D._Session_1_Slides_Calculations_Nutrition.pptx

NICU Calculations

1. Calculations, TPN and Nutrition NICU Bootcamp

2. Our objectives for this NICU Boot Camp session are as follows: Increase overall confidence in caring for infants in the NICU Determine appropriate nutritional needs and fluid management for NICU patients Determine calculations for patients in the NICU

3. Calculations Total Daily Fluid (ml/kg/day) Total ml in 24 hours ÷ weight in kg = ml/kg/day Includes TPN, lipids, enteral feeds, drips, transfusions, and if <1000 g all medications/flushes in your total intake Use previous day’s weight or birth weight if < 1 wk old or dry weight if appropriate Round to nearest whole number

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5. Calculations Total Calories (kcal/kg/day) Feeds, Dextrose, Protein, and Lipids Add up all calories from each source to get total kcal/day then divide by weight Use the same weight as when calculating total daily fluid Round to nearest whole number

6. Calculations Calories from enteral feeds (kcal/day)= (ml feeds/day)(kcal/oz)(oz/30ml) Remember to use appropriate caloric density of the infant’s breast milk or formula EBM (expressed breast milk) is 20 kcal/oz EBM + 1 vial HMF/50 ml = 22 kcal/oz EBM + 1 vial HMF/25 ml = 24 kcal/oz Standard term infant formula (Enfamil NB or Similac Advance) is 20 kcal/oz Standard preterm formula (Premature Enfamil/PEF or Similac Special Care/SSC) can be either 20, 22, or 24 kcal/oz Standard discharge preterm formula ( Enfacare /EC or Neosure /NS) is 22 kcal/oz Divide by the weight to get kcal/kg/day No decimals!!!

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8. Calculations - TPN Calories from dextrose (kcal/day) = (total ml dextrose/day) (g dextrose/100ml)(3.4 kcal/g) Calories from intralipids (kcal/day) = (total ml IL/day)(2 kcal/ml) *Calories from protein (kcal/day) = (total grams protein/day)(4kcal/gram) *not all institutions calculate protein calories For this and all example slides, insert screen shots pertinent to your institution

9. Calculations Outputs Urine (Total ml of urine/day) ÷ (weight in kg) ÷ (24 hours/day) = ml/kg/h Round to nearest tenth Ostomy (Total ml stool out/day) ÷ (weight in kg) = ml/kg/day Goal is usually less than 40 ml/kg/day Round to nearest whole number Total Input and Output For most patients, you do not need to report on rounds the total input (ml/day) or total output (ml/day) unless we ask We would follow these numbers for infants with renal insufficiency and heart failure. Please have this documented in your note in case we ask.

10. Note For this and all example slides, insert screen shots pertinent to your institution

11. TPN and Fluids

12. What is my goal for fluids? Preterm < 1000 g BW Newborn Day (DOL 0): 100ml/kg/day DOL 1: generally 120ml/kg/day Continue increase by about 20ml/kg/day to 150-180 ml/kg/day Preterm > 1000 g BW Newborn Day (DOL 0): 80ml/kg/day DOL 1: 100 ml/kg/day Continue as above to goal 150-160ml/kg/day Some infants may need more fluids if on phototherapy or if hypernatremia develops

13. What is my goal for fluids? Term Newborn Day (DOL 0): 70-80ml/kg/day DOL 1: 80-100 ml/kg/day DOL 2: 1o0-120 ml/kg/day Continue as above to goal 120-150ml/kg/day Making a baby NPO Put them on the same or close to Total Fluids as they were on with feeds Some patients, however, like those with congenital heart defects or BPD, might require a lower goal IFV rate compared to enteral nutrition

14. How do I calculate for new fluids? Start with total fluid goal (ml/kg/day) to get your total goal volume Example TFG 150 ml/kg/d for 1 kg infant 150 ml/kg/d x 1 kg = 150 ml/day (total goal volume) Subtract total volume of all medication drips and flushes (UAC or central line fluids) Subtract any feeds Subtract Lipids +/- subtract for transfusions Use today’s weight or birth weight if less than 1 wk old or dry weight Take the remaining total volume and divide by 24, this will give you your IVF or TPN rate

