Level of evidence (LOE);
Grade of recommendation (GOR)3`
Indication: Preterm Infants < 32 weeks and/or < 1500 g – PN should be commenced within the first 12 h of life (on admission).
Indication: Infants at high risk of NEC (e.g. absent or reversed foetal umbilical artery flow, perinatal asphyxia) or with illness in whom establishment of enteral feeding is likely to be delayed by 3–5 days.
Fluids: Starting parenteral fluid intake at 60 ml/kg/day with daily increase by 20–30 ml/kg/day to an average maximum of 150 ml/kg/day. Titrate to clinical need (urine output and specific gravity, weight, serum sodium).
Energy: Minimal energy requirements are met with 50–60 kcal/kg/day, but 100–120 kcal/kg/day facilitate maximal protein accretion. A newborn infant receiving PN needs fewer calories (90–100 kcal/kg/day) than a newborn fed enterally because there is no energy lost in the stools and there is less thermogenesis.
Dextrose: Maximal glucose oxidation has been reported in preterm infants to be 8.3 mg/kg per min (12 g/kg per day) and in term infants 13 mg/kg per min (18 g/kg per day).
Carbohydrate provides 40–60% of total energy.
Amino acids: (1) commence parenteral AA within the first 24 h of birth (LOE I, GOR C), (2) commence parenteral AA at 2 g/kg/day (LOE II, GOR C), and
(3) incrementally increase amino acid infusions to a maximum 4 g/kg/day by day 3–5 of life in preterm neonates (LOE I, GOR C).
The safety of (1) commencement parenteral AA in excess of 3 to 3.5 g/kg/day and (2) maintenance AA intake in excess of 4.5 g/kg/day has not been proven in clinical trials.
Lipids: Commence lipids at 1 g/kg/day and increase by 1 g each day to 3 g/kg/day. If lipid infusion is increased in increments of 0.5 to 1 g/kg per day, it may be possible to monitor for hypertriglyceridaemia [triglycerides > 2.8 mmol/L]. Essential fatty acid deficiency occurs rapidly and can be prevented with introduction of as little as 0.5 to 1 g/kg/day of lipid infusion [linoleic acid]. Reduce but do not stop lipid infusion in the event of hypertriglyceridaemia.
Sodium: Minimal sodium intake of approximately 1 mmol/kg/day on day 1 using a starter PN formulation.
Standard formulations will gradually increase sodium to a maximum 4.6 mmol/kg/d in preterm and 3.4 mmol/kg/day in term infants at 135 ml/kg/day of PN.
LOE II, GOR C
Potassium: Minimal potassium intake using starter PN formulation, with an increase in standard formulations to a maximum 3.0 mmol/kg/day in preterm and 2.7 mmol/kg/day in term infants.
LOE III-2, GOR C
Acetate and chloride: First 3 mmol/kg/day of anion to be provided as chloride, next 3.5 mmol/kg/day of anion [reduced from 6 mmol/kg/day] to be provided as acetate and thereafter as chloride again.
Calcium, phosphorus and magnesium: Parenteral Ca and P intakes to a maximum of 2.3 mmol/kg/day and 1.8 mmol/kg/day respectively. LOE II
For Mg intake a minimum of 0.2 mmol/kg/day and maximum of 0.3 mmol/kg/day is appropriate for LBW infants. LOE 111–3
Trace elements: Add zinc, selenium and iodine as individual trace elements to all AA/dextrose formulations.
For those infants, who are on exclusive PN for more than 2 to 4 weeks with minimal enteral intake, other trace elements (copper, manganese and molybdenum) can be added to the formulations.
LOE IV, GOR C
Heparin: Heparin for peripherally placed percutaneous central venous catheters found a reduced risk of catheter occlusion.
LOE I, GOR C
Hanging time: 48 h for PN solution and lipid.
LOE II, GOR C
Route of administration: Peripherally inserted central catheters (PICC’s) should be used preferentially to provide central venous access in neonates receiving prolonged PN as PICC use results in improved nutrient intake, fewer insertion attempts and fewer extravasation injuries.
Umbilical vessels can be used for PN. UVC compared to peripheral venous catheter reduces insertion attempts with no increase in risk of infection or necrotising enterocolitis.
LOE I GOR B
Cessation of PN:
Amino acid/dextrose infusion: cease when infant tolerating 120 (to 140) mL/kg/day of enteral feeds.
Lipid: halve infusion when infant tolerating 100 mL/kg/day enteral feeds and cease when tolerating 120 mL/kg/day enteral feeds.