NEONATAL TOTAL PARENTERAL NUTRITION MADE SIMPLE & PRACTICAL

NEONATAL TPN MADE SIMPLE & PRACTICAL BY PROF.DR CHAKRADHAR MADDELA

1. DR. CHAKRADHAR MADDELA
CONSULTANT NEONATOLOGIST
•MD MSc Neonatal Medicine Cardiff , DCH, PGD
NEONATOLOGY Southampton ESN,
•DHSc Echocardiography, Fellowship Cardiology (General &
Paediatric), DHSc Diabetology
•“NEONATAL TOTAL PARENTRAL NUTRITION MADE SIMPLE”.

2. NEONATAL TOTAL PARENTERAL NUTRITION
•TERM AND PRETERM INFANTS
•PRACTICE POINTS

3. WATER REQUIREMENT
•START WITH 60 -80 ml / kg / day
•Gradually increase 15 -20 ml /kg/day
•Reach 150 –180 ml / kg / day

4. ENERGY REQUIREMENTS (KCAL /KG/DAY)
•Preterm : Calories (C )<24 hrs 60 –80,
NPE(kcal/kg/day):Protein 40 -60,
•24 -72 hrs C 80 –100, NPE:Pro 60 –65,
•>72hrs C 100 –120, NPE:Pro 85 –100 : Protein Cal 18 –
25 kcal / gm

5. GLUCOSE (G/KG/DAY)
•PRETERM :<24hrs : 5.8 -12 (4 –8 mg / kg / min )
•24 –72 hrs: 12 –16 (8-11 mg / kg / min )
•>72 hrs : maximum 17.3 ( 12 mg / kg / min ).
•TERM : same as for PTI.
•Irrespective of GA : Minimum amt glu in 24hrs
5.8gm/kg/day (4mg/kg/min)

6. GLUCOSE PRODUCTION & UTILIZATION
•GLUCOSE PRODUCTION : Term –5mg/kg/min. PTI –5mg/kg/min
(glycogenolysis) + 4-5mg/kg/min (gluconeogenesis).
•GLUCOSE UTILIZATION : Term –3.5 –4.5 mg / kg / min, PTI –
Double
•DAILY GLUCOSE INTAKE : 5.8 –17.3gm/kg/day (4-12 mg/kg/min)
•HYPERGLYCEMIA : >140mg/dl of plasma /Sr glucose, >125mg/dl of
whole blood.
•INSULIN THERAPY : > 180mg/dl

7. GLUCOSE INFUSION RATE (GIR) & DEXTROSE BLEND
•GIR = %DEXTROSE SOLUTION ×FLUID ml / kg / day ÷144
•PREPARATION OF DEXTROSE % by 5%D and 25% D =5X –
25 =Y, X = required % of dextrose, y = amount of 25%
dextrose in ml

8. GLUCOSE INFUSION RATE (MG/KG/MIN)
•Start: 4-6mg/kg/min
•Advance: 1-2mg/kg/min
•Goal : 12mg/kg/min
•HYPERGLYCEMIA : Reduce GIR by 20%
•AVOID : GIR < 4mg/kg/min (Hypoglycemia & Brain injury )
•LIPOGENESIS & FATTY LIVER: GIR > 18 -20mg/kg/min

9. DEXTROSE % CALCULATION FROM DESIRED GIR
•Desired GIR mg/kg/min ×Wt Kg = mg glucose / min
•Mg Glu / min ÷1000 (mg / gm) = gm / min
•Gm / min ×1440 (minutes / day) = gm / day
•Gm / day ÷Total ml / day (Total fluid –total additives ie
AA, fats, Na, K, Cal, Mg, trace elements ) ×100 =
Dextrose %

10. GIR CALCULATION FROM KNOWN DEXTROSE %
•Dextrose % ÷100 ×ml / day = gm / day
•Gm / day ÷1440 = gm / minute
•Gm / minute ×1000 = mg / minute
•Mg / minute ÷kg = mg / kg / minute

11. AMINOACIDS (PROTEIN EQUIVALENT G/KG/DAY)
•Preterm : <24hrs -2 –2.5, 24 –72 hrs –2.7 –3.5, >72hrs –2.7
–4gm/kg/day
•Term : Initially 1.5gm/kg/day increasing to 3gm/kg/day by
day 5
•Minimum protein req to prevent tissue loss –1.5gm/kg/day.

12. PROTEIN UTILIZATION & ACCRETION
•MINIMUM PROTEIN INTAKE TO PREVENT EXISTING TISSUE
LOSS: 1.5gm/kg/day
•ELBW / <29WKS GA POSITIVE NITROGEN BALANCE (Target
Pro intake ) : Start 1.5 –2.4 gm/kg/day on day1. Increase
upto 3.6 -4gm/kg/day in association with 90kcal/kg/day of
nonprotein energy. Reach target protein intake <by day 5.
•NON NITROGEN ENERGY KCAL PER GM PROTEIN : 18 –25
Kcal / Gm protein.