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17. What type of fluids should I use? If TPN unavailable or anticipate frequent changing of fluids . . . < 1kg start D5 > 1kg start D10 DOL 0 and beyond: add 200-300mg CaGluconate /100mL of fluid DOL 1 (or later if ELBW) add electrolytes as follows <24 hours old usually do not need additional electrolytes >24 hours old monitor electrolytes and alter amounts based on laboratory values In general, for older infants usually add 3mEq NaCL /100mL and 2mEq KCl /100mL of fluid This also goes for patients being made NPO If the patient was on electrolyte supplements in their feeds or have abnormal values on the BMP, you may need more than the recommended values Don’t forget about heparin for Central lines

18. TPN Dextrose Generally, start with D5 or D10 Maximum dextrose concentration Peripheral IV: 12% Central line: generally, don’t go above 20% Glucose infusion rate (GIR) mg/kg/min How to calculate it: (D___ x Rate (ml/ hr )x 0.167) / weight (kg) Goal GIR Start at 5-6 mg/kg/min for preemie and 6-8 mg/kg/min for term Recommended maximum 12 mg/kg/min This may not be possible in a very small baby, follow point of care glucose Use glucoses on blood gases and GIR to determine dextrose concentration of TPN/fluids Generally, increase or decrease GIR by 1 or 2 mg/kg/min per day 10 7.8 For this and all example slides, insert screen shots pertinent to your institution

19. TPN Protein Start at 2-3 g/kg/day and increase by 0.5-1 g/kg/d Goal Premature infants: 3.5-4 g/kg/day Term: 3 g/kg/day Hepatic or renal dysfunction may alter requirements Decrease to 2 g/kg/day once your baby is on 50% of goal feeds 3 For this and all example slides, insert screen shots pertinent to your institution

20. Intralipids Use 20% intralipid solution Start at 1-3 g/kg/day and increase by 0.5-1 g/kg/d Goal Term and Preterm Infants: 3g/kg/day Usually run over 24 hours to maximize clearance Use triglycerides to monitor the tolerance to lipid load (goal TG <150-200 mg/ dL ) Consider limiting lipids with severe hyperbilirubinemia or severe pulmonary hypertension For infants with TPN cholestasis (D bili >2 mg/ dL or >20% of total), decrease lipid infusion to 1g/kg/day To calculate __g/kg/day x Weight (in kg) x 5 = total volume in ml 32 24 1.3 For this and all example slides, insert screen shots pertinent to your institution

21. TPN - Electrolytes Electrolytes Determine the total amount of Na and K infant needs then decide how to divide between Cl, acetate, and phos . Acetate and chloride are given in the amounts necessary for acid-base balance Try to give phos as NaPhos rather than Kphos to limit aluminum exposure Potassium should be removed or limited in patients with renal failure Infants with immature renal function or on certain medications may require additional sodium and potassium Monitor electrolytes daily when first starting TPN May back off to a few times a week once you are not needing to make changes often 3 1 2 2 2 For this and all example slides, insert screen shots pertinent to your institution

22. TPN - Electrolytes Magnesium, Calcium and Phosphate Use the back of the TPN sheet for starting guidelines and laboratory results to guide supplementation afterwards 2.5 0.3 For this and all example slides, insert screen shots pertinent to your institution

23. TPN –Vitamins and Trace Elements Vitamins Check based on weight Trace elements Refer to the back on the TPN form for recommendations Additional Zinc should be added in preterm infants or infants ≤3kg For patients with TPN cholestasis (direct bilirubin > 2mg/ dL or > 20% of total) Remove manganese from TPN Reduce or remove copper from TPN For patients with chronic renal failure Remove selenium and chromium from TPN For this and all example slides, insert screen shots pertinent to your institution

24. Other TPN Stuff Heparin if central line For infants > 1 kg use 1 unit/ml For infants < 1 kg use 0.5 units/ml Typically no Zantac Consider carnitine Add 10 mg/kg/day if infant has been receiving TPN for > 4 weeks Don’t forget to sign/date/time May reorder TPN subsequent dates if not changing lipids, lytes , dextrose or protein 6 8 17 Before Lunch!! 6/9/17 10ml/ hr 555-5555 or NICU For this and all example slides, insert screen shots pertinent to your institution

