Parenteral nutrition in neonate

Goals minimizes weight loss improves growth and neurodevelopmental outcome reduce the risk of mortality and NEC

Caloric concentration A. Dextrose: 3.4 kcal/g. B. Protein: 4 kcal/g. C. Fat: 9 kcal/g.

Carbohydrates  5 to 6 mg/kg per minute be required in the preterm infant to prevent hypoglycemia  In ELBW neonate glucose starting at 3.5 mg/kg per minute (5 g/kg day) and slowly increasing to 12 mg/kg/min over several days  Dextrose is provided to maintain blood sugar between mg/dl

 In the presence of hyperglycemia, glucose infusion rate should not be reduced below 4 mg/kg/min.  Insulin may be required to maintain adequate blood glucose levels, although its routine use is not recommended

proteins  Inadequate protein intake : Failure to thrive(lose 1 g/kg per day) Hypoalbuminemia Edema

 Amino acid intake produced positive nitrogen balance and appropriate growth  Glutathione, an antioxidant concentrations rise with early amino acid administration  Early amino acid supplementation may help decrease hyperglycemia and hyperkalemia

Amino Acid Solations  The ideal mixture of amino acids for PN in premature infants is unknow  TrophAmine, Aminosyn PF, Aminoven are available that contain less of those potentially neurotoxic amino acids

 In preterm ELBW and VLBW infants, 3.5 g/kg/d of amino acids should be started on day 1 and is associated with better linear growth and neurodevelopmental outcomes.  Term infants who are likely to have delayed initiation of enteral nutrition should be started on 1.5 g/kg/d of proteins

Lipid  Intravenous lipid administration provides essential fatty acids  provides needed energy for tissue healing and growth  combination of lipids and amino acids reduce episodes of hyperglycemia

 Starting lipids at 0.5–1 g/kg/d within 24 hours of birth is safe.  Advance by 0.5–1.0 g/kg/d as tolerated up to 3.0 g/kg/d.  The infusion is given continuously over 20–24 hours.  The rate should not exceed 0.12–0.15 g/kg/h  The use of 20% emulsions is preferred over 10%

 Lipids should be administered separately from amino acids  caution may be needed in hyperbilirubinemia  New lipid formulation(omegaven,smoflipid)

 Vitamins  minerals  Trace elements  Heparin

Monitoring  Weight Daily  Length Weekly  Head circumference Weekly  Intake and output Daily  Glucose 2–3 times per day ; then as needed  Calcium, phosphorus, 2–3 times per week; then every 1–2 weeks

 Electrolytes (Na, Cl, K, CO2) Daily, then 2–3 times per week. BUN and creatinine 2–3 per week; then every 1–2 weeks  Bilirubin Weekly  Ammonia Weekly if using high protein

 Total protein and albumin every 2–3 weeks  AST/ALT every 2–3 weeks  Triglycerides 1–2 per week  Vitamins and trace minerals as indicated  Urine  Specific gravity and glucose 1–3 times per day initially; then as needed

Intravenous routes used in PN  A. Central PN. Central PN is usually reserved for patients requiring long-term(>2 weeks administration of most calories).  Basically, this type of nutrition involves infusion of a hypertonic nutrient solution (15–30% dextrose)

 B. Peripheral PN. The maximum concentration of dextrose that can be administered is12.5%  C. Umbilical catheters. PN can be given through an umbilical artery catheter but it is not preferred and should be used with caution. Maximum dextrose in UAC is 15%.

cmplications nutrient-related :  hypoglycemia (plasma sugar < 50 mg%)  hyperglycemia (plasma sugar > 150 mg)  Hyperammonemia  metabolic acidosis (protein related);  hypertriglyceridemia (triglyceride > 200mg/dl)  Cholestasis

`  Risk factors cholestasis : prematurity sepsis hypoxia hemodynamic instability duration of PN delayed entral feeding

 Catheter-related : malposition and infection pneumothorax pneumomediastinum, chylothorax  Infection: Staphylococcus Pseudomonas spp, Klebsiella spp Candida albicans.