Specialized Nutrition in Pediatrics

SPECIALIZED NUTRITION SUPPORT IN PEDIATRICS (NEONATES, INFANTS, CHILDREN AND ADOLESCENTS)

Overview
The following section pertains to specialized nutrition support regimens, parenteral nutrition (PN), and enteral tube feeding, specific to the unique developmental stages in the pediatric population. Many aspects of the delivery of enteral and parenteral nutrition are consistent with standards for the adult population (1). However some major differences do exist and this section will address the unique application and use of parenteral and enteral nutrition during the various stages of age, growth, and development in pediatrics. Because of the unique needs of this population, additional support resources may be needed (1-3). Refer to Enteral and Parenteral Nutrition in Adults, for additional information regarding the provision and delivery, of enteral and parenteral nutrition.

Indications (1-3)
Neonatal:

Premature infant (< 38 weeks gestational age) and low-birth-weight infant

Gastrointestinal conditions:

Esophageal and intestinal atresia
Gastroschisis and exomphalos
Microvillus atrophy
Lymphangiectasia
Short-bowel syndrome
Fistulas
Prolonged postoperative ileus
Inflammatory bowel disease
Hepatitis
Pancreatitis
Peritonitis
Postradiation enteritis
Oromotor dysfunction

Hypermetabolic conditions:

Sepsis
Multiple organ failure
Malignancies
Acquired immunodeficiency syndrome (AIDS)

Perioperative nutrition
Inborn errors of metabolism

Parenteral and Enteral Nutrition Support for Neonates

Overview and Definition of Neonate
The patient population in the neonatal intensive care unit (NICU) may include preterm infants as young as 22 weeks gestation as well as infants born full term but who are critically ill or have a low birth weight that places them at risk of medical complications. Neonates are generally categorized by weight to indicate their distinctive physiologic status and nutrition needs as follows:

low birth weight (LBW, less than 2500 g)
very low birth weight (VLBW, less than 1500 g)
extremely low birth weight (ELBW, less than 1000g)
micropremie (less than 750 g)

Numerous physiologic factors differentiate preterm and term infants. Preterm infants have: low carbohydrate and fat stores; elevated metabolic rates due to a higher percentage of metabolically active tissue; high evaporative losses; and immature gastrointestinal systems (2). Neonates, particularly small preterm infants, go through a 1- to 2-week period of transition after birth (3). Nutrition and fluid management are substantially different in the periods of transition and subsequent stabilization (3). A wide range of neonatal feeding regimens is practiced (3). Tables B-5 and B-6 describe the most current data and guidelines for initiation of parenteral and enteral care (3) and are consistent with the most recent ASPEN evidence-based practice guidelines (2).

Table B-5: Nutrition Needs of the Transitional and Stable Preterm Infant <1000 g at Birth
		Transitional		Stable
	Unit of Measure	Parenteral Needs (per kg/day)	Enteral Needs (per kg/day)	Parenteral Needs (per kg/day)	Enteral Needs (per kg/day)
Water	mL	<5 days, 90 – 140	<5 days, 90 – 140	120 – 150	150 – 200
		<2 wk, 80 – 120	<2 wk, 80 – 120
Energy	kcal	35 – ³90 in 7 – 14 days	110 – 120 as tolerated	80 – ³90	110 – 120
Protein	g	0 – 3.8	3.6 – 3.8	3.6 – 3.8	3.6 – 3.8
Carbohydrate	g	6 – 12a	–	6 – 12a	–
Fat	g	0.5 – 1 up to 3	–	0.5 – 1 up to 3	–
Vitamin A	IU	700 – 1500	700 – 1500	700 – 1500	700 – 1500
Vitamin D	IU	40 – 160b	150 – 400b	40 – 160c	150 – 400b
Vitamin E	IU	3.5c	6 – 12d	3.5c	6 – 12d
Supplement HM*		–	3.5	–	3.5
Vitamin K	µg	300	300	8 – 10	8 – 10
Ascorbate	mg	15 – 25	18 – 24	15 – 25	18 – 24
Thiamin	µg	200 – 350	180 – 240	200 – 350	180 – 240
Riboflavin	µg	150 – 200	250 – 360	150 – 200	250 – 360
Pyridoxine	µg	150 – 200	150 – 210	150 – 200	150 – 210
Niacin	mg	4 – 6.8	3.6 – 4.8	4 – 6.8	3.6 – 4.8
Pantothenate	µg	1 – 2	1.2 – 1.7	1 – 2	1.2 – 1.7
Biotin	µg	5 – 8	3.6 – 6	5 – 8	3.6 – 6
Folate	µg	56	25 – 50	56	25 – 50
Vitamin B12	µg	0.3	0.3	0.3	0.3
Sodium	mEq	0 – 3	0 – 3	2 – 3	2 – 3
Potassium	mEq	0 – 3	0 – 3	2 – 3	2 – 3
Chloride	mEq	0 – 3	0 – 3	2 – 3	2 – 3
Calcium	mmol	1.5 – 2.25e	3 – 5.63	1.5 – 2.25e	3.0 – 5.63
Phosphorus	mmol	1.5 – 2.25e	1.94 – 4.52	1.5 – 2.25e	1.94 – 4.52
Magnesium	mmol	0.18 – 0.30e	0.33 – 0.63	0.18 – 0.30e	0.33 – 0.63
Iron	mg	0 – 0.2	0 – 2	0.1 – 0.2	2
Zinc	µg	150	500 – 800	400	1000
Copper	µg	20	120	20	120 – 150
Selenium	µg	1.3	1.3	1.5 – 2	1.3 – 3
Chromium	µg	0.05	0.05	0.05 – 0.2	0.1 – 0.5
Manganese	µg	0.75	0.75	1	7.5
Molybdenum	µg	0	0.3	0.25	0.3
Iodine	µg	1	11 – 27	1	30 – 60
aMaximum = 18 g. bMaximum = 400 IU/day. cMaximum = 7 IU. dMaximum = 25 IU. eAssuming a fluid intake of 120 – 150 mL/kg per day. HM = human milk. Source: Adapted with permission from Tsang RC, Lucas A, Uauy R, eds. Nutritional Needs of the Preterm Infant.* Baltimore, Md: Williams & Wilkins; 1994:292-295.

