The rate of glucose utilization in children. Protocol of parenteral nutrition in the practice of neonatal intensive care unit. Calculation of the rate of introduction of the stock solution

catad_tema Neonatology - articles Comments Published in the journal: Bulletin of Intensive Care, 2006.

Lecture for practitioners E.N. Baibarina, A.G. Antonov

State Institution Scientific Center for Obstetrics, Gynecology and Perinatology (Director - Academician of the Russian Academy of Medical Sciences, Professor V.I. Kulakov), Russian Academy of Medical Sciences. Moscow

Parenteral nutrition (PN) of newborns has been used in our country for more than twenty years, during which time a lot of data has been accumulated both on theoretical and practical aspects of its use. Although the world is actively developing and producing drugs for PN available in our country, this method of nutrition in newborns is not widely used and is not always adequate.

Development and improvement of methods of resuscitation-intensive care, introduction of surfactant therapy, high-frequency ventilation of the lungs, replacement therapy intravenous immunoglobulins significantly improved the survival of children with very low and extremely low body weight. Thus, according to the data of the Scientific Center for Anti-Age and Psychiatry of the Russian Academy of Medical Sciences for 2005, the survival rate of premature babies weighing 500-749 g was 12.5%; 750-999g - 66.7%; 1000-1249g - 84.6%; 1250-1499 - 92.7%. Improving the survival of very preterm infants is impossible without the widespread and competent use of parenteral nutrition, a full understanding of the pathways of metabolism of PN substrates by doctors, the ability to correctly calculate doses of drugs, predict and prevent possible complications.

I. METABOLISM PATHWAYS OF PP SUBSTRATES

The purpose of PP is to provide protein synthesis processes, which, as can be seen from the scheme in Fig. 1, require amino acids and energy. The supply of energy is carried out by the introduction of carbohydrates and fats, and, as will be said below, the ratio of these substrates can be different. The pathway of amino acid metabolism can be twofold - amino acids can be consumed to carry out protein synthesis processes (which is favorable) or, under conditions of energy deficiency, enter the process of gluconeogenesis with the formation of urea (which is unfavorable). Of course, in the body all of these transformations of amino acids occur simultaneously, but the predominant path may be different. So, in an experiment on rats, it was shown that under conditions of excess protein intake and insufficient energy intake, 57% of the obtained amino acids are oxidized to urea. To maintain sufficient anabolic effectiveness of PP, at least 30 non-protein kilocalories should be administered for each gram of amino acids.

II. EFFICIENCY EVALUATION OF PP

Evaluating the effectiveness of PN in critically ill neonates is not easy. Classic criteria such as weight gain and thickness gain skin fold in acute situations, they mainly reflect the dynamics of water exchange. In the absence of kidney pathology, it is possible to use the method for assessing the urea increment, which is based on the fact that if an amino acid molecule does not enter into protein synthesis, then it decomposes with the formation of a urea molecule. The difference in the concentration of urea before and after the introduction of amino acids is called the increment. The lower it is (up to negative values), the higher the efficiency of the PP.

The classical method for determining the nitrogen balance is extremely laborious and is hardly applicable in wide clinical practice. We use a rough estimate of the nitrogen balance based on the fact that 65% of the nitrogen excreted by children is urine urea nitrogen. The results of applying this technique correlate well with other clinical and biochemical parameters and allow monitoring the adequacy of the therapy.

III. PRODUCTS FOR PARENTERAL NUTRITION

Sources of amino acids. Modern drugs this class are solutions of crystalline amino acids (PKA). Protein hydrolysates have many disadvantages (imbalance of the amino acid composition, the presence of ballast substances) and are no longer used in neonatology. The most famous drugs of this class are Vamin 18, Aminosteril KE 10% (Fresenius Kabi), Moriamin-5-2 (Russel Morisita). The composition of the RCA is constantly being improved. Now, in addition to general-purpose drugs, so-called targeted drugs are being created that contribute not only to optimal absorption of amino acids in certain clinical conditions (renal and liver failure, hypercatabolic conditions), but also to eliminate the types of amino acid imbalance inherent in these conditions.

One of the directions in the creation of targeted drugs is the development of special drugs for newborns and infants, which are based on the amino acid composition of human milk. The specificity of its composition is high content essential amino acids (about 50%), cysteine, tyrosine and proline, while phenylalanine and glycine are present in small amounts. Recently, it has been considered necessary to introduce taurine into the composition of RCA for children, the biosynthesis of which from methionine and cysteine ​​in newborns is reduced. Taurine (2-aminoethanesulfonic acid) for newborns is an indispensable AA. Taurine is involved in several important physiological processes, including regulation of calcium influx and neuronal excitability, detoxification, membrane stabilization, and regulation of osmotic pressure. Taurine is involved in the synthesis of bile acids. Taurine prevents or eliminates cholestasis and prevents the development of retinal degeneration (develops with taurine deficiency in children). Most famous the following drugs for parenteral nutrition of infants: Aminoven Infant (Fresenius Kabi), Vaminolact (import to the Russian Federation was stopped in 2004). There is an opinion that glutamic acid (not to be confused with glutamine!) should not be added to RKA for children, since the increase in the content of sodium and water in glial cells caused by it is unfavorable in acute cerebral pathology. There are reports of the effectiveness of the introduction of glutamine in parenteral nutrition of newborns.

The concentration of amino acids in preparations usually ranges from 5 to 10%, with total parenteral nutrition, the dose of amino acids (dry matter!) Is 2-2.5 g / kg.

Energy sources. The drugs in this group include glucose and fat emulsions. The energy value of 1 g of glucose is 4 kcal. 1 g of fat is approximately 9-10 kcal. The best known fat emulsions are Intralipid (Fresenius Kabi), Lipofundin (B.Braun), Lipovenoz (Fresenius Kabi). The proportion of energy supplied by carbohydrates and fats can be different. The use of fat emulsions provides the body with polyunsaturated fatty acids, helps protect the vein wall from irritation by hyperosmolar solutions. Thus, the use of balanced PP should be considered preferable, however, in the absence of fat emulsions, it is possible to provide the child with the necessary energy only due to glucose. According to the classical schemes of PP, children receive 60-70% of non-protein energy supply due to glucose, 30-40% due to fat. With the introduction of fats in smaller proportions, protein retention in the body of newborns decreases.

IV. DOSAGES OF DRUGS FOR PP

When carrying out complete PN for newborns older than 7 days, the dose of amino acids should be 2-2.5 g / kg, fat - 2-4 g / kg glucose - 12-15 g / kg per day. At the same time, the energy supply will be up to 80-110 kcal/kg. It is necessary to come to the indicated dosages gradually, increasing the number of administered drugs in accordance with their tolerance, while observing the necessary proportion between plastic and energy substrates (see the algorithm for compiling PP programs).

The approximate daily energy requirement is:

V. ALGORITHM FOR PLANNING THE PROGRAM

1. Calculation of the total amount of fluid needed by the child per day

2. Decision on the issue of the use of drugs for infusion therapy for special purposes (drugs of volemic action, intravenous immunoglobulins, etc.) and their volume.

3. Calculation of the amount of concentrated solutions of electrolytes / vitamins / trace elements needed by the child, based on the physiological daily requirement and the magnitude of the identified deficit. The recommended dose of a complex of water-soluble vitamins for intravenous administration (Soluvit N, Fresenius Kabi) is 1 ml / kg (when diluted in 10 ml), the dose of a complex of fat-soluble vitamins (Vitalipid Children's, Fresenius Kabi) is 4 ml / kg per day.

4. Determining the volume of the amino acid solution, based on the following approximate calculation: - When prescribing a total liquid volume of 40-60 ml / kg - 0.6 g / kg of amino acids. - When prescribing a total liquid volume of 85-100 ml / kg - 1.5 g / kg of amino acids

When prescribing a total volume of liquid 125-150 ml / kg - 2-2.5 g / kg of amino acids.

