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D._Session_1_Slides_Calculations_Nutrition.pptx
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- 2. Our objectives forthis NICU Boot Camp session are as follows: Increase overall confidence in caring for infants in the NICU Determine appropriate nutritional needs and fluid management for NICU patients Determine calculations for patients in the NICU
- 3. Calculations Total DailyFluid (ml/kg/day) Total ml in 24 hours ÷ weight in kg = ml/kg/day Includes TPN, lipids, enteral feeds, drips, transfusions, and if <1000 g all medications/flushes in your total intake Use previous day’s weight or birth weight if < 1 wk old or dry weight if appropriate Round to nearest whole number
- 4. For this andall example slides, insert screen shots pertinent to your institution
- 5. Calculations Total Calories(kcal/kg/day) Feeds, Dextrose, Protein, and Lipids Add up all calories from each source to get total kcal/day then divide by weight Use the same weight as when calculating total daily fluid Round to nearest whole number
- 6. Calculations Calories fromenteral feeds (kcal/day)= (ml feeds/day)(kcal/oz)(oz/30ml) Remember to use appropriate caloric density of the infant’s breast milk or formula EBM (expressed breast milk) is 20 kcal/oz EBM + 1 vial HMF/50 ml = 22 kcal/oz EBM + 1 vial HMF/25 ml = 24 kcal/oz Standard term infant formula (Enfamil NB or Similac Advance) is 20 kcal/oz Standard preterm formula (Premature Enfamil/PEF or Similac Special Care/SSC) can be either 20, 22, or 24 kcal/oz Standard discharge preterm formula (Enfacare/EC or Neosure/NS) is 22 kcal/oz Divide by the weight to get kcal/kg/day No decimals!!!
- 7. For this andall example slides, insert screen shots pertinent to your institution
- 8. Calculations - TPN Calories from dextrose (kcal/day) = (total ml dextrose/day) (g dextrose/100ml)(3.4 kcal/g) Calories from intralipids (kcal/day) = (total ml IL/day)(2 kcal/ml) *Calories from protein (kcal/day) = (total grams protein/day)(4kcal/gram) *not all institutions calculate protein calories For this and all example slides, insert screen shots pertinent to your institution
- 9. Calculations Outputs Urine (Total ml of urine/day) ÷ (weight in kg) ÷ (24 hours/day) = ml/kg/h Round to nearest tenth Ostomy (Total ml stool out/day) ÷ (weight in kg) = ml/kg/day Goal is usually less than 40 ml/kg/day Round to nearest whole number Total Input and Output For most patients, you do not need to report on rounds the total input (ml/day) or total output (ml/day) unless we ask We would follow these numbers for infants with renal insufficiency and heart failure. Please have this documented in your note in case we ask.
- 10. Note For this andall example slides, insert screen shots pertinent to your institution
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- 12. What is mygoal for fluids? Preterm < 1000 g BW Newborn Day (DOL 0): 100ml/kg/day DOL 1: generally 120ml/kg/day Continue increase by about 20ml/kg/day to 150-180 ml/kg/day Preterm > 1000 g BW Newborn Day (DOL 0): 80ml/kg/day DOL 1: 100 ml/kg/day Continue as above to goal 150-160ml/kg/day Some infants may need more fluids if on phototherapy or if hypernatremia develops
- 13. What is mygoal for fluids? Term Newborn Day (DOL 0): 70-80ml/kg/day DOL 1: 80-100 ml/kg/day DOL 2: 1o0-120 ml/kg/day Continue as above to goal 120-150ml/kg/day Making a baby NPO Put them on the same or close to Total Fluids as they were on with feeds Some patients, however, like those with congenital heart defects or BPD, might require a lower goal IFV rate compared to enteral nutrition
- 14. How do Icalculate for new fluids? Start with total fluid goal (ml/kg/day) to get your total goal volume Example TFG 150 ml/kg/d for 1 kg infant 150 ml/kg/d x 1 kg = 150 ml/day (total goal volume) Subtract total volume of all medication drips and flushes (UAC or central line fluids) Subtract any feeds Subtract Lipids +/- subtract for transfusions Use today’s weight or birth weight if less than 1 wk old or dry weight Take the remaining total volume and divide by 24, this will give you your IVF or TPN rate
- 15. For this andall example slides, insert screen shots pertinent to your institution
- 16. For this andall example slides, insert screen shots pertinent to your institution
