PARENTERAL NUTRITION STRATEGIES

FOR OPTIMAL OUTCOME

Rinawati Rohsiswatmo

Neonatology Division - Child Health Department

Faculty of Medicine University of Indonesia
Cipto Mangunkusumo Hospital
 The highest ratio of weight gain
in fetus are at week
26 to 36
Optimal growth for the premature is the growth
curve intra uterine, this requires the nutrients to be
digestable and absorbable.
6th World Congress Perinatal Medicine In Developing Countries, Jakarta,
March 9th, 2010
GENERAL PRINCIPLES
• Metabolic and nutritional requirements do not
stop with birth

• The metabolic and nutrient requirements of the

newborn are equal to or greater than those of
the fetus.

• Hours, not days, are the longest period infants

should be allowed to not receive nutrition, IV or
PO

• Intravenous feeding is always indicated when

normal metabolic and nutritional needs are not
met by normal enteral feeding
How to reach optimal growth and
development of preterm infants?

¨ Enteral or oral ASAP

¨ Parenteral nutrition (if there are some
contraindication)
Implikasi Klinis Patofisiologi Nothing Per Oral (NPO)
TOTAL PARENTERAL NUTRITION
¨ Total parenteral nutrition (TPN) is the intravenous
infusion of all nutrients necessary for metabolic
requirements and growth

¨ Parenteral nutrition (PN) refers to the supplemental

intravenous infusion of nutrients by peripheral or
central vein
INDICATIONS FOR PARENTERAL NUTRITION

Unstable CV and respiratory status

No evidence of gut function, major

GI anomalies, major surgery; NEC

Severe IUGR

BW < 1000 gram

Contraindication for oral-enteral
feeding
¨ Shock
¨ Gastro intestinal bleeding
¨ Severe illness (not stable yet)
¨ Gastro intestinal Obstruction
When to start total parenteral
nutrition in preterm ??
Panduan nutrisi enteral  bayi prematur di  RSCM

Oral  care
 THE FIRST GOLDEN HOUR

¨ Axillary temperature 36,5ºC – 37,5ºC

¨ Glucose 50 mg/dl – 110 mg/dl
¨ Glucose and amino acid infusion within 1 hour of birth

Val Castrodale, MSN, RN, NNP-BC; Shannon Rinehart, RNC-NIC, BSN. The Golden Hour, improving the stabilization of the very low birth-
weight infant. The natinal association of neonatal nurses. 2014.F9-14
Aggressive early total parenteral nutrition
in low birth-weight infants
32 ventilator-dependent preterm infants were
prospectively randomized into two groups

The Early Total Parenteral Nutrition The Late Total Parenteral Group
(ETPN) group Nutrition (LTPN):

¤ 3,5 g/kg-day amino 2g/kg-day of AA and 0,5

acids g/kg-day of IL each
¤ 3g/kg-day of 20% increased by 0,5 g/kg-day
Intralipid (IL), starting to a maximum of 3,5 and 3
within 1 hour after birth g/kg-day, respectively.

Ibrahim et al. J Perinatol.2004 Aug;24(8):482-6

 Aggressive early TPN....
¨ Plasma level of cholesterol, triglycerides, bicarbonate,
blood urea nitrogen, creatinine, and pH were similar in
both groups during the study period.

¨ aggressive intake of AA and IL can be tolerated

immediately after birth by VLBW infants.