13. RECOMMENDATIONS FOR PRACTICE
•PTI : Start with 2 –2.5gm/kg/day as soon as possible.
•TARGET PARENTERAL PROTEIN INTAKE IN PTI : 2.7 –
4gm/kg/day by day5 + adequate calorie intake.
•TERM INFANT & PTI >34 WKS (TARGET PROTEIN INTAKE):
3gm/kg/day by day5.
•PREPARATION : 10% AMINOVEN

14. CALORIE NITROGEN RATIO ( CNR) CALCULATION
•CNR = CARBOHYDRATE CALORIES (gm×3.4) + FAT CALORIES(gm×9) ×
6.25 ÷AMINO ACIDS IN GM, 6.35 is a constant
•CNR = 100 –200 cal / gm is normal
•NP (non protein) CALORIES / gm AA RATIO = 24 -32 ( approx 25
nonprotein kcal/kg for q1gm protein /kg promote protein
utilization )

15. LIPIDS (G / KG / DAY )
•Preterm : < 24 hrs –2 gm/kg/day, 24 –72 hrs -2.5 -3.5
•gm/kg/day, 3.5 –4gm/kg/day
•20% SMOF / INTRALIPID in ml = gm / kg / day ×Wt ÷0.2
•Term : Same as for PTI.

16. LIPID UTILIZATION, ACCRETION & PROVISION
•Fetal fat requirements :double during 3
rd
trimester, from 1 gm
/kg/day to 2 gm / kg / day
•PROVISION OF LIPIDS : Start 2gm/kg/day on day1& 3gm/kg/day on
day2.
•TARGET LIPID INTAKE : 3.5gm/kg/day in 1
st
week, well tolerated.
•LIPID PREPARATION : 20% lipids lower in phospholipids & better
plasma clearance of Triglycerides.
•LIPID INFUSION TOLERANCE : 24hr infusion is better tolerated than
intermittent infusion.

17. RECOMMENDATIONS FOR PRACTICE
•DAY1 : Start with 2gm/kg/day.. Gradually increase to 3.5 to 4gm/kg/day. Newer
formulations upto 3gm/kg/day only.
•20% lipid emulsion –preparation of choice, SMOF, INTRALIPID
•Infusion –continuously over 24hrs
•Carnitine supplementation enhances lipid utilization
•Lipids atleast 0.5gm/kg/day is required to prevent EFA deficiency
•Monitor triglycerides in babies 1. <1.5kg, 2.sepsis 3.CP decompensation, 4.PPHN &
5.hyperbilirubinemia near exchange transfusion level.

18. RECOMMENDATIONS
•NUTRITIONAL NEEDS = 60:30:10, CARBOHYDRATES 60%,
FATS 25 -30 % & PROTEINS 10 –15 %
•BAG 1 = DEXTROSE + AA + ADDITIVES, TRACE ELEMENTS
•BAG 2 = LIPIDS + VITAMINS THROUGH SEPARATE LINE
AND AMBER COLOURED OR SILVER COVERING FOR LIGHT
•HEPARIN USE ONLY IN SELECTED CASES
•STOP TPN WHEN 2/3 OF TOTAL CALORIES MET BY
ENTERAL ROUTE
•ACHIEVE FULL ENTERAL FEEDS BY 10 –14 DAYS

19. DR CHAKRADHAR MADDELA
MD MSC NEONATE DCH PGD NEONATOLOGY
IV SODIUM 0.9%
1000ML /1L NS=154 MEQ SODIUM +154 MEQ CHLORIDE =154MOSM / L
EACH ML NS =0.154MEQ NA+CL
10ML = 1.54MEQ NA + CL
100 ML = 900 MG NACL
DAILY REQ = 1-3 MEQ / KG
3% SALINE : 1 ML = 0.5 MEQ (DOSAGE = 2 –6ML /KG /DAY )
1ML CON. RINGER LACTATE = 3 MEQ SODIUM

20. POTASSIUM CHLORIDE, KCL
•10 ml KCl = 20 mEq K*, 1ml of inj. KCl = 2 mEq potassium
•Daily requirement = 1-2 mEq / kg 48-72Hr, 1-3mEq/kg/day >72hrs
•Daily Potphos = 0.5 ml / kg
•15% Kesol, KCl = 1 ml = 2 mEq

21. CALCIUM GLUCONATE 10%
•1ml of calcium gluconate = 95 mg calcium gluconate = 0.22mmol
Calcium
•10ml = 950mg calcium gluconate = 2.2 mmol calcium
•1ml 10% calcium gluconate = 0.465 =0.5 mEq = 9mg elemental Ca
•Dosage : 4 -8 ml / kg
•Preterm -1.5 –2mmol/kg/day, Term –0.8 –1.5mmol/kg/day

22. PHOSPHATE (MMOL/KG/DAY)
•Dosage : Preterm –1.5 –2 mmol /kg/day
•Term –0.8 -1.2 mmol / kg / day

23. MAGNESIUM SULPHATE 50% W/V
•1ml 50% mgso4 = 500mg Mgso4 = 2mmol of Mg2+ = 4 mEq /1ml
•2ml ampoule = 1gm Mg
•10 ml = 5gm = 5000mg
•Dosage –Preterm 0.18-0.3mmol/kg, Term –0.2 mmol/kg/day = 4 units
/ kg with 40U insulin syringe.

