A Multi-Institutional, Retrospective, Observational Study on Administration Status and Safety of In-Hospital Oral Selenium Preparation in Pediatric Patients Predominantly Suffering from Gastrointestinal Disease

OBJECTIVES

Selenium deficiency in patients with gastrointestinal diseases treated with long-term central venous nutrition is a clinical problem. Only injectable selenium is approved in Japan, and oral selenium preparations are prepared in hospitals from reagents, but their efficacy and safety are unknown.

METHODS

We conducted a retrospective study investigating the relationship between selenium administration and oral selenium formulations and adverse events.

RESULTS

In this study, 239 selenium-treated cases and 220 selenium-untreated cases adjusted for patient background were selected as a reference group. The median (interquartile range, IQR) age was 1.3 (0.4-4.4) and 1.3 (0.3-4.5) years, respectively; gastrointestinal diseases were most common in 110 (46.0%) and 104 (47.3%) cases. The median (IQR) duration of treatment or observation with oral selenium was 446 (128-1157) and 414 (141-1064) days, respectively. The median (IQR) dose per body weight at the maintenance dose was 2.6 (1.7-3.9) μg/kg, and the median (IQR) serum selenium concentration at the maintenance dose was 8.5 (7.0-10.6) μg/mL within the upper tolerated dose limit and approximately the reference range. There was no difference in selenium dose, serum selenium concentration, or serum-selenium-concentration-to-dose ratio (C/D ratio) for adverse events. The incidence of adverse events was compared with that of patients not treated with selenium.

CONCLUSIONS

An oral selenium preparation administered below the upper tolerated dose limit can be used effectively and safely in pediatric patients.

Evaluating the risk of manganese-induced neurotoxicity of parenteral nutrition: review of the current literature

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.

Low level prenatal exposure to a mixture of Sr, Se and Mn and neurocognitive development of 2-year-old children

The excess or deficiency of trace metals can cause adverse neurocognitive development. Evidence of health effect of trace metal mixtures on neurocognitive development is limited in children. We evaluated associations of prenatal exposure to trace metals and metal mixtures with neurocognitive development of 2-year-old children. A total of 544 mother-child pairs were included in the study. The concentrations of 10 trace metals in maternal urine were monitored before delivery. Neurocognitive development indexes, including mental development index (MDI) and psychomotor development index (PDI), were assessed using the Bayley Scales of Infant Development. Linear regression analysis was performed to explore the effects of single-metal and multi-metal exposures. Bayesian Kernel Machine regression (BKMR) was used to investigate overall effect of exposure to metal mixtures and potential interactions among mixture components. We found positive associations of urinary strontium (Sr) and Selenium (Se) levels with MDI scores among all children in the single-metal model. Sr was positively related to MDI, while Manganese (Mn) was negatively associated with PDI in the multi-metal model. The results from BKMR model in girls revealed that MDI scores were improved with the increasing concentrations of Sr, Se and Mn mixture until the concentrations reached their 30th percentiles (Sr: 149.49 μg/g creatinine, Se:18.38 μg/g creatinine, Mn:1.96 μg/g creatinine), with no effect after that threshold level. Sr played a positive role in mental development among mixture components, which was consistent with the results of Sr in the multi-metal models. No signification association of mixture with MDI/PDI was found in boys. The study suggested potential sex-specific association of Sr, Se and Mn mixture levels (at or below their 30th percentiles) with improved mental development, and beneficial role of Sr.

Laboratory Monitoring of Children on Home Parenteral Nutrition: A Prospective Study

BACKGROUND

The primary hypothesis of this article is that a team approach in creating a protocolized laboratory monitoring schedule for home parenteral nutrition (PN) patients improves patient safety by decreasing the occurrence of nutrition deficiencies and is cost-effective.

METHODS

In this prospective cohort study of home PN patients, each patient followed an established protocol of laboratory monitoring and weekly review by an interdisciplinary team of dietitians, nurses, and physicians. Data collected included anthropometric measurements, laboratory results, deviations from laboratory protocols, laboratory charges, PN shortage information, and means of ameliorating such shortages. Cost-effectiveness analysis was only performed for nonmicronutrient laboratory tests.

