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Sarah Swaintek
Dietetic Intern
Sodexo Mid-Atlantic
February 4, 2013

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
To understand the components of TPN/EN neonatal nutrition support.
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To assess nutrition support tolerance in a neonatal setting.
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To identify similarities and differences between nutrition support in neonatal vs adult acute care setting.

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34 yo Female
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G1P000  G1P1
Maternal hx of hyperthyroidism (no treatment)
Presented w/
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Preterm Premature rupture of membranes (PPROM) and contractions, Rubella immune, RPR non reactive, Hepatitis B negative, GBS status unknown

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NICU called to Labor and Delivery:
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NSVD at 31 weeks and 2 days
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Via assistance of vacuum
Placental infarction during delivery
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Baby @ 20 seconds of life:
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Cyanotic, no cry at birth, no respiratory effort
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Suctioned, stimulated  grunting and retracting
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APGAR
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At minute 1 = 3
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At minutes 5 = 7
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Welcome to the world BBR!
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Baby transferred to NICU

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
BBR is an ex 31 and 2/7 male admitted to NICU w/
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Prematurity
Respiratory Distress
R/O Sepsis
LBW
Birth weight
Classification
High birth weight
Normal birth weight
LBW
VLBW
ELBW
Weight (gm)
>4000gm
2500gm – 3999gm
< 2500gm
< 1500gm
< 1000gm

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Intrauterine growth rate
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3 rd Trimester:
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Ca, Phos, PRO, fat needs
Deposition of Stores
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Gut immaturity
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Lung immaturity
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Need for Nutrition Support!

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BW: 1875gm (LBW)
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Length: 43.5cm (17.1 inches)
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Observations:
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Appearance: Cachetic, No dysmorphic features, Palate intact
Lungs: Increased WOB
CV: No murmur
Abd: Soft, nondistended
Ext: Moves all 4 extremities equally
Skin: Translucent
Gestational Age Classification
Large for Gestational Age (LGA)
Appropriate for Gestational Age (AGA)
Small for Gestational Age (SGA)
Growth Percentile
>90 th percentile
10 th -90 th percentile
<10 th percentile

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Total fluid goal @ 90 mL
NPO
PPN: D10P2IL1 at
6.7mL per hour
NO LYTES!
IVF D10W at 7mL per hour
NS Bolus at 18mL over 30 minutes
D10 = %
Dextrose
P2 = Protein in gm/kg
IL1 = Lipid in gm/kg

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Bubble CPAP
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ABG, Chest and Abdominal X-ray
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Labs:
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Total bilirubin, BMP, Mg, Phos, CBC, Blood Culture, CRP (in 12 hours)
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Medications:
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Antibiotics:
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Start Ampicillin and Gentamicin via PIV

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BBR is an ex 31(2) week male; now 31(4) weeks.
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DOL#2
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BW: 1875gm (50 th -90 th %)
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AGA as plotted on growth chart.
CBW: 1835gm
Intrauterine Growth Rate: 25.7gm/d
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Length: 43.5cm (50 th -90 th %)
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Meds: ampicillin, gentamicin
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Nutrition-focused Physical Findings:
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Isolette
PIV
SMIV
OG tube in place
Phototherapy x1
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No stool since admit

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Current Intake:
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PN (via peripheral line): D10P3IL2
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No lytes
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MVI and TME included
EN: trophic feeds
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Breastmilk/Premie Good Start (PGS) 24 at 2mL q3hrs
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Residuals: 0.5mL (x3)
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Estimated Needs/Nutrition Rx: 90-110kcal/kg, 4-4.5gm/kg
PRO
Nutrient Practice Guideline
Total Fluid Goal
Currently
Receiving
93 mL/kg/d 90-110 mL/kg/d
Total Kcal Intake
Total Protein Intake
53.5 kcal/kg (TPN) 90-120 kcal/kg (TPN)
2.5 gm/kg 4-4.5 gm/kg

