`

`W. Mihatsch et al. / Clinical Nutrition 37 (2018) 2360-2365
`
`2361
`
`Type of publications: Original papers, meta-analyses and
`overviews.
`Key words: (Parenteral Nutrition or (Infusions, Parenteral)) or
`(parenteral and nutrition); (calcium or phosphorus or phosphate*
`or bone or mineralization or magnesium)
`Age: Child, infant, preterm
`Language: English.
`
`component, Ca, P, and Mg also play major roles in many physiologic
`processes [1,2).
`In infants and children growth is the major determinant of
`mineral requirements. This is best analyzed for fetal growth
`where there is a linear association between fetal weight and
`total body content of Ca and P (0.21 mmol (8.3 mg) Ca/g and
`0.15 mmol (4.7 mg) P/g) [3-6). Given an average fetal weight
`
`Table: Recommendations for calcium, phosphorus and magnesium in PN
`
`R 8.1
`
`R 8.2
`
`R 8.3
`
`R 8.4
`
`R 8.5
`
`R 8.6
`
`R 8.7
`R 8.8
`
`R 8.9
`
`R 8.10
`
`R8.11
`
`R 8.12
`
`R8.13
`
`R 8.14
`
`In infants, children and adolescents on PN appropriate amounts of Ca, P and Mg should be provided to ensure optimal growth and bone mineralization ( GPP,
`strong recommendation)
`The mineral accretion of the fetus, healthy infant, child, and adolescent may be used as a reference for Ca, P and Mg provision ( GPP, conditional
`recommendation)
`In the individual infant appropriate PN should provide a simultaneous slight surplus of Ca, P, and Mg to ensure optimal tissue and bone mineral accretion
`(GPP, conditional recommendation)
`Ca infusion may be used for prevention and treatment of early neonatal hypocalcaemia that is common and generally not associated with obvious clinical
`problems such as tetany (GPP, conditional recommendation)
`In preterm infants on PN who were exposed to maternal Mg therapy, Mg intakes need to be adapted to postnatal blood concentrations (LoE 2, RG B,
`conditional recommendation)
`Acidic solutions packaged in glass vials, such as calcium gluconate, are contaminated with aluminum and should not be used in PN (LoE 3, RG 0, strong
`recommendation)
`It is recommended to use organic Ca and P salts for compounding of PN solutions to prevent precipitation (GPP, strong recommendation)
`The adequacy of Ca and P intakes in preterm infants can be adjusted until both start being excreted simultaneously with low urine concentrations
`(> 1 mmol/L) indicative of a slight surplus ( extrapolated evidence derived from enteral nutrition LoE 2+ studies, RG B, conditional recommendation)
`The recommended parenteral intake for calcium, phosphorus, and magnesium intake in newborns and children on parenteral nutrition in mmol (mg)/kg/d is
`as follows (LoE 2, 3 and 4, RG 0, conditional recommendation)
`Age
`Ca mmol (mg)/kg/d
`
`Mg mmol (mg)/kg/d
`
`P mmol (mg)/kg/d
`
`Preterm infants during the first days of life
`Growing Premature
`0- 6m*
`7-12 m
`1-18 y
`
`0.8-2.0 (32-80)
`1.6-3.5 (64-140)
`0.8- 1.5 (30- 60)
`0.5 (20)
`0.25-0.4 (10-16)
`
`1.0-2.0 (31-62)
`1.6-3.5 (50-108)
`0.7- 1.3 (20- 40)
`0.5 (15)
`0.2-0.7 (6-22)
`
`0.1-0.2 (2.5-5.0)
`0.2-0.3 ( 5.0-7.5) infants
`0.1- 0.2 (2.4- 5)
`0.15 (4)
`0.1 (2.4)
`
`*Includes term newborns.
