How to handle patients needing IV multivitamins
Recommendations point out alternatives
The American Society for Parenteral and Enteral Nutrition (ASPEN) in Silver Spring, MD, has developed the following recommendations for both infants and adults:
For neonates less than 36 weeks gestation or under 1500 g, ASPEN recommends reserving MVI-Pediatric and Cernevit for neonates, as there is currently no other source of pediatric multivitamins. Agencies whose supplies of MVI-Pediatric are exhausted who are treating neonates in the above category are asked to check with neighboring institutions to see if they have a supply they can share.
ASPEN also reminds agencies that other multivitamins contain propylene glycol and similar quantities of polysorbate 80 and 20 which could be toxic in infants born less than 36 weeks gestation or under 1500 g.
For neonates and infants more than 36 weeks gestation and children less than 11 years old, ASPEN recommends using adult multivitamins with additional supplementation of Vitamin K, such as:
• MVI-12 (Astra)/Multi-12 (Sabex) dosed at 2 ml/kg body weight to a maximum dose of 5 ml/day, or
• MVC (Fujisawa) dosed at 0.5 ml/kg body weight to a maximum dose of 1 ml/day.
MVC does not supply folic acid, cyanocobalamin, or biotin. Therefore, supplementation of 140 mcg/day of folic acid and an intramuscular or subcutaneous injection of cyanocobalamin 100 mcg/month is necessary. No parenteral biotin is commercially available, and children receiving long-term total parenteral nutrition (TPN) may be at risk of developing biotin deficiency.
The above must be supplemented with vitamin K at a dose of 80 mcg daily for infants less that 2500 g and 200 mcg daily for those greater than 2500 g.
Pediatric patients over 11 years old requiring parenteral vitamins can be managed using the recommendations for adult patients, keeping the following in mind:
• All patients greater than 1250 g and able to absorb 50% of nutrients orally should receive vitamins enterally.
• Agencies are aware of problems among TPN patients who may be unaccustomed to having to take vitamins or who may be having trouble absorbing the oral vitamins. Many of the reported cases of vitamin deficiency have been among patients using oral vitamins.
• All patients using oral vitamin preparations must receive thiamin.
For adult patients, ASPEN has released the following recommendations:
1. Thiamin is critical. Several deaths have resulted from cardiac failure due to thiamin deficiency when long-term TPN patients did not receive vitamins for a few weeks. Patients receiving a carbohydrate load are particularly susceptible to thiamin deficiency. The Atlanta-based Centers for Disease Control and Prevention is already aware of cases of thiamin deficiency related to this shortage. This situation is particularly distressing given that thiamin is available. It should also be noted that megaloblastic anemia secondary to folate deficiency has been reported in TPN patients who did not receive folate for four to five weeks. Injectables of both thiamin hydrochloride and folic acid are available for this purpose.
2. Use oral vitamin preparations if appropriate. It is very important to be aware of problems among TPN patients who may be unaccustomed to having to take vitamins or may be having trouble absorbing the oral vitamins. Many of the reported cases of vitamin deficiency have been among patients using oral vitamins. All patients using oral vitamin preparations must receive IV thiamin.
Note: Oral vitamin preparations are not appropriate for patients who have insufficient gastrointestinal function to ensure adequate absorption.
3. Conserve MVI-12 by reducing the daily dose or giving vitamins three times a week.
4. Use Fujisawa’s Multi Vitamin Concentrate 5 ml three times a week along with intravenous supplementation of folic acid (0.4 - 1.0 mg/day) and monthly intramuscular or subcutaneous administration of cyanocobalamin (100 mcg). Due to differences in the vitamin profiles between MVC and MVI-12, the above steps are approximations of equivalency. It is important to remain vigilant to clinical signs of deficiency. (No parenteral biotin product is commercially available to use for supplementation. Biotin deficiency has been reported to develop in adults as early as two months after receiving TPN containing no biotin. Patients on long-term TPN with short bowel syndrome and repeated therapies of antibiotics are at greatest risk.)
5. If a multivitamin preparation is needed and not available, individual vitamin preparations, both oral and injectable, are available. Optimally, patients should receive the individual vitamins listed below on a daily basis. However, this regimen may be difficult for patients in the home setting; such patients should receive, at a minimum, thiamin and folate three times a week. All patients should receive monthly cyanocobalomin. Suggested doses (unless otherwise clinically indicated) are:
• thiamin, 50 mg IV 3 times a week;
• folate, 0.4 - 1.0 mg IV daily;
• ascorbic acid, 100 mg IV daily;
• pyridoxine, 5 - 10 mg IV daily;
• niacin, 40 - 50 mg IV daily;
• cyanocobalamin, 100 mcg IM or SQ monthly.
ASPEN adds that because the adult multivitamin shortage has become a shortage of pediatric multivitamins, agencies using MVI-Pediatric for adult patients should discontinue. ASPEN asks that you share your supply with a local Neonatal Intensive Care Unit, as there is no other source of vitamins for neonates on TPN.
Both ASPEN and the CDC also ask that you report to them any complications as a result of the IV multivitamin shortage by calling (301) 587-6315 and (404) 639-6413, respectively.
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