Table B-6: Nutrition Needs of the Transitional and Stable Preterm Infant >1000 g at Birth
		Transitional		Stable
	Unit of Measure	Parenteral Needs (per kg/day)	Enteral Needs (per kg/day)	Parenteral Needs (per kg/day)	Enteral Needs(per kg/day)
Water	mL	<5 days, 90 – 140	<5 days, 90 – 120	120 – 150	150 – 200
		<2 wk, 80 – 120	<2 wk, 80 – 100
Energy	kcal	35 – ³90 in 4 – 6 days	110 – 120 as tolerated	80 – ³90	110 – 120
Protein	g	0 – 3.6	3.0 – 3.6	3.0 – 3.6	3.0 – 3.6
Carbohydrate	g	6 – 12 a	–	6 – 12 a	–
Fat	g	0.5 – 1 up to 3	–	0.5 – 1 up to 3	–
Vitamin A	IU	700	700	700 – 1500	700 – 1500
Vitamin D	IU	40 – 160b	150 – 400b	40 – 160b	150 – 400b
Vitamin E	IU	3.5c	6 – 12d	3.5c	6 – 12d
Supplement HM*		–	3.5	–	3.5
Vitamin K	µg	300	300	8 – 10	8 – 10
Ascorbate	mg	15 – 25	18 – 24	15 – 25	18 – 24
Thiamin	µg	200 – 350	180 – 240	200 – 350	180 – 240
Riboflavin	µg	150 – 200	250 – 360	150 – 200	250 – 360
Pyridoxine	µg	150 – 200	150 – 210	150 – 200	150 – 210
Niacin	mg	4 – 6.8	3.6 – 4.8	4 – 6.8	3.6 – 4.8
Pantothenate	µg	1 – 2	1.2 – 1.7	1 – 2	1.2 – 1.7
Biotin	µg	5 – 8	3.6 – 6	5 – 8	3.6 – 6
Folate	µg	56	25 – 50	56	25 – 50
Vitamin B12	µg	0.3	0.3	0.3	0.3
Sodium	mEq	0 – 3	0 – 3	2 – 3	2 – 3
Potassium	mEq	0 – 3	0 – 3	2 – 3	2 – 3
Chloride	mEq	0 – 3	0 – 3	2 – 3	2 – 3
Calcium	mmol	1.5 – 2.25e	3.0 – 5.63	1.5 – 2.25e	3 – 5.63
Phosphorus	mmol	1.5 – 2.25e	1.94 – 4.52	1.5 – 2.25e	1.94 – 4.52
Magnesium	mmol	0.18 – 0.30e	0.33 – 0.63	0.18 – 0.30e	0.33 – 0.63
Iron	mg	0 – 0.2	0 – 2	0.1 – 0.2	2
Zinc	µg	150	500 – 800	400 – 1000	1000
Copper	µg	20	120	20	120 – 150
Selenium	µg	1.3	1.3	1.5 – 2	1.3 – 3
Chromium	µg	0.05	0.05	0.05 – 0.2	0.1 – 0.5
Manganese	µg	0.75	0.75	1	7.5
Molybdenum	µg	0	0.3	0.25	0.3
Iodine	µg	1	11 – 27	1	30 – 60
aMaximum = 18 g. bMaximum = 400 IU/d. cMaximum = 7 IU. dMaximum = 25 IU. eAssuming a fluid intake of 120 – 150 mL/kg per day. HM = human milk. Source: Adapted with permission from Tsang RC, Lucas A, Uauy R, eds. Nutritional Needs of the Preterm Infant.* Baltimore, Md: Williams & Wilkins; 1994:292-295.