¨ Early TPN significantly increased positive nitrogen

balance and calori intake, without increasing the risk of
metabolic acidosis, hypercholesterolemia, or
hypertriglyceridemia.
Ibrahim et al. J Perinatol.2004 Aug;24(8):482-6
Mean nitrogen retention improved during first week of
life

Ibrahim et al. J Perinatol.2004 Aug;24(8):482-6

Nitrogen Balance Before and During
TPN in Premature Infants

mg/kg/day g/kg/day
No TPN TPN
400 2.5

300 1.9

200 1.3

100 0.6

0 0
7 14 21
-100 -0.6
N Intake
-200 N Urine -1.3
N Retention
Postnatal age (days)
Schanler, J Pediatr 1994;125:961
Even the lung benefit from increased amino
acid intake in ELBW infants

<3 g/kg/day > 4 g/kg/day

Amino acid intake week 2 (g/kg/day) 3.3 3.9
Acetate intake (mEq/kg/day) 2.9 2.2
Serum bicarbonate (mEq/dL) 23 24
Blood Urea Nitrogen (mg/dL) 12 18
Weight gain, birth to week 2 (g) + 36 + 46
Broncho pulmonary Dysplasia (%) 28 5
Length of hospital stays (days) 61 52

Porcelli, J Pediatr Gastroenterol Nutr 2002; 34: 174-9

AMINO ACIDS
¨ Amino acids are required for growth, formation of
the body tissues, enzymes, and erythrocyte

¨ Taurin   Important  in  infant  

brain,  and  retina  
development.  
TAURIN

¨ Formation and maturation of brain cells

¨ Maintenance of retinal functions (vision).

q Production of bile salts by conjugation with bile acids

and regulation of bile flow

¨ Build muscle and increase motor function

EARLY AMINO ACID

AA  administration  2.4  g/kg/day  within 2  hours  after  birth          

à better  outcome  compared  with  slow  stepping-­up  daily    
amino  acid  administration
Te  Braake  FWJ, et  al.  J  Pediatr  2005;;147:457-­61.
Poindexter  BB.   J  Pediatr  2005;;147:420-­1.

Long  term  study  of  ELBW with  mean  birth  weight  800  g & GA
26  wk;;  given  early  amino  acid  infusion  showed  significant  
growth  in  36  weeks  postmenstrual  age.

Poindexter  BB, et  al.   J  Pediatr  2006;;148:300-­5.

19
Early aggressive protein to reduce deficits
(Dinerstein, 2006)
Delayed TPN, Hyperglycemia & Hyperkalemia

Delayed TPN

Insulin

Glucose K+
 FLUID REQUIREMENTS

Age ( day ) 1 2 3 4 5+

mL/kg/day 60 90 120 150 150+

Fluid  requirements  mL/kg/day

22
 FLUID REQUIREMENTS....

Weight Day 1-2 Day 3-15 Day >15

>2500 g 70 130 130+

1501-2500g 80 110 130+

1251-1500g 90 120 130+

1001-1250g 100 130 140+

750-1000g 105 140 150+

Fluid  requirements  mL/kg/day

23
Amino • Start amino acids within 2 hours of birth
with 1.5-3 g/kg/day & increase by 1
Acids g/kg daily to max 4.0 g/kg/day

• Start lipids within 24 hrs of birth at 1.0

Lipid g/kg/day & increase by 0.5-1 g/kg
daily to max 3.0 g/kg/day

Glucose • Initiate GIR à4mg/kg/min & increased

daily by 1-2 mg/kg/min

TPN • Don’t stop TPN until enteral feeds are

>90% of requirements
Calorie Need Related Nitrogen
Balance
Positive Nitrogen Balance (Anabolic Condition)
reached by 60 Kcal/kg/day and amino acid intake
2,5-3 g/kg/day

Fetus Growth needs 80-85 Kcal/kg/day and amino

acid intake 2,7-3,5g/kg/day

Extra Uterine Growth need 90-120 Kcal/kg/day

(minimal 70 Kcal) and amino acid intake about 2,5-
3g/kg/day

25
 Clinical Practice: Total Parenteral
Nutrition Administration

¨ Should be given early at the first hour,

especially for ELBW infant
¨ Use Birth weight or the highest weight to
calculate total fluid intake
¨ Consider clinical appereance, Laboratorium
result for giving glucose, amino acid and Lipid
Parenteral nutrition requirements
Protein
Requirement is high during the first year of life

8 essential amino acids + another 7 are needed (histidin,

cystein, taurine, tyrosine, prolin, glutamine, arginine)

In neonates, It is recommended to give max 3.0-4.0

g/kg/day. The smallest the babies the highest the
number
Amino acid requirements.

