/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/cpg/,/clinical/cckm-tools/content/cpg/nutrition/,

/clinical/cckm-tools/content/cpg/nutrition/name-97708-en.cckm

20170237

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Nutrition

Parenteral Nutrition - Pediatric/Neonatal - Inpatient/Ambulatory

Parenteral Nutrition - Pediatric/Neonatal - Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nutrition


1
Parenteral Nutrition - Pediatric/Neonatal
- Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 4
SCOPE ...................................................................................................................................... 5
METHODOLOGY ...................................................................................................................... 6
DEFINITIONS ............................................................................................................................ 7
INTRODUCTION ....................................................................................................................... 7
RECOMMENDATIONS .............................................................................................................. 8
TABLE 1: DEFINING PEDIATRIC MALNUTRITION ................................................................. 8
TABLE 2. ESTIMATING ENERGY NEEDS IN CRITICAL ILLNESS ......................................... 9
TABLE 3. ACTIVITY AND STRESS FACTORS FOR ESTIMATING ENERGY NEEDS ............ 9
TABLE 4. SUGGESTED CANDIDATES FOR INDIRECT CALORIMETRY ..............................10
TABLE 5: PEDIATRIC PROTEIN REQUIREMENTS ................................................................10
TABLE 6. INITIATION AND ADVANCEMENT OF PN MACRONUTRIENTS ...........................11
TABLE 7. HOLLIDAY SEGAR EQUATION TO DETERMINE DAILY MAINTENANCE FLUID
REQUIREMENTS .....................................................................................................................12
TABLE 8. INITIAL FLUID REQUIREMENTS FOR PRETERM NEONATES ............................12
TABLE 9. NEONATAL & PEDIATRIC DAILY ELECTROLYTE DOSE RECOMMENDATIONS
.................................................................................................................................................13
TABLE 10. PEDIATRIC MULTIVITAMIN DOSING ...................................................................13
TABLE 11. PARENTERAL TRACE ELEMENT RECOMMENDATIONS FOR INFANTS AND
CHILDREN ...............................................................................................................................14
TABLE 12. GROWTH PARAMETERS .....................................................................................17
TABLE 13. LABORATORY MONITORING FOR HOME PN PATIENTS ..................................17
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

2
UW HEALTH IMPLEMENTATION ............................................................................................20
APPENDIX A. EVIDENCE GRADING SCHEME(S) .................................................................22
APPENDIX B. RESPIRATORY QUOTIENT FOR SINGLE AND MIXED FUELS, LIPOGENESIS
.................................................................................................................................................23
APPENDIX C. USUAL ADULT ELECTROLYTE REQUIREMENTS .........................................24
APPENDIX D. CALCULATING OSMOLARITY IN PERIPHERAL PARENTERAL NUTRITION
.................................................................................................................................................25
APPENDIX E. COMPATIBILITY OF PARENTERAL NUTRITION AND FORMULARY
MEDICATIONS WITH Y-SITE ADMINISTRATION ...................................................................26
APPENDIX F. HOME PARENTERAL NUTRITION ..................................................................30
REFERENCES .........................................................................................................................32
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

3
CPG Contact for Content:
Name: Susan Stone, PharmD, BCNSP, CNSC, Clinical Nutrition Support
Phone Number: (608) 263-1290
Email Address: SLuskin@uwhealth.org
CPG Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS, Drug Policy Manager
Phone Number: (608) 265-0341
Email Address: PTrapskin@uwhealth.org
Guideline Author(s):
Susan Stone, PharmD, BCNSP, CNSC; Pharmacy
Andrea Magee, MS, RD, CNSC, CD Clinical Nutrition
Laura Bodine, MS, RD, CNSC, CD; Clinical Nutrition
Rachel Parks, MS, RD, CNSC; Clinical Nutrition
Gretchen Manthei, PharmD, BCNSP; Pharmacy
Caitlin Curtis, PharmD, BCNSP; Pharmacy
Monica Bogenschutz, PharmD, BCPS; Pharmacy
Coordinating Team Members:
Amanda Condon, PharmD, Pharmacy
Carin Endres, PharmD, BCPS; Drug Policy Program
Review Individuals/Bodies:
Peter Nichol, MD, PhD - Pediatric Surgery
Luther Sigurdsson, MD - Pediatric Gastroenterology
Jamie Limjoco, MD - Medical Director of the NICU
Sabrina Butteris, MD; Pediatrics, Hospitalists
Christian Capitini, MD; Pediatrics, Hematology
Scott Hagen, MD; Pediatrics, PICU
Mary Schroth, MD; Pediatrics, Pulmonary
Monica Bogenschutz, PharmD, BCPS
Gretchen Manthei, PharmD, BCNSP
Susan Kleppin, RPh, FASHP, Chartwell
Committee Approvals/Dates:
UW Health Nutrition Committee (02/2016)
Pharmacy & Therapeutics Committee (Last Periodic Review: 01/19/2017)
Release Date: January 2017 | Next Review Date: January 2019
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

4
Executive Summary
Guideline Overview
This guideline describes the optimal use of parenteral nutrition in neonatal and pediatric
patients.
Key Revisions (2016 Periodic Review)
1. Expansion of pediatric malnutrition definition
2. Added recommendations for when to start parenteral nutrition cycling in neonates
3. Update of references and grading
Key Practice Recommendations
1. Consider parenteral nutrition if all attempts at enteral nutrition or oral feeding are
unsuccessful
2. Indications:
a. Patients unable to meet needs through oral or enteral nutrition support
b. Lack of enteral access
c. Gut failure or absence
d. Chylous ascites or chylothorax if chylous output remains elevated despite use of
high medium chain triglyceride/low long chain triglyceride feeding
e. Patients on high-dose inotropes or with clinically significant hemodynamic
instability
3. Nutritional requirements
a. Energy
b. Protein
c. Carbohydrate
d. Intravenous Fat Emulsion (IVFE)
e. Fluid
f. Electrolytes
g. Trace Elements
h. Vitamins
4. Routine addition of insulin to parenteral nutrition is discouraged
5. Percutaneous catheters advanced to the superior vena cava are preferred for central
parenteral nutrition
6. Administration of parenteral nutrition should follow safe practices related to maintenance
of tubing, limiting hang time for IVFE, and use of filters to prevent infusion of intrinsic or
extrinsic contaminants
7. Complications of parenteral nutrition include
a. Glycogen storage as fat
b. Hepatic steatosis
c. Increased carbon dioxide production
d. Cholestasis
e. Metabolic Bone Disease
8. Monitoring should include the following, depending on duration of parenteral nutrition
a. Anthropometrics
b. Blood chemistries including magnesium and phosphate
c. Triglycerides
d. Point-of-care glucoses every two to six hours for certain patients
e. C-reactive protein
f. AST and ALT, alkaline phosphatase, and bilirubin
g. Carnitine
h. Vitamins A, B-6, B-12, D, and E
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

5
i. Trace elements
j. Iron studies
k. Essential fatty acid profile
9. Cyclic parenteral nutrition should be considered in patients on or anticipated to be on
long-term parenteral nutrition, patients who are on home parenteral nutrition, patients
with cholestasis to prevent worsening hepatic dysfunction, and patients who are ready to
transition to oral intake
10. Patients should be evaluated daily for ability to begin oral feedings or enteral nutrition
11. Most patients should have parenteral nutrition rates gradually weaned to off to prevent
hypoglycemia
12. Home parenteral nutrition may be indicated for patients who are stable enough for
discharge but cannot receive sufficient energy and protein enterally or orally to meet
their needs
13. Physical traits and limitations of parenteral nutrition include 3-in-1 stability and
medications added in or Y-sited
Companion Documents
1. Nutrition Support – Developing, ordering and monitoring a Nutrition Support Care Plan -
Adult/Pediatric/Neonatal
Scope
Disease/Condition(s): Initiation, advancement, and monitoring of parenteral nutrition as well as
supplementation for the neonatal and pediatric populations.
Clinical Specialty: Pediatrics, Neonatology
Intended Users: Physicians, Advanced Practice Providers, Pharmacists, Dietitians, and Nurses
Objective(s): The objective of this guideline is to standardize the use of parenteral nutrition
throughout the institution to improve patient outcomes and safety.
Target Population: Neonatal and pediatric patients requiring parenteral nutrition.
Interventions and Practices Considered: Initiation, modification, and discontinuation of
parenteral nutrition in the neonatal and pediatric population.
Major Outcomes Considered: Appropriate management of patients receiving parenteral
nutrition including:
Safe and effective infusion of parenteral nutrition, appropriate growth, alleviation of signs and
symptoms of malnutrition, and limitation of complications of parenteral nutrition.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

6
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. A review of PubMed database was
conducted with combinations of the keywords: parenteral nutrition, intravenous fat emulsion,
parenteral nutrition compatibility, electrolyte replacement, enteral nutrition, insulin management,
parenteral nutrition stability, or special populations. References from the articles were also
searched. Finally, the personal libraries of the authors were queried and expert opinion and
clinical experience were also considered during discussions of the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).
Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.
Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using a modified Grading
of Recommendations Assessment, Development and Evaluation (GRADE) methodology
developed by the American Heart Association and American College of Cardiology1 (see
Appendix A).
Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.
Recognition of Potential Health Care Disparities:
Socioeconomic factors may affect parenteral nutrition provision. Home parenteral nutrition is an
expensive therapy that often requires insurance pre-certification prior to coverage.2,3 Therefore,
socioeconomic status and insurance coverage may impact who can receive parenteral nutrition
in the home care setting. Additionally, one study reported a potential for racial or geographic
disparities in the provision and complication rates of parenteral nutrition in certain subsets of
malnourished patients with inflammatory bowel disease, although the mechanism of this
difference was not determined3.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

