Neonatal parenteral nutrition Dr HOMA BABAEI

n In VLBW newborn full enteral feedings are generally delayed because of the severity of medical problems associated with prematurity, such as immature lung function (which often requires endotracheal intubation and mechanical ventilation), hypothermia, infections, and hypotension

n As a result, the nutritional requirements of VLBW infants are rarely met by enteral feeds in the first two weeks after birth

n inadequate nutrition in the first weeks of life of premature infants results in growth failure and may lead to permanent mental effects. n The early use of adequate PN minimizes weight loss, improves growth and neurodevelopmental outcome, and appears to reduce the risk of mortality and later adverse outcomes, such as necrotizing enterocolitis and bronchopulmonary dysplasia.. n In one study of 148 extremely low birth weight (ELBW) survivors (birth weight below 1000 g), increasing caloric and protein intakes during the first week of life were associated with increases in the Bayley Mental Development Index (MDI) scores at 18 months of corrected

Indication for initiating PN n Infant with birth weight < 1500 gr n Infant with birth weight > 1500 gr that significant enteral intake is not expected for>3 days n GI abnormality, NEC

INFUSION ROUTES: n Peripheral –AAP recommends osmolarity between 300 and 900 mosm/l. n Centeral (svc,ivc) –>7 days inability for enteral feeding

PN for premature infant includes: –Adequate calories for Energy expenditure and Growth -Carbohydrate to prevent hypoglycemia -Adequate protein intake -Fatty acids - Mineral, electrolyte,Vitamins, trace elements

Energy Needs n Expenditure –Resting metabolic rate –Activity –Thermoregulation n Growth

Energy requirments in the parenteraly fed infant n Energy requirments: –BMR : –Thermoregulation 0-5 % –(Thermal stresses increase Energy E by100%) n Activity 0- 5% n Energy cost of growth 15 n Energy stored n Energy extered 15 n Total energy requirement : kcal/kg/d

Component of parenteral nutrition n Fluid n Carbohydrate n Lipids n Protein n Electrolytes n Vitamins and n Trace elements

n Carbohydrate and fat provide the calories(40-45%) n Pr for positive nitrogen balance and tissue growth n Studies shown: higher distribution of carbohydrate –adverse effects on respiratory metabolism n glucose conversion to fat.. Rise pco2 & oxygen consumption

n Intake of glucose (without lipid): protein oxidation n A study reported that preterm infants who received a PN solution contain higher energy from glucose without amino acid had frequent episodes of hyperglycemia. n With a greater AA supply associated with higher insulin secretion and normoglycemia.

Intravenous carbohydrate requirements n Neural tissue make up agreater proportion of BW( higher brain to body ratio) n Glycogenolysis &gluconeogenesis are minimal in VLBW(decresed fat stores). n Term 3-5mg/kg/day n Srart with 6 -8 mg/kg/min,advance by 1- 2mg/kg/min daily to amaximum of 12mg/kg/min(15mg/kg/min in selected cases) n Dextrose yields 3.4kcal/g.

n ELBW need to be started on a 5% glucose solution

Intravenous carbohydrate requirements n Complication : –Hyperglycemia(ELBW) = BS>150 BS <200 do not intervention Treatment: ( D/W 5%) Insulin : u /kg /h

INTRAVENOUS LIPID n Lipid solution are made up of :neutral triglycerides,egg yolk phospholipids, glycerol, soybean, n Prevent essential fatty acid deficiency –Linoleic and linolenic acids essential fatty acids. n Serve as energy source

n In VLBW : risk of essential fatty acid deficiency within 72 h of life ( dermatitis, thrombocytopenia ). n Intitiated within h of life

INTRAVENOUS LIPID n Intravenous lipids are available as:10%,20%,30%. n Lipid intake of gr/kg/d is required to prevent essential fatty acid deficiency n Started at 1g/kg/d and increased to 3g/kg/d (3.5g/kg/d in the ELBW)

INTRAVENOUS LIPID n Do not allow lipids to exceed 60% of total caloric intake. n Lipid infusion rates >0.25g/kg/h associated with decreases in po2. n Infusion during 24 h (change syrings) n Jaundice requiring phototherapy :concentration >2gr/kg/day shoud be avoided.