5. Determination of the volume of fat emulsion. At the beginning of its use, its dose is 0.5 g / kg, then it increases to 2-2.5 g / kg

6. Determination of the volume of glucose solution. To do this, from the volume obtained in paragraph 1, subtract the volumes obtained in PP.2-5. On the first day of PP, a 10% glucose solution is prescribed, on the second day - 15%, from the third day - a 20% solution (under the control of blood glucose).

7. Checking and, if necessary, correcting the ratios between plastic and energy substrates. In case of insufficient energy supply in terms of 1 g of amino acids, the dose of glucose and / or fat should be increased, or the dose of amino acids should be reduced.

8. Distribute received volumes of preparations. The rate of their administration is calculated so that the total infusion time is up to 24 hours per day.

VI. EXAMPLES OF PR PROGRAMMING

Example 1. (Mixed PP)

A child weighing 3000 g, age 13 days, diagnosed with intrauterine infection (pneumonia, enterocolitis), was on a ventilator for 12 days, did not digest the injected milk, is currently fed through a tube with expressed breast milk 20 ml 8 times a day. 1.Total liquid volume 150ml/kg = 450ml. With food gets 20 x 8 = 160ml. With drinking gets 10 x 5 = 50 ml. Should receive 240 ml intravenously. 2. There are no plans to introduce special drugs. 3. 3 ml of 7.5% potassium chloride, 2 ml of 10% calcium gluconate. 4. Dose of amino acids - 2g/kg = 6g. He receives approximately 3 g with milk. The need for additional administration of amino acids is 3 g. When using the drug Aminoven Infant 6%, which contains 6 g of amino acids per 100 ml, its volume will be 50 ml. 5. It was decided to administer fat at 1g/kg (half the dose used in full PN), which would be 15ml with Lipovenoz 20% or Intralipid 20% (20g in 100ml). 6.Volume of liquid for glucose administration is 240-5-50-15= 170ml 7.Energy requirement is 100 kcal/kg = 300 kcal Receives 112 kcal with milk With fat emulsion - 30 kcal from the fact that 1 g of glucose provides 4 kcal). Requires the introduction of 20% glucose.

8.Destination:

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Parenteral nutrition protocol in neonatal intensive care unit practice

Prutkin M. E. Regional Children's Clinical Hospital No. 1, Yekaterinburg

In the neonatological literature of recent years, much attention has been paid to the issues of nutritional support. Providing adequate nutrition to a critically ill newborn protects him from possible future complications and promotes adequate growth and development. The introduction of modern protocols for adequate nutrition in the neonatal intensive care unit contributes to improved nutrient intake, growth, reduction of the patient's stay in the hospital and, consequently, a decrease in the cost of patient care.

In this review, we would like to present the data of modern evidence-based studies and propose a strategy for nutritional support in the practice of the neonatal intensive care unit.

Physiological characteristics of the newborn and adaptation to independent nutrition. In utero, the fetus receives all the necessary nutrients through the placenta. Placental nutrient metabolism can be regarded as a balanced parenteral nutrition containing proteins, fats, carbohydrates, vitamins and trace elements. I would like to recall that during the 3rd trimester of pregnancy there is an unprecedented increase in fetal body weight. If the body weight of the fetus at 26 weeks of gestation is about 1000 g, then at 40 weeks of gestation (that is, after only 3 months), the newborn baby already weighs about 3000 g. Thus, over the last 14 weeks of pregnancy, the fetus triples its weight. It is during these 14 weeks that the main accumulation of nutrients by the fetus takes place, which it will need for subsequent adaptation to extrauterine life.

Table 2. Physiological features of the newborn

The process of absorption of fatty acids with a long chain is difficult due to insufficient activity of bile acids.

Stocks of nutrients. The more premature a newborn baby is born, the less nutritional supply it has. Immediately after birth and the crossing of the umbilical cord, the flow of nutrients to the fetus through the placental system stops, and a high nutrient requirement remains. It should also be remembered that due to the structural and functional immaturity of the digestive organs, the ability of premature newborns to self-enteral nutrition is limited (Table 2). Since the ideal model for the growth and development of a premature baby for us will be intrauterine growth and development of the fetus, our task is to provide our patient with the same balanced, complete and adequate nutrition as the one he received in utero.

Table 3 provides estimates of the energy needs of the growing preterm infant according to the American Academy of Pediatrics and the European Society of Gastroenterology and Nutrition.

Table 3

Features of the metabolism of nutrients in newborns

fluid and electrolytes. During the first week of life, a newborn baby undergoes significant changes in water and electrolyte metabolism, which reflect the process of its adaptation to the conditions of extrauterine life. The total amount of fluid in the body decreases and the fluid is redistributed between the intercellular and intracellular sectors (Fig. 2).

Rice. 2 Influence of age on fluid distribution between sectors

It is these redistributions that lead to the "physiological" loss in body weight, which develops in the first week of life. A great influence on water-electrolyte metabolism, especially in small premature newborns, can be exerted by the so-called. "imperceptible loss" of fluid. Correction of the dose of liquid is carried out on the basis of the rate of diuresis (2-5 ml / kg / h), the relative density of urine (1002 - 1010) and the dynamics of body weight.

Sodium is the main cation in the extracellular fluid. Approximately 80% of the sodium in the body is metabolically available. The sodium requirement is usually 3 mmol/kg/day. In small premature babies, due to the immaturity of the tubular system, there may be a significant loss of sodium. These losses may require compensation up to 7-8 mmol / kg / day.

Potassium is the main intracellular cation (approximately 75% of potassium is found in muscle cells). Plasma potassium concentration is determined by many factors (acid-base disorders, asphyxia, insulin therapy) and is not a reliable indicator of potassium reserves in the body. The usual requirement for potassium is 2 mmol/kg/day.

Chlorides are the main anions in the extracellular fluid. An overdose, as well as a deficiency of chlorides, can lead to a violation of the acid-base state. The need for chlorides is 2 - 6 mEq / kg / day.

Calcium - mainly localized in the bones. Approximately 60% of plasma calcium is associated with protein (albumin), therefore, even the measurement of biochemically active (ionized) calcium does not make it possible to reliably judge calcium stores in the body. The need for calcium is usually 1-2 mEq/kg/day.

Magnesium - mainly (60%) is found in the bones. Most of the remaining magnesium is found intracellularly, so measurement of plasma magnesium does not provide an accurate estimate of magnesium stores in the body. However, this does not mean that plasma magnesium concentrations should not be monitored. Typically, the need for magnesium is 0.5 mEq / kg / day. Magnesium should be dated with caution in newborns whose mothers received magnesium sulfate therapy before delivery. For the treatment of persistent hypocalcemia, an increase in the dose of magnesium may be required.

During the entire gestation period, the fetus receives glucose from the mother through the placenta. The blood sugar level of the fetus is approximately 70% of that of the mother. Under conditions of maternal normoglycemia, the fetus practically does not synthesize glucose itself, despite the fact that gluconeogenesis enzymes are determined starting from the 3rd month of gestation. Thus, in the case of starvation of the mother, the fetus is able to synthesize glucose itself early enough from products such as ketone bodies.

Glycogen begins to be synthesized in the fetus from the 9th week of gestation. Interestingly, on early dates gestation, glycogen accumulation occurs mainly in the lungs and in the heart muscle, and then, during the third trimester of pregnancy, the main glycogen stores are formed in the liver and skeletal muscles, and disappear in the lungs. It was noted that the survival of a newborn after asphyxia directly depends on the content of glycogen in the myocardium. A decrease in glycogen content in the lungs begins at 34-36 weeks, which may be due to the consumption of this energy source for the synthesis of surfactant.

Factors such as maternal starvation, placental insufficiency, and multiple pregnancies can influence the rate of glycogen accumulation. Acute asphyxia does not affect the glycogen content in fetal tissues, while chronic hypoxia, such as in maternal preeclampsia, can lead to a deficiency in glycogen storage.

