Pediatric Parenteral Nutrition

Ana Abad-Jorge, MS, RD, CNSC

Director, Dietetic Internship Program

Pediatric Nutrition Specialist

UVA Health System

Charlottesville, VA

Learning Objectives

Identify 5 common indications for PN in infants & childrenDetermine parenteral energy and protein requirements for infants and childrenDiscuss 4 common complications of overfeeding.Review how to begin and advance the following macronutrients: % dextrose, protein and lipids.Calculate glucose infusion rate (GIR) and discuss its significance.List 3 common signs of essential fatty acid deficiencyGiven a TPN and lipid prescription and the child’s weight, determine TPN calories.Discuss laboratory monitoring for children on PN.

Indications for Parenteral Nutrition in Infants and Children

Gastrointestinal Anomalies & Complications i.e. NEC, gastroschesis, short bowel

Promotion of healing of TE fistula

Inflammatory bowel disease (severe cases)

Pediatric malignancies with severe GI problems

Preterm infants with severe respiratory distress, immature gut motility & function

Critically ill (trauma, sepsis) patients with ileus and/or abdominal trauma

Parenteral Nutrition Requirements

Age Calories (kcal/kg) Protein (gm/kg)

Preterm SGA

90 – 100 95 - 115

3.0 – 4.0 3.5 - 4.0

0 – 1 BPD or CHD

80 – 100 90 – 130

2.5 – 3.0 3.0 – 3.5

1 - 7 75 - 90 1.5 - 2.0

7-12 60 - 75 1.5 - 2.0

12 - 18 30 - 60 1.0 - 1.5

Approach for the Critically Ill Pediatric Patient

Begin with BEE for the first 1 – 3 daysGradually advance energy delivery toward above outlined goals, as status improves (usually below RDA)

Indirect calorimetry still considered the “gold standard” although not typically used given financial and training considerations.

Complications of Overfeeding

Excess CO2 production & increased minute ventilation

Pulmonary edema and respiratory failureHyperglycemia, which may lead to immuno-suppression, and increased infection ratesLipogenesis due to increased insulin productionGeneralized immunosuppressionHepatic complications: fatty liver, intrahepatic cholestasis, due to excess carbohydrate or protein delivery.

Maintenance Fluid Requirements for Children

Body Weight Amount Fluid/day

0.5 - 2.0 kg 120 -250 ml/kg

2 - 10 kg 100 ml/kg

11 - 20 kg 1000 ml + 50 ml/kg for each kg>10 kg

> 20 kg 1500 ml + 20 ml/kg for each kg>20 kg

Fluid Requirements Skills Check

What are the maintenance fluid requirements of a 17 kg child?

ANSWER: 1350 ml

What is this volume per kg?

ANSWER: 79 kcal/kg

Use of Carbohydrate in PNDextrose (D-Glucose) = 3.4 kcal/gmIndications for peripheral vs. central PN:

1. Peripheral - max. of D10 - D12 % (PPN) Why? - Indicated for short term PN < 2 weeks 2. Central - usual max of D20 - 25% (CPN) - For periods > 2 weeks, or if infant has poor access

may use a surgical central line or a PICC-lineSmall preterms: frequent hyperglycemia Why?Initiation and advancement: Determine GIR

1. Preterms - advance by 0.5 - 2% q day 2. Older infants/children- adv. by 2.5 - 5% q day

Glucose Infusion Rate (GIR)

Calculating GIR: Calculating GIR: Rate X % Dextrose

Weight (kg) X 6

Units: mg glucose/kg/minuteUnits: mg glucose/kg/minute

GuidelinesGuidelines

Infants: Limit GIR to 12 – 14 mg/kg/min : Limit GIR to 12 – 14 mg/kg/min

Children: Limit GIR to 7 – 12 mg/kg/minChildren: Limit GIR to 7 – 12 mg/kg/min

GIR Calculation Problem

Infant in the PICU diagnosed with neuroblastoma, receiving chemotherapy.Weight: 6.8 kgInfant’s TPN advanced over the weekend to: D25% TPN with 20 gm TrophAmine/dayTPN Rate: 28 ml/hrCalculate: GIR

GIR Calculation

Calculating GIR: Calculating GIR: 28 X 25

6.8 kg X 6

ANSWER: 17.2 mg/glucose/kg/min

What can you say about this GIR level?