- 17. What type offluids should I use? If TPN unavailable or anticipate frequent changing of fluids . . . < 1kg start D5 > 1kg start D10 DOL 0 and beyond: add 200-300mg CaGluconate/100mL of fluid DOL 1 (or later if ELBW) add electrolytes as follows <24 hours old usually do not need additional electrolytes >24 hours old monitor electrolytes and alter amounts based on laboratory values In general, for older infants usually add 3mEq NaCL/100mL and 2mEq KCl/100mL of fluid This also goes for patients being made NPO If the patient was on electrolyte supplements in their feeds or have abnormal values on the BMP, you may need more than the recommended values Don’t forget about heparin for Central lines
- 18. TPN Dextrose Generally,start with D5 or D10 Maximum dextrose concentration Peripheral IV: 12% Central line: generally, don’t go above 20% Glucose infusion rate (GIR) mg/kg/min How to calculate it: (D___ x Rate (ml/hr)x 0.167) / weight (kg) Goal GIR Start at 5-6 mg/kg/min for preemie and 6-8 mg/kg/min for term Recommended maximum 12 mg/kg/min This may not be possible in a very small baby, follow point of care glucose Use glucoses on blood gases and GIR to determine dextrose concentration of TPN/fluids Generally, increase or decrease GIR by 1 or 2 mg/kg/min per day 10 7.8 For this and all example slides, insert screen shots pertinent to your institution
- 19. TPN Protein Startat 2-3 g/kg/day and increase by 0.5-1 g/kg/d Goal Premature infants: 3.5-4 g/kg/day Term: 3 g/kg/day Hepatic or renal dysfunction may alter requirements Decrease to 2 g/kg/day once your baby is on 50% of goal feeds 3 For this and all example slides, insert screen shots pertinent to your institution
- 20. Intralipids Use 20%intralipid solution Start at 1-3 g/kg/day and increase by 0.5-1 g/kg/d Goal Term and Preterm Infants: 3g/kg/day Usually run over 24 hours to maximize clearance Use triglycerides to monitor the tolerance to lipid load (goal TG <150-200 mg/dL) Consider limiting lipids with severe hyperbilirubinemia or severe pulmonary hypertension For infants with TPN cholestasis (D bili >2 mg/dL or >20% of total), decrease lipid infusion to 1g/kg/day To calculate __g/kg/day x Weight (in kg) x 5 = total volume in ml 32 24 1.3 For this and all example slides, insert screen shots pertinent to your institution
- 21. TPN - Electrolytes Electrolytes Determine the total amount of Na and K infant needs then decide how to divide between Cl, acetate, and phos. Acetate and chloride are given in the amounts necessary for acid-base balance Try to give phos as NaPhos rather than Kphos to limit aluminum exposure Potassium should be removed or limited in patients with renal failure Infants with immature renal function or on certain medications may require additional sodium and potassium Monitor electrolytes daily when first starting TPN May back off to a few times a week once you are not needing to make changes often 3 1 2 0 0 2 0 2 For this and all example slides, insert screen shots pertinent to your institution
- 22. TPN - Electrolytes Magnesium, Calcium and Phosphate Use the back of the TPN sheet for starting guidelines and laboratory results to guide supplementation afterwards 2.5 0.3 For this and all example slides, insert screen shots pertinent to your institution
- 23. TPN –Vitamins andTrace Elements Vitamins Check based on weight Trace elements Refer to the back on the TPN form for recommendations Additional Zinc should be added in preterm infants or infants ≤3kg For patients with TPN cholestasis (direct bilirubin > 2mg/dL or > 20% of total) Remove manganese from TPN Reduce or remove copper from TPN For patients with chronic renal failure Remove selenium and chromium from TPN For this and all example slides, insert screen shots pertinent to your institution
- 24. Other TPN Stuff Heparin if central line For infants > 1 kg use 1 unit/ml For infants < 1 kg use 0.5 units/ml Typically no Zantac Consider carnitine Add 10 mg/kg/day if infant has been receiving TPN for > 4 weeks Don’t forget to sign/date/time May reorder TPN subsequent dates if not changing lipids, lytes, dextrose or protein 6 8 17 Before Lunch!! 6/9/17 10ml/hr 555-5555 or NICU For this and all example slides, insert screen shots pertinent to your institution
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- 26. What feeds doI choose? Use breast milk (20 kcal/oz) if available Keep infant on same brand they were on prior to transfer This applies to premature formula only For term infants, you may use the formula available on WIC formulary If starting enteral feeds for the first time You may use the formula available on WIC formulary or based on hospital contract