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Laboratory Test
Na
K+
Cl-
CO2
BUN
Cr
Glucose
Ca
Mg
Phos
H/H
CRP
Tbili
Dbili
Lab Value
140
4.7
107
26.9
21
0.8
43-70
7.1
2.4
5.7
18.2/51.6
7.3
11.9
0.4
Reference Range
134-146
3.7-5.9
95-110
20-28
3-25
0.3-1
20-80
8-11
1.2-2.2
5-8
11-17/35-49
<5
6-8
<2

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One of the most common problems encountered in newborns.
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Characterized by yellow-pigmented skin and increased bilirubin concentrations in the blood.
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Phototherapy
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The process of using fluorescent light to aid in the breakdown of bilirubin into a form the body can more quickly eliminate.
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Transforms bilirubin into water-soluble isomers that can be eliminated without conjugation in the liver.
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To be considered:
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Maximizing skin exposure
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Eye protection and care
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Thermoregulation
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Nutrition Implications:
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Increased fluid loss
Jaundice babies typically don’t feed well
Hypocalcemia

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Inadequate energy intake related to prematurity and recent delivery AEB infant currently meeting
<70% of estimated kcal and protein needs.

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Nutrient Delivery –
Continue TPN, titrate to meet estimated needs
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Trophic feeds with Breastmilk as feasible
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Coordination of Care –
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Maternal lactation support and education
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GOAL: Regain BW by DOL #7

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Indicator
PN tolerance
Criteria
Labs WNL
Adequacy of nutrient regimen, weight gain
Weekly growth parameters WNL

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Moderate
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RD to f/u in 6-8 days

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BBR is now an ex 31(2) week male; now 32 weeks.
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DOL#5
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BW: 1875gm (50 th -90 th %)
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CBW: 1780gm
Intrauterine Growth Rate: 27.1gm/d
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Length: 43.5cm (50 th -90 th %)
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Meds: ampicillin, gentamicin, caffeine, s/p glycerin
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Biochemical:
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Tbili-11.1, Dbili-2.9
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Nutrition-focused Physical Findings:
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Isolette
CPAP
OG tube in place
PIV
Pacifier
Phototherapy x2
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Stool x1

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Laboratory Test Lab Value
Na
K+
BUN
Cr
Glucose
Ca
Mg
Phos
Alk Phos
TG
GGT
AST
ALT
Tbili
Dbili
4 
35
49
303
42
28
11.1

2.9

136
3.8
35 
0.5
67
10.7
2.4
Reference Range
136-143
4.1-5.6
3-25
<1.3
20-80
8-11
1.5-2.2
6.1-11.7
≤400
≤250
15-75
16-74
1-25
6-8
<0.2

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Current Intake:
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PN (via peripheral line): D10P4.5IL2.5
EN: Breastmilk
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6mL q3hr via OG (advancing by 1mL q6hr)
Residuals: 0.5-3mL (x6)
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Estimated Needs: 90-110kcal/kg (TPN), 4-4.5gm/kg PRO
Nutrient
Total Fluid Goal
Total Kcal Intake
Total Protein Intake
Currently
Receiving
151 mL/kg/d
110 kcal/kg
4.8 gm/kg
Practice Guideline
120-150 mL/kg/d
90-120 kcal/kg (EN)
4-4.5 gm/kg

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Inadequate oral intake related to prematurity AEB dependence on parenteral and enteral nutrition support

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Nutrient Delivery –
Continue parenteral nutrition until enteral nutrition reaches 75% of goal volume/calories
Taper PPN as EN increases (decrease protein to
4gm/kg)
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Hold Trace Mineral elements until direct bili is <2
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Add back Zinc
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Coordination of Care –
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Maternal lactation support and education
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D/w team on Rounds today
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GOAL: Regain BW by DOL #7

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Indicator
PN tolerance
EN tolerance
Growth
Criteria
BMP, Mg, Phos,
LFTs, TG, Bilirubin
Residuals, emesis, feed advance
Average daily wt gain
WNL, weekly growth parameters, growth chart WNL, weekly growth matches intrauterine growth

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High
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RD to f/u in 3-5 days

