بسم الله الرحمن الرحيم

Pediatric parenteral nutrition M.safarian,MSc,MD, PhD Mashhad University of Medical Sciences, Nutrition Department

Indication: Unsafe or non functional GI Malnurished children Increased risk of malnutrition: They include infants who have gone: 2-3 days without adequate intake older children who have gone 4-5 days

Peripheral parenteral nutrition: • the patient is not fluid-restricted • nutrient needs can be met, and • central PN is not feasible.

Central parenteral nutrition: the patient is fluid-restricted peripheral access is limited, and nutritional needs cannot be met by peripheral PN.

PPN vs. TPN PPN TPN Peripheral access Central access <900 mOsm/L Max D12.5% Can go up to D15% with non-central PICC Usually requires increased fluid allowance TPN Central access No osmolarity limitations Typical max dextrose usually D25% however can go up to D30% prn ASPEN (2010)

Nutritional requirements Energy: less than EN In children & infants approximately 7-15% In neonate approximately ~25%

Nutritional requirements Energy: increased when : compromised respiratory status, sepsis, thermal burns, cardiac failure, chronic growth failure, who are recovering from surgery

Nutritional requirements Energy: Assessment: Weight change for short periods Growth pattern for long term Also : other anthropometrics

Parenteral Nutrition Kcal Goal kcal dictate macronutrient goals Extubated: provide ~10% < DRIs due to lack of thermogenesis Intubated: REE or ~80% DRI (dependent on pt’s age) usually appropriate Fung (2000)

Resting Energy Expenditure Age (years) REE (kcal/kg/day) 0 – 1 55 1 – 3 57 4 –6 48 7 –10 40 11-14 (Male/Female) 32 15-18 (Male/Female) 27

Factors adding to REE Multiplication factor Maintenance 0.2 Activity 0.1-0.25 Fever 0.13/per degree > 38ºC Simple Trauma Multiple Injuries 0.4 Burns 0.5-1 Sepsis Growth 0.5

Nutritional requirements Protein: AA in parenteral nutrition

Parenteral AA Guidelines Age Initiate Advance Maximum <1yr 1-2g/kg/day 1g/kg/day 4g/kg/day 1-10yr 1.5-3g/kg/day >10yr (adolescents) 0.8-2.5g/kg/day ***Goal aa correspond to ASPEN protein guidelines for critical illness ***4kcal/g aa ASPEN (2010)

Nutritional requirements Protein: Assessment: There is no good marker

Nutritional requirements Carbohydrate: Solutions greater than 12.5% dextrose should not be infused should be initiated in a stepwise fashion Assessment: evaluation of serum glucose levels

GIR/Dextrose Guidelines Age Initiate Advance Maximum <1yr ~6-9mg/kg/min 1-2mg/kg/min Goal: 10-12mg/kg/min Max: 14mg/kg/min 1-10yr Max: 8-10mg/kg/min >10yr (adolescents) Max: 5-6mg/kg/min ASPEN (2010)

Nutritional requirements Fat: Assessment: Tolerance is measured by an Intralipid level, a measure of unmetabolized intravenous fat or artificial chylomicrons. A level <1.0 g/L indicates acceptable clearance.

Do not give intravenous lipids to patients with an allergy to egg or soy due to the presence of egg and soy protein in the intravenous preparation.

Coss-Bu et al. (2001), ASPEN (2010) Parenteral Lipids Age Initiate Advance Maximum <1yr 1g/kg/day 3g/kg/day 1-10yr 2-3g/kg/day >10yr (adolescents) 1-2.5g/kg/day -goals dependent on total kcal goals -do not exceed 60% kcal via lipid (ketosis) -maximum lipid clearance 0.15g/kg/H Coss-Bu et al. (2001), ASPEN (2010)

Fat Emulsion What TG level is appropriate? < 200 if a trial period off < 300-350 if continuously infusing Lipid calories should not exceed dextrose calories Do not exceed 0.15 g/kg/hr infusion

Fat Emulsion When might Fat calories exceed carbohydrate calories? Patients with an elevated CO2 Fluid restricted patients Do not exceed 60% of total calories