Insulin is the main anabolic hormone of the fetus throughout the gestational period. Insulin appears in the pancreatic tissue by 8-10 weeks of gestation and the level of its secretion in a full-term newborn corresponds to that of an adult. The fetal pancreas is less sensitive to hyperglycemia. It is noted that the increased content of amino acids makes the stimulation of insulin production more effective. Animal studies have shown that under conditions of hyperinsulinism, protein synthesis and the rate of glucose utilization are increased, while with insulin deficiency, the number of cells and the content of DNA in the cell decrease. These data explain the macrosomia of children from mothers with diabetes, which during the entire gestational period are in conditions of hyperglycemia and, consequently, hyperinsulinism. Glucagon is found in the fetus from the 15th week of gestation, but its role remains unexplored.

After childbirth and the cessation of glucose supply through the placenta, under the influence of a number of hormonal factors (glucagon, catecholamines), gluconeogenesis enzymes are activated, which usually lasts 2 weeks after birth, regardless of gestational age. Regardless of the route of administration (enteral or parenteral), 1/3 of glucose is utilized in the intestines and liver, up to 2/3 is distributed throughout the body. Most of the absorbed glucose is used for energy production

Studies have shown that, on average, the rate of production/utilization of glucose in a full-term newborn is 3.3–5.5 mg/kg/min. .

Maintaining blood glucose levels depends on the level of glycogenolysis and gluconeogenesis in the liver and the rate of its utilization in the periphery.

As mentioned above, during the third trimester of pregnancy, there is a significant growth and development of the child. Since the ideal model for the development of a child is the intrauterine development of a fetus of the appropriate gestational age, the need for protein in a premature baby and the rate of its accumulation can be estimated by observing the protein metabolism of the fetus.

If adequate protein supplementation does not occur after the birth of the baby and the cessation of the placental circulation, this can lead to a negative nitrogen balance and loss of protein. At the same time, several studies have shown that protein intake at a dose of 1 g/kg is able to neutralize the negative nitrogen balance, and increasing the dose of protein, even with a modest energy subsidy, can make the nitrogen balance positive (Table 6).

Table 6. Studies of nitrogen balance in newborns during the 1st week of life.

Protein accumulation in preterm infants is influenced by various factors.

• Nutritional factors (number of amino acids in the nutrition program, protein/energy ratio, baseline nutritional status)
• Physiological factors (compliance with gestational age, individual characteristics, etc.)
• Endocrine factors (insulin-like growth factor, etc.)
• Pathological factors (sepsis and other painful conditions).

Protein absorption in a healthy premature baby with a gestational age of 26-35 weeks of gestation is approximately 70%. The remaining 30% is oxidized and excreted. It should be noted that the lower the gestational age of the child, the greater the active protein metabolism in terms of a unit of body weight is observed in his body.

Since the synthesis of endogenous protein is an energy-dependent process, a certain ratio of protein and energy is required for the optimal accumulation of protein in the body of a premature baby. In conditions of energy deficiency, endogenous proteins are used as a source of energy and

Therefore, the nitrogen balance remains negative. Under conditions of suboptimal energy supply (50-90 kcal/kg/day), an increase in both protein and energy intake leads to protein accumulation in the body. Under conditions of sufficient energy supply (120 kcal / kg / day), protein accumulation stabilizes and a further increase in protein supplementation does not lead to its further accumulation. The ratio of 10 kcal/1 g of protein is considered optimal for growth and development. Some sources give a ratio of 1 protein calorie to 10 non-protein calories.

Amino acid deficiency, in addition to negative consequences for protein growth and accumulation, can lead to such adverse consequences as a decrease in plasma insulin-like growth factor, impaired activity of cellular glucose transporters and, consequently, hyperglycemia, hyperkalemia, and cell energy deficiency. The exchange of amino acids in newborns has a number of features (Table 7).

Table 7. Features of amino acid metabolism in newborns

The above features determine the need to use special amino acid mixtures for parenteral nutrition of newborns, adapted to the metabolic characteristics of the newborn. The use of such preparations makes it possible to meet the needs of the newborn in amino acids and to avoid rather serious complications of parenteral nutrition.

The protein requirement of a premature newborn is 2.5-3 g/kg.

The latest data from Thureen PJ et all. show that even early administration of 3 g/kg/day of amino acids did not lead to toxic complications, but improved nitrogen balance.

An experiment on premature animals showed that a positive nitrogen balance and accumulation of nitrogen in newborns with early use of amino acids is associated with an increase in the synthesis of albumin and skeletal muscle protein.

Taking into account the above considerations, protein supplementation begins from the 2nd day of life, if the child's condition is stabilized by this point in time, or immediately after stabilization of the central hemodynamics and gas exchange, if this occurs later than the 2nd day of life. As a source of proteins during parenteral nutrition, solutions of crystalline amino acids (Aminoven-Infant, Trofamine) specially adapted for newborns are used. Unadapted amino acid preparations should not be used in neonates.

Lipids are a necessary substrate for the normal functioning of the body of a newborn child. The table shows that fats are not only a necessary and beneficial source of energy, but also a necessary substrate for the synthesis of cell membranes and such necessary biologically active substances as prostaglandins, lecotriens, etc. Fatty acids contribute to the maturation of the retina and brain. In addition, it should be remembered that the main component of the surfactant are phospholipids.

The body of a full-term newborn baby contains from 16% to 18% white fat. In addition, there is a small amount of brown fat, which is necessary for the production of heat. The main accumulation of fat occurs during the last 12-14 weeks of gestation. Premature babies are born with a significant deficiency of fat. In addition, preterm infants cannot synthesize some essential fatty acids from available precursors. The required amounts of these essential fatty acids are found in breast milk and are not found in infant formula. artificial feeding. There is some evidence that the addition of these fatty acids to preterm infant formula promotes retinal maturation, although no long-term benefit has been found. .

Recent studies indicate that the use of fats (Intralipid was used in the study) during parenteral nutrition contributes to the formation of gluconeogenesis in preterm infants.

Published data showing the feasibility of introducing clinical practice and the use of olive oil-based fat emulsions in preterm infants. These emulsions contain less polyunsaturated fatty acids and more vitamin E. Moreover, vitamin E in such formulations is more available than in formulations based on soybean oil. This combination may be beneficial in oxidatively stressed neonates whose antioxidant defenses are weak.

Studies by Kao et al on parenteral fat utilization have shown that fat absorption is not limited. daily dose(for example, 1 g / kg / day), and the rate of administration of the fat emulsion. It is not recommended to exceed the infusion rate of more than 0.4-0.8 g / kg / day. Some factors (stress, shock, surgery) may affect the ability to utilize fats. In this case, the rate of fat infusion is recommended to be reduced or stopped altogether. In addition, studies have shown that the use of 20% fat emulsions was associated with fewer metabolic complications than the use of 10% fat emulsions.

The rate of fat utilization will also depend on both the total energy expenditure of the newborn and the amount of glucose the infant is receiving. There is evidence that the use of glucose at a dose of more than 20 g / kg / day inhibits the utilization of fats.

Several studies have investigated the relationship between plasma free fatty acids and unconjugated bilirubin concentrations. None of them showed a positive correlation.

Data on the effect of fat emulsions on gas exchange and pulmonary vascular resistance remain controversial. Fat emulsions (Lipovenoz, Intralipid) we start using from 3-4 days of life, if we believe that by 7-10 days of life the child will not begin to absorb 70-80 kcal/kg enterally.

vitamins

The need for preterm infants in vitamins is presented in table 10.