7
Definitions
1. Birth Weight Classification:
1.1. Small for gestational age (SGA): < 10th percentile birth weight for gestational age
1.2. Appropriate for gestational age (AGA): 10th to 90th percentile birth weight for
gestational age
1.3. Large for gestational age (LGA): > 90th percentile birth weight for gestational age
2. Classification of Preterm Infants by Birth Weight: ELBW ≤ 1000 gram, VLBW ≤ 1500
gram, LBW ≤ 2500 gram4
3. Dosing Weight: a patient-specific weight determined by the clinician to arrive at a
specific nutrient dose. It may be the actual weight, birth weight (used in neonates until
birth weight is regained following post-natal diuresis), ideal or adjusted body weight of
the individual, depending on clinical status.
4. EN – Enteral nutrition is the provision of nutrients via the gastrointestinal (GI) tract
through a tube, catheter, or stoma.
5. Gestational Age Classification: Preterm infants are those born < 37 weeks gestation,
with late preterm infants classified as being born from 34 to 36 weeks. Term infants are
born at 37 to 41 weeks gestation. Those born > 42 weeks are considered post-term.
6. Infant: Birth to 12 months of age.
7. IVFE - Intravenous fat emulsion is an oil-in-water emulsion of oils, egg yolk phospholipid,
and glycerin.
8. Neonate: An infant during the first 28 days of life.
9. Obesity – BMI-for-age > 95th percentile5
10. Osmolarity – the theoretical, calculated, osmotic concentration of a liquid expressed in
osmoles or mOsmol per liter of a solution.
11. Overweight - BMI-for-age > 85th and < 95th percentile5
12. PN – Parenteral nutrition is the intravenous administration of nutrients.
12.1. Central: PN administered into a large diameter vein, usually the superior vena
cava, adjacent to the right atrium.
12.2. Peripheral: PN administered through a peripheral vein; usually the hand or
forearm. To reduce risk for phlebitis, the maximum osmolarity tolerated by a
peripheral vein is 900 mOsm/L.
12.3. Midline: midline is a 7-inch catheter inserted in the antecubital region with the tip
located in the axillary region.
13. Starter PN: A pre-mixed PN solution containing AA 3 or 3.5% with Dextrose 10 or 12.5%
(with minimal or no electrolytes) with or without heparin designed for the use
immediately after birth in premature or term infants who weigh < 2 kg.
14. Underweight - < 5th percentile for weight-for-length or BMI-for-age6
Introduction
This guideline is designed to ensure safe and optimal provision of PN for neonatal and pediatric
patients. The goal of PN is to provide substrates for daily metabolism as well as growth while
oral or enteral feedings are insufficient to meet nutrition needs. Nutrients will be individualized
to meet the infant or child’s nutrition needs while minimizing iatrogenic effects secondary to PN
administration. Transition to oral intake or EN will be initiated as soon as clinically able for all
neonatal and pediatric patients.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

8
Recommendations
1. Consider PN only if all attempts at EN or oral feeding are unsuccessful, the gastrointestinal tract
is not functional, or it is anticipated that there will be a prolonged period of suboptimal EN
provision or oral intake7. (UW Health Class I, Level C)
2. Indications
2.1. Patients unable to meet needs through oral or enteral nutrition support. (UW Health Class I,
Level C)
2.1.1. A review of growth history, using the appropriate growth chart, including z-scores (if
applicable), for age and sex, will assist with determining the nutritional status of the
patient and thus timing for initiation of PN (Table 1).6
Table 1: Defining Pediatric Malnutrition









Acute malnutrition ≤ 3 months duration and chronic malnutrition > 3 months
2.1.2. Lack of enteral access and/or inadequate EN for8:
2.1.2.1. Newborn premature infant for < 24 hours9,10 (UW Health Class I, Level B)
2.1.2.1.1. Infant with BW < 2 kg will use starter PN immediately after birth for up to
1 to 2 days, or as clinically indicated.
2.1.2.2. Newborn full-term infant for 2 to 3 days8 UW Health Class I, Level C)
2.1.2.3. Critically ill child [e.g. closed head injury (CHI), burn, multi-trauma] for < 2
days11-14 (UW Health Class I, Level C)
2.1.2.4. Child who is malnourished on admission for 3 to 5 days15 (UW Health Class I,
Level C)
2.1.2.5. Well-nourished child for 5 to 7 days16 (UW Health Class I, Level C)
2.1.2.6. Child with spinal muscular atrophy (SMA) who will be NPO for more than 4 to
6 hours (UW Health Class IIa, Level C)
2.1.3. Gut failure or absence:7,8,17 (UW Health Class I, Level C
2.1.3.1. Congenital or acquired anomalies of the GI tract: gastroschisis, bowel
fistula(s), atresia(s)8,18
2.1.3.2. Severe pancreatitis refractory to EN7
Mild Moderate Severe
Weight-for-length
OR BMI-for-age z
score
-1 to -1.9 -2 to -2.9 -3 or greater
Length/height-for-
age z score
No data No data -3 or greater
MUAC z score -1 to -1.9 -2 to -2.9 -3 or greater
Weight gain
velocity
(<2 year of age)
< 75% of norm < 50% of norm < 25% of norm
Weight loss
(2 to 20 years)
5% UBW 7.5% UBW 10% UBW
Deceleration in
weight-for-length
or BMI
Decline of 1 z
score
Decline of 2 z
scores
Decline of 3 z
scores
Inadequate
nutrient intake
51 to 75%
estimated
needs
26 to 50%
estimated needs
≤ 25% estimated
needs
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

9
2.1.3.3. Malabsorption syndromes: celiac sprue, inflammatory bowel disease, short
bowel syndrome8,19,20
2.1.3.4. Suspicion for or confirmed necrotizing enterocolitis (NEC)8,21
2.1.3.5. Motility disorders: prolonged ileus, prolonged bowel obstruction7
2.1.3.6. Chronic intractable diarrhea or vomiting8
2.1.3.7. Side effects from antineoplastic therapy or bone marrow transplantation such
as graft vs host disease, mucositis, typhlitis8
2.1.3.8. High output enterocutaneous fistula8
2.1.4. Chylous ascites or chylothorax if chylous output remains elevated despite use of high
medium chain triglyceride (MCT)/low long chain triglyceride (LCT) feeding22. (UW
Health Class I, Level C)
2.1.5. Patients on high-dose inotropes or with clinically significant hemodynamic instability23.
UW Health Class I, Level C)
3. Nutritional Requirements
Determination of nutrition requirements for neonatal and pediatric patients is individualized. This
includes evaluation of the patient’s current anthropometrics, growth history, age, clinical status
and overall goals as determined by the health care team. Nutrient needs should be determined by
or in conjunction with a registered dietitian with neonatal or pediatric expertise.
3.1. Energy24-27
3.1.1. Provide adequate energy to meet patient specific requirements. (UW Health Class IIa,
Level C)
3.1.1.1. For preterm and term infants, aim to provide 90 to 120 kcal/kg/day.
3.1.1.2. For older infants, children, and adolescents, please refer to Tables 2 & 3 for
calculating energy requirements.28,29
Table 2. Estimating Energy Needs in Critical Illness
Estimating Energy Needs in Critical Illness
Age
(years) Gender
Resting Energy Expenditure (REE) Equations (Kcal/day)
WHO30 Schofield28
0-3
Male (60.9 x Wt) - 54 (0.167 x Wt) + (15.174 x Ht) - 617.6
Female (61.0 x Wt) - 51 (16.25 x Wt) + (10.232 x Ht) - 413.5
3-10
Male (22.7 x Wt) + 495 (19.59 x Wt) + (1.303 x Ht) + 414.9
Female (22.5 x Wt) + 499 (16.969 x Wt) + (1.618 x Ht) + 371.2
10-18
Male (17.5 x Wt) + 651 (16.25 x Wt) + (1.372 x Ht) + 515.5
Female (12.2 x Wt) + 746 (8.365 x Wt) + (4.65 x Ht) + 200
Weight in kilograms, height in centimeters
Table 3. Activity and Stress Factors for Estimating Energy Needs
Activity and Stress Factors x REE/BMR29
Condition Factor Condition Factor
ICU on Ventilator Activity 1.0 to
1.15
Pneumonia Stress 1.3 to 1.4
Major Surgery Stress 1.2 to 1.3 Head Injury Stress 1.3 to 1.4
Multiple Fractures Stress 1.2 to 1.3 Liver Failure Stress 1.4 to 1.5
Peritonitis Stress 1.2 to 1.5 Sepsis Stress 1.4 to 1.5
Cardiac Failure Stress 1.25 to 1.5 Burns Stress 1.5 to 2.0
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

10
3.1.2. Provide approximately 10% fewer calories for PN than is required for EN due to the
absence of the thermic effect of food (TEF), calories required for digestion and
absorption31. (UW Health Class I, Level C)
3.1.3. For obese patients, may use actual body weight when estimating calories and aim for
initial goal of calculated REE.32,33 (UW Health Class IIb, Level C).
3.1.4. Avoid overfeeding34-36. (UW Health Class III, Level C)
3.1.4.1. Overfeeding can contribute to glycogen deposition, mild fatty changes in
hepatocytes leading to elevated liver function tests and does not contribute to
further anabolism
3.1.4.2. Overfeeding may result in hyperglycemia, increased carbon dioxide
production and associated morbidity and mortality.
3.1.4.3. Predictive equations can be utilized to prevent overfeeding by estimating
resting energy expenditure (REE) and basal metabolic rate (BMR).
3.1.4.4. The best way to prevent overfeeding is by the use of indirect calorimetry.
3.1.5. Indirect calorimetry34,37,38 (UW Health Class I, Level C)
3.1.5.1. Use indirect calorimetry (IC) to measure REE when energy estimates are in
question and those at risk for over or under feeding34 (Table 4).
Table 4. Suggested Candidates for Indirect Calorimetry
Parameter Specific Indicator 34
Weight
Underweight: BMI-for-age or weight-for-length < 5th percentile
Overweight/Obese: BMI-for-age > 85th percentile
Weight change: gain or loss of > 10%
Respiratory Failure to wean or need to escalate respiratory therapy, requires mechanical ventilation
for > 7 days
Hypermetabolism Status epilepticus, dysautonomic storms, SIRS, hyperthermia
Hypometabolism Pentobarbital/midazolam coma, muscle paralytic, hypothermia
Diagnosis Burns/thermal injury, oncologic diagnosis (including BMT), neurologic trauma (traumatic,
hypoxic and/or ischemic)
SIRS – systemic inflammatory response syndrome
3.1.5.2. Energy requirements can be measured by the use of IC and can assist with
optimization of caloric provision, particularly during critical illness. The oxygen
and CO2 concentrations of inspired and expired gas are measured to
determine the respiratory quotient (RQ) which also may provide information
on substrate utilization34. (See Appendix B)
3.1.5.3. Of note, current literature suggests that the RQ may not accurately represent
substrate utilization during acute illness, but may be used to confirm validity of
IC measurement34.
3.2. Protein24-27
3.2.1. It is reasonable to provide adequate protein to meet patient requirements (Table 5).
(UW Health Class IIa, Level C). Crystalline amino acids are the principle parenteral
protein source providing 4 kcal/gram.
Table 5: Pediatric Protein Requirements
Pediatric
Classification Protein
25
Premature infant 3 to 4 g/kg/d
0 to 2 years 2 to 3.5 g/kg/d
2 to 13 years 1.5 to 2.5 g/kg/d
13 to 18 years 1.5 to 2 g/kg/d
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

