Development of hypervitaminosis A in a patient on long-term parenteral hyperalimentation

Indications and complications of inpatient parenteral nutrition prescribed to children in a large tertiary referral hospital

BACKGROUND

Parenteral Nutrition (PN) is prescribed to children with intestinal failure. Although life saving, complications are common. Recommendations for indications and constituents of PN are made in the 2005 guidelines by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). The aim of this study was to establish if the indications for prescribing PN in a tertiary children's hospital were appropriate, and to identify complications encountered. Data were compared to those published by the National Confidential Enquiry into patient outcome and death (NCEPOD) carried out in the United Kingdom in 2010.

METHODS

Children and newborns receiving inpatient PN over a 6 months period were entered into the study and data was collected prospectively. The appropriate indications for the use of PN were based on the ESPGHAN guidelines. Recorded complications were divided into metabolic, central venous catheter (CVC) related, hepatobiliary and nutritional.

RESULTS

A total of 303 children (67 newborns) were entered into the study. The main indications for the start of PN were critical illness (66/303), surgery (63/303) and bone marrow transplantation (28/303). The ESPGHAN recommendations were followed in 91.7% (278/303) of cases (95.5% of newborns, 90.7% of children). PN was considered inappropriate in 12/303 patients and equivocal in 13. The mean PN duration was 18 days (1-160) and the incidence of complications correlated to the length of PN prescribed. Metabolic, hepatobiliary and CVC related complications affected 74.6, 24.4, 16.4% of newborns and 76.7, 37.7 and 24.6% of children respectively. In relation to the appropriate indications for the start of PN our results mirrored those reported by the NCEPOD audit (92.4% of newborns and 88.6% children). However, the incidence of metabolic disturbances was higher in our cohort (74.6% vs 30.4% in children, 76.7% vs 14.3% in newborns) but CVC related complications lower amongst our newborns (16,4% vs 25%).

CONCLUSIONS

Although the indications for inpatient PN in children is mostly justified, there is still a proportion who is receiving PN unnecessarily. PN related complications remain common. There is a need for better education amongst health professionals prescribing PN and access to nutritional support teams to reduce unwanted side effects.

Surveillance for skeletal toxicity of children treated with etretinate

Following recent reports of the development of skeletal abnormalities in patients treated with etretinate (Tigason), we have examined 19 children and adolescents on long-term treatment with etretinate, using 99mtechnetium methylene diphosphonate (99mTcMDP) whole body bone scans and musculoskeletal assessment. No significant bony abnormalities were detected. We believe that the available evidence does not warrant alarm, and that long-term etretinate therapy can probably be given with a low risk of musculoskeletal toxicity if certain precautions are taken, in particular the use of low maintenance dose levels, early investigation of symptoms of musculoskeletal pain or stiffness, and regular 99mTcMDP bone scans.

Problems of trace elements and vitamins during long-term total parenteral nutrition: a case report of idiopathic intestinal pseudo-obstruction

An 8-year-old girl with chronic idiopathic intestinal pseudo-obstruction (CIIP), who is the first case of CIIP in Japan, has been receiving total parenteral nutrition (TPN) for more than 6 years. During this time, she experienced deficiencies of copper, zinc, vitamin A, vitamin B12, folic acid, and biotin, and an excess of vitamin A; she exhibited a series of signs and symptoms due to these deficiencies and vitamin A overdosage. Nevertheless, careful monitoring of serum levels of trace elements and vitamins and appropriate therapy have almost solved these problems. She has achieved normal physical and mental development and goes to school, while receiving home parenteral nutrition with an ambulatory infusion system.

Premature epiphyseal closure--a complication of etretinate therapy in children

Two children are described who developed premature epiphyseal closure while receiving etretinate for treatment of congenital hyperkeratotic disorders. The first patient was an 8 1/2-year-old boy with nonbullous ichthyosiform erythroderma who had been on treatment for 6 years, 4 months when premature fusion of the right distal tibial epiphysis was detected. Shortness of stature, thinning of long bones, and traumatic fractures were also observed in this patient. The second child was an 11-year-old girl with systematized verrucous nevi in whom symmetric fusion of both elbow epiphyses and narrowing of the femoral epiphyses bilaterally were noted following treatment with etretinate for 5 years, 5 months.