Table 10. Newborn needs for water- and fat-soluble vitamins

The domestic pharmaceutical industry produces a fairly large range of vitamin preparations for parenteral administration. The use of these drugs during parenteral nutrition in newborns does not seem rational due to the incompatibility of most of these drugs with each other in solution and the difficulties in dosing, based on the needs shown in the table. The use of multivitamin preparations seems to be optimal. In the domestic market, water-soluble multivitamins for parenteral administration are represented by Soluvit, and fat-soluble ones by Vitalipid.

SOLUVIT N (SOLUVIT N) is added to the solution for parenteral nutrition at the rate of 1 ml/kg. It can also be added to fat emulsion. Provides the child with a daily requirement for all water-soluble vitamins.

Vitalipid N infant - A special preparation containing fat-soluble vitamins to meet the daily requirement for fat-soluble vitamins: A, D, E and K1. The drug is soluble only in fat emulsion. Available in ampoules of 10 ml

Indications for parenteral nutrition.

Parenteral nutrition should provide nutrient delivery when enteral nutrition is not possible (esophageal atresia, ulcerative necrotizing enterocolitis) or its volume is insufficient to cover the metabolic needs of the newborn child.

In conclusion, I would like to note that the method of parenteral nutrition described above has been successfully used in the neonatal intensive care unit of the Regional Children's Hospital in Yekaterinburg for about 10 years. A computer program has been developed to speed up and optimize calculations. The use of this algorithm made it possible to optimize the use of expensive drugs for parenteral nutrition, to minimize the frequency possible complications and optimize the use of blood products.

References: on the website vestvit.ru

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PROTOCOL OF INFUSION THERAPY IN NEWBORN

GOU VPO St. Petersburg State Pediatric Medical Academy of the Ministry of Health and Social Development of Russia

Mostovoy A.V., Prutkin M.E., Gorelik K.D., Karpova A.L.

PROTOCOL OF INFUSION THERAPY AND PARENTERAL

NUTRITION FOR NEWBORN

Reviewers:

Prof. Aleksandrovich Yu.S. Prof. Gordeev V.I.

St. Petersburg

A.V. Mostovoy1, 4, M.E. Prutkin2, K.D. Gorelik4, A.L. Karpova3.

1St. Petersburg State Pediatric Medical Academy,

2Regional Children's Hospital, Yekaterinburg

3Regional maternity hospital, Yaroslavl

4Children's city ​​Hospital No. 1, St. Petersburg

The purpose of the protocol was to unify approaches to the organization of infusion therapy and parenteral nutrition for newborns with various perinatal pathologies who, for whatever reason, do not receive adequate enteral nutrition in a given age period (the volume of actual enteral nutrition is less than 75% of the proper amount).

The main task of organizing parenteral nutrition in a newborn child with severe perinatal pathology is to simulate (create a model) the intrauterine intake of nutrients.

The concept of early parenteral nutrition:

the main task is the subsidy of the required amount of amino acids

providing energy through the most early introduction fat

the introduction of glucose, taking into account the characteristics of its intrauterine intake.

Some features of intrauterine intake of nutrients:

In utero, amino acids enter the fetus in the amount of 3.5 - 4.0 g / kg / day (more than he can absorb)

Excess amino acids in the fetus are oxidized and serve as a source of energy

The rate of glucose intake in the fetus is within 6 - 10 mg / kg / min.

Prerequisites for early parenteral nutrition:

amino acids and fat emulsions should be ingested from the first day of life (B)

protein loss is inversely related to gestational age

in newborns with extremely low body weight (ELBW), losses are 2 times higher than those in comparison with full-term newborns

in newborns with ELMT, the loss of protein from the total depot is 1-2% per day if they do not receive amino acids intravenously

delay in protein donation in the first week of life leads to an increase in protein deficiency up to 25% of the total content in the body of a premature baby with ELBW

cases of hyperkalemia can be reduced by subsidizing amino acids in a parenteral nutrition program at a dose of at least 1 g/kg/day, starting from the first day of life in preterm infants weighing less than 1500 grams (II)

administration of amino acids intravenously can maintain protein balance and improve protein absorption

early introduction of amino acids is safe and effective

early introduction of amino acids promotes better growth and development

maximum parenteral intake of amino acids should be between 2 and a maximum of 4 g/kg/day in preterm and term infants (B)

maximum lipid intake should not exceed 3–4 g/kg/day in preterm and term neonates (B)

fluid restriction with sodium chloride restriction may reduce the need for mechanical ventilation

_____________________

* A - high-quality meta-analyses or RCTs, as well as RCTs with sufficient strength, performed on a "target population" of patients.

B - meta-analyses or randomized controlled trials (RCTs) or high-quality case-controlstudies or low-grade RCTs but with high sensitivity relative to the control group.

C - well collected cases or cohort studies with low risk of error.

D - evidence obtained from small studies, case reports, expert opinion.

Principles of organization of parenteral nutrition:

A complete understanding of the metabolic pathways of parenteral nutrition substrates is required.

The ability to correctly calculate the dose of drugs is necessary

It is necessary to provide adequate venous access (as a rule, a central venous catheter: umbilical, deep line, etc.; less often peripheral). The use of peripheral venous access is possible in 1-2 days of life in newborns with ENMT and VLBW, provided that the percentage of glucose in the basic infusion program (prepared parenteral nutrition solution) is less than 12.5%

Know the features of equipment and consumables used for infusion therapy and parenteral nutrition

It is necessary to know about possible complications, to be able to predict and prevent them.

ALGORITHM FOR CALCULATION OF INFUSION THERAPY AND PARENTERAL NUTRITION

I. Calculation total fluids per day

III. Calculation of the required volume of electrolytes

IV. Fat emulsion volume calculation

V. Calculation of the dose of amino acids

VI. Calculation of the dose of glucose based on the rate of utilization VII. Determination of the volume attributable to glucose

VIII. Selection of the required volume of glucose of various concentrations IX. Infusion program, calculation of the infusion rate of solutions and

concentration of glucose in the infusion solution

X. Determination and calculation of the final daily number of calories.

I. Calculation of the total amount of liquid

1. All newborns requiring fluid therapy and / or parenteral nutrition should determine the total amount of fluid administered. However, before proceeding with the calculation of the volume of infusion and / or parenteral nutrition, it is necessary to answer the following questions:

a. Does the child have signs of arterial hypotension?

The main signs of arterial hypotension that you need to pay attention to: violation of peripheral perfusion of tissues (pale skin, turns pink when rubbed, the symptom of a "white spot" for more than 3 seconds, a decrease in the rate of diuresis), tachycardia, weak pulsation in the peripheral arteries, the presence of partially compensated metabolic acidosis

b. Does the child show signs of shock?

The main signs of shock: signs respiratory failure(apnea, decrease in saturation, swelling of the wings of the nose, tachypnea, retraction of compliant places chest, bradypnea, increased work of breathing). Violation of peripheral perfusion of tissues (pale skin, turns pink when rubbed, a symptom of a "white spot" for more than 3 seconds, cold extremities). Disorders of central hemodynamics (tachycardia or bradycardia, low blood pressure), metabolic acidosis, decrease in diuresis (during the first 6-12 hours less than 0.5 ml/kg/hour, at the age of more than 24 hours less than 1.0 ml/kg/hour). Impaired consciousness (apnea, lethargy, decreased muscle tone, drowsiness, etc.).

2. If you answer yes to one of the questions posed, it is necessary to start therapy for arterial hypotension or shock, using the appropriate protocols, and only after stabilization of the condition, restoration of tissue perfusion and normalization of oxygenation, you can start parenteral administration nutrients.

3. If you can firmly answer “No” to the questions, start the traditional calculation of parenteral nutrition using this protocol.

