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Parenteral and Enteral Nutrition in Neonates


Parenteral and Enteral Nutrition in Neonates NICU Night Team Curriculum Case A 26 week female is born precipitously to a healthy 20 year old G1P1 with an ... – PowerPoint PPT presentation

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Title: Parenteral and Enteral Nutrition in Neonates

Parenteral and Enteral Nutrition in Neonates
  • NICU Night Team Curriculum

  • Define basic nutritional requirements for
    neonatal growth
  • Describe specific nutritional problems faced by
    low birthweight and premature infants
  • Know components and advantages of breastmilk
    indications for specific types of formulas
  • Determine components of TPN and be able to write
    fluid orders
  • Formulate an individualized plan for starting and
    advancing parenteral/enteral feeds

Goals of Nutrition
  • To achieve a postnatal growth at a rate that
    approximates the intrauterine growth of a normal
    fetus at the same post-conceptional age
  • Provide balance in fluid homeostasis and
  • Avoid imbalance in macro-nutrients
  • Provide micro-nutrients and vitamins

  • A 26 week female is born precipitously to a
    healthy 20 year old G1P1 with an uncomplicated
  • 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 infants caloric requirement?
  • What fluids do you order?

Gastrointestinal Development
  • Fetal swallowing, motility in 2nd trimester
  • 18 week fetus swallows 18-50ml/kg/day
  • Term 300-700ml/day
  • Fetal swallowing regulates the volume of amniotic
    fluid and controls somatic growth of the GI tract
  • Intestines double in length from 25-40 weeks
  • Functionally mature gut by 33-34 weeks
  • Intestine in final anatomic position by 20 weeks
  • Premature Infant GI tract
  • Delayed gastric emptying seen in preterm
  • Breast milk, glucose polymers, prone positioning
    facilitate gastric emptying
  • Total gut transit time in preterm 1-5 days
  • Stooling delayed until after 3 days
  • ? feeding volume ?s motility

Growth General Facts
  • Last trimester of pregnancy
  • Fat and glycogen storing
  • Iron reserves
  • Calcium and phosphoruos deposits
  • Premature babies more fluid (85-95), 10
    protein, 0.1 fat.
  • No glycogen stores
  • The growth of VLBW infants lags considerably
    after birth

Growth Goals
  • Weight 20-30 g/day
  • Length 1cm/week
  • HC 0.5cm/week
  • Correlates with brain growth and later development

Caloric Requirements for Growth
  • Preterm goal 120kcal/kg/day
  • Term goal 110kcal/kg/day
  • Total Fluid of enteral feeds required to deliver
    adequate calories for growth is 150cc/kg/day

Total Parenteral Nutrition
  • Determine fluid requirement (mL/kg/day) for first
    day of life
  • Full-term infants 6080 mL/kg/day
  • Late preterm and preterm infants (3037 weeks)
    80 mL/kg/day
  • Very-preterm infants 100120 mL/kg/day
  • Determine 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/hr
  • GIR (15 x 8.3 x 0.1667) 2 10.3mg/kg/min
  • (15 x 8.3 ) (6 x 2) 10.3

Total Parenteral Nutrition
  • Protein and amino acids
  • Start with 2- 3 g/kg/day
  • Increase 0.51.5 g/kg/day to a total of 34
  • Goal for premature infants 4g/kg/day
  • Goal for term infants 3g/kg/day
  • Source trophamine
  • Calculate electrolytes to add to bag
  • DOL1 dextrose in water with no eletrolutes is
    usually appropriate except in premies with low Ca
    stores who may require Ca
  • DOL2 add electrolytes to the bag based on
    estimated daily requirements and BMP
  • Estimated Needs
  • NaCl 2-4 mEq/kg/day
  • KCl 1-2 mEq/kg/day (NOTE Do not supplement K
    until UOP gt1cc/kg/hr, especially in premies)
  • CaGluconate 200-400mg/kg/day (NOTE mg not mEq
    and Ca cannot be infused at gt200mg/kg/day through
    a central line)