`In preterm infants with intrauterine growth restriction on PN careful monitoring of the plasma phosphate concentration within the first days of life is
`required to prevent severe hypophosphataemia that can result in muscle weakness, respiratory failure, cardiac dysfunction, and death (LoE 3, RG 0, strong
`recommendation)
`In preterm infants on early PN during the first days of life lower Ca, P and Mg intakes are recommended than in growing stable preterm infants (Table 1) (LoE
`2, RG B, conditional recommendation)
`In early PN when calcium and phosphorus intakes are low (Table 1) and protein and energy are optimized it is recommended to use a molar Ca:P ratio below
`1 (0.8-1.0) to reduce the incidence of early postnatal hypercalcaemia and hypophosphataemia (LoE 2, RG B, strong recommendation)
`In infants and children on PN regular monitoring of the individual alkaline phosphatase, Ca, P and Mg serum concentrations and Ca and P urine
`concentrations is required (Extrapolated evidence from LoE 2 and 3 studies, RG 0, strong recommendation)
`In infants and children on long term PN the risk of metabolic bone disease requires periodic monitoring of Ca, P, vitamin D and bone mineral status (LoE
`2 + and 3, RG 0, strong recommendation)
`
`2. Introduction
`
`R 8.1
`
`R 8.2
`
`R 8.3
`
`In infants, children and adolescents on PN appropriate amounts
`of Ca, P and Mg should be provided to ensure optimal growth
`and bone mineralization (GPP, strong recommendation,
`strong consensus)
`The mineral accretion of the fetus, healthy infant, child, and
`adolescent may be used as a reference for ca, P and Mg provision
`(GPP, conditional recommendation, strong consensus)
`In the individual infant appropriate PN should provide a
`simultaneous slight surplus of Ca, P, and Mg to ensure optimal
`tissue and bone mineral accretion, (GPP, conditional
`recommendation, strong consensus)
`
`Calcium (Ca), phosphorus (P) and magnesium (Mg) are consid(cid:173)
`ered together as 98%, 80% and 65% of their body content within the
`skeleton. The majority of Ca and P are found together as compo(cid:173)
`nents ofmicrocrystalline apatite [Ca5(PO4 h(OH)), the bone mineral
`which is forming in bone only if Ca and P are simultaneously
`available in optimal proportions. Of the total body phosphorus 20%
`is found in tissue. The molar Ca:P ratio is 1.67 in apatite and 1.3 in
`the whole body. In addition to their function as skeleton
`
`gain of 17 g/kg/d before 35 weeks of gestation [7) the average
`fetal accretion is 3.4 mmol Ca/kg/d and 2.6 mmol P/kg/
`d respectively. This has been proposed as a reference mark for
`growing preterm infants [8,9). However, it is important to keep
`in mind that in infants, children, and adolescents the mineral
`intake should be adjusted to the individual weight gain/growth
`to avoid an intake that is either too low or too high.
`The following model is based on the average fetal weight gain
`(17 g/kg/d) and mineral accretion. Approximately 98% of the fetal
`calcium accretion (3.4 mmol/kg/d) is used for bone mineralization
`(microcrystalline apatite formation). The corresponding phos(cid:173)
`phorus accretion in apatite is 2 mmol/kg/d (98 % x 3.4 mmol/kg/d/
`1.67). The remaining fetal phosphorus accretion of0.6 mmol/kg/d is
`used for tissue accretion. Protein is the major determinant of tissue
`accretion. It has been estimated that 1 g of protein accretion needs
`0.3 mmol (9.3 mg) of phosphorus [10-12). Therefore, in the present
`calculation model the remaining 0.6 mmol of phosphorus corre(cid:173)
`sponds to a protein accretion of 2 g/kg/d. This is a reasonable es(cid:173)
`timate of average fetal protein accretion [3-6).
`Taking all these considerations into account, the following
`theoretical model for estimation of P requirements has been pub(cid:173)
`lished: [10-12)
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`P requirement (mmol) = [caldum deposition (mmol/kg)/
`1.67] + [protein accretion (g)*0.33]
`
`Ca, P and protein accretion are quantitatively not known in the
`individual infant. In any case, optimal PN should provide a simul(cid:173)
`taneous slight surplus of Ca and P to ensure optimal tissue and bone
`mineral accretion. Based on fetal total body analysis the theoretical
`optimal molar Ca:P ratio in PN for achievement of fetal body
`composition would be 1.3 in stable growing infants.
