5 year-old male with long-term HPN dependence secondary to short bowel syndrome is seen for routine follow-up. Enteral tolerance is currently maximized. PN currently providing energy 45 kcal/kg/day, protein 1.3 gram/kg/day, IV soybean lipids 1 gram/kg/day, glucose infusion rate 10 mg/kg/minute. There has been no weigh gain for 3 consecutive outpatient visits. Z-score as follows: Weight -2, Height -2.5, BMI -0.5. All labs are stable, including micronutrients and inflammatory markers. What is the next appropriate step?
The correct answer is C. Increase glucose infusion rate by 2 mg/kg/minute to increase calories by 10%. Nutrition should be advanced by enteral route whenever possible. However, PN support should be increased when growth is faltering as evinced by 2-3 consecutive visits with inadequate weight or height gain or weight loss. If soybean based IV lipid emulsions are used, the dose should be restricted to at most 1 gram/kg/day in patients on long-term PN. Protein should be used for lean mass accrual, not caloric support per se. A number of micronutrients could be considered to explain inadequate growth velocity in this patient, such as zinc, copper, sodium and others. Levels may be checked, and providers should ensure that there’s adequate dietary provision. Inflammation may interact with growth and protein catabolism through a variety of mechanisms, including tumor necrosis factor alpha.