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Peds TPN 2010

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Pediatric Parenteral Nutrition Support

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Peds TPN 2010

  1. 1. Pediatric Parenteral Nutrition Ana Abad-Jorge, MS, RD, CNSC Director, Dietetic Internship Program Pediatric Nutrition Specialist UVA Health System Charlottesville, VA
  2. 2. Learning Objectives Identify 5 common indications for PN in infants & children Determine parenteral energy and protein requirements for infants and children Discuss 4 common complications of overfeeding. Review how to begin and advance the following macronutrients: % dextrose, protein and lipids. Calculate glucose infusion rate (GIR) and discuss its significance. List 3 common signs of essential fatty acid deficiency Given a TPN and lipid prescription and the child’s weight, determine TPN calories. Discuss laboratory monitoring for children on PN.
  3. 3. Indications for Parenteral Nutrition in Infants and Children Gastrointestinal Anomalies & Complications i.e. NEC, gastroschesis, short bowel Promotion of healing of TE fistula Inflammatory bowel disease (severe cases) Pediatric malignancies with severe GI problems Preterm infants with severe respiratory distress, immature gut motility & function Critically ill (trauma, sepsis) patients with ileus and/or abdominal trauma
  4. 4. Parenteral Nutrition Requirements Age Calories (kcal/kg) Protein (gm/kg) Preterm SGA 90 – 100 95 - 115 3.0 – 4.0 3.5 - 4.0 0 – 1 BPD or CHD 80 – 100 90 – 130 2.5 – 3.0 3.0 – 3.5 1 - 7 75 - 90 1.5 - 2.0 7-12 60 - 75 1.5 - 2.0 12 - 18 30 - 60 1.0 - 1.5
  5. 5. Approach for the Critically Ill Pediatric Patient Begin with BEE for the first 1 – 3 days Gradually advance energy delivery toward above outlined goals, as status improves (usually below RDA) Indirect calorimetry still considered the “gold standard” although not typically used given financial and training considerations.
  6. 6. Complications of Overfeeding Excess CO2 production & increased minute ventilation Pulmonary edema and respiratory failure Hyperglycemia, which may lead to immuno- suppression, and increased infection rates Lipogenesis due to increased insulin production Generalized immunosuppression Hepatic complications: fatty liver, intrahepatic cholestasis, due to excess carbohydrate or protein delivery.
  7. 7. Maintenance Fluid Requirements for Children Body Weight Amount Fluid/day 0.5 - 2.0 kg 120 -250 ml/kg 2 - 10 kg 100 ml/kg 11 - 20 kg 1000 ml + 50 ml/kg for each kg>10 kg > 20 kg 1500 ml + 20 ml/kg for each kg>20 kg
  8. 8. Fluid Requirements Skills Check What are the maintenance fluid requirements of a 17 kg child? ANSWER: 1350 ml What is this volume per kg? ANSWER: 79 kcal/kg
  9. 9. Use of Carbohydrate in PN Dextrose (D-Glucose) = 3.4 kcal/gm Indications for peripheral vs. central PN: 1. Peripheral - max. of D10 - D12 % (PPN) Why? - Indicated for short term PN < 2 weeks 2. Central - usual max of D20 - 25% (CPN) - For periods > 2 weeks, or if infant has poor access may use a surgical central line or a PICC-line Small preterms: frequent hyperglycemia Why? Initiation and advancement: Determine GIR 1. Preterms - advance by 0.5 - 2% q day 2. Older infants/children- adv. by 2.5 - 5% q day
  10. 10. Glucose Infusion Rate (GIR) Calculating GIR:Calculating GIR: Rate X % Dextrose Weight (kg) X 6 Units: mg glucose/kg/minuteUnits: mg glucose/kg/minute GuidelinesGuidelines Infants: Limit GIR to 12 – 14 mg/kg/min: Limit GIR to 12 – 14 mg/kg/min Children: Limit GIR to 7 – 12 mg/kg/minChildren: Limit GIR to 7 – 12 mg/kg/min
  11. 11. GIR Calculation Problem Infant in the PICU diagnosed with neuroblastoma, receiving chemotherapy. Weight: 6.8 kg Infant’s TPN advanced over the weekend to: D25% TPN with 20 gm TrophAmine/day TPN Rate: 28 ml/hr Calculate: GIR
  12. 12. GIR Calculation Calculating GIR:Calculating GIR: 28 X 25 6.8 kg X 6 ANSWER: 17.2 mg/glucose/kg/min What can you say about this GIR level?
