Presentation on theme: "Parenteral and Enteral Nutrition in Neonates"— Presentation transcript:
1 Parenteral and Enteral Nutrition in Neonates Basics-protein early on-practical part-take out theory save as supplement-work related cheat sheet and problemsNICU Night Team Curriculum
2 Objectives Define basic nutritional requirements for neonatal growth Describe specific nutritional problems faced by low birthweight and premature infantsKnow components and advantages of breastmilk; indications for specific types of formulasDetermine components of TPN and be able to write fluid ordersFormulate an individualized plan for starting and advancing parenteral/enteral feeds
3 Goals of NutritionTo achieve a postnatal growth at a rate that approximates the intrauterine growth of a normal fetus at the same post-conceptional ageProvide balance in fluid homeostasis and electrolytesAvoid imbalance in macro-nutrientsProvide micro-nutrients and vitamins
4 CaseA 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 trimester18 week fetus swallows 18-50ml/kg/dayTerm ml/dayFetal swallowing regulates the volume of amniotic fluid and controls somatic growth of the GI tractIntestines double in length from weeksFunctionally mature gut by weeksIntestine in final anatomic position by 20 weeksPremature Infant GI tract:Delayed gastric emptying seen in pretermBreast milk, glucose polymers, prone positioning facilitate gastric emptyingTotal gut transit time in preterm 1-5 daysStooling delayed until after 3 days feeding volume ’s motility
6 Growth – General Facts Last trimester of pregnancy Fat and glycogen storingIron reservesCalcium and phosphoruos depositsPremature babies more fluid (85%-95%), 10% protein, 0.1% fat.No glycogen storesThe 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/dayTerm goal: ~110kcal/kg/dayTotal 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 lifeFull-term infants: 60–80 mL/kg/dayLate preterm and preterm infants (30–37 weeks): 80 mL/kg/dayVery-preterm infants: 100–120 mL/kg/dayDetermine 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/hrGIR: (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 acidsStart with 2- 3 g/kg/dayIncrease 0.5–1.5 g/kg/day to a total of 3–4 mg/kg/dayGoal for premature infants: 4g/kg/dayGoal for term infants: 3g/kg/daySource: trophamineCalculate electrolytes to add to bagDOL#1: dextrose in water with no eletrolutes is usually appropriate except in premies with low Ca stores who may require CaDOL#2: add electrolytes to the bag based on estimated daily requirements and BMPEstimated Needs:NaCl = 2-4 mEq/kg/dayKCl = 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 nutrientsLipidsCysteinPhosphrousMagnesiumTrace MineralsMVIHeparin
12 Total Parenteral Nutrition Central TPNPeripheral TPNEasy to meet nutrition needsNo limits on osmolarityLittle risk of phlebitisLong term useMay require general anesthesiaGreater risk of infectionIncreased costGreater risk of mechanical injury, air embolism, venous obstructionUnable to meet needs for Ca/Phos needsMaximum rate of Calcium gluconate is 200mg/kg/dMaximum % dextrose is 12.5%Short term useLess risk for catheter related infectionsLower cost ?Less risk of mechanical injury, air embolism, venous obstructionTotal 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 stableAbsence of food in the GI tract produces mucosal and villous atrophy and reduction of enzymes necessary for digestion and substrate absorptionTrophic 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 infantsImproves gastric emptying timeMatures the mucosal barrierPromotes earlier & appearance of IgAVastly ’s incidence of NECMore significant induction of lactase activity compared to formula fed premiesComposition:Varies with gestationVaries according to maternal dietVaries 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 toleratedPretermFeeds are often initiated with breastmilk, Sim 20 or SSC 24Trophic tube feeds may be continuous or bolus and advanced gradually (10-20mL/kg/day)Transition to bolus from continuous typically begins after achieving full feedsPO feeds typically attempted around weeks, when premies develop suck and swallow coordinationPremies are often supplemented with TPN as they work up on feedsGoal discharge formula is Neosure 22
18 Practice ProblemsBaby 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 ml1.9 mEq of potassium per 100 ml3.0 mEq of calcium per 100 ml1.2 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/day1.6 mMol of phosphorus/kg/day
20 Practice ProblemsBaby 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 mlPotassium: 1.5 mEq per 100 mlCalcium: 2.7 mEq per 100 mlPhosphorus: 1.1 mMol per 100 ml
22 ReferencesAmerican 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 PractitionersAdamkin, D. Nutrition Management of the Very Low-birthweight Infant: I. Total Parenteral Nutrition and Minimal Enteral Nutrition. NeoReviews 2006;7;e602-e607Hay, W. Strategies for Feeding the Preterm Infant. Neonatology ; 94(4): 245–254.Thank you NNPs Carol and Terri!