Management of Hyperglycemia in Infants & Children on PN

Initially may need to back down on % dextrose in PNHyperglycemia may be caused by decreased insulin production, insulin resistance or stress response.Insulin administration to preterm or critically ill infants is controversial due to variable responses. What are they?Close monitoring is necessary to prevent episodes of hypoglycemia, which may lead to brain damage.If closely monitored, insulin administration can result in increased energy intake and weight gain.Initial dose = 0.05-0.1 U/kg/hour via a continuous infusion; monitor blood glucose q hour initially.

Initiation and Advancement of Protein in PN:

Preterm & term infants: – Begin at 1.5 - 2.0 gm/kg q day and – Advance by 1 gm/kg q day to endpoint

goal.Older children: Begin at 1 – 2 gm/kg and advance to goal by Day 2 of PNEndpoint goals:

- Preterm & term infants: 3.5 - 4 gm/kg - Older children: 1.5 - 2.5 gm/kg

Advantages of TrophAmine:

Provides essential amino acids (taurine, tyrosine, histidine) 60% EAAPromotes plasma amino acid profiles within normal neonatal target rangeDecreases tendency for cholestasisAddition of cysteine HCl decreases pH of PN: improves solubility of Ca & Phos

Recommended for infants < 2 years old

Initiation and Advancement of Lipid in PN:

Preterm & term infants: – Begin at 0.5 - 1.0 gm/kg q day and – Advance by 0.5 - 1 gm/kg q day to

endpoint goal.Older children: Begin at 1.0 gm/kg and advance to goal by Day 2 of PNEndpoint goals:

- Preterm & term infants: 2.5 – 4 gm/kg - Older children: 1.0 – 2.5 gm/kg

Use of Lipids in PN in Children

Minimal goals for provision of EFA: 0.5 - 1.0 gm/kg/day

Intralipid: 54% linoleic acid 1. 10% Intralipid - 1.1 kcal/ml 2. 20% Intralipid - 2.0 kcal/ml (Only at UVA-HS)

Intralipid provides 10 kcal/gm (due to glycerol)Egg phospholipid may be allergy sourceSGA infants are more susceptible to hyperlipidemia Why?

Clinical Signs of EFA Deficiency

Reduced growth rate

Flaky dry skin

Poor hair growth

Thrombocytopenia ….What is this?

Increased susceptibility to infections

Impaired wound healing

Intralipid should be used with caution:

Hyperbilirubinemia Fatty acids may displace bilirubin from albumin binding

sites, increasing the risk of kernicterus.

Pulmonary hypertension or severe RDS Excess lipid intake may decrease CO2 & O2 diffusion

capacity across the alveolar membranes.

Sepsis Excess lipid increases arachidonic acid production, and

thus 2 series prostaglandins and 4 series leukotrienes. These substances may cause increased risk of immunosuppression.

The Use of Carnitine in PNPreterm/SGA infants on long term PN may become carnitine deficient due to lacking some enzymes needed for biosynthesis.

Symptoms may include: cardiomyopathy, increased triglycerides hypotonia, muscle weakness, acidosis, failure to thrive.

Improvement in carnitine status can lead to: Improved lipid tolerance Improved nitrogen accretion Improved growth.

What does carnitine do???

Functions of Carnitine

Transports long-chain fatty acids into the mitochondria for beta-oxidation

Regulates rate of fatty acid oxidationAssists in ATP productionScavenger of harmful acyl groups that may lead to lipid membrane oxidationMaintains pool of free CoA in mitochondria

Recommended Dosages for Children

50-100 mg/kg/day level is used (may be therapeutic)Some negative effects reported at greater than 50 mg/kg/dayMay be prudent to use 10-20 mg/kg/day, especially in infantsSide effects: diarrhea, nausea, cramping; risk for seizures

