NEONATAL INTENSIVE CARE UNIT Section 1 Organisational Policy Current Version is held on the Intranet First ratified: October 2019 Review date: October 2022 Issue 2 Page 1 of 14 Author: Vennila Ponnusamy Contact details: [email protected] Guideline History Date Comments Approved By 2016 G. Szita, V. Ponnusamy NGG Prevention and Management of Metabolic Bone Disease of Prematurity
Prevention and Management of Metabolic Bone Disease of Prematurity
Jan 12, 2023
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Microsoft Word - Metabolic Bone Disease Dec 2019.docIntranet
Prevention and Management of Metabolic Bone Disease of
Prematurity
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b. Infants at high risk 4
c. Prevention of MBD 4
d. Pathway for management 5
e. Supplementation (calcium, phosphate) 6
f. Parathyroid Hormone 6
g. Vitamin D 6
i. Xrays 7
2. Appendices
a. Calcium phosphate ratios for a variety of parenteral regimes 8
b. Calcium phosphate ratios for a variety of feeding regimes 9
c. Calcium preparations 10
3. Supporting References 11
5. Guideline Governance 12
b. Document Checklist 14
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Metabolic Bone Disease
Preterm infants are at significant risk of metabolic bone disease because skeletal growth and bone mineralisation take place mostly during the latter stages of pregnancy. Metabolic bone disease of prematurity (MBD) is essentially a substrate deficiency disease. Providing at-risk infants with adequate calcium and phosphate through breast milk fortification or use of specific preterm formulas helps prevent metabolic bone disease. MBD is diagnosed based on biochemical changes noted in routine bloods. Raising alkaline phosphatase (ALP) >600 U/L is an early sign of MBD. There is no cut-off value for marker of MBD. High ALP >800 U/L often is considered a marker for MBD. A combination of high ALP, low phosphate and elevated parathyroid hormone (PTH) is highly sensitive and specific for a diagnosis of MBD. Routine supplementation of oral phosphates in high risk neonates could lead to secondary hyperparathyroidism, and thus worsen MBD. Therefore in cases of suspected MBD with elevated ALP and low phosphate, PTH measurement will help in establishing if there is underlying calcium or phosphate deficiency to provide correct supplementation. Treatment of MBD with oral supplements should ensure optimal calcium and phosphate ratio of 1.5:1 to 1.7:1 on a milligram to milligram basis to avoid secondary hyperparathyroidism. Vitamin D is required for the absorption of calcium and phosphate from the intestine to enable bone mineralisation. All babies, irrespective of type of feed, should receive 400 IU of Vitamin D (ABIDEC 0.6ml) daily until fully weaned. Additional Vitamin D supplementation is only needed in confirmed cases of deficiency/insufficiency (<50 nmol/L). In line with the Department of Health recommendations, parents should be advised to continue supplementing with an appropriate multi-vitamin until the age of 5 years.
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Infants at high risk of developing MBD: (All babies in extremely-high risk and high risk feeding pathway)
• <29 Weeks gestation • <1000 grams • IUGR < 2nd centile • Very poor growth • Preterm baby fed on EBM without BMF • Babies on parenteral nutrition for > 2 weeks. • Babies with chronic lung disease • Necrotising enterocolitis • Babies who are on prolonged use of demineralising drugs like steroids, loop diuretics,
antacids or methylxanthines
- Use of preterm formulas when needed
- Routine Vit D supplementation (ABIDEC)
- Regular 1 -2 weekly review of bone chemistry
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For all high risk infants, once they are on full feeds for a week – follow this guidance:
Raised ALP (>600 U/L) & / or Low PO4 (<1.8 mmol/L)
