LRI Children’s Hospital 
                                   Parenteral Nutrition - Monitoring and Weaning UHL Childrens 
                                                                          Hospital Guideline (Part 2 of 3) 
                           Staff relevant to:                                                   Medical, nursing, pharmacy, dietetic staff 
                           Team approval date:                                                  October 2019 
                           Version:                                                             V 2 
                           Revision due:                                                        April 2023 (6 month extension given following Chair’s approval) 
                           Written by:                                                          David Harris, Dr Hemant Bhavsar, Dr Anne Willmott, 
                                                                                                R. Zseli, Kristian Bravin 
                           Trust Ref:                                                           C43/2018 
                           Acknowledgement: This document is based on the extensive review by Ghazala Javid and 
                           the Paediatric Gastroenterology Team over the last 15 years 
      
                           Contents 
                           Section 3:  Monitoring ........................................................................................................... 3 
                               Biochemical Monitoring ..................................................................................................... 4 
                               Adjustments based on Blood Results ................................................................................ 5 
                               Physical Assessment ......................................................................................................... 5 
                           Section 4: Troubleshooting .................................................................................................... 5 
                               Refeeding syndrome ......................................................................................................... 5 
                               Refeeding Syndrome Prevention ....................................................................................... 6 
                               Prophylactic vitamins ......................................................................................................... 8 
                               Metabolic complications .................................................................................................... 9 
                                   Hypoglycaemia ............................................................................................................. 10 
                                   Hyperglycaemia ............................................................................................................ 10 
                                   Hypertriglyceridemia ..................................................................................................... 10 
                           Parenteral Nutrition - Monitoring and Weaning UHL Childrens Hospital Guideline      Trust Ref: C43/2018                                                         Page 1 of 22 
      
                           V: 2 Approved by Children’s Clinical Practice Group : October 2019                                                                                 Next Review: April 2023 
                           6 month extension given following Chair’s approval 
                           NB: Paper copies of this document may not be most recent version. The definitive version is held in the Trust Policy and Guideline Library 
                                   Metabolic acidosis ......................................................................................................... 11 
                                   Cholestasis ................................................................................................................... 11 
                                   In acute sepsis, significant acidosis, liver derangement ................................................ 12 
                                   Line Infection Prophylaxis (inc Taurolock) and Treatment ............................................. 12 
                                   Chylothorax ................................................................................................................... 13 
                                   Failure to thrive whilst on PN......................................................................................... 14 
                               Section 5 - Administration Issues ...................................................................................... 14 
                                   Unavailability of PN ....................................................................................................... 14 
                                   Increased fluid requirements ......................................................................................... 14 
                                   Line Failure ................................................................................................................... 15 
                                   Medication incompatibilities .......................................................................................... 15 
                               Preterm and term infants .................................................................................................. 15 
                               Children ............................................................................................................................ 16 
                               Appendix 1 – Information Sheet for Weaning TPN ............................................................ 21 
                           INFORMATION SHEET FOR WEANING TPN .................................................................... 21 
                           Rates to be prescribed on the drug chart for each 24 hour period ................................ 21 
                               Appendix 2 - How to calculate reduced infusion rates of paediatric TPN........................... 22 
                           1. Introduction and who Guideline applies to 
      
                           Parenteral nutrition (PN) is nutrition that is delivered to the circulation without using the gut. It 
                           is complex and expensive. A multidisciplinary approach to the management of these patients 
                           is needed to optimise therapy and reduce complications. Close liaison between the patient’s 
                           clinical team and the ward Dietician or Paediatric Gastroenterologist on service is vital to 
                           achieve optimum care. 
                           This guideline applies to all Health Professionals who administer PN to Neonates, Infants, 
                           Children and Young People cared for in UHL Childrens Hospital, including those aged 16-25 
                           on Ward 27 (Teenage, Young Adult Cancer Unit) or in EMCHC. Young adults aged 16-18 
                           years who are being cared for on all other UHL wards requiring PN should be referred to the 
                           Leicester Intestinal Failure team (LIFT) 
                           Related documents: 
                                  •      Adults - please see Policy for the Administration of Parenteral Nutrition via a 
                                         Central Venous Catheter in Adults B22/2015 
                                  •      NNU Neonates - please see Neonatal Parenteral Nutrition Guidelines 
                                         C28/2018 
      
                           UHL Parenteral Nutrition in Children - Initiation – referral, ordering, prescribing and 
                           administration Trust ref: C42/2018 
                           Parenteral Nutrition - Monitoring and Weaning UHL Childrens Hospital Guideline      Trust Ref: C43/2018                                                         Page 2 of 22 
      
