[Skip to content]

.

Parenteral nutrition

Parenteral nutrition (PN) is the administration of nutrition directly into the bloodstream. It is the method of providing nutrition to children who have severe intestinal failure.

Parenteral nutrition may either provide the child’s full nutritional requirements or more frequently just part, when it is not possible to give the full requirements enterally.

Parenteral nutrition is invasive, has associated risks and should only be used when there is no alternative method of feeding available. 

Assessment for PN

PN may be required for these conditions:

  • prematurity

  • necrotising enterocolitis

  • acute pancreatitis (enteral feeds are usually recommended)

  • intestinal failure:

    • short bowel syndrome

    • protracted diarrhoea with faltering

    • chronic intestinal pseudo-obstruction

    • post-operative abdominal surgery

    • radiation/cytotoxic therapy

  • organ failure:

    • acute renal failure

    • acute liver failure

  • hyper-catabolism:

    • extensive burns

    • severe trauma

Refer to the assessment flowchart (PDF, 210KB). 

No patient should have PN unless a request form is completed (see Appendix 1).

PN needs to be requested by 10.30am for a tailormade bespoke bag to be provided. PN is compounded by pharmacy staff in a laminar airflow cabinet under clean room conditions. The solutions are prepared individually for each child depending on weight, height, clinical condition and the intravenous route available. 

Feeding regimens are built up over two to four days during which time the protein, fat and carbohydrate content are increased.

In certain circumstances, a standard bag will be used, eg when PN is initiated after 10.30am on a weekday or at the weekend, or when the number of PN bags needed exceeds pharmacy capacity.

Administering PN

PN can be administered in a number of ways: 

Continuous PN

This is a 24-hour continuous treatment. It is used when commencing treatment and is warranted by the condition of the child. However, although the vamin is infused over 24 hours, the lipid is only infused for 20 hours unless on cyclical PN. It is switched off for four hours prior to blood sampling to allow for clearance of the fat emulsion from the plasma.

Cyclical PN

Parenteral nutrition is infused for less than 24 hours. Cyclical PN can be used when the child is on a stable regimen and tolerates a reduced infusion time (see completion of infusion).

Constituents of PN

Solution A (ie amino acid solution)

  • amino acids:

    • Vaminolact® for children under 15kg
    • Vamin 18 EF® for children over one year, who are fluid restricted

  • glucose and electrolytes

  • zinc, copper, selenium, manganese, fluoride, iodine and chloride:

    • Peditrace® for children under 15kg
    • Additrace® for those over 15kg
  • Solivito N®: water-soluble vitamins if a non lipid containing regimen

Solution B (ie lipid)

  • lipid emulsions:

    • Intralipid® 20 per cent
    • SMOF® 20 per cent
  • Vitlipid N infant®: fat-soluble vitamins
  • Solivito N®: water-soluble vitamins if a lipid containing regime

Management

To help maintain the safety of the child, all aspects of the management of PN must be performed by suitably trained nursing staff. Unless it is contra-indicated, prior to requesting PN, medical staff should liaise with their ward dietitian to ensure that the child has had an appropriate trial of enteral feeding. 

The multi-disciplinary Nutrition Support team (NST) does a twice weekly ward round of all children receiving parenteral nutrition in the hospital. They are available to discuss any aspects of parenteral nutrition.

Contact numbers for the Nutrition support team (NST)
Position  Contact number 

Senior Pharmacist: Clinical Nutrition

Bleep 0311/Ext 1180

Specialist Nutrition Pharmacist

Bleep 0377/Ext 5340

Specialist Nutrition Pharmacist Bleep 0731/Ext 5340
Specialist Nutrition Pharmacist  Ext 5340 
Consultant Paediatric Gastroenterologist  Ext 8384
Gastroenterology Registrar Bleep 0661
Clinical Nurse Specialist (CNS) Nutrition Bleep 0921/Ext 8304
CNS Nutrition  Bleep 1027 
CNS Nutrition  Bleep 0360
Senior Biochemist Ext 5278
Duty biochemist  Bleep 0589
At night and outside office hours:
On-call pharmacist

Bleep 0714

Clinical site practitioner (CSP) Ext 8169/Bleep 0313 

Inform the child and family

Ensure that the family are informed of the following: (Rationales 1, 2 and 3)

  • the reason for the PN

  • what it will involve

  • the likely duration of the PN

  • the potential side effects of PN

  • the likely impact on the child and family

The ward play specialist should be informed to enable them to work with the child (Rationale 4). Family will be given the leaflet Short Term Parenteral Nutrition by ward staff.