Check adequate Calcium/Phosphate requirements met with milk feeds / TPN
Check PTH and Vit D with next bloods in a week – on Monday, as PTH assay is done on Tuesday
Raised PTH (>8.5 pmol/L) –
Normal or Low PTH (<8.5 pmol/L) –
Likely Phosphate deficiency
Stop Phosphate supplements if prescribed Check adequate enteral Ca:PO4 ratio of 1.5:1 to
1.7:1 Check if adequate Ca:PO4 in PN prescribed (1.3:1
to 1.7:1) Start Calcium supplements if needed Optimise 25OH-Vit D if <50 nmol/L
Start Phosphate supplements Check adequate enteral Ca:PO4
ratio of 1.5:1 to 1.7:1 Check if adequate Ca:PO4 in PN
prescribed (1.3:1 to 1.7:1)
Repeat Ca /PO4 / ALP and PTH in 1 week if ALP is > 1000 U/L Repeat Ca /PO4 / ALP and PTH in 2 weeks if ALP is 600 -1000 U/L
Check Vit D levels once a month if on additional Vit D supplementation
Adjust dose of Calcium supplements based on serum calcium levels Only stop calcium supplements when PTH is less than 8.5pmol/L
Adjust dose of PO4 supplements based on serum PO4 levels and ALP
Only stop Vit D supplements when Vit D levels and PTH are normal
To Note:
No risk of nephrocalcinosis if PTH levels are high Elevated PTH causes depletion of 25-OH Vit D - So continue supplementation of Vit D until PTH and
Vit D levels are both normalised If both Calcium and Phosphate supplements are prescribed to a baby - Ensure they are not given
together, as they precipitate in the feeds Aim to normalise biochemistry and stop supplements by 34 weeks. If needs longer supplementation, check biochemistry in 1-2 weeks after stopping. If baby is
discharged prior to blood tests, book in phlebotomy clinic within 2 weeks after discharge. If needs to continue supplements after discharge, inform NCOT team and do TTO for 4 weeks
supply. NCOT team to plan blood tests after stopping supplements.
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Treatment doses: Aim for a corrected calcium level of 2.2 - 2.7mmol/L with a phosphate level of 1.3 - 2.4 mmol/L, with Ca>PO4. Calcium supplementation: Preparations and dose for calcium: Cacit 500 mg effervescent tabs: 12.5mmol/25ml when made up to liquid form Each tablet contains 1.25g calcium carbonate which when dissolved in water provides 500mg of calcium (equivalent to 12.5mmol of calcium) as calcium citrate. Administration: Dissolve 1 tablet in 24mL water resulting in an orange flavoured solution containing 12.5mmol of Calcium in 25mL, from which the required dose can be withdrawn. Recommended starting dose = 0.25mmol/kg QDS. Adjust doses according to repeat blood tests and Ca:Po4 ratio from milk /TPN and supplements. 1 mmol of calcium provides 40 mg of calcium Phosphate supplementation: Sodium acid phosphate – Recommended dose 0.25mmol/kg QDS. The dose can be given in 2 divided doses in babies >1.5 Kg. 1 mmol of phosphate provides 95mg of phosphate (Potassium dihydrogen phosphate preparation) Parathyroid hormone level: This is performed in our biochemistry lab, and takes an average turnaround of 3 working days. Normal levels = 2 - 8.5 pmol/L. Serum vitamin D level: Vit D levels are performed in our biochemistry lab and the results are usually available within 1-2 days. • (25(OH)D), if < 25 nmol/L, the baby is vitamin D deficient, supplement with 3000 units
Cholecalciferol daily for 3 months. Monitor biochemistry regularly. After 3 months treatment recheck serum Vit D levels along with alkaline phosphatase, PTH, calcium and phosphate. Ensure supplementation with a daily dose of at least 400 units vitamin D is undertaken after treatment.
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• If serum levels are between 25-50 nmol/L, the baby’s vitamin D status is insufficient, provide
dietary advice and ensure maintenance supplementation with a daily dose of at least 400 units vitamin D is continued. Recheck Vit D levels in 3 months’ time.
