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Ribeiro Menezes IMN, Nascimento PDA, Peixoto RRA, Oliveira A. Nutritional profile and risk assessment of inorganic elements in enteral and parenteral nutrition formulas. J Trace Elem Med Biol 2024; 84:127442. [PMID: 38554676 DOI: 10.1016/j.jtemb.2024.127442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/02/2024]
Abstract
The contents of essential (Ca, Fe, K, Na, P, and Zn) and potentially toxic inorganic elements (As, Al, Cd, Cr, Cu, Mn, and Pb) in enteral and parenteral nutrition formulas were evaluated by inductively coupled plasma optical emission spectrometry (ICP OES) and graphite furnace atomic absorption spectrometry (GFAAS). A total of 30 enteral formulas, 23 parenteral solution components, and 3 parenteral solutions were analyzed. The elements Ca and K presented the higher contents (72-2918 mg L-1 and 235-2760 mg L-1) while the lowest concentration levels were found for As and Cd (<0.68 µg L-1 and <0.01-0.62 µg L-1) in the studied samples. The validated analytical methods presented an accuracy of 75-116% and RSD values lower than 9.8%. Calcium gluconate and magnesium sulfate, which are used as raw materials in parenteral solution, are potential sources of Al and Mn contamination. A Hazard Quotient (HQ) >1 was obtained for Al (27 ± 1 µg L-1) in one of the parenteral samples, whereas the established limit is 25 µg L-1. Enteral samples were considered safe for consumption regarding the Al, As, and Cd levels. One healing-specific and pediatric formula contained Pb at levels above 0.25 µg kg-day-1, too high for safe consumption. The enteral formulas (pediatric, diabetes-specific, renal-specific, healing-specific, and standard formula with addition of fiber) presented risks in relation to the consumption of Cr and Mn (>250 µg day-1 and >11 mg day-1). The results indicate the need for strict monitoring, considering that these formulations are often the single patient's food source.
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Affiliation(s)
| | - Patricia de A Nascimento
- Federal University of Paraná - UFPR, Department of Chemistry, Curitiba, Paraná 81531-980, Brazil
| | - Rafaella R A Peixoto
- Federal Fluminense University - UFF, Department of Analytical Chemistry, Niterói 24220-900, Brazil
| | - Andrea Oliveira
- Federal University of Paraná - UFPR, Department of Chemistry, Curitiba, Paraná 81531-980, Brazil.
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Barbieri J, Cober MP. Select micronutrients for the preterm neonate. Nutr Clin Pract 2023; 38 Suppl 2:S66-S83. [PMID: 37721469 DOI: 10.1002/ncp.11054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/04/2023] [Accepted: 07/09/2023] [Indexed: 09/19/2023] Open
Abstract
If premature neonates are not provided with adequate nutrition, they will quickly become deficient because of increased requirements and a lack of nutrient stores to achieve adequate growth. The provision of many of the recommended micronutrients for pediatric and adult patients is challenging in premature neonates because of the limited data surrounding the true needs of premature neonates and the difficulty in assessing adequate serum levels of these nutrients in this patient population. Parenteral and enteral nutrition shortages further complicate providing adequate micronutrients to premature neonates. This review will discuss select micronutrients and their importance to the preterm neonate, with special emphasis on micronutrients with limited evidence and more challenging supplementation and repletion strategies.