11
3.2.2. It is reasonable to provide appropriate protein composition to meet patient needs.24-27
(UW Health Class IIb, Level C)
3.2.2.1. TrophAmine® is recommended to meet the specific amino acid requirements
from birth to 12 months of age (corrected age).
3.2.2.2. Clinisol® is recommended to meet the amino acid requirements for patients
>12 months old.
3.2.2.3. For premature infants or term infants with birth weight < 2 kg, use starter PN
to achieve an initial protein intake at approximately 2.5 to 3 g/kg depending on
rate of infusion.
3.2.2.4. It is reasonable to consider adding cysteine (30 to 40 mg per gram of amino
acid) for premature and infants up to 6 months of age.39 (UW Health Class
IIb, Level B)
3.2.3. Recommend starting at goal amino acid provision on day 1 of PN. 24-27 (UW Health
Class I, Level C)
3.2.4. It is reasonable to provide protein at the expense of energy if fluid restriction prevents
adequate provision of both40. (UW Health Class IIa, Level C)
3.2.5. Provide at least 1.1 g protein per kg to achieve net zero nitrogen balance and prevent
catabolism in neonates.41 (UW Health Class I, Level B)
3.3. Carbohydrate24-27
3.3.1. Provide adequate carbohydrate to meet minimal requirements and provide sufficient
energy. Dextrose monohydrate is the primary calorie source in PN, which yields 3.4
kcal/g. (UW Health Class I, Level C)
3.3.2. Target acceptable glucose concentrations of 80 to 180 mg/dL42,43 (UW Health Class I,
Level B)
3.3.3. Use the following equation to calculate glucose infusion rate:
Glucose infusion rate (mg/kg/min) = dextrose (grams/kg/day) x 1000 mg/gram
time in minutes
3.3.4. Initiation, advancement, and maximum glucose infusion rate (GIR) should vary based
on the patient’s age, weight, and clinical status. Please refer to Table 6 for initiation,
advancement, and maximal GIR parameters.
Table 6. Initiation and Advancement of PN Macronutrients
Initiation 25,44,45 (Daily) Advance By Goals
Infants (<1yr) Preterm Term Preterm Term Preterm Term
Protein (g/kg) 3 to 4 2 to 3.5 - - 3 to 4 2 to 3.5
CHO (mg/kg/min) 4 to 6 6 to 9 1 to 2 2-3.5 10 to 14 (max 14-
18)
12-14 (max 14-
18)
Fat (g/kg) 0.5 to 1.5 1 to 2 0.5 to 1.5 1 to 1.5 3 to 3.5
(Max 0.17 g/kg/h)
3
(Max 0.15 g/kg/h)
Children (1-10 y)
Protein (g/kg) 1.5 to 2.5 - 1.5 to 2.5
CHO (mg/kg/min) 3-6 or dextrose 10%
equivalent
2-3 or dextrose
5%/day 8 to 10
Fat (g/kg) 1 to 2 0.5 to 1 2 to 2.5
Adolescents
Protein (g/kg) 1 to 2 - 1 to 2
CHO (mg/kg/min) 3.5 or dextrose 10% 1 to 2 or dextrose
5%/day 5 to 7
Fat (g/kg) 1 1 1 to 2
CHO – carbohydrate
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

12
3.4. Intravenous Fat Emulsion (IVFE) 24-27
3.4.1. Provide sufficient fat to meet calorie needs and prevent essential fatty acid deficiency
(EFAD). Intralipid 20 percent provides 2 kcal/mL or 10 kcal/g of soybean-based fat.
(UW Health Class I, Level C)
3.4.2. Administer IVFE to prevent EFAD25,44-46 (UW Health Class I, Level B):
3.4.2.1. At least 0.5 to 1 g/kg/day for infants and young children.
3.4.2.2. At least 2 to 4 percent of total calories for older children and adolescents.
3.4.3. Administer < 60 percent of total calories as fat in order to prevent ketosis. (Exception:
patients requiring the ketogenic diet). (UW Health Class I, Level C)
3.4.4. Do not exceed an infusion rate of 0.17 g/kg/h for neonates, 0.15 g/kg/h for infants and
children or 0.11 g/kg/h for adolescents and adults. Rapid infusion can result in
coagulopathy, hepatomegaly, elevated liver function tests, and thrombocytopenia.47
(UW Health Class I, Level B)
3.4.5. The hang-time for an individual bag of IVFE (lipids) is 12 hours to prevent microbial
growth.48 This may be administered as one or two separate infusions in a 24-hour
period. (UW Health Class I, Level C)
3.4.6. Subtract propofol calories with sustained (usually continuous intravenous infusion)
propofol therapy; decrease or discontinue IVFE to avoid exceeding maximum IVFE
infusion rate. (UW Health Class I, Level C)
3.4.7. Levocarnitine:49,50 (UW Health Class IIa, Level C)
3.4.7.1. It is reasonable to add on day 1 of PN for infants at a dose of 5 mg/kg/day if
no enteral source of nutrition is provided
3.4.7.2. Increase or add at a dose of 10 to 20 mg/kg/day for patients with
hypertriglyceridemia to assist with the transport of fatty acids from the cytosol
into the mitochondria.
3.4.7.3. Should be supplemented daily for those with carnitine deficiency or metabolic
disorders.
3.4.7.4. Should be considered in patients with cardiomyopathy or for patients with (or
to prevent) anthracycline–induced cardiomyopathy 51-56
3.5. Fluid57 (UW Health Class I, Level B)
3.5.1. A standard approach to calculating a starting estimate of maintenance fluid
requirements for the pediatric patient is as follows (Tables 7, 8):
Table 7. Holliday Segar Equation to Determine Daily Maintenance Fluid Requirements
Body Weight (kg) Amount of Fluid per Day 57
1 to 10 100 mL/kg
11 to 20 1000 mL plus 50 mL/kg for each kg > 10 kg
> 20 kg 1500 mL plus 20 mL/kg for each kg > 20 kg
Table 8. Initial Fluid Requirements for Preterm Neonates
Birth Weight < 750 g 750 to 1000 g 1000 to 2500 g > 2500 g
Fluid (mL/kg/d)
(DOL 1) 58-60
100 80 to 100 60 to 80 60
Advancement 20 to 40 mL/kg/d based on clinical status
Goal 150 mL/kg/d
3.5.2. Patients with cardiac anomalies and surgical neonates are commonly fluid-restricted.
PN volume should adhere to total fluid goals.
3.5.3. PN can provide a portion or all of the daily fluids.
3.6. Electrolytes61 (UW Health Class I, Level C)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

13
3.6.1. Provide electrolytes to meet patients’ individual needs and maintain blood
concentrations within the normal range.
3.6.2. In the first 24 to 48 hours of life, premature and term infants usually do not require
sodium, potassium, chloride, calcium (depending on clinical status) and phosphorus.
Once adequate urine output has been established, electrolytes should be added
according to clinical condition.
Table 9. Neonatal & Pediatric Daily Electrolyte Dose Recommendations
Electrolyte25 Preterm Neonates Infants/Children
Adolescents
and Children >
50 kg
Sodium Initial: 1 to 2 mEq/kg 2 to 5 mEq/kg 1 to 2 mEq/kg Goal: 2 to 5 mEq/kg
Potassium Initial: 0.5 to 2 mEq/kg 2 to 4 mEq/kg 1 to 2 mEq/kg Goal: 2 to 4 mEq/kg
Calcium Initial: 1.5 to 2 mEq/kg 0.5 to 4 mEq/kg 10 to 20 mEq Goal: 2 to 4 mEq/kg
Phosphorus
Initial: 0.5 to 1
mMol/kg 0.5 to 2 mMol/kg 10 to 40 mMol
Goal: 1 to 2 mMol/kg
Magnesium 0.3 to 0.5 mEq/kg 0.3 to 0.5 mEq/kg 10 to 30 mEq
Acetate As needed to maintain acid-base balance
Chloride As needed to maintain acid-base balance
See Appendix C. for usual adult electrolyte requirements.
3.6.3. Provide calcium to phosphorus ratios for optimal bone accretion if clinical condition and
PN compatibility allow.48,62 Optimal mineral retention may be obtained with a calcium to
phosphorus ratio of 2.2 to 2.6 mEq calcium to 1 mMol phosphorus. Ratios < 1.6 mEq
calcium to 1 Mmol phosphorus or alternate-day infusions may result in mineral wasting
and increased risk of metabolic bone disease.63
3.6.4. For peripheral lines, calcium content should be limited to 1 mEq/100 mL.64
3.7. Vitamins61,65 (UW Health Class I, Level C)
3.7.1. Provide vitamins parenterally, enterally, or orally, depending on clinical condition and
formulation. Dose is dependent upon age, weight, and development. (Table 10.)
Table 10. Pediatric Multivitamin Dosing
Weight (kg) Dose
< 2.5 2 mL/kg
> 2.5 5 mL/day
Patients > 11 years old will use adult
multivitamin (MVI-12); usual dose is 10 mL/day
3.7.2. Altered Requirements25 (UW Health Class IIb, Level C)
3.7.2.1. Hemodialysis, CRRT – May provide additional water soluble vitamins (e.g.,
thiamine, pyridoxine, folic acid) to replace vitamins removed during the
dialysis process66
3.7.2.2. Liver failure or coagulopathy – may consider providing additional
phytonadione 1 to 5 mg daily65
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