25. Enteral Feeds

26. What feeds do I choose? Use breast milk (20 kcal/ oz ) if available Keep infant on same brand they were on prior to transfer This applies to premature formula only For term infants, you may use the formula available on WIC formulary If starting enteral feeds for the first time You may use the formula available on WIC formulary or based on hospital contract

27. Formulas Premature formulas In-hospital formula Premature Enfamil (PEF) – 20-24 kcal/oz Similac Special Care (SSC) – 20-24 kcal/oz Cannot discharge infants on these formulas Discharge premature formulas Enfacare (Enfamil) or Neosure ( Similac ) These are standard 22 kcal/ oz Term formulas: Enfamil Newborn or Similac Advance Use parenteral preference or WIC supplied formula

28. Specialty Formulas Gentlease Low lactose formula Used for lactose intolerance or infants with drug withdrawal Similac Sensitive Low lactose formula Used for lactose intolerance or infants with drug withdrawal

29. Specialty Formulas Pregestimil Casein hydrolysate lactose-free formula with medium-chain triglycerides Used for postop hearts, post-NEC or feeding intolerance Alimentum or Nutramingen Casein hydrolysate lactose-free formula Used in cow milk protein allergies EleCare and Neocate Amino acid based formula Used in feeding intolerance or post-NEC ProSobee or Isomil Soy formula Used in galactosemia

30. How many calories do I use? Always start with 20 kcal/ oz Consider increasing calories/adding fortifiers once tolerating 80-100mL/kg feeds In general, go to 22 kcal/ oz for 1-2 days then increase 24 kcal/ oz Infants with increased caloric needs or requiring fluid restriction such as congenital heart disease may require feeds fortified greater than 24 kcal/ oz Fortifiers/Calorie boosters HMF (human milk fortifier) 1 vial per 50 ml gives 22 kcal breast milk 1 vial per 25 mL gives 24 kcal breast milk

31. How do I increase feeds? Increasing feeds In general, we increase by total of 20-30ml/kg/day based on age and weight using our feeding protocol Increasing feeds at a faster rate may be a risk factor for NEC Usually full volume is 150-160 ml/kg/day

32. What are the goals? Caloric goals 100-110 kcal/kg/day for a term baby 110-120 kcal/kg/day for a preemie Only if on all enteral feeds (not TPN) If on full TPN, caloric goal is usually 85-95 kcal/kg/day Some babies may require even higher caloric goals due to increased caloric expenditure such as heart disease or BPD Goal weight gain is average of 20-30 g per day

33. When should I be concerned? Monitor for signs of intolerance to help determine if ok to advance feeds Residuals Green is abnormal For a baby on bolus feeds Generally, up to 1/3 of the total volume is an acceptable residual For a baby on continuous feeds 1.5 times the hourly rate is acceptable, up to 2 times in some babies Abdominal Distention Emesis

34. When can a baby nipple feed? ~34 weeks corrected age Coordination of suck-swallow-breathe reflex Consider earlier if infant is showing signs of readiness including rooting, sucking on pacifier, alert state, and good tone. Bolus or near-bolus feeds Fed into stomach (NG or OG) Typically, not while being fed transpylorically If on continuous feeds, we usually transition to bolus first Compress feeds slowly over a few days Typically start with one-two nipple attempts per day. Advancing nipple attempts depends on how well the baby is doing nipple full volume no suck apnea or bradycardia with attempts gaining weight

35. References ElHassan, Nahed O., and Jeffrey R. Kaiser. “Parenteral Nutrition in the Neonatal Intensive Care Unit.” Neoreviews , American Academy of Pediatrics, 1 Mar. 2011 Gomella, Tricia Lacy, et al. Neonatology: Management, Procedures, on-Call Problems, Diseases, and Drugs. McGraw-Hill Education Medical, 2013. Torrazza , Roberto Murgas , and Josef Neu. “Evidence-Based Guidelines for Optimization of Nutrition for the Very Low Birthweight Infant.” NeoReviews , vol. 14, no. 7, 2013, doi:10.1542/neo.14-7-e340.