RESULTS

Fifteen children (male, n = 6) with a median age of 59 months (range, 19-216) were included in this study. Primary diagnoses included short bowel syndrome (47%) and intestinal pseudo-obstruction (40%). Patients received PN mixtures from 6 different infusion companies and experienced 60 different shortages in the PN formulation requiring adjustments or substitutions (mean, 4 shortages per patient). All patients had appropriate growth and complete micronutrient monitoring. No patient experienced any clinical symptoms due to shortages. The median number of laboratory draws/patient per month was 2.9 preprotocol compared with 1.14 postprotocol (P = .003). The median per patient per month charges were $2014 (interquartile range [IQR], 1471-2780) preprotocol compared with $792 (IQR, 435-1140) postprotocol (P = .002).

CONCLUSIONS

A structured team approach to laboratory monitoring of home PN patients can simplify PN management, significantly decrease monthly laboratory costs, and lead to fewer laboratory draws while improving micronutrient monitoring and preventing deficiencies.

Discrepancies Between Prescribed and Actual Pediatric Home Parenteral Nutrition Solutions

BACKGROUND

Home parenteral nutrition (HPN) is increasingly prescribed for pediatric patients with complex medical conditions. Commercial vendors are widely available to compound HPN. The aim of this study was to determine the frequency of discrepancies between written HPN prescriptions and commercially compounded solutions, as well as to record the associated severity of harm from discrepancies.

METHODS

From January to April 2013, 2 clinical pharmacists independently and prospectively reconciled HPN compounding records with electronic prescriptions (gold standard) during all routine ambulatory encounters to a multidisciplinary HPN program. Types, severity, and causes of discrepancies were recorded.

RESULTS

Sixty-one unique patients were identified for inclusion during 117 visits. HPN solutions were compounded at 13 unique vendors across 14 states. Of all 100 compounding records, 46 (46%) contained at least 1 discrepancy, with a total of 60 discrepancies identified, affecting 34 of 61 (56%) patients. There was at least 1 discrepancy in solutions originating from 10 of 13 (77%) home infusion companies. Discrepancies were classified as Medication Error Reporting and Prevention levels C (n = 37) and D (n = 23; ie, all reaching patient but not causing harm).

CONCLUSIONS

We found an alarmingly high rate of preparation discrepancies in a cohort of pediatric patients receiving HPN. Routine reconciliation of HPN compounds with intended prescriptions may be critical for ambulatory patients receiving this high-risk therapy. While home infusion commercial vendors provide an indispensable function, discrepancies and errors with potential for harm may be more common than previously appreciated.

Neuroimaging identifies increased manganese deposition in infants receiving parenteral nutrition

BACKGROUND

Manganese, an essential metal for normal growth and development, is neurotoxic on excessive exposure. Standard trace element-supplemented neonatal parenteral nutrition (PN) has a high manganese content and bypasses normal gastrointestinal absorptive control mechanisms, which places infants at risk of manganese neurotoxicity. Magnetic resonance (MR) relaxometry demonstrating short T1 relaxation time (T1R) in the basal ganglia reflects excessive brain manganese accumulation.

OBJECTIVE

This study tested the hypothesis that infants with greater parenteral manganese exposure have higher brain manganese accumulation, as measured by MR imaging, than do infants with lower parenteral manganese exposure.

DESIGN

Infants exposed to parenteral manganese were enrolled in a prospective cohort study. Infants classified as having high manganese exposure received >75% of their nutrition in the preceding 4 wk as PN. All others were classified as having low exposure. Daily parenteral and enteral manganese intakes were calculated. Whole-blood manganese was measured by high-resolution inductively coupled plasma mass spectrometry. Brain MR relaxometry was interpreted by a masked reviewer. Linear regression models, adjusted for gestational age (GA) at birth, estimated the association of relaxometry indexes with total and parenteral manganese exposures.

RESULTS

Seventy-three infants were enrolled. High-quality MR images were available for 58 infants, 39 with high and 19 with low manganese exposure. Four infants with a high exposure had blood manganese concentrations >30 μg/L. After controlling for GA, higher parenteral and total manganese intakes were associated with a lower T1R (P = 0.01) in the globus pallidus and putamen but were not associated with whole-blood manganese (range: 3.6-56.6 μg/L). Elevated conjugated bilirubin magnified the association between parenteral manganese and decreasing T1R.

CONCLUSION

A short T1R for GA identifies infants at risk of increased brain manganese deposition associated with PN solutions commonly used to nourish critically ill infants. These trials were registered at clinicaltrials.gov as NCT00392977 and NCT00392730.