14
3.7.2.3. Refeeding syndrome – may consider providing additional thiamine 25 to 50
mg/day for three days to prevent encephalopathy67
3.8. Trace Elements61 (UW Health Class I, Level C)
3.8.1. Provide trace elements parenterally, enterally, or orally, depending on clinical condition
and formulation. Dose is dependent upon age, weight, and development. (Table 11)40
Table 11. Parenteral Trace Element Recommendations for Infants and Children
Trace
Element
Premature
Neonates
(mcg/kg/day)
Term Infants
(mcg/kg/day)
Children
(mcg/kg/day)
Zinc 400 250 (< 3 month old)
50 (> 3 month old)
50
(max = 5 mg/day)
Copper 30 20 20
(max = 500 mcg/day)
Manganese 1 1 1
(max = 50 mcg/day)
Chromium 0.05 to 0.3 0.2
(max = 5 mcg/day)
0.2
(max = 5 mcg/day)
Selenium 1.5 to 4.5 1 to 3 1 to 3
(max = 100 mcg/d)
Iodine 1 1 mcg/day 1 mcg/day
3.8.2. Premature infants or infants and children who are anticipated to be on long-term PN (>
2 to 4 weeks) may have trace elements dosed separately (due to contamination of the
PN products with aluminum, manganese, chromium and other trace minerals during
the manufacturing process).48
3.8.3. Altered Requirements (UW Health Class IIb, Level C):
3.8.3.1. Cholestasis or severe liver dysfunction – may administer zinc, selenium,
copper and chromium individually and remove multi-trace elements from PN
[trace elements stored in the liver (e.g., manganese) may need to be removed
when the direct bilirubin is > 2 mg/dL]68
3.8.3.2. Renal disease – may consider removing chromium and selenium in patients
with chronic renal failure.40
3.8.3.3. Long–term PN – may limit the amount of PN and duration of PN therapy since
aluminum toxicity may occur, especially with premature infants, due to
contamination of parenteral products.40
3.8.3.4. Burn or large wounds – Consider providing additional zinc and selenium69
3.8.3.5. Increased GI losses – Consider providing additional zinc at an amount based
on diarrhea volume or fistula output.70
3.8.3.6. Iodine – available in Peditrace® product, but not supplied in US-manufactured
pediatric trace element products
3.8.3.7. Iron – available in Peditrace® product, but not supplied in US-manufactured
pediatric trace element products
3.8.3.7.1. Supplementation is required for patients on long-term PN as the
sole nutrition source. (UW Health Class I, Level C)
3.8.3.7.2. Supplementation may be oral, enteral, or parenteral, depending on
gastrointestinal tract anatomy and absorptive capacity
4. Insulin
4.1. Routine addition of insulin to PN is discouraged. If the pediatric patient requires less insulin
or more glucose, the PN may need to be stopped, depriving the patient of nutrients.42,43 (UW
Health Class III, Level C)
4.2. Consider consulting pediatric endocrinology if patient requires insulin while on PN.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

15
5. Route of Administration71-73 (UW Health Class I, Level B)
5.1. Central Parenteral Nutrition: percutaneous catheters advanced into the superior vena cava
are preferred to a percutaneous jugular or femoral site to minimize the risk of infection with
non-tunneled central venous catheters. (UW Health Class I, Level B)
5.2. Peripheral Parenteral Nutrition48, including midline catheters74 (UW Health Class IIb, Level
C)
5.2.1. Peripheral administration may be considered as a temporizing measure for 48 to 72
hours.
5.2.2. Limitations/Contraindications – Patients who are fluid-restricted, have limited venous
access or if unable to meet at least 50% of nutritional requirements
5.2.3. Maintain osmolality less than 900 mOsm/L25,33 (See Appendix D for calculations) (UW
Health Class IIa, Level C)
5.3. Umbilical arterial catheters (UAC) or umbilical venous catheters (UVC) can be used to
administer PN; add heparin 0.5 unit/mL to PN solutions through this route.75 Nursing Patient
Care Policy 1.48P – Care of Umbilical Catheters (Arterial and Venous)
6. Administration48 (UW Health Class I, Level B)
6.1. Maintain central and peripheral tubing according to Nursing Patient Care Policy 1.21
Maintenance and Discontinuation of Central Venous Access Devices – Non-PICC (Adult &
Pediatric) and Policy 1.23 AP – Continuous Peripheral Intravenous Therapy (Adult &
Pediatric)
6.2. IVFE - The hang time for an individual bag of lipids is 12 hours to prevent microbial growth.
This may be administered as one or two separate infusions in a 24-hour period76
6.2.1. If fat is < 2% of total volume, administer IVFE as an infusion separate from PN (not as
a 3-in1 PN or total nutrient admixture, TNA)
6.3. Use filters to prevent infusion of intrinsic (e.g., aluminum) or extrinsic (introduced upon
compounding) contaminants.76
6.3.1. 1.2 micron filter is recommended for PN with IVFE
6.3.2. 0.2 micron filter is recommended for aqueous parenteral nutrition solutions without
IVFE (e.g., 2-in-1) (a 0.2 micron filter should be avoided with TNAs or 3-in-1 PNs as
the lipid emulsion cannot pass through the filter intact)
6.3.3. Filters may be changed every one to three days.
6.3.4. Clogged filters indicate a problem and should be replaced with a new filter
6.4. Cyclic PN (see 9.0 Cyclic (Intermittent) Parenteral Nutrition)
6.5. Compatibility – see Appendix E
7. Complications48 (UW Health Class I, Level B)
7.1. Carbohydrate in the PN should be limited as excess carbohydrate can result in glycogen
storage as fat, hepatic steatosis, increased carbon dioxide production.77 (see section 3.3
Carbohydrate)
7.2. Institute the following to decrease risk of cholestasis with long-term PN lack of EN.78-80
7.2.1. Limit IVFE dosage to 1 to 2 g/kg/day81
7.2.2. Recommend cycling the IVFE for the duration of the PN cycle
7.2.3. Cycle the PN as soon as clinically feasible
7.2.4. Start EN as soon as possible82
7.3. Metabolic Bone Disease83 (UW Health Class I, Level C)
7.3.1. Limit duration of PN to minimize risk of metabolic bone disease.
7.3.2. Provide adequate calcium/phosphate ratio to minimize metabolic bone disease.
7.3.3. Start EN as soon as possible
7.3.4. Supplement calcium and phosphate enterally to meet requirements for adequate bone
mineralization
7.4. Refer to UWHC Guidelines for Anti-Infective Lock Solutions to prevent line infections84-86
8. Monitoring (UW Health Class I, Level C)
8.1. Baseline assessment – Obtain the following prior to PN initiation, if possible:8
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

16
8.1.1. Anthropometrics
8.1.1.1. Height or length
8.1.1.2. Weight
8.1.1.3. Weight for length or BMI for age
8.1.1.4. Head circumference (for children under 36 months)
8.1.2. Blood Chemistries
8.1.2.1. Electrolytes (sodium, potassium, chloride, bicarbonate), BUN, creatinine,
glucose, transaminases (alanine aminotransferase or ALT and aspartate
aminotransferase or AST), alkaline phosphatase, total bilirubin
[comprehensive metabolic panel (CMP)]
8.1.2.2. Direct bilirubin, if indicated by clinical condition or age
8.1.2.3. Magnesium
8.1.2.4. Phosphate
8.1.2.5. Triglycerides
8.2. Clinical monitoring40
8.2.1. In most patients, the following should be checked daily for the first four days of PN:
8.2.1.1. Electrolytes (sodium, potassium, chloride, bicarbonate), BUN, creatinine,
glucose [basic metabolic panel (BMP)]
8.2.1.2. Magnesium
8.2.1.3. Phosphate
8.2.2. In certain patients (e.g. those on glucocorticoids, diabetics, neonates), point-of-care
glucoses every two to six hours may be indicated
8.2.3. Blood (or serum) triglycerides should be obtained within the first 24 to 72 hours of
starting IVFE therapy and once goal dose is achieved.
8.2.4. The following should be considered at least once weekly for patients who continue PN
for more than 5 days:
8.2.4.1. Electrolytes (sodium, potassium, chloride, bicarbonate), glucose, BUN,
creatinine, calcium, total bilirubin, direct bilirubin (in infants and others as
indicated), AST, ALT, alkaline phosphatase [comprehensive metabolic panel]
8.2.4.2. Magnesium
8.2.4.3. Phosphate
8.2.4.4. Triglycerides (if on IVFE)
8.2.4.4.1. Infants and young children: target triglycerides less than 250 mg/dL.
8.2.4.4.2. Older children and adolescents: target triglycerides less than 400
mg/dL.
8.2.4.5. C-reactive protein
8.2.5. Long-term monitoring parameters
8.2.5.1. For patients on PN for at least a month, obtain a carnitine level
8.2.5.2. For patients on PN > 3 months, obtain the following quarterly to semi-
annually, depending on clinical condition and ability to take enteral or oral
nutrition
8.2.5.2.1. Carnitine
8.2.5.2.2. Vitamins A, D (specify 25-hydroxy-) and E.
8.2.5.2.3. Trace elements: zinc, selenium, copper, chromium, manganese
8.2.5.2.4. Iron studies (iron, total iron binding capacity or TIBC, percentage
saturation, transferrin, and ferritin)
8.2.5.2.5. Vitamins B-6
8.2.5.2.6. Vitamin B-12 or methylmalonic acid
8.2.5.2.7. Essential fatty acid profile (to evaluate triene:tetraene ratio)
8.3. Premature infant specifics
In those patients with elevated alkaline phosphate, consider checking fractionated alkaline
phosphatase to determine etiology of elevation; consider consultation with Endocrinology.
8.4. Please refer to Home Parenteral Nutrition section (Appendix F) for monitoring when initiating
PN in the ambulatory setting.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

17
Table 12. Growth Parameters
Parameter40 Initial Week During Hospitalization
Outpatient for those
with EN or PN
Weight
Infants
Children
Daily
Daily to Weekly
Daily
Daily to Weekly
Weekly to Monthly
Weekly to Every Clinic
Length
Infants
Children
Baseline
Baseline
Weekly
Monthly
Monthly or at Clinic
Head
Circumference
Baseline Weekly to Monthly Monthly or at Clinic
Weight Gain Daily to Weekly Daily to Weekly Weekly to Monthly
Linear Growth Weekly to
Monthly
Weekly to Monthly Monthly
Table 13. Laboratory Monitoring for Home PN Patients
Laboratory Value40 Weekly Monthly Every 3 Months Every 6 Months
Basic metabolic
panel (BMP) X
Comprehensive
metabolic panel
(CMP)
First 1 to 4 weeks
after discharge
Once stable *
Pre-albumin First 1 to 4 weeks
after discharge
Once stable *
Conjugated (or
direct) bilirubin Baseline Once stable *
Complete blood
count (CBC) with
differential
First 1 to 4 weeks
after discharge
Once stable *
GGT Baseline X
Magnesium
Phosphorus X Once stable *
Triglycerides First 1 to 4 weeks
after discharge
Once stable *
PT, PTT/INR X When stable
Iron
Ferritin
TIBC
%Sat, Transferrin
First 3 to 6
months of PN When stable *
25-OH Vitamin D
Vitamin A
Vitamin E
X
Copper
Ceruloplasmin
Chromium
Manganese
Selenium
If cholestasis
present
For non-
cholestatic
patients
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

