Trace Element Provision in Parenteral Nutrition in Children: One Size Does Not Fit All

Abstract

Routine administration of trace elements is recognised as a standard of care in children requiring parenteral nutrition. However, there is a lack of global consensus regarding trace elements provision and dosing in pediatric parenteral nutrition. This review provides an overview of available evidence regarding trace elements supply and posology in parenteral nutrition in neonates and children. Trace elements provision in children should be tailored to the weight and clinical condition of the child with emphasis on those at risk of toxicity or deficiency. Based on current evidence, there is a need to review the formulation of commercial solutions that contain multiple-trace elements and to enable individual trace elements additives to be available for specific indications. Literature supports the removal of chromium provision whereas manganese and molybdenum supplementation are debated. Preterm neonates may have higher parenteral requirements in iodine, selenium and copper than previously recommended. There is growing support for the routine provision of iron in long-term parenteral nutrition. Further studies on trace elements contamination of parenteral nutrition solutions are needed for a range of trace elements.

Adequacy of Parenteral Nutrition in Preterm Infants According to Current Recommendations: A Study in A Spanish Hospital

“…This may be due to an inaccurate control of days of PN, because 86.7% of preterm infants for whom trace elements were not initiated on the established days began receiving trace elements on day 6. It should be noted that the published guidelines of the ASPEN, SENPE and ESPEN scientific societies do not specify when administration of these micronutrients should begin; this should be reviewed, because a consensus that specifies how these micronutrients should be supplied is needed [33].…”

Parenteral Provision of Micronutrients to Pediatric Patients: An International Expert Consensus Paper

“…2 The necessity of additional provision of certain TEs, such as Cr and Mn, has been questioned because of the ubiquitous contamination of these elements within other PN components. 80 Reliance on unknown and variable amounts of contaminants to provide these micronutrients is still being recommended but is not a defensible policy. 2 Since neonates may be particularly vulnerable to excessive doses of these contaminants, more research is needed to further inform the maximum allowable levels of these contaminants and their relative safety.…”

“…Apppropriate investigations are listed in Table 6. Fat-soluble vitamins, on the other hand, can be measured on a 6-to 12-weekly basis 80,83 in patients receiving long-term PN.…”

Nutritional Management for Infants and Children Pre and Post-Liver Transplant

“…Heavy metals are usually excreted in the bile, and without bile flow accumulate and may be deposited in the basal ganglia resulting in movement disorders [2]. Routine supplementation of chromium is avoided at Seattle Children's given lack of evidence for deficiency with supportive evidence for toxicity in pediatric patients on long term PN [13]. Sodium is not limited in enteral nutrition for infants to ensure adequate nutrition for brain development anticipating losses from potential causes such as emesis or diuretics.…”

“…Micronutrient recommendations for infants and children with ESLD (general starting guidelines per our institution[1,2,13].…”