Initiation and Advancement of Macronutrients

  1. Dextrose - Begin PN at 10 - 15% dextrose depending on whether the line is peripheral or central and the clinical status and age of the child. Advance by 2.5 - 5% in older infants and children and by 5 - 10% per day in adolescents until an endpoint of D12.5% dextrose for PPN or generally between 20 - 25% dextrose for CPN, as needed to meet nutritional needs.
  2. Provision of excess carbohydrate calories may lead to the following adverse effects: hyperglycemia, hepatotoxicity, cholestasis, glycosuria, osmotic diuresis
  3. Insulin Use - Critically ill pediatric patients experiencing hyperglycemia from stress or medical management may need to have insulin added to the TPN. A general guideline is addition of 1 unit of regular insulin per 10 grams of carbohydrate calories. Alternatively, 75% of the previous day's sliding scale insulin dose may be added to the TPN bag.
  4. Protein - Infants under 2 years of age should be started on a pediatric parenteral amino acid solution such as TrophAmine (B. Braun, Irvine, CA). This amino acid formulation for pediatric patients provides numerous advantages including: provides essential amino acids for infants, promotes plasma amino acid profiles within normal neonatal target range, decreases the tendency for development of cholestasis, and decreases the pH of the solution thus improving calcium and phosphorus solubility (7.2 mEq of Ca + Phos per 100 ml of PN solution).
  5. Protein Advancement in Infants and Children - Begin at 1.5 - 2 gm/kg per day and advance to endpoint goal by Day 2. In infants with renal insufficiency or failure may need to limit protein to 1.0 gm/kg/day on first day of PN.
  6. Lipids - Lipids may be safely used on a daily basis in most patients. Begin lipids at 1.0 gm/kg and advance by 1.0 gm/kg per day depending on a child's age and lipid clearance to the appropriate endpoint goal of 3 gm/kg in infants and 1 - 2.0 gm/kg in older children and adolescents, depending on clinical status.
  7. Essential Fatty Acid (EFA) Requirements - 20% Intralipid (2 kcal/cc) should be provided at a minimum dose of 0.5 - 1.0 gm/kg per day for provision of essential fatty acid (EFA) requirements. Signs of EFA deficiency include: reduced growth rate, impaired wound healing, increased susceptibility to infections, thromobocytopenia, and flaky dry skin .