18
Zinc
If patient has
ileostomy or
increased stool
losses
X When stable *
Free & Total acyl-
carnitine X
Essential Fatty Acid
Profile X
* stability refers to both the patient (clinically stable) and the lab value (little weekly variability)
9. Cyclic (Intermittent) Parenteral Nutrition 27,87( UW Health Class I, Level C)
9.1. Cyclic PN should be considered, and, if clinically feasible, administered in:
9.1.1. Patients on or anticipated to be on long-term PN (>2 to 4 weeks) to prevent cholestasis
9.1.2. Patients who are on stable home PN
9.1.3. Patients with cholestasis to prevent worsening hepatic dysfunction
9.1.4. Patients who are ready to transition to oral intake to meet their needs
9.1.5. Patients who will benefit from time off PN to increase mobility and/or improve quality of
life
9.2. The duration of the cycle is dependent on:
9.2.1. Expected time that patient can be without nutrition based on age and clinical status:
For infants < 4 months of age, keep PN cycle > to 20 hours until EN comprises > 20%
nutrition needs.78
9.2.2. Rate of potassium infusion should be < 0.2 mEq/kg/h during the maximal rate of
infusion unless patient is on telemetry.
9.2.3. Glucose infusion rate should be appropriate to maintain blood glucose without inducing
hyper- or hypoglycemia as the PN is cycled on or off. Most cycles include a 1 to 2 hour
ramp-up and ramp-down in rate.
9.3. Neonates should be at least 3 weeks of age prior to cycling87
.
10. Transition to Enteral Nutrition23,88 ( UW Health Class I, Level B)
10.1. For transition to EN in premature and surgical infants in the NICU, please refer to NICU
enteral nutrition clinical practice guideline.
10.2. For transition to EN in infants and older children, please refer to the AFCH Pediatric enteral
nutrition clinical practice guideline.
10.3. Because the enteral feeding route is preferred to the parenteral route, patients receiving PN
should be evaluated daily for ability to begin oral feedings or EN.
10.4. Small-volume EN (trophic feeding) should be initiated as soon as clinically feasible to
preserve gut mucosa.
10.5. During the transition to EN, PN should be continued while EN is increased so that adequate
calorie/protein provision and growth are sustained.
11. Discontinuation of Parenteral Nutrition25 (UW Health Class I, Level C)
11.1. Most patients should have PN rates gradually weaned to off to prevent hypoglycemia.
11.2. PN should be discontinued when patients can receive sufficient oral or enteral intake to
meet a caloric and protein goal that will maintain health and support appropriate growth.
This goal is individualized based on clinical condition, age, and underlying nutrition status.
11.3. Patients should demonstrate appropriate nutrient intake and growth on enteral/oral nutrition
after the termination of PN and prior to removal of the venous access device.33,89,90
12. Home Parenteral Nutrition91-94 (UW Health Class I, Level C)
12.1. Home PN may be indicated for patients who are stable enough for discharge but cannot
receive sufficient energy and protein enterally or orally to meet their needs.
12.1.1. Patients should be medically stable on the current PN.
12.1.2. Care should be coordinated through a home care company and insurance
coverage verified.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

19
12.1.3. Caregivers should be adequately educated on sterile technique and infusion pump
use
12.1.4. Follow-up with a physician who will assume responsibility for the patient’s PN
prescription and monitoring should be arranged prior to discharge.
12.2. Formulas should, for the majority of patients, be individualized, and should provide
sufficient calories and protein, including any enteral or oral intake, to meet their needs.
12.3. Monitoring should be done on a routine basis. Please refer to Tables 11and 12 in the
monitoring section.
12.4. Initiation of PN in the home setting is strongly discouraged, with rare exceptions, due to the
complex nature of PN therapy.
12.5. See Appendix F. for further details on home PN.
13. Physical Traits and Limitations of PN
13.1 Stability of 3-in-1 PNs95 (used on older children whose fluid requirements permit use of this
type of PN)
13.1.1 In order to keep the lipid emulsion stable in a 3-in-1 PN, the macronutrients should
be in the following percentages: amino acids greater than or equal to 4% of total
volume, dextrose greater than or equal to 10% of total volume, and IVFE greater
than or equal to 2% of total volume.
13.1.2 In order to keep the lipid emulsion stable in a 3-in-1 PN, the total divalent and
trivalent cation concentration (predominately magnesium and calcium) should be
less than 20 mEq per liter.
13.2 Medications in or Y-sited with PNs
13.2.1 Medications should only be added to or Y-sited with the PN if they are deemed
compatible by a reputable source (e.g., Trissel’s Stability of Compounded
Formulations, King Guide to Parenteral Admixture) at the dose or concentration
being administered96-99. [Note: lack of evidence does NOT indicate compatibility or
stability.] See Appendix E for specific information on compatibilities.
13.2.2 Levocarnitine may be added to PN with lipids at a dose of 200 mg/liter for 24 hours
at room temperature or for 30 days at refrigeration. Levocarnitine may be added to
PN without lipids at a dose of 420mg/L at room temperature for 24 hours (UW
Health Class I, Level C)100
13.3 Physical/Chemical Limitations with PN
13.3.1 A reputable source (e.g. Abacus) should be consulted to determine calcium-
phosphate compatibility or stability in the PN. (There is a limit to the amount of
calcium and phosphate that can be added to the PN; this amount depends on pH,
temperature, and PN additives; compatibility curves have been established to assist
in this assessment. Exceeding this limit may result in calcium-phosphate
precipitation with subsequent loss of IV access, soft tissue deposition, pulmonary
embolus, and possibly death.)
13.3.2 The limit for sodium in the PN is 154 mEq/liter, which is the equivalent of 0.9%
sodium chloride (for patient safety).
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

20
UW Health Implementation
Potential Benefits:
ξ Patient safety when advancing macronutrients
ξ Uniform, appropriate patient monitoring which conforms to national standards
ξ More optimal, clinically appropriate delivery of macronutrients (protein, dextrose, fat), fluid,
electrolytes, specific amino acids, vitamins, and trace elements
ξ Cost-effective use of PN with earlier transition to oral feeding or EN.
Potential Harms:
ξ Possibility that patients may not have appropriate assessment or ongoing medical
evaluation of PN or EN therapy.
Qualifying Statements:
Few randomized controlled trials are available for parenteral nutrition. Recommendations are
often based on extrapolation from enteral or oral data and many are not well-supported by trails
with parenteral nutrition. In the pediatric population, specifically children, including the critical
care pediatric population, recommendations and best practice combine data extrapolated from
adult populations and the neonatal populations, which tend to be better studied.
Recommendations may change as more clinical trials are published.
Pertinent UW Health Policies & Procedures
1. Insertion, Maintenance, and Discontinuation of Central Vascular Access Devices for
Prevention of Central Line-Associated Bloodstream Infection
2. Policy 1.23 AP – Continuous Peripheral Intravenous Therapy (Adult & Pediatric)
3. Nursing Patient Care Policy 1.48P – Care of Umbilical Catheters (Arterial and Venous)
4. Standard of Medical Care in Diabetes – Adult/Pediatric – Inpatient/Ambulatory Clinical
Practice Guideline
5. UWHC Guidelines for Anti-Infective Lock Solutions
6. NICU enteral nutrition clinical practice guideline
7. AFCH Pediatric enteral nutrition clinical practice guideline
Implementation Plan/Clinical Tools
1. The guideline will be presented to the Pediatric Practice Committee at a monthly meeting,
and members of the PNST will volunteer to present at individual nursing unit or
departmental meetings.
2. A competency for practitioners will be developed and made available to physicians,
pharmacists (will be required for pediatric and NICU pharmacists), dietitians, nurses, and
other allied health professionals. The competency will be available via the Training and
Education Gateway on UConnect.
3. PN and lipid orders and PN order sets will reflect and support the guideline
recommendations with integration into Health Link
Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

21
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

22
Appendix A. Evidence Grading Scheme(s)
Figure 1. AHA/ACC Grading Scheme
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

23
Appendix B. Respiratory Quotient for Single and Mixed Fuels, Lipogenesis
Substrate/Condition Respiratory Quotient
(RQ)
Carbohydrate oxidation 1
Mixed substrate oxidation 0.85
Fat oxidation 0.7
Protein oxidation 0.82
Lipogenesis >1.0
non-steady state hyperventilation >1.0
 A RQ > 1.0 is associated with overfeeding and is undesirable in patients with pulmonary compromise.
Lipogenesis from overfeeding increases CO2 production and ventilatory demand which may impede
attempts to wean intubated patients off mechanical ventilation.
 A RQ < 0.85 may be indicative of underfeeding.
 To order Indirect Calorimetry from Health Link Order Entry, select Pulmonary Function Lab Testing
(Indirect Calorimetry). In order detail, enter the Reason for the Exam as determination of energy
needs and in the Special Studies field select Nutrition Analysis.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

24
Appendix C. Usual Adult Electrolyte Requirements
Electrolyte Recommendations per 24 Hours
Calcium 10 to 15 mEq/day
Magnesium 8 to 20 mEq/day
Potassium 1 to 2 mEq/kg
Sodium 1 to 2 mEq/kg
Chloride as needed to maintain acid-base balance
Acetate as needed to maintain acid-base balance
Phosphorus 20 to 40 mMol/day
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

25
Appendix D. Calculating Osmolarity in Peripheral Parenteral Nutrition
Maintain total mOsm/L of PPN less than 900 mOsm/L
1. Dextrose grams/L x 5 = mOsm/L
2. Protein grams/L x 10 = mOsm/L
3. Convert mOsm/L of electrolytes in PN to mOsm/L
Electrolyte mEq/mL mOsm/mL
NaCl 4 8
Na Acetate 2 4
KCl 2 4
K Acetate 2 4
Na Phos
Na Phos
4
3 mMol
7
K Phos
K Phos
4.3
3 mMol
7.4
Ca++ 0.465 0.68
Mg++ 4 4.06
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