`Physiologically the provision of P for tissue accretion in the
`growing body has priority. In cases of relative P deficiency, available
`P is primarily directed to the cellular metabolism, reducing bone
`mineralization or even inducing bone demineralization (13).
`Therefore, the first priority in provision of early or incomplete PN is
`the provision of sufficient P in order to avoid severe hypo(cid:173)
`phosphataemia, which may be life threatening. Consequently,
`especially in early or incomplete PN with high amino acid intake a
`molar Ca:P ratio in the PN solution less than 1.3 (i.e. 0.8-1.0) is
`required to prevent hypophosphataemia (11,13-16).
`In PN minerals are directly available for tissue accretion and bone
`mineralization in contrast to enteral nutrition where the individual
`mineral absorption has to be considered ( especially calcium ab(cid:173)
`sorption which varies considerably from 20% to 80% (17)). Losses via
`skin, feces and especially urine ( e.g. transient phosphorus loosing
`tubulopathy (18 )) have to be taken into account as well.
`Owing to the lack of data, it is not possible to perform an
`equivalent calculation of the required mineral intake for infants and
`children.
`
`3. calcium
`
`R 8.4
`
`Ca infusion may be used for prevention and treatment of early
`neonatal hypocalcaemia that is common and generally not
`associated with obvious clinical problems such as tetany
`(GPP, conditional recommendation, strong consensus).
`
`Ca is the most abundant mineral in the body. In blood, Ca exists
`in three fractions : ionized Ca (-50%), protein bound Ca (-40%), and a
`small amount of Ca that is complexed with other molecules such as
`citrate and phosphate. Blood Ca is tightly controlled by the actions
`of several hormones that maintain Ca homeostasis, especially
`parathyroid hormone (PTH), calcitonin and 1,25(OH)i-vitamin D.
`The main homeostatic control of blood Ca is deposition in or release
`from bone. Renal reabsorption of filtered Ca depends on Ca plasma
`concentration, Ca requirements, renal tubular function, and last but
`not least the availability of P for microcrystalline apatite formation
`in growing infants ( e.g. corresponding to hypophosphataemia there
`is paradoxical calciuria in preterm infants fed human milk in the
`absence of P fortification) (2,19-23 ].
`Total body Ca content is around 28 g in term newborns.
`Approximately 1 kg of Ca is deposited between birth and adult(cid:173)
`hood. In children, daily Ca accretion rates average between 3.7 and
`5.0 mmol/d (150 and 200 mg/d). However, since growth velocity is
`not uniform, accretion rates may be as high as 10 mmol/d ( 400 mg/
`d) during infancy and puberty. A study using dual energy x-ray
`absorptiometry found an average bone Ca accretion rate of
`5.5 mmol/d (220 mg/d) and 7.9 mmol/d (317 mg/d) in girls and boys
`respectively during stage III puberty (24).
`In newborns, owing to the interruption of placental transfer at
`birth, early hypocalcaemia rapidly occurs during the first 24-48 h
`of life owing to a relative immaturity of hormonal control ( delayed
`PTH surge). This early neonatal hypocalcaemia is common and
`generally not associated with obvious clinical problems such as
`
`tetany. Ca infusion will usually prevent or treat early neonatal
`hypocalcaemia [25,26).
`In children, recommendations for enteral intake assume an
`absorption rate of 50-60% [2). In PN Ca supplies may be limited
`owing to the risk of precipitation ofCa-P-salts (12,19). However, this
`can be prevented by using organic phosphorus compounds such as
`glycerophosphate (26-28).
