Intravenous Nutrition

Reviewed by Malcolm Battin & Barbara Cormack

July 2008

Indications	Standard Solutions	Examples
Individualised Solutions	References	Other Documents

When enteral feedings are not possible, the use of intravenous nutrition is essential for the care of the sick newborn.
The goals of intravenous nutrition are several-fold:

to promote nitrogen retention and protein sparing,
to provide energy for metabolic processes, and

to establish growth and maturation during the critical postnatal period.

The premature newborn has limited energy stores, which become rapidly depleted with starvation. Infants receiving only intravenous glucose may lose protein stores at a rate of up to 1.0g/kg/day.
In the first week of life, ELBW infants require 75-85 kcal/kg/day whilst VLBW infants require 60-70 kcal/kg/day. Protein requirements are between 2 and 3.5g/kg/day.
Stable premature and term newborns generally require more than 105 kcal/kg/day and 3.5 to 4.0g/kg/day of amino acids¹ to support growth and nitrogen retention at a rate comparable with the intrauterine rate.

Indications for Intravenous Nutrition

Preterm infants <1500g with contraindications to full enteral feedings
Larger premature and sick term newborns in whom it is anticipated that full enteral feedings will be delayed beyond 7 days of age.
- The majority of larger infants can initially be commenced on 10% dextrose (with additives).

Standard Intravenous Nutrition Solutions

Almost all babies can be commenced on a standard solution. Two solutions are available:
Starter solution is to be used from day 0 to day 2-3 in infants <1000g at birth.
- Starter solution should be given at a maximum of 30ml/kg/day (1.25ml/kg/hour). This will provide 2g/kg/day of protein.
- Due to the high osmolality, it must be given via a central line (UVC, longline or surgical CVL).
- Starter solution has no significant quantities of sodium or potassium.
P100 solution can be used from birth in larger infants or those very preterm infants without central venous access.
- If used in the first 2 days, the maximal allowable amount is 51ml/kg/day (2.1ml/kg/hour). This will provide 2g/kg/day of protein, but will also give sodium and potassium that would not normally be present in Starter solution.
- The usual maximal amount is 90ml/kg/day (3.75ml/kg/hour, providing 3.5g/kg/day of protein), although the volume administered can be increased to 103ml/kg/day (4.3ml/kg/hour, 4.0g/kg/day of protein).
- The solution is can be administered through a peripheral IV but for infants who are likely to remain on IVN for more than a few days, a longline should be considered.
The solutions provide the recommended nutrient intakes in a relatively small volume. This is to ensure that, as infusions are added or the infant is on restricted fluid intakes, their nutritional needs are met.

	Starter For use from Days 0-2 Must be given via UVC, longline, or surgical CVL		P100 For use Day 2 and beyond Can be given from birth if necessary
	Composition	Usual intake at 30 ml/kg/day	Composition	Usual intake at 90 ml/kg/day
Protein	67.9 g/L	2.0 g/kg/day	42.0 g/L	3.8 g/kg/day
Nitrogen	10.9 g/L	0.3 g/kg/day	6.70 g/L	0.6 g/kg/day
Amino acid	70.0 g/L	2.1 g/kg	43.0 g/L	3.9 g/kg
Glucose	150 g/L	4.5 g/kg/day	100 g/L	9.0 g/kg/day
Sodium	3.5 mmol/L	0.1 mmol/kg/day	55 mmol/L	5 mmol/kg/day
Potassium	0 mmol/L	0 mmol/kg/day	28.0 mmol/L	2.5 mmol/kg/day
Chloride	0 mmol/L	0 mmol/kg/day	28.0 mmol/L	2.5 mmol/kg/day
Gluconate	32.2 mmol/L	1.0 mmol/kg/day	34.0 mmol/L	3.1 mmol/kg/day
Acetate	67.9 mmol/L	2.0 mmol/kg/day	56.71 mmol/L	5.1 mmol/kg/day
Calcium	16.10 mmol/L	0.5 mmol/kg/day	17.02 mmol/L	1.5 mmol/kg/day
Phosphate	0 mmol/L	0 mmol/kg/day	19.0 mmol/L	1.7 mmol/kg/day
Magnesium	Nil	Nil	2.8 mmol/L	0.25 mmol/kg/day
Trace elements	0 ml/L	0 ml/kg/day	11 ml/L	1 ml/kg/day
Zinc	5 mg/L	150 mcg/kg/day	Included in trace elements
Heparin	500 U/L	15 U/kg/day	500 U/L	45 U/kg/day
Energy	782 kcal/L	23 kcal/kg/day	497 kcal/L	45 kcal/kg/day
Osmolality	1398mOsm/kg		1067 mOsm/kg

Additional dextrose is titrated on top of the IVN to meet fluid intake requirements. Either IVN or dextrose are decreased as feeds increase (this will depend on protein intakes).
- In preterm infants, combined IVN and oral protein intakes should be limited to 4.5g/kg/day.
- In term infants, combined IVN and oral protein intakes should be limited to 4.0g/kg/day.
- As oral feeds increase protein intakes to these levels, IVN will be titrated down.
A calculator is available to assist with the management of feed and fluid volumes.
The bag containing the IVN will come with a tear-off label providing the batch number - this needs to be placed in the baby's clinical notes.