Recommended Rate of Weight Gain for Neonates
During the first week of life, diuresis occurs as the neonate’s extracellular fluid compartment contracts. Neonates are expected to lose 10% to 20% of their birth weight by 4 to 6 days of life (4). Recommended goals for weight gain after this period of diuresis are based on gestational age; guidelines can be found in Table B-7 (4). Weight gain goals are usually expressed in grams per kilogram per day for infants weighing less than 1000 g and grams per day for larger infants. The growth goal for a premature infant is based on intrauterine growth rate and is generally recommended to be a 1.5% (15g/kg) increase in weight per day (3).

Table B-7: Goals for Daily Weight Gain (4)
Gestational Age	Weight Gain Goal
< 27 weeks	10 – 20 g/day
27 – 40 weeks	20 – 35 g/day
40 weeks to 3 months	20 – 30 g/day
< 37 weeks	10 – 20 g/kg per day

Parenteral and Enteral Fluid, Macronutrient, and Vitamin/Mineral Requirements for Neonates
Tables B-5 and Table B-6 outline the specific parenteral and enteral needs of preterm infants based on weight at birth and during the transitional phase (1 to 2 weeks after birth) or the stable phase (more than 2 weeks after birth).

Parenteral Nutrition Guidelines for Neonates
Table B-8 provides the Guidelines for Parenteral Nutrition Administration in Preterm Infants established by the American Academy of Pediatrics Committee on Nutrition and the American Society for Parenteral and Enteral Nutrition (5,6). In addition to these established guidelines, practical information is provided below to assist the clinician in estimating individualized fluid and nutrient requirements in neonates.

Table B-8: Guidelines for Parenteral Nutrition Administration in Preterm Infants (2,5,6)

For relatively stable infants, start on the first day of life.
Begin protein at 1.5 to 2 g per kg/day and advance by 0.25 to 0.5 g per kg/day up to a maximum of 3 to 3.85 g per kg/day. Monitor for serum urea nitrogen (BUN) increases and unexplained metabolic acidosis with incremental changes above 2 g per kg/day. If unexplained BUN elevation occurs, consider checking serum ammonia level. For infants with sepsis, high cardiopressor support, or significant birth asphyxia with renal impairment, start at 1 g per kg/day protein and advance as tolerated 0.25 to 0.5 g per kg/day.
Supply 25 kcal of energy per gram of protein intake if possible. Use a combination of glucose and lipid as energy sources.
Begin glucose infusion at 4 to 6 mg/kg per minute.
If hyperglycemia occurs at a glucose intake of <3 to 4 mg/kg per minute, ensure that amino acid is being delivered. Consider reducing or discontinuing intravenous (IV) lipid. If hyperglycemia persists, consider exogenous insulin. Increase glucose intake to a minimum of 6 mg/kg/minute and adjust insulin infusion rate to achieve a plasma glucose concentration of 100 to 120 mg/dL.
Upper limit of glucose intake is at maximal glucose oxidative capacity of 16 to 18 g/kg per day.
In stable ELBW infants, lipid can be started at 1 to 2 g/kg per day (lower levels for the smallest infants). Increase by 0.25 to 0.5 g/kg per day up to 3 g/kg/per day. Monitor serum triglycerides levels at each incremental change, particularly if the previous triglyceride level was high. Maintain serum triglyceride concentrations <150 mg/dL. In all infants, minimal intake should be 0.5 g/kg per day beginning on the first day of life. If the infant is septic or critically ill, has severe respiratory disease, or is approaching bilirubin levels that may require exchange transfusion, the lipid intake can be held at 0.5 g/kg per day. Monitor triglyceride levels closely in these infants with any incremental changes.
Administer IV heparin to ELBW infants receiving IV lipid to enhance lipid metabolism, particularly if they are intolerant of higher lipid intakes. Heparin also should be used, even if PN is administered by a peripheral vein.
Infuse daily lipid dose over 20 to 24 hours.
Lipid intakes above 3 g/kg per day can be administered if needed to meet energy requirements or in certain cases of growth failure at seemingly adequate protein and energy intakes.
Parenteral nutrition should be accompanied by early minimal enteral feedings. As enteral nutrition increases, decrease parenteral nutrition intakes proportionately unless there is evidence of malabsorption of the gastrointestinal (GI) tract.
Consider protective covering of PN formulations and lipid, particularly if the infant is receiving phototherapy.
Parenteral vitamin dosing of a commercially available pediatric multivitamin product in premature infants is 2 mL/kg (maximum of 5 mL/day)

Adapted with permission from the American Society for Parental and Enteral Nutrition (ASPEN), The Science and Practice of Nutrition Support A Case-Based Core Curriculum; 2001; Chapter 16; Nutrition Support in Neonatology; page 332; table 16.3. ASPEN does not endorse the use of this material in any form other than its entirety.