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Affiliation(s)
- Jessica Barbieri
- Department of Nutritional Services, Akron Children's Hospital, Akron, Ohio, USA
| | - Mary Petrea Cober
- Department of Pharmacy, Akron Children's Hospital, Akron, Ohio, USA
- Department of Pharmacy Practice, Northeast Ohio Medical University, Rootstown, Ohio, USA
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Robinson DT, Calkins KL, Chen Y, Cober MP, Falciglia GH, Church DD, Mey J, McKeever L, Sentongo T. Guidelines for parenteral nutrition in preterm infants: The American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr 2023; 47:830-858. [PMID: 37610837 DOI: 10.1002/jpen.2550] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 05/12/2023] [Accepted: 05/31/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Parenteral nutrition (PN) is prescribed for preterm infants until nutrition needs are met via the enteral route, but unanswered questions remain regarding PN best practices in this population. METHODS An interdisciplinary committee was assembled to answer 12 questions concerning the provision of PN to preterm infants. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process was used. Questions addressed parenteral macronutrient doses, lipid injectable emulsion (ILE) composition, and clinically relevant outcomes, including PNALD, early childhood growth, and neurodevelopment. Preterm infants with congenital gastrointestinal disorders or infants already diagnosed with necrotizing enterocolitis or PN-associated liver disease (PNALD) at study entry were excluded. RESULTS The committee reviewed 2460 citations published between 2001 and 2023 and evaluated 57 clinical trials. For most questions, quality of evidence was very low. Most analyses yielded no significant differences between comparison groups. A multicomponent oil ILE was associated with a reduction in stage 3 or higher retinopathy of prematurity (ROP) compared to an ILE containing 100% soybean oil. For all other questions, expert opinion was provided. CONCLUSION Most clinical outcomes were not significantly different between comparison groups when evaluating timing of PN initiation, amino acid dose, and ILE composition. Future clinical trials should standardize outcome definitions to permit statistical conflation of data, thereby permitting more evidence based recommendations in future guidelines. This guideline has been approved by the ASPEN 2022-2023 Board of Directors.
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Affiliation(s)
- Daniel T Robinson
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Kara L Calkins
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | | | - M Petrea Cober
- Akron Children's Hospital, Akron, Ohio, USA
- College of Pharmacy, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Gustave H Falciglia
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - David D Church
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, Center for Translational Research in Aging & Longevity, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jacob Mey
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
| | - Liam McKeever
- Department of Clinical Nutrition Chicago, Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy Sentongo
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
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Farhan M, McCallion N, Bennet J, Cram A, O'Brien F. Stability and compatibility of parenteral nutrition solutions; a review of influencing factors. Eur J Pharm Biopharm 2023; 187:87-95. [PMID: 37061100 DOI: 10.1016/j.ejpb.2023.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 04/17/2023]
Abstract
Both stability and compatibility of parenteral nutrition solutions (PNS) with drug products are major concerns for clinicians and clinical pharmacists, especially when concurrent administration of PNS with intravenous medications (IVM) is unavoidable. Since the same physicochemical principles apply to both adult's and paediatrics' PNS, concerns about stability and compatibility may still apply to both. However, these concerns are relatively more common in paediatrics and neonatal clinical settings, where limited vascular access can be problematic and the coadministration of PNS and drugs is more common. In neonatal and paediatric populations, there have been few experimental studies and comprehensive evaluations looking at medication compatibility with frequently used PNS. This work is part of a larger research project concerned for compatibility of PNS with commonly used intravenous medication in paediatric and neonates. This paper captures and reviews published data on factors influencing stability and compatibility of parenteral nutrition solutions. This information will help clinicians and clinical pharmacists to understand the principals of the stability and compatibility of PNS, furthermore, it will inform better design of future compatibility studies, as it highlights the complexity of PNS and the multiple factors influencing the stability of PNS, and hence its compatibility with IVM. When preparing, prescribing, and administering the PNS, especially when co-administration with IVM is unavoidable, it is important to take into account the physicochemical properties of the PNS components and IVM as well as administration conditions and environmental factors. These factors should also be considered in the design of the compatibility studies of the PNS with the IVM.
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Affiliation(s)
- Mahmoud Farhan
- School of Postgraduate Studies, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Naomi McCallion
- Department of Pediatrics, Rotunda Hospital, Dublin, Ireland; Department of Pediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of neonatology, Children Hospital Ireland, Dublin, Ireland.
| | | | | | - Fiona O'Brien
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland.