26
Appendix E. Compatibility of Parenteral Nutrition and Formulary
Medications with Y-Site Administration
Ideally medications wouhould not be administered with PN, but many patients receive multiple
intravenous medications with limited IV access. Multiple resources evaluate compatibility with PN;
however, at times recommendations conflict and are not always reproducible101-105. Some studies
evaluate physical compatibility only, while others evaluate both physical and chemical compatibility. If a
medication is injected concomitantly with a PN through a Y-site, the time of admixture does not allow for
substantial chemical degradation. (Potential exceptions are those situations where the flow rates are very
low, as with neonatal PNs). Moreover, clinically significant chemical degradation reactions seldom occur
in 4 hours or less. Unlike chemical incompatibilities, physical or visual incompatibility is identified by
precipitants or changes in emulsion. Precipitants can be life-threatening, but are not always identifiable
due to their small size, translucency, concomittant fat emulsion infusion. Compatibility data is not
available for all medications; however, lack of data does not confer compatibility.
Key
C - Compatible
I - Incompatible
— - Compatibility data not available
C/I - Conflicting data with strength of evidence supporting compatibility
I/C - Conflicting data with strength of evidence supporting incompatibility
D5W - dextrose 5%
NS - sodium chloride 0.9%
Medication Admixture type
2-in-1 lipids 3-in-1
Acetazolamide I — —
Acyclovir sodium 7 mg/mL D5W I I I
Albumin I I I
Aldesleukin C C —
Alprostadil (10 & 20 mcg/mL) C C/I —
Amikacin sulfate 5 mg/mL D5W C C/I C/I
Aminophylline 2.5 mg/mL D5W C/I C C
Amphotericin B 0.6 mg/mL D5W I I I
Ampicillin sodium 20 mg/mL NS C/I C C
Ampicillin/Sulbactam 20/10 mg NS C C C
Argatroban C — —
Ascorbic acid C — —
Atracurium besylate C — —
Aztreonam 40 mg/mL D5W C C C
Bumetanide 0.04 mg/mL D5W C C C
Buprenorphine 0.04 mg/mL D5W C C C
Butorphanol 0.04 mg/mL D5W C C C
Calcium Chloride C C C
Calcium Gluconate 40 mg/mL (0.19 mEq/mL) D5W C — C
Caffeine citrate C — —
Carboplatin 5 mg/mL D5W C C C
Cefazolin 20 mg/mL D5W I C C
Cefepime C — —
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

27
Medication Admixture type
2-in-1 lipids 3-in-1
Cefotaxime 20 mg/mL C C C
Cefoxitin 20 mg/mL D5W C C C
Ceftazidime 40 mg/mL C C C
Ceftriaxone 20 mg/mL D5W I C I
Cefuroxime 30 mg/mL D5W C C C
Chloramphenicol C C —
Chlorpromazine 2 mg/mL D5W C C C
Ciprofloxacin 1 mg/mL D5W I C C
Cisplatin 1 mg/mL undiluted I C I
Clindamycin 10 mg/mL D5W C C C
Cyclophosphamide 10 mg/mL D5W C C C
Cyclosporine 5 mg/mL D5W I C/I I
Cytarabine 50 mg/mL undiluted C C I
Dexamethasone 1 mg/mL D5W C C C
Diazepam C — —
Digoxin 0.25 mg/mL undiluted C C C
Diphenhydramine 2 mg/mL D5W
Diphenhydramine 50 mg/mL undiluted
C

C

C
C
Dobutamine 4 mg/mL D5W C C C
Dopamine 3200 mcg/mL D5W C C/I I
Doxorubicin 2 mg/mL undiluted C — C
Doxycycline 1 mg/mL D5W C I I
Droperidol 0.4 mg/mL D5W C I I
Enalaprilat 0.1 mg/mL D5W C C C
Epinephrine C — —
Epoetin alfa C — —
Ertapenem — — —
Erythromycin C C C
Fentanyl 12.5 mcg/mL D5W
Fentanyl 50 mcg/mL undiluted
C
C
C

C

Fluconazole 2 mg/mL undiluted C C C
Fluorouracil 16 mg/mL I C/I I
Folic acid C — —
Foscarnet C — —
Fosphenytoin 50 mg PE/mL C — —
Furosemide 3 mg/mL D5W I C C
Ganciclovir 20 mg/mL D5W I I I
Gentamicin 5 mg/mL D5W C C C
Haloperidol 0.2 mg/mL D5W C I C
Heparin 100 Units/mL undiluted C I I
Hydrocortisone 1 mg/mL D5W C C C
Hydromorphone 0.5 mg/mL D5W C I/C I
Hydroxyzine 2 mg/mL D5W C C C
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

28
Medication Admixture type
2-in-1 lipids 3-in-1
Ifosfamide 25 mg/mL D5W C — C
Imipenem-Cilastatin 10 mg/mL NS C C C
Immune Globulin — — —
Insulin, regular human 1 units/mL D5W C C C
Iron dextran C/I — I/C
Isoproterenol C C C
Leucovorin 2 mg/mL D5W C C C
Lidocaine C C C
Linezolid C — —
Lorazepam 0.1 mg/mL D5W C I I
Magnesium sulfate 100 mg/mL (0.81 mEq/mL) D5W C C C
Mannitol 15% undiluted (150 mg/mL) C C C
Meperidine 4 mg/mL D5W C C C
Meropenem 20 mg/mL D5W — C C
Mesna 10 mg/mL D5W C C C
Methotrexate 15 mg/mL D5W I C C
Methylprednisolone 5 mg/mL D5W C C C
Metoclopramide 5 mg/mL D5W I C C
Metronidazole undiluted C C C
Midazolam 2 mg/mL I I I
Milrinone C — —
Mitoxantrone 0.5 mg/mL D5W I C C
Morphine 1 mg/mL D5W
Morphine 15 mg/mL undiluted
C
— C/I
C
I
Nafcillin 20 mg/mL D5W C — C
Nalbuphine 10 mg/mL undiluted C I C
Nitroglycerin 400 mcg/mL D5W C C C
Nitroprusside 400 mcg/mL D5W C C C
Norepinephrine16 mcg/mL D5W C C C
Octreotide 10 mcg/mL D5W C C C
Ondansetron 1 mg/mL D5W C I I
Oxacillin C C C
Paclitaxel 1.2 mg/mL D5W C C C
Penicillin G potassium C C C
Penicillin G sodium C — —
Pentobarbital 5 mg/mL D5W C I I
Phenobarbital 5 mg/mL D5W C I I
Phenytoin I I —
Phosphate potassium 3 mmol/mL undiluted I I I
Phosphate sodium 3 mmol/mL undiluted I I I
Phytonadione C C —
Piperacillin/Tazobactam 40/5 mg/mL D5W C C C
Potassium chloride 0.1 mEq/mL D5W C C C
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

29
Medication Admixture type
2-in-1 lipids 3-in-1
Prochlorperazine 0.5 mg/mL D5W C C C
Promethazine 2 mg/mL D5W I C C
Propofol 10 mg/mL undiluted C — —
Ranitidine 2 mg/mL D5W C C C
Sodium bicarbonate 1 mEq/mL undiluted I I I
Tacrolimus 1 mg/mL D5W C C C
Ticarcillin/Clavulanate 30/0.1 mg/mL D5W C — C
Tobramycin 5 mg/mL D5W C — C
Trimethoprim-Sulfamethoxazole 0.8/4 mg/mL D5W C C C
Vancomycin 10 mg/mL D5W C C C
Vecuronium C — —
Zidovudine 4 mg/mL D5W C C C
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

30
Appendix F. Home Parenteral Nutrition
Parenteral nutrition can be provided in the home setting for patients requiring PN beyond their hospital
stay who are medically and metabolically stable. Patients also need to be able to care for themselves or
have a willing, capable caregiver in the home. Home PN is provided through collaboration of healthcare
personnel within and outside the hospital including a home infusion pharmacy, a home health agency and
the prescribing team to provide safe care for a patient. It is essential that care plan elements are in place
prior to discharging a patient home. 91-94
1. Home PN referral: Discharge planning for home PN begins when the team identifies the patient
as requiring PN beyond their hospital stay. For patients who are currently inpatient at UWHC, a
referral for home PN is initiated by the social worker or case manager. Chartwell Midwest
Wisconsin is the UWHC affiliated home infusion pharmacy; however, patients are provided all of
their options for in network home infusion pharmacies who participate with their insurer.
Ultimately, the SNST will work closely with the home infusion pharmacy to coordinate the
transition of PN therapy from hospital to home and ensure appropriate clinical information and
orders (formula, lab schedule, ancillary orders) have been provided. In developing the home PN
care plan, elements to consider may include immediate and long term nutritional goals,
anticipated duration of therapy, and target weight or growth. Once the PN formula is stable,
cycling goals have been met, the patients and/or caregiver have received adequate training, the
outpatient care team has been confirmed, and the home infusion pharmacy is established, the
patient can be safely discharged.
2. Outpatient accountable team managing patient: It is essential that an agreement has been
reached with a physician to order and monitor PN in the outpatient setting prior to the patient
being discharged from UWHC. As PN is a complex therapy, a knowledgeable multidisciplinary
clinical team is needed to successfully minimize and manage the associated potential
complications (metabolic, infectious, mechanical). For patients with the agreeable ordering
physician in the UW Health system, the patient may have care coordinated for co-management
under UWHC delegation protocol by a member of the UW SNST, PNST or Chartwell pharmacist
team. This aspect of the care plan additionally requires confirmation prior to discharge and
appropriate activation of the delegation protocol for the outpatient case.
3. IV access: The patient must have an appropriate functional central venous access device to
safely receive PN in the home. Commonly used devices include implantable ports, tunneled
central venous catheters or peripherally inserted central catheters. The home infusion pharmacy
will require written documentation of line type and tip confirmation. Peripheral IV lines are not
acceptable for use with home PN.
4. Outpatient PN initiation: Outpatient PN start is discouraged in most scenarios due to patient
safety considerations. Certain patient populations can be at risk for electrolyte changes after TPN
initiation and require close monitoring. In weighing risks and benefits, it is safer for most patients
to be admitted to the hospital to initiate and stabilize the patient on an appropriate regimen before
going home. Anticipating a 3-5 day stay to initiate PN in the hospital is reasonable.
5. Insurance aspects: Insurance considerations need to be kept in mind when arranging for home
PN. Verifying reimbursement early in the home PN referral process is essential as insurance
coverage and criteria can significantly impact the home PN care plan and documentation needs.
Particularly for patients with Medicare, there are very stringent criteria from the Centers for
Medicare and Medicaid Services which must be met and documented in the patient’s clinical
record prior to hospital discharge to meet Medicare B coverage. Requests for changes in the
outpatient setting such as calorie changes, frequency of administration changes, oral intake
status, or introduction of enteral nutrition may have impacts on Medicare B coverage of the PN
therapy in the outpatient setting.
6. Patient expectations: Patients can expect extensive training and education in the hospital by
Chartwell RNs (if Chartwell patient) and initial home health RN involvement with the expectation
that the patient or caregiver become independent in administration with the PN. The aim of
education is to reduce the risk of complications and optimize safe practices in the home setting.
Patients will always have phone support from the home infusion pharmacy. Patients can expect
to need labs drawn on a frequent basis (often weekly) that may decrease in frequency over time.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

31
Patients will need to keep records of items such as weight and intake/output for the team. Some
patients may need to check blood sugars. Patients need to maintain a relationship with the MD of
record and have an office visit at least annually.
7. Outpatient monitoring: All PN patients are monitored closely after discharge from the hospital.
The home infusion pharmacy and outpatient managing medical team work together to provide
long-term ongoing monitoring of the patient. Adjustments in PN formulas are made based upon
laboratory values, intake/output records, patient assessments and nutritional goals or desired end
points.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