Estimating Fluid and Electrolyte Requirements
To estimate fluid and electrolyte requirements in neonates, see Tables B-5, B-6, and B-8. Factors that influence fluid requirements include the infant’s gestational age; use of humidified isolettes, heat shields, and thermal blankets; use of radiant warmers or phototherapy; respiratory status; elevated body temperature; and use of diuretics (7). Preterm infants have greater fluid requirements due to higher insensible water losses compared with term infants. Use of humidified isolettes, heat shields, and thermal blankets helps reduce insensible water losses, whereas use of radiant warmers and phototherapy results in greater insensible water loss (7). The dietitian should evaluate these factors along with changes in body weight, serum sodium, and urine output when estimating fluid requirements in neonates.

Plotting of the neonate’s weight changes on daily growth curves can reflect fluid status, including diuresis, fluid loss, or fluid overload (8). Daily monitoring of serum sodium levels in addition to monitoring urine output is recommended. A diagnosis of oliguria is considered in a newborn when the urine output is less than 1 mL/kg per hour (9). If an infant’s urine output drops below 2 mL/kg per hour, the infant may be receiving inadequate fluid and should be monitored. During the first 2 weeks of life, parenteral fluid and electrolyte provision is adjusted daily to ensure postnatal diuresis and subsequent growth. Table B-9 can be used for fluid and electrolyte management during this time. In general, a preterm infant’s initial fluid prescription for the first day of life is approximately 80 to 100 mL/kg per day (7). Daily increases are generally 10 to 20 mL/kg per day (10). Goal fluid intakes or maximal fluid intakes are generally 140 to 160 mL/kg per day (10).

Table B-9: Fluid and Electrolyte Provision Guidelines (11)
Phase 1: Transition (first 3 - 5 days of life)
Birth Weight (g)	Expected Weight Loss (%)	Fluid Intake (mL/kg per day)	Sodium Intake (mEq/kg per day)	Chloride Intake (mEq/kg per day)	Potassium Intake (mEq/kg per day)
<1000	15 – 20	90 – 140	0	0	0
1000 – 1500	10 – 15	80 – 120	0	0	0

Phase 2: Stabilization (5 - 14 days of life)
Birth Weight (g)	Expected Weight Loss (%)	Fluid Intake (mL/kg per day)	Sodium Intake (mEq/kg per day)	Chloride Intake (mEq/kg per day)	Potassium Intake (mEq/kg per day)
<1000	0	80 – 120	2 – 3	2	1 – 2
1000 – 1500	0	80 – 100	2 – 3	2	1 – 2

Phase 3: Growth
Weight Gain (g/kg per day)	Parenteral Volume (mL/kg per day)	Enteral Volume (mL/kg per day)	Sodium Intake (mEq/kg per day)	Chloride Intake (mEq/kg per day)	Potassium Intake (mEq/kg per day)
15 – 20	140 – 160	150 – 200	3 – 5	3 – 5	2 – 3

Energy and Protein Requirements
See Tables B-5, B-6, and B-8 to determine the energy and protein requirements. In addition, the following guidelines can be used to estimate optimal nitrogen balance and meet growth requirements for preterm neonates (12):

Positive nitrogen balance requirements: 60 kcal/kg nonprotein energy
Growth requirements: 70 kcal/kg nonprotein energy
Nitrogen retention at fetal rate: 80 to 85 kcal/kg nonprotein energy and 3.5 to 3.85 g of protein/kg/day (2)

Retention at fetal rate refers to the amount of energy and protein it takes to match the growth and nitrogen retention rates of a fetus the same postconceptual age and is the goal of medical nutrition therapy for preterm infants. An infant can grow with less energy (less than 85 kcal of nonprotein energy) and protein (less than 3.5 g of protein per kilogram/day), but the growth and nitrogen retention rates will not match the fetal growth and nitrogen retention rates.

Guidelines for initiating and advancing protein requirements are outlined in Table B-10 (10,12,13).

Table B-10: Goal Protein Requirements (g/kg) in Neonates
Initiation	Advancement	Goal
1.5 (12)	1	3.5 – 3.85 (2,11)

It is not recommended to advance or increase protein intake if the patient’s BUN level is 50 mg/dL or higher, if urine output is low, and if acidosis is present. It is recommended that cysteine, a conditionally essential amino acid, is added at an amount of 40 mg of cysteine per gram of protein (14). It has been suggested that cysteine be decreased or held in patients who weigh less than 1250 g and present with severe acidosis (15).

