Berthold Koletzko
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The recommendations on parenteral sub- strate supply to stable patients are summarized in table 1 . In individual patients, other dosages may be required, depending on the patients’ con- dition.
Water
Fluid needs vary markedly and must be adapted to the individual patient’s condition. For exam- ple, some renal or cardiac disorders require lower water intakes, whereas higher intakes are needed with enhanced fluid losses (e.g. due to fever, hy- perventilation or diarrhoea, or from wounds or fistulae). Monitoring of the fluid status is neces- sary, considering the patient’s clinical status, body weight and possibly water intake and excre- tion, blood electrolytes, acid base status, haema- tocrit, urine-specific gravity and urine electro- lytes. The postnatal fluid supply should be gradu- ally increased ( table 2 ).
Energy
Energy needs vary with physical activity, growth and the possible need to correct malnutrition.
The energy supply can be adjusted based on for- mulae for energy expenditure (see Chapter 1.3.2) and during weight changes. Low energy supplies induce failure to thrive, but excessive energy in- take (‘hyperalimentation’) must also be avoided because it may induce metabolic imbalances, liv- er damage and a serious refeeding syndrome particularly in severely malnourished patients [4] .
Amino Acids
Parenteral amino acid requirements are lower than enteral needs because PN bypasses intestinal
amino acid uptake and utilization. Amino acid Table 1. Recommended dosages for parenteral substrate supply to stable patients by age Age groupWater, ml/kgEnergy,Amino acidsGlucose,Lipids, kcal/kgg/kgg/kgg triglyceri- des/kg
Sodium, mmol/kgPotassium, mmol/kgCalcium, mmol/kgPhosphorus, mmol/kgMagnesium, mmol/kg Preterm140 – 160110 – 1201.5 – 418up to 3 – 43 – 5 (–7)2 – 5 Neonate (1st month)140 – 16090 – 1001.5 – 318up to 3 – 42 – 31.5 – 3 0 – 1 years120 – 150 (max. 180)90 – 1001 – 2.516 – 18up to 3 – 42 – 31 – 30 – 6 months: 0.8 7 – 12 months: 0.50.50.2 1 – 2 years80 – 120 (max. 150)75 – 901 – 21 – 3up to 2 – 31 – 31 – 30.20.20.1 3 – 6 years80 – 10075 – 901 – 21 – 3up to 2 – 31 – 31 – 30.20.20.1 7 – 12 years60 – 8060 – 751 – 21 – 3up to 2 – 31 – 31 – 30.20.20.1 13 – 18 years50 – 7030 – 601 – 21 – 3up to 2 – 31 – 31 – 30.20.20.1 Depending on the condition of the individual patient, different dosages may be required. Adapted from Koletzko et al. [3]. K+ supplementation should usually start after onset of diuresis. Chloride supply usually equals the sum of sodium and potassium supply.
160 Koletzko
utilization requires an energy supply of ∼ 30–40 kcal/g of amino acid to prevent excessive amino acid oxidation. In very-low-birth-weight infants (VLBWI) requiring PN, amino acid supply should start on the first day of life with a dose of ≥ 2 g/kg per day [5] . Infants and young children should receive paediatric amino acid solutions with ad- equate amounts of cysteine, taurine and tyrosine (conditionally essential amino acids; see Chapter 1.3.3).
Glucose
Glucose is the only carbohydrate recommended for PN and should provide 60–75% of non-pro- tein calorie intake. During the first days on PN, the glucose supply should be gradually increased.
In preterm infants, the glucose intake should be- gin with 4–8 mg/kg per minute (5.8–11.5 g/kg per day) and increase gradually. In critically ill chil- dren, the glucose intake should be ≤ 5 mg/kg per minute (7.2 g/kg per day). Glucose infusion for term neonates and children ≤ 2 years should not exceed 18 g/kg per day (13 mg/kg per minute).
Glucose intake should be adapted to the adminis- tration of drugs that impair glucose metabolism (e.g. steroids, somatostatin analogues and tacroli- mus). Very high glucose intakes and marked hy- perglycaemia should be avoided because they
may induce increased lipogenesis and tissue fat deposition, liver steatosis, enhanced CO 2 produc- tion, impaired protein metabolism and possibly increased infection-related morbidity and mor- tality [3] . In critically ill and unstable patients, the glucose dosage should be lower and increased ac- cording to the patient’s condition and blood glu- cose levels.
