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)

1. Allow an extra 30ml/kg/day enteral feeds before weaning PN
2. Concentrate PN during weaning phase

Weaning PN recommendations (older children)

1. consider reducing hours (break during day)
2. 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