Infants TPN

[Rani Sudarshana]

My question is about energy requirements of infants.

When I am planning the infants TPN’s, giving attention that %40-50 of total calories must come from fat.

I learned this from books and educations, but I don’t know WHY?

from nearly two months I have started to work as an educator in the pharmacy faculty.

making is so easy than teaching 😀 so I need to learn the mechanisms more.

I know daily requirements for children are approximately 150% of basal metabolic rate with additional calories to support activity and growth.

But why from lipids? if it is only interest with calories, I can find this calories from carbohydrates also.

tnx for your interest.

[Alchemist]

Thanks for your interesting inquiry.

Kindly find the below suggested reasons for favoring the use of lipids over carbohydrates and especially for premature infants:-

1- lipids typically provide energy in an amount of 2.6 times that of dextrose. Therefore providing energy from carbohydrates instead of lipids will cause an overwhelmig carbohydrate load. Here we come to your concern.

2- Dextrose = CO2, many premature infants already have ARDS! (Theoretically thinking)

3- Dextrose higher than 18 gm/kg tends to shift the metabolic process to lipogenesis.

4- Lipid intake is needed to prevent essential fatty acid deficiency.

[Nawal Schmitt]

In addition to what alchemist stated earlier, below are my thoughts:

In neonatal parenteral nutrition, lipids are not allowed to exceed 60% of total caloric intake due to potential complications/risks: 

o Hyperlipidemia.

o 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. 

o Potential increased risk or exacerbation of chronic lung disease. 

o Potential exacerbation of Persistent Pulmonary Hypertension (PPHN).

o Lipid overload syndrome with coagulopathy and liver failure.

Please keep in mind that very preterm infants may not tolerate that much dextrose and may even need insulin as an infusion to achieve adequate caloric intake without hyperglycemia.

Potential complications/risks of carbohydrate include: 

o Hyperglycemia or hypoglycemia.

o Glycosuria and potential osmotic diuresis.

o Cholestasis and/or hepatic steatosis with high caloric intake usually from long-term high concentration infusion.

Hope that helps. 

[Heather Blois]

In addition to the great thoughts of Alchemist and Nawal, mines are shown below… In summary life is about BALANCE and the balance theory necessitates calories diversion as explained below. The concept is the same among Adults and Pediatrics.

1. The source of provided calories to meet Energy Expenditure must be diversed between Dextrose and Lipid as the oxidative capacity of both dextrose and fat in Pediatrics (and in adults) is limited. Therefore, around 60% of calories must be provided as Carbohydrate (not more than 70% and not less than 20%). In adult, the maximum oxidative capacity is 5mg/kg/min and if you do a simple calculation, this accounts to 60% of total needed calories. The minimal dextrose that needs to be provided to an adult  patient even with Glucose intolerance is 120-150g per day; this accounts to 2 mg/kg/min or 25% of total calories. Extra dextrose calories above 5mg/kg/min or 60-70% of total calories leads to Liponeogenesis (de novo lipogenesis) thus huge production of CO2 (RQ = VO2/CO2 more than 8).

2. Lipid is much safer source of calories than carbohydrate if the clearance capacity is assured. As said by Alchemist, lipid produces lower CO2 upon oxidation (Respiratory Quotient is 0.7 compared to 1 with Dextrose). Lipid does not cause electrolytes derangement like dextrose as fat stimulates little insulin release. However, Dextrose is much more efficient source of calories as it stimulates more Insulin that is important for the shift of intracellular ions; therefore synthesis of a balanced cell. Extra lipid beyond 1.5g/kg/day or 60% of total calories lead to Lipogenesis (Fatty liver disease)

3. Minimal dose of lipid to prevent Essential Fatty Acid deficiency is 10% of total calories or around 0.25g/kg/d. We make it 40% to support Dextrose in the formation of cell membrane that is phospholipid in nature and to replete the wasted calories from the catabolic/metabolic process.

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