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Nutrition - intravenous nutrition

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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 longer than 3-5 days.
    • The majority of larger infants can initially be commenced on 10% glucose (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 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 glucose is titrated on top of the IVN to meet fluid intake requirements. Either IVN or glucose 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% Glucose 23ml/kg/day 21.6ml 0.9ml/hour


As the fluid intake increases or decreases, the volume of 10% glucose will be titrated on top of the arterial, IVN and Intralipid rates.
If medications are required (for example, inotropes), the glucose 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% Glucose 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% Glucose 38ml/kg/day 36.0ml 1.5ml/hour
  • As feeds increase, the 10% glucose is decreased.
  • If the UAC is removed, the 10% glucose is 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.

Calculators

  1. IVN and Fluids Calculator preterm infants
  2. IVN and Fluids Calculator for term infants
  3. Individualised IVN worksheet
  4. Fluids Calculator
  5. Calories Calculator

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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Document Control

  • Date last published: 01 July 2008
  • Document type: Clinical Guideline
  • Services responsible: Neonatology, Paediatric Dietitians
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years