- 27. Formulas Premature formulas In-hospital formula Premature Enfamil (PEF) – 20-24 kcal/oz Similac Special Care (SSC) – 20-24 kcal/oz Cannot discharge infants on these formulas Discharge premature formulas Enfacare (Enfamil) or Neosure (Similac) These are standard 22 kcal/oz Term formulas: Enfamil Newborn or Similac Advance Use parenteral preference or WIC supplied formula
- 28. Specialty Formulas Gentlease Low lactose formula Used for lactose intolerance or infants with drug withdrawal Similac Sensitive Low lactose formula Used for lactose intolerance or infants with drug withdrawal
- 29. Specialty Formulas Pregestimil Casein hydrolysate lactose-free formula with medium-chain triglycerides Used for postop hearts, post-NEC or feeding intolerance Alimentum or Nutramingen Casein hydrolysate lactose-free formula Used in cow milk protein allergies EleCare and Neocate Amino acid based formula Used in feeding intolerance or post-NEC ProSobee or Isomil Soy formula Used in galactosemia
- 30. How many caloriesdo I use? Always start with 20 kcal/oz Consider increasing calories/adding fortifiers once tolerating 80- 100mL/kg feeds In general, go to 22 kcal/oz for 1-2 days then increase 24 kcal/oz Infants with increased caloric needs or requiring fluid restriction such as congenital heart disease may require feeds fortified greater than 24 kcal/oz Fortifiers/Calorie boosters HMF (human milk fortifier) 1 vial per 50 ml gives 22 kcal breast milk 1 vial per 25 mL gives 24 kcal breast milk
- 31. How do Iincrease feeds? Increasing feeds In general, we increase by total of 20-30ml/kg/day based on age and weight using our feeding protocol Increasing feeds at a faster rate may be a risk factor for NEC Usually full volume is 150-160 ml/kg/day
- 32. What are thegoals? Caloric goals 100-110 kcal/kg/day for a term baby 110-120 kcal/kg/day for a preemie Only if on all enteral feeds (not TPN) If on full TPN, caloric goal is usually 85-95 kcal/kg/day Some babies may require even higher caloric goals due to increased caloric expenditure such as heart disease or BPD Goal weight gain is average of 20-30 g per day
- 33. When should Ibe concerned? Monitor for signs of intolerance to help determine if ok to advance feeds Residuals Green is abnormal For a baby on bolus feeds Generally, up to 1/3 of the total volume is an acceptable residual For a baby on continuous feeds 1.5 times the hourly rate is acceptable, up to 2 times in some babies Abdominal Distention Emesis
- 34. When can ababy nipple feed? ~34 weeks corrected age Coordination of suck-swallow-breathe reflex Consider earlier if infant is showing signs of readiness including rooting, sucking on pacifier, alert state, and good tone. Bolus or near-bolus feeds Fed into stomach (NG or OG) Typically, not while being fed transpylorically If on continuous feeds, we usually transition to bolus first Compress feeds slowly over a few days Typically start with one-two nipple attempts per day. Advancing nipple attempts depends on how well the baby is doing nipple full volume no suck apnea or bradycardia with attempts gaining weight
- 35. References ElHassan, NahedO., and Jeffrey R. Kaiser. “Parenteral Nutrition in the Neonatal Intensive Care Unit.” Neoreviews, American Academy of Pediatrics, 1 Mar. 2011 Gomella, Tricia Lacy, et al. Neonatology: Management, Procedures, on- Call Problems, Diseases, and Drugs. McGraw-Hill Education Medical, 2013. Torrazza, Roberto Murgas, and Josef Neu. “Evidence-Based Guidelines for Optimization of Nutrition for the Very Low Birthweight Infant.” NeoReviews, vol. 14, no. 7, 2013, doi:10.1542/neo.14-7-e340.
Editor's Notes
- #1 Here we will talk about Calculations, TPN, and Formula
- #2 Here are a list of the objectives for NICU Boot Camp. Take a minute to familiarize yourself with them. Pause and allow time for the trainee to read and ask any questions.
- #3 Our neonates have fluid goals calculated differently than other pediatric patients. We look at total fluid goals in a 24-hour period based on weight in kilograms. We take the total daily fluid received in milliliters and divide that by the patient's weight in kilograms to give us the mL/kg/day intake. It is important to remember that this total should include everything - nutrition, TPN/fluids, medications, flushes, continuous drips, transfusions. If the infant is less than 1000 grams, then we also include all of the recorded medications and flushes in the total daily fluids. For the calculations, use the birthweight if that patient is < 7 days old, a dry weight if appropriate, or the weight from the previous day to calculate the intake per kilogram from the previous 24 hours. Round to the nearest whole number.
