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Micronutrient Supplementation in Preterm Infants

Clinical Guideline

V1.0

August 2020

Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0 of 13

Summary

NO

YES Routine

supplementation not required Supplementation with Abidec +/- Folic

acid +/- Iron may be required when infant reaches 150ml/kg/day enteral

feeds

Refer to Micronutrient Supplementation In Preterm Infants –

Clinical Guideline for feed-specific requirements and doses

Include guidance for GP on ongoing supplement prescription requirements in

discharge summary.

Review supplementation with every feed change

GP to review supplementation with any further feed change post-discharge

Was the infant born <34 weeks gestation

OR <1800g birth weight?

END

START


1. Aim/Purpose of this Guideline

1.1. The vitamin and mineral content of breastmilk (or standard infant formula) is likely to be insufficient for many preterm infants (1). Breastfed preterm infants with a birth weight <1800g will need supplementation to meet recommended micronutrient intakes (2,3). The aim of this guideline is to provide clear, evidence-based guidance for providing micronutrient supplements to preterm infants, both during their stay on the neonatal unit/transitional care and following discharge home. This guideline applies to: Neonatal nurses; Midwives; Doctors; Neonatal Dietitians; Pharmacists; GPs.

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2. The Guidance

2.1. Additional micronutrient supplementation should be considered for all preterm infants born at less than 34 weeks gestation OR with birth weight less than 1800g.

2.2. The micronutrient supplements required will vary depending on feed choice.

Recommended doses are specified in the following table:

2.3. If an infant is receiving a combination of different feed types, follow the

supplementation guidance for whichever feed is given in the highest volume.

2.4. Micronutrient supplements should be reviewed every time an infant’s feed is changed, both as an inpatient and in the community.

2.5. In special circumstances, it may be necessary to refer to the neonatal

dietitian, who will calculate individual micronutrient intake and offer advice on supplementation.

Unfortified breastmilk

Half-strength

fortified breastmilk

Term formula

Nutriprem 1

Nutriprem 2

Full-strength fortified

breastmilk When to prescribe

Abidec 0.6ml OD 0.3ml OD Not required

10am Start when tolerating 150ml/kg/day feeds.

Stop at 12 months

corrected

Folic Acid

500mcg OD for DAT++/+++

positive baby for 8 weeks.

50mcg OD

Not required

Not required

2pm Start when tolerating 150ml/kg/day feeds.

Stop at discharge.

Iron

1ml Sytron OD

(5.5mg elemental

iron)

Not required

1ml Sytron OD

(5.5mg elemental

iron)

6pm Start at day 28.

Stop at 12 months

corrected

Phosphate

Consider supplementation only if serum phosphate <1.8mmol/L and ALP >500

1 mmol/kg/day

Split doses

Decision to start/stop based on bloods.


2.6. Include guidance for GP on ongoing supplement prescription requirements in the Badger discharge summary.

2.7. Parents should be made aware that The Department of Health recommend

that all children aged 6 months to 5 years are given a daily multivitamin containing A,C and D unless they are taking more than 500ml of formula milk daily (4).

3. Monitoring compliance and effectiveness

Element to be monitored

The prescription of supplements as per recommendations in this guideline, for inpatients and post-discharge.

Lead Neonatal dietitian

Tool Micronutrient supplementation audit tool – see appendix 4 Please use Excel version available in the Dietetics Neonatal Shared folder: S:\TR11\Dietetics\Nut&dt\Specialities\Neonatal\Audit\Micronutrient supplementation audit tool.xlsx

Frequency Annual audit and report

Reporting arrangements

Child Health Directorate Audit meetings

Acting on recommendations and Lead(s)

The Neonatal Dietitian will work with the paediatricians and pharmacists to agree a suitable action plan to address recommendations.

Change in practice and lessons to be shared

Required changes to practice will be identified and actioned within 3 months of audit. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Inclusion & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://intranet-rcht.cornwall.nhs.uk/shelf/equality-and-diversity/


Appendix 1. Governance Information

Document Title Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0

This document replaces (exact title of previous version):

New Document

Date Issued/Approved: 15 July 2020

Date Valid From: August 2020

Date Valid To: August 2023

Directorate / Department responsible (author/owner):

Neonatal - Georgia Kirwin, Neonatal Dietitian

Contact details: 01872 252409

Brief summary of contents

This guideline is designed to provide guidance to neonatal staff and general practitioners on prescription of micronutrient supplements to preterm infants.

