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Hypertonic formula resulting from added oral medications
Insights
Oral elixirs, like calcium glubionate, significantly increase infant formula osmolality, posing a risk for necrotizing enterocolitis in premature infants. Intravenous preparations are a safer alternative due to lower osmolality.
Area of Science:
- Neonatal Medicine
- Pediatric Pharmacology
- Clinical Pharmacy
Background:
- Necrotizing enterocolitis (NEC) is a serious gastrointestinal condition affecting premature infants.
- Medications administered orally to neonates can alter gastrointestinal physiology.
- The osmolality of enteral feeds is a critical factor in neonatal gut health.
Observation:
- A premature infant developed necrotizing enterocolitis after receiving calcium glubionate elixir in feedings.
- The osmolality of several common oral elixirs (theophylline, phenobarbital, dexamethasone, digoxin) was significantly higher than their intravenous counterparts.
- Mixing oral elixirs like dexamethasone and phenobarbital with infant formula drastically increased formula osmolality.
Findings:
- Oral elixir preparations, particularly dexamethasone and phenobarbital, markedly increase formula osmolality when administered in clinically relevant doses.
- The osmolality increase in formula-drug mixtures can exceed 300% compared to formula alone.
- The osmolality impact of digoxin, theophylline, and calcium glubionate elixirs on formula was less pronounced but still notable.
Implications:
- High osmolality from oral elixirs may contribute to the pathogenesis of necrotizing enterocolitis in vulnerable premature infants.
- Switching to intravenous formulations or using lower osmolality oral preparations may mitigate NEC risk.
- Healthcare providers should carefully consider medication formulation and osmolality when prescribing for premature neonates.
Abstract:
Necrotizing enterocolitis developed in a premature infant after a medication in elixir form, calcium glubionate, was added to his feedings. The osmolalities of this medication and four others--theophylline elixir, phenobarbital elixir, dexamethasone elixir, and digoxin elixir--were measured by freezing-point depression and compared with the osmolalities of the analogous intravenous (IV) preparations. The osmolalities of the IV preparations were much lower than those of the corresponding oral preparations, except in the case of digoxin. When clinically appropriate doses of dexamethasone and phenobarbital elixirs were mixed in volumes of formula appropriate for a single feeding for a 1,500-g infant, the osmolalities of the drug-formula mixtures increased at least 300% over formula alone. This effect was less noticeable with digoxin elixir, theophylline elixir, and calcium glubionate.