Phar 653 Clinical Pharmacotherapeutics III
PEDIATRICS: Spring 2002
Donna M. Kraus, Pharm.D.
PEDIATRIC NUTRITION
Goal: To familiarize
students with the differences in nutritional requirements between adults and children with
respect to fluids, electrolytes, calories, carbohydrates, proteins, fats and trace
elements.
Objectives:
1. Given the age, weight and disease state of a child, calculate the daily maintenance
fluids and total daily fluid requirement.
2. List the indications and monitoring parameters (with monitoring frequency) for a child
receiving TPN.
3. Given the age, weight and disease state of a child, be able to describe how to
initiate and advance TPN with respect to fluids, carbohydrates, protein and fat.
4. Given the age, weight, disease states and TPN order for a pediatric patient,
determine if the TPN order is adequate in terms of supplying appropriate calories,
protein, fats, electrolytes, minerals, vitamins and trace elements.
5. For both central and peripheral TPN, list the maximum concentration of dextrose that
can be used.
6. Explain why neonates and young infants need special amino acid formulations.
7. Discuss the important neonatal issues regarding lipid metabolism and the
controversies/complications surrounding its use.
8. List and discuss the common complications of TPN.
9. List the 4 advantages of breast feeding.
10. Discuss the differences in human milk, cow milk and infant formulas with respect to
protein, carbohydrates, fats, and mineral content.
11. For each of the following types of infant formulas, list 3 different brand names,
how the content differs between types, the rationale of why each type would be used, and
the disease state(s) that each would be used in
a. Cow milk-based infant formulas
b. Soy based infant formulas
c. Therapeutic infant formulas
d. Preterm infant formulas
12. Given a pediatric patient case, be able to appropriately recommend an infant
formula and whether or not the infant requires vitamin or mineral supplements.
PEDIATRIC NUTRITION
Required Reading:
Anderson JD, Chessman KH. Chapter 130/ Pediatric and Geriatric Nutrition Support in Pharmacotherapy,
A Pathophysiologic Approach. 4th ed. DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells
BG, Posey LM, editors. Appleton & Lange, Stamford, Connecticut, 1999 (pages 2293 -
2303).
Highly Suggested Readings:
Cochran EB, Phelps SJ, Helms RA. Parenteral nutrition in pediatric patients. Clinical
Pharmacy Vol 7, May 1988, pp 351 - 66.
McKenzie MW, Bender KJ, Seals AJ. Infant formula products in The Handbook of
Nonprescription Drugs, 12th Edition, Allen LA, ed, Washington,DC: APhA 2000 (pages
439 - 464).
Additional References:
Manual of Pediatric Parenteral Nutrition, Kerner JA (editor), 1983, John Wily and Sons
Publishers, New York.
Total Parenteral Nutrition, Lebenthal E (editor), 1986, Raven Press, New York.
Marshall LL. Infant formula products. American Pharmacy. Vol NS33, No 10.
October 1993:55-60.
ASPEN Board of Directors. Guidelines for the use of parenteral and enteral nutrition in
adult and pediatric patients. Journal of Parenteral and Enteral Nutrition
1993:17:1SA - 52SA.
Phar 653 Clinical Pharmacotherapeutics III
Donna M. Kraus, Pharm.D.
PEDIATRIC NUTRITION
I. Introduction: Adequate nutrition for the proper growth and development of a child
requires individualization. The amount and type of fluid, calories, electrolytes, and
trace elements are all based on age, weight, nutritional status, and disease state.
II. The total daily fluid requirement of any patient is equal to the
normal daily maintenance fluids plus replacement of any fluid deficit plus replacement of
any significant abnormal ongoing losses. Two methods to calculate normal maintenance fluids are described
below. Normal maintenance fluids provide replacement for normal body functions and for
normal losses (for example, insensible water loss, urine output and stool losses). Other
factors that may increase the patient's total daily fluid requirements
need to be replaced in addition to the normal daily maintenance fluids.
Total daily fluid requirement =
Normal Maintenance Fluids + Deficit + Ongoing Abnormal Losses
Total daily fluid requirements may be increased by: 1) increases in insensible
water losses due to such factors as fever, hyperventilation, phototherapy,
radiant warming, skin breakdown, burns, etc. 2) initial deficits of fluid
i.e., dehydration 3) significant ongoing abnormal losses such as
diarrhea, vomiting, nasogastric tube losses, high output renal failure, etc.
| A. Daily maintenance fluid requirements (i.e., normal maintenance fluids) are those required to
maintain normal homeostasis for a 24 hour period. Surface area and body weight are two
common methods used for the calculation of maintenance fluids in pediatric patients. NOTE:
Premature infants will have greater daily maintenance fluid requirements then those shown
here due to their larger surface area to body weight ratio and thinner skin, both of which
significantly increase their insensible water losses from the skin. In fact, preterm
infants < 750 grams often require 200 - 250 ml/kg/day to prevent dehydration. Due to
their highly specialized needs, calculation of fluid requirements for premature neonates
will be considered beyond the scope of this lecture.
| 1. Daily maintenance fluid requirements calculated by body surface
area: For pediatric patients, the amount of daily maintenance fluid required is
in the range of 1500 - 1800 ml/m2/day. Usually 1500 ml/m2/day
is used. The surface area method is usually used in children > 10 kilograms because a
precise measurement of surface area is often difficult in smaller infants. 2. Daily maintenance fluid requirements calculated by body weight
| Weight |
Daily maintenance fluid requirements |
| < 2.5 kg |
120 ml/kg/day. |
| 2.5 - 10 kg |
100 ml/kg/day. |
| 11 - 20 kg |
1000 ml plus 50 ml/kg for
every kg over 10 kg. |
| > 20 kg |
1500 ml plus 20 ml/kg for
every kg over 20 kg. |
EXAMPLES:
| Weight: |
Maintenance fluid |
| 8 kg : 100
ml/kg/day = 800 ml/day |
| 15 kg : 1000 ml
+ (50 ml/kg * 5) = 1000 + 250 = 1250 ml/day |
| 27 kg : 1500 ml
+ (20 ml/kg * 7) = 1500 + 140 = 1640 ml/day |
3. Factors
which may increase insensible water loss will increase daily fluid requirements.
a. Estimates of additional
insensible water loss (e.g., fever) can be calculated as a percent increase of normal
maintenance fluids (e.g. for fever, increase daily fluid by 12% of normal maintenance for
every degree Centigrade over 37 degrees).
b. Neonates who receive
phototherapy require 20 ml/kg/day additional fluid due to increased insensible water loss.
|
B. Fluid deficit is
calculated by clinical assessment of dehydration.
NOTE: If the pediatric patient is hemodynamically stable, 1/2 of
the fluid deficit is replaced over the first 8 hours, and the second 1/2 of the fluid
deficit is replaced over the next 16 hours.
C. Ongoing losses also need to be
replaced. Estimates of sensible fluid losses can usually be easily measured (e.g., NG tube
losses, vomiting, etc).
D. Fluid restriction: As in adults, the
amount of daily fluids administered to a pediatric patient may need to be restricted.
Situations which require fluid restriction include patients with cerebral edema,
congestive heart failure, renal failure, SIADH, patent ductus arteriosus, and certain
pulmonary disorders. Fluid restriction may be calculated 1) as a percent of maintenance
fluids (e.g., 2/3 or 3/4 maintenance) or 2) as insensible loss (300 - 400 ml/m2)
plus urine output. |
III. Pediatric Total Parenteral Nutrition (TPN)
A. The indications for TPN in children are
similar to the indications in adults, i.e., if the G.I. tract cannot be used as a route of
administration for nutrition, then parenteral nutrition may be indicated. One big
difference vs adults is that due to fewer body stores and a higher caloric daily
requirement, children are started on hyperalimentation sooner than adults. Generally, the
smaller or younger the child is, the sooner (s)he needs appropriate nutritional intake.
Indications:
| 1. Congenital or acquired anomalies if the G.I.
tract: gastroschisis, bowel fistulas, intestinal obstruction, atresias, short gut
syndrome. NOTE: "Short gut syndrome" or
"short bowel syndrome" is a condition which is present after a significant
amount of intestine has been surgically removed. Often these patients are dependent upon
lifetime parenteral nutrition.
2. Chronic or recurrent diarrhea:
malabsorption syndrome, inflammatory bowel disease.