- #4 Presenter tip: For this and all example slides, insert screen shots pertinent to your institution Here is an example of how the data will be presented in the online medical record. We are under the "input and output" tab to the left. Let's say this patient had a weight yesterday of 900g (or 0.9kg). Notice the numbers circled, the daily intake total is 161.56mL. What would this patient's ml/kg/d for the previous day be? Allow time for trainee response. The correct answer is found by taking 161.56 and dividing by 0.9 which gives you the answer of 180ml/kg/d. Image Credit: Image created by author, Christy Mumphrey, MD
- #5 To calculate calories received for the day, we will need to account for all calories obtained from enteral feeds as well as lipids, TPN and/or Dextrose containing IVFs. We will figure out the calories for each of these and then add the total up. Once the total calories are obtained, we will divide by the same weight used for the total fluid intake. Again, this should be rounded to the nearest whole number.
- #6 Presenter Tip: THIS AND OTHER NUTRITION SLIDES CAN BE ADAPTED USING FORMULAS PERTINENT TO YOUR INSTITUTION! First, we will talk about calculating calories from enteral nutrition. Something important to realize is that different sources of enteral nutrition have different caloric densities. Expressed breast milk (EBM) is 20 kcal per ounce but can be fortified using Human Milk Fortifier (HMF) to be 22 kcal per ounce or 24 kcal per ounce. Standard term and preterm formulas are based off breast milk and are also 20 kcal per ounce. Preterm formulas Similac Special Care (SSC) and Premature Enfamil (PEF) can also come as 22 kcal per ounce or 24 kcal per ounce. Standard discharge preterm formulas like Neosure (NS) and Enfacare (EC) are 22 kcal per ounce. As you can see, the caloric content of enteral formulas is given in calories per ounce. We will therefore have to figure out the total milliliters received by the patient and then divide by 30 since there are 30 milliliters in an ounce. Then we will multiply by either 20, 22, or 24 to figure out the calories given. We will then divide the total calories by the weight to give kcal/kg/day. Again, round to nearest whole number.
- #7 Presenter tip: For this and all example slides, insert screen shots pertinent to your institution Here is an example again on the "intake and output" screen, lets calculate the kcal/kg/day from enteral feedings. Make sure you are only calculating the calories from the enteral feeds and not the total fluid taken in for the day. The total enteral intake for the day is circled. If you don’t know the caloric density of the formula, you can click on the number and it should come up labeled. Advance presentation. In this case it is 24 kcal per ounce. Let’s calculate. Allow time for trainees to perform the calculation and give a response. Take the total enteral volume of 360 milliliters per day and divide by 30 milliliters per ounce to give you the number of ounces per day. Next, multiply the total ounces per day by 24 kcal per ounce to give the answer of 288 kcal per day. Finally, divide the 288 kcal per day by the weight to get kcal/kg/day. For this patient, the weight is 2.54kg which gives us a total of 113 kcal/kg/day. Image Credit: Images created by author, Christy Mumphrey, MD
- #8 Presenter tip: For this and all example slides, insert screen shots pertinent to your institution Here is an example again on the "intake and output" screen. Now, we will figure out the calories obtained from total parenteral nutrition or TPN. First, to calculate the calories obtained from dextrose solution, either TPN or IVF, use the formula provided in the first bullet. Take the total milliliters given of dextrose for the day and multiply by the grams of dextrose per 100 milliliters and the constant of 3.4 kcal per gram. Next, use the formula found in the second bullet to calculate the calories obtained from lipid solution. Take the total milliliters of intralipids given per day and multiply the constant of 2 kcal per milliliter. *Finally, use the formula in the third bullet to calculate the calories obtained from protein. Take the total grams of protein received in the day (“x” grams x kg) and multiply x 4kcal per gram) *not all institutions calculate protein calories Let’s do an example calculation using this patient with a weight of 1.382kg If you are unsure of the concentration of the dextrose solution, you can click on number to give the percent dextrose. Advance slide. This patient is receiving D10. Go ahead and calculate the calories per kilogram per day obtained from both the dextrose and intralipids. Allow time for trainees to calculate and respond. For dextrose, multiply 198.4ml with 10g/100ml and 3.4kcal/g to give 67.4 kcal per day from dextrose. To obtain the calories per kilogram per day, simply divide by the weight of 1.382 to give the final answer of 48 kcal/kg/day. For lipids, multiply (13.2ml with 2kcal/ml to give 26.4 kcal per day. Again, divide by the weight of 1.382 to give the final answer of 19 kcal/kg/day Protein adds little to the calories and is not calculated in all institutions, however, if this child was receiving 3g/kg/day of protein, the calories would be 3g x 1.382kg to give 4.15grams of protein multiplied x 4kcal would give 16.5kcal per day. Divide that by the weight of 1.382 and you would receive 12kcal/kg/day. If the patient is only on TPN, just add dextrose and lipid calories together to get the total kcal per kilogram per day, which in this patient would be 67kcal/kg/d. If the patient is on feeds too, add those as well to get the final total. Image Credit: Images created by author, Christy Mumphrey, MD
- #9 Now, we will calculate the output in a day. Again, we will look at the total milliliters per kilogram put out in a day, but will further divide this into an hourly rate. For urine output, take the total urine measured in a day, divide by the weight in kilograms, and then divide by 24 hours to get the urine output in milliliters per kilogram per hour. This number should be rounded to the nearest tenth. Some patients will have an ostomy and the output is calculated in the same manner. The goal for ostomy output is less than 40mL/kg/day. For most patients, you do not need to report the total input (ml/day) or total output (ml/day) on rounds unless we ask. Patients in which we would follow these numbers include infants with renal insufficiency and heart failure. Please have this documented in your note in case we ask.