Milk contents of vitamin D: • 0.6 ml Abidec contains 400 units vitamin D • 100ml NP1 – 120 units vitamin D • 100 ml NP2 – 68 units vitamin D • 1 L of unfortified EBM – less than 25 units • 100 ml EBM with 2% breast milk fortifier – 240 units vitamin D
Preparations for Vitamin D:
Fultium D3 drops: https://www.medicines.org.uk/emc/product/6861/smpc 3 drops of Fultium D3 = 200 units 1 ml of Fultium D3 = 2740 units. 41 drops = approximately 1 ml
Dose: For Vit D Deficiency: 1 ml of Futilium D3 (2740 units) + 0.6 ml of ABIDEC (400 units) = total of 3140 units Discuss with Paediatric Pharmacist for more details. Urinary calcium and phosphate ratio: Urinary calcium and phosphate excretion can be used for additional diagnostic purposes and supplementation as indicated. It is not reliable when on diuretics. • Ca:PO4 ratio > 1 : Relative ↑urinary Calcium loss, Body tries to retain Phosphate, possible
Phosphate depletion, consider additional Phosphate supplements • Ca:PO4 ratio < 1 : Relative ↑urinary Phosphate loss, Body tries to retain Calcium, possible
calcium depletion, consider additional Calcium supplements X-Rays: There are a number of radiological changes seen in MBD, including demineralisation or “osteopenia,” rachitic changes, and/or fractures. Consistently high ALP can indicate underlying fractures in severe MBD. Examine babies carefully to check for any bony deformities. As fractures of ribs are common in high risk preterm babies, Please do a CXR and document formal report in notes.
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Appendix 1 - Calcium:Phosphate Ratios for a Variety of Parenteral Regimens
volume type of PN Calcium mmol/kg/d ay
Calcium mg/kg/day
ratio Ca:PO4 (mmol)
equivalent to Ca:PO4 (mmol)
equivalent to Ca:PO4 (mg)
60ml/kg/day no sodium PN 0.5 20 0.5 47.5 1.5g/kg/day= 0.11 10.45 0.5 : 0.61 1.0 : 1.22 20 57.95 ratio 1: 2.9
90ml/kg/day no sodium PN 0.8 32 0.8 76 2g/kg/day= 0.15 14.25 0.8 : 0.95 1.0 : 1.19 32 90.25 ratio 1: 2.8
120ml/kg/day no sodium PN 1.1 44 1.1 104.5 3g/kg/day= 0.23 21.85 1.3 : 1.33 1.0 : 1.02 44 126.35 ratio 1: 2.9
150ml/kg/day no sodium PN 1.3 52 1.3 123.5 3.5g/kg/day=0.26 24.7 1.3 : 1.56 1.0 : 1.2 52 148.20 ratio 1:2.9
60ml/kg/day low sodium PN 0.6 24 0.8 76 1.5g/kg/day= 0.11 10.45 0.6 : 0.91 1.0 : 1.52 24 86.45 ratio 1: 3.6
90ml/kg/day low sodium PN 0.9 36 1.2 114 2g/kg/day= 0.15 14.25 0.9 : 1.35 1.0 : 1.5 36 128.25 ratio 1: 3.6
120ml/kg/day low sodium PN 1.2 48 1.6 152 3g/kg/day= 0.23 21.85 1.2 : 1.83 1.0 : 1.53 48 173.85 ratio 1: 3.6
150ml/kg/day low sodium PN 1.5 60 2 190 3.5g/kg/day=0.26 24.7 1.5 : 2.26 1.0 : 1.51 60 214.70 ratio 1: 3.6
60ml/kg/day high sodium PN 0.6 24 0.8 76 1.5g/kg/day= 0.11 10.45 0.6 : 0.91 1.0 : 1.52 24 86.45 ratio 1: 3.6
90ml/kg/day high sodium PN 0.9 36 1.2 114 2g/kg/day= 0.15 14.25 0.9 : 1.35 1.0 : 1.5 36 128.25 ratio 1: 3.6
120ml/kg/day high sodium PN 1.2 48 1.6 152 3g/kg/day= 0.23 21.85 1.2 : 1.83 1.0 : 1.53 48 173.85 ratio 1: 3.6
150ml/kg/day high sodium PN 1.5 60 2 190 3.5g/kg/day=0.26 24.7 1.5 : 2.26 1.0 : 1.51 60 214.70 ratio 1: 3.6 PN volume based on SMOF running at 12%. It will change if SMOF at 6% or stopped NOTE SMOF contains 0.45mmol phosphate in 30ml (42.75 mg in 30ml) calcium 1mmol= 40mg phosphate (PO4) 1mmol=95mg
ratio Ca:PO4 (mg)
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Appendix 2 - Calcium:Phosphate Ratios for a Variety of Feeding Regimens Calcium mg Phosphate mg Ratio Per 150mls Breast Milk 37.5 21.75 1.72
2.2g (2%) Nutriprem Breast Milk Fortifier (per 2.2g) - 33.0 19.0 1.74
1g(2%) SMA Breast Milk Fortifier (per 1g) 19 11 1.72 Per 150 mls NP1 151.5 94.5 1.60 Per 150 mls NP2 87 48 1.81 Per 150 mls SMA Gold Prem 1 174 115.5 1.50 Per 150 mls SMA Gold Prem 2 120 72 1.66
All combinations of MEBM with any fortifier at 2%, 3% and 4% will provide calcium and phosphate ratio of 1.72 to 1.73
If on additional calcium or phosphate supplements, please add them to calculate the ratio.