3. Preterm infants
4. Malnutrition (i.e. TPN as a supplement
in certain diseases in which adequate caloric intake is not being achieved via the oral
route: cystic fibrosis, cancer, anorexia nervosa, hypermetabolic states, e.g., burns).
5. Patient who are NPO (or who will be
NPO) for sufficient periods of time to cause a significant decrease in caloric intake
(e.g., post-operative patients). |
B. Pediatric Parenteral
Nutrition Practice Guidelines (from the American Society for Parenteral and
Enteral Nutrition1):
| 1. Patients who are
candidates for parenteral nutrition support are those requiring nonvolitional feeding who
are either already malnourished or are at risk of developing malnutrition. 2. Peripheral parenteral nutrition
should be used to provide partial or total nutrition for up to 2 weeks in patients who
cannot ingest or absorb oral or enterally delivered nutrients, or when central vein
parenteral nutrition is not feasible.
3. Peripheral parenteral
nutrition may be used for short-term (less than 2 weeks) maintenance, supplemental
nutrition, or repletion nutrition support in some older infants and children who are not
fluid restricted.
4. Central intravenous
nutrition support should be used in patients who do not tolerate enteral nutrition support
or in whom peripheral access is limited, parenteral support will last longer than 2 weeks,
nutrient needs cannot be met by peripheral parenteral nutrition, or fluid restriction is
required. |
C. Monitoring: In order to assure
that TPN is meeting the nutritional goals, growth parameters (i.e., weight, height, head
circumference) need to be assessed periodically. Monitoring of specific laboratory
parameters assures adequate intake and decreases the complications of TPN. (See
required reading: Table 108.11, Suggested monitoring schedule during pediatric
TPN)
D. Fluid Calculations
| 1. Initial: The actual
volume of TPN (hyperalimentation plus intralipid) to be given is calculated by subtracting
the volume of the patient's other necessary fluids (e.g., continuous dopamine infusions,
arterial lines, etc.) from the total daily fluid requirement. In patients who are not
fluid restricted, who do not have fluid deficits or ongoing abnormal losses, and who do
not receive other fluids, TPN is usually started at normal daily maintenance fluids. 2. Advancement of TPN fluid:
In order to provide an adequate amount of calories for normal growth and development, the
daily total fluid volume will need to exceed the daily normal maintenance fluid
requirements.
a. Precautions: Congestive heart failure
can easily be produced in a pediatric patient, if fluids are advanced too rapidly or too
much fluid is given per day. Daily fluids should be increased according to the following
guidelines and patients need to be monitored for signs/symptoms of fluid overload, edema,
and CHF.
b. For infants < 10 kg the
initial daily fluid volume may be increased (if tolerated) by 10 ml/kg/day until the
desired caloric intake is achieved. The maximum amount of fluid (if tolerated) is 200
ml/kg/day.
c. For infants > 10 kg, the initial daily fluid volume may be increased by
10% of the initial volume per day (if tolerated) until the desired
caloric intake is achieved. The maximum amount of fluid (if tolerated) is 4000 ml/m2/day). |
|
E. Caloric Requirements: The goal
of TPN is to provide adequate calories and nutrients for proper growth and development of
the child. Proper growth of the child is determined by maintenance of the child's
respective growth percentile for age and gender. For example, if an infant is 75th
percentile for height and weight at age 3 months, then the goal is to maintain the 75th
percentile for height and weight at older ages (i.e. as the child gets older, (s)he should
be following the 75th percentile growth curves).
NOTE: Although controversial,
the goal of nutrition in the preterm infant is to achieve a postnatal growth rate equal to
the intra-uterine growth rate of a fetus at the same postconceptional age.
1. Caloric requirements per kg are greater in
infants compared to children and adults. Children also require more calories per
Kg than adults. These increases in caloric requirements are due to increases in cellular
growth and physical activity, as well as an increased heat loss (due to the larger surface
area per body weight seen in infants and children vs adults).
TPN caloric
requirements2
| AGE (yrs) |
Kcal/kg/day |
| 0 - 1 |
90 - 120 |
| 1 - 7 |
75 - 90 |
| 7 - 12 |
60 - 75 |
| 12 - 18 |
30 - 60 |
2.
Factors that
increase caloric requirements: Similar to adults, certain factors will
increase daily caloric
requirements in children.
| FACTOR |
INCREASE IN CALORIC NEED2 |
| Fever |
10 - 12 % for each degree
> 37o C |
| Cardiac failure |
15 - 25 % |
| Major surgery |
20 - 30 % |
| Burns |
up to 100 % |
| Severe sepsis |
40 - 50 % |
| Long term growth failure |
50 - 100 % |
NOTE:
Infants with protein calorie malnutrition may require 150 - 175 Kcal/kg/day for growth |
F. Carbohydrates: As in
adults, pediatric patients are NOT started on TPN with the highest amount of dextrose
required to give adequate calories. Carbohydrates are started at a lower amount and
advanced in a stepwise fashion to allow an appropriate response of the pancreas. This
stepwise advancement allows the pancreas to adjust to the higher amounts of dextrose given
by secreting larger amounts of endogenous insulin. Hyperglycemia, glucosuria and osmotic
diuresis are thus prevented. (NOTE: Dextrose = 3.4 Kcal/gram)
1. Carbohydrate intake must
be calculated for newborns and the very low birth weight premature infant in terms of
gm/kg/day or mg/kg/min.
a. Preterm infants < 1
kg
1. Initial: 3 - 5
mg/kg/minute (Homeostasis)
2. Advance by: 0.5 - 1
mg/kg/minute per day
b. Term newborns and older
infants
1. Initial: 7 - 8
mg/kg/minute
2. Advance by: 2 - 4
mg/kg/minute per day
c. Infants: Usual maximum
rate of infusion: 18 - 20 mg/kg/minute
d. Children: Usually require
6 - 9 mg/kg/minute |
2. Practical guidelines:
Recommendations according to percent dextrose: Serum and urine glucose must be monitored
as some patients may not tolerate these increases. These patients (usually preterm
infants) will require other percent concentrations of dextrose, e.g., 6%, 7% etc.
| Patient Age Group |
Initial concentration |
Advance by |
| Premature infants Newborn infants |
5 % Dextrose |
2.5 % Dextrose every other day
|
| Older infants Children
|
5 % Dextrose |
2.5 % Dextrose per day |
| Teenagers Adults |
5 % Dextrose |
5 % Dextrose per
day |
NOTE: Premature and
newborn infants are more likely to become hypoglycemic if the dextrose solution is
suddenly discontinued. Serum dextrose must be monitored if TPN discontinued. Excess
carbohydrates (in comparison to protein and fats) may result in fatty infiltrates of the
liver and an increase in pCO2 on blood gas.
3. Maximum dextrose
concentrations for infants and children
| a. Peripheral: 10%.
Concentrations above 10% are associated with an increase in phlebitis and a decreased
duration of use of the peripheral line. The peripheral use of 12.5% dextrose containing
TPN is discouraged however, 12.5% dextrose containing TPN is sometimes used in patients
who require higher calories or who are fluid restricted. Close supervision of the IV site
then becomes mandatory (e.g., direct nursing care, ICU care). b. Central: 20 - 25 %.
The rapid dilution of TPN solutions with the larger quantities of blood in central veins,
allows for solutions with higher final osmolalities to be used centrally (i.e., higher
concentrations of dextrose). Typically, dextrose concentrations up to 20 % are used
centrally. TPN with 25 % dextrose is usually reserved for severely malnourished patients.
Occasionally, concentrations greater than 25% (i.e. 30 - 35 %) have been used in older
infants and children who are severely fluid restricted |
|
G. Protein Requirements:
Pediatric patients require a greater amount of protein per kilogram per day compared to
adults. Again, this is due to their increased growth rates.3
| Age group |
Daily amount of parenteral protein to promote nitrogen retention |
| Premature neonates and
infants |
2.5 - 3 grams/kg/day |
| Greater than 1 year of age |
1.5 - 2 grams/kg/day |
| Adolescents & adults |
1 - 1.5 grams/kg/day |
1. Initiation and Advancement:
Similar to carbohydrates, pediatric patients are NOT started at the daily amount of
protein to promote nitrogen retention. Again, patients are started on lower amounts of
protein and advanced in a stepwise fashion.
a. Neonates: Start with 0.5
- 1 gram/kg/day of protein and advance daily by 0.5 gm/kg/day.
b. Older
infants and children: Start with 1 gram/kg/day and advance daily by 0.5 - 1 gm/kg/day.