- #10 Presenter tip: For this and all example slides, insert screen shots pertinent to your institution Here is a sample of the daily progress note and where to place the numbers we have just looked up and calculated. Note to please also put the components of the TPN including dextrose concentration and protein and lipid content. Also put the type of feeds.
- #11 Next, we will talk about goals for TPN and fluids and projecting fluids based on these goals.
- #12 The 4/2/1 rule does not apply for the NICU as it does in older pediatric patients. This would calculate a goal of 100mL/kg/day which is good for dehydration purposes, but does not allow for good nutrition for growth and development. In general, preterm patients less than 1000 grams will start at a higher total fluid goal of 100mL/kg/day due to increased insensible losses and will usually be increase daily by 20mL/kg/day up to a maximum of 150-180mL/kg/day. Those preterm patients over 1000 grams will require a little less fluid initially and will begin at 80mL/kg day. These patients will also increase by 20mL/kg/day up to a goal of 150-160mL/kg/day. These are general goals. Some infants may need more fluids if on phototherapy or if hypernatremia develops.
- #13 Term newborn patients may require even less fluid initially and may begin at 60-80ml/kg/day. Fluids are increased in the same 20mL/kg/day fashion. When a baby is made NPO, they should be placed on fluids to continue the same total fluid goal that was projected prior to being made NPO. For example, if a patient was receiving 140mL/kg/day of feeds, IV fluids should be projected at 140mL/kg/day. On some occasions, a patient with BPD or congenital heart disease may require less IVF rate than enteral nutrition rate.
- #14 Now we will begin with a goal for the day and work backwards to calculate the hourly fluid rate for the day. First, start with total fluid goal (TFG) in milliliters per kilogram per day to get your total goal volume. For example, with a TFG of 150 ml/kg/d for 1 kg infant, the total fluid needed for the day would be the product of 150ml/kg/day and 1kg which is 150 ml per day. Next, subtract total volume of all medication drips and flushes, which include UAC or central line fluids. Then, subtract any feeds and/or lipids that will be given to the patient for that day. If indicated, subtract for transfusions that will be given. You should ask in rounds if transfusions should be added on top or included in the total daily fluid goal. Finally, take the remaining total volume and divide by 24, this will give you your IVF or TPN rate in milliliters per hour. Remember to now use today’s weight or birth weight if less than 1 wk old or dry weight when performing these calculations.
- #15 Presenter tip: For this and all example slides, insert screen shots pertinent to your institution Let’s try an example. This baby weighs 3.2kg and you want to calculate daily fluids based on a TFG of 150ml/kg/day. Multiply 3.2kg by 150ml/kg/day to get a total of 480 ml/day This baby has two flushes running at 0.75ml/hr and three drip meds running at different rates. We need to add up the total fluids from these that the patient would get for 24h. Add all the individual rates and multiply times 24 hours. So, (0.75+0.75+0.64+0.19+0.72) x24 = 73.2ml This patient is not receiving lipids or feeds so we do not need to subtract those. But, we want to give 15ml/kg of blood today and subtract from total fluid volume which is 48ml. To obtain the fluid rate for the TPN, we need to figure out what is left over after subtracting everything else. 480ml minus 73.2ml from the med drips and flushes minus 48ml from blood is equal to 358.8ml. –-Finally divide by 24 hr to get the rate of TPN at 15ml/hr As an alternative for a patient on drips, you can subtract feeds and blood out of total fluids and divide by 24 hours to get a total fluid rate. So, 480 minus 48 = 432, divide by 24hr to get 18ml/hr. You can give this as a total fluid rate if you have meds that are changing and nurse will automatically adjust TPN rate to other meds. Image Credit: Image created by author, Christy Mumphrey, MD.