Pediatric MultivitaminsVitamin C - 80 mg

Vitamin A - 2300 IU

Vitamin D - 400 IU

Vitamin E - 7 IU

Vitamin K - 0.2 mg

Biotin - 20 ug

5 ml for wt up to 40 kg

2 ml/kg Peds MVI for wt through 2.5 kg

Vitamin B1 - 1.2 mg

Vitamin B2 - 1.4 mg

Vitamin B3 - 17 mg

Vitamin B6 - 1 mg

Vitamin B12- 1 ug

Folic Acid - 140 ug

Use 10 ml adult MVI for children > 40 kg

Pediatric Trace Element SolutionTrace Element Content

Zinc 300 ug

Copper 20 ug

Chromium 0.17 ug

Manganese 5 ug

* Use 0.2 ml/kg/day for children up to 5 kg.

* Add 100ug/kg zinc for infants < 2.5 kg * Add 50 ug/kg zinc for post-op heart infants or to aid in wound healing.

Recommended Calcium & Phosphorus Intakes for PN:

Child Age Calcium (mEq/kg)

Phosphorus (mMol/kg)

Preterm/Term 3.5 - 4.5 1.2 – 1.6

2 - 12 yrs 1 - 2.5 0.8 – 1.0

Adolescents 1.0 0.5

Note: 1mMol = 2mEq

General Guidelines for PN Solubility: Protein, Calcium and Phosphorus

Per every 100 ml/kg of PN can add:– 4 gm/kg TrophAmine– 4 mEq/kg of Calcium– 1.5 mMol/kg of Phosphorus

Can add only 40 gm of TrophAmine/L in TPN

Can add 45 - 50 gm of standard amino acids/L

Solubility Limits for Calcium & Phosphorus– 5.2 mEq/100 ml of Ca + Phos for standard amino acids– 7.2 mEq/100 ml of Ca + Phos for TrophAmine

Neonatal TPN Practice Problem: Part I

2 month old infant s/p cardiac surgery for Tetrology of Fallot (TOF)Infant weight: 3.6 kg

Infant is to begin TPN and lipids on POD #1, but given volume restriction and multiple I.V. medications post-op, he can only receive 6 ml/hr of TPN.What type of protein will you use? Why?

TrophAmine

Neonatal TPN Practice Problem: Part II

How many ml/kg of TPN will the infant receive?

6 ml/hr X 24 hr / 3.6 kg = 40 ml/kg

What is the maximum amount of Calcium you can order in mEq/kg?

1.6 mEq/kg

What is the maximum amount of Phosphorus you can order in mMol/kg?

0.6 mMol/kg

Use of H2 Blockers in TPN

Recommended for use in infants and children on TPN for at least 1 week who will not be enterally fed.Prevents excess HCl acid production, used for ulcer prophylaxis.Pediatric dose for Famotidine:

0.8 – 1.0 mg/kg

Use of Parenteral Iron (Imferon)

Controversial due to concerns of increased risk of gram negative sepsis

Infants with iron deficiency anemia with decreased hemoglobin/hematocrit or serum ferritin need iron in PNBegin 0.5-0.8 mg/kg/day for 1-3 weeksMonitor indices of iron status: HCT/HGB, MCV, serum Fe, ferritin

Selenium Supplementation in PN:

Selenium deficiency:cardiomyopathyskeletal muscle tenderness/painerythrocyte macrocytosisloss of pigmentation of hair and skin

Selenium deficiency may occur with long term selenium free PN

Supplementation: 1-2 ug/kg/day

Normal Selenium: 6.3-12.6 ug/dl

Calculation of Total Calories & Nutrients from Parenteral Nutrition

PN volume = PN rate (ml/hr) X 24 hours

a. Calories from Dextrose PN volume X % dextrose X 3.4 kcal/gmb. Calories from Protein Total grams protein/day X 4.0 kcal/gm or gm/kg protein X wt (kg) X 4.0 kcal/gmc. Calories from Fat Intralipid volume X 1.1 kcal/cc (10% IL) Intralipid volume X 2.0 kcal/cc (20% IL) @ UVA-HS

d. Kcal/kg = a + b + c / weight (kg)

Peds TPN Example

Infant with Short Bowel Syndrome

Weight: 5 kg

TPN Prescription: D 20% TPN with 3 gm/kg TrophAmine at 20 ml/hr X 24 hours.

