# Nutrition in Pediatric Intensive Care: A Narrative Review
## 9 Parenteral Nutrition  
Parenteral nutrition (PN) is associated with higher morbidity, infectious complications and mortality in comparison with enteral nutrition [11; 12]. PN can be individually initiated during the first week of PICU stay in children unable to receive any enteral nutrition; however, supplemental PN should be delayed after the first 7 days (in patients on enteral nutrition) [1; 18]. When considering supplemental PN, the content must be individualized daily according to protein and E targets and the amount of enterally delivered feeding tolerance. On the other hand, total parenteral nutrition should involve complete E delivery and protein delivery based on ideally mixed protein, carbohydrates, lipids ratio (e.g., 25:50:25% of energy content) together with trace minerals, vitamins and electrolytes. So-called peripheral parenteral nutrition can be administered through the peripheral venous cannula, due to osmolarity <850 mosmol (does not irritate the vein walls, lower risk of phlebitis). Low osmolarity is derived from a glucose/dextrose concentration below 10%, a lower concentration of nutrients and sometimes a lack of lipid emulsion in the mix (therefore, these types of PN cannot be used for total parenteral nutrition). Total PN, due to high osmolarity, should be administered through a central vein catheter (CVC), peripherally inserted central venous catheter (PICC), tunneled central venous catheter or implanted port system in the central vein [46]. When prescribing total PN, individually based nutrition (all parts of the system--macronutrients and micronutrients being prescribed by the clinician, prepared mainly by the hospital pharmacy), or commercially based/standard (prepared by the pharmaceutic companies) can be chosen. According the recent recommendations, standard (commercially available default all-in-one preparations) should be preferred in the majority of patients (including newborns), if possible, to reach the individual nutritional  
\begin{table}
\begin{tabular}{p{14.2 pt} p{142.3 pt} p{142.3 pt}} \hline \hline
1. & Prokinetics & Metoclopramide, Domperidone—agents for gastric motility improvement \\
2. & Continuous enteral feeding via enteral feeding pump & Usually, 18–19 h of continuous administration via gastric tube with 5–6 h pause \\
3. & Bowel stimulation & Erythromycin—stimulate the bowel motility Consider subcutaneous naltrexone in patients on opioidsSuppository rectally applied \\
4. & Oligomeric formula & Oligomeric formula or peptide-based formula \\
5. & Post-pyloric feeding & Jejunal tube placement and continuous enteral feeding without the night pause \\ \hline \hline \end{tabular}
\end{table}
Table 5: Methods to improve enteral feeding intolerance.  
requirements, with individually based PN being another option [47]. If standard parenteral nutrition is used, micronutrients should also be added using the prepared mixtures of water- and lipid-soluble vitamins and trace elements. The specifics of prematurely born infants need to be taken into account, and additional solutions might be needed to cover their specific needs, e.g., higher calcium and phosphorus demands.