  13. 13. Management of Hyperglycemia in Infants & Children on PN Initially may need to back down on % dextrose in PN Hyperglycemia may be caused by decreased insulin production, insulin resistance or stress response. Insulin administration to preterm or critically ill infants is controversial due to variable responses. What are they? Close monitoring is necessary to prevent episodes of hypoglycemia, which may lead to brain damage. If closely monitored, insulin administration can result in increased energy intake and weight gain. Initial dose = 0.05-0.1 U/kg/hour via a continuous infusion; monitor blood glucose q hour initially.
  14. 14. Initiation and Advancement of Protein in PN: Preterm & term infants: – Begin at 1.5 - 2.0 gm/kg q day and – Advance by 1 gm/kg q day to endpoint goal. Older children: Begin at 1 – 2 gm/kg and advance to goal by Day 2 of PN Endpoint goals: - Preterm & term infants: 3.5 - 4 gm/kg - Older children: 1.5 - 2.5 gm/kg
  15. 15. Advantages of TrophAmine: Provides essential amino acids (taurine, tyrosine, histidine) 60% EAA Promotes plasma amino acid profiles within normal neonatal target range Decreases tendency for cholestasis Addition of cysteine HCl decreases pH of PN: improves solubility of Ca & Phos Recommended for infants < 2 years old
  16. 16. Initiation and Advancement of Lipid in PN: Preterm & term infants: – Begin at 0.5 - 1.0 gm/kg q day and – Advance by 0.5 - 1 gm/kg q day to endpoint goal. Older children: Begin at 1.0 gm/kg and advance to goal by Day 2 of PN Endpoint goals: - Preterm & term infants: 2.5 – 4 gm/kg - Older children: 1.0 – 2.5 gm/kg
  17. 17. Use of Lipids in PN in Children Minimal goals for provision of EFA: 0.5 - 1.0 gm/kg/day Intralipid: 54% linoleic acid 1. 10% Intralipid - 1.1 kcal/ml 2. 20% Intralipid - 2.0 kcal/ml (Only at UVA-HS) Intralipid provides 10 kcal/gm (due to glycerol) Egg phospholipid may be allergy source SGA infants are more susceptible to hyperlipidemia Why?
  18. 18. Clinical Signs of EFA Deficiency Reduced growth rate Flaky dry skin Poor hair growth Thrombocytopenia ….What is this? Increased susceptibility to infections Impaired wound healing
  19. 19. Intralipid should be used with caution: Hyperbilirubinemia  Fatty acids may displace bilirubin from albumin binding sites, increasing the risk of kernicterus. Pulmonary hypertension or severe RDS  Excess lipid intake may decrease CO2 & O2 diffusion capacity across the alveolar membranes. Sepsis  Excess lipid increases arachidonic acid production, and thus 2 series prostaglandins and 4 series leukotrienes. These substances may cause increased risk of immunosuppression.
  20. 20. The Use of Carnitine in PN Preterm/SGA infants on long term PN may become carnitine deficient due to lacking some enzymes needed for biosynthesis. Symptoms may include: cardiomyopathy, increased triglycerides hypotonia, muscle weakness, acidosis, failure to thrive. Improvement in carnitine status can lead to: Improved lipid tolerance Improved nitrogen accretion Improved growth.
  21. 21. What does carnitine do???