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BBR is an ex 31(2) week male; now 32(5) weeks; DOL#10
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CBW: 1910gm (35gm increase)
Intrauterine Growth Rate: 27.1gm/d
Length: 43.5cm (50-90 th %)
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Meds: None currently
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Biochemical Data:
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Tbili-10.4 (direct 0.6)
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Nutrition-focused Physical Findings:
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Isolette
CPAP
OG tube in place
Pacifier
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Stool x7

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12/31/12
Nutrition Support PN via PIV
EN via OG
Nutrition Composition PN = D10P3IL2
EN = Breastmilk/PGS22
Rate PN = Continuous
EN = Tropic
Residuals 0.5mL (x3)
24-Hour Nutrient
Provision
TFG: 93mL/kg/d
Kcal: 53.5kcal/kg/d
PRO: 2.5gm/kg/d
01/03/13
PN via PIV
EN via OG
PN = D10P4.5IL2.5
EN = Breastmilk
PN = Continuous
EN = 6mL q3hr
0.5-3mL (x6)
TFG: 151mL/kg/d
Kcal:110kcal/kg/d
PRO: 4.8gm/kg/d
01/08/13
EN via OG
(PN d/c 01/04/13
Breastmilk/Premie
Good Start 24
40mL q3hr over 45 min
0.8-12mL (x8)
TGF: 151mL/kg/d
Kcal: 108kcal/kg/d
PRO: 3gm/kg/d

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Nutrition Rx: 120-130kcal/kg, 3.5-4gm/kg PRO
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Nutrition Diagnosis:
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Inadequate oral intake related to prematurity AEB dependence on EN nutrition support (on-going dx, new s/s)
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Inadequate kcal and protein intake related to marginal TF tolerance AEB high residual volumes and inability to reach goal feed volumes (new dx)
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Nutrition Interventions:
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Nutrient Delivery:
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Continue EN feeds, advance as tolerated
Fortify breastmilk to 22kcal/oz w/ HMF to help meet needs
Coordination of Care:
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Maternal lactation support and education
 d/w team
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Nutrition Goals:
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Regain BW by DOL#7 (goal met)
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Infant to tolerate current feed volume and continue to advance w/ residuals <20% of feed volume, 16-20gm/d wt gain; over 7 days (new goal)

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Ex 31(2) week male; now 33 weeks; DOL#12
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CBW: 2045gm
Average Daily Weight Gain: 37.8gm/d
Intrauterine Growth Rate: 30gm/d
Length: 45cm (50 th -90 th %)
Head Circumference: 29cm
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Meds: IV antibiotics (ampicillin,vancomycin), nystatin, caffeine
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Biochemical Data:
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Alk Phos-587
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Nutrition-focused Physical Findings:
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Isolette
CPAP
PIV
OG tube in place
Pacifier
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Stool x7

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12/31/12
Nutrition Support PN via PIV
EN via OG
Nutrition
Composition
Rate
Residuals
PN = D10P3IL2
EN =
Breastmilk/PGS22
PN = Continuous
EN = Tropic
0.5mL (x3)
24-Hour Nutrient
Provision
TFG: 93mL/kg/d
Kcal:
53.5kcal/kg/d
PRO: 2.5gm/kg/d
01/03/13
PN via PIV
EN via OG
PN = D10P4.5IL2.5
EN = Breastmilk
01/08/13
EN via OG
(PN d/c 01/04/13
Breastmilk/Premie
Good Start 24
01/10/13
EN via OG
Breastmilk
(HMF22)/PGS24
PN = Continuous
EN = 6mL q3hr
0.5-3mL (x6)
TFG: 151mL/kg/d
Kcal:110kcal/kg/d
PRO: 4.8gm/kg/d
40mL q3hr over 45 min
0.8-12mL (x8)
40mL q3hr over 45 min
2-5mL (x6)
TGF: 151mL/kg/d
Kcal: 108kcal/kg/d
PRO: 3gm/kg/d
TFG: 156mL/kg/d
Kcal: 123kcal/kg/d
PRO: 3.7gm/kg/d