- #16 Presenter tip: For this and all example slides, insert screen shots pertinent to your institution This is what the front of our institution’s TPN form looks like. You will use this form for ordering TPN for your patients.
- #17 Now we have figured out the rate, what about the formulation? The goal is to start TPN as soon as possible. If TPN is unavailable or you anticipate frequent changing of fluids, start D5 in infants less than 1kg and D10 in infants greater than 1kg. On the first day of life and beyond, add 200 to 300 milligrams of calcium gluconate per 100 milliliters of fluid. Infants who are less than 24 hours old usually do not need additional electrolytes. For infants over 24 hours of age, monitor electrolytes and alter supplemented amounts based on laboratory values. In general, for older infants we usually add 3 milliequivalents of sodium chloride per 100 milliliters of fluid and 2 milliequivalents of potassium chloride per 100 milliliters of fluid. We also use these amounts of electrolyte supplements in patients being made NPO. If the patient was on electrolyte supplements in their feeds or have abnormal values on the BMP, you may need more than the recommended values. Don’t forget about adding heparin for patients with central lines. For example, a basic NPO fluid would be: D10W + 3meq NaCl/100mL + 2 meq KCl/100mL + 200mg CaGluconate/100mL +/- 0.5-1u heparin/mL.
- #18 Presenter tip: For this and all example slides, insert screen shots pertinent to your institution Much like IVFs, most kids will initially be on either D5 or D10 in TPN. The maximum dextrose concentration in a peripheral IV is about 12%. For central lines, we generally don’t go above 20%. The next calculation we will learn is the glucose infusion rate. It is important to think about the glucose infusion rate (GIR) and know what it is for each patient. To calculate the GIR we use the formula listed in the slide, multiplying the dextrose concentration, the rate of the fluids in milliliters per hour and 0.167 which remains constants. This product divided by the weight (in kg) is the GIR in milligrams per kilogram per minute. The goal GIR is to start at 5 to 6 mg/kg/min for preemies and 6 to 8 mg/kg/min for term infants. The recommended maximum GIR is 12 mg/kg/min. A GIR of 12mg/kg/min may not be possible in a very small baby. You should follow point of care glucoses and the GIR to determine dextrose concentration of TPN/fluids. In general, the GIR is increased or decreased by 1 or 2 mg/kg/min per day. Remember, the GIR is determined not only by dextrose concentration but also the rate of the fluids. Therefore, if you have a child you are advancing fluids on, or a baby who had blood taken out of total fluids the day before, you may not be able to advance the dextrose because the rate of TPN is higher. Let’s take a minute and do an example calculation. Your patient has D10 running at 15ml/hr and is 3.2kg. Allow time for trainees to calculate and respond. Take the product of 10, 15 and 0.167 and divide by the weight to give you a GIR of 7.8. Advance the slide. Don’t forget to fill in your dextrose concentration and GIR on the TPN form. Image Credit: Image created by author, Christy Mumphrey, MD
- #19 Presenter tip: For this and all example slides, insert screen shots pertinent to your institution Now we have filled out the Dextrose component, let's talk about protein goals. In general, start protein at 2 to 3 grams per kilogram per day and increase by 0.5 to 1 gram per kilogram per day with the goal in premature infants of 3.5 to 4 grams per kilogram per day and term infants of 3 grams per kilogram per day. Hepatic or renal dysfunction may alter requirements. You should decrease the protein to 2 grams per kilogram per day once your baby is on 50% of goal feeds. Advance slide. Don’t forget to put protein in the TPN. Image credit: Image created by author, Christy Mumphrey, MD
- #20 Lipids are the final major component of TPN. We use a 20% intralipid solution and begin at 1 to 3 grams per kilogram per day and increase by 0.5 to 1 grams per kilogram per day to a goal of 3 grams per kilogram per day in most infants. Lipids should be run over 24 hours to maximize clearance. We use triglyceride levels to monitor the tolerance to lipid load with the goal level to be less than 150 to 200 mg/dL. You should consider limiting lipids in infants with severe hyperbilirubinemia or severe pulmonary hypertension. For infants with TPN cholestasis which is defined as a direct bilirubin greater than 2 milligrams per deciliter or 20% of the total, decrease lipid infusion to 1g/kg/day. Lipids at 0.5 to 1 gram per kilogram per day are required to prevent fatty acid deficiency To calculate the volume of lipids needed for the day, take the desired amount in grams per kilogram per day and multiply that number by the patient’s weight and by 5. Let’s take a minute to do a sample calculation. We want to give our 3.2kg baby 2g/kg/day of lipids. Allow time for trainees to calculate and respond. Multiply 2, 3.2 and 5 to give the answer of 32ml/day of lipids. Then divide by 24 hrs to get rate = 1.3ml/hr. Advance slide. Put total milliliters, rate and 24 hours on the TPN form. Image credit: Image created by author, Christy Mumphrey, MD
