1. Parenteral and Enteral Nutrition in Neonates
Basics
-protein early on
-practical part
-take out theory save as supplement
-work related cheat sheet and problems
NICU Night Team Curriculum

2. Objectives Define basic nutritional requirements for neonatal growth
Describe specific nutritional problems faced by low birthweight and premature infants
Know components and advantages of breastmilk; indications for specific types of formulas
Determine components of TPN and be able to write fluid orders
Formulate an individualized plan for starting and advancing parenteral/enteral feeds

3. Goals of Nutrition
To achieve a postnatal growth at a rate that approximates the intrauterine growth of a normal fetus at the same post-conceptional age
Provide balance in fluid homeostasis and electrolytes
Avoid imbalance in macro-nutrients
Provide micro-nutrients and vitamins

4. Case
A 26 week female is born precipitously to a healthy 20 year old G1P1 with an uncomplicated pregnancy.
The baby is transferred to the NICU where a UAC and UVC are placed. You are getting ready to order fluids for this baby.
What is your goal growth for this infant?
What is this infant’s caloric requirement?
What fluids do you order?

5. Gastrointestinal Development
Fetal swallowing, motility in 2nd trimester
18 week fetus swallows 18-50ml/kg/day
Term ml/day
Fetal swallowing regulates the volume of amniotic fluid and controls somatic growth of the GI tract
Intestines double in length from weeks
Functionally mature gut by weeks
Intestine in final anatomic position by 20 weeks
Premature Infant GI tract:
Delayed gastric emptying seen in preterm
Breast milk, glucose polymers, prone positioning facilitate gastric emptying
Total gut transit time in preterm 1-5 days
Stooling delayed until after 3 days
 feeding volume ’s motility

6. Growth – General Facts Last trimester of pregnancy
Fat and glycogen storing
Iron reserves
Calcium and phosphoruos deposits
Premature babies more fluid (85%-95%), 10% protein, 0.1% fat.
No glycogen stores
The growth of VLBW infants lags considerably after birth

7. Growth Goals Weight: 20-30 g/day Length: ~1cm/week HC: 0.5cm/week
Correlates with brain growth and later development

8. Caloric Requirements for Growth
Preterm goal: ~120kcal/kg/day
Term goal: ~110kcal/kg/day
Total Fluid of enteral feeds required to deliver adequate calories for growth is ~150cc/kg/day

9. Total Parenteral Nutrition
Determine fluid requirement (mL/kg/day) for first day of life
Full-term infants: 60–80 mL/kg/day
Late preterm and preterm infants (30–37 weeks): 80 mL/kg/day
Very-preterm infants: 100–120 mL/kg/day
Determine Glucose Infusion Rate (GIR)
GIR: (% dextrose x IV rate ) ÷ (6 x wt in kg) Calculate GIR from known dextrose concentration (%).
Example: An infant weighs 2 kg and is receiving 100 ml/kg/day of dextrose 15% solution.
IV rate: 100 × 2 = 200 ml/day ÷ 24 = 8.3 ml/hr
GIR: (15% x 8.3 x ) ÷ 2 = 10.3mg/kg/min
(15% x 8.3 ) ÷ (6 x 2) = 10.3 mg/kg/min

10. Total Parenteral Nutrition
Protein and amino acids
Start with 2- 3 g/kg/day
Increase 0.5–1.5 g/kg/day to a total of 3–4 mg/kg/day
Goal for premature infants: 4g/kg/day
Goal for term infants: 3g/kg/day
Source: trophamine
Calculate electrolytes to add to bag
DOL#1: dextrose in water with no eletrolutes is usually appropriate except in premies with low Ca stores who may require Ca
DOL#2: add electrolytes to the bag based on estimated daily requirements and BMP
Estimated Needs:
NaCl = 2-4 mEq/kg/day
KCl = 1-2 mEq/kg/day (NOTE: Do not supplement K until UOP >1cc/kg/hr, especially in premies)
CaGluconate = mg/kg/day (NOTE: mg not mEq and Ca cannot be infused at >200mg/kg/day through a central line)

