Parenteral/Enteral Nutrition in Neonates

							Parenteral and Enteral Nutrition
         in Neonates

        NICU Night Team Curriculum
                    Objectives
• 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 electrolytes
• Avoid imbalance in macro-nutrients
• Provide micro-nutrients and vitamins
                     Case
A 26 week female is born precipitously to a
      healthy 20 year old G1P1 with an
         uncomplicated pregnancy.
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 infant’s 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: 60–80 mL/kg/day
       Late preterm and preterm infants (30–37 weeks): 80 mL/kg/day
       Very-preterm infants: 100–120 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 mg/kg/min
             Total Parenteral Nutrition
Protein and amino acids
•       Start with 2- 3 g/kg/day
    –     Increase 0.5–1.5 g/kg/day to a total of 3–4 mg/kg/day
•       Goal for premature infants: 4g/kg/day
•       Goal for term infants: 3g/kg/day
•       Source: trophamine

Calculate electrolytes to add to bag
•       DOL#1: dextrose in water with no eletrolutes is usually appropriate except in
        premies with low Ca stores who may require Ca
•       DOL#2: 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 >1cc/kg/hr, especially in
            premies)
          • CaGluconate =200-400mg/kg/day (NOTE: mg not mEq and Ca cannot be infused at
            >200mg/kg/day through a central line)
     Total Parentral Nutrition
Other added nutrients
• Lipids
• Cystein
• Phosphrous
• Magnesium
• Trace Minerals
• MVI
• Heparin
Central TPN                              Peripheral TPN
•   Easy to meet nutrition needs           – Unable to meet needs for
•   No limits on osmolarity                  Ca/Phos needs
•   Little risk of phlebitis               – Maximum rate of Calcium
•   Long term use                            gluconate is 200mg/kg/d
•   May require general anesthesia         – Maximum % dextrose is
•   Greater risk of infection                12.5%
•   Increased cost                         – Short term use
•   Greater risk of mechanical injury,     – Less risk for catheter related
    air embolism, venous obstruction         infections
                                           – Lower cost ?
                                           – Less risk of mechanical injury,
                                             air embolism, venous
                                             obstruction

         Total Parenteral Nutrition
                      Enteral Nutrition
• Breast milk is best!
• The American Academy of Pediatrics (2005) recommends
  breastfeeding for the first year of life.
• 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
  (30cc=1oz)
• Specialized formulas and fortifiers allow caloric content to be
  increased
                                  Breastmilk
•   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 coordination
   – 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
  solution.
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
                                               References

•    American Academy of Pediatrics, Section on Breastfeeding. (2005). Policy statement: Breastfeeding and the use of
     human milk. Pediatrics, 115(2), 496–506.
•    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 2006;7;e602-e607
•    Hay, W. Strategies for Feeding the Preterm Infant. Neonatology. 2008 ; 94(4): 245–254.

Thank you NNPs Carol and Terri!