HYPERALIMENTATION COMPOSITION

1. Amino acids: start at 0.5 gm/kg/day with maximum of 3-3.5 gm/kg/day (preemies may be started at 1gm/kg).

2. Intralipid: start at 0.5 gm/kg/day with maximum of 3-3.5 gm/kg/day.

3. The maximum glucose concentration: peripheral TPN - 12.5%; central TPN - 30%

4. Ideal Calories: 90-100 kcal/kg/day.

5. Adjust electrolyte composition according to daily lab results.

6. Trace elements 0.2 cc/kg/day should be ordered daily. Selenium 0.10 µg/kg/day will be added automatically by the pharmacy.

7. Vitamins as Pediatric MVI should be ordered:

• < 1kg: 1/3 amp Ped MVI
• 1-2 kg: 2/3 amp
• >2 kg: 1 amp

8. Use routine Parenteral Nutrition Order form for ordering hyperalimentation.

9. A precipitate may form in the IV tubing if 2 x Ca (mEq/liter) + P (mMole/liter) exceeds 50-55.

10. Only minimal phosphorus may be added to central hyperalimentation until protein is added. Phosphorus in mMoles should not exceed gms/100 ml/day protein (i.e., 2 gms/100 ml protein = 2 mMoles P).

11. Calcium may be added only to central hyperalimentation solution.

12. As feedings are advanced, the protein and glucose content of the hyperalimentation solution should be slowly reduced.

13. Increase protein by 0.5 gm/kg/day in VLBW infants. Older infants, particularly postoperative, may start at 2-2.5 gm/kg/day.

14. Phosphorous can not be added without Na or K (available as NaPO4 or K PO4).

Intralipids

1. Intralipid is a 20% fat emulsion yielding 2.2 kcal/cc.
2. Intralipid should provide no more than 50% of total caloric intake (approximately 3 gm/kg/day). Serum triglycerides should be <150 mg/100 ml.
3. The preferred route of administration is by peripheral IV. However, with approval by the attending neonatologist, Intralipid may be given by central line. Do not administer via UAC.
4. Intralipid should either be stopped or reduced to 0.5 gm/kg/day while phototherapy is in use.
5. Use with caution in infants with respiratory distress, SGA, and low birth weight.
6. Increase lipids by 0.5 gm/kg/day in VLBW infants. Older infants can start at 2-2.5 gm/kg/day.
7. Maximum infusion rate: preterm - 0.75ml/kg/hr; term - 1.25ml/kg/hr. Check serum TG if >max rate.
8. Cycling Hyperal Fluid

In specific situations, "cycling" hyperalimentation (having a period of time when no hyperal fluid is being infused) may be beneficial to prevent cholestasis or progression of cholestatic jaundice. One theory behind this regimen is that time off from TPN allows the liver to recover from potentially toxic substrates associated with amino acids. Cycling should be considered if the infant will require exclusively IV nutrition for an extended time.

In neonates, cycling can began over a period of 22 hours and gradually decreased by 2 hour increments down to an infusion period of 18 hours. A dextrose-containing solution should be infused while the hyperal is turned off to prevent hypoglycemia. Sodium and potassium should be added to the solution in patients with difficult to control serum electrolytes.

Suggested Routine Labs

• Labs may have to be more frequent for <1000 gm infants.

Test	First 3-5 days	Thereafter **
Na, K, Cl, CO2, Glu	q day	q MWF
BUN, creatine	every other day	q M
Phosphorus, Ca, Mg	every other day	q M
Hgb, plts	until stable	q M
ALT (SGOT), bili, ammonia	baseline	every other Monday
urine glucose	q shift	q day
prealbumin/albumin		as indicated
Triglycerides	q M	when IL at 2.5-3gm/kg/d

• ** This assumes that hyperal remins relatively unchanged the first week. With changes, some labs may have to be checked more frequently.

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