1 mmol of Calcium provides 40 mg and 1 mmol of Phosphate provides 95 mg
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2. Supporting References
• Chinoy A et al, Arch Dis Child fetal neonatal Ed 2019;0:F1-F7. Metabolic bone disease of prematurity:causes, recognition, prevention, treatment and long term consequences.
• Valentina Bozzetti and Paolo Tagliabue, Metabolic Bone Disease in preterm newborn: an update on nutritional issues, Italian Journal of Pediatrics 2009, 35:20
• Carol L. Wagner and Frank R. Greer, Prevention of Rickets and Vitamin D Deficiency in Infants,
Children and Adolescents, Pediatrics 2008; 122; 1142 • ESPGHAN guidance, Vitamin D in the Healthy European Paediatric Population, , Journal of
Pediatric Gastroenterology and Nutrition 2013, Vol 56, No 6 • Sujata Edate and Shailini Bahl, Diagnosis and Management of Vitamin D Deficiency, ASPH
Paediatric guidelines, 2012 • Roberta A McCarthy et al, Vitamin D nutritional status in preterm infants and response to
supplementation, British Journal of Nutrition (2013), 110, 156-163 • Angela Lucas-Herald, Sandra Butler, Prevalence and Characteristics of Rib Fractures in Ex-
preterm Infants, Pediatrics 2012: 130; 1116 • Scientific Advisory committee on Nutrition, Department of Health, Vitamin D and Health, report
available online: https://www.gov.uk/government/groups/scientific-advisory-committee-on- nutrition
• Stacy E. Rustico, Andrew C. Calabria, Samuel J. Garber, Metabolic bone disease of
prematurity, Journal of Clinical & Translational Endocrinology, 2014; Vol 1: 85-91
3. Supporting relevant trust guidelines
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a. Scope
This guideline in relevant to all staff caring for babies across neonatal intensive care, transitional care and maternity.
b. Purpose
i. This guidelines aims to facilitate a common approach to the management of babies admitted under neonatal care. At times deviation from the guideline may be necessary, this should be documented and is the responsibility of the attending consultant.
ii. This guideline is subject to regular review to ensure ongoing evidence based practice.
c. Duties and Responsibilities
All healthcare professionals responsible for the care of newborn infants in NICU are duty bound to ensure good practice with regards to this guideline.
d. Approval and Ratification
This guideline will be approved and ratified by the Neonatal Guidelines Group.
e. Dissemination and Implementation
i. This guideline will be uploaded to the trust intranet ‘Neonatal Guidelines’ page and thus available for common use.
ii. This guideline will be shared as part of ongoing education within the Neonatal Unit for both medical and nursing staff.
iii. All members of staff are invited to attend and give comments on the guideline as part of the ratification process.
f. Review and Revision Arrangements
a. This policy will be reviewed on a 5 yearly basis. b. If new information comes to light prior to the review date, an earlier review will
be prompted. c. Amendments to the document shall be clearly marked on the document control
sheet and the updated version uploaded to the intranet. Minor amendments will be ratified through the Neonatal Guidelines Group. A minor amendment would consist of no major change in process, and includes but is not limited to, amendments to documents within the appendices.