Lipids
Lipid emulsions supply essential fatty acids and energy at iso-osmolarity. Lipids should generally provide 25–40% of non-protein PN calories.
Parenteral lipid intake is usually limited to 3–4 g/kg per day (0.13–0.17 g/kg per hour) in infants and 2–3 g/kg per day (0.08–0.13 g/kg per hour) in children. In VLBWI requiring PN, the supply of lipid emulsions should start on the first day with a dose of at least 2 g/kg per day [5] . A step- wise increase of lipid infusion rates by 0.5–1 g/
kg per day has not been shown to improve toler- ance, but it allows monitoring for hypertriglyc- eridaemia. Regular plasma triglyceride measure- ments are recommended, particularly in criti- cally ill or infected patients during PN. A dosage reduction should be considered at triglyceride concentrations during infusion >250 mg/dl in infants or >400 mg/dl in children, but there
Table 2. Recommended standard parenteral fluid supply (in ml) Time after birth
1 day 2 days 3 days 4 days 5 days 6 days
Term neonate 60–120 80–120 100–130 120–150 140–160 140–180 Preterm neonate
>1,500 g 60–80 80–100 100–120 120–150 140–160 140–160
<1,500 g 80–90 100–110 120–130 130–150 140–160 160–180 In neonates, parenteral fluid supply should be gradually increased over the first days of life. Ad- apted from Koletzko et al. [3].
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 158–162 DOI: 10.1159/000375190
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should always be a minimum linoleic acid intake to prevent essential fatty acid deficiency (pre- term infants: ≥ 0.25 g linoleic acid/kg per day;
term infants/children: ≥ 0.1 g/kg per day). In ne- onates requiring PN, lipids can start on day 1 of life and should start no later than day 3. In young infants, lipids should be administered continu- ously over ∼ 24 h.
During phototherapy, validated light-protect- ed tubing for lipid emulsions is recommended to decrease hydroperoxide formation. Lipid emul- sions have no demonstrable effect on hyperbili- rubinaemia. There is no firm evidence on adverse effects in severe acute respiratory failure, but avoiding high lipid dosages in these patients ap- pears prudent. In severe, progressive PN-associ- ated cholestasis, a decrease in or transient inter- ruption of intravenous lipids should be consid- ered.
Commercial lipid emulsions based on soy- bean oil, or mixtures of olive and soybean oils or of medium-chain triglycerides and soybean oil, as well as mixed emulsions with fish oil are con- sidered safe and are registered for paediatric pa- tients in many countries around the world. In a meta-analysis of randomized controlled trials in VLBWI, the use of mixed emulsions without and with fish oil showed a 25% lower risk of sep- sis than the use of 100% soybean oil emulsions [6] . In view of these data and concerns on an im- balanced fatty acid composition and an appar- ently high risk of liver damage, the use of lipid emulsions based only on soybean oil has been discouraged in young infants, and these emul- sions are not preferred for use in paediatric pa- tients [2] .
Other Aspects
Vitamins and minerals should be supplied with all PN and provided over several days. Cyclical PN (over ∼ 8–14 h/day) should be considered from the age of 3–6 months onwards [2, 4] .
Individualized prescriptions of paediatric PN are widely used, but standard PN solutions are suitable for many paediatric patients with ade- quate monitoring and the possible addition of electrolytes/nutrients. They can improve the quality and safety of PN and reduce costs [7] .
The risks of PN are best reduced by limiting its amount and duration combined with persistent attempts to increase the amount of enteral feed- ings as tolerated. Rather than enteral starvation, minimal enteral feeds should be given whenever possible, and experienced paediatricians and di- eticians should be involved.
Conclusions
• PN is an essential and often life-saving treat- ment for infants and children who cannot be adequately fed orally or enterally
• PN should only be used when all alternative options have been explored, including ade- quate care, specialized EN and artificial feed- ing devices
• PN can induce severe adverse effects. The risk is reduced by a meticulous approach, estab- lishment of a multidisciplinary nutrition sup- port team, avoidance of unbalanced or exces- sive substrate supplies, strict hygiene measures to reduce catheter infections, concomitant minimal enteral feeding and forceful enhance- ment of enteral feeding where possible to lim- it the amount and duration of PN
References 1 Agostoni C, Axelson I, Colomb V, Gou- let O, Koletzko B, Michaelsen KF, Puntis JW, Rigo J, Shamir R, Szajewska H, Turck D: The need for nutrition support teams in pediatric units: a commentary by the ESPGHAN Committee on Nutri- tion. J Pediatr Gastroenterol Nutr 2005;
41: 8–11.
