Total Parenteral Nutrition
Total parenteral nutrition (TPN) aims to provide nutritional requirements for optimal growth and maturation of the infant. It is a substitute for enteral feeding in circumstances where the establishment of full enteral feeds will be delayed or inadequate. However, the preferred form of nutrition for the neonate remains breast milk.35
Why is it necessary?
TPN is used to provide nutrition in situations in which establishment of full enteral nutrition is likely to be delayed. The provision of balanced nutrition (carbohydrate, protein and fat) is essential to provide for growth and prevent catabolism. Early TPN with dextrose, amino acids and lipid has been shown to reduce hypoglycaemia, increase plasma amino acid levels32 and increase albumin levels in preterm infants.41 Studies are few that prove TPN decreases either morbidity or mortality and are now unlikely to be undertaken as it would be deemed unethical to withhold TPN from a control group.
Indications for TPN
Central cannula: Peripherally inserted central catheters (PICC’s) should be used preferentially to provide central venous access in neonates receiving prolonged TPN as PICC use results in improved nutrient intake and fewer insertion attempts.1,2
Umbilical catheters: In neonates, umbilical vessels can be used for TPN.1 UVC compared to peripheral venous catheter reduces insertion attempts with no increase in risk of infection or necrotising enterocolitis.28 The risk of complication may increases if umbilical venous catheters are being left in place for more than 14 days.7, 36 (See central line policy and UVC policy – site PICC line before 7 days or by 48 hours if non-ideally sited).
Peripheral cannula: As phlebitis of peripheral veins can be expected when the osmolality of the intravenous solution exceeds 600 mOsm1, 20, peripheral veins should be used for short term venous access and for providing partial nutritional supplementation. Although extravasation injury occurs in up to 10% of infants managed only with peripheral infusion of TPN,2 it is unclear if the risk of peripheral TPN is greater than the risk of peripheral crystalloid infusion.
Premature infants tolerate TPN from day 1 of post-natal life.4, 8, 23
Standardised TPN bags have been developed by a NSW working group with substantial consensus agreement from ANZNN. The following bags are available (TPN Consensus Group Formulations):
Volume of fluid
[At 150ml/Kg/day total, this will be made of 135 ml/kg/day parenteral nutrition + 18ml/kg/day lipid]
Daily increase in lipid starting at 1 g/kg/day, increasing by 1g/kg/day. Monitor triglyceride levels with each increase. If triglyceride levels >2.8 mmol/L, consider reducing the lipid emulsions by 1 g/kg/day increments but aim to continue at least 0.5g/kg/day to prevent essential fatty acid deficiency.
Components of TPN
Volumes are increased over the first 7 days in line with the feeding protocol with the aim of delivering 150 ml/kg/day by day 7.
An RCT found that an anion regimen where the first 3 mmol was provided as chloride, the next 6 mmol as acetate, and thereafter as chloride again reduces metabolic acidosis and hyperchloraemia.33
Premature infants require high intakes of Ca and P to mimic fetal accretion rates. Use of calcium gluconate 75mg/kg/day and inorganic phosphate 45mg/kg/day (glucose-l-phosphate) increases solubility and resulted in increased Ca and P retention and reduced PTH.11 However, there is concern regarding precipitation of Ca and P in TPN solutions preventing higher amounts being delivered. Low AA concentrations and high temperatures (in infusion tubing in the infant humidicrib) are significant risk factors for the precipitation of the insoluble dibasic calcium phosphate that may be fatal upon intravenous infusion. The AA concentration of the TPN formula should not be less than 15 g/L (and ideally >30 g/L) when high intakes of calcium (15 mmol/L) and phosphate (16.6 mmol/L) are prescribed.39
Trace element syringes:Trace elements are recommended with long term TPN. However, precise requirements for individual nutrients remain a matter of debate.12
TPN solutions may be contaminated with aluminium and chromium.
Patients with cholestatic jaundice should be closely monitored for copper toxicity.
Patients with renal impairment may not be able to excrete selenium, molybdenum, zinc and chromium.
Trace elements Zinc, Selenium and Iodine are added to TPN infusion bags at the following rates:
Prolonged parenteral nutrition
Monitoring trace elementsIf on long term TPN (>2 weeks duration) perform trace element assays and adjust dose as required.