4. Table 1 presents a simplified approach to determining the daily fluid requirement for preterm infants placed in an incubator with adequate humidification of the baby's environment and a thermoneutral environment:

Table 1

Fluid requirements for incubated neonates (ml/kg/day)

5. If the child has reached the third day of life or the so-called "transitional phase", you can focus on the values ​​below (table No. 2). The transitional phase ends when the rate of diuresis stabilizes at 1 ml/kg/hour, relative density urine becomes > 1012 and the level of sodium excretion decreases:

*- if the child is in an incubator, the need is reduced by 10-20%

**- for monovalent ions 1 mEq = 1 mmol

6. Table No. 3 presents the recommended values ​​for the physiological need for fluid for newborns under the age of two weeks of life (the so-called stabilization phase). For premature babies, an increase in sodium excretion is important, against the background of the development of polyuria. Also during this period, it is important to expand the volume of enteral nutrition, so this age requires special attention from the doctor when calculating the total volume of fluid and nutrients.

CLINICAL EXAMPLE:

Child 3 days of life, weight - 1200 g at birth Due volume of infusion per day = Daily fluid requirement (ADS) × body weight (kg)

Lifespan = 100 ml/kg Due infusion per day = 120 ml × 1.2 = 120 ml

Answer: total fluid volume (infusion therapy + parenteral nutrition

Enteral nutrition) = 120 ml per day

II.Calculation of enteral nutrition

Table No. 4 presents data on the energy value, composition and osmolarity of some milk mixtures in comparison with the average composition of female breast milk. These data are necessary for accurate calculation of nutrients for newborns with mixed enteral and parenteral nutrition.

Energy requirements of newborns:

The energy requirements of newborns depend on various factors: gestational and postnatal age, body weight, energy pathway, growth rate, child activity, and environmentally determined heat loss. Sick children, as well as newborns who are in serious stressful situations (sepsis, BPD, surgical pathology), need to increase the energy supply to the body

Protein is not an ideal source of energy, it is intended for the synthesis of new tissues. When a child receives an adequate amount of non-protein calories, he maintains a positive nitrogen balance. Part of the protein in this case is spent on synthetic purposes. Therefore, it is impossible to take into account all the calories from the injected protein, since part of it will not be available to cover energy needs, and will be used by the body for plastic purposes.

The ideal ratio of incoming energy: 65% from carbohydrates and 35% from fat emulsions. In general, starting from the second week of life, children with a normal growth rate need 100-120 kcal / kg / day, and only in rare cases, the requirements can increase significantly, for example, in patients with BPD up to 160 - 180 kcal / kg / day

Table 5

Energy needs of newborns in the early neonatal period

The need for energy in children of the early neonatal period is unevenly distributed. Table No. 7 shows the approximate number of calories depending on the age of the child:

In the first week of life, the optimal energy supply should be in the range of 50-90 kcal / kg / day. Sufficient energy supply by day 7 of life in term newborns should be -120 kcal/kg/day. When parenteral nutrition is given to preterm infants, the energy requirement is less due to no stool losses, no episodes of heat or cold stress, and less physical activity. Thus, the general energy

requirements for parenteral nutrition can be approximately 80 -

100 kcal/kg/day.

Calorie method for calculating nutrition for preterm infants

CLINICAL EXAMPLE:

Patient's body weight - 1.2 kg Age - 3 days of life Milk formula - Pre-Nutrilon

* where 8 is the number of feedings per day

Minimum trophic nutrition (MTP). The minimum trophic nutrition is defined as the amount of nutrition received by the child enterally in an amount of ≤ 20 ml / kg / day. Advantages of MTP:

Accelerates the maturation of motor and other functions of the gastrointestinal tract (GIT)

Improves enteral nutrition tolerance

Accelerates the time to achieve full enteral nutrition

Does not increase (according to some reports reduces) the incidence of NEC

Reduces the duration of hospitalization.

The child assimilates the Pre-Nutrilon mixture, 1.5 ml every 3 hours

Enteral Actual Daily Feeding (ml) = Single Feeding Volume (ml) x Number of Feeds

Enteral feeding volume per day = 1.5 ml x 8 feedings = 12 ml/day

Calculation of the amount of nutrients and calories that the child will receive per day enterally:

Carbohydrate enteral = 12 ml x 8.2 / 100 = 0.98 g Protein enteral = 12 ml x 2.2 / 100 = 0.26 g Fat enteral = 12 ml x 4.4 / 100 = 0.53 g

Enteral calories = 12 ml x 80/100 = 9.6 kcal

III. Calculation of the required volume of electrolytes

It is advisable to start the introduction of sodium and potassium no earlier than the third day of life, calcium

- from the first days of life.

1. CALCULATION OF SODIUM DOSE

Sodium requirement is 2 mmol/kg/day

Hyponatremia 150 mmol/l, dangerous > 155 mmol/l

1 mmol (mEq) of sodium is contained in 0.58 ml of 10% NaCl

1 mmol (mEq) of sodium is contained in 6.7 ml of 0.9% NaCl

1 ml of 0.9% (physiological) sodium chloride solution contains 0.15 mmol Na

Clinical example (continued)

Age - 3 days of life, body weight - 1.2 kg, sodium requirement - 1.0 mmol / kg / day

V saline = 1.2 × 1.0 / 0.15 = 8.0 ml

CORRECTION OF HYPONATREMIA (Na

Volume of 10% NaCl (ml) = (135 - Patient's Na) × body m × 0.175

2. CALCULATION OF THE DOSE OF POTASSIUM

The need for potassium is 2 - 3 mmol / kg / day

Hypokalemia

Hyperkalemia > 6.0 mmol/L (in the absence of hemolysis), dangerous > 6.5 mmol/L (or if there are pathological changes on the ECG)

1 mmol (mEq) of potassium is contained in 1 ml of 7.5% KCl

1 mmol (mEq) of potassium is contained in 1.8 ml of 4% KCl

V (ml 4% KCl) = K+ requirement (mmol) × mbody × 2

Clinical example (continued)

Age - 3 days of life, body weight - 1.2 kg, potassium requirement - 1.0 mmol / kg / day

V 4% KCl (ml) = 1.0 x 1.2 x 2.0 = 2.4 ml

* Effect of pH on K+: 0.1 pH changes → change9 K+ by 0.3-0.6 mmol/L (High acid, more K+; Low acid, less K+)

III. CALCULATION OF THE DOSE OF CALCIUM

The need for Ca ++ in newborns is 1-2 mmol / kg / day

hypocalcemia

Hypercalcemia > 1.25 mmol/l (ionized Ca++)

1 ml of 10% calcium chloride contains 0.9 mmol Ca++

1 ml of 10% calcium gluconate contains 0.3 mmol Ca++

Clinical example (continued)

Age - 3 days of life, body weight - 1.2 kg, calcium requirement - 1.0 mmol / kg / day

V 10% CaCl2 (ml) = 1 x 1.2 x 1.1*=1.3 ml

*- calculation coefficient for 10% calcium chloride is 1.1, for 10% calcium gluconate - 3.3

4. CALCULATION OF THE DOSE OF MAGNESIUM:

The need for magnesium is 0.5 mmol / kg / day

Hypomagnesemia 1.5 mmol/l

1 ml of 25% magnesium sulfate contains 2 mmol of magnesium

Clinical example (continued)

Age - 3 days of life, body weight - 1.2 kg, magnesium requirement - 0.5 mmol / kg / day