Suggested Keywords: Neonatal, nutrition, infant feeding, vitamins, supplements, micronutrients

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Approval route for consultation and ratification:

Neonatal Guidelines Group

General Manager confirming approval processes

Mary Baulch

Name of Governance Lead confirming approval by specialty and care group management meetings

Caroline Amukusana

Links to key external standards none


Related Documents:

1. Uauy R, Koletzko B. Defining the nutritional needs of preterm infants. In: World Review of Nutrition and Dietetics. S. Karger AG; 2014. p. 4–10.

2. Lapillonne A, Bronsky J, Campoy C, Embleton N, Fewtrell M, Fidler Mis N, et al. Feeding the Late and Moderately Preterm Infant. J Pediatr Gastroenterol Nutr [Internet]. 2019 Aug [cited 2020 Jul 8];69(2):259–70. Available from: https://pubmed.ncbi.nlm.nih.gov/31095091/

3. Agostoni ÃC, Buonocore G, Carnielli V, De

Curtis M, Darmaun jj D, Decsi ô T, et al. Enteral Nutrient Supply for Preterm Infants: Commentary From the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition. 2009 [cited 2020 May 30]; Available from: www.kindergesundheit.de

4. NHS. Vitamins for children - NHS [Internet]. 2018 [cited 2020 Jul 8]. Available from: https://www.nhs.uk/conditions/pregnancy-and-baby/vitamins-for-children/

5. Darlow BA, Graham PJ, Rojas-Reyes MX. Vitamin A supplementation to prevent mortality and short- and long-term morbidity in very low birth weight infants. Vol. 2016, Cochrane Database of Systematic Reviews. John Wiley and Sons Ltd; 2016.

6. Chinoy A, Mughal MZ, Padidela R. Metabolic bone disease of prematurity: Causes, recognition, prevention, treatment and long-term consequences [Internet]. Vol. 104, Archives of Disease in Childhood: Fetal and Neonatal Edition. BMJ Publishing Group; 2019 [cited 2020 Jul 2]. p. F560–6. Available from: https://fn.bmj.com/content/104/5/F560

Training Need Identified? No

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder

Clinical / Neonatal


Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job

Title)

July 2020 V1.0 Initial issue Georgia Kirwin, Neonatal Dietitian

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust

Policy for the Development and Management of Knowledge, Procedural and Web

Documents (The Policy on Policies). It should not be altered in any way without the

express permission of the author or their Line Manager.


Appendix 2. Equality Impact Assessment

Section 1: Equality Impact Assessment Form

Name of the strategy / policy /proposal / service function to be assessed Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0

Directorate and service area: Child health directorate - Neonatal

Is this a new or existing Policy? New

Name of individual completing EIA Georgia Kirwin, Neonatal Dietitian

Contact details: 01872 252409

1. Policy Aim Who is the strategy / policy / proposal / service function aimed at?

This guideline is designed to provide guidance to neonatal staff and general practitioners on prescription of micronutrient supplements to preterm infants.

2. Policy Objectives As above

3. Policy Intended Outcomes

To enable appropriate and consistent micronutrient prescribing for preterm infants.

4. How will you measure the outcome?

See section 3

5. Who is intended to benefit from the policy?

Preterm infants

6a). Who did you consult with?

b). Please list any groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

x

Please record specific names of groups: Neonatal Guidelines Group Neonatal dietitians at University Hospitals Bristol and North Bristol NHS Trust.

c). What was the outcome of the consultation?

Approved 15 July 2020


7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have a positive/negative impact on:

Protected Characteristic

Yes No Unsure Rationale for Assessment / Existing Evidence

Age X

Sex (male, female non-binary, asexual etc.)

X

Gender reassignment

X

Race/ethnic communities /groups x

Any information provided should be in an accessible format for the parent/carer’s needs – i.e. available in different languages if required/access to an interpreter if required

Disability (learning disability, physical disability, sensory impairment, mental health problems and some long term health conditions)

X

Those parent/carers with any identified additional needs will be referred for additional support as appropriate - i.e to the Liaison team or for specialised equipment. Written information will be provided in a format to meet the family’s needs e.g. easy read, audio etc

Religion/ other beliefs

X

All staff should be aware of any beliefs that may impact on treatment. Information on Halal/Kosher suitability of supplements has been requested

Marriage and civil partnership X

Pregnancy and maternity X

Sexual orientation (bisexual, gay,

heterosexual, lesbian) X

If all characteristics are ticked ‘no’, and this is not a major working or service change, you can end the assessment here as long as you have a robust rationale in place.