Examples

Consider a 27 week 950g infant, on day 2:

Fluid	Intake (ml/kg/day)	Intake (ml/day)	Intake (ml/hour)
Total fluid intake	75ml/kg/day	71.3ml	3.0ml/hour
UAC (0.45% NaCl)	13ml/kg/day	12.0ml	0.5ml/hour
Oral feeds	Counted as "extra"	(6ml 1ml every 4 hours)
IVN (Starter)	30ml/kg/day	28.8ml	1.2ml/hour
Intralipid 20% (2g/kg/day)	10ml/kg/day	9.6ml	0.4ml/hour
10% Dextrose	23ml/kg/day	21.6ml	0.9ml/hour

As the fluid intake increases or decreases, the volume of 10% dextrose will be titrated on top of the arterial, IVN and Intralipid rates.
If medications are required (for example, inotropes), the dextrose infusion are initially decreased. For example,

Fluid	Intake (ml/kg/day)	Intake (ml/day)	Intake (ml/hour)
Total fluid intake	75ml/kg/day	71.3ml	3.0ml/hour
UAC (0.45% NaCl)	13ml/kg/day	12.0ml	0.5ml/hour
Oral feeds	Counted as extra	(6ml 1ml every 4 hours)
Dopamine (5mcg/kg/min)	13ml/kg/day	12.0ml	0.5ml/hour
IVN (Starter)	30ml/kg/day	28.8ml	1.2ml/hour
Intralipid 20% (2g/kg/day)	10ml/kg/day	9.6ml	0.4ml/hour
10% Dextrose	10ml/kg/day	9.6ml	0.4ml/hour

Consider the same 27 week 950g infant 5 days later on day 7.

Fluid	Intake (ml/kg/day)	Intake (ml/day)	Intake (ml/hour)
Total fluid intake	180ml/kg/day	172.8ml	7.2ml/hour
UAC (0.9% NaCl)	13ml/kg/day	12.0ml	0.5ml/hour
Oral feeds	25ml/kg/day	24.0ml	2ml Q2H
IVN (P100)	90ml/kg/day	86.4ml	3.6ml/hour
Intralipid 20% (3g/kg/day)	15ml/kg/day	14.4ml	0.6ml/hour
10% Dextrose	38ml/kg/day	36.0ml	1.5ml/hour

As feeds increase, the 10% dextrose is decreased.
If the UAC is removed, the 10% dextrose in increased.
Once the feeds increase to 4ml every 2 hours, the baby will be receiving 4.5g/kg/day of enteral and intravenous protein. Further increases in feeds should result in the IVN amino acid solution being reduced.
Use the IVN fluids calculator to demonstrate how changes in fluid intakes alter nutritional intakes.

Individualised Amino Acid Solutions

Special solutions require prospective approval by a specialist and should be countersigned by them each day.
- See also the Individualised Solution Worksheet for calculating and prescribing individualised IVN solutions.
- Individualised solutions cost substantially more than standard solutions and have not been shown to have any advantage over appropriately formulated standard solutions in the majority of infants.³
- Their main role in our NICU are in those infants who have significant fluid restriction, or several infusions that may impact on the delivered volume of IVN.
- There may be alternative methods of changing nutrient and electrolyte intake, such as a simultaneous infusion of sodium, potassium, or glucose.

References

1	Consensus Recommendations; Summary of Reasonable Nutrient Intakes for Preterm Infants In: Tsang R, Uauy R, Koletzko B, Zlotkin S. Nutrition of the Preterm Infant. Scientific Basis and Practical Guidelines. Cincinnati, Ohio: Digital Publishing Inc; 2005: 415-6.
2	Guidelines on Paediatric Parenteral Nutrition of the ESPGHAN and the ESPEN, J Pediatr Gastroenterol Nutr 2005;41 Suppl 2:S1-87.
3	Yeung MY, Smyth JP, Maheshwari R, Shah S. Evaluation of standardized versus individualized total parenteral nutrition regime for neonates less than 33 weeks gestation. J Paediatr Child Health 2003;39:613-7.

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Intravenous Nutrition

Indications for Intravenous Nutrition

Standard Intravenous Nutrition Solutions

Starter For use from Days 0-2 Must be given via UVC, longline, or surgical CVL

P100 For use Day 2 and beyond Can be given from birth if necessary

Examples

Individualised Amino Acid Solutions

References

Starter
For use from Days 0-2
Must be given via UVC, longline, or surgical CVL

P100
For use Day 2 and beyond
Can be given from birth if necessary