Age group Amino acids gkglday

Preterm neonates 2.5 - 3.0
Fullterm neonates, infants 2.0 - 2.5
carbohydrate

Very preterm infants may

not tolerate that much
Start with 4-6 dextrose and may even
mg/kg/min or need insulin as an infusion
to achieve adequate
D10-D12.5 calorie intake without
hyperglycemia

Advance by 1-3
mg/kg/min daily to a Hyperglycemia is more
maximum of 12 commonly encountered
mg/kg/min. GIR during anesthesia and
>10mg/kg/min may result surgery
in glycosuria and osmotic
diuresis
Lipid/fat

♪ Lipid prevent essential fatty acid deficiency, provide energy

substrates and improve delivery of fat soluble vitamins

♪ LBW infants may have immature mechanisms for fat

metabolism. A number of clinical conditions inhibit lipid
clearance e.g. infection, stress and malnutrition

♪ Start lipids at 1g/kg/day, at the same time as amino acids

prevent essential fatty acid deficiency; dose gradually
increased up to 3 g/kg/day (3.5g/kg/day in ELBW infants)
consider use smaller doses in sepsis, compromised pulmonary
function, hyperbilirubinaemia
 …Lipid/fat
♪ Add carnitine 50 mmol/kg/day if receiving lipid
> 1 month to make the tolerancy of lipid better

♪ It is infused continuously over as much of the 24

hour period as practical

♪ Avoid concentrations >2g/kg/day if infant has

jaundice requiring phototherapy
 …Lipid/fat
♪ Preparation of 20% emulsion is better than 10 %
2 solutions of lipid : 50% MCT/50% LCT; 100 %
LCT

♪ The use heparin at 0,5 to 1 units/ml of TPN solutions

(max 137 units/day) can facilitate lipoprotein lipase
activity to help stabilize serum triglyceride values

♪ Lipid clearance monitored by plasma triglyceride

levels (maximum triglyceride concentration ranges
from 150mg/dl to 200mg/dl)
 …Lipid/fat
¨ Potential complication /risks include :
Hyperlipidemia

Potential risk of kernicterus at low levels of unconjugated

bilirubin because of displacement of bilirubin from albumin
binding sites by free fatty acids. As a general rule, do not
advance lipids beyond 0.5 g/kg/d until bilirubin is below
threshold for phototherapy

Potential increased risk or exarcerbation of

chronic lung disease
Potential exacerbation of Persistent
Pulmonary Hypertension (PPHN)
Lipid overload syndrome with coagulopathy
and liver failure
Minerals and fat and water soluble
vitamins
Minerals including trace elements, fat and water soluble
vitamins should be put in the parenteral nutrition
programme directly

Preterm infants and term infants receiving long-term

parenteral nutrition are at increased risk for bone
demineralization and fractures

Calcium and phosphate requirements for LBW infants

sometimes exceed their solubility in PN solutions depending
on the pH of the individual solution
…Minerals and fat and water soluble
vitamins
Calcium(Ca) and phosphorus (P) delivery should be
maximized for all infants receiving PN

Calcium is only allowed if the TPN if the line is

central

If only a peripheral line is available, add

phosphorus to the TPN and give Ca gluconate
separately
…Minerals and fat and water soluble
vitamins
Magnesium is ordered in mEq/kg/day based on
recommended intake of this nutrient and on
individual serum levels

Essential trace elements include zinc, copper,

selenium, chromium, manganese, molybdenum,
iodide and iron should be added

Heparin : the addition of heparin to intravenous

solutions may help maintain catheter patency. In
addition, heparin may enhance the release of
lipoprotein lipase. Addition of 0.5-1 units/ml is
routinely used in clinical practice
 …Minerals and fat and water soluble vitamins