`
`4. Phosphorus
`
`In addition to its presence in bone, P is also the principal intra(cid:173)
`cellular anion, mainly in the form of phosphate. P plays a critical role
`in energy metabolism. In cells, most of the Pis present in adenosine
`triphosphate, nucleic acids, and membranes. P deficiency results in
`inadequate supplies of energy-rich phosphates and, in particular,
`inhibition of glyceraldehyde-3-phosphate dehydrogenase, which
`plays a key position in glycolysis. Thereby P deficiency reduces
`adenosine triphosphate and 2,3-diphosphoglycerate levels and
`leads to left displacement of the oxygen-hemoglobin dissociation
`curve with decreased peripheral oxygen uptake and transport. Se(cid:173)
`vere P deficiency may induce several clinical disorders including
`muscle weakness, delay in weaning from respiratory support,
`glucose intolerance, nosocomial infections and death (29-31).
`Two thirds of blood P is organic and 1 /3 is inorganic. Blood P
`concentration is usually measured as phosphate concentration that
`may vary according to growth, intake and renal excretion. Renal
`reabsorption threshold of phosphate is higher in infants than in
`adults (2,12,18,19). Therefore, particular attention should be paid to
`phosphate laboratory reference values in newborns, especially in
`premature infants. Indeed, the lower limit of the reference value is
`higher in premature infants (1.6 mmol/1, 5 mg/di) than in adults
`(1.0 mmol/1, 3 mg/di). As laboratories frequently use adult refer(cid:173)
`ences, this may result in underestimation ofhypophosphataemia in
`these infants (12,19,31 ).
`In newborn infants total body P is around 16 g rising to
`600-900 g in an adult with 80% in bone and 9% in skeletal muscle
`[ 1 ]. P retention is related to bone mineralization, lean body mass
`accretion, and protein retention. Within physiological limits for
`compounding of PN the previously introduced equation may be
`used for estimation of the Ca:P ratio in PN.
`
`P intake (mmol) = [caldum intake (mmol/kg)/1.67] + [protein ac(cid:173)
`cretion (g)*0.3 J
`
`In stable premature infants on parenteral nutrition considering
`an optimal protein accretion of 2-2.5 g/kg/d and a Ca intake of
`2 mmol/kg/d (which is below the intrauterine Ca accretion), the
`ideal Ca:P ratio seems close to 1, between 0.8 and 1.2 (2,12,19).
`Considering the identical protein accretion of 2-2.5 g/kg/d with a
`Ca intake of 3 mmol/kg Ca (which is closer to the intrauterine Ca
`accretion), a higher Ca:P ratio may be used. It is important to keep
`in mind that this is different in enteral nutrition.
`
`5. Magnesium
`
`R 8.5
`
`In preterm infants on PN who were exposed to maternal Mg
`therapy, Mg intakes need to be adapted to postnatal blood
`concentrations (LoE 2, RG B, conditional recommendation,
`strong consensus)
`
`Magnesium is the fourth most abundant mineral in the body
`and the second most abundant intracellular cation. In blood,
`about 1 /3 of Mg is attached to plasma proteins and the
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`remaining 2/3 is filtrated by the kidney [2]. Particular attention
`should also be paid to Mg laboratory reference values in new(cid:173)
`borns, which are higher than in adults. Recently, a normal range
`of 0.7-1.5 mmol/L has been suggested for premature and term
`newborns during the first two weeks of life (32]. However, total
`blood Mg concentration is not the best estimate of the biologi(cid:173)
`cally active fraction (ionized Mg). The concentration in red blood
`cells (around 2.5 mmol/L) represents a better indicator of Mg
`content in tissues [2].
`Fetal accretion is 0.12-0.20 mmol/kg/d (2.9-4.8 mg/kg/d)
`(8,33,34]. In the term newborn the total body Mg is around 0.8 g
`rising to 25 gin adulthood. Intakes and renal function play a critical
`role in Mg homeostasis. Around one third of Mg intake is usually
`excreted in the urine and 5-15% offiltrated Mg is reabsorbed. Mg is
`essential to the activity of the Mg-dependent adenyl-cyclase
`involved both in the PTH release and activity on bone. Thus, in Mg
`deficiency there is both deficient PTH release and peripheral
`resistance to PTH with subsequent hypocalcaemia [2].
