From: Dr. Chaakradhar Maddela MSc Neonate,Cardiff MD DCH ,DHSc 2D ECHO FC Cardiology, DHSc Diabetology, FC Health Research,NeoNate Neurology,BPNA, Simplified and made easy form of neonatal parenteral nutrition

1. DR. CHAKRADHAR MADDELA
CONSULTANT NEONATOLOGIST
• MD MSc Neonatal Medicine Cardiff , DCH, PGD
NEONATOLOGY Southampton ESN, Fellowship in Ped &
Neonatal Ventilation (ESPNIC), DHSc Echocardiography,
Fellowship Cardiology (General & Paediatric), DHSc
Diabetology, Fellowship in Health Research (ICMR),
NeoNate Neurology (BPNA).

2. NEONATAL TOTAL PARENTERAL NUTRITION
• TERM AND PRETERM INFANTS
• PRACTICE POINTS

3. WATER REQUIREMENT
• START WITH 60 -80 ml / kg / day
• Gradually increase 15 -20 ml /kg/day
• Reach 150 – 180 ml / kg / day

4. ENERGY REQUIREMENTS (KCAL /KG/DAY)
• Preterm : C <24 hrs 60 – 80, NPE(kcal/kg/day):Protein 40
• -60, 24 -72 hrs C 80 – 100, NPE:Pro 60 – 65, >72hrs C
• 100 – 120, NPE:Pro 85 – 100 : Protein Cal 18 – 25 kcal /
gm

5. GLUCOSE (G/KG/DAY)
• PRETERM :<24hrs : 5.8 - 12 (4 – 8 mg / kg / min )
• 24 – 72 hrs: 12 – 16 (8-11 mg / kg / min )
• >72 hrs : maximum 17.3 ( 12 mg / kg / min ).
• TERM : same as for PTI.
• Irrespective of GA : Minimum amt glu in 24hrs
5.8gm/kg/day (4mg/kg/min)

6. GLUCOSE PRODUCTION & UTILIZATION
• GLUCOSE PRODUCTION : Term – 5mg/kg/min. PTI – 5mg/kg/min
(glycogenolysis) + 4-5mg/kg/min (gluconeogenesis).
• GLUCOSE UTILIZATION : Term – 3.5 – 4.5 mg / kg / min, PTI –
Double
• DAILY GLUCOSE INTAKE : 5.8 – 17.3gm/kg/day (4-12 mg/kg/min)
• HYPERGLYCEMIA : >140mg/dl of plasma /Sr glucose, >125mg/dl of
whole blood.
• INSULIN THERAPY : > 180mg/dl

7. GLUCOSE INFUSION RATE (GIR) & DEXTROSE BLEND
• GIR = %DEXTROSE SOLUTION × FLUID ml / kg / day ÷ 144
• PREPARATION OF DEXTROSE % by 5%D and 25% D =5X –
25 =Y, X = required % of dextrose, y = amount of 25%
dextrose in ml

8. GLUCOSE INFUSION RATE (MG/KG/MIN)
• Start: 4-6mg/kg/min
• Advance: 1-2mg/kg/min
• Goal : 12mg/kg/min
• HYPERGLYCEMIA : Reduce GIR by 20%
• AVOID : GIR < 4mg/kg/min (Hypoglycemia & Brain injury )
• LIPOGENESIS & FATTY LIVER: GIR > 18 -20mg/kg/min

9. DEXTROSE % CALCULATION FROM DESIRED GIR
• Desired GIR mg/kg/min × Wt Kg = mg glucose / min
• Mg Glu / min ÷ 1000 (mg / gm) = gm / min
• Gm / min × 1440 (minutes / day) = gm / day
• Gm / day ÷ Total ml / day (Total fluid – total additives ie
AA, fats, Na, K, Cal, Mg, trace elements ) × 100 =
Dextrose %

10. GIR CALCULATION FROM KNOWN DEXTROSE %
• Dextrose % ÷ 100 × ml / day = gm / day
• Gm / day ÷ 1440 = gm / minute
• Gm / minute × 1000 = mg / minute
• Mg / minute ÷ kg = mg / kg / minute

11. AMINOACIDS (PROTEIN EQUIVALENT G/KG/DAY)
• Preterm : <24hrs -2 – 2.5, 24 – 72 hrs – 2.7 – 3.5, >72hrs – 2.7
– 4gm/kg/day
• Term : Initially 1.5gm/kg/day increasing to 3gm/kg/day by
day 5
• Minimum protein req to prevent tissue loss – 1.5gm/kg/day.

