This document discusses paediatric parenteral nutrition. It begins by defining malnutrition and outlining its causes. The goals of nutrition support are then stated as preserving good nutritional status, preventing malnutrition, and providing adequate nutrients to meet metabolic needs. The indications for parenteral nutrition (PN) include inability to meet nutrient requirements orally or enterally to prevent or correct malnutrition. Central and peripheral lines are discussed for administering PN depending on osmolarity and dextrose concentration needs. Fluid, calorie, protein, carbohydrate, lipid, electrolyte, vitamin and trace element requirements are outlined based on age. Compounding problems, monitoring, complications and references are also summarized.

1. PAEDIATRIC PARENTERAL
NUTRITION
Ezatul Mazuin Ayla binti Mamdooh Waffa
Hospital Sultanah Aminah
Johor BahruJohor Bahru

2. INTRODUCTIONINTRODUCTION
Malnutrition
pathologic state of varying severity with clinical features caused
by deficiency, excess, or imbalance of essential nutrients.
The cause may be
primary (involving the quantity or quality of food consumed)
secondary (involving alterations in nutrient requirements, utilization, or
excretion).
(A.S.P.E.N 2002)(A.S.P.E.N 2002)
Primary malnutrition
common cause of morbidity & mortality in the developing
countries
nearly 40% of children under 5 years of age are affected

3. INTRODUCTIONINTRODUCTION
Malnutrition due to the effects of acute or chronic disease →
negative effect on recovery or response to therapy.
There is an association between malnutrition, mortality and
morbidity
good nutritional profile → responsive to clinical treatment.
(Spagnuolo et al 2010)

4. INTRODUCTIONINTRODUCTION
Preterm neonates
limited energy reserves
nutrients for
tissue growth and development
the energy and catabolic cost of any morbidity.
(Morgan & Kovar 1992)(Morgan & Kovar 1992)
Nutritional compromise during critical period of rapid brain
growth (30 weeks’ gestation to 6 months of life) → could
permanently impair cognitive function
(Lucas et al 1998)

5. GOALS OF NUTRITION SUPPORT
To preserve a good nutritional status
To prevent malnutrition
To provide therapy to help patients with various
disorders
To provide adequate nutritient to meet metabolicTo provide adequate nutritient to meet metabolic
needs
To improve the nutritional and metabolic condition
To avoid complications
To improve patient outcomes
(Kolaric et al 2006, Spagnuolo et al 2010)

6. In preparing and planning for a patient to receive PN,
the goals should be clearly stated by determining the
patient’s
(1) nutritional requirements,(1) nutritional requirements,
(2) baseline metabolic parameters,
(3) anticipated PN duration,
(4) accessibility of central veins,
(5) the most appropriate device for placement, and
(6) the complications of therapy.
ASPEN 2002

7. THERAPEUTIC GOALS OF PN
The therapeutic goal of PN in children
to maintain nutritional status and to achieve balanced
somatic growth.
Somatic growth spurt occur in early infancy and
adolescence
sensitive to energy restriction because of high basal andsensitive to energy restriction because of high basal and
anabolic requirements.
To provide sufficient nutrients parenterally to sustain
growth in infants and children suffering from intestinal
failure or severe functional intestinal immaturity
ASPEN 2002, Horn 2003, Koletzko et al 2005.

8. INDICATIONS FOR PN
Patient is unable to meet their nutrient requirements orally or
enterally
→to prevent or correct malnutrition or to sustain appropriate
growth. (B)
The maximum period of tolerable undernutrition depends on the
patient’s age, baseline nutrition status, and underlying medical
conditions
PN should be initiated
within 1 day of birth in neonates
within 5 to 7 days in pediatric patients (C)
depending on age, baseline nutritional status, and underlying
medical conditions
ASPEN 2002, Horn 2003, Koletzko et al 2005
a short PN course of < 5 days is unlikely to give significant nutrition
benefits
Spagnuolo et al 2010

9. Central Line
• hypertonic solution with
higher osmolarity.
•full PN support in children.
Peripheral Line
• Not to exceed 900 mOsm/L
• limited to dextrose
concentrations of less
than 12.5%.
ADMINISTRATION OF PN
Venous
Access
•Prolonged PN
•associated with infectious
and mechanical
complications
•rarely indicated
• partial PN
supplementation
• bridge therapy for
patients awaiting
central access
•Short term (usu. < 2 weeks)
ASPEN 2002, Horn 2003, Koletzko et al 2005