24. POINTS TO REMEMBER
•1 mEq Ca = 20 mg elemental Calcium
•1 mEq Mg = 12 mg elemental Magnesium
•Ca:Ph:Vit D intake -Ca intake 20-90mg/kg/day 1-
4mEq/kg/D, Ph = 35 –70mg/kg/day (1-2mMol/kg/D),
Vitamin D = 400iu/D
•Ca:Ph molar ratio : 1.3-1.7:1

25. POINTS TO REMEMBER
•Ca & Ph solubility in TPN : L-cysteine increases acidity of
TPN solution & allows increased concentration without
precipitation
•Ca (mEq/100ml) + P (mMol/100ml) = 2.5 peripheral vein
(Ca cannot exceed 1mEq/100ml), 4 central vein (max.
Con. 5 with cysteine )

26. CALCULATION OF MOLAR RATIO, CA & P
•Divide Ca in mEq by 2 = mMol Ca
•Divide mMol Ca by mMol P
•mMol Ca : mMol P

27. INJECTION CELECEL
CHROMIUM + COPPER + MANGANESE + SELENIUM
•Dosage : 0.1 –0.2 ml / kg
•Preparation : 3 ml
•Other brand name : Peditrace / Neotrace

28. INJECTION MVI PAEDIATRIC
•Dosage : 1 ml / kg
•Preparation : 10ml ampoule... Adult / pediatric

29. KEY ESPGHAN NUTRITIONAL RECOMMENDATIONS PER KG BW / DAY
•ENERGY –110-135 kcal
•PROTEIN –3.5 –4.5 gm
•CARBOHYDRATES –11.6-13.2gm
•FATS –4.8 –6.6 gm
•VITAMIN A –1, 333 –3330 IU RE
•VITAMIN D –800 –1000 IU
•FOLIC ACID –35 –100 microgm
•SODIUM –69 –115 mg
•POTASSIUM –66 –132 mg
•CALCIUM –120 –140 mg
•PHOSPHORUS –60 –90 mg
•IRON –2-3 mg

30. TRACE ELEMENTS
MANGANESE –6.3 -25 MCG
COPPER -90 –120 MCG
IODINE 10 –50 MCG
SELENIUM –4.5 –9 MCG
CHROMIUM -0.022 –1.112 MCG
MOLYBDENUM –0.27 –4.5 MCG
FLUORIDE -1.4 –55 MCG
•ESPGHAN NUTRITIONAL RECOMMENDATIONS PER 100 KCAL (PTI)
•PROTEINS -3.2 –4.1 gm
•FATS –4.4 –6.0 gm
•LINOLEIC ACID –360 –1400 mg
•ALPHA LINOLEIC ACID –50 mg
•ARACHIDONIC ACID –16 –39 mg
•DHA –11 –27 mg
•CARBOHYDRATES –10.5 –12 gm
•VITAMIN A –1199 –2464 IU
•VITAMIN D –800 –1000 IU
•VITAMIN E –3.0 –14.9 IU
•VITAMIN K –4 –25 mcg

32. STEPS IN TPN
•1)TOTAL FLUID REQUIREMENT / KG /DAY =
ADDITIVE FLUIDS =
•ENTERAL FEEDS =
•2)Aminoacids requirement = gm/kg/D = 10%
aminoven in 10-30 ml /kg
•3)Lipids 20% =gm/kg/D ×Wt ÷0.2 in ml

33. •4)ADDITIVES
•Sodium = 3%Saline 4 -6ml/kg/d, Concentrated RL
1ml/kg/D
•Potassium = 0.5 –1ml/kg/d in ml Potphos
•Calcium =4-8ml/kg/d
•MVI PED = 1ml/kg/d
•Celecel = 0.1 –0.2ml / kg /d
•50% Magnesium sulphate = 3units /kg/d with insulin
syringe 40 IU or 0.1 ml /kg/d

34. •5) Dextrose infusion calculation at 6mg/kg/min
•6) CNR, calorie nitrogen ratio calculation
•7) Routine iv heparin not indicated in neonates
•Heparin = 1 unit / ml of fluid (Total amount of
fluids )
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