1. بسم الله الرحمن الرحيم

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

3. 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

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

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

6. 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)

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

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

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

10. 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)

11. 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

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

13. Nutritional requirements
Protein:
AA in parenteral nutrition

15. 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)
g/kg/day
***Goal aa correspond to ASPEN protein guidelines for critical illness
***4kcal/g aa
ASPEN (2010)

16. Nutritional requirements
Protein:
Assessment:
There is no good marker

17. 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

19. 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)

20. 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.

21. 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.

23. 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)

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

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

26. 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
meq/kg
10-30meq/day
Acetate
As needed to maintain acid-base balance
Chloride
Assuming normal organ function and losses
ASPEN (2010)

27. 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)

28. 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%

29. 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

30. 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

31. 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

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

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

34. 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

35. 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)

36. 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)

37. 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/ )
Positive balance in the range of 2-4 g nitrogen/day is desirable

38. 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

39. Other complications Chylothorax Elevated serum urea Hyperglycemia
Glycosuria
Hyperbilirobinemia
Hyperlipidemia
Hypoglycemia

41. Thank you