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Al-Saleh I, Al-Rouqi R, Alnuwaysir H, Aldhalaan H, Alismail E, Binmanee A, Hawari A, Alhazzani F, Bin Jabr M. Exposure of preterm neonates to toxic metals during their stay in the Neonatal Intensive Care Unit and its impact on neurodevelopment at 2 months of age. J Trace Elem Med Biol 2023; 78:127173. [PMID: 37060676 DOI: 10.1016/j.jtemb.2023.127173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/27/2022] [Accepted: 04/04/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND Premature neonates might be exposed to toxic metals during their stay in the neonatal intensive care unit (NICU), which could adversely affect neurodevelopment; however, limited evidence is available. The present study was therefore designed to assess the exposure to mercury, lead, cadmium, arsenic, and manganese of preterm neonates who received total parenteral nutrition (TPN) and/or red blood cell (RBC) transfusions during their NICU stay and the risk of neurodevelopment delay at the age of 2 months. METHODS We recruited 33 preterm neonates who required TPN during their NICU admission. Blood samples were collected for metal analysis at two different time points (admission and before discharge). Metals in the daily TPN received by preterm neonates were analyzed. Neurodevelopment was assessed using the Ages and Stages Questionnaire Edition 3 (ASQ-3). RESULTS All samples of TPN had metal contamination: 96% exceeded the critical arsenic limit (0.3 μg/kg body weight/day); daily manganese intake from TPN for preterm neonates exceeded the recommended dose (1 µg/kg body weight) as it was added intentionally to TPN solutions, raising potential safety concerns. All samples of RBC transfusions exceeded the estimated intravenous reference dose for lead (0.19 µg/kg body weight). Levels of mercury, lead and manganese in preterm neonates at discharge decreased 0.867 µg/L (95% CI, 0.76, 0.988), 0.831 (95%CI, 0.779, 0.886) and 0.847 µg/L (95% CI, 0.775, 0.926), respectively. A decrease in ASQ-3-problem solving scores was associated with higher levels of blood lead in preterm neonates taken at admission (ß = -0.405, 95%CI = -0.655, -0.014), and with plasma manganese (ß = -0.562, 95%CI = -0.995, -0.172). We also observed an association between decreased personal social domain scores with higher blood lead levels of preterm neonates before discharge (ß = -0.537, 95%CI = -0.905, -0.045). CONCLUSION Our findings provide evidence to suggest negative impacts on the neurodevelopment at 2 months of preterm infants exposed to certain metals, possibly related to TPN intake and/or blood transfusions received during their NICU stay. Preterm neonates may be exposed to levels of metals in utero.
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Affiliation(s)
- Iman Al-Saleh
- Environmental Health Program, King Faisal Specialist Hospital and Research Centre, P.O. Box: 3354, Riyadh 11211, Saudi Arabia.
| | - Reem Al-Rouqi
- Environmental Health Program, King Faisal Specialist Hospital and Research Centre, P.O. Box: 3354, Riyadh 11211, Saudi Arabia
| | - Hissah Alnuwaysir
- Environmental Health Program, King Faisal Specialist Hospital and Research Centre, P.O. Box: 3354, Riyadh 11211, Saudi Arabia
| | - Hesham Aldhalaan
- Center for Autism Research, King Faisal Specialist Hospital and Research Centre, P.O. Box: 3354, Riyadh 11211, Saudi Arabia
| | - Eiman Alismail
- Center for Autism Research, King Faisal Specialist Hospital and Research Centre, P.O. Box: 3354, Riyadh 11211, Saudi Arabia
| | - Abdulaziz Binmanee
- Neonatal Critical Care Section, Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, P.O. Box: 3354, Riyadh 11211, Saudi Arabia
| | - Amal Hawari
- Neonatal Critical Care Section, Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, P.O. Box: 3354, Riyadh 11211, Saudi Arabia
| | - Fahad Alhazzani
- Neonatal Critical Care Section, Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, P.O. Box: 3354, Riyadh 11211, Saudi Arabia
| | - Mohammad Bin Jabr
- Neonatal Critical Care Section, Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, P.O. Box: 3354, Riyadh 11211, Saudi Arabia
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Dickerson RN, Bingham AL, Canada TW, Chan LN, Cober MP, Cogle SV, Tucker AM, Kumpf VJ. Significant Published Articles in 2021 for Pharmacy Nutrition Support Practice. Hosp Pharm 2022; 57:673-680. [PMID: 36081538 PMCID: PMC9445547 DOI: 10.1177/00185787221095765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2021 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not ranked, were also included. Results: A total of 211 articles were identified; 8 from the primary literature were voted by the group to be of high importance. An additional 18 guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
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Affiliation(s)
- Roland N. Dickerson
- University of Tennessee Health Science Center, College of Pharmacy, Memphis, TN, USA
| | | | - Todd W. Canada
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Sarah V. Cogle