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Neonatal Guidelines Group
Methodology
A brief account of how the likely effects of the policy was assessed (to include race and ethnic origin, disability, gender, culture, religion or belief, sexual orientation, age)
The data sources and any other information used The consultation that was carried out (who, why and how?)
Discussed at open guidelines meeting
Key Findings
Describe the results of the assessment Identify if there is adverse or a potentially adverse impacts for any equalities groups
No evidence of discrimination
No evidence of discrimination
Recommendations
State recommended changes to the proposed policy as a result of the impact assessment Where it has not been possible to amend the policy, provide the detail of any actions that have
been identified Describe the plans for reviewing the assessment
Fit for purpose
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h. Document Checklist
To be completed (electronically) and attached to any document which guides practice when submitted to the appropriate committee for approval or ratification.
Title of the document: Prevention and management of metabolic bone disease of prematurity
Policy (document) Author: Vennila Ponnusamy
Yes/No/ Unsure/NA
1. Title Is the title clear and unambiguous? Y
Is it clear whether the document is a guideline, policy, protocol or standard?
Y
Y
Is the purpose of the document clear? Y Are the intended outcomes described? Y Are the statements clear and unambiguous? Y 3. Development Process
Is there evidence of engagement with stakeholders and users?
Y
Who was engaged in a review of the document (list committees/ individuals)?
Neonatal guidelines committee (multidisciplinary). Wider stakeholder consultation prior to meeting.
Has the policy template been followed (i.e. is the format correct)?
Y
4. Evidence Base
Is the type of evidence to support the document identified explicitly?
Y
NA
Y
If appropriate, have the joint human resources/staff side committee (or equivalent) approved the document?
NA
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Comments
Is there an outline/plan to identify how this will be done?
Y
Does the plan include the necessary training/support to ensure compliance?
Y
7. Process for Monitoring Compliance
Are there measurable standards or KPIs to support monitoring compliance of the document?
8. Review Date
2022
9. Overall Responsibility for the Document
Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation?
Y
10. Equality Impact Assessment (EIA) Has a suitable EIA been completed? Y
Committee Approval (Neonatal Guidelines Committee)
If the committee is happy to approve this document, please complete the section below, date it and return it to the Policy (document) Owner
Name of Chair S. Edwards Date 14 November 2019
Ratification by Management Executive (if appropriate)
If the Management Executive is happy to ratify this document, please complete the date of ratification below and advise the Policy (document) Owner
Date: n/a
Prevention and Management of Metabolic Bone Disease of
Prematurity
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b. Infants at high risk 4
c. Prevention of MBD 4
d. Pathway for management 5
e. Supplementation (calcium, phosphate) 6
f. Parathyroid Hormone 6
g. Vitamin D 6
i. Xrays 7
2. Appendices
a. Calcium phosphate ratios for a variety of parenteral regimes 8
b. Calcium phosphate ratios for a variety of feeding regimes 9
c. Calcium preparations 10
3. Supporting References 11
5. Guideline Governance 12
b. Document Checklist 14
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Metabolic Bone Disease
Preterm infants are at significant risk of metabolic bone disease because skeletal growth and bone mineralisation take place mostly during the latter stages of pregnancy. Metabolic bone disease of prematurity (MBD) is essentially a substrate deficiency disease. Providing at-risk infants with adequate calcium and phosphate through breast milk fortification or use of specific preterm formulas helps prevent metabolic bone disease. MBD is diagnosed based on biochemical changes noted in routine bloods. Raising alkaline phosphatase (ALP) >600 U/L is an early sign of MBD. There is no cut-off value for marker of MBD. High ALP >800 U/L often is considered a marker for MBD. A combination of high ALP, low phosphate and elevated parathyroid hormone (PTH) is highly sensitive and specific for a diagnosis of MBD. Routine supplementation of oral phosphates in high risk neonates could lead to secondary hyperparathyroidism, and thus worsen MBD. Therefore in cases of suspected MBD with elevated ALP and low phosphate, PTH measurement will help in establishing if there is underlying calcium or phosphate deficiency to provide correct supplementation. Treatment of MBD with oral supplements should ensure optimal calcium and phosphate ratio of 1.5:1 to 1.7:1 on a milligram to milligram basis to avoid secondary hyperparathyroidism. Vitamin D is required for the absorption of calcium and phosphate from the intestine to enable bone mineralisation. All babies, irrespective of type of feed, should receive 400 IU of Vitamin D (ABIDEC 0.6ml) daily until fully weaned. Additional Vitamin D supplementation is only needed in confirmed cases of deficiency/insufficiency (<50 nmol/L). In line with the Department of Health recommendations, parents should be advised to continue supplementing with an appropriate multi-vitamin until the age of 5 years.