2. Pediatric essential amino acids: In
addition to the amino acids which are considered essential in adults,*
cysteine, taurine, tyrosine and histidine are thought to be essential
amino acids in neonates and young infants. These 4 amino acids are not synthesized in
adequate quantities in neonates and young infants due to their decreased activity of
enzymes. Therefore, these amino acids must be provided nutritionally.
* Isoleucine, leucine, lysine,
methionine, phenylalanine, threonine, tryptophan, and valine are considered to be the
essential amino acids for all age groups.
For example: decreased activity
of hepatic cystathionase results in a decreased production of cysteine with a subsequent
decrease in taurine. (see figure 1)3 Hepatic cystathionase is thought to
mature at approximately 6 months of age.
Neonates receiving standard adult amino acid formulations were
found to have elevated plasma concentrations of methionine, phenylalanine and glycine as
well as decreased concentrations of tyrosine, cysteine and taurine compared to normal
breast fed infants. Two amino acid formulations have been designed to meet the special
amino acid requirements in neonates and young infants. TrophamineR and
Aminosyn-PFR contain less methionine, phenylalanine and glycine than adult
formulations. Both also contain taurine, tyrosine, and histidine. L- Cysteine HCL must be
added at the time of TPN preparation due to its instability in solution for prolonged
periods.
NOTE: When using TrophamineR, 40 mg of cysteine
HCL is added to the TPN for every one gram of protein. Since cysteine HCL comes as a HCL
salt, one mmol of acetate or lactate is added to the TPN for every mmol (160 mg) of
cysteine HCL. This acetate or lactate is added to balance the HCL load and prevent a
metabolic acidosis which can be produced in premature and young infants. (Remember that
bicarbonate results from acetate and lactate via the Kreb's cycle.)
Studies have shown that neonates receiving TPN utilizing
TrophamineR had "normal" amino acid patterns i.e., patterns
that were similar to breast fed infants. Significantly greater weight gain and nitrogen
balance were seen in infants were given Trophamine compared to adult amino acid
formulations. Further studies in neonates comparing Aminosyn-PFR and TrophamineR
are needed.
4. Nonprotein calorie to gram nitrogen ratio:
If an improper amount of nonprotein calorie to gram nitrogen ratio is given to a patient,
(s)he will utilize proteins as a caloric source rather than for anabolic processes (i.e,
as building blocks for cell growth). The optimal nonprotein calorie to gram nitrogen ratio
in pediatric patients is not well defined. In the past, a nonprotein calorie to gram
nitrogen ratio of 150 -200: 1 was suggested for adults. However, it is
now realized that the ideal nonprotein calorie to gram nitrogen ratio differs with age and
severity of illness. For critically ill infants and children, a nonprotein calorie to gram
nitrogen ratio of 240 - 350: 1 has been suggested for proper utilization
of amino acids. Remember:
Grams of protein / 6.25 =
nitrogen content in grams
5. Caloric density: 4
Kcal/gram. Since it is not optimal to use protein as a caloric source, the protein caloric
content of hyperalimentation fluids is generally not calculated. |
H. Lipids: Lipids are
administered as part of TPN to prevent or reverse an essential fatty acid deficiency and
to provide a concentrated iso-osmotic source of calories.
1. Essential fatty acid
deficiency:
a. Both linoleic acid and
linolenic acid are thought to be essential.
b. The premature infant may
develop biochemical evidence of essential fatty acid deficiency in as little as 2 days,
due to limited fat stores.c. Provision of 2 - 4 % of the required total daily calories as IV
fat emulsion or approximately 0.5 - 1 gram/kg/day will prevent clinical signs and symptoms
of essential fatty acid deficiency.
d. Signs of essential fatty
acid deficiency include reduced growth, decreased platelets, impaired wound healing, dry
scaly skin and sparse hair.
e. Biochemical evidence of
essential fatty acid deficiency includes a triene:tetraene ratio greater than 0.4. |
2. Lipid Metabolism:
| a. Importance of Vitamin E: Lipid
metabolism results in lipid peroxidation and free radical formation. Free radicals can
damage cell membranes if Vitamin E is deficient. (Vitamin E acts as a free radical
scavenger.) Lipid emulsions do contain a small amount of Vitamin E, however,
supplementation with MVI is recommended, especially in infants. In order to prevent
peroxidative injury, a vitamin E : polyunsaturated fatty acid (PUFA) ratio of > 0.6
mg/g is needed. b. Decreased lipoprotein
lipase activity: Lipoprotein lipase hydrolyzes fat particles to free fatty acids
and monoglycerides. Both premature and term newborns have low lipoprotein lipase activity
compared to adults. This results in a reduced lipid clearance rate. Hypertriglyceridemia /
hyperlipidemia (fat intolerance) occurs when the rate of infusion of the fat emulsion
exceeds the plasma lipid clearance rate. Premature infants, small for gestational age
infants (regardless of gestational age) and nutritionally depleted older children are at
risk for hypertriglyceridemia. Due to decreased fat clearance, lipid infusions for these
patients should be administered over 24 hours.
NOTE: In infants and children, IntralipidR is typically infused over 18
- 24 hours.
c. Decreased metabolism of glycerol and free fatty
acids: Plasma lipid
clearance is also decreased in neonates due to their decreased metabolism of free fatty
acids and glycerol. Carnitine facilitates the transport of free fatty acids across the
mitochondrial membranes to the site of fat oxidation. Premature neonates and newborns have
limited carnitine stores which can decrease the proper utilization of free fatty acids. |
3. Lipid emulsion dosing
guidelines 2,3
| |
Premature or SGA |
Full term or AGA |
Older children |
| initial dose |
0.5 gm/kg/day |
1 gm/kg/day |
1 gm/kg/day |
| Advance by |
0.25 gm/kg/day or every
other day |
0.5 gm/kg/day |
0.5 gm/kg/day |
| Maximum dose |
3 gm/kg/day |
3 - 4 gm/kg/day |
2 - 3 gm/kg/day |
4. Serum triglycerides
should be monitored before every (or every other) increase in lipid emulsion, especially
in premature infants and routinely thereafter. If triglyceride levels are less than 200
mg/dl the patient can be maintained on her/his present dose.3
5. Caloric Content: Fats are usually
considered to contain 9 kcal/gram. Due to emulsifying agents and other additives,
IntralipidR 10% = 1.1 kcal/ml and IntralipidR 20% = 2 kcal/ml.
Usually 25 - 40 percent of the total calories are provided by lipids but no more than 60
percent of total calories should be provided by lipids.
6. Hypersensitivity reactions including
allergic reactions, fever, chills, shivering, cyanosis, flushing, nausea, vomiting,
headache, dizziness, or chest and back pain have been reported due to the egg
phospholipids which are used to emulsify fat emulsions. Patients should be monitored for
these immediate adverse reactions.
7. Controversies
| a. Hyperbilirubinemia:
Free fatty acids, which displace bilirubin from albumin binding sites, may cause an
increase in the concentration of unconjugated bilirubin and increase the risk of
kernicterus. Decreased amounts of fat emulsion (0.5 - 1 gm/kg/day i.e., just enough to
prevent essential fatty acid deficiency) are usually given to neonates with elevated
bilirubin concentrations. These decreased amount of lipids are usually given when total
bilirubin concentrations are greater than one-half that required for exchange transfusion. b. Pulmonary compromise:
In patients with pulmonary compromise, lipid emulsions may decrease pulmonary diffusion
capacity with a resultant decrease in PO2. These effects were observed when large amounts of
fat emulsion were administered over short periods of time. The risk is decreased if lipids
are infused over 24 hrs.
c. Heparin stimulates
the release of lipoprotein lipase and has been postulated to be effective in reducing
serum triglyceride concentrations in neonates receiving lipid emulsions. Further studies
are needed before routine use of heparin can be recommended.