`Requirements are also frequently based on enteral nutrition
`data. Intestinal absorption rate is usually between 35 and 50%. Mg
`retention is usually around 0.08 mmol/kg/d in infants fed human
`milk and up to 0.15 mmol/kg/d in premature infants fed enriched
`preterm infant formulas [2].
`Premature newborns exposed to maternal Mg sulfate therapy
`(preeclampsia, tocolysis) may have high levels of Mg in the first
`days of life. In addition, their low postnatal glomerular filtration
`rates during the first week of life limit their ability to excrete
`excessive Mg intakes. Thus, Mg intakes must be limited in new(cid:173)
`borns of mothers that received Mg sulfate before delivery and in(cid:173)
`takes need to be adapted to postnatal blood concentrations.
`
`6. Parenteral mineral supply
`
`R 8.7
`
`R 8.6 Acidic solutions packaged in glass vials, such as calcium gluconate,
`are contaminated with aluminum and should not be used in PN
`(LoE 3, RG 0, strong recommendation, strong consensus)
`It is recommended to use organic Ca and P salts for compounding
`of PN solutions to prevent precipitation (GPP, strong
`recommendation, strong consensus)
`R 8.8 The adequacy of Ca and P intakes in preterm infants can be
`adjusted until both start being excreted simultaneously with low
`urine concentrations (>1 mmol/L) indicative of a slight surplus
`( extrapolated evidence derived from enteral nutrition LoE
`2+ studies, RG B, conditional recommendation, strong consensus)
`
`When selecting compounds suitable for PN, the potential for Ca
`cations to precipitate with inorganic phosphate anions must be
`considered. To some degree this can be avoided by initial mixing of
`the Ca salt with amino acids and glucose solution before diluting
`the solution and by adding phosphate salt at the end of the process.
`The use of organic phosphorus compounds circumvents this
`problem. Inorganic (Ca chloride) or organic (Ca gluconate, Ca
`glycerol-phosphate) Ca salts can be used in PN solutions. Chloride
`ions may increase the anion gap and lead to metabolic acidosis
`(12,35,36]. Ca gluconate stored in glass vials is contaminated with
`aluminum. Therefore, Ca gluconate packed in polyethylene is rec(cid:173)
`ommended to reduce aluminum contamination of parenteral
`nutrition (PN) (37]. Aluminum intake should not exceed 5 µg/kg/d.
`Ca glycerophosphate is an adequate source of Ca and P but it is not
`registered for parenteral use (12].
`P can be provided as inorganic (sodium and potassium phos(cid:173)
`phate) or organic (fructose 1-6 diphosphate, sodium glycer(cid:173)
`ophosphate, disodium glucose 1 phosphate) salts. Neutral
`potassium phosphate ([K2HPO4 ] in contrast to acid potassium
`phosphate [KH2PO4]) induces a risk of precipitation that limits its
`
`use in PN. Disodium glucose-1-phosphate is widely used but its
`sodium content may limit its early utilization in premature infants
`[12.28].
`Mg may be provided using Mg sulfate or Mg chloride. However,
`Mg chloride usually increases the anion gap increasing the risk of
`metabolic acidosis. Thus, Mg is usually administered as Mg sulphate
`with few compatibility issues.
`The adequacy of Ca and P intakes can be adjusted until both are
`excreted simultaneously with low urine concentrations(> 1 mmol/
`L) indicative of a slight surplus [2,19-23].