Preparation: baseline parameters

Immediately prior to starting PN, the child’s weight, height and head circumference (<2yrs) should be recorded and dated in their health care records (Rationales 5 and 6).

The child’s height and weight must also be plotted on their centile chart (Rationale 7).

The child must be weighed completely unclothed and according to the clinical guidelines Weight, measuring a child and Height: measuring a child (Rationale 8).

The urinary electrolytes (sodium and potassium) should be recorded (Rationale 9).

Nutrition blood samples should be taken according to the relevant monitoring form. These samples should include copper, zinc, selenium, vitamins A and E (see Appendix 2) (Rationale 10).

Preparation: venous access

Central venous access for the administration of PN must be arranged (Rationale 11).

PN should be administered via a central venous catheter (CVC) (Rationale 12).

A dedicated nutrition line should be used ie a single-lumen CVC (Rationale 13).

A subcutaneous implantable port is only suitable for short term PN (Rationale 14).

PN should not be administered via a peripheral cannula.

A glucose concentration of 12.5 per cent or above should only be administered through a CVC (Rationale 16).

The specialist pharmacists must be informed immediately if a CVC is removed or replaced with a peripherally sited cannula (Rationale 17).

The intravenous device should be cared for according to the relevant clinical practice guidelines (Rationale 18). 

The child’s doctor or an independent prescriber must prescribe PN.  A 'Request to start PN’ form must be fully completed prior to the production and dispensing of the PN (see Appendix 1). 

The doctor should liaise with the ward dietitian about the nutritional aims of treatment and requirements of the child. These should be recorded in the medical notes (Rationale 19).

The prescription is required in the PN pharmacy by 10.30am (Rationale 20).

The doctor should contact the pharmacist on-call if PN is required out of hours (Rationale 21).

Pharmacy will arrange for the delivery of the PN. It will normally be delivered by 6pm (Rationale 22 and 23).

Solutions to be administered over a weekend will be delivered on Friday afternoon (Rationale 24).

It must be stored in the ward drug or PN fridge (Rationale 25).

When PN is delivered to the clinical area it should be (Rationales 22, 13 and 26):

  • checked (ie name of child, hospital number, name of ward and day PN to be given)
  • stored in the ward fridge
  • stored between 2-8°C 

The temperature of the fridge should be recorded daily (Rationale 27).

Preparation: infusion

Negotiate the time to commence PN with the child and family (Rationales 28, 29 and 30).

Remove PN from the fridge at least one hour prior to use (for small bags) and for at least four hours for larger bags (Rationales 38, 39 and 40).

The PN should be prepared in the ward treatment room (Rationales 31 and 32).

Access to the room should be restricted whilst the PN is being prepared (Rationales 33 and 34).

The PN should only be prepared at the bedside if the child is unable to leave their cubicle, eg immobility, infectious precautions, protective precautions (Rationale 31).

It is best practice to prepare PN on an individual basis, ie immediately prior to connection, not in advance (Rationales 13 and 34).

New PN solutions are supplied every 24 hours (Rationale 13).

A new administration set and filter must always be used. These are always supplied with the new solutions.

PN must be administered via an appropriate administration set incorporating a filter. These are connected to the PN solution by pharmacy (Rationale 35).

A 1.2mm filter will be added by pharmacy if the administration set does not have an integral filter (Rationale 36).

All disposable items must have luer lock connections (Rationale 37).

PN must not be decanted into a syringe (Rationale 38).

Check the PN solution for leakage and precipitate (Rationales 42 and 31).