NOTE: Heparin is routinely
used in TPN at a final concentration of 1 unit/ml to decrease thrombus formation at the
central catheter tip, and to increase the duration of patency of peripheral
hyperalimentation lines. (see required text reading) |
|
I. Electrolytes and minerals
1. Requirements:
Unless the patient has an electrolyte abnormality, start with the recommended daily amount
and adjust according to serum chemistries.
| Element |
Daily requirement
(infants and children) |
| Sodium |
2 - 4 mEq/kg |
| Potassium |
2 - 3 mEq/kg |
| Chloride |
2 - 3 mEq/kg |
| Magnesium |
0.25 - 0.5 mEq/kg |
| Calcium Gluconate |
100 - 500 mg/kg |
| Phosphorus |
1 - 2 mmol/kg |
Comments:
Sodium: Premature
neonates may require higher daily amounts.
Magnesium: Do not routinely add magnesium in the
TPN for infants whose mothers have received therapeutic dose of magnesium (i.e. for
tocolysis or prophylaxis against eclampsia). Check magnesium serum concentration first.
Magnesium may be added if serum magnesium is not elevated.
Calcium Gluconate: Usually, the higher amounts
listed are needed in premature newborns and neonates (300 - 500 mg/kg/day), while the
lower amounts are recommended for older infants (200 mg/kg/day) and toddlers (100
mg/kg/day). Older children may require only 1 - 2 grams per day of calcium gluconate.
Phosphorous: Older infants and children will
require less phosphorous (0.5 mmol/kg/day) than premature infants and newborns (up to 2
mmol/kg/day).
Potassium phosphate = 0.68 mmol
phosphate per mEq
Sodium phosphate = 0.75 mmol phosphate per mEq
2. Calcium and Phosphate
Compatibility
Since premature newborns,
neonates, and young infants require a greater amount of calcium and phosphorus compared to
adults, calcium / phosphate compatibility in hyperalimentation fluid is an important
issue. Many times the amount of calcium and phosphorous that these patients require is
greater than the solubility and calcium-phosphate can precipitate.
Many factors effect the
solubility of calcium with phosphate in hyperalimentation solutions. Specific texts (e.g.,
Trissel's Handbook on Injectable Drugs) and solubility curves4 are utilized to
determine if the amount of calcium and phosphate ordered in a hyperalimentation will
precipitate.
Factors which effect calcium
and phosphorous solubility include:
a. Concentration of calcium and phosphorous
b. Salt form of calcium
c. Concentration of amino acids
d. Type of amino acid solution
e. Concentration od dextrose
f. Addition of cysteine (effects pH)
g. Temperature of solution
h. Final pH
|
J. Vitamin requirements
| 1. MVI PediatricR provides the American
Medical Association Nutrition Advisory Group (AMA-NAG) requirements for infants greater
than 10 kg until 11 yrs of age. (See table 7 below) 5 2. Unlike the adult MVIR product, the pediatric
product contains Vitamin K.
3. FDA recommendations
for MVI PediatricR:
| Infants < 1 kg |
30 % of a vial (1.5 ml) |
| Infants 1 - 3 kg |
65 % of a vial (3.25 ml) |
| Infants > 3 kg - 11 yrs |
100% of a vial (5 ml) |
4. In
premature infants, the above FDA recommendations may not be adequate for certain vitamins
(vitamin A and E) and may result in higher serum concentrations of water soluble vitamins
(e.g., ascorbic acid). |
K. Trace elements requirements:
6
| 1. Trace elements should be
given to premature infants upon initiation of TPN and to term neonates and infants who
will receive TPN for > 2 weeks. 2. Copper, zinc, chromium, and manganese available
as combination products: EXAMPLES: Trace element content per 1 ml:
| 1 mcg |
PTE-4 |
Pedtrace |
Neotrace |
| Zinc |
1 mg |
0.5 mg |
1.5 mg |
| Copper |
0.1 mg |
0.1 mg |
0.1 mg |
| Manganese |
25 mcg |
25 mcg |
25 mcg |
| Chromium |
1 mcg |
0.85 mcg |
0.85 mcg |
The usual dose of these products is 0.2 ml/kg/day.
Please note the big difference in zinc concentrations in these products. Neotrace has the
highest amount of zinc and (just as the name implies) is intended for use in neonates.
PTE-4 and Pedtrace have less zinc than neotrace and are intended for use in infants and
children whose zinc requirements are less than neonates. If PTE-4 or
Pedtrace is used in neonates, additional zinc must be given in
order for the neonate to receive the total daily recommended amount. Children > 40 - 50
Kg should use the adult trace element formulations (e.g., Multitrace).
3. Selenium 2 - 3 mcg/kg/day up to daily
maximum of 30 - 40 mcg also needs to be added to the TPN.
4. Iodine
| a. Absorbed from topical povidone iodine solution or ointment, so
no need to add to TPN. b. Thyroid profile monitoring
recommended for long term TPN. |
5. Iron
| a. IV iron dextran is recommended for infants > 2 months of
age receiving TPN for > 1 month. Preterm infants < 2 months of age may experience
hemolysis after given IV iron dextran. b. If iron is
added to the hyperalimentation daily (controversial) the dose is 0.1 - 0.2 mg/kg/day.
c. For monthly IV replacements of iron: calculate iron needs by
the following equation and administer the dose over 3 days. (Maximum daily dose = 25 mg).
Body weight (pounds) x (100 - %
Hgb) x 0.3
= mg of elemental iron |
6. Disease states which
alter trace element requirements:
| a. Increased losses: In
diarrheal states or excess G.I. fistula losses extra zinc may be needed. b. Decreased elimination:
1. Cholestasis
(obstructive jaundice):
Eliminate copper and manganese from TPN
2. Renal failure:
Eliminate Cr and Se from TPN
NOTE: Some clinicians may
eliminate Zn
or decrease the daily amount.
|
|
L. Complications
associated with TPN include infectious, mechanical, metabolic and other problems such as
cholestasis and rickets: (see Table 9-27) 6. For further discussion of the
complications of TPN see required reading text.
| 1. Infection: The most common organisms
to cause sepsis in TPN patients are Staphylococcus epidermidis and Staph
aureus. Other common bacteria include: Streptococcus, gram-negative organisms and Candida.
Catheter site infections also occur. 2. Mechanical:
One of the many mechanical problems with central TPN is thrombus formation.
Urokinase (5,000 units/ml) may be used in children to lyse clots in catheters. When using
urokinase to lyse a catheter thrombus, it is important to "treat the clot and not the
patient" i.e., urokinase should NOT be injected past the catheter into the patient.
The internal volume (ml) of the patient's central catheter must be known and only that
same amount of urokinase used. Also, after allowing the urokinase to sit in the catheter
and dissolve the clot, the urokinase should be withdrawn from the catheter. It should not
be administered systemically to the patient. NOTE: The amount of
urokinase that is used in adults to clear a catheter can have systemic effects in small
infants if inadvertently administered through the catheter and not drawn back as required.
3. TPN cholestasis can occur in pediatric
patients, usually after about 2 weeks of TPN. Premature infants and those
receiving > 2.5 gm/kg/day of protein have a higher incidence of liver
dysfunction. Other factors which may increase the incidence of TPN cholestasis include: sepsis,
fasting (being NPO), and calorie overload. Discontinuation of
TPN will usually reverse liver dysfunction. If TPN cannot be discontinued, TPN cholestasis
may be managed by the following:
| a. Give the appropriate type and amino acids
and reduce the amino acid load. b. Give the appropriate
amount of calories (i.e. give an adequate but not an excessive
amount).
c. Cyclic hyperalimentation (i.e., cycling
the patient off of hyperalimentation for part of the day): Pediatric precautions: Infants
more often than older children and adolescents may not be able to tolerate infusion
periods less than 12 hours/day. Intolerance is usually due to inability to handle the
higher ml/hr rates of fluid volume or nutrients that are given over the shorter period of
time (i.e., the total daily amount of fluid and nutrients may be given over < 24 hours
time, this results in a higher ml/hour rate).
d. Stimulate the gut with minimal enteral feeds. |
|
M. Heparin: As previously
mentioned, heparin 1 unit per ml (final volume) of hyperalimentation solution is often
used in the pediatric population, both in central and peripheral TPN. Therapeutic doses of
heparin may be approached with extremely high hyperalimentation rates or with frequent
heparin flushes. (Maintenance doses of heparin are considered to be 10 - 25 units/kg per
hour.) Therefore, a reduction from the usual 1 unit/ml of heparin in the hyperal to 0.5
units/ml may be needed especially in small infants requiring larger volumes of fluid.
