Parenteral nutrition (PN) is a clinical intervention necessary for many neonatal and pediatric patients during acute and chronic illnesses. While patient-specific PN is regularly utilized by specialized pediatric hospitals for patients varying from extremely low birth weight infants through adolescents, pharmacists working in an adult facility may not be as familiar with these therapies. By sharing lessons learned about key clinical features, safety concerns, and ordering processes, we aim to provide helpful insight to those needing to provide PN for the pediatric population who would otherwise not routinely do so.

The University of Iowa Stead Family Children’s Hospital (UI-SFCH) is a 209-bed children’s hospital with a Level IV NICU and Level I trauma center. Medication distribution to patient care areas is completed using a hybrid of centralized and decentralized approaches. Both the preparation and distribution of PN are conducted by a multidisciplinary team that manages the decision-making, processing, compounding, and delivery of products throughout the hospital.

Candidates for Parental Nutrition

Pediatric patients who may require total PN include those with gastrointestinal malformations, injury, or failure, as well as neonates who cannot meet energy expenditure and growth solely through enteral nutrition.1 Gastrointestinal malformation examples include short bowel syndrome, mucosal diseases from radiation therapy or autoimmune enteropathy, bowel obstructions due to strictures or adhesions, and motility disorders like Hirschsprung’s disease. PN may be delayed up to one week if the indication is self-limited in an infant, pediatric, or adolescent patient; however, for most patients who are intolerant to oral intake, or determined to not tolerate, extended enteral intake should be initiated within one to three days for infants and four to five days for pediatrics and adolescents. Premature and very low birth weight neonates (less than 1500 g) should be initiated on PN promptly after birth.

Risk Mitigation

While there are many risks associated with PN in general, additional complexities arise in the pediatric population. Each product is patient-specific, necessitating careful evaluation of disease state, indication for parenteral nutrition, acuity, age, weight, and weight-based dosing of volume and components within the PN preparations. Transcription errors may be more prone to occur as a result of the patient-specific volume, lipid, and ingredient components. Compatibility issues may also arise due to limited intravenous (IV) access sites and stability with concurrent medications. There are various approaches facilities should consider undertaking to address these risks.

Multidisciplinary Approach

Multidisciplinary patient-centered care for PN planning and ordering is one risk mitigation strategy (see the FIGURE). At UI-SFCH, daily recommendations are driven by dieticians in collaboration with physicians, mid-level practitioners, and pharmacists. Communication among team members includes discussion about the patient’s clinical status, organ function, and current medication regimen to optimize nutritional needs.

Click here to view a larger version of this FIGURE.

Following provider order entry, the pediatric clinical pharmacist can compare the current PN order against the two previous PN orders in the electronic health record (EHR), listing individual components and highlighting changes in the current order during order verification. Once the order is transcribed into the automated compounding device, two operations-based pharmacists double-check calcium and phosphate solubility, product osmolality, and manual additions before initiating compounding. Prior to administration, two nurses provide a final check of each printed product label against the order in the computer order entry and then scan and program the infusion pump for administration. Involving multiple healthcare professionals and incorporating redundancies throughout the prescribing and administration process are essential for reducing errors with high-risk PN medications.

Standardized Formulations

Standardized formulations can add significant efficiency and safety improvements to every step of the PN process. While commercially available premixed 2-in-1 PN formulations may be appropriate for some adult-sized adolescent patients with limited electrolyte abnormalities, younger pediatric patients, especially neonates, have different protein, electrolyte, and volume requirements than adolescents and adults. These specific needs have prompted some pediatric hospitals to create unique starter recipe PNs that contain minimal, if any, electrolytes, standard dextrose, and protein to meet the baseline needs of newly initiated PNs, most commonly utilized in neonates. The benefit of using a standard starter recipe is that PN can be initiated without delay in the smallest neonates after birth. This formulation will meet the needs of the neonate until an individualized formula can be created.