Trace elements are recommended as 0.2 mL/kg/d of trace

element solution containing zinc, manganese, copper, and
chromium
Preterm infants need additional zinc (300
mcg/kg/d) and selenium (2 mcg/kg/d)

Term infants need additional zinc (200

mcg/kg/d) and selenium (2 mcg/kg/d)

For infants with cholestasis (i.e, direct bilirubin >2.5 mg/dl), discontinue
the trace element solution and give :
- Zinc 400 mcg/kg/d TOTAL (preterm infants) -
300 mcg/kg/d TOTAL (term infants)
- Chromium 0.2 mcg/kg/d
- Selenium 0.2 mcg/kg/d
- Discontinue selenium with patients on renal dialysis
…Minerals and fat and water soluble
vitamins
Aluminum : aluminum is found as a contaminant
in parenteral solutions. Aluminum is associate
with impaired neurologic development and
decreased bone calcium uptake. The
recommended IV aluminum exposure is ‘no
more than 5

Filtering : In-line filters are recommended for

use during administration of parenteral nutrition
to reduce the incidens of phlebitis, micro
precipitates, air embolus and infection.
ELECTROLYTE REQUIREMENTS

• 2-4 mmol (24 ml ½ N/S

SODIUM contains1.8 mmol Na+)

• 1-2 mmol (avoid K+ in infants

POTASSIUM <1,250 g in first 2 days)

CALCIUM & • 1-2 mmol

PHOSPHOR
• 0,15-0,3 mmol
MAGNESIUM
 Clinical Practice....

¨ Micro nutrient:
¤ Zn given at dose 300mcg/kg since day one

¤ Other micronutrient is added only if intake by

enteral <50% and parenteral nutrition is given
more than 2 weeks
¤ Doses : 0.04 ml/kg two times a week

¤ Avoid Cu and Mn at obstructive icterus

¤ Avoid Se and Cr at renal disfunction

 Clinical Practice....

¨ Fat Soluble Vitamin: can be added into daily

lipid; Vitalipid dose: 4mg/kg(0,4g/kg/lipid)

¨ Heparin can be added to parenteral nutrition at

dose 0,5U/ml ( To decrease trigliseride level)

¨ Sodium Acetate is added to parenteral nutrition

for baby with hipercloremic metabolic acidocic
(dose: 1-4 mEq/kg/day)
LAB MONITORING SCHEDULE

SCHEDULE LAB
DAILY urine glucose, vital signs (temperature,
respiratory rate, heart rate, blood pressure)
3x/WEEK serum electrolytes, HCO3, renal function,
calcium, magnesium, Phosphor
WEEKLY liver function tests incl protein/albumin,
haematocrit, FBC

Serum TG: 4 hrs after increase in

lipid dose
 TPN REGIMENTS IN CIPTO MANGUNKUSUMO HOSPITAL
(requiring peripheral line – providing less calories)

Birth  Weight    <1000  g  or  GA  <28  weeks

1  g  =  30  ml
HARI CAIRAN GIR PROTEIN LIPID
(ml/kg) (mg/kg/me (g/kg)
nit)

<700g 700-999g
Hari 0 100 6-8 2.5 0.5 1.0
Hari 1 110 7-8 3.5 1.0 2.0
Hari 2 130 8-9 4 1.5 3.0
Hari 3 140 9-10 4 2.0 3.0
Hari 4 150 10-11 4 2.5 3.0
Hari 5 160 11-12 4 3.0 3.0
 TPN REGIMENTS IN CIPTO MANGUNKUSUMO HOSPITAL
(requiring peripheral line – providing less calories)
Birth  Weight  :   1000-­‐1500  g  or  GA  28-­‐32  weeks
1  g  =  30  ml

HARI CAIRAN GIR PROTEIN LIPID

(ml/kg) (mg/kg/me (g/kg)
nit)