Check the following match when comparing the child’s intravenous prescription chart against the PN solution and the pharmacy therapy sheet, according to the Trust's medicine administration policy (Rationales 43, 44 and 45):

  • first name and family name
  • date of birth
  • hospital number
  • ward name
  • day of infusion
  • route of administration
  • glucose concentration
  • volume to be infused
  • duration of infusion
  • rate of infusion - if cyclical PN, the prescriber should always prescribe a wind down on the IV prescription chart

If there are discrepancies between the child’s prescription and the pharmacy therapy sheet (Rationale 46):

  • The discrepancies must be resolved with the on-call pharmacist and/or the medical staff. If the child is unstable, the prescriber may have changed the rate on the prescription chart.
  • If the PN is not given, an incident form must be completed via Datix (Rationale 47).

Alaris™ Signature Edition® GOLD intravenous infusion pumps are the standard pumps used at Great Ormond Street Hospital for the infusion of PN. This equipment may not be the same for use in a home PN patient (Rationale 48).

Syringe pumps should not be used (Rationale 49).

A thorough hand wash must be performed before and after the procedure (Rationale 31).

Standard (universal) precautions must be adopted (Rationale 31).

The PN should be prepared using an aseptic non-touch technique (Rationale 31).

The administration set and filter should be primed with the PN solution with the lipid solution first, followed by the amino acid solution mixing at the point of entry to the access device (Rationales 50, 51 and 52).

Vitamins are usually added to the lipid bag but when lipid is not prescribed, only water-soluble vitamins will be added by pharmacy to the amino acid solution. If this is the case, the amino acid solution must be covered and protected from light (Rationale 53).

If the child is requiring additional IV therapy, eg antibiotics, an administration set should be connected below the filter (Rationales 54 and 55).

Do not add any other drugs or solutions to the prepared PN solution (Rationales 26 and 31).

Connect infusion

The windows and doors should be shut and fans should be switched off (Rationales 31 and 56). 

Immediately prior to starting PN, the following observations of the child should be recorded (Rationale 57):

  • temperature
  • heart rate
  • respiratory rate
  • blood pressure

The prescription and child’s identity should be checked by two registered nurses in line with the medicine administration policy before connection (Rationale 58).

Using an aseptic non-touch technique (Rationales 31 and 58): 

  • Prepare and assess the child’s CVC according to the relevant clinical procedure guidelines (Rationales 15 and 59).
  • Attach the administration set to the patient (Rationale 60).

The infusion pump should have the following correctly set (Rationales 61 and 62):

  • rate
  • volume to be infused
  • pressure alarms

The level of the pump should be positioned within 30cm of the heart and the pressure alarm set, according to the instructions attached to the infusion device (Rationales 63 and 64).

The infusion pump must be secured onto the infusion stand and whenever possible run off mains electricity. If the battery runs out completely, it must be sent to Biomedical engineering.

Check (Rationales 65 and 66):

  • all connections in the system are tight
  • all the relevant clamps are open

All equipment must be disposed of according to the waste management policy (Rationale 67).

The accessing of the intravenous therapy device and the beginning of PN infusion must be documented in the child’s health care records. Any difficulties encountered must also be recorded (Rationale 68).

Managing infusion: general

The NST should be contacted if there are any concerns about a child receiving PN (Rationale 69). 

The NST reviews children receiving PN on Tuesdays between 2.30-4.30pm and Wednesday 10.00-11.00am (Rationale 70).

The team may be contacted for multi-disciplinary discussions of children receiving PN (Rationales 13 and 71).

Do not add any other drug or solution to the prepared PN solution (Rationales 13 and 26).

Disconnection or manipulation of the PN system should not occur (Rationale 71).

If there is an accidental disconnection:

  • discard the PN
  • do not re-spike bag of PN
  • flush and heparinise the CVC as prescribed
  • seek medical advice

Interruption of the PN should be avoided whenever possible (Rationale 72).

It is recommended that IV medications should not be administered via the PN administration set. If the child requires multiple infusions/or antibiotics these should be filtered via  a multiple lumen extension set or Y-connections should be connected to the child’s CVC before connecting the PN line. The pharmacy must be contacted for advice when it is thought to be unavoidable (Rationales 73 and 74).