PN Electrolyte Dosing Guidelines Preterm Neonates Infants/ Children Adolescents/ Children >50kg Na 2-5meq/kg 1-2meq/kg K 2-4meq/kg Ca 0.5-4meq/kg 10-20meq/day Phos 1-2mmol/kg 0.5-2mmol/kg 10-40mmol/day Mg 0.3-0.5meq/kg 10-30meq/day Acetate As needed to maintain acid-base balance Chloride Assuming normal organ function and losses ASPEN (2010)

Btaiche and Khalidi (2002), Kaufman (2002) PNALD PNALD Avoid macronutrient overfeeding in general Decrease lipids GIR ≤ 12.5mg/kg/min Cholestatic trace elements Decreased Cu; no Mn Cycle TPN as able Initiate EN asap (even trophic feeds) IL: build up of excess phytosterols therby increasing the lithogenesis of bile; omega-6 FA pro-inflammatory Cu and Mn are excreted in bile Trophic feeds to stimulate Cholecystokinin Btaiche and Khalidi (2002), Kaufman (2002)

PN-suggested guidelines for Initiation and Maintenance Substrate Initiation Advancement Goals Comments Dextrose 10% 2-5%/day 25% Increase as tolerated. Consider insulin if hyperglycemic Amino acids 1 g/kg/day 0.5-1 g/kg/day 2-3 g/kg/day Maintain calorie:nitrogen ratio at approximately 200:1 20% Lipids Only use 20%

Monitoring Initial: weight, height, Total protein/Albumin (TP/Alb), Transthyretin (TTR); Daily Chem until stable Stable: weekly Chem and bimonthly TG, LFT’s, TB/DB Chronic: bimonthly Chem and monthly TG, LFT’s, TP/Alb/TTR

Suggested monitoring Protocol Weight Urine dip for glucose Bedside glucose Labs First week Daily Q shift Daily SMA-7, Ca, Mg, Phos, triglycerides Q OD LFTs Subsequently SMA-7, Ca, Mg, Phos 2x/wk CBC, LFTs weekly Triglycerides 2x/wk

Calculations Dextrose ____g/100ml Dextrose  ____ml/day = ____grams/day _____g/day  (weight  1.44) = _____mg/kg/min _____g/kg/day  3.4 kcal/g = _____ kcal/kg/day

Calculations Fat 20 grams/100ml Fat  _____ml/day = _____grams/day _____g/kg/day  9 kcal/g = _____ kcal/kg/day

Calculations grams Protein  6.25 = _____ Nitrogen Non-protein calories  Nitrogen = Calorie:Nitrogen ratio Keep Cal/N ratio 150-200:1

Key points There may not exhibit significant hyper catabolism post-injury Their energy need may be decreased due to: Decreased physical activity, Transient absence of growth during the acute illness

Key points Overfeeding: Impair liver function by inducing steatosis/cholestasis Increase risk of infection Hyperglycemia Prolonged mechanical ventilation Prolonged icu LOS No benefit to the maintenance of lean body mass (LBM) Agus and Jaksic (2002)

Overfeeding complications Hyperglycemia glycosuria dehydration Lipogenesis fatty liver liver dysfunction Electrolyte abnormalities: PO4 , K, Mg Volume overload, CHF CO2 production- ventilatory demand O2 consumption Increased mortality (in adult studies)

MONITORING Prevent Overfeeding Carbohydrate: High RQ indicates CHO excess, stool reducing substances Protein: Nitrogen balance Fat: triglyceride Visceral protein monitoring Electrolytes, vitamin levels Nitrogen balance=(dietary protein/6.25)-(Urine urea nitrogen/0.8 +4) Positive balance in the range of 2-4 g nitrogen/day is desirable

Other complications CHOLESTASIS elevated conjugated bilirubin and other liver function tests. Patients most at risk to develop cholestasis: • overfeeding • lack enteral nutrition • long-term parenteral nutrition • gastrointestinal surgery • were preterm • a history of recurrent sepsis • peak conjugated bilirubin may occur up to one month after cessation of PN

Other complications Chylothorax Elevated serum urea Hyperglycemia Glycosuria Hyperbilirobinemia Hyperlipidemia Hypoglycemia

Thank you