  22. 22. Functions of Carnitine Transports long-chain fatty acids into the mitochondria for beta-oxidation Regulates rate of fatty acid oxidation Assists in ATP production Scavenger of harmful acyl groups that may lead to lipid membrane oxidation Maintains pool of free CoA in mitochondria
  23. 23. Recommended Dosages for Children 50-100 mg/kg/day level is used (may be therapeutic) Some negative effects reported at greater than 50 mg/kg/day May be prudent to use 10-20 mg/kg/day, especially in infants Side effects: diarrhea, nausea, cramping; risk for seizures
  24. 24. Pediatric Multivitamins Vitamin C - 80 mg Vitamin A - 2300 IU Vitamin D - 400 IU Vitamin E - 7 IU Vitamin K - 0.2 mg Biotin - 20 ug 5 ml for wt up to 40 kg 2 ml/kg Peds MVI for wt through 2.5 kg Vitamin B1 - 1.2 mg Vitamin B2 - 1.4 mg Vitamin B3 - 17 mg Vitamin B6 - 1 mg Vitamin B12- 1 ug Folic Acid - 140 ug Use 10 ml adult MVI for children > 40 kg
  25. 25. Pediatric Trace Element Solution Trace Element Content Zinc 300 ug Copper 20 ug Chromium 0.17 ug Manganese 5 ug * Use 0.2 ml/kg/day for children up to 5 kg. * Add 100ug/kg zinc for infants < 2.5 kg * Add 50 ug/kg zinc for post-op heart infants or to aid in wound healing.
  26. 26. Recommended Calcium & Phosphorus Intakes for PN: Child Age Calcium (mEq/kg) Phosphorus (mMol/kg) Preterm/Term 3.5 - 4.5 1.2 – 1.6 2 - 12 yrs 1 - 2.5 0.8 – 1.0 Adolescents 1.0 0.5 Note: 1mMol = 2mEq
  27. 27. General Guidelines for PN Solubility: Protein, Calcium and Phosphorus Per every 100 ml/kg of PN can add: – 4 gm/kg TrophAmine – 4 mEq/kg of Calcium – 1.5 mMol/kg of Phosphorus Can add only 40 gm of TrophAmine/L in TPN Can add 45 - 50 gm of standard amino acids/L Solubility Limits for Calcium & Phosphorus – 5.2 mEq/100 ml of Ca + Phos for standard amino acids – 7.2 mEq/100 ml of Ca + Phos for TrophAmine
  28. 28. Neonatal TPN Practice Problem: Part I 2 month old infant s/p cardiac surgery for Tetrology of Fallot (TOF) Infant weight: 3.6 kg Infant is to begin TPN and lipids on POD #1, but given volume restriction and multiple I.V. medications post-op, he can only receive 6 ml/hr of TPN. What type of protein will you use? Why? TrophAmine
  29. 29. Neonatal TPN Practice Problem: Part II How many ml/kg of TPN will the infant receive? 6 ml/hr X 24 hr / 3.6 kg = 40 ml/kg What is the maximum amount of Calcium you can order in mEq/kg? 1.6 mEq/kg What is the maximum amount of Phosphorus you can order in mMol/kg? 0.6 mMol/kg
  30. 30. Use of H2 Blockers in TPN Recommended for use in infants and children on TPN for at least 1 week who will not be enterally fed. Prevents excess HCl acid production, used for ulcer prophylaxis. Pediatric dose for Famotidine: 0.8 – 1.0 mg/kg
  31. 31. Use of Parenteral Iron (Imferon) Controversial due to concerns of increased risk of gram negative sepsis Infants with iron deficiency anemia with decreased hemoglobin/hematocrit or serum ferritin need iron in PN Begin 0.5-0.8 mg/kg/day for 1-3 weeks Monitor indices of iron status: HCT/HGB, MCV, serum Fe, ferritin
  32. 32. Selenium Supplementation in PN: Selenium deficiency: cardiomyopathy skeletal muscle tenderness/pain erythrocyte macrocytosis loss of pigmentation of hair and skin Selenium deficiency may occur with long term selenium free PN Supplementation: 1-2 ug/kg/day Normal Selenium: 6.3-12.6 ug/dl
  33. 33. Calculation of Total Calories & Nutrients from Parenteral Nutrition PN volume = PN rate (ml/hr) X 24 hours a. Calories from Dextrose PN volume X % dextrose X 3.4 kcal/gm b. Calories from Protein Total grams protein/day X 4.0 kcal/gm or gm/kg protein X wt (kg) X 4.0 kcal/gm c. Calories from Fat Intralipid volume X 1.1 kcal/cc (10% IL) Intralipid volume X 2.0 kcal/cc (20% IL) @ UVA-HS d. Kcal/kg = a + b + c / weight (kg)
  34. 34. Peds TPN Example Infant with Short Bowel Syndrome Weight: 5 kg TPN Prescription: D 20% TPN with 3 gm/kg TrophAmine at 20 ml/hr X 24 hours. Lipid order: 50 ml of 20% Intralipid Calculate TPN total kcal and kcal/kg
