- Parenteral nutrition (PN) is the intravenous administration of amino acids (proteins), lipids, carbohydrates, electrolytes, minerals, vitamins and trace elements necessary for metabolic requirements and growth.
- PN may be total, i.e. total parenteral nutrition (TPN) where all nutrients are administered, usually via a central venous line, until the infant is again ready to take enteral feeds.
- PN may also be partial, i.e. partial parenteral nutrition (PPN) where it is used to supplement enteral feeds in infants who cannot yet tolerate their full complement of enteral feeds.
- If possible, the enteral route should also be used, even if it is only able to supply a fraction of the required nutrients.
- PN should be used only when it is not possible to meet nutritional requirements enterally or when there is gastrointestinal dysfunction resulting in inability to tolerate enteral nutrition for a prolonged time: 1 to 3 days in infants, 4 to 5 days for children and adolescents.
- Administer PN preferably via a central venous line, especially when it is expected that the infant will require TPN for more than 7 days. For partial parenteral nutrition, a peripheral venous line may be used, especially where it is expected that the infant will require PPN for only a few days (< 7 days). Only PN solutions which contain lipids and have an osmolarity of < 1000 mOsm/L and non-lipid containing PN solutions with an osmolarity < 800 mOsm/L can be safely administered via a peripheral vein.
- Check peripheral vein infusion sites and patency of the line/catheter regularly for tissue infiltration.
- Transport and store PN solutions at 2–8ºC. Start administration of the PN solutions within one hour after removal from the refrigerator.
- Do not make additions to a PN bag or decant contents as the stability and/or the sterility may be compromised.
- Do not use the PN line to collect blood samples.
- Administer PN through a dedicated line and do not administer medications, blood, etc. through the PN line.
- Use a 1.2 micron in-line filter for lipid containing PN solutions and a 0.2 micron filter for lipid-free PN solutions.
- Adhere to a strict aseptic technique when administering PN solutions. Check solution and administration sets before starting the infusion.
- Use bags within 24 hours of starting the infusion.
- PN should be prescribed and administered under the supervision of a paediatrician and dietician.
COMPLICATIONS OF PN:
- IV line/catheter complications, e.g. extravasation, blockage or bacterial/fungal contamination;
- metabolic complications, e.g. hyperglycaemia, high ammonia, metabolic acidosis, electrolyte and mineral disturbances and hyperlipidaemia;
- infection/sepsis; and
- cholestatic hepatitis.
Monitor:
- vital signs and hydration;
- blood glucose 12 hourly, maintain blood glucose at 2.6–6.0 mmol/L;
- electrolytes, minerals and acid-base on a daily basis or more regularly if necessary;
- growth parameters and weight, once weekly;
- infection markers at least once weekly or more frequently if necessary; and
- liver enzymes, bilirubin, ammonia, lipids, urea and creatinine once weekly or more frequently, as indicated by the condition of the infant.
PARENTERAL NUTRITION FORMULATIONS
Use the standard TPN formulations that are commercially available for paediatric use and that have been manufactured at a GMP (Good Manufacturing Practice) compliant site and have been regulated by the Medicines Control Council.
PARENTERAL NUTRITION, NEONATAL
DESCRIPTION
Parenteral nutrition (PN) should be considered within 24 hours in neonates where enteral feeds are not indicated, not tolerated or are contra-indicated due to medical or surgical conditions, e.g. NEC, post intestinal surgery, ileus, bowel obstruction and malabsorption, severe hypoperfusion / significant vasopressor-ionotropic support.
DOSE AND DURATION OF PN INFUSION
The volume of PN to be administered to the neonate depends on the age, weight and underlying disease of the neonate. Use the daily fluid requirements as a guide to determine the volume of PN solution to be administered.
The maximum volume of TPN for a neonate should not exceed 150 mL/kg/24 hours. The PN solution should be administered over 24 hours depending on the condition of the infant and volume to be administered. The remainder of the daily fluid requirements should be made up by an IV neonatal maintenance solution.
Discuss choice of PN and methods of initiating PN with a relevant expert prior to initiating PN. Taper PN as the infant becomes able to tolerate enteral feeds.
Caution
Extravasation of peripheral nutrition solutions causes severe tissue damage and necrosis.
Do not infuse peripheral nutrition solutions into poorly running IV lines.
AVERAGE DAILY REQUIREMENTS
| Preterm neonate | Preterm neonate | Term neonate | |
|---|---|---|---|
| < 1500 g | ≥ 1500 g |
| The figures below are for stable full requirements after the transition phase (i.e. > day 5) – The slow increase in requirements during the transition phase is usually addressed by the incremental introduction of TPN with the parallel withdrawal of crystalloid infusion during this phase. |
| Fluid mL/kg | 140–180 | 140–160 | 140–170 |
| Energy kcal/kg | 110–120 | 110–120 | 90–100 |
| Protein g/kg | 1.5–4 | 1.5–4 | 1.5–3 |
| CHO g/kg | 6–12 | 6–12 | 10-18 |
| Lipid g/kg | 3–4 | 3–4 | 3-4 |
Adapted from ESPGHAN 2005.
Some infants may be intolerant to the total daily requirements of the different nutrients and may require slow up-titration.
REFERRAL
- No progress with the introduction of enteral feeds.
- Recurrent/serious complications.
- Absolute contraindications to enteral feeds.
PARENTERAL NUTRITION, PAEDIATRICS
DOSE AND DURATION OF PN INFUSION
The maximum volume of TPN for a child depends on the age, weight and underlying disease and is based on the total daily fluid requirements.
AVERAGE DAILY REQUIREMENTS
|
Birth – 3 months |
> 3 months – 1 year |
>1 – 3 years |
> 3 – 6 years |
> 6 – 12 years |
|
|---|---|---|---|---|---|
|
Fluid mL/kg |
120-150 | 120-150 | 80-100 | 80 | 60-80 |
|
Energy kcal/kg |
90-100 | 90-100 | 75-90 | 75-90 | 60-75 |
|
Protein g/kg |
1.5-3 | 1-2.5 | 1-2.5 | 1-2 | 1-2 |
| CHO g/kg | 18 | 18 | 14 | 14 | 12 |
| Lipid g/kg | 3-4 | 3-4 | 2-3 | 2-3 | 2-3 |
Adapted from ESPGHAN 2005.
AVERAGE DAILY REQUIREMENTS
The daily nutritional requirements are influenced by age, physical activity and underlying diseases/disorders, e.g. burns, liver failure, etc.
REFERRAL
- No progress with the introduction of enteral feeds.
- Recurrent/serious complications.
- Absolute contraindications to enteral feeds.