Parenteral and Enteral Nutrition

Nutritional Support Basics - Fueling Tiny Humans

• Goal: Meet nutritional needs when oral intake is insufficient or impossible.
• Enteral Nutrition (EN): Preferred; uses the gut (e.g., NG, OG, gastrostomy). "If gut works, use it!"
• Parenteral Nutrition (PN): IV route; when GI tract is non-functional or inaccessible (e.g., TPN).
• Key Indications: Prematurity, severe malnutrition, critical illness (burns, sepsis), major GI surgery/anomaly, short bowel syndrome.

⭐ EN is more physiological, helps maintain gut mucosal integrity, and is associated with fewer septic complications compared to PN.

Enteral Nutrition - Gut Instincts

• Motto: "If gut works, use it!" Preferred over PN.
• Indications: Functional GIT, poor oral intake (e.g., prematurity, critical illness, dysphagia).
• Access Routes:
  • Short-term (< 4-6 wks): Nasogastric (NG), Orogastric (OG), Nasojejunal (NJ).
  • Long-term (> 4-6 wks): Gastrostomy (PEG), Jejunostomy (PEJ).
• Types of Feeds:
  • Polymeric (standard formulas)
  • Semi-elemental/Elemental (hydrolyzed nutrients)
  • Disease-specific (e.g., renal, hepatic)
  • Fortified Human Milk (FHM) for preterms.
• Administration: Bolus, intermittent, continuous.
• Complications:
  • GI: Diarrhea, vomiting, aspiration.
  • Mechanical: Tube issues (block, displacement).
  • Metabolic: Refeeding syndrome.

⭐ For high aspiration risk or gastroparesis, nasojejunal (NJ) or post-pyloric feeding is preferred. oka

Parenteral Nutrition - Vein Ventures

• IV nutrition if GIT non-functional/inaccessible: >3-5 days (infants), >7 days (children/adolescents).
• Components & Targets:
  • Carbohydrates (Dextrose): Glucose Infusion Rate (GIR) 4-8 mg/kg/min (max 14-18 g/kg/d).
  • Amino Acids (Pediatric): 1.5-3 g/kg/d.
  • Lipids (EFAs, calories): 0.5-3 g/kg/d (max 40-60% non-protein calories).
  • Electrolytes, Vitamins, Trace Elements: Daily adjustment.
• Access Routes:
  • PPN (Peripheral): Short-term (<2 wks); osmolarity <900 mOsm/L; phlebitis risk.
  • TPN (Central): Long-term (>2 wks); high osmolarity; via PICC, Broviac.
• Indications: Short bowel syndrome, severe malabsorption, NEC, prolonged ileus, major surgery/trauma.
• Complications:
  • Catheter: CLABSI (most common serious), thrombosis.
  • Metabolic: Hyper/hypoglycemia, PNALD, refeeding syndrome, electrolyte imbalance, hypertriglyceridemia.

⭐ PNALD (Parenteral Nutrition-Associated Liver Disease) risk is increased with prematurity, prolonged TPN duration, sepsis, and use of soy-based lipid emulsions.

Monitoring & Troubleshooting - The Watchful Eye

• Regular Checks:
  • Clinical: Wt, I/O, GI (EN), catheter site (PN).
  • Labs: Glucose, electrolytes (K, PO4, Mg), LFTs, RFTs, TGs. Daily → 2-3x/wk.
• Refeeding Syndrome: ⚠️
  • Risk: Severe malnutrition.
  • Signs: ↓PO4, ↓K, ↓Mg. 📌 PHOS-K-MAG
  • Rx: Correct electrolytes. Start low (~10 kcal/kg/d), advance slow.
• Other Issues:
  • PN: PNALD, sepsis, hyperglycemia, ↑TGs.
  • EN: Diarrhea, aspiration, tube issues.
• Transition (PN → EN): Overlap. Stop PN if EN meets >75% needs.

⭐ Thiamine 100-300mg IV/PO daily for 3-5 days before nutrition in high-risk refeeding patients prevents Wernicke's encephalopathy.

High‑Yield Points - ⚡ Biggest Takeaways

• Parenteral Nutrition (PN) is for a non-functional GIT; Enteral Nutrition (EN) is preferred if the GIT is functional, as it maintains gut integrity.
• Central PN is for long-term use and hyperosmolar solutions; Peripheral PN (PPN) is for short-term use (<2 weeks) with lower osmolarity solutions.
• Monitor for refeeding syndrome (↓PO₄, ↓K, ↓Mg) upon PN/EN initiation in malnourished patients.
• Prolonged PN is a significant risk factor for cholestasis, especially in infants.
• Nasojejunal (NJ) tubes are preferred over nasogastric (NG) tubes in patients with high aspiration risk or gastroparesis.
• Early EN (within 24-48 hours) is crucial in critically ill children if the GIT is functional, improving outcomes.