  35. 35. TPN Calorie Calculations TPN Volume? 20 ml/hr X 24 hours = 480 ml Dextrose Calories? = 480 ml X .20 X 3.4 = 326 kcal (a) Protein Calories? = 3 gm/kg X 5.0 kg X 4 kcal/gm = 60 kcal (b) Fat Calories? = 50 ml X 2.0 kcal/ml = 100 kcal (c) Total Calories = a + b + c/wt (kg) = 486 kcal/5.0 kg = 97 kcal/kg
  36. 36. Pediatric Cyclic Parenteral Nutrition Recommended for children on long term PN, who will benefit from a nocturnal PN schedule Advantages: Provides a “window” or break when no PN is given, allows for normal activities during the day: ambulation, therapies, school etc.. Provides a physiological “break” from PN, which has been shown to decrease incidence of cholestasis and hepatic toxicity PN must be tapered on and off, to help prevent episodes of hyper & hypoglycemia – Example: 10 ml/hr X 1 hr, 20 ml/hr X 10 hr, 10 ml/hr X 1 hr
  37. 37. Monitoring Growth & Tolerance of Pediatric PN Anthropometrics: daily weights in infants, weekly in older children, length & head circumference for assessment of linear growth Laboratory Monitoring: 1. Initial Monitoring: Basic Metabolic Panel to include: Na, K, Cl, CO2, BUN, Cr, Glucose, Ca, Mg, and Phos 2. Weekly PN Monitoring: TPN Profile (NICU) or Hepatic Panel A + triglycerides, prealbumin Need: Albumin, AST/ALT, Alkaline phosphatase, triglycerides, and conjugated bilirubin
  38. 38. Complications of PN in Children Metabolic Complications: electrolyte disturbances, hyperglycemia, hyperammonemia, metabolic alkalosis Complications with Intralipids: hyperlipidemia in SGA infants and during sepsis, decreased activity of lipoprotein lipase. Use lipids with caution with: 1. Hyperbilirubinemia 2. Infection/sepsis 3. Severe or chronic lung disease Liver Dysfunction 1. Cholestasis: caused by excess kcal or protein 2. Fatty liver: related to excess calories, including CHO calories
  39. 39. Role of the Nutritionist in Managing Pediatric Parenteral Nutrition Work closely with physicians or residents ordering the PN to make appropriate recommendations, so that PN order changes can be entered in a timely manner. Educate physicians and pediatric residents on the “how-to’s” of pediatric PN on regular basis Whenever possible work to obtain “verbal” or “pended” order privileges on PN. The R.D. would then be able to enter PN orders.
  40. 40. Role of the Nutritionist in Monitoring Pediatric Parenteral Nutrition Work closely with physicians, nurses and computer specialists to make changes to PN ordering forms or be part of team to develop order screens when using the electronic medical record (EMR) ordering process. Work closely with nurse practitioners and home health companies to facilitate transition from hospital to home and to ensure that patient receives the appropriate PN formulation in the home setting.
  41. 41. Pediatric PN Case Study 5 year old girl admitted to PICU following an MVA. She has experienced: – Significant abdominal trauma, perforation of duodenum – Splenic laceration – Right femur fracture Admission weight: 18 kg (50th %-ile) NCHS curves Post-operative Day 1: Receiving D5% ¼ NS at 50 ml/hr. She had central line placed in the OR. Consult: Begin PN and lipids, TPN rate to start at 50 ml/hr to replace above IV fluids.
  42. 42. Questions to Consider …. What are this child’s calorie, protein and fluid requirements? How would you start TPN and lipids on Day 1? Calculate calorie, protein and fat intake (in gm/kg) based on your first TPN order. How would you advance the TPN macronutrients to meet this child’s nutritional needs? What amino acid solution would you use and why? What labs should be checked on a daily basis? Which ones on a weekly basis?
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Pediatric Parenteral Nutrition Support

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