I am confident that section 2 of this EIA does not need completing as there are no highlighted risks of negative impact occurring because of this policy.

Name of person confirming result of initial impact assessment:

Georgia Kirwin, Neonatal Dietitian

If you have ticked ‘yes’ to any characteristic above OR this is a major working or service change, you will need to complete section 2 of the EIA form available here: Section 2. Full Equality Analysis For guidance please refer to the Equality Impact Assessments Policy (available from the document library) or contact the Human Rights, Equality and Inclusion Lead [email protected]

http://doclibrary-rcht-intranet.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/ChiefExecutive/Templates/Section2FullEqualityAnalysis.docx

mailto:[email protected]


Appendix 3. Supporting Information The micronutrients that may need supplementing in preterm infants are as follows:

Vitamin A: Plays a role in vision, growth, healing, reproduction, cell differentiation and immune function; also important in fetal lung cell differentiation and surfactant synthesis (1). Cochrane review suggested vitamin A supplementation slightly reduced the risk of death and chronic lung disease at 36 weeks corrected age (5). Unfortified breastmilk or term formula will not provide sufficient vitamin A to meet preterm requirements defined by ESPGHAN (3). Appropriate levels of vitamin A are routinely included in breastmilk fortifier, infant multivitamin preparations and preterm formulas.

B and C vitamins: There is little capacity for storage of these water-soluble vitamins within the body; preterm infants will quickly develop deficiencies without regular intake. Preterm infants are likely to have particularly high requirements for B vitamins due to their high metabolic rate and rapid tissue turnover (1). Unfortified breastmilk will not provide sufficient B and C vitamins to meet preterm requirements defined by ESPGHAN (3). Appropriate levels of B and C vitamins are routinely included in term formula (excepting Niacin), breastmilk fortifier, Abidec and preterm formulas.

Vitamin D: Plays a role in the absorption of calcium and phosphate, and is therefore important in bone metabolism. 400IU/day (10mcg) is thought to be appropriate to maintain serum vitamin D levels and avoid the risks associated with excessive intake (1). However, ESPGHAN recommend 20-25mcg/day, based on evidence suggesting many infants are already vitamin D deficient at birth, due to maternal deficiency (3). Preterm formulas contain relatively low concentrations of vitamin D, to avoid toxicity with high intakes. All infants, except those receiving breastmilk fortifier, will need supplementation with a vitamin D-containing multivitamin preparation e.g. Abidec.

Folate: In preterm infants, folate demands of growth outstrip intake from unfortified breastmilk, which may contribute to folate deficiency. However, there is little evidence that low folate levels contribute to anemia of prematurity (1,3). Preterm formulas and breastmilk fortifier will provide adequate folic acid to meet ESPGHAN requirements, but infants receiving term formulas or unfortified breastmilk will need supplementation. It is not included in infant multivitamin preparations eg Abidec.

Iron: Preterm infants are born with lower iron stores than term infants, due to iron accretion occurring in the third trimester. Losses through phlebotomy also decrease iron levels. Risks of iron depletion include anaemia and poor neurodevelopment. Risks of excess supplementation include poor growth and increased infection risk. Uauy and Koletzko (1) recommend commencing supplementation at 2 weeks in infants with birth weight <1500g. ESPGHAN recommend commencing supplementation at 2-4 weeks of age for infants with birth weight <1800g(3). Supplemental iron is included in preterm formulas but not in breastmilk fortifier or infant multivitamin preparations e.g. Abidec.


Phosphate: Accretion of phosphate in the third trimester occurs at a rate of 50–65 mg/kg/day. Phosphate absorption varies from 60-95% in preterm infants – this variation accounts for the wide variety in intake recommendations from various professional bodies (1). Human milk fortifier, added to the breast milk, and preterm formulae are designed to provide increased calcium and phosphorus requirements for preterm infants. There is a lack of evidence to support routine supplementation of oral phosphate in preterm infants (6). On commencing phosphate supplements, infants may need calcium supplementation to maintain an appropriate calcium to phosphate ratio.


Appendix 4. Audit Tool

Please use Excel version available in the Dietetics Neonatal Shared folder - S:\TR11\Dietetics\Nut&dt\Specialities\Neonatal\Audit\Micronutrient supplementation audit tool.xlsx

Patient no Birth weight Gestation at birth Time point at audit Outcome - Abidec Outcome - Folic acid Outcome - Iron Outcome - Phosphate