Additional standardization efforts at UI-SFCH include templates with baseline standard ingredients that may be modified to fit patient-specific needs, such as neonatal reduced sodium, standard neonatal with electrolytes, and pediatric electrolyte free. Neonatal templates include a neonatal-specific protein source and cysteine to improve calcium and phosphate solubility; pediatric templates include standard protein and electrolytes, trace elements, and pediatric-specific multivitamin contents.

Standardizing Ordering

Utilizing computerized provider order entry (CPOE) is best practice for preventing transcription errors that can occur with handwritten, verbal, and telephone orders.2 Standardized electronic ordering allows for the development of order sets or standard templates with clear instructions and guidance for pediatric-specific product selection encompassing electrolyte salt forms, medication additives with correct doses, and calculating weight-based measurements. Additionally, order sets can include forcing functions to ensure required elements such as dosing weight and central vs peripheral administration routes are input prior to order submission.

All healthcare professionals involved in monitoring, ordering, verifying, or administering PNs should be required to complete education and demonstrate competency in these areas. To ensure a standardized approach to PN is consistently followed, the processes should be formalized in institutional policies and procedures (P&Ps). These P&Ps should address clinical dosing recommendations for pediatric patients, the ordering processes, and the monitoring of both laboratory and clinical changes. For healthcare sites unfamiliar with pediatric weight-based dosing requirements by age, the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines and dosing recommendations are easily accessible and widely practiced.3 Any changes and recommendations, including long-term plans and nutritional goals, should be formally documented in the patient’s chart.

Conclusion

Special considerations must be made for PN initiation, product selection, compounding, and administration for pediatric patients. A multidisciplinary team approach and standardization of protocols are important frameworks to support the mitigation of risk. Using the expertise from a multidisciplinary team can help to optimize the daily assessments of patients’ nutritional needs and goals while simultaneously minimizing the risk of error.

References

1. Worthington P, Balint J, Bechtold M, et al. When is Parenteral nutrition appropriate? JPEN J Parenter Enteral Nutr. 2017;41(3):324-377.
2. Ayers P, Adams S, Boullata J, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr. 2014;38(3):296-333.
3. American Society for Parenteral and Enteral Nutrition. Appropriate Dosing for Parenteral Nutrition: ASPEN Recommendations. 2020. https://www.nutritioncare.org/uploadedFiles/Documents/Guidelines_and_Clinical_Resources/PN%20Dosing%201-Sheet-Nov%202020-FINAL.pdf

Kayla Huebner, PharmD, BCPPS, is a pediatric clinical pharmacist at the University of Iowa Hospitals & Clinics Stead Family Children’s Hospital. She completed her doctor of pharmacy at the University of Wisconsin- Madison, PGY1 pharmacy residency at the University of Tennessee Health Science Center and Le Bonheur Children’s Hospital, and PGY2 pediatric pharmacy residency at Children’s Minnesota.

Felix Lam, PharmD, MBA, BCPS, is the pediatric pharmacy operations manager for the University of Iowa Hospitals & Clinics in Iowa City, Iowa. He earned his doctor of pharmacy from the University of North Carolina Eshelman School of Pharmacy and his MBA with an emphasis on health care management from the Johns Hopkins Carey Business School while completing a combined PGY1/PGY2 in health-system pharmacy administration at The Johns Hopkins Hospital.

Leah Rasmussen, PharmD, is a PGY2 pediatric pharmacy resident at the University of Iowa Hospitals & Clinics Stead Family Children’s Hospital. She completed her doctor of pharmacy at the University of Iowa College of Pharmacy, and PGY1 Pharmacy Residency at the University of Iowa Hospitals & Clinics.

Sarah B. Tierney, PharmD, BCPPS is the pediatric clinical pharmacy manager and previously practiced in the neonatal intensive care unit as the clinical pharmacy specialist at the University of Iowa Hospitals & Clinics. Dr. Tierney is also the director of the PGY2 specialty residency in pediatrics at UIHC and an adjunct associate professor at the University of Iowa College of Pharmacy.