The intravenous device should be cared for according to the relevant clinical procedure guidelines (Rationale 19).

If the filter blocks during the administration of the PN solution (Rationale 75):

  • stop the infusion and give appropriate IV fluids if required
  • inform the child’s doctor
  • inform the PN pharmacist, or if out of hours, the on-call pharmacist
  • return the administration set to Pharmacy, Pharmacy will inform the ward of the batch number of the giving set

Managing infusion: monitoring 

The frequency of all the following observations depends on the clinical condition of the child and any underlying disease processes (Rationale 77). 

The following should be monitored and recorded hourly (Rationales 78 and 79):

  • infusion pump pressure
  • infusion rate
  • fluid volume infused

All lines and connections should be checked hourly for leakage and kinking (Rationales31, 81 and 82).

Accurate recordings of the child’s intake (oral and intravenous) and output should be made on the fluid intake chart (Rationale 83).

The following observations should be recorded at least every four hours until PN is fully established (Rationale 84):

  • heart rate
  • temperature
  • respiratory rate
  • blood pressure

The child’s urine should be analysed daily on the ward, at the same time, for glucose and ketones (Rationale 85 and 86).

Blood sugar should be monitored and recorded:

  • every four hours until stable or as glucose monitoring policy for neonates (Reference 5)
  • whenever the glucose concentration is increased (Rationale 85)
  • when receiving cyclical PN, at 30 minutes after stopping PN and as clinically indicated (Rationale 87)

Blood samples for electrolytes and liver function tests should be marked as urgent if the results are needed on the same day (Rationale 88).

Blood should be taken from the line four hours after stopping the lipid infusion (Rationale 89).

The child’s urine electrolytes should initially be monitored twice weekly, then when required (Rationale 91).

Nutritional bloods should be monitored monthly. These include zinc, copper, selenium, vitamins A and E, and ferritin (see Appendix 2) (Rationale 88).

The child must be weighed while completely undressed, daily for the first five days, then at least twice weekly on the same scales and at the same time every day. This should be recorded and dated appropriately on the child’s weight chart (Rationale 92, 93 and 94).

See clinical guideline Weight: measuring a child.

Depending on the condition of the child, this may subsequently change to weekly. This is the minimum frequency.

A monthly weight must be recorded on the child’s centile chart.

The child must be weighed once or even twice daily if acutely unwell (Rationale 96).

The height of the child should be measured accurately using appropriate equipment, recorded in the medical notes and dated appropriately every month. This should be plotted on the child’s percentile chart Height: measuring a child (Rationale 97).

Management of complications

Sepsis

  • Treat line infection and continue PN via the CVC (Rationale 98). 

Cholestatic liver disease

  • Consider ursodexoycholic acid at 10mg/kg TDS (Rationale 99). 
  • Reduce lipids from once daily to full requirements three times per week (Rationale 100). 
  • Consider changing lipid source to SMOF® - discuss with the NST (Rationale 101). 
  • Consider cyclical PN (Rationale 102).

Completion of infusion: continuous PN

The new solutions and the administration sets should be changed without delay according to the child’s prescription (Rationale 109). 

The total volume of PN infused must be recorded on the child’s fluid balance chart (Rationale 68).

When disconnecting the PN, the ‘infusion rate’ and the ‘volume to be infused’ must be cleared on the infusion pump. The ‘volume infused’ recorded on the infusion pump is cleared in the morning when a new fluid chart is commenced. The infusion rate and volume to be infused must be reset when reconnecting (Rationale 105).

Disconnection of infusion and reconnection of the new infusion should be done according to the guidelines for the specific intravenous therapy device being used (Rationale 108).

The disconnection and reconnection must be recorded in the child’s health care records (Rationale 68).

All used equipment should be disposed of according to the waste management policy (Rationale 106).

Completion of infusion: cyclical PN

During the last hour of the infusion, the infusion rate of the vamin must be reduced in stages to prevent rebound hypoglycaemia, especially in infants (Rationale 103). 

The general principal is to approximately half the infusion rate for 30 minutes, then half the rate again for 30 minutes for a total of one hour.

