TPN

protein (4 kcal/g)

Start on DOL# 1 and increase by 1 g/kg/day to goal
Preterm goal: 4.5 g/kg/day (ELBW may not tolerate it initially)
Term goal: 3.5 g/kg/day
Renal failure/azotemia: 2-2.5 g/kg/day (not less than 1.5 g/kg/day)
Hypoalbuminemia: additional protein may be required if serum albumin < 3.0 g/dL, and/or BUN < 5 mg/dL
If severe metabolic acidosis, hold L-cysteine for few days

Start on DOL #1 at 1 g/kg/day in ELBW and 2 g/kg/day for older preterm and term infants
Increase by 0.5-1 g/kg/day up to 3 g/kg/day if TG level is normal
Check TG in infants <1500 grams before they are increased to 3 (goal is triglycerides < 200 mg/ dL)
Stop IL when enteral volume intake >120 mL/kg/day
Chylothorax: no need to withhold IV lipids
Cholestasis: decrease IV lipids to 2 g/kg/day if direct bili > 2 mg/ dL and increasing.
Sepsis: check triglyceride levels and adjust lipids as needed to keep TG <200 mg/dL
If lipids withheld for any reason, do so < 5 days (prevent essential fatty acid deficiencies)

Start Na 1-2 mEq/kg/day on DOL #2-3
- Infants are born with excess sodium and will usually have a salt diuresis ~DOL 3
Start K 1-2 mEq/kg/day on DOL #2-3 if adequate UOP
Start Mg 0.5-1 mEq/kg/day on DOL #3
Start calcium on DOL #1
Start phosphorus on DOL #2 at Ca: Phos ratio of 1.3:1
Progress to goal for both calcium and phosphorus in 2-3 days
- <32 weeks GA or <2 kg: Ca 75 mg/kg and Phos 57 mg/kg
- >32 weeks GA or >2 kg: Ca 60 mg/kg and Phos 46 mg/kg

Start at the appropriate formulation for gestational age on DOL # 1
Preterm formulation: continue until 3.5 kg
Term formulation: term infants and preterms when >3.5 kg
Cholestasis formulation for severe disease: direct bilirubin > 5 mg/dL with upward trend
- Check serum copper once/month (while on TPN) if the infant is >44 weeks C.A.
- If serum copper > 1.45 microgram/mL -> change to cholestasis trace elements
- If < 1.45 microgram/mL -> continue age-appropriate trace elements