Aluminum in Preterm Infants: Less is More
Source: Bishop N, et al. Aluminum neurotoxicity in preterm infants receiving intravenous feeding solutions. N Engl J Med 1997; 336:1557-1561.
Neurologists would be well advised to learn more about treatable perinatal problems that, if left alone, endanger future outcomes. Over the lifetime of the child, any measure that might improve developmental outcome in this patient population would be welcome. Bishop et al suggest that aluminum neurotoxicity may be a preventable cause of brain injury in preterm infants.
Intravenous hyperalimentation has been a mainstay of modern therapy in preterm infants before 31-32 week post-conceptional age (CA). Many such infants born at CA = 23-24 weeks may receive intravenous hyperalimentation for several months. Using atomic-absorption spectroscopy, Bishop et al determined that "standard" hyperalimentation solutions expose such children to about 45 mcg/kg/d of aluminum. Changing the source of calcium in these solutions from calcium gluconate to calcium chloride resulted in a 90% reduction of aluminum exposure (aluminum is apparently a contaminant introduced in the manufacture of the gluconate salt). The authors then compared developmental outcome (at 18 months of age) in 227 premature infants randomly assigned to receiving "standard" hyperalimentation to those receiving aluminum depleted hyperalimentation.
Among the 157 of 227 infants without neuromotor impairment at 18 months, Bayley Mental Development Index scores were significantly higher in the infants receiving aluminum depleted hyperalimentation. A score of less than 85, believed to predict future academic difficulties, occurred in 39% of the children receiving standard hyperalimentation but only 17% of children receiving low aluminum-content hyperalimentation (P = 0.03). Bishop et al calculated a dose effect that amounted to a one point reduction in the Bayley Index for each day that the child received hyperalimentation.
Neurologists should consider these potential toxic effects of hyperalimentation solutions in children, particularly those with reduced renal function. rt
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