pediatric parenteral nutrition
TRANSCRIPT
PEDIATRICPARENTERAL NUTRITION
Salmiah HassanPharmacist, HTWU
Enteral NutritionEnteral Nutrition is given when oral route is
not feasible eg. intubated & sedatedExamples of enteral access are;1.Feeding through nose (nasogastric,
nasoduodenal & nasojejunal)2.Gastrostomy3.JejunostomyUndergoes complex process of digestion along
gastrointestinal tract and metabolism by liver before being absorbed to blood circulation
Parenteral Nutrition• Nutrients given to patient directly into
the systemic circulation• Bypass the GI tract and the first
circulation through the liver
Enteral vs Parenteral Route
Enteral vs Parenteral Route?Whenever possible, oral/enteral route should
be the choice for feeding (If the gut works,use it)
Advantages;1.Prevention of mucosal atrophy by luminal
supply of substrates; support of the mucosal barrier against pathogens
2.Support of the intestinal immune system and improvement of immuno-competence, prophylaxis against infection and sepsis
3.Improvement of intestinal perfusions
TPN: OVERVIEW
OUTLINESIndication of TPN Assessment of Nutrition SupportCaloric requirementMacronutrientsMicronutrientsMonitoring ParameterPeripheral PN vs Central PNCyclical PNTPN Requisition FormSetting Up TPNAdjustment of PN Run Rate
INDICATION OF TPN
INDICATION PAEDIATRIC
NeonatesBW <1.5kg, (VLBW, ELBW)<30wks gestational age
Necrotizing Enterocolitis (NEC)GIT abnormalities: Gastrochisis, omphalocele, tracheo-
esophageal fistula, GIT atresia, malrotation, SBS, diaphragmatic hernia
Fig 1: Omphalocele
Fig 2: Gastrochisis
CONTRA-INDICATIONSA FUNCTIONING GASTROINESTINAL TRACTACUTE METABOLIC DERANGEMENT (Do
correction first!)TPN should not be used during periods of
acute haemodynamic instability or during surgical operations since the nutrient solutions may be used inadvertly for fluid resuscitation
Fluid , electrolyte and acid-base imbalance must be corrected. Hypoalbuminemia needs correction.
WHEN TO START PN?Within 12-24 hours of injury/ surgery or
after stabilization of vital organ functionCheck:-Impaired oxygenation-Impaired perfusion or volume depletion-Electrolytes & metabolic derangement-Requirement for inotropesEnsure these issues are settled and
stabilized withinthe first 24 hours
ASSESSMENT OF NUTRITION SUPPORT
ASSESSMENT OF NUTRITION SUPPORT -PAEDIATRIC1. Paediatric
1. Growth curves• Babson• Lubchenco2. Intake/Output, urine output3. Weight (always use best weight – best
dry weight)4. Initial drop of weight in neonate is
expected for neonate• Post natal weight loss of 5-15% per day is
acceptable
NORMAL GROWTHPreterm infants-
Required 110 -120kcal/kg/dayExpected daily weight gain -15g/kg/d
Full term infants:-Require 90 – 100 kcal/kg/dayInitial weight gain 25 – 30 grams/day by DOL
14: regain birth weight3 months: gain 1 pound /month4 – 6 months: double birth weight 1 year: triple birth weight, length increases by
50%.2 years (puberty): gain 2-3 kg/year, grow 5 – 8
cm/year
CALORIC REQUIREMENT
CALORIC REQUIREMENTAGE (YR) Kcal/KgBW/ Day
Pre – term 110 – 120 0 – 1 90 – 100 1 – 7 75 – 90 7 – 12 60 – 75 12 – 18 30 – 60
Adults > 18y.o 25 – 30
Table adapted from ESPGHAN 2005, ESPEN 2009
Weight For Calculation???Paediatric
Neonates – Birth Weight, Best dry WeightChildren – Best Weight, Best Dry Weight
MACRONUTRIENTS
CARBOHYDRATEProvided as glucose
main source of energy in nutritionUsually contributes to osmolarity in PN solution.
Peripheral vein concentrationUp to 12.5% dextrose is well tolerated –
provided no other osmolarity-increasing agents are added and patient is not fluid restricted
Adequate carbohydrates are needed to help prevent lipolysis, and transient protein breakdown.