`
`6.1. Requirements for calcium, phosphate and magnesium in
`children
`
`R 8.9
`
`R 8.10
`
`The recommended parenteral intake for calcium, phosphorus,
`and magnesium in newborns and children on parenteral
`nutrition in mmol (mg)/kg/d is given in Table 1 (LoE 2, 3 and 4,
`RG 0, conditional recommendation, strong consensus)
`In preterm infants with intrauterine growth restriction on PN
`careful monitoring of the plasma phosphate concentration
`within the first days of life is required to prevent severe
`hypophosphatemia that can result in muscle weakness,
`respiratory failure, cardiac dysfunction, and death (LoE 3,
`RG o, conditional recommendation, strong consensus)
`
`Recommendations for parenteral intake of Ca, P and Mg are
`given in the Table 1. In individualized PN, especially if Ca and P
`intakes at the upper range are used, stability, compatibility and
`solubility of minerals need to be tested by the local pharmacy to
`avoid the risk of precipitation (27]. Blood concentrations and urine
`output require periodic monitoring during PN (see guideline on
`monitoring). In particular, monitoring of the plasma phosphate
`concentration is critical. In cases of relative P deficiency, available P
`is primarily directed to cellular metabolism, reducing bone
`mineralization or even inducing bone demineralization (13].
`Hypophosphataemia was observed in preterm infants on PN with
`inappropriately low P intake (13] and high amino acid dosage
`(15,16] (refeeding-like syndrome) [11,12,14-16]. In significantly
`malnourished patients hypophosphataemia has also been observed
`during nutritional rehabilitation (refeeding syndrome). Extreme
`hypophosphataemia can result in muscle weakness, respiratory
`failure, cardiac dysfunction, and death [38].
`
`6.2. Requirements in preterm infants and newborns
`
`R 8.11
`
`R 8.12
`
`R 8.13
`
`In preterm infants on early PN during the first days of life lower
`Ca, P and Mg intakes are recommended than in growing stable
`preterm infants (Table 1) (LoE 2, RG B, conditional
`recommendation, strong consensus)
`In early PN when calcium and phosphorus intakes are low
`(Table 1) and protein and energy are optimized it is
`recommended to use a molar Ca:P ratio below 1 (0.8-1.0) to
`reduce the incidence of early postnatal hypercalcaemia and
`hypophosphataemia (LoE 2, RG B, strong recommendation,
`strong consensus)
`In infants and children on PN regular monitoring of the
`individual alkaline phosphatase, Ca, P and Mg plasma
`concentrations and Ca and P urine concentrations is required
`(Extrapolated evidence from LoE 2 and 3 studies, RG 0, strong
`recommendation, strong consensus)
`
`Owing to the wide range of individual growth velocities in
`preterm infants (5-20 g/kg/d), a wide range of requirements was
`proposed in previous recommendations: Ca 1.0-4.0 mmol/kg per
`day, P 0.75-3.0 mmol/kg per day, and a molar Ca:P ratio around 1.3
`(mass ratio around 1.7) [1,39].
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`
`Table 1
`Recommendations for calcium, phosphorus, and magnesium intake in newborns
`and children on parenteral nutrition.
`
`Age
`
`Suggested parenteral intake in mmol (mg)/kg/d
`p
`
`Mg
`
`Ca
`
`0.8-2.0 (32-80)
`
`1.0-2.0 (31-62)
`
`0.1-0.2 (2.5-5.0)
`
`Preterm infants
`during the first
`days of life
`Growing premature 1.6-3.5 (64-140) 1.6-3.5 (50-108) 0.2-0.3 (5.0-7.5)
`infants
`0-6m•
`7-12 m
`1-18 y
`
`0.7-1.3 (20-40)
`0.8-1.5 (30-60)
`0.5 (15)
`0.5 (20)
`0.25-0.4 ( 10-16) 0.2-0.7 (6-22)
`
`0.1-0.2 (2.4-5)
`0.15 (4)
`0.1 (2.4)
`
`a Includes term newborns.
`
`Very low birth weight and small for gestational age infants are at
`risk for early hypophosphataemia owing to their high P needs for
`growth (11,12,31 ]. In these infants, tubular phosphate reabsorption,
`which is usually 85-90%, increases to its maximum. In addition, Ca
`cannot be fixed in the bone inducing hypercalcaemia, hyper(cid:173)
`calciuria, and if prolonged bone demineralization, osteopenia, and
`nephrocalcinosis (11,19,31]. In early PN with low total Ca and P
`intake, molar Ca:P ratios below 1 (0.8-1.0) may reduce the inci(cid:173)
`dence of early postnatal hypophosphataemia and consequent
`hypercalcaemia when protein and energy intakes are optimized
`from the first day of life (11,12,19].