10. FLUID REQUIREMENTS
Fluid needs vary with the age & weight of the child and should be
adjusted accordingly.
Total water requirements consist of
the maintenance needs
replacement of ongoing losses (insensible water loss, urinary losses,
and stool losses)
replacement of deficits.
ASPEN 2002, Horn 2003, Koletzko et al 2005
renal failure
congestive heart failure, etc
Decrease fluid req
Fever
phototherapy
hyperventilation
hypermetabolism
gastrointestinal losses, etc
Increase fluid req

11. FLUID REQUIREMENTS
Body weight Fluid requirements
< 10 kg 100 ml/kg per day
11 – 20 kg 1,000 ml per day + 50 ml/kg for
ASPEN 2002, Horn 2003, Koletzko et al 2005
11 – 20 kg 1,000 ml per day + 50 ml/kg for
each kg above 10 kg
> 20 kg 1,500 ml per day + 20 ml/kg for
each kg above 20 kg

12. CALORIC REQUIREMENTS
Energy in a child is required for both maintenance of body
metabolism as well as for growth
ASPEN 2002, Horn 2003, Koletzko et al 2005
Estimation Of Caloric Requirements
110 – 120 kcal/kg/dayPre-term 110 – 120 kcal/kg/dayPre-term
90 – 100 kcal/kg/day0 – 1 year
75 – 90 kcal/kg/day1 – 7 year
60 – 75 kcal/kg/day7 – 12 year
30 – 60 kcal/kg/day12 – 18 year
ASPEN 2002, Koletzko et al 2005

13. COMPONENTS OF PN
Macronutrients
Protein (Amino Acids)
Carbohydrate (Dextrose)
Lipid
Micronutrient
Electrolytes
Vitamins
Trace Elements

14. PROTEN REQUIREMENTS
Protein (amino acids) requirements should be adjusted according to the
age of the child. (B)
Amino acid preparation → crystalline, branched amino acids
Amino acids are generally not metabolized to supply energy but to
provide structural and visceral proteins and enzymes
Age Protein requirements (g/kg/day)
Low birth weight 3 – 4
Full-term 2 – 3Full-term 2 – 3
1 to 10 years 1.0 – 1.2
Adolescence
Boys
Girls
0.9
0.8
1 to 10 years 1.0 – 1.2
Critically ill
child/adolescent
1.5
ASPEN 2002, Kolaric et al 2006

15. CARBOHYDRATE REQUIREMENTS
Carbohydrates are the main sources of energy → should
comprise 40% to 50% of the caloric intake in infants and
children. (C)
The most commonly used carbohydrate is glucose → readily
used by all body tissues
Initial glucose concentration usually 5-10%
Gradually increase up to 17.5% - 20%
Concentration > 12.5% → central venous accessConcentration > 12.5% → central venous access
Total amount should not exceed daily amount the body can
utilize. If exceeded:
fatty liver
insulin resistance
hyperglycemia
Carbohydrate administration should be closely monitored and
adjusted in the postoperative period in neonates and children
to avoid hyperglycemia.
ASPEN 2002, Koletzko et al 2005 , Kolaric et al 2006

16. LIPID REQUIREMENTS
providing high energy needs without carbohydrate
overload
carbohydrate overload
→ increase in CO2 levels in blood (hypercapnia)
→ hyperglycaemia due to insulin resistance
supplementing essential fatty acids
low osmolality → good use in peripheral applicationslow osmolality → good use in peripheral applications
20% lipid emulsion preferred over 10%
10% has higher phospholipid to triglyceride ratio → decreased
lipid clearance & elevated TG levels
Initiate: 1 g/kg/day
Max: 2 – 3 g/kg/day
Older children
Initiate: 0.5 g/kg/day
Max: 3 – 4 g/kg/day
Neonate
Koletzko et al 2005 , Kolaric et al 2006

17. ELECTROLYTES REQUIREMENTS
Electrolytes are added to PN according to patient’s individual
requirements based on blood chemistry
The basic daily requirements influenced by multiple factors:
increased body temperature
abnormal losses through the gastroenterological tractabnormal losses through the gastroenterological tract
(vomiting, diarrhoea)
increased anabolism (starvation),
increased loss of water through damaged skin in burn patients,
heart and kidney malfunctions,
medical drug therapy,
external factors (humidity, outside temperature).
Horn 2003, , Kolaric et al 2006