11. Total Parentral Nutrition
Other added nutrients
Lipids
Cystein
Phosphrous
Magnesium
Trace Minerals
MVI
Heparin

12. Total Parenteral Nutrition
Central TPN
Peripheral TPN
Easy to meet nutrition needs
No limits on osmolarity
Little risk of phlebitis
Long term use
May require general anesthesia
Greater risk of infection
Increased cost
Greater risk of mechanical injury, air embolism, venous obstruction
Unable to meet needs for Ca/Phos needs
Maximum rate of Calcium gluconate is 200mg/kg/d
Maximum % dextrose is 12.5%
Short term use
Less risk for catheter related infections
Lower cost ?
Less risk of mechanical injury, air embolism, venous obstruction
Total Parenteral Nutrition

13. Enteral Nutrition Breast milk is best!
The American Academy of Pediatrics (2005) recommends breastfeeding for the first year of life.
Started when an infant is clinically stable
Absence of food in the GI tract produces mucosal and villous atrophy and reduction of enzymes necessary for digestion and substrate absorption
Trophic hormones normally produced in the mouth, stomach, and gut in response to enteral feeding are diminished.
Breastmilk and standard infant formula have 20kcal/30cc (30cc=1oz)
Specialized formulas and fortifiers allow caloric content to be increased

14. Breastmilk Preferred source of enteral nutrition
Very well tolerated by most infants
Improves gastric emptying time
Matures the mucosal barrier
Promotes earlier &  appearance of IgA
Vastly ’s incidence of NEC
More significant induction of lactase activity compared to formula fed premies
Composition:
Varies with gestation
Varies according to maternal diet
Varies within a feeding( fat in last ½ fdg)
Varies within the day( fat in PM over AM)

15. Enteral Nutrition in the NICU
Term:
If clinically stable, start PO ad lib feeds and advance as tolerated
Preterm
Feeds are often initiated with breastmilk, Sim 20 or SSC 24
Trophic tube feeds may be continuous or bolus and advanced gradually (10-20mL/kg/day)
Transition to bolus from continuous typically begins after achieving full feeds
PO feeds typically attempted around weeks, when premies develop suck and swallow coordination
Premies are often supplemented with TPN as they work up on feeds
Goal discharge formula is Neosure 22

16. What to Feed?

17. What to Feed?

18. Practice Problems
Baby boy B weighs 1.2 kg. The IV rate is 6.8 ml/hr, and the IV fluid contains the following:
1.5 mEq of sodium per 100 ml
1.9 mEq of potassium per 100 ml
3.0 mEq of calcium per 100 ml
1.2 mMol of phosphorus per 100 ml.
Calculate the amount of sodium/kg/day, potassium/kg/day, calcium/kg/day, and phosphorus/kg/day that baby boy B is receiving.

19. Answer: 2 mEq of sodium/kg/day 2.6 mEq of potassium/kg/day
4.1 mEq of calcium/kg/day
1.6 mMol of phosphorus/kg/day

20. Practice Problems
Baby boy C weighs 1.5 kg. Total IV fluids are to be calculated at 140 ml/kg/day. The infant is receiving central TPN. Lipids are 2 gram/kg/day. Write TPN orders (including dextrose concentration and IV rates) to give baby C a glucose infusion rate of 8 mg/kg/min. Write orders for 4 mEq/kg of sodium, 2 mEq/kg of potassium, 3.5 mEq of calcium, and 1.5 mMol of phosphorus to be added to every 100 ml of IV base solution.

21. Answer: Lipids: 0.6 ml/hr PN fluids: dextrose 8.9% at 8.1 ml/hr
Sodium: 3.1 mEq per 100 ml
Potassium: 1.5 mEq per 100 ml
Calcium: 2.7 mEq per 100 ml
Phosphorus: 1.1 mMol per 100 ml

22. References
American Academy of Pediatrics, Section on Breastfeeding. (2005). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 115(2), 496–506.
Carlson, C, Shirland, S. Neonatal Parenteral and Enteral Nutrition, Resource Guide. National Association of Neonatal Nurse Practitioners
Adamkin, D. Nutrition Management of the Very Low-birthweight Infant: I. Total Parenteral Nutrition and Minimal Enteral Nutrition. NeoReviews 2006;7;e602-e607
Hay, W. Strategies for Feeding the Preterm Infant. Neonatology ; 94(4): 245–254.
Thank you NNPs Carol and Terri!