- #21 Presenter tip: For this and all example slides, insert screen shots pertinent to your institution Now we need to determine the electrolytes to be added to the TPN. Determine the total amount of sodium and potassium that the infant needs and then decide how to divide between chloride, acetate and phosphate. Acetate and chloride are given in the amounts necessary for acid base balance. Acetate is generally not used unless the patient is acidotic and may cause over-alkalinization. When giving phosphorus, try to give it as sodium phosphate rather than potassium phosphate to limit aluminum exposure which contaminates TPN. Potassium should be removed or limited in patients with renal failure. Infants with immature renal function or on certain medications may require additional sodium and potassium. Electrolytes should be monitored daily when first starting TPN. Once the electrolytes stabilize, lab values may be checked less frequently. Advance slide. Don’t forget to add the desired amounts of electrolytes to the TPN order form. Image credit: Image created by author, Christy Mumphrey, MD
- #22 Presenter tip: For this and all example slides, insert screen shots pertinent to your institution Suggested starting amounts of magnesium, calcium, and phosphate can be found on the back of our TPN form. Advance slide. Use the laboratory results to guide supplementation afterwards. Advance slide. Add the desired values to the TPN order form. Image credit: Images created by author, Christy Mumphrey, MD
- #23 Presenter tip: For this and all example slides, insert screen shots pertinent to your institution Vitamins and trace elements are an important component in neonatal TPN. When giving vitamins, check the appropriate box based on the weight of the infant. Advance slide. The recommendations for trace elements can be found on the back of the TPN form. The recommended amounts are already on the TPN order form, the appropriate boxes must be checked. Additional Zinc should be added in preterm infants or infants weighing less than 3 kilograms. Advance slide. For patients with TPN cholestasis, manganese should not be given in the TPN and copper should be either removed or reduced in the TPN. You can consider giving these elements once/week. Advance slide. For patients with chronic renal failure, selenium and chromium should be removed from the TPN. Advance slide. Image credit: Images created by author, Christy Mumphrey, MD
- #24 Presenter tip: For this and all example slides, insert screen shots pertinent to your institution There are a few other components that may be added to the TPN. Heparin should be added if there is a central line used to deliver the TPN. For infants weighing greater than 1 kilogram, use a heparin concentration of 1 unit per milliliter. For infants weighing less than 1 kilogram, use a heparin concentration of 0.5 units per milliliter. We typically do not add Zantac to TPN. H2 blockers alter the GI bacterial flora which may increase the risk of NEC. The addition of zantac should be done with guidance from fellow or attending. The addition of carnitine should be considered in infants who are on TPN for greater than 4 weeks at a dose of 10 milligrams per kilogram per day. Advance slide. Don’t forget to sign, date and time your TPN order. Advance slide. You may reorder TPN on subsequent dates using the same form if the composition of the TPN is unchanged. Advance slide. Image credit: Images created by author, Christy Mumphrey, MD
- #25 Now we will move on to enteral feedings.
- #26 Breast milk is almost always the first choice for enteral nutrition. Use breast milk (20 kcal/oz) if available. If the infant is on formula, keep infant on same brand they were on prior to transfer if it was tolerated well. This applies to premature formula only. For term infants, you may use the formula available on WIC formulary. If starting enteral feeds for the first time you may use the formula available on WIC formulary or based on hospital contract. Image credit: Images created by author, Christy Mumphrey, MD.
- #27 There are many formulas to choose from and it can be confusing at times. Premature formulas have better protein and micronutrients than term formulas and are divided into in-hospital and discharge formulas. In hospital, premature formulas include Premature Enfamil or PEF and Similac Special Care or SSC. Both formulas are available in caloric concentrations of 20-24 kcal per ounce. These are only available in house and infants cannot be discharged on these formulas. Preterm infants must be transitioned to a discharge formula prior to discharge. Advance slide. The discharge formulas are Enfacare or Neosure and come in a standard concentration of 22 kcal per ounce. Example of term formulas commonly used are Enfamil Newborn or Similac Advance. Image credit: Images created by author, Christy Mumphrey, MD
- #28 Now we will talk a little about your specialty formulas. These are mostly used for term infants as we mentioned previously that the preterm formula is better designed for a growing preterm infant. In special circumstances where the traditional term formula is not tolerated, we may consider changing to one of these formulas. Both Gentlease and Similac Sensitive have lower amounts of lactose than standard formulas. They may be used for infants with suspected lactose intolerance or infants with drug withdrawal. Image Credit: Images created by author, Christy Mumphrey, MD
- #29 Even more specialized formulas are the partially hydrolyzed formulas used for more significant feeding intolerance. Pregestimil is a casein hydrolysate lactose-free formula with medium-chain triglycerides. We use pregestimil for infants who are postop hearts, post-NEC or for feeding intolerance. Alimentum and Nutramingen are also casein hydrolysate lactose-free formulas. These formulas are used for infants with cow’s milk protein allergies. EleCare and Neocate are amino acid based formulas and are even more hydrolyzed. These formulas are also used for infants with feeding intolerance or post-NEC. ProSobee and Isomil are soy formulas and are not generally used except for infants with galactosemia. Image credit: Images created by author, Christy Mumphrey, MD.