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Infants at high risk of developing MBD: (All babies in extremely-high risk and high risk feeding pathway)
• <29 Weeks gestation • <1000 grams • IUGR < 2nd centile • Very poor growth • Preterm baby fed on EBM without BMF • Babies on parenteral nutrition for > 2 weeks. • Babies with chronic lung disease • Necrotising enterocolitis • Babies who are on prolonged use of demineralising drugs like steroids, loop diuretics,
antacids or methylxanthines
- Use of preterm formulas when needed
- Routine Vit D supplementation (ABIDEC)
- Regular 1 -2 weekly review of bone chemistry
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For all high risk infants, once they are on full feeds for a week – follow this guidance:
Raised ALP (>600 U/L) & / or Low PO4 (<1.8 mmol/L)
Check adequate Calcium/Phosphate requirements met with milk feeds / TPN
Check PTH and Vit D with next bloods in a week – on Monday, as PTH assay is done on Tuesday
Raised PTH (>8.5 pmol/L) –
Normal or Low PTH (<8.5 pmol/L) –
Likely Phosphate deficiency
Stop Phosphate supplements if prescribed Check adequate enteral Ca:PO4 ratio of 1.5:1 to
1.7:1 Check if adequate Ca:PO4 in PN prescribed (1.3:1
to 1.7:1) Start Calcium supplements if needed Optimise 25OH-Vit D if <50 nmol/L
Start Phosphate supplements Check adequate enteral Ca:PO4
ratio of 1.5:1 to 1.7:1 Check if adequate Ca:PO4 in PN
prescribed (1.3:1 to 1.7:1)
Repeat Ca /PO4 / ALP and PTH in 1 week if ALP is > 1000 U/L Repeat Ca /PO4 / ALP and PTH in 2 weeks if ALP is 600 -1000 U/L
Check Vit D levels once a month if on additional Vit D supplementation
Adjust dose of Calcium supplements based on serum calcium levels Only stop calcium supplements when PTH is less than 8.5pmol/L
Adjust dose of PO4 supplements based on serum PO4 levels and ALP
Only stop Vit D supplements when Vit D levels and PTH are normal
To Note:
No risk of nephrocalcinosis if PTH levels are high Elevated PTH causes depletion of 25-OH Vit D - So continue supplementation of Vit D until PTH and
Vit D levels are both normalised If both Calcium and Phosphate supplements are prescribed to a baby - Ensure they are not given
together, as they precipitate in the feeds Aim to normalise biochemistry and stop supplements by 34 weeks. If needs longer supplementation, check biochemistry in 1-2 weeks after stopping. If baby is
discharged prior to blood tests, book in phlebotomy clinic within 2 weeks after discharge. If needs to continue supplements after discharge, inform NCOT team and do TTO for 4 weeks
supply. NCOT team to plan blood tests after stopping supplements.