12. PROTEIN UTILIZATION & ACCRETION
• MINIMUM PROTEIN INTAKE TO PREVENT EXISTING TISSUE
LOSS: 1.5gm/kg/day
• ELBW / <29WKS GA POSITIVE NITROGEN BALANCE (Target
Pro intake ) : Start 1.5 – 2.4 gm/kg/day on day1. Increase
upto 3.6 - 4gm/kg/day in association with 90kcal/kg/day of
nonprotein energy. Reach target protein intake <by day 5.
• NON NITROGEN ENERGY KCAL PER GM PROTEIN : 18 – 25
Kcal / Gm protein.

13. RECOMMENDATIONS FOR PRACTICE
• PTI : Start with 2 – 2.5gm/kg/day as soon as possible.
• TARGET PARENTERAL PROTEIN INTAKE IN PTI : 2.7 –
4gm/kg/day by day5 + adequate calorie intake.
• TERM INFANT & PTI >34 WKS (TARGET PROTEIN INTAKE):
3gm/kg/day by day5.
• PREPARATION : 10% AMINOVEN

14. CALORIE NITROGEN RATIO ( CNR) CALCULATION
• CNR = CARBOHYDRATE CALORIES (gm×3.4) + FAT CALORIES(gm×9) ×
6.25 ÷ AMINO ACIDS IN GM, 6.35 is a constant
• CNR = 100 – 200 cal / gm is normal
• NP (non protein) CALORIES / gm AA RATIO = 24 -32 ( approx 25
nonprotein kcal/kg for q1gm protein /kg promote protein
utilization )

15. LIPIDS (G / KG / DAY )
• Preterm : < 24 hrs – 2 gm/kg/day, 24 – 72 hrs -2.5 -3.5
• gm/kg/day, 3.5 – 4gm/kg/day
• 20% SMOF / INTRALIPID in ml = gm / kg / day × Wt ÷ 0.2
• Term : Same as for PTI.

16. LIPID UTILIZATION, ACCRETION & PROVISION
• Fetal fat requirements :double during 3rd trimester, from 1 gm
/kg/day to 2 gm / kg / day
• PROVISION OF LIPIDS : Start 2gm/kg/day on day1& 3gm/kg/day on
day2.
• TARGET LIPID INTAKE : 3.5gm/kg/day in 1st week, well tolerated.
• LIPID PREPARATION : 20% lipids lower in phospholipids & better
plasma clearance of Triglycerides.
• LIPID INFUSION TOLERANCE : 24hr infusion is better tolerated than
intermittent infusion.

17. RECOMMENDATIONS FOR PRACTICE
• DAY1 : Start with 2gm/kg/day.. Gradually increase to 3.5 to 4gm/kg/day. Newer
formulations upto 3gm/kg/day only.
• 20% lipid emulsion – preparation of choice, SMOF, INTRALIPID
• Infusion – continuously over 24hrs
• Carnitine supplementation enhances lipid utilization
• Lipids atleast 0.5gm/kg/day is required to prevent EFA deficiency
• Monitor triglycerides in babies 1. <1.5kg, 2.sepsis 3.CP decompensation, 4.PPHN &
5.hyperbilirubinemia near exchange transfusion level.

18. RECOMMENDATIONS
• NUTRITIONAL NEEDS = 60:30:10, CARBOHYDRATES 60%,
FATS 25 -30 % & PROTEINS 10 – 15 %
• BAG 1 = DEXTROSE + AA + ADDITIVES, TRACE ELEMENTS
• BAG 2 = LIPIDS + VITAMINS THROUGH SEPARATE LINE
AND AMBER COLOURED OR SILVER COVERING FOR LIGHT
• HEPARIN USE ONLY IN SELECTED CASES
• STOP TPN WHEN 2/3 OF TOTAL CALORIES MET BY
ENTERAL ROUTE
• ACHIEVE FULL ENTERAL FEEDS BY 10 – 14 DAYS

19. DR CHAKRADHAR MADDELA
MD MSC NEONATE DCH PGD NEONATOLOGY
IV SODIUM 0.9%
1000ML /1L NS=154 MEQ SODIUM +154 MEQ CHLORIDE =154MOSM / L
EACH ML NS =0.154MEQ NA+CL
10ML = 1.54MEQ NA + CL
100 ML = 900 MG NACL
DAILY REQ = 1-3 MEQ / KG
3% SALINE : 1 ML = 0.5 MEQ (DOSAGE = 2 – 6ML /KG /DAY )
1ML CON. RINGER LACTATE = 3 MEQ SODIUM