32
References
1. Tricoci P, Allen J, Kramer J, Califf R, Smith S. Scientific evidence underlying the
ACC/AHA Clinical Practice Guidelines. . JAMA. 2009;301(8):831-841.
2. Sanchez R. The Payer's Perspective. Journal of Parenteral and Enteral Nutrition.
2002;26(5_suppl):S10-S10.
3. Nguyen GC, Munsell M, Brant SR, LaVeist TA. Racial and geographic disparities
in the utilization of parenteral nutrition among inflammatory bowel disease
inpatients diagnosed with malnutrition in the United States. JPEN Journal of
parenteral and enteral nutrition. 2009;33(5):563-568.
4. World Health Organization Statistical Information System (WHOSIS). Indicator
definitions and metadata, 2008. World Health Organization web site.
http://www.who.int/whosis/indicators/compendium/2008/2bwn/en/ . Accessed
April 19, 2012.
5. Center for Disease Control and Prevention (CDC). Basics of childhood obesity.
http://www.cdc.gov/obesity/childhood/basics.html. Accessed February 19, 2014.
6. Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: a
paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr.
2013;37(4):460-481.
7. Guidelines for the Use of Parenteral and Enteral Nutrition
in Adult and Pediatric Patients. JPEN J Parenter Enteral Nutr. 2002;26(1
suppl):1SA-138SA.
8. Corkins MR, Griggs KC, Groh-Wargo S, et al. Standards for nutrition support:
pediatric hospitalized patients. Nutr Clin Pract. 2013;28(2):263-276.
9. Ziegler EE. Meeting the Nutritional Needs of the Low-Birth-Weight Infant. Ann
Nutr Metab. 2011;58(suppl 1):8-18.
10. Valentine CJ, Fernandez S, Rogers LK, et al. Early amino-acid administration
improves preterm infant weight. J Perinatol. 2009;29(6):428-432.
11. Mtaweh H, Smith R, Kochanek PM, et al. Energy Expenditure in Children after
Severe Traumatic Brain Injury. Pediatric critical care medicine : a journal of the
Society of Critical Care Medicine and the World Federation of Pediatric Intensive
and Critical Care Societies. 2014;15(3):242-249.
12. Briassoulis G, Filippou O, Kanariou M, Papassotiriou I, Hatzis T. Temporal
nutritional and inflammatory changes in children with severe head injury fed a
regular or an immune-enhancing diet: A randomized, controlled trial. Pediatric
critical care medicine : a journal of the Society of Critical Care Medicine and the
World Federation of Pediatric Intensive and Critical Care Societies. 2006;7(1):56-
62.
13. Joffe A, Anton N, Lequier L, et al. Nutritional support for critically ill children.
Cochrane Database Syst Rev. 2009(2):Cd005144.
14. Chan MM, Chan GM. Nutritional therapy for burns in children and adults.
Nutrition.25(3):261-269.
15. Duggan C, Rizzo C, Cooper A, et al. Effectiveness of a clinical practice guideline
for parenteral nutrition: a 5-year follow-up study in a pediatric teaching hospital.
JPEN J Parenter Enteral Nutr. 2002;26(6):377-381.
16. Skillman HE, Wischmeyer PE. Nutrition therapy in critically ill infants and
children. JPEN J Parenter Enteral Nutr. 2008;32(5):520-534.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

33
17. Vermilyea S, Goh VL. Enteral Feedings in Children: Sorting Out Tubes, Buttons,
and Formulas. Nutr Clin Pract. 2016;31(1):59-67.
18. Phillips JD, Raval MV, Redden C, Weiner TM. Gastroschisis, atresia, dysmotility:
surgical treatment strategies for a distinct clinical entity. J Pediatr Surg.
2008;43(12):2208-2212.
19. Lutter CK, Habicht JP, Rivera JA, Montrell R. The relationship between energy
intake and diarrhoeal disease in their effects on nchild growth: biological model,
evidence, and implications for public health policy. Food Nutr Bull. 1992;14:36-
42.
20. Rosenberg IH, Solomons NW, RE S. Malabsorption associated with diarrhea and
intestinal infections. Am J Clin Nutr. 1977;30:1248-1253.
21. Bohnhorst B, Muller S, Dordelmann M, Peter CS, Petersen C, Poets CF. Early
feeding after necrotizing enterocolitis in preterm infants. J Pediatr.
2003;143(4):484-487.
22. Chan EH, Russell JL, Williams WG, Van Arsdell GS, Coles JG, McCrindle BW.
Postoperative chylothorax after cardiothoracic surgery in children. The Annals of
thoracic surgery. 2005;80(5):1864-1870.
23. Groh-Wargo S, Sapsford A. Enteral nutrition support of the preterm infant in the
neonatal intensive care unit. Nutr Clin Pract. 2009;24(3):363-376.
24. Bechard LJ, Parrott JS, Mehta NM. Systematic review of the influence of energy
and protein intake on protein balance in critically ill children. J Pediatr.
2012;161(2):333-339 e331.
25. Corkins MR, ed The A.S.P.E.N pediatric nutrition support core curriculum. Silver
Spring, MD: American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.);
2010.
26. Duggan C, Watkins JB, Walker WA. Nutrition in Pediatrics: Basic Science and
Clinical Applications. 4th ed. Hamilton, Ontario, CA: B. C. Decker Inc; 2008.
27. Slicker J, Vermilyea S. Pediatric parenteral nutrition: putting the microscope on
macronutrients and micronutrients. Nutr Clin Pract. 2009;24(4):481-486.
28. Schofield WN. Predicting basal metabolic rate, new standards and review of
previous work. Human nutrition Clinical nutrition. 1985;39 Suppl 1:5-41.
29. Sax HC, Scuba WW. The ASPEN Nutrition Support Practice Manual. Silver
Spring, Md: ASPEN; 1998.
30. Food and Agriculture Organization of the United Nations UNU, World Health
Organization. . Human energy requirements: Report of a Joint FAO/WHO/UNU
Expert Consultation. Rome: Food and Agricultural Organization of the United
Nations; 17-24 October 2001 2004.
31. Tappy L. Thermic effect of food and sympathetic nervous system activity in
humans. Reproduction, nutrition, development. 1996;36(4):391-397.
32. Jesuit C, Dillon C, Compher C, Lenders CM. A.S.P.E.N. clinical guidelines:
nutrition support of hospitalized pediatric patients with obesity. JPEN J Parenter
Enteral Nutr. 2010;34(1):13-20.
33. Mehta NM, Compher C. A.S.P.E.N. Clinical Guidelines: nutrition support of the
critically ill child. JPEN J Parenter Enteral Nutr. 2009;33(3):260-276.
34. McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the Provision and
Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

34
of Critical Care Medicine (SCCM) and American Society for Parenteral and
Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009;33(3):277-
316.
35. Alaedeen DI, Walsh MC, Chwals WJ. Total parenteral nutrition-associated
hyperglycemia correlates with prolonged mechanical ventilation and hospital stay
in septic infants. J Pediatr Surg. 2006;41(1):239-244; discussion 239-244.
36. Mehta NM, Bechard LJ, Dolan M, Ariagno K, Jiang H, Duggan C. Energy
imbalance and the risk of overfeeding in critically ill children. Pediatric critical
care medicine : a journal of the Society of Critical Care Medicine and the World
Federation of Pediatric Intensive and Critical Care Societies. 2011;12(4):398-
405.
37. Frankenfield D, Roth-Yousey L, Compher C. Comparison of predictive equations
for resting metabolic rate in healthy nonobese and obese adults: a systematic
review. Journal of the American Dietetic Association. 2005;105(5):775-789.
38. Boullata J, Williams J, Cottrell F, Hudson L, Compher C. Accurate determination
of energy needs in hospitalized patients. Journal of the American Dietetic
Association. 2007;107(3):393-401.
39. Soghier LM, Brion LP. Cysteine, cystine or N-acetylcysteine supplementation in
parenterally fed neonates. Cochrane Database Syst Rev. 2006(4):CD004869.
40. Crill CM, Gura KM. Parenteral Nutrition Support. Silver Spring, MD2015.
41. Zello GA, Menendez CE, Rafii M, et al. Minimum protein intake for the preterm
neonate determined by protein and amino acid kinetics. Pediatr Res.
2003;53(2):338-344.
42. Arsenault D, Brenn M, Kim S, et al. A.S.P.E.N. Clinical Guidelines:
hyperglycemia and hypoglycemia in the neonate receiving parenteral nutrition.
JPEN J Parenter Enteral Nutr. 2012;36(1):81-95.
43. Kleinman Re, ed Pediatric Nutrition Handbook. Elk Grove Village, IL: American
Academy of Pediatrics; 2009. Parenteral Nutrition
44. Bulbul A, Okan F, Bulbul L, Nuhoglu A. Effect of low versus high early parenteral
nutrition on plasma amino acid profiles in very low birth-weight infants. J Matern
Fetal Neonatal Med. 2012;25(6):770-776.
45. Burattini I, Bellagamba MP, Spagnoli C, et al. Targeting 2.5 versus 4 g/kg/day of
amino acids for extremely low birth weight infants: a randomized clinical trial. J
Pediatr. 2013;163(5):1278-1282 e1271.
46. Baker SS, Baker RD, M DA. Pediatric nutrition support. Boston, MA: Jones and
Bartlett; 2006.
47. Brans YW, Andrew DS, Carrillo DW, Dutton EP, Menchaca EM, Puleo-Scheppke
BA. Tolerance of fat emulsions in very-low-birth-weight neonates. Am J Dis Child.
1988;142(2):145-152.
48. Boullata JI, Gilbert K, Sacks G, et al. A.S.P.E.N. Clinical Guidelines: Parenteral
Nutrition Ordering, Order Review, Compounding, Labeling, and Dispensing.
Journal of Parenteral and Enteral Nutrition. 2014.
49. Crill CM, Helms RA. The use of carnitine in pediatric nutrition. Nutr Clin Pract.
2007;22(2):204-213.
50. Crill CM, Storm MC, Christensen ML, Hankins CT, Bruce Jenkins M, Helms RA.
Carnitine supplementation in premature neonates: effect on plasma and red
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