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Page 6 of 14
Treatment doses: Aim for a corrected calcium level of 2.2 - 2.7mmol/L with a phosphate level of 1.3 - 2.4 mmol/L, with Ca>PO4. Calcium supplementation: Preparations and dose for calcium: Cacit 500 mg effervescent tabs: 12.5mmol/25ml when made up to liquid form Each tablet contains 1.25g calcium carbonate which when dissolved in water provides 500mg of calcium (equivalent to 12.5mmol of calcium) as calcium citrate. Administration: Dissolve 1 tablet in 24mL water resulting in an orange flavoured solution containing 12.5mmol of Calcium in 25mL, from which the required dose can be withdrawn. Recommended starting dose = 0.25mmol/kg QDS. Adjust doses according to repeat blood tests and Ca:Po4 ratio from milk /TPN and supplements. 1 mmol of calcium provides 40 mg of calcium Phosphate supplementation: Sodium acid phosphate – Recommended dose 0.25mmol/kg QDS. The dose can be given in 2 divided doses in babies >1.5 Kg. 1 mmol of phosphate provides 95mg of phosphate (Potassium dihydrogen phosphate preparation) Parathyroid hormone level: This is performed in our biochemistry lab, and takes an average turnaround of 3 working days. Normal levels = 2 - 8.5 pmol/L. Serum vitamin D level: Vit D levels are performed in our biochemistry lab and the results are usually available within 1-2 days. • (25(OH)D), if < 25 nmol/L, the baby is vitamin D deficient, supplement with 3000 units
Cholecalciferol daily for 3 months. Monitor biochemistry regularly. After 3 months treatment recheck serum Vit D levels along with alkaline phosphatase, PTH, calcium and phosphate. Ensure supplementation with a daily dose of at least 400 units vitamin D is undertaken after treatment.
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Page 7 of 14
• If serum levels are between 25-50 nmol/L, the baby’s vitamin D status is insufficient, provide
dietary advice and ensure maintenance supplementation with a daily dose of at least 400 units vitamin D is continued. Recheck Vit D levels in 3 months’ time.
Milk contents of vitamin D: • 0.6 ml Abidec contains 400 units vitamin D • 100ml NP1 – 120 units vitamin D • 100 ml NP2 – 68 units vitamin D • 1 L of unfortified EBM – less than 25 units • 100 ml EBM with 2% breast milk fortifier – 240 units vitamin D
Preparations for Vitamin D:
Fultium D3 drops: https://www.medicines.org.uk/emc/product/6861/smpc 3 drops of Fultium D3 = 200 units 1 ml of Fultium D3 = 2740 units. 41 drops = approximately 1 ml
Dose: For Vit D Deficiency: 1 ml of Futilium D3 (2740 units) + 0.6 ml of ABIDEC (400 units) = total of 3140 units Discuss with Paediatric Pharmacist for more details. Urinary calcium and phosphate ratio: Urinary calcium and phosphate excretion can be used for additional diagnostic purposes and supplementation as indicated. It is not reliable when on diuretics. • Ca:PO4 ratio > 1 : Relative ↑urinary Calcium loss, Body tries to retain Phosphate, possible
Phosphate depletion, consider additional Phosphate supplements • Ca:PO4 ratio < 1 : Relative ↑urinary Phosphate loss, Body tries to retain Calcium, possible
calcium depletion, consider additional Calcium supplements X-Rays: There are a number of radiological changes seen in MBD, including demineralisation or “osteopenia,” rachitic changes, and/or fractures. Consistently high ALP can indicate underlying fractures in severe MBD. Examine babies carefully to check for any bony deformities. As fractures of ribs are common in high risk preterm babies, Please do a CXR and document formal report in notes.
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Appendix 1 - Calcium:Phosphate Ratios for a Variety of Parenteral Regimens