Generally, glucose started at 10% for newborn at day 1 of PN and gradually increase up to 15%.
Overfeeding with glucoseExcess amount of glucose intake results in
hyperglycemiaIncreased lipogenesis thus promoting fat deposition
Eventually, leads to hepatic steatosis with an impairment of the LF & enhanced production of VLDL TG by the liver
↑ CO2 production and minute ventilation Impaired protein metabolismRisk of infection
↑ blood glucose level have been shown in adult ICU patients to be associated with ↑ infectious related mortality.
Hyperglycemia in animal model reduces the ability of lung macrophages to fight infection
PROTEINProtein prevent catabolism
Therefore, need to be started early to promote positive nitrogen balance
Protein may ↓ frequency and severity neonatal hyperglycemia by stimulating endogenous insulin secretion and stimulates growth by enhancing insulin and insulin-like growth factor release.
Protein Requirement in NeonateRivera et al. – significant +ve Nitrogen balance
when protein intake of 1.5g/kg/day.Parenteral intake of 3.2g/kg per day results
+ve Nitrogen balance with no detrimental effects on plasma AA profiles.
Ibrahim et al showed that preterm infants are able to tolerate 3.5g/kg/d from birth onwards
RECOMMENDED PARENTERAL AMINO ACIDS SUPPLY (g/kgBW/Day)
MINIMUM INTAKE MAXIMUM INTAKE
PRETERM 1.5 4TERM (1ST
MO) 1.5 3
1ST MO – 3RD YR
1 3
3RD YR– 5TH YR 1 36THYR – 12TH YR 1 3
TYPE OF PROTEIN USEDNeonates and children
VAMINOLACT 6.53%AMINOVEN INFANT 10%
Premature neonate and infants required more essential AA than adults due to immature metabolic pathway for metabolising AA in NB.
pediatric parenteral AA provide more essential AA and less non-essential AA with addition of some semi essential AA such asCysteine – maintaining calcium homeostasisTyrosine Taurine – prevent cholestasis and retina
dysfunction
Glutamine in childrenNo evidence to support the routine use of
glutamine in preterm babiesStudies show that no effects of glutamine
supplementation on sepsis or mortality, tolerance towards EN, NEC or growth
No available data in supporting glutamine used in older children.
SOLUTION A
SOLUTION B
SOLUTION C
Protein 4g 6g 8gGlucose 10% 10%,
12.5%, 14%
10%, 12.5%,
14%Na
content4mmol 4mmol 4mmol
Ca content
1.67mmol 1.67mmol 1.67mmol
Volume 200ml 200ml 200ml
STANDARD SOLUTION
FATLipid
prevent essential FA deficiency, provide high energy needs without CHO
overload improve delivery of fat soluble vitamins.
Maximum fat oxidation occurs when IVFE provide 40% of the non-protein calories in newborns.
In infants, NB and preterm, IVFE – administered 24h
Essential FA deficiencyOmmission of IVFE may lead to EFA deficiency
(Cooke RJ et al, Lee EJ et al)In newborn infants who cannot receive sufficient
enteral feeding, intravenous lipid emulsions should be started no later than on the third day of life, but may be started on the first day of life(ESPGHAN 2005)
In order to prevent EFA-deficiency, 0.25g/kg/d should be given to preterm infants0.1g/kg/d – term infants and older children
Fat Requirement in NeonateStart lipids at 1g/kg/day, at the same time as amino acids
are started, to prevent essential fatty acid deficiency; gradually increase dose up to 3 g/kg/day (3.5g/kg/day in ELBW infants)
Exogenous lipid may interfere with respiratory function. Suggested mechanisms include impaired gas exchange from pulmonary intravascular accumulation or impaired lymph drainage resulting in oedema. Lipid may also aggravate pulmonary hypertension in susceptible individuals. So, use smaller doses in sepsis, compromised pulmonary function, hyperbilirubinaemia/ jaundice requiring phototherapy(≤ 2g/kg/day) (Peads Protocols 2012)
LBW infants may have immature mechanisms for fat metabolism. Some conditions inhibit lipid clearance e.g. infection, stress, malnutrition So, lipid clearance monitored by plasma triglyceride (TG) levels (Max TG concentration ranges from 150 mg/dl to 200 mg/dl) (Paediatric Protocols 2012)
Fat Requirement in Neonate
TYPE OF LIPID USEDSmoflipid 20%
LCT, MCT, olive oil, fish oilOxidized rapidly , reduced liver
derangement, anti-inflammatory effects
The syringe and infusion line should be shielded from ambient light.