Pibloktoq (hysteria) and Inuit nutrition: possible implication of hypervitaminosis A

The hysterical reaction among Eskimo peoples known as pibloktoq, one of a group of aberrant behaviors occurring among Arctic and Circumarctic societies termed 'arctic hysterias', has been explained by a variety of theories: ecological, nutritional, biological-physiological, psychological-psychoanalytic, social structural and cultural. This study hypothesizes the possible implication of vitamin intoxication, namely, hypervitaminosis A, in the etiology of some cases of pibloktoq. Its biocultural approach implicates elements of several explanatory classes, which are not mutually exclusive. Experimental and clinical studies of nonhumans and humans reveal somatic and behavioral effects of hypervitaminosis A which closely parallel many of the symptoms reported for Western patients diagnosed as hysterical and Inuit sufferers of pibloktoq. Eskimo nutrition provides abundant sources of vitamin A and lays the probable basis in some individuals for hypervitaminosis A through ingestion of livers, kidneys, and fat of arctic fish and mammals, where the vitamin often is stored in poisonous quantities. Possible connections between pibloktoq and hypervitamonosis A are explored. A multifactorial framework may yield a more compelling model of some cases of pibloktoq than those that are mainly unicausal, since, among other things, the disturbance has been reported for males and females, adults and children, and dogs.

Storage of mixtures for total parenteral nutrition III. Stability of vitamins in TPN mixtures

TPN mixtures should contain all nutritional element necessary in the nutritional therapy--including unstable vitamins. In this study the stability of ascorbic acid and folic acid was investigated in a TPN mixture containing 12 vitamins by HPLC and microbiological assays. The degradation of both vitamins proceeded by first order kinetics. Half-lives for ascorbic acid were 1.1 h, 2.9 h, and 8.9 h when stored at 24 degrees C by daylight, 24 degrees C protected from light, and 4 degrees C protected by light, respectively. Under similar conditions half-lives for folic acid were 2.7 h, 5.4 h, and 24 h. The degradation rates found make pre-addition of these two vitamins to TPN mixtures questionable, storage for longer periods is inappropriate. For TPN patients receiving additional fluid intravenously it was found that addition of multivitamins to isotonic NaCl-solution was advisable. For other TPN patients alternative ways of vitamin administration might be preferable. When testing the stability of vitamins in TPN mixtures it was found that the brand of multivitamin preparation used was of importance. It should be stressed that data on the stability of vitamins derived from studies on the addition of a single vitamin cannot be extrapolated to multivitamin preparations because of possible mutual vitamin interactions.

Total intravenous hyperalimentation (TIH) complications in childhood: a radiological survey

Sixty consecutive patients, except for one 7-year-old patient, their ages varying from 1 day to 12 months received total intravenous hyperalimentation (TIH). It was possible to observe non-pathological catheter malpositions and, in 14 patients, other complications. The most serious complications observed included the following: thrombus and pericatheter thrombus calcification; superior vena cava thrombotic occlusion; hydrothorax; mediastinal effusion; generalized septic arthritis; venous transfixion with flooding of the soft tissues of the neck; vein wall lesions; collateral vertebral circulation; and a catheter tip blocked in vein. A brief comment is given on the use of this procedure and what may happen.

Experience with home parenteral nutrition

Twenty-nine patients underwent courses of home parenteral nutrition therapy ranging from 1.5 to 52 months (mean 14.5 months). The primary diagnoses responsible for the requirement of home parenteral nutrition were radiation enteritis in seven patients, short bowel syndrome secondary to resection in seven, Crohn's disease in two, malabsorption states in six, and other reasons in seven. Seventeen patients (57 percent) had at least one complication. Nine patients had intravenous catheter complications and nine had metabolic complications. Nine patients have died, 11 have been successfully weaned from home parenteral nutrition, and 9 continue to receive home parenteral nutrition. Home parenteral nutrition is useful in a variety of catastrophic clinical situations, including preparation for subsequent operative therapy, temporary malabsorption, and permanent disability of the gastrointestinal tract. Complications are frequent and may be life-threatening.