Validated Screening tools in paediatrics, recommended frequancy
STAMP: 2-17 yr, 5 steps
PYMS: 1-16 yr, 4 steps (widely adopted in UK, BMI)
Weaning PN recommendations (Infants)
- Allow an extra 30ml/kg/day enteral feeds before weaning PN
- Concentrate PN during weaning phase
Weaning PN recommendations (older children)
- consider reducing hours (break during day)
- Wind downs (to prevent hypoglycemia, 19 hrs full, 30min 50% rate, 2nd 30min 50% rate, 4 hrs off)
Weaning PN for long term HPN patients
Night off PN (may require IV fluids)
NEC Conservative Management
• NBM 5-10 days
• Parenteral nutrition
• Triple antibiotics
What’s the expected small intestinal
length for a 30 week gestation infant?
~175cm
The presence of protein and fat in the duodenum stimulate
production of ....
CCK -> gallbladder contraction
Possible Benefits of recycling stoma losses
• Improved fluid and electrolyte balance
• Faster rate of weight gain (improved capacity for absorption)
• Cessation of PN in 60% of patients
• Liver enzyme and function profiles improved
• Reduction in size discrepancy between proximal and distal bowel
• Reduction in rates of post operative anastomotic strictures and leakage
Managing IFALD
1. SMOF lipid
2. Cycle lipid component (e.g. give lipid on alternate days – 1 day on, 1 day off)
3. 3g/kg/day parenteral fat (10kcal/1g) = 30kcal/kg
Anti-infective factors in human milk
1. lactoferrin
2. immunoglobulins
Non nutritive components of formula
• Nucleotides
• Oligosaccharides
Monogen formula fat content
84% MCT
16% LCT
Trophic feeding maximum rate
12-24 ml/kg/day
Feed advancement recommendations (term vs preterm)
Preterm high risk -> 10-20 ml/kg/day
Term standard risk -> 30 ml/kg/day
Fresh MEBM vs pasteurised DEBM
MEBM higher
- micronutrients
- immunoactivite factors
- trophic factors
DEBM lower
- Microbes
DEBM criteria for eligibility
All babies < 32 weeks and or <1000g
When DEBM supply low only babies will receive it ?
High risk of feed intolerance:
<31 weeks on PN
Abdominal surgery or recovering from NEC
End diastolic flow
Growth restriction below 2nd centile
BMF recommendations
1g to 25 ml of BM
Start hen EN reach 40-100ml/kg/day
Protein hydrolysed 1.3g and 16 kcal
No iron added, provideing vitamines and minerals
Nutriprem 1 content and indications
Whole protein + 9% MCT + lactose = Osmo 310
For preterm infants, < 2Kg
Nutriprem 2 indications
Preterm infants <35 weeks, >2kg
Up to 6 months corrected age
hydrolyzed nutriprem content
EHP+ 7% MCT + lactose = Osmo 410
TPN ratios recommendations
Non-protein energy = 60-75% CHO + 25-40% lipids
AA intake = at least 1.5 g/kg/day
NPE to N : 20-30 kcal / 1g AA
Total energy: 30-40 kcal/ 1gAA
25kcal/1 g AA
AA to protein / 1.12
PN criteria
weight < or = 1.5 kg
Gestation < or = 30 +6 weeks
IUGR between 31-34 weeks or EDF or 31-37 feed not expected
NEC
IF
<37 weeks NBM for 48 hrs
When to start PN
within 6 hrs of birth or admission
Supplementary glucose % and advancement of PN in neonates 25 weeks and over
more than or = 5 days
10% glucose max rate 30 ml/kg/day
Supplementary glucose % and advancement of PN in neonates 24 +6 weeks and under
over > or = 7 days
5% glucose
Lipid rate reduced if TG level is
> or = 2.8 mmol/l
SCAMP
-Two-compartment standardised PN
-Maintenance PN bag= Glucose, protein, electrolytes, trace elements
Rate: 60 -> 75 -> 90 ml/kg/day maximum
-Lipid PN syringe= Fat, water and fat soluble vitamins
6,1 -> 12,2 -> 17ml, 3g/kg/day maximum
+Supplementary infusion of glucose 10% or 5%
+Supplementary infusion of electrolytes
- Primene amino acid course allowing longer shelf life
NEON
- Two-compartment standardised PN
- start up and maintenance bag
Depending on postnatal day of life run at a different rate
- Can use side arms of glucose 5% and 10%
x- Does not use additional electrolytes
Lower starting protein and glucose delivery than SCAMP
- Primene amino acid source- allows longer shelf life
Only licensed three compartment neonatal PN
Amino acid, glucose and lipid separately
NUMETA
Glucose Infusion Guidelines Preterm
Start at 6-9 g/kg/day (4.1–6.3 mg/kg/min)
After 4 days 9–16 g/kg/day
Maximum intake 16 g/kg/day (11 mg/kg/min)
Can you think of a candidate that would be better
on a standardised PN bag than bespoke PN
- A baby meeting nutritional recommendations and growing well on
- A baby that is extremely fluid restricted
- At a weekend or out of hours