MICRONUTRIENTS
ELECTROLYTES REQUIREMENT ContOnly basic requirement of electrolytes should
be covered in PN bagPN is not meant for fast electrolytes or fluid
correction!!Profound deviations should be corrected
independently from nutrition therapy
ELECTROLYTES REQUIREMENTS
BIRTH WEIGHT
Sodium Potassium
Calcium Phosphate
Magnesium
1 mo – 1 yr
2.0 – 3.0 1.5 – 3.0 0.8 0.5 0.2
Term neonate
2.0 – 5.0 1.0 – 3.0 1.3 – 3.0 1.0 – 2.3 0.2
>1500g 3.0 – 5.0 1.0 – 3.0 1.3 – 3.0 1.0 – 2.3 0.2<1500g 2.0 – 5.0 1.0 – 2.0 1.3 – 3.0 1.0 – 2.3 0.2
Table adapted from ESPGHAN 2005
Electrolytes Correction FORMULAE
Sodium Correction(Hosp Likas/ HQE 2)
Increase up to 5-8 mmol/kg/day (max) in PN bag
Sodium Correction(Hosp Tawau)
Increase 0.5mmol for each maintenance (3mmol/kg/day) = 3.5 mmol/kg/day.
Run PN half rate (Na 1.5mmol/kg/day from bag) and give IVD Na 2mmol/kg/day-Cost saving
Potassium Correction
Increase 1.5mmol fpr each maintenance (2.5mmol/kg/day) = 4 mmol/kg/day.
Run PN half rate (K 1.3mmol/kg/day from bag) and give IVD K 2.7mmol/kg/day-Cost saving
Electrolytes Correction (Na) Fast Sodium Correction: May use 1. NaCl 3% (0.513mmol Na/ml) Run= IVB 30min /IVI 1-2hr,
check back Na level 2. NaCl 0.9% (0.153mmol Na/ml) Run= IVI 6 hours, check back
Na level 1/5NSD5% and 1/5NSD10% not suitable
bcos of low Na contents
Calculation example:BW= 2.6kg, Na= 122 mmol/LFast Na correction: NaCl 3% : 1) TPN half rate (Na 1.5mmol/kg/day) 2) Another 2mmol/kg/day from NaCl 3% Total to add in= 2 x 2.6 = 5.2mmol (10ml NaCl
3%) Run 5ml/hr for 2 hrs,check back Na level
NaCl 0.9%: 1)TPN half rate (Na 1.5mmol/kg/day) 2)Another 2mmol/kg/day from NaCl 0.9% Total to add in= 2 x 2.6 = 5.2 mmol (34ml
NaCl 0.9%) Run 5.6ml/hr for 6 hrs,check back Na level
Electrolytes Correction (K) Fast Potassium Correction: May use : KCL 10% (1.34mmol K/ml) Run= IVI 2hrs, check back K
level
Calculation example:BW= 2.6kg, K= 2.6 mmol/LFast K correction: KCL 10% : 1) TPN half rate (K 1.3mmol/kg/day) 2) Another 2.7mmol/kg/day from KCL
10% Total to add in= 2.7 x 2.6 = 7mmol
(5.2ml KCL 10%) Run 5ml/hr for 2 hrs,check back K
level
FACTORS AFFECTINGCALCIUM/PHOSPHATE COMPATIBILITYpH: higher pH increases risk of precipitationTemperature/light: higher temp/direct light
increases risk of precipitationConcentration of calcium and phosphate should not
be more 30mmol per liter of solutionAmino acid: higher conc promotes solubility →
decrease risk of precipitationCalcium salt: gluconate preferred over chloridePresence of IVFE: Increase pH → increase risk of
precipitationPresence of Heparin and Calcium may destabilized
IVFE
Recent issues with calcium gluconate!!Recent issues with calcium gluconate!!