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Nutrition Rx: 120-130kcal/kg, 3.5-4gm/kg PRO
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Nutrition Diagnosis:
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Inadequate oral intake related to prematurity AEB dependence on EN support (ongoing dx)
Increased nutrient needs related to prematurity AEB elevated Alk
Phos and need for breastmilk fortification (for adequate kcal/Ca/Phos) (new dx)
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Nutrition Interventions:
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Nutrient Delivery:
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Continue EN feeds, advance as tolerated
Fortify breastmilk to 24 kcal/oz with HMF to help meet needs
Coordination of Care
 d/w team today in Rounds
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Nutrition Goals:
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Infant to tolerate current feed volume and continue to advance w/ residuals <20% of feed volume, 16-20gm/d wt gain; over 7 days (new goal)

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Ex 31(2) week male; now 34 weeks; DOL#19
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CBW: 2275gm (10 th -50 th %)
Average Daily Weight Gain: 32.8gm/d (1/10-1/17),
 comparative 31.4gm (1/09-1/16) given 90gm weight gain overnight
Intrauterine Growth Rate: 31.4gm/d
Length: 48cm (90 th -97 th %)
Head Circumference: 30.5cm (10 th -50 th %)
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Meds: caffeine, Lasix (last dose 1/16)
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Biochemical Data:
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Alk Phos-458 (trending down), Ca-9.6, Phos-7.4
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Nutrition-focused Physical Findings:
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Isolette (open-crib trial today)
CPAP
PIV (d/c 01/17)
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OG tube in place
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Stool x2

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Nutrition
Support
Nutrition
Composition
Rate
Residuals
24-Hour
Nutrient
Provision
12/31/12
PN via PIV
EN via OG
PN = D10P3IL2
EN =
Breastmilk/PGS22
PN = Continuous
EN = Tropic
0.5mL (x3)
TFG: 93mL/kg/d
Kcal: 53.5kcal/kg/d
PRO: 2.5gm/kg/d
01/03/13
PN via PIV
EN via OG
PN = D10P4.5IL2.5
EN = Breastmilk
PN = Continuous
EN = 6mL q3hr
0.5-3mL (x6)
TFG: 151mL/kg/d
Kcal:110kcal/kg/d
PRO: 4.8gm/kg/d
01/08/13
EN via OG
(PN d/c 01/04/13
Breastmilk/Premie
Good Start 24
40mL q3hr over 45 min
0.8-12mL (x8)
TGF: 151mL/kg/d
Kcal: 108kcal/kg/d
PRO: 3gm/kg/d
01/10/13
EN via OG
Breastmilk
(HMF22)/PGS24
01/17/13
EN via OG
Breastmilk
(HMF24)
40mL q3hr over 45 min
2-5mL (x6)
TFG: 156mL/kg/d
Kcal: 123kcal/kg/d
PRO: 3.7gm/kg/d
42mL q3hr over
45 min
1mL (x1)
TFG: 148mL/kg/d
Kcal: 118mL/kg/d
PRO: 3.5gm/kg/d

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Nutrition Rx:
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Estimated Needs: 120-130kcal/kg, 3.5-4gm/kg PRO
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Nutrition Diagnosis :
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Inadequate kcal and protein intake related to current EN rate AEB total kcal intake not meeting estimated needs.
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Nutrition Intervention:
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Coordination of Care – maternal lactation support and education, consider non- nutritive breastfeeding practices as medically feasible.
Coordination of Care – d/w team today in Rounds
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GOAL:
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Infant to tolerate current feed volume and continue to advance with residuals <20% feed volume
16-20gm/day weight gain (over 7 days)

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Challenges in NICU setting
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Volume tolerance
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Ca/Phos needs
Mimicking the intrauterine growth
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Nutrition Support in NICU setting
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Access site
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Hyperglycemia
TPN induced cholestasis
Increased Ca/Phos needs
Overlap in modalities
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Similarities and Differences from Adult Care
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Initiation of Nutrition Support
Tolerance/Residuals
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Speed of happenings
Less evidence-based research on practice guidelines
Shortages advantage

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Illinois, 2000.
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.

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