NB: the wind down rates must be less than the original rate especially in young infants.

For infants < four months of age, wind down rates of:

  • 10ml/hour for 30 minutes = 5ml
  • 6ml/hour for 30 minutes = 3ml then stop
  • Total volume for wind down = 8ml

Infants < 1 year:

  • 20ml/hour for 30 minutes = 10ml
  • 10ml/hour for 30 minutes = 5ml
  • Total volume for the wind down = 15ml

For older children: 

  • 40ml/hour for 30 minutes = 20ml
  • 20ml/hour for 30 minutes = 10ml
  • Total volume for the wind down = 30ml
  • 60ml/hour for 30 minutes = 30ml
  • 30ml/hour for 30 minutes = 15ml 
  • Total volume for the wind down = 45ml

Example 1

  • 4kg infant is prescribed 130ml/kg/day PN

PN volumes are:

  • ‘vamin’ 120ml/kg/day over 24 hours
  • lipids 10ml/kg/day over 20 hours

To infuse over 22 hours: 

  • Final vamin volume = 480ml – 8ml wind down volume for an infant = 472ml

Rates including wind down:

  • 472mls over 21 hours = 22.5ml/hour over 21 hours then
  • 10ml/hour for 30 minutes = 5ml then
  • 6ml/hour for 30 minutes = 3ml then stop

Prescribe the wind down rates on the intravenous fluid chart.

When first starting a cyclical regimen, or when increasing the hours when PN is not being infused, the child’s blood glucose level must be monitored within 30 minutes of stopping PN and then as clinically indicated (Rationale 103).

The total volume of PN infused must be recorded on the child’s fluid balance chart (Rationale 66).

When disconnecting the PN, the ‘infusion rate’ and the ‘volume to be infused’ must be cleared on the infusion pump. The ‘volume infused’ recorded on the infusion pump is cleared in the morning when a new fluid chart is commenced. The infusion rate and volume to be infused must be reset when reconnecting (Rationale 104).

Disconnection of the infusion and reconnection of the new infusion must be done according to the guidelines for the specific intravenous therapy device being used (Rationale 105).

The disconnection and reconnection must be recorded in the child’s health care records (Rationale 68).

All used equipment should be disposed of according to the waste management policy (Rationale 106).

Completion of treatment

The specialist pharmacists must be informed when PN is no longer required. The child’s doctor must do this (Rationales 110 and 111). 

When finishing treatment, the volume of PN to be infused should be decreased as the child’s enteral intake increases (Rationales 112 and 113).

The child’s height and weight should be recorded at the end of treatment (Rationale 114).

The child’s height, weight and enteral intake should continue to be monitored by the ward dietitian (Rationale 115).

The intravenous access device should be removed when it is no longer required (Rationale 13).

Going home on PN

The child should be referred to the gastroenterology team and the nutrition nurses should be contacted to discuss arrangements with the child's parents/carers (Rationale 116).

Appendix

Appendix 1: Request form to start parenteral nutrition (PDF, 114KB)  

Appendix 2: Parenteral nutrition monitoring form (PDF, 92KB)