Calculating calories from protein:

Grams of protein per kilogram x Dosing weight (actual weight or estimated dry weight) of PN = Total grams of protein
Total grams of protein x 4 calories/g = calories from protein

For example, to provide an infant weighing 1.5 kg (1500 g) with 3.5 g of protein per kilogram calories from protein, the calculation is as follows:

3.5 g of protein per kilogram x 1.5 kg (dosing weight) = 5.25 g of protein
5.25 g of protein x 4 calories/g = 21 calories

Parenteral amino acid solutions for preterm infants (such as TrophAmine) have been developed to produce plasma amino acid patterns that are comparable to those seen in breast-fed infants of the same gestational age (16). These pediatric amino acid solutions have improved nitrogen balance and normalized BUN concentrations by providing conditionally essential amino acids (eg, cysteine, taurine, tyrosine, and histidine) and less glycine and methionine (16,17). TrophAmine contains conditionally essential amino acids taurine and tyrosine, and two amino acids found in human milk: glutamic and aspartic acids (16). The amino acid phenylalanine levels are lower in TrophAmine due to observed elevations of serum phenylalanine seen in infants who are given adult amino acid formulations (16).

Glucose (Dextrose) Requirements
See Tables B-7, B-8, and B-10 to determine glucose requirements. The most recent ASPEN guidelines suggest glucose administration should be advanced as tolerated to 10 to 13 mg/kg/minute to meet caloric goals (2). Glucose administration should be such that intake meets energy expenditure needs, maximizes protein anabolism, prevents hypoglycemia (less than 45 mg/dL), and avoids negative effects of excessive glucose administration (3). Glucose, which is provided in the form of dextrose, is often referred to as glucose infusion rate (GIR) (10). Calculating the GIR in place of referring to the percentage of dextrose will help prevent too rapid an advancement in glucose. There are several ways to calculate the GIR. One method is as follows:

Sample Calculating glucose infusion rate:

GIR = Percent dextrose (using decimal for % dextrose) x 1000 x mL/kg/1440 minutes per 24 hours

For example, baby B is an infant with a birth weight of 1.0 kg (1000 g) and a gestational age of 28 weeks. The physician inquires about how much glucose to prescribe. The doctor wants to provide the infant with 70 mL/kg of total parenteral nutrition, excluding lipid volume and other drips. The glucose requirement is calculated as follows:

4 mg/kg per minute = 70 mL/kg x 1000 x X/1440 minutes (if infused over 24 hours)
5760=70,000X
X=5760/70,000 = 8.25%

To check: GIR = 70 mL/kg x 1000 x 0.0825/1440 minutes
GIR = 70 mL/kg x 1000 x 0.0825/1440 minutes

Advancement of glucose should be evaluated based on the patient’s glucose level and hemodynamic stability. Table B-7 contains guidelines for glucose administration developed by the American Society for Parenteral and Enteral Nutrition (ASPEN) and the American Academy of Pediatrics (AAP). Table B-11 outlines general guidelines for advancement of the glucose infusion rate (10).

Table B-11: Recommended Glucose Infusion Rate (mg/kg per minute) for Neonates
Initiation	Advancement	Goal
4 – 6	1 – 2	10-13 (2)

It is recommended that advancement of GIR occur as long as blood glucose levels are under 150 mg/dL. If a patient’s blood glucose levels are above 150 mg/dL and urine output is excessive (more than 5 mL/kg per hour) and positive for glucose in the urine, GIR should decrease (10). In addition to hyperglycemia, it is important to prevent hypoglycemia. Retrospective studies have shown hypoglycemia events (less than 45 mg/dL) in premature infants correlate with adverse neurodevelopmental outcomes, lasting for as long as 5 years (18,19). Adverse outcomes of hypoglycemia may include reduced head circumference (reduced brain weight, brain volume, cellularity, and myelin levels) and diminished performance in perceptive and motor capacity and intelligence quotient (IQ) (18,19).

Lipid Requirements
See Tables B-5, B-6, and Table B-8 for guidelines on lipid requirements. The goal for lipid intake should be to prevent essential fatty acid (EFA) deficiency and to meet metabolic energy needs if intake from other energy substrates is insufficient. Essential fatty acids are critical to postnatal brain development. Deficiency of EFA can be prevented with as little as 0.5 to 1 g/kg per day of IV lipid (4,6). It is recommended that a gradual intake of IV lipid with a maximum fat intake of 3 g/kg per day or 0.15 g/kg per hour be provided over 24 hours (2,5,6,12). Complications from early and/or rapid advancement of lipid infusion include lipid intolerance, altered glucose metabolism, increased free bilirubin concentrations, acute impaired pulmonary function and interference with immune function (6). Interventions to improve lipid clearance and tolerance include addition of low-dose heparin (1 U/mL) to parenteral feeding formulation to induce lipoprotein lipase activity; and avoidance of more than 1g/kg per day of lipid in infants with severe hyperbilirubinemia (2,6). Plasma triglyceride concentrations provide a reasonable guide to lipid clearance with recommended maximal ranges less than 150 mg/dL (5,12). If serum triglyceride concentrations exceed 200 mg/dL in the neonate, lipid emulsion infusion should be suspended and then restarted at a rate of 0.5 to 1 g/kg per day (2). It is recommended that triglyceride levels be evaluated with every 1 g/kg increase in lipid infusion to assess lipid clearance. To avoid hypertriglyceridemia in patients weighing below 1500 g, the rate of the lipid infusion should not exceed 0.12 to 0.15 g/kg per hour (10,12). Table B-12 outlines general goals for advancing lipid levels (12).