Aluminium contamination which is leached from the glass ampoules, prolonged used may cause NeurotoxicitiesRenal impairment
Recent circular from KKM (11/10/2012)Stop using calcium gluconate injection from
glass ampoules in the production of PNAlternative choice??? calcium gluconate
injection in plastic ampoules
TRACE ELEMENTSTrace elements are essential micronutrients for
support of human metabolic processes.Product used in children – Peditrace
Recommended dose 1ml/kg (max 15ml)
TRACE ELEMENTSPEDITRACE (mcg/1
ml)RDA
ZINC CHLORIDE 521 450 – 500 COPPER CHLORIDE 53.7 20MANGANESE CHOLIRIDE
3.6 1
SODIUM SELENITE 4.38 2.0 – 3.0SODIUM FLUORIDE 126POTASSIUM IODIDE 1.31 1* CHROMIUM - 0.2**IRON - 50 – 100 (long term
PN)MOLYBDENUM - 0.01 – 0.25* Cr usually is a contaminant in PN solutions to a degree that satisfies requirement.** not available commercially as a component in PN mixtures due to the concern of iron overload
MICRONUTRIENTS SPECIAL CONSIDERATIONSCholestatic liver disease/impared biliary
excretionDecrease amount of copper and manganese
Renal failureDecrease amount of chromium and selenium
Patients with significant ostomy drainage of persistent diarrheaGive additional zinc supplementation
VITAMINSLipid soluble vitamins children – Vitalipid N Infant
Recommended dose – 4ml/kg/day (max 10ml)Water soluble vitamins children & adult – Soluvit N
Recommended dose Children – 1ml/kg/day (max 10ml)
Recommended dose Adult – 10mlCernevit
Used in adult pt only!!!Combination of water soluble vitamin and lipid
soluble vitamin (ommision Vit K)
VITAMINSWater Soluble Vitamins – Soluvit N
Recommended dose – 1ml/kg/day (max 10ml)
SOLUVIT N PER ML
RDA (kg/day )
Thiamine, B1 0.31mg 0.35 – 0.50mgRiboflavin, B2 0.49mg 0.15 – 0.20 mgNicotinamide 4.0mg 4.0 – 6.8mg Pyridoxine, B6 0.49mg 0.15 – 0.20 mg Sodium panthothenic
1.65mg 1.0 – 2.0 mg
Ascobic acid 11.3mg 15 – 25 mgBiotin 6.0mcg 5.0 – 8.0 mcgFolic acid 40mcg 56 mcgcyanocobalamin 0.5mcg 0.3mcg
VITAMINSLipid soluble vitamins – Vitalipid N Infant
Recommended dose – 4ml/kg/day (max 10ml) VITALIPID N PER
MLRDA (dose/kg/day )
A 69mcg 150 – 300mcgD2 1.0mcg 0.8 mcgE 0.64mg 2.8 – 3.5mgK1 20mcg 10mcg
MONITORING PARAMETERS
MONITORING PARAMETERSDaily I/O, urine output, weight, DXT,
ABGSerum electrolytes including
phosphorus, calcium, magnesiumDaily for BUSE monitoring until serum is
stable then twice a weekLiver function test
initiation of PN and after 3-4 days of initiation of TPN then weekly
Serum triglycerideInitation of TPN then weekly especially
patient that is expected on long-term of PN
PERIPHERAL PN VS CENTRAL PN
Peripheral Venous Access Vs Central Venous Access
VS
Peripheral Venous Access
Central Venous Access
Peripheral PNOsmolarity – concentration of solute per
liter solutionOsmolarity
Not more than 900 mOsm/L (ESPGHAN 2005)Not more than 850 mOsm/L (ESPEN 2009)Not more than 925mOsm/L (Mahshid Roayaee, The
Pharmacy Practice, MAC 2002, www.childrenmercy.org)Possible to give PN with osmolality around
1100mOsm/kg for up to 10 days via peripheral veins in most patient. (ESPEN 2009) – trial on adult patient only!!!