Hari 0 80 6-8 2.5 1.0

Hari 1 100 7-8 3.5 2.0
Hari 2 120 8-9 4 3.0
Hari 3 140 9-10 4 3.0
Hari 4 150 10-11 4 3.0
Hari 5 150 11-12 4 3.0
 TPN REGIMENTS IN CIPTO MANGUNKUSUMO HOSPITAL
(requiring peripheral line – providing less calories)
Birth  Weight  :   1500-­‐2500  g  or  GA  33-­‐37  weeks
1  g  =  30  ml

HARI CAIRAN GIR PROTEIN LIPID

(ml/kg) (mg/kg/me (g/kg)
nit)

Hari 0 60 4-6 0 0
Hari 1 80 6-8 1.5 1.0
Hari 2 100 8-9 2.5 2.0
Hari 3 120 9-10 3.0 3.0
Hari 4 140 10-11 3.0 3.0
Hari 5 150 11-12 3.0 3.0
 TPN REGIMENTS IN CIPTO MANGUNKUSUMO HOSPITAL
(requiring peripheral line – providing less calories)
Birth  Weight  :   ≥2500g  or  GA  28-­‐32  weeks
1  g  =  30  ml

HARI CAIRAN GIR PROTEIN LIPID

(ml/kg) (mg/kg/me (g/kg)
nit)

Hari 0 60 4-6 0 0
Hari 1 80 6-8 0 0
Hari 2 100 8-9 1.0 1.0
Hari 3 120 9-10 2.0 2.0
Hari 4 140 10-11 3.0 3.0
Hari 5 150 11-12 3.0 3.0
Usia gestasi Berat lahir <700 Usia gestasi Usia gestasi 28-­32 Usia gestasi 33-­ Cukup bulan (37-­
g <28 minggu minggu ATAU <37 minggu ATAU 42 minggu)
ATAU
ATAU
Berat lahir 1000 -­ Berat lahir 1500-­
Berat lahir bayi Berat lahir 1500 g 2500 g
<1000 g

TPN mulai hari 0 Ya Ya Ya Tidak Tidak

TPN agresif Ya Ya Ya Tidak Tidak

Energi (menurut REE) 50 kkal/kg/hari

Kebutuhan karbohidrat 6-­8 mg/kg/menit 6-­8 mg/kg/menit 6-­8 mg/kg/menit 4-­6 mg/kg/menit 4-­6 mg/kg/menit
dalam GIR

Target protein (g/kg/hari) 4,0 4,0 4,0 3,0 3,0

Dosis awal protein hari 0 2,5 2,5 2,5 0 0

Peningkatan dosis 1,0 g/kg per hari

protein
Target lipid (g/kg/hari) 3,0

Dosis awal lipid hari 0 0,5 1,0 1,0 0 0

(g/kg/d)
Dosis lipid hari 1 1,0 2,0 2,0 1,0 0

Peningkatan dosis lipid 0,5 1,0 1,0 1,0 1,0

 CONTENTS OF PG SOLUTION
Component PG 1 PG 2

Amino acids 6 % 17 ml 17 ml

Ca Glukonas 10 % 1,6 ml 1,6 ml

Dextrose 40 % 6,3 ml 7,4 ml

Dextrose 10 % 14,7 ml 10,3 ml

Potassium 0,4 ml 1 ml

NaCl 3 % 0 2,7 ml

Amount 40 cc 40 cc

49
SUMMARY

¨ Early nutrition (immediately after birth) in premature

babies is important to prevent significant morbidity.

¨ Many of the dogmas that have prevented rapid

incorporation of early nutrition have either been
disproved, not based on fact or weak.