Table B-12: Goals for Advancing Lipid Levels (g/kg) in Neonates (2,5,6,12)
Initiation	Advancement	Goal
0.5 – 1	1	3

Sample calculation energy supplied from a 20% lipid emulsion:
Intralipids g/kg ´ Dosing weight of PN = Grams of intralipids x 100 mL/20g = Milliliters of lipid x 2 kcal/mL = Kilocalories from lipid

For example: Baby B is prescribed lipids to be initiated at 0.5 g/kg. Baby B weighs 1 kg. How many milliliters of fluid and how many calories will this provide?

0.5 g/kg of intralipids x 1 kg = 0.5 g of intralipids x 100 mL/20g = 2.5 mL

The recommended daily intakes (per kilogram) of calcium and phosphorus are much higher in premature infants than the full-term infant (see Tables B-7 and B-8). During the final trimester of pregnancy, fetal calcium and phosphorus accretion rates peak. Attaining these rates after premature birth is very difficult for several reasons, including (3):

physical incompatibilities and solubility limitations of IV calcium gluconate and phosphate salts
reduced oral bioavailability
inadequate content in premature human milk
use of medications that promote renal calcium wasting

Special attention should be given to formulation pH and absolute content of calcium and phosphorus. Also, the sequence of additives to the solution during the compounding process is important to prevent precipitation. For optimal mineral retention, a ratio of calcium to phosphorus of 1.3 to 1.7:1 by weight (mEq:mmol) is recommended (2,3,20,21). Calcium gluconate can be irritating to peripheral vessels and can cause serious tissue necrosis if infiltration occurs. Administering more than 10 mEq/L is recommended to prevent risk (3). Despite advances in PN, a subset of neonates remain at high risk for metabolic bone disease (MBD). Routine biochemical screening for metabolic bone disease should include serum calcium, phosphorus, and alkaline phosphatase and should be evaluated every 2 to 3 weeks on infants requiring long-term PN nutrition (longer than 2 weeks) (3). Serum aluminum concentrations should be measured whenever unexplained metabolic bone disease is present in long-term PN patients (2). Contributing factors to this MBD include inadequate provision of calcium and phosphorus, long-term loop diuretic and glucocorticoid therapy, vitamin D deficiency in full-term hospitalized breast-fed infants with inadequate sunlight exposure and preterm infants on unfortified breast milk, aluminum loading, malabsorption, and immobility (3). Maximizing the intake of calcium and phosphorus is important. The addition of fortifier to human breast milk in the rapidly growing premature infant is also important to improve calcium and phosphorus intakes (3). In patients with low PTH and 1,25 hydroxyvitamin D concentration with MBD, vitamin D should be removed from the PN solution (2).

Requirements for Vitamins/Minerals
Currently, there is not a parenteral product that meets the individual needs Tables B-5, B-6, and B-8 of the premature infant for both vitamins and minerals. Formulations for pediatric multivitamins therefore must be used. In general these formulations provide higher amounts of certain water-soluble vitamins (thiamin, riboflavin, pyridoxine, and cyanocobalamin) and lower amounts of fat-soluble vitamins, specifically vitamin A to the premature infant than is required (22,23). The water-soluble vitamins can be safely excreted by the kidneys. The dietitian may need to make adjustments in vitamin A intake to meet individualized needs (6,24).

Enteral Feedings for Neonates
Tables B-5 and B-6 show the enteral needs of preterm infants. The use of minimal enteral feeds (MEF) is advocated as a supplement to PN (3). Currently there is no well-established definition for MEF. It usually refers to the use of human milk and/or a variety of formulas of different dilutions at an intake of 1 to 25 mL/kg per day (3). Several randomized trials have demonstrated the efficacy of MEF, including no difference or a decreased incidence in necrotizing enterocolitis compared with use of PN alone (2,3,25). Benefits of using MEF include faster weight gain, smaller gastric residuals, improved feeding tolerance, enhanced mineral absorption, and less time under phototherapy. In addition, trophic effects on the GI system have been documented. Contraindications to initiating MEF may include asphyxia, hypotension, hypoxia, and medications with potential GI complications such as indomethacin (3).