- Auburn University – Harrison School of Pharmacy, Auburn, AL, USA
| | - Anne M. Tucker
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Advances in Trace Element Supplementation for Parenteral Nutrition. Nutrients 2022; 14:nu14091770. [PMID: 35565737 PMCID: PMC9105959 DOI: 10.3390/nu14091770] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/14/2022] [Accepted: 04/20/2022] [Indexed: 02/05/2023] Open
Abstract
Parenteral nutrition (PN) provides support for patients lacking sufficient intestinal absorption of nutrients. Historically, the need for trace element (TE) supplementation was poorly appreciated, and multi-TE products were not initially subjected to rigorous oversight by the United States Food and Drug Administration (FDA). Subsequently, the American Society for Parenteral and Enteral Nutrition (ASPEN) issued dosage recommendations for PN, which are updated periodically. The FDA has implemented review and approval processes to ensure access to safer and more effective TE products. The development of a multi-TE product meeting ASPEN recommendations and FDA requirements is the result of a partnership between the FDA, industry, and clinicians with expertise in PN. This article examines the rationale for the development of TRALEMENT® (Trace Elements Injection 4*) and the FDA’s rigorous requirements leading to its review and approval. This combination product contains copper, manganese, selenium, and zinc and is indicated for use in adults and pediatric patients weighing ≥10 kg. Comprehensive management of PN therapy requires consideration of many factors when prescribing, reviewing, preparing, and administering PN, as well as monitoring the nutritional status of patients receiving PN. Understanding patients’ TE requirements and incorporating them into PN is an important part of contemporary PN therapy.
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Corrigendum. JPEN J Parenter Enteral Nutr 2022; 46:737. [PMID: 35112733 DOI: 10.1002/jpen.2325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Martins AC, Ruella Oliveira S, Barbosa F, Tinkov AA, V A, Santamaría A, Lee E, Bowman AB, Aschner M. Evaluating the risk of manganese-induced neurotoxicity of parenteral nutrition: review of the current literature. Expert Opin Drug Metab Toxicol 2021; 17:581-593. [PMID: 33620266 PMCID: PMC8122055 DOI: 10.1080/17425255.2021.1894123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/19/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Several diseases and clinical conditions can affect enteral nutrition and adequate gastrointestinal uptake. In this respect, parenteral nutrition (PN) is necessary for the provision of deficient trace elements. However, some essential elements, such as manganese (Mn) may be toxic to children and adults when parenterally administered in excess, leading to toxic, especially neurotoxic effects. AREAS COVERED Here, we briefly provide an overview on Mn, addressing its sources of exposure, the role of Mn in the etiology of neurodegenerative diseases, and focusing on potential mechanisms associated with Mn-induced neurotoxicity. In addition, we discuss the potential consequences of overexposure to Mn inherent to PN. EXPERT OPINION In this critical review, we suggest that additional research is required to safely set Mn levels in PN, and that eliminating Mn as an additive should be considered by physicians and nutritionists on a case by case basis in the meantime to avoid the greater risk of neurotoxicity by its presence. There is a need to better define clinical biomarkers for Mn toxicity by PN, as well as identify new effective agents to treat Mn-neurotoxicity. Moreover, we highlight the importance of the development of new guidelines and practice safeguards to protect patients from excessive Mn exposure and neurotoxicity upon PN administration.
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Affiliation(s)
- Airton C. Martins
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Silvana Ruella Oliveira
- Department of Clinical Analyses, Toxicology and Food Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo-USP, Ribeirão Preto, Brazil
| | - Fernando Barbosa
- Department of Clinical Analyses, Toxicology and Food Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo-USP, Ribeirão Preto, Brazil
| | - Alexey A. Tinkov
- Yaroslavl State University, Yaroslavl, Russia
- IM Sechenov First Moscow State Medical University, Moscow, Russia
| | - Anatoly V
- IM Sechenov First Moscow State Medical University, Moscow, Russia
- Federal Scientific Center of Biological Systems and Agrotechnologies of the Russian Academy of Sciences, Orenburg, Russia
| | - Abel Santamaría
- Laboratorio de Aminoácidos Excitadores, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico
| | - Eunsook Lee
- Department of Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL 32307, USA
| | - Aaron B. Bowman
- School of Health Sciences, Purdue University, West Lafayette, IN, USA
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, USA
- IM Sechenov First Moscow State Medical University, Moscow, Russia
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