Initiation and Advancement of Macronutrients
- 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.
- Provision of excess carbohydrate calories may lead to the following
adverse effects: hyperglycemia, hepatotoxicity, cholestasis,
glycosuria, osmotic diuresis
- 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.
- 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).
- 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.
- 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.
- 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 .