Neonatal Parenteral Nutrition Guideline Dr M Hogan, Maire Cullen ANNP, Una Toland Ward Manager, Sandra Kilpatrick Neonatal Pharmacist

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1 CLINICAL GUIDELINES ID TAG Title: Author: Designation: Speciality / Division: Directorate: Neonatal Parenteral Nutrition Guideline Dr M Hogan, Maire Cullen ANNP, Una Toland Ward Manager, Sandra Kilpatrick Neonatal Pharmacist CYP Neonatal Acute Paediatrics Date Uploaded: 30 th December 2014 Review Date: 1 st February 2016 Approved by: Dr M. Hogan Clinical Guideline ID: CG0072

2 Neonatal Parenteral Nutrition Guideline 1. Indications for Parenteral Nutrition.Consider TPN early in the following infants: < 1500gm Contraindications to enteral feeding eg: RDS, Critically ill Failure of enteral nutrition Necrotising Enterocolitis Congenital Abnormality of the gut NB:If outside normal working hours, the Standard TPN bags should be used The indications for commencing TPN should be documented in the case notes. 2. Assessment prior to commencing Parenteral Nutrition Prior to commencing Parenteral Nutrition all infants should have the following: Medical History Full physical examination Plot growth parameters weight, length and head circumference Full blood count Urea, creatinine and electrolytes Glucose

3 Calcium and Phosphate Liver function tests including Albumin 3. Prescribing Parenteral Nutrition Parenteral Nutrition should be prescribed using the Ascribe computer programme available on the computer in NNU. The completed prescription should then be filed in the patient s notes. A handwritten prescription on the TPN form is acceptable only when the ascribe programme is not available due to an IT problem. The TPN prescription should be with pharmacy for 11.00am. Parenteral Nutrition can be prescribed by middle grade trainees and above with supervision and input from Consultants and the wider multi-disciplinary team (Pharmacist, Advanced Neonatal Nurse Practitioners, and Dietician). Composition of the TPN should be based on the individual infant s requirements and daily U+E. Bags are based on a concentration of 10% Glucose with amino acids, electrolytes ( to include magnesium and phosphate from day 1), vitamins and trace elements. Lipids are provided in a separate syringe along with fat soluble vitamins. Amino Acids should be added from the first day of life. Preterm commence 2gm/kg/day - day 1, increase 2.5gm/kg/day - day 2, and 3 gm/kg/day -day 3, 3.5gm/kg/day-day 4.

4 Term infants Commence 2gm/kg/day day 1 and 2.5gm/kg/day- day 2, 3gm/kg/day- day 3 Maximum amino acid intake for Term baby 3gm/kg/day Lipids Commence 1gm/kg/day day one, 2gm/kg/day day 2, 3gm /kg/day 3 (Max 3g/kg/day) Vitlipid will be included in the total fat content ( 0.4gm in 4 ml vitlipid) Administer over 24 hours No evidence that gradually increasing lipid concentration improves tolerance Calorie requirement The calorie requirement for preterm babies is kcal/kg/day and term babies kcal/kg/day. This can be met by increasing the glucose content of the TPN Day 1-10% glucose, Day 2 11% glucose, Day % glucose. It is preferable to have a percutaneous long line for the higher glucose concentration 12.5%. If this is not possible, consider using the lower glucose concentration 10% and introducing enteral feeds as soon as possible Standard TPN can be prescribed at the weekends and out of hours. Lipid infusions are not available out of hours. Standard TPN can be commenced without the initial electrolyte check providing the blood sample is taken at 12 hours of age. The fluid volume prescribed is as per the unit fluid guidelines

5 Parenteral Nutrition should be administered via appropriate vascular access. Central Venous Access is the most appropriate: Umbilical Venous Line Peripherally Inserted Long Line 4. Venous Access Peripheral Access is acceptable in the following circumstances: Temporarily while awaiting Central access- NB: GLUCOSE CONCENTRATION MUST BE LESS THAN 12.5% If parenteral nutrition is only likely to be needed on a short term basis. Following failed attempts at central access. Insertion of Central Access should be performed by staff who have been trained and are competent in the technique. It should be clearly documented in the patient s notes (on appropriate form) The type of Central Venous Catheter The technique of insertion The site of insertion The site of the tip of the catheter as confirmed radio logically Name and Designation of the operator.

