Total parenteral nutrition in Pediatrics

Total Parenteral Nutrition (TPN) in pediatrics is a life-sustaining therapy that delivers all essential nutrients directly into the bloodstream via a central venous catheter when the gastrointestinal tract is non-functional or needs rest. It’s commonly used in neonates, children with short bowel syndrome, severe malabsorption, or critical illness.

Nutritional support can be administered through a central venous access is termed total parenteral nutrition (TPN). It is also called IV alimentation.

Types/Components of Total Parenteral Nutrition Solution

1. Highly concentrated solution of carbohydrates (CHO)
2. Lipid emulsion to supply need for essential fatty acids
3. Total nutrient admixture (TNA) with components of total parenteral nutrition (TPN) plus lipids and other additives. TNA refers to a PN formula with CHO, lipids, amino acids, vitamins, minerals, water, trace elements, and other additives in a single container. It is also known as three-in-one admixture, trimix, or all-in-one parenteral admixture.

Nurse’s Responsibility

• When administered cycled IPN, the solution is infused at half the prescribed rate for the first and last hour to prevent hyper- and hypoglycemia.
• Initiation of infusion should be slow and then gradually increase the rate of flow.
• Monitor the blood glucose level frequently such as every 4-6 hours at early stage, and every 12th hourly thereafter.
• If blood glucose levels are elevated, subcutaneous administration of insulin may be needed.
• Perform catheter site care, tubing and filter changes, and dressing changes according to institutional policy.
• Inspect the insertion site closely for signs of infection.
• Monitor the child’s daily weight, vital signs, and intake/ output.
• Review laboratory test results, which can aid in early detection of problems, such as infection or electrolyte deficits/ excess.
• Adhere to strict aseptic technique.
• Adhere to institutional policy for flushing of the catheter and maintaining catheter patency.
• Ensure that the system remains closed at all times. Secure all the connections, use occlusive dressing, and clamp the catheter or have a child perform the Valsalva maneuver during tubing and cap changes.

Points to Remember

• If any reason the TPN infusion is interrupted or stops, begin an infusion of a 10% dextrose solution at the same infusion rate as of TPN. This helps to prevent rebound hypoglycemia that may occur due to increased insulin secretion by the child’s body in response to the use of highly concentrated TPN solution.
• Never administer any medication, blood, or other solution through the TPN lumen. Doing so will increase the risk for contamination of the system and infection.

Health Education of the Child and Family

Children who require long-term TPN therapy may receive TPN in home.

• Provide written and verbal instructions about the care involved.
• Demonstrate the care to parents and child (if appropriate).
• Develop plans for troubleshooting problem with devices and equipment and give instructions to how to recognize and treat complications.
• Also teach them about danger signs and symptoms that require immediate notification.
• Significant others, for example, teacher should be informed about venous access devices.

Promoting Growth and Development

• Vigorous sports should be avoided.
• Provide love, comfort, support, and socialization to the child during TPN as like enteral feeding.
• Provide opportunities for holding and cuddling the child.
• Allow the older child to participate in activities that can help to occupy the time associated with meals.
• Child’s dental care should not be neglected.
  Encourage the child and parents to participate in the care to promote a sense of independence as well as a sense of control over the situation.
  Infants and toddlers should be allowed to crawl and pull up to standing position to promote optimum development.
• Running the tubing under one-piece clothing outfit and out the back often encourages ambulation.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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