INTRAVENOUS LIPID n Triglyceride concentration below mg/dl n Lipid peroxidation result in formation of organic free radicals ---- tissue injury –Light,especially phototherapy

INTRAVENOUS LIPID n Complication: –Pulmonary hypertention(PPHN)(free radical) –Hyperlipidemia –Kernicterus –Impaird lymph drainage –edema

INTRAVENOUS LIPID n Monitoring: –Lipid infusion reaches 1.5g/kg/d –Lipid infusion reaches 3g/kg/d –weekly

AMINOACID REQUIREMENT n VLBW with no AA --- lose 1g/kg/d of protein every day –1-2% total endogenous body protein stores n Combined use of early AA & glucose within first 24 h replaces urinary nitrogen loss. n In premature infants : 3.5 to 4 g/kg/day is needed to meet intrauterine accretion. n ≥4 g/kg/day with lower rate of BPD but failed to improvement in growth

n Administer AA intake 3.5 g/kg on day of birth. n This level of AA in PN reduce risk of hyperglycemic episodes versus lower AA concentration.

calcium n Reduce intake, n impaird response to PTH n Increased calcitonin level n Increased urinary loss

Inadequate of calcium n Osteopenia of prematurity n Fracture n Affect chest wall stability ----atelectasia &chronic lung disease

n Immediately after birth PN should include enough ca ( elemental mg/kg/d) n P : not needed in 1 -2 first day. n Added if P<5mg/dl

n Calcium:80 mg/kg/d n Phosphorus:40-70 mg/kg/d n Ca/p ratio =1.7/1 optimal for bone mineralization

Vitamin n 1cc/kg/d in preterm(max 5cc) n 5cc/d in term n Vit A

Electrolytes n Sodium need is 2-3mEq/kg/d in term &4- 5mEq/kg/d in the preterm n Potassium need is 2-3mEq/kg/d in both term &preterm. n Magnesium:3-7.2mg/kg/d

mineral, trace element n Zinc : –250 microg/kg/d for term –400microg/kg/d for preterm n Other trace elements n Only trace elemnt recommended from the first day PN are zinc and selenium n Other trace elemnt after 2 weeks of age n Iron :parenteral iron only after 1 month

TPN WEANING n Milk >50CC/kg/d –TPN gradually tapered off n Milk > CC/kg/d—TPN stopped n Dextrose stopped with tapering n Lipid may be stopped without tapering

COMPLICATIONS OF PN n Electrolyte imbalance n Hypoglycemia,hyperglycemia,hypocalce mia,hypercalcemia,…. n Cholestasis n Complication related to the infusion line

cholestasis n Multifactorial –Sepsis, hypoxia,.. –Prolonged lack of enteral nutrition –Aminoacid toxicity n Serum bile acids n Gamma –glutamyltranspeptidase n Hepatic transaminases

Venous line complication n Thrombosis n Infection –Staphylococcus epidermidis –Candida albicans

LAB TEST testInitialWhen stable Electrolytes, BUN/Cr Daily2-3X/week glucoseQ6hr-dailyDaily&when changing CHO Ca,ionizedDaily2-3X/week P,mg,bili,ALT,A LKP,ALb baselineweekly Triglycerid1.5g/fat/kg/d, 3g/fat/kg/d weekly CBC.PLTweekly

example n FLUID at 140ml/kg/d n D12.5% g/kg kcal/kg n AMINOACIDS---3g/kg kcal/kg n LIPID 20%-- --3g/kg kcal/kg n TOTAL 99 kcal/kg