Instructions
Note: TPN is usually needed only if the patient cannot receive adequate nutrition via the gut. Consider alternate enteral supplementation if appropriate.

• Use appropriate worksheet a guide to ordering. Note: There are two different worksheets depending on the child's weight (30 kg or less and more than 30 kg)
• For "Calculations," multiply patient weight (wt) or total volume of TPN by multiplication factors. Multiplication factors are usual ranges. Note suggestions for first day and maximum amounts. Adjust as needed.
• Right column corresponds to CRIS ordering template
• Be sure to order an inpatient schedule. Standard for short term TPN is to run over 24 hours. For longer term TPN, seek advice on "short-cycle" TPN.
• Intralipids (20% Fat Emulsion): Placed as a separate order under "Fat Emulsion." See appropriate TPN Worksheet for suggestions.
• Seek advice from nutritionist, clinical pharmacy specialist, or pediatric consultant as needed.

References

• Clinical Center Nutrition Support Handbook, January 2001. Website: http://intranet.cc.nih.gov/nutrition/handbook/
• Cox J and Symons H. Nutrition and Growth. In Gunn VL and Nechyba C. The Harriet Lane Handbook. 16th edition. Mosby, 2002.

TPN Ordering for young children < 30 kg

Components	Suggestions	Calculations (Weight = ____kg (wt))	Order in CRIS: Everything except volume is listed in the “TPN Additives” field of the CRIS order form.
Volume	Use daily fluid requirement formulas	TPN desired = ___mL	____mL Final Volume
Amino Acids	- Day 1: 1 g/kg - Day 2 and on: 2 g/kg - Max.: 3g/kg	wt * 1.5-2.5g/kg = ___ grams	____g Amino Acids
Glucose	- Day 1: D10% - Advance by 5%/day to goal - Day 2: D10-15% - Max. peripheral D12.5%	Volume * %desired Examples: For 5% = Volume * 0.05 =____grams For X%= Volume * X/100=____grams	____g glucose
Sodium	- Start with all sodium as NaCl - Adjust each day based on serum bicarb. - If acidotic, increase acetate and decrease chloride. - If alkalotic, decrease acetate	wt * 2-4 mEq/kg = ____ mEq Total of Na components should equal this amount. Day 1: - wt * 3mEq NaCl - 0 mEq Na Acetate - 0 mEq Na Phos	____mEq NaCl (____MEq Na Acetate) (____mMol Na Phos)
Potassium	- Total phosphorus (K Phos or Na Phos) should be 0.5-2 mMol/kg - 1mMol K Phos = 1.5mEq K - If alkalotic, can change Acetate to KCl	wt * 2-3 mEq/kg = ____ mEq Total of K components should equal this amount. Day 1: - wt * 1 mMol/kg K Phos - wt * 1 mEq K Acetate - 0 mEq KCl Adjust based on labs	(____mEq KCl) ____MEq K Acetate ____mMol K Phos
Calcium	- Start with 0.5 mEq/day - Advance if needed - Maximum = 40 mEq/ day and 30mEq/liter	wt * 0.5-2.5 mEq/kg = ____mEq	____mEq Ca gluconate
Magnesium	- Start with 0.3 mEq/kg/day -Advance if low magnesium. - Maximum = 24 mEq/day	wt * 0.3-1 mEq/kg = ___ mEq	____mEq MgSO4
Selenium	Max = 40 mcg	wt * 2 mcg/kg = ____mEq	____mcg Selenium
Pediatric trace minerals	Max = 10 mL/day	wt * 0.2mL/kg	___ mL trace minerals
Vitamins			Dose Pediatric MVI
Other additives	Consult with nutritionist	Ranitidine = wt * 3 mg/kg Heparin (For central lines: Vol.* 0.5U/mL)	Only order as needed.
Intralipids	- Ordered separately - Maximum 20mL/kg/day	Day 1, order 5 mL/kg/day. Day 2, order 10 mL/kg/day. Day 3 and on, order 15 mL/kg /day.	Order volume desired under "Fat Emulsion," part of the TPN order set.