Rationale

Rationale 1: To obtain informed consent. 
Rationale 2: To promote safe delivery of PN. 
Rationale 3: To maximise the effectiveness of the PN. 
Rationale 4: To enable psychological preparation. 
Rationale 5: To enable accuracy of PN formulation. 
Rationale 6: To determine the subsequent effectiveness of the PN. 
Rationale 7: To monitor their growth. 
Rationale 8: To obtain an accurate measurement. 
Rationale 9: To monitor the subsequent effectiveness of the PN. 
Rationale 10: To assess the nutritional status of the child. 
Rationale 11: To enable the PN to be infused. 
Rationale 12: To minimise the risks of extravasation. 
Rationale 13: To reduce risk of infection. 
Rationale 14: Infusion ports are associated with an increased risk of extravasation and infection. 
Rationale 15: Due to the risk of extravasation. 
Rationale 16: A glucose concentration above 12.5 per cent is hypertonic and acidic. This can cause phlebitis and lead to extravasation.
Rationale 17: In order to avoid wastage of tailormade bespoke bags.
Rationale 18: To reduce risk.
Rationale 19: To ensure the nutritional requirements of the child are met.
Rationale 20: To ensure the child receives tailor made PN that day.
Rationale 21: It is the responsibility of the doctor to organise the PN.
Rationale 22: To avoid a delay in the treatment.
Rationale 23: To maintain the child’s treatment cycle.
Rationale 24: PN pharmacy is closed at the weekend.
Rationale 25: To maintain the stability of the PN.
Rationale 26: To maintain the microbiological and physical stability of the product.
Rationale 27: To provide a record for quality assurance.
Rationale 28: To promote a partnership in care.
Rationale 29: To ensure the child is present on the ward.
Rationale 30: To promote effective planning.
Rationale 31: To minimise the risk of infection.
Rationale 32: To provide ease of access to required resources.
Rationale 33: To promote effective time management.
Rationale 34: To reduce the risk of mistakes.
Rationale 35: To remove particles produced during the manufacture of PN.
Rationale 36: To avoid particulate contamination.
Rationale 37: To minimise the risk of accidental disconnection which could result in embolism, haemorrhage and infection.
Rationale 38: To avoid contamination of the PN.
Rationale 39: To avoid infusing a solution that is too cold causing hypothermia and minimising the appearance of champagne bubbles.
Rationale 40: To ensure PN is at room temperature.
Rationale 41: To ensure the stability of the PN.
Rationale 42: To ensure the PN is fit for use.
Rationale 43: To ensure the correct product is prepared for the correct patient.
Rationale 44: To ensure the prescription is correct.
Rationale 45: To ensure appropriate nutrition is maintained.
Rationale 46: Discrepancies may be due to changes in the child’s clinical condition.
Rationale 47: To minimise risk.
Rationale 48: To ensure accuracy of infusion.
Rationale 49: To reduce the risk of contamination.
Rationale 50: To prevent air embolism.
Rationale 51: To ensure the administration set is patent.
Rationale 52: To prevent precipitation.
Rationale 53: Some water-soluble vitamins are light sensitive, particularly vitamin B2.
Rationale 54: Only vamin should be filtered.
Rationale 55: To minimise the risk of infection by reducing the number of times the CVAD is accessed.
Rationale 56: To minimise the number of procedures undertaken by the child’s bed.
Rationale 57: To establish the baseline for subsequent observations.
Rationale 58: To reduce the risk of a drug error.
Rationale 59: To assess patency and position of the CVAD.
Rationale 60: To enable treatment to commence.
Rationale 61: To maintain patient safety.
Rationale 62: To promote the effective use of the medical device.
Rationale 63: To maintain gravity thus avoiding siphonage.
Rationale 64: To ensure the pressure alarm functions correctly.
Rationale 65: To prevent accidental disconnection.
Rationale 66: To facilitate flow of PN.
Rationale 67: Safe practice as detailed in hospital policy.
Rationale 68: To maintain an accurate record.
Rationale 69: To enable issues to be resolved.
Rationale 70: To review current PN regimens and promote the most effective use of PN.
Rationale 71: To ensure the safety of the child.
Rationale 72: To maintain the child’s nutritional support according to their prescription.
Rationale 73: To prevent potential drug interactions.
Rationale 74: To prevent potential absorption of the drug into the filter.
Rationale 75: To obtain a standard PN solution from pharmacy.
Rationale 76: To enable investigation of the blockage.
Rationale 77: To meet the needs of the child.
Rationale 78: To ensure accuracy of infusion pump.
Rationale 79: To contribute to assessment of patency of CVAD.
Rationale 80: To enable the early detection of extravasation and phlebitis.
Rationale 81: To reduce risk of haemorrhage.
Rationale 82: To minimise risk of embolism.
Rationale 83: To monitor fluid intake to help prevent dehydration or fluid overload.
Rationale 84: To observe for fluid overload.
Rationale 85: To monitor tolerance to glucose in PN.
Rationale 86: It can be an early indicator of sepsis.
Rationale 87: To check for rebound hypoglycaemia.
Rationale 88: To guide the maintenance of normal blood chemistry by altering the constituents of the PN solution.
Rationale 89: To allow for alteration of PN solution.
Rationale 90: To allow for clearance of fat emulsion from the plasma, which can alter the results. Rationale 91: To monitor total body sodium and potassium.
Rationale 92: To measure the effectiveness of treatment.
Rationale 93: To enable accuracy of PN formulation.
Rationale 94: To monitor fluid overload.
Rationale 95: To ensure consistency of recording.
Rationale 96: To observe for fluid overload or dehydration.
Rationale 97: To measure the effectiveness of treatment.
Rationale 98: To ensure adequate nutrition during sepsis.
Rationale 99: To improve biliary flow.
Rationale 100: To allow for lipid metabolism and clearance between lipid containing PN.
Rationale 101: To reduce the omega six content of the lipid emulsion.
Rationale 102: To promote clearance of lipid.
Rationale 103: To prevent rebound hypoglycemia.
Rationale 104: To ensure tolerance to a cyclical regimen.
Rationale 105: To minimise the risk of error on reconnection.
Rationale 106: To meet hospital guidelines.
Rationale 107: Safe practice as detailed in hospital guidelines.
Rationale 108: Safe practice as detailed in hospital policy.
Rationale 109: To maintain treatment regime.
Rationale 110: To ensure the child’s nutritional requirements are met.
Rationale 111: To reduce wastage and therefore costs.
Rationale 112: To prevent fluid overload.
Rationale 113: To re-establish enteral nutrition.
Rationale 114: To audit the effectiveness of the treatment.
Rationale 115: To monitor progress.
Rationale 116: To ensure appropriate referral is completed and the home care company can be informed. 