20. POTASSIUM CHLORIDE, KCL
• 10 ml KCl = 20 mEq K*, 1ml of inj. KCl = 2 mEq potassium
• Daily requirement = 1-2 mEq / kg 48-72Hr, 1-3mEq/kg/day >72hrs
• Daily Potphos = 0.5 ml / kg
• 15% Kesol, KCl = 1 ml = 2 mEq

21. CALCIUM GLUCONATE 10%
• 1ml of calcium gluconate = 95 mg calcium gluconate = 0.22mmol
Calcium
• 10ml = 950mg calcium gluconate = 2.2 mmol calcium
• 1ml 10% calcium gluconate = 0.465 =0.5 mEq = 9mg elemental Ca
• Dosage : 4 -8 ml / kg
• Preterm -1.5 – 2mmol/kg/day, Term – 0.8 – 1.5mmol/kg/day

22. PHOSPHATE (MMOL/KG/DAY)
• Dosage : Preterm – 1.5 – 2 mmol /kg/day
• Term – 0.8 -1.2 mmol / kg / day

23. MAGNESIUM SULPHATE 50% W/V
• 1ml 50% mgso4 = 500mg Mgso4 = 2mmol of Mg2+ = 4 mEq /1ml
• 2ml ampoule = 1gm Mg
• 10 ml = 5gm = 5000mg
• Dosage – Preterm 0.18-0.3mmol/kg, Term – 0.2 mmol/kg/day = 4 units
/ kg with 40U insulin syringe.

24. POINTS TO REMEMBER
• 1 mEq Ca = 20 mg elemental Calcium
• 1 mEq Mg = 12 mg elemental Magnesium
• Ca:Ph:Vit D intake - Ca intake 20-90mg/kg/day 1-
4mEq/kg/D, Ph = 35 – 70mg/kg/day (1-2mMol/kg/D),
Vitamin D = 400iu/D
• Ca:Ph molar ratio : 1.3-1.7:1

25. POINTS TO REMEMBER
• Ca & Ph solubility in TPN : L-cysteine increases acidity of
TPN solution & allows increased concentration without
precipitation
• Ca (mEq/100ml) + P (mMol/100ml) = 2.5 peripheral vein
(Ca cannot exceed 1mEq/100ml), 4 central vein (max.
Con. 5 with cysteine )

26. CALCULATION OF MOLAR RATIO, CA & P
• Divide Ca in mEq by 2 = mMol Ca
• Divide mMol Ca by mMol P
• mMol Ca : mMol P

27. INJECTION CELECEL
CHROMIUM + COPPER + MANGANESE + SELENIUM
• Dosage : 0.1 – 0.2 ml / kg
• Preparation : 3 ml
• Other brand name : Peditrace / Neotrace

28. INJECTION MVI PAEDIATRIC
• Dosage : 1 ml / kg
• Preparation : 10ml ampoule... Adult / pediatric

29. MICRO & MACRO NUTRIENTS REQUIREMENTS PTI
(BAPM)

30. MONITORING OF NEONATES ON TPN, FROM BAPM)

32. STEPS IN TPN
• 1)TOTAL FLUID REQUIREMENT / KG /DAY =
ADDITIVE FLUIDS =
• ENTERAL FEEDS =
• 2)Aminoacids requirement = gm/kg/D = 10%
aminoven in 10-30 ml /kg
• 3)Lipids 20% =gm/kg/D × Wt ÷ 0.2 in ml

33. • 4)ADDITIVES
• Sodium = 3%Saline 4 -6ml/kg/d, Concentrated RL
1ml/kg/D
• Potassium = 0.5 – 1ml/kg/d in ml Potphos
• Calcium =4-8ml/kg/d
• MVI PED = 1ml/kg/d
• Celecel = 0.1 – 0.2ml / kg /d
• 50% Magnesium sulphate = 3units /kg/d with insulin
syringe 40 IU or 0.1 ml /kg/d

34. • 5) Dextrose infusion calculation at 6mg/kg/min
• 6) CNR, calorie nitrogen ratio calculation
• 7) Routine iv heparin not indicated in neonates
• Heparin = 1 unit / ml of fluid (Total amount of
fluids )