The contents of specific infant formulas can be reviewed in Pediatric Diets, Infant Formula Comparison Chart. Several products are available specifically for preterm infants. These include both preterm formulas and fortifiers added to human milk (3). The formulas are designed to provide more ideal intake for infants at less than 32 weeks gestation and include increased protein, energy, calcium, and phosphorus as well as essential fatty acids, particularly vitamins E and D. Generally whey is the predominant protein, which may improve intake of specific amino acids that may be low in preterm infants (eg, cystine and taurine) and others that may be excessively high (methionine) (3). Carbohydrate source is a combination of glucose and lactose polymers providing low osmolality and may improve lactose intolerance. Fat is provided as a combination of vegetable oils, long-chain triglycerides, and medium-chain triglycerides (3). The AAP Committee on Nutrition recommends breast-feeding as the optimal source of infant nutrition during the first 6 months of life and is recommended whenever possible (26).

Parenteral and Enteral Nutrition Support for Infants, Children, and Adolescents
The components of a pediatric PN and enteral nutrition formulation are the same as for adults (27). However, one of the major differences is that protein, lipid, and electrolytes are frequently prescribed on a basis of per kilogram body weight per day (28). Table B-13 (28) provides guidelines for estimating fluid requirements in pediatric patients. Table B-14 provides recommendations for parenteral protein requirements (29), and Table B-15 provides recommendations for daily parenteral electrolyte and mineral requirements (29). Table B-16 provides parenteral trace element daily requirements for pediatrics and Table B-17 provides recommendations for pediatric parenteral multiple vitamins (29). Unlike current adult IV multivitamin preparations, pediatric formulations contain vitamin K (28).

Table B-13: Estimation of Maintenance Fluid Requirements in Pediatric Patients (28)
Body Weight (kg)	Baseline Fluid Requirements per Day
3 – 10	100 mL/kg
11 – 20	1000 mL + 50 mL/kg for each kilogram over 10 kg
>20	1500 mL + 20 mL/kg for each kilogram over 20 kg
Source: Reprinted with permission from Davis A. Indications and techniques for enteral feeds. In: Baker SB, Baker RD, Davis A, eds. Pediatric Enteral Nutrition. Gaithersburg, Md: Aspen Publishers Inc; 1994:76.

Table B-14: Daily Protein Requirements (g/kg) for Parenteral Nutrition in Pediatric Patients(29)*
Infants	2 – 2.5
Children	1.5 – 2
Adolescents	0.8 – 2
* Assumes normal age-related organ function. Adapted with permission from the American Society for Parental and Enteral Nutrition (ASPEN), The Science and Practice of Nutrition Support A Case-Based Core Curriculum; 2001; Chapter 17; Pediatrics; pages 357; table 17.8. ASPEN does not endorse the use of this material in any form other than its entirety.

Table B-15: Daily Electrolyte and Mineral Requirements for Pediatric Patients (29)*
Electrolyte	Infants/Children	Adolescents
Sodium	2 – 6 mEq/kg	Individualized
Chloride	2 – 5 mEq/kg	Individualized
Potassium	2 – 3 mEq/kg	Individualized

Table B-16: Trace Element Daily Requirements for Pediatrics (29)*
Trace Element	Requirements for Children <5 years old (µg/kg)	Requirements for Older Children and Adolescents
Zinc	100	2 – 5 mg
Copper	20	200 – 500 mg
Manganese	2 – 10	50 – 150 mg
Chromium	0.14 – 0.2	5 – 15 mg
Selenium	2 – 3†	30 – 40 mg
Iodide	1‡	N/A
* Assumes normal age-related organ function. Recommended intakes of trace elements cannot be achieved through the use of a single pediatric multitrace product. Only through the use of individualized trace element products can recommend intakes of trace elements be achieved. † Limit = 40 µg/kg. ‡ Percutaneous absorption from protein-bound iodine may be adequate. Adapted with permission from the American Society for Parental and Enteral Nutrition (ASPEN), The Science and Practice of Nutrition Support A Case-Based Core Curriculum; 2001; Chapter 17; Pediatrics; pages 358; table 17.10. ASPEN does not endorse the use of this material in any form other than its entirety.

Table B-17: Daily Dose Recommendations for Pediatric Multiple Vitamins (29)*
Manufacturer		National Advisory Group
Weight (kg)	Dose (mL)	Weight (kg)	Dose
<1	1.5	<2.5	2 mL/kg
1 – 3	3.25	>2.5	5 mL
>3	5
* Assumes normal age-related organ function. Pediatric multiple vitamin formulations (5 mL: vitamin A, 2300 IU; vitamin D, 400 IU; vitamin E, 7 IU; vitamin K, 200 µg; vitamin C, 200 mg; thiamin, 1.2 mg; riboflavin, 1.4 mg; niacin, 17 mg; pyridoxine, 1 mg; pantothenic acid, 5 mg; vitamin B12, 1 µg; biotin, 20 µg; and folic acid, 140 µg).
Adapted with permission from the American Society for Parental and Enteral Nutrition (ASPEN), The Science and Practice of Nutrition Support A Case-Based Core Curriculum; 2001; Chapter 17; Pediatrics; pages 358; table 17.11. ASPEN does not endorse the use of this material in any form other than its entirety.