References

Reference 1: 
JPEN (2002) Guidelines for the use of parenteral and enteral nutrition in adults and paediatric patients. Journal of Parenteral and Enteral Nutrition 26:1: 1SA-138SA.  

Reference 2: 
Bravery K (1999) Paediatric intravenous therapy Dougherty L and Lamb J In: Intravenous Therapy in Nursing Practice. Edinburgh, Churchill Livingstone.  

Reference 3: 
Burnham P (1999) Parenteral nutrition Dougherty L and Lamb J In: Intravenous Therapy in Nursing Practice. Edinburgh, Churchill Livingstone.

Reference 4: 
Department of Health (2003) Winning Ways: Working together to reduce healthcare associated infection. London, Department of Health.

Reference 5: 
Koletzko B, Goulet O, Hunt J, Krohn K, Shamir R, Parenteral Nutrition Guidelines Working Group, European Society for Clinical Nutrition and Metabolism, European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), European Society of Paediatric Research (ESPR) (2005) 1. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr 41 Suppl 2: S1-87.

Reference 6: 
Royal College of Nursing IV Therapy Forum (2003) Standards for Infusion Therapy. London, Royal College of Nursing.

Reference 7: 
Acra S, Rollins C (1999) Principles and guidelines for parenteral nutrition in childrenPediatric Annals 28(2): 113-120.  

Reference 8: 
Silk D B A (Editor) (1994) Organisation of Nutritional Support in Hospitals. Maidenhead, British Association for Parenteral Nutrition.

Reference 9: 
Sizer T (Editor) (1996) Standards and Guidelines for Nutritional Support of Patients in Hospitals. Maidenhead, British Association for Parenteral and Enteral Nutrition.

Document control information

Lead author(s) 
Venetia Horn, Senior Specialist Pharmacist: Clinical Nutrition, Pharmacy

Additional authors
Dr Susan Hill, Consultant Paediatric Gastroenterologist
Anna Hughes, Clinical Nurse Specialist Nutritionsit
Sarah Macdonald, Principal Dietitian, Dietetic Department

Document owner
Venetia Horn, Senior Specialist Pharmacist: Clinical Nutrition, Pharmacy

Approved by
Clinical Practice Committee

First introduced: 31 January 2001 
Date approved: 
31 January 2013
Review schedule: 
Two years 
Next review: 
31 January 2015 
Document version: 
3.1 
Replaces version: 
3.0