V 25% MgSO4 (ml)= 0.5 x 1.2/ 2= 0.3 ml

Although the issues of parenteral nutrition (PN) of newborns began to be widely studied back in the seventies, drugs for PN are being actively developed and produced in the world, available in our country, this method of treatment is unreasonably rarely used in newborns. This is due to the existence of several myths regarding the use of PN in newborns and, in particular, premature babies.
The first of these is that PN may not be used in newborns who are able to absorb at least a small amount of milk and receive intravenous glucose and whole protein preparations (plasma, albumin).
The second is the belief that the use of PN is fraught with serious complications, the risk of which is higher than the risk of adverse effects of partial fasting.
In fact, the effect of partial starvation, although it cannot be easily isolated from a complex set of pathological manifestations characteristic of a seriously ill newborn, it is a background that largely determines the course of the underlying disease, the incidence of complications and, accordingly, the outcome. After all, protein synthesis determines the course of reparative processes, the synthesis of antibodies, and the normal course of metabolic processes at the cellular level, not to mention the growth and development of the child's body.
Despite the fact that the list of possible complications of PP is large, they occur infrequently and for the most part are easily eliminated.
Based on the foregoing, we believe that parenteral nutrition should be more widely used in those newborns who for some reason do not receive oral nutrition at all or receive it in limited quantities (enterocolitis, paresis or dyskinesia gastrointestinal tract, condition after surgical correction of intestinal diseases, extreme immaturity digestive system in extremely low birth weight children). According to the neonatal resuscitation department of the Scientific Center for AGP RAMS, among children whose body weight is below 1000 g, 100% needed PP, with a body weight of 1000 to 1499 g - 92%, with a weight of 1500 to 2000 g - 53 %, with a mass of more than 2000 g -38%. However, widespread implementation of PN is possible only if doctors fully understand the pathways of PN substrate metabolism, the ability to correctly calculate doses of drugs, predict and prevent possible complications.

b. Energy sources
The drugs in this group include glucose and fat emulsions. The energy value of 1 g of glucose is 4 kcal, 1 g of fat is approximately 10 kcal. The best known fat emulsions are Intralipid (Phagmacia), Lipofundin MCT (B.Braun), Lipovenoz (Fgesenius).
As can be seen from Fig. 1, the proportion of energy supplied by carbohydrates and fats can be different. This is the basis for the existence of two PP methods - the so-called lipid method (Scandinavian method, balanced PP method) and glucose (Dudrik hyperalimentation method). The difference between these methods lies in the energy substrates used - when using the lipid method, glucose and fat emulsions are used, and when using the hyperalimentation method, only glucose is used. It is clear that in order to provide an equivalent calorific value in the hyperalimentation system, much larger amounts of glucose have to be used than in the Scandinavian method, and since the total volume of fluid administered is limited, glucose is administered in the form of highly concentrated solutions into the central veins. The method of hyperalimentation is less physiological than the method of balanced PP - it does not provide a sufficient supply of energy substrate during the period of gradual adaptation of the body to a carbohydrate load. Tolerance to glucose in seriously ill newborns, especially premature ones, is reduced due to the release of contrinsular hormones. Therefore, in the initial period of PP using the hyperalimentation method, hyperglycemia and glucosuria are frequent, albeit easily eliminated, complications. Long-term intake of large doses of carbohydrates - 20-30 g of dry matter per 1 kg of body weight causes a significant release of endogenous insulin, which causes the frequency of hypoglycemia and makes it difficult to cancel the PP according to this system. In addition, the use of fat emulsions provides the body with polyunsaturated fatty acids, helps protect the vein wall from irritation by hypermolar solutions. Thus, the use of balanced PN should be considered preferable, however, in the absence of fat emulsions, it is quite possible to provide the child with the necessary energy only due to glucose. According to the classical schemes of PP, children receive 60-70% of non-protein energy supply due to glucose, 30-40% due to fat. With the introduction of fats in smaller proportions, protein retention in the body of newborns is reduced (4).

1. Calculation of the total volume of fluid needed by the child per day.
2. Solving the issue of the use of drugs for special infusion therapy (blood, plasma, rheopolyglucin, immunoglobulin) and their volume.
3. Calculation of the amount of concentrated electrolyte solutions needed by the child, based on the physiological daily requirement and the magnitude of the identified deficit. When calculating the need for sodium, it is necessary to take into account its content in blood substitutes and solutions used for intravenous jet injections.
4. Determination of the volume of the amino acid solution, based on the following approximate calculation:
5. Determination of the volume of the fat emulsion. At the beginning of its use, its dose is 0.5 g / kg, then it rises to 2.0 g / kg.
6. Determination of the volume of glucose solution. To do this, from the volume obtained in paragraph 1, subtract the volumes obtained in paragraphs. 2-5. On the first day of PP, a 10% glucose solution is prescribed, on the second day - 15%, from the third day - a 20% solution (under the control of blood glucose).
7. Checking and, if necessary, correcting the relationship between plastic and energy substrates. In case of insufficient energy supply in terms of 1 g of amino acids, the dose of glucose and / or fat should be increased, or the dose of amino acids should be reduced.
8. Distribute the received volumes of drugs for infusion based on the fact that the fat emulsion does not mix with other drugs and is administered either continuously throughout the day through a tee, or as part of a general infusion program in two or three doses at a rate not exceeding 5-7 ml /hour. Amino acid solutions are mixed with glucose and electrolyte solutions. The rate of their administration is calculated so that the total infusion time is 24 hours a day.

1. Additional administration of sodium is not indicated (with plasma and physiological saline, on which the preparations administered by injection are diluted, he receives 2.3 mmol / kg of sodium). The need for potassium is 3 mmol / kg = 9 mmol = 9 ml of a 7.5% potassium chloride solution. The need for magnesium is provided by magnesium sulfate 25% solution 0.1 ml / kg = 0.3 ml. Calcium requirement -1 ml/kg = 3 ml. The volume of liquid for the introduction of electrolytes is 20 ml (taking into account the introduction of other medications).
2. The dose of amino acids is 2 g / kg = 6 g. When using the drug Aminovenoz (Fgesenius), which contains 6% amino acids (6 g in 100 ml), its volume will be 100 ml.
3. Dose of fat emulsion 2 g/kg = 6 g. When using the drug Lipovenoz 20% (Fgesenius) (20 g in 100 ml), its volume will be 30 ml.
4. The volume of glucose will be:
   360 ml - 30 ml - 20 ml -100 ml - 30 ml = 180 ml
   Since the child received PP with a gradual increase in glucose concentration for 5 days already and no hyperglycemia was noted, 20% glucose is prescribed.
5. Check: Dose of amino acids 6 g. Energy supply due to fat 6 g = 60 kcal. Energy supply due to glucose 180 ml of a 20% solution = 36 g = 144 kcal. In total, 1 g of amino acids accounts for 34 kcal. Total energy supply 24 kcal (RKA) + 60 kcal (fat) + 144 kcal (glucose) = 228 kcal = 76 kcal / kg.
6. Appointments:
   Lipovenosis 20% 30 ml through a tee at a rate of 1.3 ml/hour
   Aminovenosis ped 6% - 40.0
   Glucose 20% - 60.0
   Potassium chloride 7.5% - 4.5
   #
   Aminovenosis ped 6% - 30.0 Glucose 20% - 60.0
   Calcium gluconate 10% - 3.0
   #
   Speed ​​13 ml/hour
   Plasma B (111) -30.0
   #
   Aminovenosis ped 6% - 30.0
   Glucose 20% - 60.0
   Potassium chloride 7.5% - 4.5
   Magnesium sulfate 25% - 0.3

The growth of newborns and premature babies does not stop or slow down after birth. Accordingly, the postnatal need for calories and proteins does not decrease! Until the preterm infant is capable of complete enteral absorption, parenteral coverage of these needs is important.

This is especially true of glucose subsidies immediately after birth, otherwise it threatens severe hypoglycemia. With the gradual establishment of enteral nutrition, parenteral infusion therapy can be reduced.

The use of computer programs (eg Visite 2000) for counting and preparing infusion solutions and drugs reduces the risk of errors and improves quality [E2].

Volume of infusion

1st day (birthday):

Fluid intake:

• The total infusion volume may vary depending on the balance, blood pressure, enteral absorption capacity, blood sugar levels, and additional vascular access (eg, arterial catheter + 4.8-7.3 ml/day).

Vitamin K

• preterm infants weighing > 1500 g: 2 mg orally (if the child is in satisfactory condition), otherwise 100-200 mcg/kg body weight intramuscularly, subcutaneously or intravenously slowly.
• premature babies with body weight< 1500 г: 100-200 мкг/кг массы тела внутримышечно, подкожно или внутривенно медленно (максимальная абсолютная доза 1 мг).
• alternative: 3 ml/kg body weight Vitalipid infant from the first day of life.