IV. Pediatric Enteral Nutrition
A. Breast-feeding: "Breast is
best": Mature human milk better meets the nutritional demands of human infants than
cow's milk. Human milk is the standard against which all infant formulas are compared.
Most commercially available (cow's) milk-based infant formulas are designed to closely
approximate human breast milk.
1. Advantages of breast feeding and
breast milk: Aside from the differences in protein, fat, carbohydrate and renal solute
load (see next page) that exist between human milk and cow's milk, there are several other
advantages of breast-feeding and breast milk.7
 2. Disadvantages of breast-feeding:
| 1. Infant nutrition is dependent upon maternal nutrition 2. Possible mastitis (inflammation of the breast)
3. Transfer of drugs and/or pollutants (DDT, PDBs, etc.) to the
infant
4. Transfer of viruses (Hepatitis B, CMV, HIV)
5. Transfer of allergen's from maternal diet to infant |
3.
Weaning
| 1. A gradual weaning of breast-feeding starting after 4 - 6
months of age is typical. 2. Bottle (or cup) feedings
are increased over a period of several weeks as breast-feedings are decreased and finally
discontinued. |
|
B. Comparison of nutrient composition of human
milk, cow's milk and milk based infant formulas.
1. Protein: Human milk
contains a lower amount of protein compared to cow's milk, but is easier to digest.
a. Protein types: There
are two major types of proteins that are found in milk.
1. Whey protein
contains alpha-lactalbumin, beta-lactoglobulin, lactoferrin, albumin, lysozyme and IgA,
IgG and IgM. Whey protein is highly soluble and easier to digest.
2. Casein protein
contains a mixture of caseins (alpha, beta, gamma and kappa). Casein is relatively insoluble and forms "tough" curds.
b. Whey: Casein ratio
1. Breast milk 60:40 to
70:30
2. Cow's milk 20:80
3. Milk-based infant formula
60:40
Human milk contains a lower
casein content and therefore is more easy to digest, compared to cow's milk. Milk-based
infant formulas are made with heat-treated cow's milk proteins which form smaller,
softer curds than raw or pasteurized cow's milk.
b. Other protein differences: breast milk vs cow's milk
1. Lactoferrin is found in greater
quantities in human milk then cow's milk. Lactoferrin is an iron binding protein found in
whey (1/3 saturated with iron). Lactoferrin increases the bioavailability of iron. It also
has an inhibitory effect on E. Coli and may offer some protection against enteric
infection.
2. Secretory IgA is also found in greater
quantities in human milk than cow's milk. As an immunoglobulin, it may offer some local
G.I. protection against infection.
3. Lysozyme is found in human milk but not
in cow's milk. Lysozyme has bactericidal effects.
c. Protein sources, other than
cow's milk protein, may be used for infant formulas. These include vegetable protein (soy)
or protein hydrolysate (enzymatic breakdown products of casein or whey
which result in reduced antigenicity).
|
2. Fats: Human milk and
cow's milk contain a similar total amount of fat but the type of fats differ.
| a. Human milk contains more of the
essential fatty acid, linoleic acid, compared to cow's milk. Typical
commercial infant formulas contain ever more linoleic acid. b.
Human milk but not cow's milk contains human milk lipase
to aid in the digestion of fat.
c. Human milk contains long chain
unsaturated fatty acids as well as medium chain fatty acids.
Cow's milk contains short and long (primarily saturated) fatty acids. Milk based infant
formulas replace butterfat with vegetable oil and special MCT oils to provide highly
digestible, unsaturated, medium-chain triglycerides (MCTs). |
3. Carbohydrates: Because cow's milk
contains less carbohydrates than human milk, supplementation of cow's milk with
carbohydrates to make milk-based formulas is necessary.
| a. Lactose is the primary carbohydrate
for human milk, cow's milk and milk-based infant formulas. b.
Infants are especially prone to lactose intolerance. The activity
of the intestinal enzyme lactase is not fully developed until late in fetal life. In
addition, infants may have a temporary reduction in lactase with diarrhea or malnutrition.
(Lactase, as you recall, is the enzyme which is found in the brush border of the small
intestine. Lactase cleaves lactose into galactose and glucose which are then absorbed.)
Without lactase, the increased amount of lactose in the intestine creates an osmotic
gradient in the colon that results in diarrhea. Excess lactose is also fermented by
bacteria in the gut to produce CO2 and lactic acid.
c. Other carbohydrates such as dextrins, maltose, corn syrup
solids and sucrose are can also be used in infant formulas (i.e., lactose-free formulas). |
4. Renal solute load, osmolality, and caloric content
| a. Cow's milk has three times the ash
(mineral residue) and protein content as that of human milk. This results in a much higher
renal solute load for cow's milk as compared to human milk. As you recall, renal
solute load is related to the protein (urea) and mineral content of a formula. The renal
solute load represents the total amount of water-soluble substances that must be removed
from the body by the kidneys. The renal solute load of human milk = 79 mOsm/l, Cow's milk
= 228 mOsm/l. b. Osmolality is
directly related to the mineral and carbohydrate content of a formula. The osmolality of
human milk is approximately 300 mOsm/kg. Most formulas intended for use in infants are
iso-osmotic. Generally, the higher the caloric content, the higher the osmolality. Infant
formulas for preterm infants (24 cal/oz) have osmolalities less than 400 mOsm/kg.
c. Caloric content: Human and cow's milk
have 20 kcal/oz. Most infant formulas are either 20 or 24 kcal/oz. |
4. Mineral content:
Although less in content/ml, both zinc and iron in human milk is more readily absorbed
(ie, more bioavailable) than zinc and iron in cow's milk. Infants fed whole cow's milk
diets often have iron deficiency anemias due to the decreased bioavailability of iron. The
calcium to phosphorus ratio for human milk is 2:1, while for cow's milk it is 1:1.
|
C. Types and uses of infant
formulas
(NOTE: composition is per
100 kcal.)
1. Complete cow milk-based
infant formulas9
a. Used for normal term infants
b. Lactose is carbohydrate source
2. Complete soy based infant formulas9
a. Soy protein rather than cow protein
b. Lactose free
c. Used for
1. lactose intolerance or primary lactase deficiency (e.g.,
galactosemia)
2. milk allergy (NOTE: Protein hydrolysate formulas rather than
soy based formulas are preferred for infants with cow milk allergy. About 10% of infants
with cow milk allergy will also react to soy protein)
d. For disaccharide intolerance (sucrase deficiency) use Prosobee
or Isomil SF
3. Therapeutic Formulas 9 /disease states
a. For fat malabsorption states, such as
cystic fibrosis, short bowel syndrome, bile acid deficiency or cholestasis use Portagen
or Pregestimil.
b. For general malabsorption states, use Pregestimil.
c. For protein and disaccharide intolerance,
use Pregestamil or Nutramigen.
d. For congestive heart failure or when low salt
content is needed, use Lonalac (short-term use only, Na = 1 mEq/l), SMA,
or Similac 60/40.
e. For chronic renal failure use PM
60/40, SMA
f. For phenylketonuria use Lofenalac
g. For galactosemia use soy based
formulas, Nutramigen or meat-based formulas (older infants).
4. Preterm formulas: differences include:
a. Partial substitution of glucose polymers for lactose
b. Increased protein
c. Substitution of long-chain fatty acids with MCT
d. Increased concentrations of vitamin D, calcium and phosphorus
to promote bone growth
e. Altered concentrations of iron and vitamin E to prevent
hemolytic anemia.
D. Supplemental foods are introduced at 4
to 6 months of age (after the infant has established the ability to swallow
non-liquid foods). Introducing foods at this time also allows the infant to develop
his/her host defense mechanisms to protect the infant from foreign proteins (i.e., food
allergies are less likely to develop). In addition, the continued maturation of kidneys at
this time will increase the handling of renal solute loads.
| 1. Feedings
are usually started with iron fortified cereals such as rice. (Oatmeal cereals may
follow.)
2. Vegetables, fruits, and
pureed meats may also be introduced with cereal.
3. It is important to add one new food at a time and continue for
3 to 4 days before adding another. This allows time to evaluate allergy or sensitivity
problems and to identify the food which caused the problem.
4. Iron fortified cereals are usually continued until about 2
years of age as an iron source. |
E. Vitamin and mineral supplementation: It is now
recommended that all infants receive iron fortified infant
formulas. (These are commercially available)
1. General recommendations for
supplements in healthy infants10
2. Fluoride supplementation is dependent
upon age and concentration of fluoride in the drinking water. 11
NOTE: Fluoride dose is in mg/day.