Filtration is aimed at filtering out particulate matter including mineral precipitates and microbes from infusates. It is recommended that TPN admixtures should be administered through a terminal filter.17 However, limited RCT data has not yet demonstrated a benefit from this practice.18
Duration of infusion
Parenteral solution and lipid are to be infused over 48 hours.
TPN administration requires careful clinical and laboratory monitoring. Adequate growth is best determined by linear growth as weight gain can reflect an increase in total body water rather than tissue accretion. In addition to routine observations the following are required for short term TPN use.
Routine TPN Biochemistry Orders
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13. ESPGHAN. ESPGHAN Guidelines on Paediatric Parenteral Nutrition. 2. Energy. J Pediatr Gastroenterol Nutr. 2005;41 Suppl 2:S5-11.
14. ESPGHAN. ESPGHAN Guidelines on Paediatric Parenteral Nutrition. 3. Amino Acids. J Pediatr Gastroenterol Nutr. 2005;41 Suppl 2:S12-8.
15. ESPGHAN. ESPGHAN Guidelines on Paediatric Parenteral Nutrition. 4. Lipids. J Pediatr Gastroenterol Nutr. 2005;41 Suppl 2:S19-27.
16. ESPGHAN. ESPGHAN Guidelines on Paediatric Parenteral Nutrition. 5. Carbohydrates. J Pediatr Gastroenterol Nutr. 2005;41 Suppl 2:S28-32.
17. ESPGHAN. ESPGHAN Guidelines on Paediatric Parenteral Nutrition. 12. Complications. J Pediatr Gastroenterol Nutr. 2005;41 Suppl 2:S76-84.
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20. Gazitua R, Wilson K, Bistrian BR, Blackburn GL. Factors determining peripheral vein tolerance to amino acid infusions. Arch Surg. 1979;114:897-900.
21. Gobel Y, Koletzko B, Bohles HJ, Engelsberger I, Forget D, Le Brun A, Peters J, Zimmermann A. Parenteral fat emulsions based on olive and soybean oils: a randomized clinical trial in preterm infants. J Pediatr Gastroenterol Nutr. 2003;37:161-7.
22. Goulet O, de Potter S, Antebi H, Driss F, Colomb V, Bereziat G, Alcindor LG, Corriol O, Le Brun A, Dutot G, Forget D, Perennec V, Ricour C. Long-term efficacy and safety of a new olive oil-based intravenous fat emulsion in pediatric patients: a double-blind randomized study. Am J Clin Nutr. 1999;70:338-45.
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25. Laborie S, Lavoie JC, Chessex P. Increased urinary peroxides in newborn infants receiving parenteral nutrition exposed to light. J Pediatr. 2000;136:628-32.
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27. Laborie S, Lavoie JC, Pineault M, Chessex P. Contribution of multivitamins, air, and light in the generation of peroxides in adult and neonatal parenteral nutrition solutions. Ann Pharmacother. 2000;34:440-5.
28. Loisel DB, Smith MM, MacDonald MG, Martin GR. Intravenous access in newborn infants: impact of extended umbilical venous catheter use on requirement for peripheral venous lines. J Perinatol. 1996;16:461-6.
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39. Singh H, Dumas GJ, Silvestri AP, Young S, Martin CR, Bistrian BR, Driscoll DF. Physical compatibility of neonatal total parenteral nutrition admixtures containing organic calcium and inorganic phosphate salts in a simulated infusion at 37 degrees C. Pediatr Crit Care Med. 2009;10:213-6.
40. Thureen PJ, Melara D, Fennessey PV, Hay WW, Jr. Effect of low versus high intravenous amino acid intake on very low birth weight infants in the early neonatal period. Pediatr Res. 2003;53:24-32.
41. van den Akker CH, te Braake FW, Schierbeek H, Rietveld T, Wattimena DJ, Bunt JE, van Goudoever JB. Albumin synthesis in premature neonates is stimulated by parenterally administered amino acids during the first days of life. Am J Clin Nutr. 2007;86:1003-8.
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Main Author: A/Prof David Osborn
Created: May, 2011