing more calcium
and phosphorus to be added).
Acetate concentration: acetate can
raise the pH of the solution. The amount
of acetate should be limited in the TPN
to allow for maximum calcium and
phosphorus.

Sodium glycerophosphate used as source of

organic phosphate. That's will yield to a
maximum use of calcium and phosphate in
the TPN.

SECTION 6
VITAMINS
Vitamins are an important part of TPN
MVI pediatric

<1 kg

1.5 ml/day

1-3 kg

3.25 ml/day

Maximum 5 ml/day in >3 kg

TRACE ELEMENTS
(a mixture of zinc, copper, chromium,
manganese).
zinc and copper are required for growth.
Deficiencies of zinc (alteration of the
intestine, skin, immunity, and growth) and
copper (hypochromic anemia, osteoporosis,
and neutropenia) can occur. Zinc
requirements may increase in infants with
high stool output, gastrointestinal fluid losses,
or renal failure.

15

16

 Copper and manganese need to be

omitted in the presence of cholestasis as
indicated by direct bilirubin 2mg /dl.
Selenium, chromium, and molybedenum
need to be omitted in infants with renal
dysfunction.
Carnitine: premature infants receiving
exclusively PN need carnitine to allow fat
oxidation at the mitochondria.

HEPARIN

Add 0.5-1 unit/ml to all TPN solutions to

GUIDELINES FOR METABOLIC

MONITORING DURING PARENTERAL
NUTRITION
What to be
monitored

Initially

Later

weight
head circumference

Daily
Baseline

Daily
Twice weekly

Intake and output

Every shift

Daily

Serum electrolytes
urea nitrogen
creatinine.

Baseline and
every 1-3 days

Every week

Baseline, then as
needed clinically

Every 1-2 weeks

Baseline

Every 1-2 weeks

Total and direct

bilirubin
Alanine
Aminotransferase,
Aspartate aminotransferase, and
alkaline phosphatase

improve lipid clearance.

When TPN is given peripherally, continue

to add heparin to aid lipid utilization.

17

Admixture osmolarity refers to the osmoles of

solute per liter of solution. Osmolarity is
measured in milliosmoles per liter (mOsm/L).
PN admixture osmolarity is important
because the IV access site used for a given
infusion is dictated by admixture osmolarity.
The higher the osmolarity, the larger the vein
needed to accommodate the formulation.
A formulation with high osmolarity infused
into a small peripheral nein will cause

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irritation and pain, with damage to the

vessel (phlebitis), which will necessitate
frequent changes of the IV site.

Estimating osmolarity: Formulation

osmolarity can be estimated by adding
the osmolar contribution from each
component of the PN formulation and
dividing by the total volume (in liters) of
the formulation. The approximate
osmolar contribution of commonly used
components of a PN admixture is as
follows:
a) Amino acids: 1g = 10 mOsm
b) Dextrose: 1g = 5 mOsm
c) 20% IVFE: 1g = 0.71 mOsm (product
dependent)
d) Calcium Gluconate: 1 mEq = 1.4
mOsm
e) Magnesium sulfate: 1 mEq = 1 mOsm
f) Potassium (chloride, acetate, of
phosphate salt): 1 mEq= 2 mOsm
g) Sodium (chloride, acetate, of
phosphate salt): 1 mEq = 2 mOsm

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REFERENCES
Koo WWK, Cepeda E. Parenteral nutrition in neonates. In:
Rombeau JL, Rolandelli RH. Eds. Clinical Nutrition:
Parenteral Nutrition. 3rd. ed. Philadelphia, PA: WB
Saunders; 2000 :463-475.
Zielger EE, Thureen PJ, Carlson SJ. Aggressive nutrition
of the very low birth weight infant. Clin Perinatol.
2002;29:225-244.
A.S.P.E.N. Board of Directors and the Clinical Guidelines
Task Force. Guidelines for the use of parenteral and
enteral nutrition in adult and pediatric patients. J
parenter Enteral Nutr. 2002;26(1 supp1):1SA-138SA.
American Journal of Health-System Pharmacy.
60(10):1041-1044, May 15, 2003. Pereira-da-Silva, Luis;
Nurmamodo, Abdurrachid; Videira Amaral, Joao M; Rosa,
Maria L; Almedia, Maria C; Ribeiro, Maria L.

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