6 Appropriate monitoring and handling of the venous access device: Daily inspection of the site of insertion Handle only using aseptic technique If possible use exclusively for parenteral nutrition with alternative access for drugs. Careful vigilance for signs of line sepsis (increasing respiratory requirements, deteriorating blood gases, temperature instability, vomiting, poor perfusion, decreasing blood pressure, tachycardia or bradycardias, falling platelets, rising inflammatory markers) Follow appropriate care bundle 5. Administration Parenteral nutrition should be administered through the designated venous line via an appropriate giving set with a burette. TPN should not be drawn into a syringe and run on a side arm. TPN should be checked by two trained staff and the bag checked against the prescription filed in the patient s notes and patients arm bands. Lipids should be administered over a 20hour and when administration stopped increase flow rate of TPN to compensate until new bag /syringe is erected See guideline on the procedure for handling central lines available in NNU

7 6. Monitoring When an infant is receiving Parenteral Nutrition the following monitoring must be undertaken: Capillary glucose monitoring 12hourly and if stable consider daily Hourly fluid balance to include: o Inputs (parenteral nutrition, any additional IV fluids, drug infusions, flushes) o Outputs (urine, stool, aspirates, vomit) Daily urea, creatinine and electrolytes to include calcium, magnesium and phosphate Once weekly liver function tests and lipid profile. Pharmacy will send a reminder to neonatal staff on day 7 of TPN. Consider checking lipid profile on day 3 if infant <800gm. Twice weekly weight check. Once weekly length and head circumference, plot values on centile charts weekly. The TPN prescription will be filed in the main part of the chart 7. Electrolyte / Metabolic disturbances/ Caloric content Glucose Hyperglycaemia > 11 mmol/l o Insulin infusion Add 10 units/kg to 50 mls of 10% Glucose to give a solution of 0.2 units/kg/ml and infuse according to the table on insulin guideline ( located on legacy trust site) Hypoglycaemia < 2.6 mmol/l ( assess line patency)

8 o Liberate fluids if otherwise clinically appropriate o Increase glucose concentration of the parenteral nutrition o Profound symptomatic hypoglycaemia should be treated with a bolus of dextrose 2.5-5ml/kg of 10% glucose Sodium (provided as chloride salt) Normal values: mmol/l Normal daily requirements: mmol/kg Adjust according to daily U+E and fluid balance on prescription. Potassium ( provided as chloride salt) Normal values: mmol/l Normal daily requirements: 1 2 mmol/kg Adjust according to daily U+E on prescription. Calcium Normal values: mmol/l Normal daily requirements: mmol/kg Phosphorous Normal values 1.8mmol/l Normal daily requirements 0.5mmol/kg Magnesium Normal values mmol/l Normal daily requirement 0.2mmol/ kg

9 Liver Function One third of infants who receive TPN for more than 2 weeks develop jaundice Biliary sludging and calculi may develop This usually resolves once enteral feeding is established Need to be vigilant as it can develop to cirrhosis and liver failure Lipids Hypertrigylceridaemia <2.2mmol/l continue mmol/l maintain current infusion Value between 2.5 to 2.8mmol/l reduce infusion by 1gm/kg/day >2.8mmol/l stop infusion, recheck level 48 hours later and if normal values recommence 0.5gm /kg /day to prevent fatty acid deficiency Peditrace This contains trace elements Zn 2+ CU 2+ Mn 2+ Se 2+ F - I - dose 0.5ml/kg on day 1 and 1ml/kg from day 2 onwards SolvitoN Water soluble vitamins and folic acid dose 1ml /kg from day 1 onwards Vitlipid N Emulsion of fat soluble vitamins dose 4mls/kg day 1 onwards to a maximum dose 10mls

10 8. Discontinuing Parenteral Nutrition Prepare full 24 hours TPN volume and reduce TPN volume to take account of enteral feeds given. If feeds are > 50%, consider discontinuing the lipid infusion. In this case commence dalivit 0.3mls orally, if appropriate, to ensure continual supply of fat soluble vitamins. When recommencing TPN seek advice from pharmacist re: regime to recommence

11 References 1.NCEPOD Recommendations A Mixed bag ESPAGHN guideline on parenteral nutrition (journal of paediatric gastroenterology and Nutrition 2012) 3.Manual of neonatal intensive Care Rennie and Roberton 4.Improving practice and reducing risk in the provision of Parental Nutrition for neonates and children- A report for the Paediatric Chief Phamacists Group(November 2011)