Lipid order: 50 ml of 20% Intralipid

Calculate TPN total kcal and kcal/kg

TPN Calorie Calculations

TPN Volume?

20 ml/hr X 24 hours = 480 ml

Dextrose Calories?

= 480 ml X .20 X 3.4 = 326 kcal (a)

Protein Calories?

= 3 gm/kg X 5.0 kg X 4 kcal/gm = 60 kcal (b)

Fat Calories?

= 50 ml X 2.0 kcal/ml = 100 kcal (c)

Total Calories = a + b + c/wt (kg)

= 486 kcal/5.0 kg = 97 kcal/kg

Pediatric Cyclic Parenteral Nutrition

Recommended for children on long term PN, who will benefit from a nocturnal PN schedule

Advantages: Provides a “window” or break when no PN is given, allows for normal activities during the day: ambulation, therapies, school etc..

Provides a physiological “break” from PN, which has been shown to decrease incidence of cholestasis and hepatic toxicity

PN must be tapered on and off, to help prevent episodes of hyper & hypoglycemia– Example: 10 ml/hr X 1 hr, 20 ml/hr X 10 hr, 10 ml/hr X 1 hr

Monitoring Growth & Tolerance of Pediatric PN

Anthropometrics: daily weights in infants, weekly in older children, length & head circumference for assessment of linear growthLaboratory Monitoring:

1. Initial Monitoring: Basic Metabolic Panel to include: Na, K, Cl, CO2, BUN, Cr, Glucose, Ca, Mg, and Phos

2. Weekly PN Monitoring: TPN Profile (NICU) or Hepatic Panel A + triglycerides, prealbumin

Need: Albumin, AST/ALT, Alkaline phosphatase, triglycerides, and conjugated bilirubin

Complications of PN in ChildrenMetabolic Complications: electrolyte disturbances, hyperglycemia, hyperammonemia, metabolic alkalosisComplications with Intralipids: hyperlipidemia in SGA infants and during sepsis, decreased activity of lipoprotein lipase. Use lipids with caution with:

1. Hyperbilirubinemia 2. Infection/sepsis 3. Severe or chronic lung disease

Liver Dysfunction 1. Cholestasis: caused by excess kcal or protein 2. Fatty liver: related to excess calories, including

CHO calories

Role of the Nutritionist in Managing Pediatric Parenteral Nutrition

Work closely with physicians or residents ordering the PN to make appropriate recommendations, so that PN order changes can be entered in a timely manner.

Educate physicians and pediatric residents on the “how-to’s” of pediatric PN on regular basis

Whenever possible work to obtain “verbal” or “pended” order privileges on PN. The R.D. would then be able to enter PN orders.

Role of the Nutritionist in Monitoring Pediatric Parenteral Nutrition

Work closely with physicians, nurses and computer specialists to make changes to PN ordering forms or be part of team to develop order screens when using the electronic medical record (EMR) ordering process.

Work closely with nurse practitioners and home health companies to facilitate transition from hospital to home and to ensure that patient receives the appropriate PN formulation in the home setting.

Pediatric PN Case Study

5 year old girl admitted to PICU following an MVA. She has experienced:– Significant abdominal trauma, perforation of duodenum– Splenic laceration– Right femur fracture

Admission weight: 18 kg (50th %-ile) NCHS curvesPost-operative Day 1: Receiving D5% ¼ NS at 50 ml/hr. She had central line placed in the OR.Consult: Begin PN and lipids, TPN rate to start at 50 ml/hr to replace above IV fluids.

Questions to Consider ….What are this child’s calorie, protein and fluid requirements?How would you start TPN and lipids on Day 1?Calculate calorie, protein and fat intake (in gm/kg) based on your first TPN order.How would you advance the TPN macronutrients to meet this child’s nutritional needs?What amino acid solution would you use and why?What labs should be checked on a daily basis? Which ones on a weekly basis?