Total Parentral Nutrition
  • Other added nutrients
  • Lipids
  • Cystein
  • Phosphrous
  • Magnesium
  • Trace Minerals
  • MVI
  • Heparin

Total Parenteral Nutrition
  • Central TPN
  • Peripheral TPN
  • Easy to meet nutrition needs
  • No limits on osmolarity
  • Little risk of phlebitis
  • Long term use
  • May require general anesthesia
  • Greater risk of infection
  • Increased cost
  • Greater risk of mechanical injury, air embolism,
    venous obstruction
  • Unable to meet needs for Ca/Phos needs
  • Maximum rate of Calcium gluconate is 200mg/kg/d
  • Maximum dextrose is 12.5
  • Short term use
  • Less risk for catheter related infections
  • Lower cost ?
  • Less risk of mechanical injury, air embolism,
    venous obstruction

Enteral Nutrition
  • Breast milk is best!
  • The American Academy of Pediatrics (2005)
    recommends breastfeeding for the first year of
  • Started when an infant is clinically stable
  • Absence of food in the GI tract produces mucosal
    and villous atrophy and reduction of enzymes
    necessary for digestion and substrate absorption
  • Trophic hormones normally produced in the mouth,
    stomach, and gut in response to enteral feeding
    are diminished.
  • Breastmilk and standard infant formula have
    20kcal/30cc (30cc1oz)
  • Specialized formulas and fortifiers allow caloric
    content to be increased

  • Preferred source of enteral nutrition
  • Very well tolerated by most infants
  • Improves gastric emptying time
  • Matures the mucosal barrier
  • Promotes earlier ? appearance of IgA
  • Vastly ?s incidence of NEC
  • More significant induction of lactase activity
    compared to formula fed premies
  • Composition
  • Varies with gestation
  • Varies according to maternal diet
  • Varies within a feeding(? fat in last ½ fdg)
  • Varies within the day(? fat in PM over AM)

Enteral Nutrition in the NICU
  • Term
  • If clinically stable, start PO ad lib feeds and
    advance as tolerated
  • Preterm
  • Feeds are often initiated with breastmilk, Sim 20
    or SSC 24
  • Trophic tube feeds may be continuous or bolus and
    advanced gradually (10-20mL/kg/day)
  • Transition to bolus from continuous typically
    begins after achieving full feeds
  • PO feeds typically attempted around 32-34 weeks,
    when premies develop suck and swallow
  • Premies are often supplemented with TPN as they
    work up on feeds
  • Goal discharge formula is Neosure 22

What to Feed?
What to Feed?
Practice Problems
  • Baby 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 ml
  • 1.9 mEq of potassium per 100 ml
  • 3.0 mEq of calcium per 100 ml
  • 1.2 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.

  • Answer
  • 2 mEq of sodium/kg/day
  • 2.6 mEq of potassium/kg/day
  • 4.1 mEq of calcium/kg/day
  • 1.6 mMol of phosphorus/kg/day

Practice Problems
  • Baby 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

  • Answer
  • Lipids 0.6 ml/hr
  • PN fluids dextrose 8.9 at 8.1 ml/hr
  • Sodium 3.1 mEq per 100 ml
  • Potassium 1.5 mEq per 100 ml
  • Calcium 2.7 mEq per 100 ml
  • Phosphorus 1.1 mMol per 100 ml

  • American Academy of Pediatrics, Section on
    Breastfeeding. (2005). Policy statement
    Breastfeeding and the use of human milk.
    Pediatrics, 115(2), 496506.
  • Carlson, C, Shirland, S. Neonatal Parenteral and
    Enteral Nutrition, Resource Guide. National
    Association of Neonatal Nurse Practitioners
  • Adamkin, D. Nutrition Management of the Very
    Low-birthweight Infant I. Total Parenteral
    Nutrition and Minimal Enteral Nutrition.
    NeoReviews 20067e602-e607
  • Hay, W. Strategies for Feeding the Preterm
    Infant. Neonatology. 2008 94(4) 245254.
  • Thank you NNPs Carol and Terri!