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Implementation of Parenteral Nutrition Formulations with Increased Calcium and Phosphate Concentrations and Its
Sushma Sureshchandra1, Rajesh Maheshwari1,2, Tamara Nowland3
1Department of Neonatology, Westmead Hospital, Westmead, NSW 2145, Australia.
Insights
Higher calcium and phosphorus in parenteral nutrition significantly reduced Metabolic Bone Disease of Prematurity (MBDP) in preterm infants. This approach also eliminated severe MBDP cases without adverse effects, improving infant bone health.
Area of Science:
- Neonatology
- Pediatric Nutrition
- Bone Metabolism
Background:
- Metabolic Bone Disease of Prematurity (MBDP) is a prevalent complication in extremely preterm infants (≤28 weeks gestation).
- Parenteral nutrition (PN) is essential for preterm infants, and its composition may influence bone health outcomes.
- Optimizing calcium (Ca) and phosphorus (P) delivery via PN is crucial for preventing MBDP.
Purpose of the Study:
- To compare the effectiveness of two standard PN formulations with differing Ca and P concentrations on MBDP incidence in preterm infants.
- To evaluate the predictive value of biochemical markers in diagnosing MBDP.
- To assess the safety of higher Ca and P concentrations in PN regarding adverse events like hypercalcemia, hypophosphatemia, and nephrocalcinosis.
Main Methods:
- Retrospective study of preterm infants (≤28 weeks gestation) receiving two different PN formulations.
- Group 1 received PN with lower Ca (1.6 mmol/kg/day) and P (1.4 mmol/kg/day).
- Group 2 received PN with higher Ca (2.3 mmol/kg/day) and P (1.8 mmol/kg/day). Biochemical and radiological data were reviewed.
Main Results:
- The incidence of MBDP decreased from 82.8% to 47.3% with the higher Ca and P PN formulation.
- Severe (Grade 2-3) MBDP was eliminated in the group receiving higher Ca and P PN (p < 0.01).
- Serum phosphate < 1.5 mmol/L and alkaline phosphatase > 500 U/L demonstrated good sensitivity and specificity for diagnosing MBDP.
Conclusions:
- Increased Ca and P concentrations in PN formulations effectively reduce MBDP incidence and severity in extremely preterm infants.
- Higher Ca and P PN did not lead to increased hypercalcemia, hypophosphatemia, or nephrocalcinosis.
- Low serum phosphate and high serum alkaline phosphatase are reliable biochemical predictors for MBDP diagnosis.
Abstract:
Background: Metabolic Bone Disease of Prematurity (MBDP) is common in extremely preterm infants (≤28 weeks gestation). Parenteral nutrition (PN) with higher calcium (Ca) and phosphorus (P) concentration started soon after birth may improve bone health in preterm infants. We compared the effect of two standard PN formulations on the incidence of MBDP and explored the predictive ability of biochemical markers for diagnosing MBDP. Methods: This retrospective study included eligible preterm infants ≤ 28 weeks gestation. Infants in group 1 (January 2016-December 2017) received PN 1 formulation with lower Ca (1.6 mmol/kg/day) and P concentration (1.4 mmol/kg/day). Infants in group 2 (June 2018-May 2020) received PN 2 formulation with higher Ca (2.3 mmol/kg/day) and P concentration (1.8 mmol/kg/day). We reviewed the biochemical and radiological investigations performed for diagnosing MBDP. Results: The incidence of MBDP reduced from 82.8% (77/93) in group 1 to 47.3% (27/57) in group 2. Grade 2-3 MBDP reduced significantly from 14% in group 1 to none in group 2 (p < 0.01). Serum phosphate < 1.5 mmol/L had a sensitivity of 79% and specificity of 77%, and alkaline phosphatase > 500 U/L showed a sensitivity of 72% and specificity of 71% for diagnosing radiological MBDP. There was no increase in hypercalcemia, hypophosphatemia or nephrocalcinosis from PN 2 formulation. Conclusions: A higher Ca and P concentration in PN reduced MBDP and eliminated grade 2-3 MBDP in our cohort without an increase in adverse events. Low serum phosphate and high serum alkaline phosphatase were the best predictors for diagnosing MBDP.
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