`Thereafter, the requirements of premature infants strongly
`depend on the individual growth velocity and are between 1 and
`4 mmol/kg/d of Ca (40-160 mg/kg/d) and 0.75-3 mmol/kg/d of P
`(23-93 mg/kg/d) with a molar Ca:P ratio around 1.3 and between
`0.2 and 0.3 mmol/kg/d for Mg (1,33). It is important to consider that
`the individual Ca, P and Mg homeostasis needs to be monitored
`regularly.
`For term infants, data obtained from breast fed infants can be
`applied to PN assuming an absorption rate of 50-60% for Ca,
`85-95% for P, and 35-50% for Mg (1,2). Therefore, taking into ac(cid:173)
`count a protein retention of 1-1.5 g/kg/d, term newborn re(cid:173)
`quirements are estimated to be between 0.8 and 1.5 mmol/kg/d for
`Ca, between 0.7 and 1.3 mmol/kg/d for P, and between 0.1 and
`0.2 mmol/kg/d for Mg.
`
`6.3. Requirements in infants and children on long term PN
`
`R8.14
`
`In infants and children on long tenn PN the risk of metabolic
`bone disease requires periodic monitoring of ca, P, vitamin D
`and bone mineral status (LoE 2 + and 3, RG O, strong
`recommendation, strong consensus)
`
`Hypercalciuria and negative calcium balance are potential
`complications of PN and can be attenuated in the short-term by
`intravenous phosphate [41,42]. This effect is not caused by alter(cid:173)
`ations in the PTH-1,25-dihydroxyvitamin D axis, but likely reflects P
`deficiency.
`Infants and children on long term PN are at risk of developing
`"metabolic bone disease" (MBD) which is characterized by incom(cid:173)
`plete mineralization of osteoid with consequent disturbances
`ranging from osteopenia to severe bone disease with fractures
`(43-48). The cause of MBD is multifactorial but mainly a calcium
`and/or phosphate deficiency. Other factors involved are negative
`calcium balance, hyperparathyroidism, and excessive vitamin D
`intake or vitamin D toxicity [49-53] and last but not least toxicity
`from aluminum in PN fluid. Although the latter has decreased with
`improvements in compounding [54,55), recent publications still
`suggest that it remains almost impossible to reduce the aluminum
`
`intake below 5 µg/kg/day in children <30 kg with currently avail(cid:173)
`able PN solutions [56,57). Frequently hypercalciuria and MBD are
`associated.
`Adequacy of phosphate intake has empirically been shown to be
`a key component in long term PN in infants and children not only
`for energy metabolism but also for optimal bone mineralization. In
`a cohort of children aged 4-13 years receiving home cyclic PN for 4
`consecutive years hypercalciuria was reversed and painful bone
`disease did not occur at a Ca intake of 0.35 mmol/kg/d and a
`phosphorus intake of 0.7 mmol/kg/d in absence of vitamin D
`administration [58). In these children Ca and P intake were
`significantly higher than previously recommended and an inverse
`Ca:P ratio of 0.5 in absence of vitamin D administration was used.
`These data suggest that the upper limit for recommended Ca and P
`intake should be increased (Table 1 ).
`BMD scores assessed in the available pediatric studies (43-45)
`do not allow clear conclusions about optimum Ca and P intake for
`infants on long term PN. However, in contrast to the previous
`recommendation, these data suggest that increasing the Ca
`recommendation up to 0.35-0.4 mmol/kg/d and providing an
`excess of phosphorus (0.7 mmol/kg/d) using a Ca:P ratio less than 1
`(close to 0.5) might be beneficial, even though this does not match
`the distribution of these elements in the human body [6,59).
`The high prevalence of MBD (43-48) requires careful and pe(cid:173)
`riodic (see guideline on monitoring) monitoring of Ca, P, vitamin D
`and bone mineral status ( e.g. by DEXA).
`
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