162 Koletzko the European Society for Clinical Nutri-
tion and Metabolism (ESPEN), support- ed by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenter- ol Nutr 2005; 41(suppl 2):S1–S87.
4 Koletzko B, Goulet O: Nutritional sup- port in infants, children and adolescents;
in Sobotka L (ed): Basics in Clinical Nu- trition. Prague, Galén, 2011, pp 625–653.
5 Koletzko B, Poindexter B, Uauy R (eds):
Nutritional Care of Preterm Infants.
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2 Jochum F, Krohn K, Kohl M, Loui A, Nomayo A, Koletzko B; DGEM Steering Committee: Parenterale Ernọhrung in der Kinder- und Jugendmedizin.
S3-Leitlinie der Deutschen Gesellschaft fỹr Ernọhrungsmedizin. Akt Ernọh- rungsmed 2014; 39: 233–255.
3 Koletzko B, Goulet O, Hunt J, Krohn K, Shamir R: Guidelines on paediatric par- enteral nutrition of the European Soci- ety of Paediatric Gastroenterology, Hep- atology and Nutrition (ESPGHAN) and
6 Vlaardingerbroek H, Veldhorst MA, Spronk S, van den Akker CH, van Goud- oever JB: Parenteral lipid administration to very-low-birth-weight infants – early introduction of lipids and use of new lipid emulsions: a systematic review and meta-analysis. Am J Clin Nutr 2012; 96:
255–268.
7 Krohn K, Babl J, Reiter K, Koletzko B:
Parenteral nutrition with standard solu- tions in paediatric intensive care pa- tients. Clin Nutr 2005; 24: 274–280.
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 158–162 DOI: 10.1159/000375190
3 Nutritional Challenges in Special Conditions and Diseases
Key Words
Obesity ã Children ã Adolescents ã Assessment ã Management
Key Messages
• The BMI [weight (kg)/height (m) 2 ] should be plotted routinely on a BMI-for-age chart
• The principles of obesity management include:
management of comorbidities; family involvement;
a developmentally appropriate approach; the use of a range of behavior change techniques; long- term dietary change; increased physical activity, and decreased sedentary behaviors
• Orlistat may be useful as an adjunct to lifestyle change for more severely obese adolescents, and metformin for adolescents with clinical insulin re- sistance
• Bariatric surgery should be considered with severe- ly obese adolescents
• Coordinated models of care for health service deliv- ery are needed for the management of pediatric obesity © 2015 S. Karger AG, Basel
Introduction
Child and adolescent obesity is a prevalent prob- lem in most westernized and rapidly westernizing countries and is associated with both immediate and longer-term complications. Effective treat- ment of those affected by obesity is vital.
Clinical Assessment
Clinical history should aid in assessing current and potential future comorbidities as well as modifiable lifestyle practices ( table 1 ) [1–4] . The BMI [weight (kg)/height (m) 2 ], a clinically useful measure of body fatness in those aged >2 years, should be plotted on nationally recommended BMI-for-age charts [5] , e.g. the WHO Child Growth Standards. However, the cutoff points used to define overweight and obesity are some- what arbitrary and may vary between countries.
For example, in the UK the cutoff points for over- weight and obesity are the 91st and 98th percen- tiles, respectively, compared with the 85th and 95th in the USA. Hence, local recommendations should be checked. A waist circumference-to- height ratio of >0.5 is associated with increased cardiometabolic risk in school-aged children [6] . Waist circumference-for-age charts are available for some countries.
Physical examination is used to assess obesity- associated comorbidities as well as signs of un- derlying genetic or endocrine disorders ( table 2 ).
The level of investigation is dependent on the pa- tient’s severity of obesity and age, the clinical findings and associated familial risk factors.
Baseline investigations may include fasting lipid screening, glucose, liver function tests and, pos- sibly, insulin [1–4] . Second-line investigations
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 163–167 DOI: 10.1159/000360331