3. Recommended daily dietary allowances for vitamins and minerals
change with age. (See tables 12)
Recently, higher daily calcium requirements have been recommended
by the NIH panel on optimal calcium intake.13
F. General Guidelines for Infant Feeding:
Remember, introduce one new food at a time and continue for 3 to 4 days before adding
another. Evaluate for allergy / hypersensitivity (diarrhea, vomiting, coughing, hives or
rash).
1. DO NOT give foods such as
nuts, seeds, popcorn, raw vegetables, hot dogs, candy or gum that may cause choking.
2. DO NOT give honey or corn syrup, which have been associated
with infant botulism.
3. DO NOT force infant to eat everything, this may lead to
overeating.
4. DO NOT give whole, 2% or skim milk under 1 year of age. Only
give 2 % or skim milk after 2 years of age.
5. DO NOT add salt or sugar to infant's food.
6 infant
formula provides all the nutrients a FT infant needs to grow on until 4 - 6 months.
7. DO NOT prop up bottle and leave infant to feed him/her self
(this may increase choking, as well as tooth decay and otitis media).
8. DO NOT leave older infant unattended at mealtime.
Age |
Physical
Development |
Nutrition
|
| Birth - 3 months
|
Stroking the cheek near the
mouth causes the infant to turn the face to that side, open mouth and attempt to suckle
(Rooting reflex). |
Breast milk or formula, 6 -
10 feedings per day (21 - 24 ounces/day). Do not give semi-solid foods.
Vit D, Fe & Fl Rx may be
recommended for breast fed infants.
No vitamin/mineral Rx needed
for FT with iron fortified infant formula.
Plain water 3 - 4 ounces/day
in very hot weather OK if tolerated.
|
| 4 - 5 months |
Infant is able to hold neck
steady and sit with support. Can begin to draw in lower lip as spoon is removed. |
Breast milk or formula, 4 -
6 feedings per day (24 - 32 ounces/day). Vitamin/mineral Rx if indicated.
May start spoon feedings of
Fe fortified dry infant cereal mixed with formula or breast milk to a thin consistency.
Start with 1 Tablespoon of rice cereal at 1 feeding for 4 - 5 days. Gradually offer other
single grain cereals and slowly increase to 3 - 4 Tablespoons per day.
|
| 7 months |
Infant can reach and grasp
for objects. Jaw begins to use up and down movement |
Breast milk or formula, 4 -
5 feedings per day (24 - 32 ounces/day). Vitamin/mineral Rx if indicated.
Fe fortified cereal: > 4 Tablespoons/day Vegetables/fruit: Start
with 1 Tablespoon strained plain vegetables such as green beans, peas or carrots. Do not
feed from jar, can cause bacterial growth. Put anticipated feeding in bowl. Feed from
bowl. Cover remaining food in jar and refrigerate Do not add salt. Gradually add 1
Tablespoon plain strained fruit such as applesauce, apricots, peaches or pears. Slowly
increase serving size to 4 - 5 Tablespoons/day.
Teething foods: Offer toast
strips, unsalted crackers, zwieback, teething biscuits.
|
| 8 - 9 months |
Infant can sit alone
without support. Baby is learning to chew. Important to offer foods that encourage
chewing. |
Breast milk or formula, 3 -
4 feedings per day (24 - 32 ounces/day). Vitamin/mineral Rx if indicated.
Fe fortified cereal: > 4 Tablespoons/day Vegetables: > 4 Tablespoons/day
Fruit: > 4 Tablespoons/day
Chewing foods: toast strips,
zwieback, unsalted crackers.
Protein Foods: Offer well
cooked, strained or ground lean beef, pork, chicken, turkey, liver, cheese, cottage
cheese, or egg yolk. Do not give egg whites until 12 months of age due to high chance of
allergic reactions. Do not add seasoning. Remove all bones before straining. May use plain
meat baby jar food (not mixed vegetables and meat dinners). Start with 1 Tablespoon and
increase to 2 Tablespoons/day.
Juice: Give Vit C containing
juice in a cup. Be sure to give fruit juice. Juice is more nutritious than fruit drink,
fruit punch, pop or koolaid. Dilute 1 part juice with 2 parts water at first. Start with 1
- 2 ounces & increase to 2 - 6 ounces according to appetite. Do not give fruit juice
by bottle especially at naptime. Fruit sugar can cause decay. Do not give citrus juices
until 1 year of age due to high chance of allergic symptoms.
Finger foods: Give soft
pieces of food such as toast strips, soft peeled fruit pieces, soft cooked vegetable
pieces, cooked macaroni or noodles, milk cheese cubes or strips.
|
| 10 - 12 months |
Infant is able to hold a
cup with help and try to feed self. Baby likes to play with food more than eat it. Expect
a smaller and more picky appetite as infant's growth rate slows at 1 year of age |
Breast milk or formula, 3 -
4 feedings per day (24 - 32 ounces/day). Offer some from a cup. Vitamin/mineral Rx if indicated.
Fe fortified cereal: 1/4
cup/day Vegetables:soft cooked 1/4 - 1/2 cup/day
Fruit and fruit juice: 1/2 -
3/4 cup/day
Bread or toast: 1 - 2
slices/day.
Protein Foods: 2 - 4
Tablespoons/day. The infant's meal pattern should be similar to that of the rest of the
family with 3 meals and 2 snacks.
|
REFERENCES
1. ASPEN Board of Directors.
Guidelines for the use of parenteral and enteral nutrition in adult and pediatric
patients. Journal of
Parenteral and Enteral Nutrition 1993:17:1SA - 52SA.
2. Manual of Pediatric
Parenteral Nutrition, Kerner JA (editor), 1983, John Wily and Sons Publishers, New York.
3. Cochran EB, Phelps SJ,
Helms RA. Parenteral nutrition in pediatric patients. Clinical Pharmacy Vol 7, May 1988,
pp 351 - 66.
4. Fitgerald KA, MacKay MW.
Calcium and phosphate solubility in neonatal parenteral nutrient solutions containing
Trophamine. Am J Hosp Pharm 1986;43:88-93.
5. Total Parenteral
Nutrition, Lebenthal E (editor), 1986, Raven Press, New York.
6. Heyman MB. "Enteral
and Parenteral Nutrition" in Rudolph's Pediatrics 19th edition. Rudolph AM, ed., 1991
Appleton & Lange, East Norwalk, Conn.
7. Wilson JT.
"Prevalence and Advantage of Breast Feeding" in Drugs in Breast Milk. ADIS
press 1981
8. Hambidge KM, Krebs NF.
"Normal Childhood Nutrition and Its Disorders" in Current Pediatric Diagnosis and
Treatment 10th edition Hathaway WE, Groothius JR, Hay WW Paisley (editors), Appleton
& Lange, East Norwalk, Conn, 1991.
9. Nichols BL. "Infant
Feeding Practice" in Nutrition During Infancy Tsang RC, Nichols BL (editors),
Hanley & Belfus, Inc, Philadelphia 1988.
10. McKenzie MW, Bender KJ,
Seals AJ. "Infant Formula Products" in The Handbook of Nonprescription Drugs, 9th Edition, APhA
editors, Washington: APhA 1990.
11. Committee on Nutrition.
Fluoride supplementation for children: interim policy recommendations. American Academy of
Pediatric News 1995;11(2):18.
12. Johnson KB (ed). The
Harriet Lane Handbook, 13th edition, Mosby Year Book, St. Louis Mo, 1993.
13. NIH Consensus
Developmental Panel on Optimal Calcium Intake. Optimal Calcium Intake. JAMA
1994;272:1942-8.
Phar 653 Clinical Pharmacotherapeutics III
Pediatric Hyperalimentation Calculations
or
So, what's a peds hyperal order supposed to look like?
Baby Doe is a 2 kg premature infant on day 7 of hyperalimentation. Hyperalimentation
was started on day 3 of life. Serum electrolytes (including Ca, Phos and Mg), liver
function tests, triglycerides, BUN and SCr are all within normal limits. Patient has a
central line.
