Presented at the Neonatal Society 2012 Spring Meeting.

Brown K, Khashu M

Poole Hospital NHS Foundation Trust

Background: Neonates, especially preterm infants need supplementation of vitamins, minerals and iron (1,2), these being the most common drug prescriptions in neonatal units. Even though there is specific guidance with regard to supplementation, anecdotal experience suggests significant variation in practice. Inappropriate supplementation can have serious adverse consequences for the infant. We explored current practice regarding vitamin, mineral and iron supplementation in neonatal units.

Methods: A questionnaire regarding the use of multivitamin preparations, iron, phosphate and folic acid supplements was emailed to neonatal network leads across England for distribution to individual unit leads. We also emailed the Neonatal Nutrition Network (N3), including units in Scotland and Ireland and some individual units if we failed to get any response through the above. Data was analysed using MS Excel.

Results: Responses were received from 13 out of 24 English Neonatal Networks. We also had responses from 2 areas of Scotland, 1 in Northern Ireland and 1 from Ireland. In total we had 25 responses with information for 50 units (26 NICU, 19 LNU and 5 SCU) as some responses included network wide guidelines. Although the response rate was not very good, they were geographically well spread.
Multivitamin preparations: 32% used Dalivit 0.3mls, 30% used Dalivit 0.6mls, 24% used Abidec 0.3mls and 42% used Abidec 0.6mls. With regards to which newborns receive multivitamin supplementation; 68% used a gestation cut off, 36% used birth weight/IUGR, 28% used gestation and birth weight combined. The timing of starting multivitamin supplements also varied, from a.s.a.p. to 28 days, the most common practice being when the baby is tolerating full feeds (66%). Duration of supplementation varied from 6 months to 5 years.
Phosphate: Eligibility criteria varied from routine supplementation for a certain weight (4%) or gestation (22%) to biochemical abnormalities (low phosphate (88%), calcium (2%), and high alkaline phosphatase (46%). Dosing varied between 0.5-2mmol/kg/day.
Iron: All units used iron supplements. Doses ranged from 0.2ml/kg/day-1.1ml/kg/day. Common practice is to use Sytron 1ml daily (70%). 12 units (24%) used a smaller dose of 0.5ml OD for babies <1.5kg. Duration of supplementation advised was from 6 months to 1 year. 42% advised continuation until on a balanced weaned diet.
Compliance: We have calculated the percentage of responders compliant with ESPGHAN or WHO recommendations for vitamin A, D and iron supplementation during a stable growing period for preterm or low birth weight infants, using example baby weights of 1.5 and 2.5kg. The only supplement that units are nearing compliance (1,3) to is iron at 2.5kg (90%). Using an example weight of 1.5kg, 92% of units are supplementing too much iron using the guideline of 2-3mg/kg/day. 30% of units are giving too much vitamin A by using Dalivit 0.6ml for a baby of 2.5kg. This increases to 62% with a baby of 1.5kg as Dalavit 0.3ml has too much vitamin A. Only 32% of units are compliant with a dose of Dalivit 0.3ml (2.5kg) and 42% with a dose of Abidec 0.6ml (1.5kg). The new guidelines for vitamin D mean that Dalivit and Abidec in the doses used are not compliant with ESPGHAN.

Conclusion: Even though the response rate to the survey was not high, the results suggest a wide variation in practice between neonatal units. Compliance to ESPGHAN and WHO guidance is poor. It would be useful to achieve some degree of consensus on a national level and optimise practice and outcomes.

Corresponding author: kelly.brown@nhs.net

References
1. Agostoni C, Buonocore G, Carnielli V.P et al. Enteral nutrient supply for preterm infants: Commentary from the ESPGHAN. J Pediatr Gastroenterol Nutr, Vol. 50, No 1, January 2010.
2. Tsang R C, Uauy R, Koletzko B et al. Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines. 2nd Edition 2005. Digital Educational Publishing ISBN-13: 978-1583521007
3. Edmonds K, Bahl R. Optimal feeding of Low Birth Weight Infants: A Technical Review. WHO. 2006. http://www.who.int/child_adolescent_health/documents/9241595094/en/index.html