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 !