Attention: Glucose supplementation is approximately 4.2 mg/kg/min - control sugar levels, if necessary, give higher concentrations possible with a central catheter!

2nd day of life: fluid intake increases by 15 ml/kg body weight/day depending on balance, diuresis, specific gravity urine, edema and body weight. Additionally:

• Sodium, potassium, chloride depending on laboratory data.
• Intravenous glucose: 8-10 (-12 in term newborns) mg/kg/min glucose. increase or decrease the dose depending on blood sugar levels and glycosuria, target: normoglycemia.
• Fat emulsion 20% 2.5-5 ml/kg in 24 hours at body weight< 1500 г.
• Vitamins: 3 ml/kg Vitalipid infant and 1 ml/kg Soluvit-N.
• Glycero-1-phosphate 1.2 ml/kg/day.

3rd day of life: fluid intake increases by 15 ml/kg of body weight/day depending on balance, diuresis, specific gravity of urine, edema and body weight. Additionally:

• Fat emulsion 20% - increase the dose to 5-10 ml / kg / day.
• Magnesium, zinc and trace elements (in preterm infants with gestational age< 28 недель возможно назначение уже с 1-2 дня жизни).

After the third day of life:

• Fluid intake should be increased approximately: up to 130 (-150) ml/kg/day depending on body weight, balance, diuresis, urine specific gravity, edema, imperceptible fluid loss and achievable caloric intake (great variability).
• Calories: If possible, build up every day. Goal: 100-130 kcal/kg/day.
• Increase in enteral feeding: the volume of enteral nutrition increases depending on the clinical condition, the residual volume in the stomach and the results of the observation of medical personnel: by 1-3 ml / kg per feeding (with tube feeding, the maximum volume of increase in enteral nutrition is 24-30 ml / day ).
• Proteins: With total parenteral nutrition, the goal is at least 3 g/kg/day.
• Fats: Maximum 3-4 g/kg/day intravenously, which is approximately 40-50% of parenterally supplied calories.

Pay attention to the application / route of administration:

With peripheral venous access, the maximum allowable concentration of glucose in the infusion solution is 12%.

With central venous access, the concentration of glucose, if necessary, can be increased to 66%. However, the proportion of glucose solution in the total infusion should be< 25-30 %.

Vitamins must be protected from light (yellow infusion set).

Never administer calcium and sodium bicarbonate together! An additional infusion of calcium is possible, which can be interrupted while the administration of sodium bicarbonate.

Calcium, intravenous fat emulsions and heparin together (combined in one solution) precipitate!

Heparin (1 IU/mL): administration via an umbilical artery catheter or a peripheral arterial catheter is allowed, not via a silastic catheter.

During phototherapy, fat emulsions for intravenous administration must be protected from light (yellow "infusion set with filter, light-protected").

Solutions and substances

Carefully all infusion solutions in glass vials contain aluminum, which is released from the glass during storage! Aluminum is neurotoxic and can lead to impaired neurodevelopment in premature infants. Therefore, whenever possible, use drugs in plastic bottles or in large glass containers.

Carbohydrates (glucose):

• With total parenteral nutrition, preterm infants need up to 12 mg/kg/min of glucose, at least 8-10 mg/kg/min, which corresponds to 46-57 kcal/kg/day.
• Excessive glucose supplementation leads to hyperglycemia [E], increased lipogenesis, and the onset of fatty liver [E2-3]. The production of CO2 increases and, as a result, the minute volume of respiration [E3], the metabolism of proteins worsens [E2-3].
• High blood sugar levels in preterm infants increase the risk of morbidity and mortality, as well as mortality from infectious causes [E2-3, adults].
• Glucose >18 g/kg should be avoided.

Advice: in case of hyperglycemia, glucose subsidies should be reduced, insulin may be prescribed. Insulin is adsorbed on the walls of the infusion system, so it is necessary to use polyethylene infusion systems or pre-wash the infusion system with 50 ml of insulin solution. Extremely immature infants and preterm infants with infectious problems are especially prone to hyperglycemia! With persistent hyperglycemia, early administration of insulin is required to avoid prolonged hypocaloric nutrition of the child.

Protein:

• Use only amino acid solutions containing taurine (Aminopad or Primene). In premature babies, start from the first day of life. A minimum of 1.5 g/kg/day [E1] is required to achieve a positive nitrogen balance. In preterm infants, the maximum amount is 4 g/kg/day, in term infants, 3 g/kg/day [E2].
• Solutions of amino acids should be stored in a place protected from light; protection from light is not necessary during infusion.

Fats:

• Use intravenous fat emulsions based on a mixture of olive and soybean oil (eg, Clinoleic; likely to have a beneficial effect on prostaglandin metabolism) or pure soybean oil (eg, Intralipid, LipovenOs 20%).
• To prevent deficiency of essential fatty acids, it is necessary to prescribe at least 0.5-1.0 g fat/kg/day, depending on the composition of the emulsion (the need for linoleic acid is at least 0.25 g/kg/day for preterm infants and 0.1 g/kg/day for term infants) [E4]. Infusion within 24 hours [E2].
• The triglyceride level should remain< 250 мг/дл [Е4|.
• Fat emulsions can also be prescribed for hemolytic anemia and infections, except when the bilirubin level reaches the border of the exchange transfusion, or in the case of septic shock. Inadequate nutrition weakens the immune system!

Watch out for acidosis.

Attention: in the presence of infection, as well as in newborns with extremely low body weight, the level of triglycerides in the blood must be controlled with the introduction of lipids already at a dose of 1-2 g / kg / day!

Trace elements: in long-term parenteral nutrition (> 2 weeks) or in preterm infants with gestational age< 28 недель начинать с 1-3 дня жизни:

• Unizinc (Zink-DL-Hydrogenaspartat): 1 ml corresponds to 650 mcg.
• Need: 150 mcg/kg/day for the first 14 days, then 400 mcg/kg/day.
• Peditrace: Administer with total parenteral nutrition > 2 weeks.
• Selenium (Selenase): with very long parenteral nutrition (months!). Need: 5 mcg/kg/day.

Note: Peditrace contains 2 mcg/mL selenium.

Caution: Peditrace contains 250 mcg/mL zinc - reduce unicin supplementation to 0.2 ml/kg/day.

Vitamins:

Fat-soluble vitamins (Vitalipid infant): in case of intolerance to intravenous lipid administration, Vital lipid diluted in amino acids or saline can be administered, or slowly - undiluted preparation (over 18-24 hours), maximum 10 ml / day.

Water-soluble vitamins (Soluvit-N): approved in Germany for use in children from 11 years of age. In other European countries, it is also allowed to use in newborns and premature babies.

Requirements: Requirements for almost all vitamins are not exactly known. All vitamins should be administered daily, with the exception of vitamin K, which can be administered once a week. There is no need to routinely determine the level of vitamins in the blood.

Special notes:

• None of the parenteral vitamin supplements listed are approved for use in premature infants. Vitalipid Infant is approved for use in full-term newborns, all other drugs - in children older than 2 or even 11 years.
• The indicated dose of Vitalipid Infant (1 ml/kg) is too low.
• Fat-soluble Frekavit has the best ratio of vitamin A to vitamin E.

Blocking the peripheral venous access with heparin, which is used intermittently (inconsistently), is controversial.

Laboratory studies for nutrition control

Comment: each blood sampling for laboratory examination must be strictly justified. In premature babies weighing > 1200 g and in a stable condition, it is enough to conduct routine laboratory tests once every 2-3 weeks to control nutrition.