35
blood cell total carnitine concentrations, nutrition parameters and morbidity. Clin
Nutr. 2006;25(6):886-896.
51. Helton E, Darragh R, Francis P, et al. Metabolic aspects of myocardial disease
and a role for L-carnitine in the treatment of childhood cardiomyopathy.
Pediatrics. 2000;105(6):1260-1270.
52. Sayed-Ahmed MM, Shaarawy S, Shouman SA, Osman AM. Reversal of
doxorubicin-induced cardiac metabolic damage by L-carnitine. Pharmacol Res.
1999;39(4):289-295.
53. Winter S, Jue K, Prochazka J, et al. The role of L-carnitine in pediatric
cardiomyopathy. J Child Neurol. 1995;10 Suppl 2:S45-51.
54. Sayed-Ahmed MMST, Gaballah HE, Abou El-Naga SA, Nicolau R, Calvanci M.
Propionyl-L-carnitine as protector against adriamycin-induced cardiomyopathy.
Pharmacol Res. 2001;43:513-521.
55. Winter S, Buist N. Cardiomyopathy in childhood, mitochondrial dysfunction, and
the role of L-carnitine. Am Heart J. 2000;139:S63-69.
56. Campos Y, Huertas R, Lorenzo G, al. e. Plasma carnitine insufficiency and
effectiveness of L-carnitine therapy in patiehnt with mitochondrial myopathy.
Muscle Nerve. 1993;1993(16):150-153.
57. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid
therapy. Pediatrics. 1957;19(5):823-832.
58. Hartnoll G. Basic principles and practical steps in the management of fluid
balance in the newborn. Semin Neonatol. 2003;8(4):307-313.
59. Lorenz JM, Kleinman LI, Ahmed G, Markarian K. Phases of fluid and electrolyte
homeostasis in the extremely low birth weight infant. Pediatrics. 1995;96(3 Pt
1):484-489.
60. Shaffer SG, Weismann DN. Fluid requirements in the preterm infant. Clin
Perinatol. 1992;19(233-250).
61. Greene HL, Hambidge KM, Schanler R, Tsang RC. Guidelines for the use of
vitamins, trace elements, calcium, magnesium, and phosphorus in infants and
children receiving total parenteral nutrition: report of the Subcommittee on
Pediatric Parenteral Nutrient Requirements from the Committee on Clinical
Practice Issues of the American Society for Clinical Nutrition. Am J Clin Nutr.
1988;48(5):1324-1342.
62. Pelegano JF, Rowe JC, Carey DE, al e. Effect of calcium/phosphorus ration
onmineral retention in parenterally fed premature infants. J Pediatr Gastroenterol
Nutr. 1991;12:351-355.
63. Groh-Wargo S, Thompson M, Hovasi Cox J. ADA pocket guide to neonatal
nutrition. Chicago, IL: American Dietetic Association; 2009.
64. Kimberger O, Ali SZ, Markstaller M, et al. Meperidine and skin surface warming
additively reduce the shivering threshold: a volunteer study. Crit Care.
2007;11(1):R29.
65. Vanek VW, Borum P, Buchman A, et al. A.S.P.E.N. position paper:
recommendations for changes in commercially available parenteral multivitamin
and multi-trace element products. Nutr Clin Pract. 2012;27(4):440-491.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

36
66. Wiesen P, Van Overmeire L, Delanaye P, Dubois B, Preiser JC. Nutrition
disorders during acute renal failure and renal replacement therapy. JPEN J
Parenter Enteral Nutr. 2011;35(2):217-222.
67. Manzanares W, Hardy G. Thiamine supplementation in the critically ill. Current
opinion in clinical nutrition and metabolic care. 2011;14(6):610-617.
68. Blackmer AB, Bailey E. Management of copper deficiency in cholestatic infants:
review of the literature and a case series. Nutr Clin Pract. 2013;28(1):75-86.
69. Berger MM, Shenkin A. Trace element requirements in critically ill burned
patients. J Trace Elem Med Biol. 2007;21 Suppl 1:44-48.
70. Jeejeebhoy K. Zinc: an essential trace element for parenteral nutrition.
Gastroenterology. 2009;137(5 Suppl):S7-12.
71. Botella-Carretero JI, Carrero C, Guerra E, et al. Role of peripherally inserted
central catheters in home parenteral nutrition: a 5-year prospective study. JPEN
J Parenter Enteral Nutr. 2013;37(4):544-549.
72. DeLegge MH, Borak G, Moore N. Central venous access in the home parenteral
nutrition population-you PICC. JPEN J Parenter Enteral Nutr. 2005;29(6):425-
428.
73. Staun M, Pironi L, Bozzetti F, et al. ESPEN Guidelines on Parenteral Nutrition:
home parenteral nutrition (HPN) in adult patients. Clin Nutr. 2009;28(4):467-479.
74. Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M. ESPEN Guidelines on
Parenteral Nutrition: central venous catheters (access, care, diagnosis and
therapy of complications). Clin Nutr. 2009;28(4):365-377.
75. Hall RT, Rhodes PG. Total parenteral alimentation via indwelling umbilical
catheters in the newborn period. Arch Dis Child. 1976;51(12):929-934.
76. Intralipid 20% [package insert]. In: Kabi F, ed. DEERFIELD, IL, USAJune 2006.
77. Nussbaum MS, Fischer JE. Pathogenesis of hepatic steatosis during total
parenteral nutrition. Surg Annu. 1991;23 Pt 2:1-11.
78. Cole CR, Kocoshis SA. Nutrition management of infants with surgical short bowel
syndrome and intestinal failure. Nutr Clin Pract. 2013;28(4):421-428.
79. Colomb V, Jobert-Giraud A, Lacaille F, Goulet O, Fournet JC, Ricour C. Role of
lipid emulsions in cholestasis associated with long-term parenteral nutrition in
children. JPEN J Parenter Enteral Nutr. 2000;24(6):345-350.
80. Lauriti G, Zani A, Aufieri R, et al. Incidence, prevention, and treatment of
parenteral nutrition-associated cholestasis and intestinal failure-associated liver
disease in infants and children: a systematic review. JPEN J Parenter Enteral
Nutr. 2014;38(1):70-85.
81. Cober MP, Killu G, Brattain A, Welch KB, Kunisaki SM, Teitelbaum DH.
Intravenous fat emulsions reduction for patients with parenteral nutrition-
associated liver disease. J Pediatr. 2012;160(3):421-427.
82. Javid PJ, Collier S, Richardson D, et al. The role of enteral nutrition in the
reversal of parenteral nutrition-associated liver dysfunction in infants. J Pediatr
Surg. 2005;40(6):1015-1018.
83. Nehra D, Carlson SJ, Fallon EM, et al. A.S.P.E.N. clinical guidelines: nutrition
support of neonatal patients at risk for metabolic bone disease. JPEN J Parenter
Enteral Nutr. 2013;37(5):570-598.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

37
84. Broom J, Woods M, Allworth A, et al. Ethanol lock therapy to treat tunnelled
central venous catheter-associated blood stream infections: results from a
prospective trial. Scand J Infect Dis. 2008;40(5):399-406.
85. Cober MP, Kovacevich DS, Teitelbaum DH. Ethanol-lock therapy for the
prevention of central venous access device infections in pediatric patients with
intestinal failure. JPEN J Parenter Enteral Nutr. 2011;35(1):67-73.
86. Opilla MT, Kirby DF, Edmond MB. Use of ethanol lock therapy to reduce the
incidence of catheter-related bloodstream infections in home parenteral nutrition
patients. JPEN J Parenter Enteral Nutr. 2007;31(4):302-305.
87. Nghiem-Rao TH, Cassidy LD, Polzin EM, Calkins CM, Arca MJ, Goday PS. Risks
and benefits of prophylactic cyclic parenteral nutrition in surgical neonates. Nutr
Clin Pract. 2013;28(6):745-752.
88. Hanson C, Sundermeier J, Dugick L, Lyden E, Anderson-Berry AL.
Implementation, process, and outcomes of nutrition best practices for infants
<1500 g. Nutr Clin Pract. 2011;26(5):614-624.
89. Bankhead R, Boullata J, Brantley S, et al. Enteral nutrition practice
recommendations. JPEN J Parenter Enteral Nutr. 2009;33(2):122-167.
90. Mehta NM. Approach to enteral feeding in the PICU. Nutr Clin Pract.
2009;24(3):377-387.
91. Kirby DF, Corrigan ML, Speerhas RA, Emery DM. Home parenteral nutrition
tutorial. JPEN J Parenter Enteral Nutr. 2012;36(6):632-644.
92. Kovacevich DS, Frederick A, Kelly D, Nishikawa R, Young L. Standards for
specialized nutrition support: home care patients. Nutr Clin Pract.
2005;20(5):579-590.
93. Kumpf VJ, Tillman EM. Home parenteral nutrition: safe transition from hospital to
home. Nutr Clin Pract. 2012;27(6):749-757.
94. Newton AF, DeLegge MH. Home initiation of parenteral nutrition. Nutr Clin Pract.
2007;22(1):57-64.
95. Driscoll DF, Bhargava HN, Li L, Zaim RH, Babayan VK, Bistrian BR.
Physicochemical stability of total nutrient admixtures. Am J Health Syst Pharm.
1995;52(6):623-634.
96. King Guide to Parenteral Admixture. Napa, CA: King Guide Publications, Inc;
2013.
97. Lexicomp Web site. https://online.lexi.com/lco/action/home/switch, Accessed
February 20, 2014.
98. Micromedex Healthcare Series Web site.
http://www.micromedexsolutions.com/micromedex2/librarian. Accessed February
20, 2014.
99. Trissel LA. Trissel's Stability of Compounded Formulations. 17th ed. Bethesda,
MD: American Society of Health-System Pharmacists, Inc; 2013.
100. Storm C, Wang B, Helms RA. Stability of carnitine in pediatric TPN and TNA
formulations. J Parenter Enteral Nutr. 1998;22(S18):Abstract 71.
101. Bouchoud L, Fonzo-Christe C, Klingmuller M, Bonnabry P. Compatibility of
intravenous medications with parenteral nutrition: in vitro evaluation. JPEN J
Parenter Enteral Nutr. 2013;37(3):416-424.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org

38
102. Newton DW. Y-site Compatibility of Intravenous Drugs With Parenteral Nutrition.
JPEN J Parenter Enteral Nutr. 2013;37(3):297-299.
103. Robinson CA, Sawyer JE. Y-site compatibility of medications with parenteral
nutrition. J Pediatr Pharmacol Ther. 2009;14(1):48-56.
104. Trissel LA, Gilbert DL, Martinez JF, Baker MB, Walter WV, Mirtallo JM.
Compatibility of medications with 3-in-1 parenteral nutrition admixtures. JPEN J
Parenter Enteral Nutr. 1999;23(2):67-74.
105. 2011 PPAG Annual Meeting Abstracts. The Journal of Pediatric Pharmacology
and Therapeutics. 2011;16(2):127-160.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2017CCKM@uwhealth.org