HYPERALIMENTATION ORDER
| Dextrose |
20 % |
| Trophamine |
2.3 % |
| Cysteine |
40 mg/gram protein |
| NaCl |
3 mEq [NOTE: additives are per day] |
| Na lactate |
3 mEq |
| KCl |
2 mEq |
| K Phosphate |
3 mEq |
| MgSO4 |
MgSO4 0.5 mEq |
| Ca Gluconate |
600 mg |
| Heparin |
1 unit/ml |
| MVI Pediatric |
3.25 ml |
| Neotrace |
0.4 ml |
| Selenium |
4 mcg |
Infuse 10.8 ml/hour x 24 hours
Intralipid 20% infuse 1.2 ml/hour x 24 hours.
1. Does this order provide the patient with daily maintenance fluid requirements?
YES it does, in fact, it provides 1.2 x maintenance:
Daily maintenance fluid requirement for a 2 kg patient:
120 ml/kg/day = 120 x 2 kg = 240 ml
This TPN order would deliver:
HAL 10.8 ml/hour x 24 hours = 259.2 ml/day
Intralipid 1.2 ml/hour x 24 hours = 28.8 ml/day
TOTAL 288.0 ml/day
288 ml/day (being given) divided by 240 ml/day (maintenance) = 1.2 times maintenance
(288/240). This amount of fluid (or even greater) would be expected because in order to
increase calories, fluids are increased in a stepwise fashion. 1.2 times the normal daily
maintenance fluids would be acceptable for an infant who has been on TPN for this amount
of time.
2. Does this order provide appropriate amounts of dextrose, protein and fats for this
infant ? Yes, Yes, Yes.
a. Dextrose: 20% dextrose requires a central line (patient has
one). Dextrose 20% would be appropriate, as long as patient is not hyperglycemic or
spilling glucose in urine
[Note: If you wanted to, you could calculate mg/kg/min of glucose by the following method:
* Remember 20 % dextrose = 20 grams/100 ml = 0.2 grams dextrose/ml
10.8 ml/hour x 0.2 grams/ml = 2.16 grams/hour
2.16 gm/hour divided by 60 min/hour = 0.036 grams/min = 36 mg/min
36 mg/min divided by 2 kg = 18 mg/kg/minute. This is in line with the normal maximum of 18
- 20 mg/kg/minute.]
b. Protein: This order would deliver 259.2 ml/day of a 2.3 % protein solution.
2.3 % = 2.3 grams/100 ml = 0.023 gram/ml
259.2 ml/day x 0.023 grams/ml = 5.96 grams/day
5.96 grams/day divided by 2 kg = 2.98 = 3 grams/kg/day of protein
Remember: For premature and term infants, the daily amount of protein needed to promote
nitrogen retention (See your notes) is 2.5 - 3 grams/kg/day, so this hyperal order would
provide an appropriate amount.
c. Fats: This order would deliver 28.8 ml/day of a 20% intralipid emulsion.
20 % = 20 grams/100 ml = 0.2 grams/ml
28.8 ml/day x 0.2 grams/ml = 5.76 grams/day of fat
5.76 grams/day divided by 2 kg = 2.88 grams/kg/day of fat
For premature infants or infants SGA the maximum recommended amount of fat/day would be
3 grams/kg/day, so this hyperal order would provide an appropriate amount |
3. What is the nonprotein caloric content of the TPN order? i.e.,
how many Kcal/kg/day will this infant receive from nonprotein substrates ? Is that
calculated amount sufficient for growth?
a. Calories from dextrose. First determine how many grams of
dextrose you are giving, and then multiply by the amount of calories per gram
10.8 ml/hour x 24 hours = 259.2 ml/day of a 20% dextrose solution. [ 20% = 20 grams/100 ml
= 0.2 grams/ml]
259.2 ml/day x 0.2 grams dextrose/ml = 51.84 grams/day dextrose
Dextrose has 3.4 Kcalories/gram, so
3.4 cal/gram x 51.84 gram = 176.3 Kcalories from dextrose
b. Calories from intralipid. Other additives (not counted in the 20% labeling) add to the
caloric density of intralipid, therefore you cannot use the same method for calculating
fat calories as you do for calculation of dextrose calories.
You need to memorize |
Intralipid 10 % = 1.1 Kcal/ml
Intralipid 20 % = 2.0 Kcal/ml |
Intralipid 20% 1.2 ml x 24 hours = 28.8 ml/day
28.8 ml x 2 Kcal/ml = 57.6 Kcal/day from Intralipid
c. Total nonprotein calories = dextrose calories plus intralipid calories=
176.3 + 57.6 = 233.9 Kcal/day
233.9 Kcal/day divided by 2 kg = 117 Kcal/kg/day.
d. Caloric requirements for 0 to 1 years of age (see notes) are 90 - 120 Kcal/kg/day.
This current TPN order should provide enough calories for growth, however, it is
most important to make sure that the child is indeed growing. Weight, height and head
circumference should be monitored and values plotted on growth charts (Don't worry I will
not make you do this on a quiz). If for some reason the child is not growing while
receiving 117 Kcal/kg/day, then the hyperal rate can be increased (usually, for this
weight of a patient, by 10 ml/kg/day). This will increase calories by increasing the
amount of dextrose delivered per day.
|
4. Please comment on the other additives in the hyperal, i.e., are
they dosed appropriately? YES indeedee, they are all OK!!
| |
Per day |
NaCl 3 mEq
|
Na lactate 3 mEq
|
Na total 6 mEq = 3 mEq/kg/day
|
KCl 2 mEq
|
K Phosphate 3 mEq
|
K total 5 mEq = 2.5 mEq/kg/day
|
| K Phosphate has 0.68 mmol phosphate per mEq = 3 mEq/day x
0.68 = 2.04 mmol phosphate per day = 1.02 mmol/kg/day. |
| MgSO4 0.5 mEq = 0.25 mEq/kg/day |
| Ca Gluconate 600 mg = 300 mg/kg/day |
| Heparin 1 unit/ml ok |
| MVI Pediatric 3.25 ml ok |
| Neotrace 0.4 ml = 0.2 ml/kg/day |
| Selenium 4 mcg = 2 mcg/kg/day |
| |
NOTE: If this was day 1 of hyperalimentation, the hyperal would be
started at the initial doses listed in your handout,
i.e., Maintenance fluid (most likely) = 120 ml/kg/day
Dextrose 5 % (or if was already on dextrose 5 % perhaps 7.5%)
Trophamine 0.5 grams/kg/day
Intralipid 0.5 grams/kg/day
For a 2 kg patient the first hyperal order may look something like this:
| Dextrose
5% |
| Trophamine
0.4% |
| Cysteine
40 mg/gram protein |
| NaCl
3 mEq |
| Na
lactate
3 mEq |
| KCl
2 mEq |
| K
Phosphate
2 mEq |
| MgSO4
0.5 mEq |
| Ca
Gluconate
600mg |
| Heparin
1 unit/ml |
| MVI
Pediatric
3.25 ml |
| Neotrace
0.4 ml |
| Selenium
4 mcg |
nfuse 9.6 ml/hour x 24 hours -----------------> 230.4 ml/day
Intralipid 10% infuse 0.5 ml/hour x 20 hours---> 10.0 ml/day
TOTAL 240.4 ml/day
This TPN would provide only 50.2 Kcal/day = 25 Kcal/kg/day, a big difference from
calories provided in the hyperal on day 7 above.
Phar 653 Clinical Pharmacotherapeutics III
PRACTICE Pediatric Nutrition Case
TG is a 6 year old male with short bowel syndrome secondary to necrotizing
enterocolitis during infancy. He is currently hospitalized for failure to gain weight at
home while receiving enteral feedings and home hyperal. The patient has been made NPO
since admission 3 days ago, when full hyperalimentation was started.
PE: Small undernourished male child in NAD, playing quietly with toys in crib. Sterile
dressing from central catheter in place.
HR 100 RR 22 BP 100/65 T 98.6o F
Weight 16 kg (less than 5th percentile for weight)
Height 105 cm (less than 5th percentile for height)
LABS: Na, K, Ca, Cl, SCr, glucose, CO2 all within normal limits for age.
Hgb/Hct 11.4/33 (lower limit of normal for age 11.5/35)
The new pediatric intern orders the following hyperalimentation for TG:
| HA # 4: |
Dextrose 10 % |
|
Amino acids 7 % |
|
NaCl 48 mEq/day |
|
KCl 32 mEq/day |
|
MgS04 40 mEq/day |
|
Ca Gluconate 4800 mg/day |
|
Heparin 1 unit/ml |
|
Selenium 48 mcg/day |
|
Infuse at 47.5 ml/hour x 24 hours |
| Intralipid 20% 6.6 ml/hour x 24 hours |
1. Do the above orders meet this child's daily maintenance fluid requirements and
requirements for protein and fat?