Blood:

• Sugar level: At first, control the sugar level at least 4 times a day, then daily on an empty stomach. If there is no glucosuria, then correction is not required at a sugar level of up to 150 mg / dl, which corresponds to 10 mmol / l.
• Electrolytes in preferential parenteral nutrition: Sodium, potassium, phosphorus and calcium in preterm infants with body weight< 1000 г вначале контролировать от одного до двух раз в день, затем при стабильных уровнях 1-2 раза в неделю. Хлор при преобладании метаболического алкалоза (BE полож.).
• Triglycerides: at intravenous administration fat 1 time per week (goal< 250 мг/дл или 2,9 "Ммоль/л), при тяжелом состоянии ребенка и у глубоко недоношенных детей - чаще.
• Urea (< 20 мг/дл или 3„3 ммоль/л признак недостатка белка) 1 раз в неделю.
• Creatinine once a week.
• Ferritin from the 4th week of life (the appointment of iron, the norm is 30-200 mcg / l).
• Reticulocytes from the 4th week of life.

Blood and urine: calcium, phosphorus, serum and urine creatinine once a week, starting from the 3rd week of life. Desired levels:

• Calcium in urine: 1.2-3 mmol/l (0.05 g/l)
• Phosphorus in urine: 1-2 mmol/l (0.031-0.063 g/l).
• Monitor if the level of calcium and phosphorus in the urine is not determined.
• With a 2-fold negative result of the determination of calcium and phosphorus in the urine: increase subsidies.

Diuresis control

All the time while infusion therapy is carried out.

In premature infants weighing< 1500 г подсчет баланса введенной и выделенной жидкости проводится 2 раза в сутки.

Goal: diuresis approximately 3-4 ml/kg/hour.

Diuresis depends on the amount of fluid administered, the maturity of the child, the tubular function of the kidneys, glucosuria, etc.

Complications of parenteral nutrition

Infections:

• Proven risks of nosocomial infections (multivariate analysis) include: duration of parenteral nutrition, duration of central venous catheter placement, and catheter manipulation. Therefore, unnecessary disconnections of the infusion set [E1b] should be avoided. Disconnect the infusion system after disinfection and only with sterile gloves. Remove blood and remnants of the nutrient infusion solution from the catheter cannula with a sterile wipe soaked in disinfectant, remove the wipe. Before and after each disconnection of the infusion system, disinfect the catheter cannula [all Elbj.
• Systems with parenteral fatty solutions should be changed every 24 hours, the rest at least 72 hours (a conclusion from "adult" medicine, which allows to reduce the disconnection of the infusion system).
• The insertion of catheters with microfilters (0.2 µm) is not recommended in order to prevent catheter-associated infections [E3].
• The recommendations of the Koch Institute for the prevention of nosocomial infections in ICU patients with birth weight should be fully followed.< 1500 г.

Blockage of the central venous catheter.

Pericardial effusion: Extravasation in the pericardium is a life-threatening condition. Therefore, the end of the central venous catheter should be outside the contour of the heart (in premature babies, 0.5 cm higher when standing in the jugular or subclavian vein) [E4].

Cholestasis: The pathogenesis of PPP-associated cholestasis is not completely understood. Most likely, this is a multifactorial event, in the development of which infection, the composition of solutions for parenteral nutrition and the underlying disease play a joint role. Undoubtedly, the earliest possible start of enteral nutrition, especially with mother's milk, and the composition of the diet perform protective functions. At the same time, lack or excess of nutrition, lack or excess of amino acids, as well as excess glucose intake are harmful. Prematurity, especially in combination with necrotizing enterocolitis or septic infections, is a risk factor [E4]. If the level of conjugated bilirubin rises continuously for no apparent reason, the lipid infusion should be reduced or stopped. With a continuous increase in transaminase levels. alkaline phosphatase or conjugated bilirubin should be treated with ursodeoxycholic acid. For PPP > 3 months and bilirubin > 50 µmol/L, thrombocytopenia< 10/нл, повреждениях мозга или печеночном фиброзе необходимо раннее направление в педиатрический центр по трансплантации печени [Е4].

With parenteral nutrition nutrients are injected into the body of the newborn intravenously(a catheter is installed for nutrition). Thus, the child receives carbohydrates, fats, amino acids, as well as vitamins and microelements necessary for life and development directly, bypassing the gastrointestinal tract.

This option is used if the baby cannot eat in the usual way. It can be complete and partial (when beneficial substances are partly obtained through the gastrointestinal tract). Today we will try to talk about the indications for parenteral nutrition of newborns.

Indications

Parenteral nutrition (PN) is an essential part of the care and treatment of infants with very low birth weight or surgical defects. The newborn should receive full feeding without interruptions. Starvation in the period after birth can lead, among other things, to abnormal development nervous system.

PP has long been used in the following cases:

• when food intake through the gastrointestinal tract is impossible;
• nutrition is disturbed due to pathology;
• with a premature baby.

The active development of medical technologies has made it possible to nurse even newborns with extremely low body weight. Feeding these babies is a major part of the fight for their lives.

Reference! A partial or complete parenteral method of feeding is prescribed by neonatologists if enteral nutrition (in which food passes through the gastrointestinal tract) requires nutrients does not exceed 90 percent of their needs.

Contraindications

It is impossible to carry out PP during resuscitation. It is prescribed only after the child's condition becomes stable. There are no other contraindications for PP.

Neonatal Parenteral Nutrition Protocol

To save a sick newborn child, it is necessary to conduct a suitable PN, which will help to avoid complications and allow normal growth and development. The introduction of modern PN protocols for premature babies contributes to the best intake of the necessary substances and reduces the stay in the intensive care unit.

Attention! Normally, the fetus receives nutrients through the placenta. In the last two weeks of gestation, it grows intensively. The earlier a preterm birth occurs, the less the baby has a supply of nutrients.

Immediately after crossing the umbilical cord, the flow of the necessary substances in the usual way stops. However, the need for them does not go away. But the digestive organs of a premature baby are neither structurally nor functionally ready for full consumption.

The best model for the development of a premature baby for doctors is the intrauterine version. Therefore, such a balanced the composition of the PP, which is most consistent with intrauterine nutrition.

When prescribing each PP ingredient, the individual needs of the infant are taken into account. The combination of components should form the correct metabolism in the body and fight against possible diseases. The specificity of the PP conduction contributes to its better assimilation.

Peculiarities! The effectiveness of parenteral nutrition can only be assessed by the harmonious growth and development of the baby.

Starting the PP, determine indicators such as:

• the content of glucose in the blood;
• plasma triglyceride levels;
• electrolytes (calcium, potassium and sodium);
• bilirubin level;
• the content of transaminases.

Every day such indicators are taken:

• change in body weight;
• diuresis;
• glucose content in urine and blood;
• the content of electrolytes in the blood;
• triglyceride level.

How to calculate: an example of calculating parenteral nutrition in newborns

The PP program is selected individually for each newborn. The required amount of liquid is calculated. A decision is made about the drugs that will be administered. Conclusions are drawn about the volumes that make up the PP, its distribution. Next - check the software and its correction (if necessary).

Calculation of parenteral nutrition in newborns carried out with the help of special computer programs (for example, the program " calculation calculator"). Below are the items to be calculated.

1. The total amount of liquid.
2. Volume of enteral nutrition.
3. The volume of electrolytes.
4. The amount of glucose, which is determined taking into account the rate of utilization.
5. The amount of fat emulsion.
6. The required dose of amino acids.
7. The amount of glucose.
8. Selection of various concentrations of glucose.
9. Insertion speed.
10. The required number of calories per day.

The PN method can only be used as a temporary approach to feeding a newborn. Parenteral nutrition is not physiological, so over time, you should try to switch to normal feeding of the child. If the baby can consume at least a little mother's milk, the doctor will prescribe enteral nutrition to improve the functioning of the child's digestive tract.

Parenteral nutrition of newborns: guidelines

The topic of nursing premature babies is very difficult. For those who would like to learn more about parenteral nutrition, good to watch the video shown below.