¨ Novel scientifically based strategies are needed to

further improve nutrition in these infants.
… protein

Decreases frequency and severity of neonatal

hyperglycaemia by stimulating endogenous insulin
secretion and stimulates growth by enhancing insulin
and insulin like growth factor release

Reduction in dosage may be needed

in critically ill, significant
hipoxaemia, sepsis

Potential complications/ risk

include : asidosis, elevated
BUN, hyperammonemia,
cholestasis with prolonged
administration
 Table -10: infusion of 20 % intravenous fat
emulsion g/kg/day (ml/kg/day)

Preterm and SGA inf Fullterm infants

neonates

Initial dose 0.5 (2.5) 1 (5) 2 (10)

Daily increase 0.5 (2.5) 1 (5) 1 (5)

Maximum 3 (15) 4 (20) 4 (20)

dose

Meurling S. Scand J Nutr/Näringsforskning.2000; 44:8-11

 KARBOHIDRAT

¨ Mulai pemberian glukosa 4-6 mg/kg/menit (6-9

g/kg/hari) & dinaikkan bertahap 1-2
mg/kg/menit (maksimal 15-18 mg/kg/menit jika
normoglikemik)

¨ Periksa kadar gula darah setiap 6 jam dan

glukosa urin setiap 8 jam, untuk mempertahankan
kadar gula darah.
 CARBOHYDRATE

¨ Start Glucose Giving 4-6mg/kg/minute (6-

9g/kg/day) & tapering up 1-2mg/kg/ minute
(maximal 15-18mg/kg/minute if normoglychemic)

¨ Examine Blood Glucose Level every 6 hours and

Examine Urine Glucose every 8 hours, to maintain
Blood Glucose Level
 KARBOHIDRAT….
¨ Konsentrasi maksimum pemberian dekstrosa 12,5%
melalui jalur intra vena perifer dan 25 % apabila
diberikan melalui vena sentral.
¨ Beberapa studi terbaru menunjukkan pemberian
pompa insulin kontinyu bermanfaat pada BBLSR,
meningkatkan asupan energi non protein dan
kenaikan berat badan yang signifikan
 CARBOHYDRATE….
¨ Maximum Dextrose Giving Concentrate is 12,5% by
Peripheral Intravenous Line and 25% if given by
Central Intravenous Line
¨ Few new studies shows continuous Insulin Pump
giving is helpful for ELBW, Increase Non Protein
intake and increase Weight significantly
PROTEIN
¨ Asam amino diberikan minimal dalam 2 jam
kelahiran mulai 1,5-3 g/kg/hari, dinaikkan
bertahap 1 g/kg/hari, maksimal 4 g/kg/hari

¨ Nitrogen urea serum dan status asam basa harus

dinilai 3x/minggu selama fase titrasi bertahap, dan
seminggu sekali setelah asupan protein maksimal
dicapai atau kondisi metabolik tidak stabil

¨ Azotemia dan asidosis terjadi apabila bayi

mendapat asupan protein lebih dari 4 g/kg/hari

¨ Komplikasi jarang terjadi bila asupan diberikan

sesuai pedoman, yaitu :1,5-3 g/kg/hari
PROTEIN
¨ Amino Acid is given minimal on 2 hours of birth starts
1,5-3g/kg/day, tapering up 1g/kg/day, maximal
4g/kg/day

¨ Urea Nitrogen Serum and Acid Base Status should be

evaluated 3 times/week during gradually titration
phase, and one times/ week after maximal protein
intake accomplished or unstable metabolic condition

¨ Azotemia and acidocis occur if infant got protein intake

more than 4g/kg/day

¨ Complication rare to occur if intake is given according

guidance, is 1,5-3g/kg/day
 LIPID
¨ Lipid diberikan dalam 24 jam setelah kelahiran, mulai
1g/kg/hari, dinaikkan bertahap 0,5-1 g/kg/hari,
maksimal 3 g/kg/hari

¨ Pemberian lipid intravena sampai 3 g/kg/hari dapat

meminimalisir intoleransi lipid

¨ Pemberian heparin dosis rendah lebih dari 24 jam

dapat memelihara kadar trigliserid
 LIPID
¨ Lipid is given during 24 hours after birth, start from
1g/kg/day, tapering up 0,5-1g/kg/day, maximum
3g/kg/day

¨ Intravenous Lipid Administration until 3 g/ kg/day can

minimize lipid intolerance

¨ Low dose heparin administration more than 24 hours

can maintain trigliseride level
 LIPID....

