PAEDIATRIC PARENTERAL NUTRITION. Ezatul Mazuin Ayla binti Mamdooh Waffa Hospital Sultanah Aminah
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1 PAEDIATRIC PARENTERAL NUTRITION Ezatul Mazuin Ayla binti Mamdooh Waffa Hospital Sultanah Aminah Johor Bahru
2 Malnutrition INTRODUCTION 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). Primary malnutrition common cause of morbidity & mortality in the developing countries nearly 40% of children under 5 years of age are affected (A.S.P.E.N 2002)
3 INTRODUCTION 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 INTRODUCTION Preterm neonates limited energy reserves nutrients for tissue growth and development the energy and catabolic cost of any morbidity. (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 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, (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 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 ADMINISTRATION OF PN Central Line hypertonic solution with higher osmolarity. full PN support in children. Prolonged PN associated with infectious and mechanical complications Venous Access Peripheral Line Not to exceed 900 mosm/l limited to dextrose concentrations of less than 12.5%. 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 Increase fluid req Fever phototherapy hyperventilation hypermetabolism gastrointestinal losses, etc Decrease fluid req renal failure congestive heart failure, etc
11 FLUID REQUIREMENTS Body weight Fluid requirements < 10 kg 100 ml/kg per day 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 ASPEN 2002, Horn 2003, Koletzko et al 2005
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 Pre-term 0 1 year 1 7 year 7 12 year year kcal/kg/day kcal/kg/day kcal/kg/day kcal/kg/day kcal/kg/day 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 to 10 years Adolescence Boys Girls to 10 years 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 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, Kolaricet al 2006
16 LIPID REQUIREMENTS providing high energy needs without carbohydrate overload carbohydrate overload increase in CO 2 levels in blood (hypercapnia) hyperglycaemia due to insulin resistance supplementing essential fatty acids low 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 Neonate Initiate: 0.5 g/kg/day Max: 3 4 g/kg/day Older children Initiate: 1 g/kg/day Max: 2 3 g/kg/day 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 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 Potassium Calcium Magnesium Phosphate Chloride 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 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 phosphates Phosphate and trace elements Trace elements and amino acids
21 MONITORING Clinical monitoring Vital signs, temperature Fluid balance (input/output), edema Weight Infusion site Infusion rate / pump Change administration tubing 24 H Biochemical monitoring Blood glucose BUSE LFT Serum creatinine Lipid profile Adequacy of nutritional management Potential complications
22 COMPLICATIONS OF PN Mechanical Catheter related sepsis Pneumothorax Dislocation of catheter Air embolism Venous thrombosis Infiltration & phlebitis Blockage of TPN infusion Metabolic Hypo/hyperglycemia Allergic reaction to AA / fats Electrolytes disturbances Thrombocyte & neutrophil dysfunction Hepatic dysfunction Metabolic acidosis Infectious Catheter-related sepsis Other Infections Nutritional Inadequate feeding Over feeding Refeeding syndrome
23 REFERENCES A.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force 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 Parenteral nutrition. AIIMS- NICU protocols. New Delhi: All India Institute of Medical Sciences. Horn, V Paediatric parenteral nutrition. Hospital Pharmacist 10: Kolaric, A., Pukšič, M. & Goričanec, D Solutions preparing for total parenteral nutrition for children. Proceedings of the 7th WSEAS International Conference on Mathematics & Computers in Biology & Chemistry, Cavtat, Croatia: June (pp1-6). Koletzko, B., Goulet, O., Hunt, J., et al 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 Parenteral Nutrition in the NICU. Nutrition Dimension.
24 REFERENCES Lucas, A., Morley, R. & Cole, T.J Randomised trial of early diet in preterm babies and later intelligence quotient.bmj 317: Shulman R.J. & Phillips. S Parenteral nutrition in infants and children. JPGN 36: Spagnuolo, M.I., Pirozzi, M.R. & Guarino, A Enteral and parenteral nutrition in pediatric patients: main clinical indications and the fundamental role of artificial nutrition to avoid malnutrition. Nutritional Therapy & Metabolism: 28: Ziegler, T.R Parenteral Nutrition in the Critically Ill Patient. N Engl J Med 361:
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