See:
ESTIMATION OF ENERGY REQUIREMENTS
ESTIMATION OF PROTEIN REQUIREMENTS

Special Considerations
If an infant or child requires PN for more than 1 month, selenium should be added to the parenteral feeding formulation. A dose of 2 mg/kg per day, up to a maximum daily dose of 30 mg/kg per day, is recommended if renal function is normal (28,30). Aluminum, a contaminant of commercial IV formulations, is a toxic factor that can cause fractures, osteopenia, and osteomalacia, as well as encephalopathy and anemia in children receiving long-term PN therapy (31). In preterm and term infants, aluminum can be neurotoxic (32). Parenteral additives that are sources of aluminum are phosphorus, calcium, trace elements, and vitamins (33). Continued efforts should be made to reduce the levels of aluminum in components of IV products (34).

Monitoring
As in adults, complications of PN can be mechanical, technical, infectious, metabolic, or nutritional (3,27,28). To monitor for complications, refer to Table B-18 (35). Growth parameters (weight, length/height, and head circumference), temperature, and laboratory data need to be observed. No optimal protocol for monitoring laboratory data has been established, but patients usually have daily monitoring of glucose and electrolytes as PN is initiated (3,27). Also see Parenteral Nutrition: Metabolic Complications of Parenteral Nutrition.

Table B-18: Suggested Clinical Monitoring Parameters for Pediatric Parenteral and Enteral Nutrition (35)
Indicator	Initial Period (1st week or if unstable)	Hospital	Outpatient Follow-up
Growth Weight for age; correct for at least 1 year	Daily	Weekly	Monthly
Height for age (length for infants)	Initially	Weekly	Monthly
Weight for height	Initially	Weekly	Monthly
Head circumference	Initially	Weekly	Monthly
Gastrointestinal Abdominal girth	Daily for infants and neonates	As needed	As needed
Gastric residuals	Hourly	As needed	As needed
Vomiting	Daily	Daily	Daily
Stool frequency and consistency	Daily	Daily	As needed
Metabolic Glucose	Daily and as needed until stable	Weekly	Weekly to monthly
Electrolytes	Daily until stable	Weekly	Weekly, progress to monthly
Serum urea nitrogen/creatinine	Initially	Weekly	Weekly to monthly
Liver function	Initially	Weekly*	Weekly to monthly*
Visceral proteins	Initially	Weekly to every 2 weeks	Weekly to monthly*†
Minerals (calcium, phosphorus, magnesium)	Initially and as needed	Weekly	Monthly
Cholesterol and triglycerides	Initially and as needed	Weekly	Monthly
Vitamins, trace elements	As needed	As needed	As needed, yearly‡
Complete blood cell count	Initially	Weekly*	Weekly to monthly*
Iron studies	As needed	As needed	As needed, yearly‡
Fluid intake/output	Daily	Daily	Daily*
Urine-specific gravity, glucose/acetone	Daily	Daily to weekly*	Weekly*
Other indicators
Patient’s overall well-being and developmental progress, general appearance
Bile acids may be used as an early indicator of cholestasis for patients receiving PN
Free fatty acids may be used to assess essential fatty acid status
* Laboratory profiles and frequency of laboratory monitoring may be altered because of disease state, clinical status, medications, or type of nutrition therapy. † Albumin is assessed monthly. ‡ In short-gut syndrome and malabsorption these need to be assessed. Source: Reprinted with permission from Klotz KK, Wessel JJ, Hennies GA. Goals of pediatric nutrition assessment. In: Merritt RJ, et al, eds. ASPEN Nutrition Support Practice Manual. Silver Spring, Md: American Society for Parenteral and Enteral Nutrition; 1998.

Enteral Nutrition in Pediatrics
Breast milk or infant formulas are used for infants being tube fed. Specific infant formulas can be reviewed in: Pediatric Diets, Infant Formula Comparison Chart. Breast milk and infant formulas are usually 20 kcal/oz, while formulas used for children are 30 kcal/oz or more (27). Monitoring parameters for a child receiving enteral feedings can be found in Table B-18. Currently no standardized protocol exists for transitioning pediatric-aged patients from parenteral to enteral and/or oral feedings, or from enteral feedings to oral feedings. Often PN or enteral nutrition can be gradually weaned as enteral/oral calories increase (27). Generally when the patient is consuming 75% of total calories from oral or enteral route, tube feedings or parenteral feeding can be discontinued respectively (37). Also see Enteral Nutrition: Management of Complications.

References

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Bibliography

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Table B-6: Nutrition Needs of the Transitional and Stable Preterm Infant >1000 g at Birth

Table B-10: Goal Protein Requirements (g/kg) in Neonates

Goal