¨ Lipid intravena 20% lebih menguntungkan

dibandingkan pada kadar 10%. Phospholipid dapat
menghambat lipoprotein lipase, oleh karena itu,
pemberian emulsi lemak rasio terendah phospholipid
dengan trigliserid dianjurkan (contohnya 0,06 dalam
20% vs 0,12 dalam 10%)

¨ Dosis asam lemak esensial perlu disesuaikan dosisnya

pada kasus sepsis, hiperbilirubinemia dan hipertensi
pulmonal
 LIPID....

¨ Intravenous lipid is more beneficial than at level 10%.

Phospholipid level can hold up Lipoprotein Lipase,
Therefore, Phospholipid with Trigliseride Lowest Lipid
Emulsion administration ratio is recommended ( for
example: 0,06 in 20% vs 0,12 in 10%)

¨ Essential Lipid Acid Dose should be proper their dose

for septic case, hyperbillirubinemia, and pulmonal
hypertention
 KLINIS PRAKTIS....
¨ Protein 1 g = 4 kkal
¨ Lipid 1 g = 9 kkal

¨ Karbohidrat :

GIR (mg/kg/min) =
Kecepatan cairan (cc/jam) x konsentrasi Dextrose (%)
6 x berat (Kg)

¨20 kal PF/EBM/IF = 0.67 kkal/ml

¨EBM + HMF/24 kal PF = 0.8 kkal/ml
PRACTICAL CLINIC
¨ Protein 1 g = 4 kkal
¨ Lipid 1 g = 9 kkal
¨ Glucose :
GIR (mg/kg/min) =

rate of infusion (ml/hr) x Dextrose (%)

6 x weight (Kg)

¨ 20 kal PF/EBM/IF = 0.67 kkal/ml

¨ EBM + HMF/24 kal PF = 0.8 kkal/ml
Essential Amino Acids
Conditionally Essential
Amino Acids
¨ Valine
¨ Leucine ¨ Cysteine
¨ Isoleucine ¨ Taurine
¨ Tyrosine
¨ Threonine
¨ Methionine ¨ Histidine
¨ Phenylalanine ¨ Arginine
¨ Glycine
¨ Lysine
¨ Tryptophan ¨ Glutamine
 PERBANDINGAN OPTIMAL KALORI
NON PROTEIN DAN NITROGEN

¨ 150-200 kalori non protein (Lipid dan

Glukosa) per gram Nitrogen (bioavailabilitas
asam amino bervariasi tergantung pada
persiapan nutrisi)
(1 gram nitrogen = 6,25 gram protein)

¨ 25 kalori non protein (Lipid dan Glukosa) per

gram Nitrogen à 25% dari lipid untuk cegah
lipogenesis dari glukosa yg membutuhkan
energi lebih
 DAILY TPN REGIMEN
Volume PG LIPID
Tipe ml/kg g/kg/day ml/kg/day g/kg/day ml/kg/day

Birth weight < 1000 g

1 g = 30 ml
Day 0 PG 1 100 2 60 1 5

Day 1 PG 1 100 3 90 2 10

Day 2 PG 1 110 3 90 3 15

Day 3 PG 1/PG 2 120 3,5 105 3 15

Day 4 PG 2 130 3,5 105 3 15

Day 5 PG 2 150 3,5 105 3 15

 DAILY TPN REGIMEN...
Volume PG LIPID
Tipe ml/kg g/kg/day ml/kg/day g/kg/day ml/kg/day

Birth weight 1000 – 1800 g

1 g = 30 ml
Day 0 PG 1 80 2 60 1 5

Day 1 PG 1 100 3 90 2 10

Day 2 PG 1 110 3 90 3 15

Day 3 PG 1/PG 2 120 3,5 105 3 15

Day 4 PG 2 130 3,5 105 3 15

Day 5 PG 2 150 3,5 105 3 15

 DAILY TPN REGIMEN
Volume PG LIPID
Tipe ml/kg g/kg/day ml/kg/day g/kg/day ml/kg/day