Total calories from TPN/ IL = (____g glucose * 3.4) + (____ g protein * 4) + (____ mL lipids * 2)

Suggested labs:
Acute panel daily Metabolic and Hepatic panels daily until stable, then 2x/week.
Triglycerides 1x/week. Prealbumin 1x/week

TPN Ordering for Children and Adolescents >30 kg

Components	Suggestions	Calculations (Weight = ____kg (wt))	Order in CRIS: Everything except volume is listed in the “TPN Additives” field of the CRIS order form.
Volume	Use daily fluid requirement formulas	TPN desired = ___mL	____mL Final Volume
Amino Acids	- Day 1: 1 g/kg - Day 2 and on: 2 g/kg	wt * 1-2g/kg = ___ grams	____g Amino Acids
Glucose	- Day 1: D10% - Advance by 5%/day to goal - Day 2: D10-15% - Max. peripheral D12.5%	Glucose = Volume * %desired Examples: For 5% = Volume * 0.05 =____grams For X%= Volume * X/100=____grams	____g glucose
Sodium	- Start with all sodium as NaCl. - Adjust each day based on serum bicarb. - If acidotic, increase acetate and decrease chloride. - If alkalotic, decrease acetate.	wt * 2-4 mEq/kg = ____ mEq Total of Na components should equal this amount. Day 1: - wt * 3mEq NaCl - 0 mEq Na Acetate - 0 mEq Na Phos	____mEq NaCl (____MEq Na Acetate) (____mMol Na Phos)
Potassium	- Total phosphorus (K Phos or Na Phos) should be 0.5-2 mMol/kg. - 1mMol K Phos = 1.5mEq K - If alkalotic, can change K Acetate to KCl	wt * 2-3 mEq/kg = ____ mEq Total of K components should equal this amount. Day 1: - wt * 1 mMol/kg K Phos - wt * 1 mEq K Acetate - 0 mEq KCl Adjust based on labs	(____mEq KCl) ____MEq K Acetate ____mMol K Phos
Calcium	- Start with 0.5 mEq/day - Advance if needed - Maximum = 40 mEq/day and 30mEq/liter	wt * 0.5-1 mEq/kg = ____mEq	____mEq Ca gluconate
Magnesium	- Start with 0.2 mEq/kg/day - Maximum = 24 mEq/day	wt * 0.2-0.3 mEq/kg = ___ mEq	____mEq MgSO4
Selenium	Max = 40 mcg	Selenium = 40 mcg	40 mcg Selenium
Pediatric trace minerals	Max = 10 mL/day	wt * 0.2mL/kg	___ mL trace minerals
Vitamins	- Use pediatric MVI if desired - Skip Pediatric MVI if using adult MVI		Dose Pediatric MVI
Other additives	- Consult with nutritionist - New screen - Skip Pediatric MVI if using adult MVI	Vitamins Ranitidine wt * 3 mg/kg (Max 150 mg) Heparin (For central lines: Vol.* 0.5U/mL) Others as needed.	Dose Adult MVI* Only order Ranitidine and heparin as needed. Consult with nutritionist
Intralipids	- Ordered separately - Maximum 20mL/kg/day	Day 1, order 5 mL/kg/day. Day 2, order 10 mL/kg/day. Day 3 and on, order 15 mL/kg /day.	Order volume desired under "Fat Emulsion," part of the TPN order set.

Total calories from TPN/ IL = (____g glucose * 3.4) + (____ g protein * 4) + (____ mL lipids * 2)

Suggested labs:
Acute panel daily Metabolic and Hepatic panels daily until stable, then 2x/week.
Triglycerides and Prealbumin 1x/week.

This information is prepared specifically for caregivers involved in clinical research at the NIH Clinical Center at the National Institutes of Health.