                           V: 2 Approved by Children’s Clinical Practice Group : October 2019                                                                                 Next Review: April 2023 
                           6 month extension given following Chair’s approval 
                           NB: Paper copies of this document may not be most recent version. The definitive version is held in the Trust Policy and Guideline Library 
                           UHL Parenteral Nutrition in Children - Supporting Information Trust ref: C44/2018 
      
                           UHL Procedure for Administering Parenteral Nutrition in Babies, Children and Young 
                           People Trust ref: C45/2018 
      
                           Guideline to identify and manage paediatric inpatients who are at risk of refeeding 
                           syndrome. Trust ref: B19/2019 
      
      
      
                           2. Guideline Standards and Procedures 
      
      
                           When considering using TPN for your patient there are a few questions to answer to 
                           demonstrate the benefits outweigh the risks of treatment 
                           There are 3 Children’s Hospital Parenteral Nutrition guidelines available (see above related 
                           documents): 
                           •      Part 1 Initiation – referral, ordering, prescribing and administration 
                                         o  Indication                                        Will TPN be beneficial? 
                                         o  Vascular Access                                   Is a central line present or planned? 
                                         o  Nutritional requirements Is there enough volume available? 
                            •     Part 2 - Ongoing care – Monitoring, troubleshooting and weaning 
                                                    o  Monitoring                             Are these assessments feasible? 
                                         o  Troubleshooting                                   What can go wrong? 
                           •      Part 3 - Information – Appendices of forms and basis for advice 
      
      
                           Section 3:  Monitoring 
      
      
                           All monitoring of the patient is the responsibility of the doctors on the clinical team 
                           looking after the patient. 
                           Parenteral Nutrition - Monitoring and Weaning UHL Childrens Hospital Guideline      Trust Ref: C43/2018                                                         Page 3 of 22 
      
                           V: 2 Approved by Children’s Clinical Practice Group : October 2019                                                                                 Next Review: April 2023 
                           6 month extension given following Chair’s approval 
                           NB: Paper copies of this document may not be most recent version. The definitive version is held in the Trust Policy and Guideline Library 
                           Biochemical Monitoring 
                           Monitoring is necessary to identify those patients with, or at risk of, electrolyte disturbances. 
      
                           Parameters                         Baseline on day 1                        Week 1                                   Week 2, 3 and 4 
                                                              commencing TPN 
                           Sodium,                            All to be done daily                     All to be done daily                     All to be done daily if unstable, 
                           potassium, urea,                                                                                                     otherwise all parameters to be 
                           creatinine                                                                                                           done thrice weekly for week 2. 
                           Blood glucose                                                                                                        On week 3 all parameters 
                                                                                                                                                checked once a week if stable 
                           Triglycerides                      Triglycerides are to 
                                                              be measured daily                                                                 Measurement of random urine 
                           Calcium                            while increasing                                                                  sodium and potassium is 
                           (albumin also                      lipids                                                                            recommended to explain the 
                           done routinely),                                                                                                     cause/s of hypo/hypernatraemia 
                           phosphate,                                                                                                           or hypo/hyperkalaemia 
                           magnesium 
                           LFTs                                                                                                                
                           Fe, Zn, Se, Cu,                                                                                                      Ferritin, Iron, zinc, selenium, 
                           Cr, Mo,                                                                                                              copper, chromium and 
                                                                                                                                                molybdenum monthly 
                                                                                                                                                Check zinc sooner if poor weight 
                                                                                                                                                gain against expected 
                           FBC                                To be done daily                         To be done daily                         To be done daily if unstable, 
                                                                                                                                                otherwise to be done three times 
                                                                                                                                                a week for week 2 
                           Clotting screen                    To be done daily                         Do on day 3 and 5                        Do once a week, unless unstable 
                           Urinalysis                         To be done daily                         To be done twice a                       Weekly for week 2 then as 
                                                                                                       week                                     needed by electrolyte 
                                                                                                                                                requirements 
                           Weight                             To be done daily                         To be done twice a                       To be done twice a week for < 1- 
                                                                                                       week for < 1year                         year old patients , unless 
                                                                                                       old patients , unless                    unstable 
                                                                                                       unstable 
                           Parenteral Nutrition - Monitoring and Weaning UHL Childrens Hospital Guideline      Trust Ref: C43/2018                                                         Page 4 of 22 
      
                           V: 2 Approved by Children’s Clinical Practice Group : October 2019                                                                                 Next Review: April 2023 
                           6 month extension given following Chair’s approval 
                           NB: Paper copies of this document may not be most recent version. The definitive version is held in the Trust Policy and Guideline Library