Birth weight > 1800 g

1 g = 30 ml
Day 0 PG 1 60 0 0 0 0

Day 1 PG 1 80 0 0 0 0

Day 2 PG 1 80 2 60 2 10

Day 3 PG 1/PG 2 100 3 90 2 10

Day 4 PG 2 120 3 90 3 15

Day 5 PG 2 150 3 90 3 15
KEBUTUHAN ELEKTROLIT

• 2-4 mmol (24 ml ½ N/S

NATRIUM mengandung 1.8 mmol Na+)

• 1-2 mmol (hindari K+ pada bayi

KALIUM dengan Berat lahir <1,250 g
dalam 2 hari pertama)

KALSIUM & • 1-2 mmol

FOSFOR
• 0,15-0,3 mmol
MAGNESIUM
Feeding  guidelines  for  preterm baby
When  to  used  preterm  formula
¨ Breastmilk+  HMF  nor  enough

¨ Weight  length  and  HC  less  than  25  IHDP  Chart/fenton  

chart

When  to  used  post  discharge  formula

¨ Weight  1800/2000  gram.  Weight,  length  and  HC  >  
p.25

When  to  used  standar  formula

¨ Z-­ score  -­2  s/d  +  2  weight  for  age  WHO  chart

¨ Z-­ score  -­2  s/d  +  2  weight  for  length  WHO  chart  

 PDF  powder  supplementation  
of  mother  breast  milk

PDF Powder Supplementation Of Mother Breast Milk

Premature

¨ Birth before reaching 37 weeks ' gestation .

¨ Incidence in Indonesia was 15.5%
¨ 2/3 of premature birth , were Small for
Gestasional Age

Riskesdas, 2013
Low Birth Weight (LBW)
¨ Birthweight < 2,500 grams .
¨ Incidence in Indonesia: 10.2%
¨ 6-30 % LBW were categorized as IUGR (Helen
Kay, 2000)
INTRA UTERINE GROWTH IN THE
LAST TRIMESTER
Brain Weight Body calcium
BW BL
375 g
3500 g 28000 mg

50 cm
800 g
30 cm 75 g 5600 mg

25  40 25  40 25  40   25  40

Gestational age (weeks) (Klein CJ. J Nutr 2002)

 IMPACT OF UNDERNUTRITION DURING
PREGNANCY AND EARLY CHILDHOOD

¨ Increased risk of dying from infectious diseases (one-third

of child deaths)
¨ Stunting is associated with reduced school performance
equivalent to 2-3 yrs of schooling
¨ Stunting associated with reduced income earning capacity
(22% average; up to 45% has been reported!)
¨ Increased risk of non-communicable diseases in adult life
¨ Stunted girl is more likely to give birth to undernourished
baby
¨ Reduced GMP by 2-3%
¨ About 20 million children suffer from severe acute
malnutrition which greatly increases risk of death
IUGR
¨ IUGR is a baby who has a birth weight below the
10th percentile of normal weight curve adjusted for
gestational age. This is a condition in which the fetus
is not able to develop in accordance with the
normal size due to a disturbance of nutrition and
oxygenation .
¨ According to WHO, in Indonesia, 2003, a
precentation of IUGR was 19,8%,
Appropriate
For
Gestasional
Age

IUGR

Small For
Gestasional
Age

Catch Up
Growth
EUGR
¨ EUGR occurs when a premature infant's growth falls
below the 10th percentile in comparison to a normal
fetus of the same gestational age.

¨ Extrauterine growth restriction (EUGR) is commonly

seen in small premature infants due to a lack of
early aggressive nutrition that results in energy and
protein deficits during the first few days of life.
These deficits lead to early postnatal growth failure
that continues at discharge resulting in growth
parameters being below the 10th percentile, which is
associated with poor neurodevelopmental outcomes.