18. ELECTROLYTES REQUIREMENTS
Electrolytes Requirements (mmol/kg/day)
Neonates Infants Children
Sodium 3-5 2-5 1-2
Potassium 1-5 2-3 1-2
Calcium 1-2 1-2 0.5-1.0
Magnesium 0.6-1.0 0.6-1.0 0.5-1.0
Phosphate 1-2 1-2 0.5-1.0
Chloride 3-5 2-5 1-2
Horn 2003, , Kolaric et al 2006

19. VITAMINS & TRACE ELEMENTS
Essential in the metabolism of carbohydrates, protein and fats
Water soluble vitamins
Soluvit N (Paeds) – 1ml/kg BW (max 10 ml)
Lipid soluble vitamins
Vitalipid N Infant – 4 ml/kg BW (max 10 ml) – for chidren <
11 years11 years
Vitalipid N Adult – 10 ml – for patients over 11 years
Trace elements
Proven essential :
Zinc, copper, iodine, iron, manganese, chromium, cobalt,
selenium, molybdenum
Peditrace – 1 ml/kg/day (max 15 ml)

20. COMPOUNDING PROBLEM
Precipitation
A precipitate is solid matter formed in the solution.
E.g.
Calcium and phosphatesCalcium and phosphates
Phosphate and trace elements
Trace elements and amino acids

21. MONITORING
Vital signs, temperature
Fluid balance
(input/output), edema
Weight
Clinical monitoring
Blood glucose
BUSE
LFT
Serum creatinine
Biochemical monitoring
Weight
Infusion site
Infusion rate / pump
Change administration
tubing – 24 H
Serum creatinine
Lipid profile
Adequacy of nutritional management
Potential complications

22. COMPLICATIONS OF PN
Catheter related sepsis
Pneumothorax
Dislocation of catheter
Air embolism
Venous thrombosis
Mechanical
Hypo/hyperglycemia
Allergic reaction to AA / fats
Electrolytes disturbances
Thrombocyte & neutrophil
dysfunction
Metabolic
Venous thrombosis
Infiltration & phlebitis
Blockage of TPN infusion
dysfunction
Hepatic dysfunction
Metabolic acidosis
Inadequate feeding
Over feeding
Refeeding syndrome
Nutritional
Catheter-related sepsis
Other Infections
Infectious

23. REFERENCESA.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force. 2002.
Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric
Patients. J Parenteral Enteral Nutr 26:1SA-138SA.
Chawla, D., Thukral , A., Agarwal, R., et al. 2008. Parenteral nutrition. AIIMS- NICU
protocols. New Delhi: All India Institute of Medical Sciences.
Horn, V. 2003. Paediatric parenteral nutrition. Hospital Pharmacist 10: 58-62.
Kolaric, A., Pukšič, M. & Goričanec, D. 2006. Solutions preparing for total parenteralKolaric, A., Pukšič, M. & Goričanec, D. 2006. Solutions preparing for total parenteral
nutrition for children. Proceedings of the 7th WSEAS International Conference on
Mathematics & Computers in Biology & Chemistry, Cavtat, Croatia: June 13-15
(pp1-6).
Koletzko, B., Goulet, O., Hunt, J., et al. 2005. Guidelines on paediatric parenteral
nutrition of the European Society of Paediatric Gastroenterology, Hepatology and
Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and
Metabolism (ESPEN), supported by the European Society of Paediatric Research
(ESPR). Journal of Pediatric Gastroenterology and Nutrition 41: S1–S4.
Liesje Nieman. 2008. Parenteral Nutrition in the NICU. Nutrition Dimension.
http://www.nutritiondimension.com/.

24. REFERENCES
Lucas, A., Morley, R. & Cole, T.J. 1998. Randomised trial of early diet in preterm
babies and later intelligence quotient.BMJ 317: 1481-1487.
Shulman R.J. & Phillips. S. 2003. Parenteral nutrition in infants and children. JPGN
36: 587–607.
Spagnuolo, M.I., Pirozzi, M.R. & Guarino, A. 2010. Enteral and parenteral nutrition in
pediatric patients: main clinical indications and the fundamental role of artificial
nutrition to avoid malnutrition. Nutritional Therapy & Metabolism: 28: 21-4.
Ziegler, T.R. 2009. Parenteral Nutrition in the Critically Ill Patient. N Engl J Med 361:
1088-97.