Neonatal Parenteral Feeding

Dr.Allam Abuhamda

Consultant of Pediatrics

Neonatal fellowship

Objectives

GOALS OF PARENTERAL NUTRITION

ENERGY NEEDS

TPN COMPOSITION

ADMINISTRATION

COMPLICATIONS

INTRODUCTION

The nutritional needs of premature infants are usually dependent upon parenteral nutrition .

Full enteral feedings are generally delayed because of the :

Prematurity

Immature lung function

Hypothermia

Infections

Hypotension

GOALS OF PARENTERAL NUTRITION (PN)

The early use of adequate PN minimizes :

Weight loss

Improves growth and neurodevelopmental outcome

Reduce the risk of mortality .

Necrotizing enterocolitis .

Bronchopulmonary dysplasia

ENERGY NEEDS

Energy requirements must cover both energy needed for energy expenditure :

o Resting metabolic rate

o Activity

o Thermoregulation

Growth

ENERGY NEEDS

The premature infant has an energy requirement of 80 to 100 kcal/kg per day .

Carbohydrates and fat primarily provide the calories for energy.

Calories derived from carbohydrates and lipids is generally about 40 and 45 percent of calories from fat and carbohydrates respectively.

GLUCOSE

Glucose is the source of carbohydrate used in parenteral nutrition .

High glucose infusion rates may be required in the preterm infant .

Infants of birth weights less than 1000 g are particularly susceptible to hyperglycemia particularly in the first few days of life

Ineffective insulin secretion End-organ insulin resistance

Decreased glucose intracellular transporters

Elevated catecholamines and glucocorticoids

Absence of enteral nutrition.

Provision of high glucose intakes

The early initiation of amino acid and lipid infusion in ELBW infants is another alternate strategy to prevent hyperglycemia.

AMINO ACIDS

Protein accruement and growth.

Replaces urinary protein loss due to protein breakdown.

In premature infants receiving PN an amino acid intake of 3.5 to 4 g/kg per day is needed to meet the intrauterine accretion rate

Replaces urinary protein loss due to protein breakdown

In premature infants receiving PN an amino acid intake of 3.5 to 4 g/kg per day is needed to meet the intrauterine accretion rate.

The essential amino acids in PN include isoleucine, leucine, lysine, methionine,

phenylalanine, threonine, tryptophan, and valine.

Conditionally essential :

cysteine , glutamine, glycine, histidine, taurine, and tyrosine.

The recommended regimen : immediately after birth with an amino acid infusion rate of 3 g/kg per day.

LIPIDS

Intravenous lipid administration provides essential fatty acids .

Small amounts of essential fatty acid are required to prevent essential fatty acid deficiency.

Intravenous fat emulsion : o Soybean o Safflower o Fish oils o Glycerin and egg yolk phospholipids added as

emulsifiers

The 20 percent IL solution versus 10 percent solution .

The accumulation of lipoprotein X appears to be due to the higher ratio of phospholipids to triglycerides in the 10 percent solution

Continuous versus intermittent infusion

Measurement of IL tolerability

Measurement of plasma or serum free fatty acid.

Omegaven utilizes fish oil which contains long-chain polyunsaturated fatty acids.

OTHER NUTRIENTS

Hypocalcemia

Phosphate metabolic abnormalities.

Hypermagnesemia may occur in premature infants whose mothers were treated with magnesium therapy.

Dose of elemental Ca ranges from 25 to 75 mg/kg per day.

The optimal ratio of Ca to P in PN is generally between 1:1.3 and 1:1.7 by weight and nearly a 1:1 molar ratio

Vitamins

Organic substances that cannot be synthesized by humans.

They are divided into water-soluble and fat-soluble vitamins.

Premature infants need higher amounts of some vitamins than do term infant.

Vitamin A o normal lung growth

o integrity of respiratory tract epithelial cells

o Immunocompetency and cell differentiation

Vitamin E

o Vitamin E is a free-radical scavenger

Water-soluble vitamins

Electrolytes

Sodium and potassium

Acetate

Trace elements

low body stores and increased requirements for growth.

Birth weight ≤2.5 kg Zinc: 400 mcg/kg Copper: 20 mcg/kg Chromium: 0.4 mcg/kg Manganese: 1 mcg/kg Selenium: 2 mcg/kg

The only trace elements recommended from the first day PN are zinc and selenium

ADMINISTRATION

PN can be infused through peripheral or central veins .

If possible the continuity of PN infusion should not be interrupted to reduce the risk of infection.

PN should be administered within the first day of life .

COMPLICATIONS

Cholestasis

Infection and sepsis

Infiltration and potentially skin sloughing, and air embolus

Bone disease may occur if adequate nutrients are not provided

Summary

PN should provide sufficient calories for energy expenditure and growth

Glucose is the carbohydrate used in PN and is a major source of caloric intake needed to meet energy needs

The delivery of adequate intakes of both protein and energy to achieve a positive nitrogen balance required for growth and to prevent protein turnover

IL administration provides essential fatty acids and is an important nonprotein source of energy

Summary

We recommend that early PN be given on the first day of life

PN can be infused through peripheral or central veins

In patients who require ongoing administration of PN, caloric concentration is increased to provide adequate calories for growth. In addition, trace elements, phosphorus, magnesium, and cysteine are added to PN

Any Questions

REFERENCES

"Approach to enteral nutrition in the premature infantLiterature review current through: Jun 2013. | This topic last updated: Jun 12, 2013

parenteral nutrition (PN) Literature review current through: Jun 2013. | This topic last updated: May 1, 2013