2. Would you fill this hyperalimentation order for this patient? Why/why not?
3. What other laboratory tests would you like to see done for this patient? Give reasons
for your selections.
KEY to Practice Pediatric Nutrition Case
1. Do the above orders meet this child's daily maintenance fluid requirements and
requirements for protein and fat?
| a. Daily fluid maintenance requirement for 16 kg patient: 100
ml/kg/day for first 10 kg = 100 x 10 kg = 1000 ml
50 ml/kg/day for next 6 kg = 50 x 6 kg = 300 ml
TOTAL = 1300 ml |
This patient does not have any factors which would increase insensible
water loss, therefore daily maintenance fluid should be 1300 ml/day. (also no deficits, no
ongoing losses)
Patient receives:
HAL: 47.5 ml/hour x 24 hours = 1140 ml
FAT: 6.6 ml/hour x 24 hours = 158 ml
TOTAL = 1298 ml |
1298 ml is close enough to 1300 ml, therefore ----> yes, patient is receiving daily
maintenance fluids.
b. Protein
Patient is receiving 1140 ml/day of 7 % amino acid solution, therefore:
[ note 7 % = 7 grams/100 ml = 0.07 grams/ml]
1140 ml/day x 0.07 grams protein/ml = 79.8 grams protein/day
79.8 grams/day divided by 16 kg = 4.98 grams/kg/day. [YIKES! Way too high]
Protein requirements for children > 1 yr of age = 1.5 - 2.5 grams/kg/day.
This hyperal would provide TWICE the normal amount of protein.
The MD intern obviously made an error in protein calculation.
Correct percent protein should be 3.5 % not 7 %.
c. FATS
Patient is receiving 158.4 ml/day of 20% Intralipid.
20 % = 20 grams/100 ml = 0.2 grams/ml
158.4 ml/day x 0.2 grams/ml = 1.98 grams of fat/kg/day. [ AOK ]
Lipid emulsion dosing guidelines for older children = 2 - 3 grams /kg/day. Therefore
child is receiving appropriate amount of FAT.
2. Would you fill this hyperalimentation order for this patient?
Why/why not? [Hint: Are there any errors or omissions?]
This hyperal should NOT be dispensed as written!!!! There are too many missing
ingredients, errors, and non-optimization of ingredients (dextrose).
| a. Protein is too high b. Dextrose is too low (ie. should have been
advanced to higher percent, patient is on day 4 of hyperal and serum glucose is normal)
c. MgS04 is too high (HAL has 2.5 mEq/kg/day; should be 0.25 - 0.5 mEq/kg/day)
d. Selenium dose is greater than maximum of 40 mcg/day.
e. MVI pediatric is missing
f. Trace elements are missing
g. Phosphorus is missing
h. Inquire about iron supplementation
i. Calcium is too high: 300 mg/kg/day for a 6 year old is high. Range given in class
for calcium gluconate = 100 - 500 mg/kg/day, but notes also say older children require 1-
2 grams/day. |
3. What other laboratory tests would you like to see done for this patient? Give
reasons for your selections.
Urine glucose: to check for spilling of glucose in urine. (If patient is
spilling glucose, it would indicate that the patient is receiving too high of a dextrose
concentration or that advancement of the hyperal's dextrose concentration was too fast.)
Serum magnesium: part of routine monitoring, plus current order is for 10 times
the normal amount of MgS04. This patient may have been getting this overdose
for sometime now and it is important to see if this patients serum Mg is elevated.
Serum phosphorous: part of routine monitoring, plus there is no phosphorous in
hyperal order. This patient may have not been receiving any phosphorous, so it is
important to see what his level is at this time.
Serum BUN and ammonia: to assess protein catabolism. If BUN and/or ammonia
is/are elevated, protein in hyperal may be too high, or may have been advanced too
quickly.
Serum bilirubin and hepatic enzymes: to monitor for adverse effects of
hyperalimentation.
Serum protein / albumin: to monitor for hyperal efficacy. If sufficient protein
is being given, these would increase to normal values.
Triglycerides and/or cholesterol: to monitor lipid therapy
Serum Fe, TIBC, MCV etc, to monitor anemia ---> r/o iron deficiency
anemia
Phar 653 Clinical
Pharmacotherapeutics III
Pediatric Case
Enteral Nutrition
RH is a 6 month old who appears at pediatric clinic. His height and
weight are 95th percentile for age.
Vital signs: HR 175 RR 30 BP 90/60
Diet: whole cow's milk
6 feedings/day, 6 ounces per feed
LABS: Hgb/HCT 9.8/29.4
Serum Fe: 12 mcg/dl (nl for age = 40 - 100)
Other indices compatible with iron deficiency anemia
Medications: None
Allergies: Amoxicillin -> rash
1. Why did this patient develop an iron deficiency anemia?
2. List the differences between human breast milk and cow's milk with respect to
protein, carbohydrates and fats.
Pediatric Case
Enteral Nutrition
KEY
RH is a 6 month old who appears at pediatric clinic. His height and weight are 95th
percentile for age.
Vital signs: HR 175 RR 30 BP 90/60
Diet: whole cow's milk
6 feedings/day, 6 ounces per feed
LABS: Hgb/HCT 9.8/29.4
Serum Fe: 12 mcg/dl (nl for age = 40 - 100)
Other indices compatible with iron deficiency anemia
Medications: None
Allergies: Amoxicillin -> rash
1. Why did this patient develop an iron deficiency anemia?
The iron deficiency anemia is most likely due to the diet of whole cow's milk. The iron
in cow's milk is less bioavailable than the iron found in human breast milk. When infants
drink only cow's milk without any other source of iron, iron deficiency anemia often
occurs.
NOTE: The above answers the question. Other important points to remember:
Whole cow's milk is higher in fat than 2% or milk or skim milk. Generally, whole cow's
milk, 2% milk and skim milk should not be given to children under 1 year of age and only
2% or skim milk should be given in children > 2 years of age. Also, infants at 4 to 6
months of age should be starting spoon feedings of iron fortified infant cereal.
2. List the differences between human breast milk and cow's milk with respect to
protein, carbohydrates and fats.
(*****This answer is straight from the handout*****)
Protein: Human milk contains a lower amount of protein compared to cow's milk,
but is easier to digest.
Protein types: Two major types of proteins are found in milk.
Whey protein contains alpha-lactalbumin, beta-lactoglobulin, lactoferrin, albumin,
lysozyme and IgA, IgG and IgM. Whey protein is highly soluble and easier to digest.
Casein protein contains a mixture of caseins (alpha, beta, gamma and kappa). Casein is
relatively insoluble and forms "tough" curds.
Protein:
|
Whey: Casein ratio |
| Breast milk |
60:40 to 70:30 |
| Cow's milk |
20:80 |
Human milk contains a lower casein content and therefore is more easy to digest,
compared to cow's milk.
Other protein differences: breast milk vs cow's milk:
Lactoferrin is found in greater quantities in human milk then cow's milk. Lactoferrin
is an iron binding protein found in whey (1/3 saturated with iron). Lactoferrin increases
the bioavailability of iron. It also has an inhibitory effect on E. Coli and may offer
some protection against enteric infection.
Secretory IgA is also found in greater quantities in human milk than cow's milk. As an
immunoglobulin, it may offer some local G.I. protection against infection.
Lysozyme is found in human milk but not in cow's milk. Lysozyme has bactericidal
effects
Fats: Human milk and cow's milk contain a similar total amount of fat but
the type of fats differ.
Human milk contains more of the essential fatty acid, linoleic acid, compared to cow's
milk.
Human milk but not cow's milk contains human milk lipase to aid in the digestion of
fat.
Human milk contains long chain unsaturated fatty acids as well as medium chain fatty
acids. Cow's milk contains short and long (primarily saturated) fatty acids.
Carbohydrates: Because cow's milk contains less carbohydrates than human
milk, supplementation of cow's milk with carbohydrates to make milk-based formulas is
necessary.
Lactose is the primary carbohydrate for human milk, cow's milk and milk-based infant
formulas |
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