- #30 Now let’s talk about the caloric concentration of enteral feedings. As a group, we always start enteral feedings with a caloric concentration of 20 kcal per ounce and consider increasing calories or adding fortifiers once tolerating 80-100mL/kg feeds. In general, fortify to 22 kcal per ounce for 1-2 days then increase 24 kcal per ounce if the patient is tolerating the increase well. Infants with increased caloric needs or requiring fluid restriction such as congenital heart disease may require feeds fortified greater than 24 kcal per ounce. Preterm formulas come pre-made at 22 or 24 kcal per ounce. With EBM, we add fortifiers to achieve higher caloric intake. Human milk fortifier or HMF when added as 1 vial per 50 ml gives 22 kcal per ounce breast milk and 1 vial per 25 mL gives 24 kcal per ounce breast milk. Image credit: Image created by author, Christy Mumphrey, MD
- #31 With a full-term baby, we may allow that child to nipple ad lib. However, with a premature child, we are much more cautious with introducing and increasing feeds. In general, we increase by total of 20 to 30 milliliters per kilogram per day based on age and weight using our feeding protocol. Increasing feeds at a faster rate may be a risk factor for NEC. Full volume feeds are usually about 150 to 160 milliliters per kilogram per day.
- #32 The caloric goal for each patient should be enough so that the infant is able to gain an average of 20 to 30 grams per day. For most term infants, the caloric goal is 100 to 110 kcal per kilogram per day. For most preterm infants, the caloric goal is 110 to 120 kcal per kilogram per day. If the infant is on full TPN, the caloric goal is usually 85 to 95 kcal per kilogram per day as additional energy is not required for digestion. Some babies may require even higher caloric goals due to increased caloric expenditure such as heart disease or bronchopulmonary dysplasia.
- #33 Feeds and intolerance is a large proportion of the concerns and calls in the NICU. We should continuously monitor for signs of intolerance to help determine if it's ok to advance feeds. Nurses will check residuals which is how much food is left in the stomach prior to the next feed to be administered. The quality and quantity of residuals come into play. Green is almost always abnormal. For a baby on bolus feeds, up to 1/3 of the total volume of the previous feed is an acceptable residual. For a baby on continuous feeds, 1.5 times the hourly rate is acceptable, up to 2 times in some babies Abdominal distention and emesis are both concerning and the patient should be examined Image Credit: Image created by author, Jeffrey Surcouf, MD
- #34 A term infant is encouraged to nipple feed while a preterm infant is given most of the feeds via a gavage tube. So, when can a preterm infant be given the opportunity to nipple? In general, at roughly 34 weeks corrected gestational age there is enough coordination of the suck-swallow-breathe reflex to attempt nipple feeding in preterm infants. Nippling can be considered earlier if the infant is showing signs of readiness including rooting, sucking on a pacifier, alert state, and good tone. To nipple, the infant should be tolerating bolus or near-bolus feeds being fed into stomach via a naso- or orogastric tube. Transpyloric feeds cannot be given via bolus and will need to be transitioned to gastric continuous feeds before then transitioning to bolus. Occasionally a small volume of feed can be nippled during this process to begin oral stimulation. Compression of feeds from continuous to bolus generally takes place slowly over a few days. We typically take the amount given over a three-hour interval and run it over 2 hours then 1 hour then 30 minutes as tolerated. Once we begin nipple attempts, we typically start with one to two nipple attempts per day. Advancing nipple attempts depends on how well the baby is doing. The infant has to be nippling full volume without significant suck apnea or bradycardia with attempts and gaining weight before allowing the infant to take more nipple attempts. For example: If an infant nipple attempts 3 times a day and takes only 1 full volume and half of the other two, it would be inappropriate to increase nippling attempts to 4 times.
- #35 Here are some useful references where the information found in this presentation may be reviewed.