Peripheral PN - ContEnergy
Energy provided is less than energy given via central line
Require higher volume of solution i.e: TF 150ml/kg/day (neonate)
Maximum dextrose content paed PN– 12.5%, providedTF - 150ml/kg/d, Protein -2g/kg/d, Fat – 2g/kg/d, Na
& K -1.5mmol/kg/d and normal maintenance for Ca2+, PO4
2 , Mg2+
For short-term PN only
Central PNOsmolarity – can be given >900mOsm/LHigher calorie can be providedSuitable for patient that is fluid restricted
CYCLICAL PN
Cyclical PNRefers to the administration of IV fluids
intermittently with regularly discontinuation of infusion.E.g. IDPNMay be used for 3-6mo of age
Advantages Alternating feeding and fasting allows changes in
insulin/glucagon balance and reduces lipogenesisAllow patient mobilizationLower the risk for the development of liver
disease
Cyclical PN - contDisadvantages
Most available data comes from studies performed in stable adults pt
May leads to hyperglycemia due to high glucose infusion rates and risks of hypoglycemia upon discontinuation
PN REQUISITION FORM
HTWU does not have TN manufacturing facilityPN ordered from HQE 2, KK – only Monday to Thursday. Take around 2 days to receive the TPN bags (May also be on
weekend)
Incomplete TN formCentral line/ peripheral line?Fluid maintenance? [Total Fluid (TF)]PN regimen?
Crucial info for TN administrationCentrally? Peripherally?Content of PN?Aseptic Technique?
TPN Requisition Form for Paediatric
TPN Form
TPN Form
How to fill in TPN form
Hypo Na+
Hyper K+
Hyperglycaemia
B/O xxx D8 OL
2 kg 100 cm
1/8/2013 12345 PICU/ HTWU
Dr. xyz
1246.22.51.3
6.455
13.212.6
Not tolerating EN
How to fill in TPN Form
4.02.0
10
Additional InformationTotal Fluid Maintenance
Please write down the TF and any additional fluid requiredE.g. BW 2kg, TF 150mL/kg/day + 5% (Phototherapy)IVD 1/5 NSD10% @ 10.6mL/HIVI Noradrenaline @ 1mL/HIVI Salbutamol @ 1mL/H 12.5 mL/H IV NaCL (artline) @ 0.5mL/H
SETTING UP TPN
Complete TPN Set (Cold-chain)
PN bag + Smoflipid + 0.2micron infusion filter + Y connector
TPN Bag+ Lipid Syringe+ Infusion filter 0.2micron+ Y-connecter
Setting up TPNSterile procedure ;1.Handwash2.PPE• Syringe pumps, Infusion pump. If area needed,
scrub with alcohol• TPN Bag – filter with 0.2micron infusion filter• Lipid (in syringe) – no need filter,bcause filtered
twice in HQE2• Use two way connector (Y connector) to combine
TPN and Lipid before infused to patient***Infusion filter 0.2 micron before Y connector
TPN label and what it means
ADJUSTING TPN RUNNING RATE
TPN Running Rate AdjustmentIf inotropes or IV infusion of drug are
tapered down/off, DO NOT automatically increase the TPN run rate to accommodate the FMNeed to calculate the content to determine
the new TPN run rateDo not exceed the recommended maximum
requirement to prevent adverse effectTop up TF with IV drip
How? During PN Request:
BW= 2.6kg, Fluid Restriction=150ml/kg/day (390ml/day)PN = 15.6ml/hr , Lipid = 0.6ml/hr
When TPN arrive: Patient is on Dopa 1ml/hr, Morphine 2ml/hr
Adjustment: Current PN Rate – (Dopa & Morphine) = 16.2-1-2 =12.6ml/hrSo,new rate is..PN @ 12.6 ml/hr *Protein at least 0.8g/kg/dayLipid @ 0.6ml/hr
ExampleDay 1 TPN:
IV TPN @ 10.1 mL/HIV Lipid @ 0.5 mL/HIVI Noradrenaline @ 1mL/H IVI Salbutamol @ 0.4mL/HIV NaCL (artline) @ 0.5mL/H Off
We will suggest:IV TPN @ 10.1 mL/H (MAX)IV Lipid @ 0.5 mL/HIV NaCL (artline) @ 0.5mL/HMaintenance fluid @ 1.4ml/hr (to TOP
UP to current requirement of fluid maintenance)
References:1. MOH Pediatric Protocols 3rd Edition,20122. European Society of Parenteral Enteral
Nutrition (ESPEN) 20093. Journal of Pediatric Gastroenterology and
Nutrition (ESPGHAN) 2005
Thank you !