volume type of PN Calcium mmol/kg/d ay
Calcium mg/kg/day
ratio Ca:PO4 (mmol)
equivalent to Ca:PO4 (mmol)
equivalent to Ca:PO4 (mg)
60ml/kg/day no sodium PN 0.5 20 0.5 47.5 1.5g/kg/day= 0.11 10.45 0.5 : 0.61 1.0 : 1.22 20 57.95 ratio 1: 2.9
90ml/kg/day no sodium PN 0.8 32 0.8 76 2g/kg/day= 0.15 14.25 0.8 : 0.95 1.0 : 1.19 32 90.25 ratio 1: 2.8
120ml/kg/day no sodium PN 1.1 44 1.1 104.5 3g/kg/day= 0.23 21.85 1.3 : 1.33 1.0 : 1.02 44 126.35 ratio 1: 2.9
150ml/kg/day no sodium PN 1.3 52 1.3 123.5 3.5g/kg/day=0.26 24.7 1.3 : 1.56 1.0 : 1.2 52 148.20 ratio 1:2.9
60ml/kg/day low sodium PN 0.6 24 0.8 76 1.5g/kg/day= 0.11 10.45 0.6 : 0.91 1.0 : 1.52 24 86.45 ratio 1: 3.6
90ml/kg/day low sodium PN 0.9 36 1.2 114 2g/kg/day= 0.15 14.25 0.9 : 1.35 1.0 : 1.5 36 128.25 ratio 1: 3.6
120ml/kg/day low sodium PN 1.2 48 1.6 152 3g/kg/day= 0.23 21.85 1.2 : 1.83 1.0 : 1.53 48 173.85 ratio 1: 3.6
150ml/kg/day low sodium PN 1.5 60 2 190 3.5g/kg/day=0.26 24.7 1.5 : 2.26 1.0 : 1.51 60 214.70 ratio 1: 3.6
60ml/kg/day high sodium PN 0.6 24 0.8 76 1.5g/kg/day= 0.11 10.45 0.6 : 0.91 1.0 : 1.52 24 86.45 ratio 1: 3.6
90ml/kg/day high sodium PN 0.9 36 1.2 114 2g/kg/day= 0.15 14.25 0.9 : 1.35 1.0 : 1.5 36 128.25 ratio 1: 3.6
120ml/kg/day high sodium PN 1.2 48 1.6 152 3g/kg/day= 0.23 21.85 1.2 : 1.83 1.0 : 1.53 48 173.85 ratio 1: 3.6
150ml/kg/day high sodium PN 1.5 60 2 190 3.5g/kg/day=0.26 24.7 1.5 : 2.26 1.0 : 1.51 60 214.70 ratio 1: 3.6 PN volume based on SMOF running at 12%. It will change if SMOF at 6% or stopped NOTE SMOF contains 0.45mmol phosphate in 30ml (42.75 mg in 30ml) calcium 1mmol= 40mg phosphate (PO4) 1mmol=95mg
ratio Ca:PO4 (mg)
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Appendix 2 - Calcium:Phosphate Ratios for a Variety of Feeding Regimens Calcium mg Phosphate mg Ratio Per 150mls Breast Milk 37.5 21.75 1.72
2.2g (2%) Nutriprem Breast Milk Fortifier (per 2.2g) - 33.0 19.0 1.74
1g(2%) SMA Breast Milk Fortifier (per 1g) 19 11 1.72 Per 150 mls NP1 151.5 94.5 1.60 Per 150 mls NP2 87 48 1.81 Per 150 mls SMA Gold Prem 1 174 115.5 1.50 Per 150 mls SMA Gold Prem 2 120 72 1.66
All combinations of MEBM with any fortifier at 2%, 3% and 4% will provide calcium and phosphate ratio of 1.72 to 1.73
If on additional calcium or phosphate supplements, please add them to calculate the ratio.
1 mmol of Calcium provides 40 mg and 1 mmol of Phosphate provides 95 mg
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2. Supporting References
• Chinoy A et al, Arch Dis Child fetal neonatal Ed 2019;0:F1-F7. Metabolic bone disease of prematurity:causes, recognition, prevention, treatment and long term consequences.
• Valentina Bozzetti and Paolo Tagliabue, Metabolic Bone Disease in preterm newborn: an update on nutritional issues, Italian Journal of Pediatrics 2009, 35:20
• Carol L. Wagner and Frank R. Greer, Prevention of Rickets and Vitamin D Deficiency in Infants,
Children and Adolescents, Pediatrics 2008; 122; 1142 • ESPGHAN guidance, Vitamin D in the Healthy European Paediatric Population, , Journal of
Pediatric Gastroenterology and Nutrition 2013, Vol 56, No 6 • Sujata Edate and Shailini Bahl, Diagnosis and Management of Vitamin D Deficiency, ASPH
Paediatric guidelines, 2012 • Roberta A McCarthy et al, Vitamin D nutritional status in preterm infants and response to
supplementation, British Journal of Nutrition (2013), 110, 156-163 • Angela Lucas-Herald, Sandra Butler, Prevalence and Characteristics of Rib Fractures in Ex-
preterm Infants, Pediatrics 2012: 130; 1116 • Scientific Advisory committee on Nutrition, Department of Health, Vitamin D and Health, report
available online: https://www.gov.uk/government/groups/scientific-advisory-committee-on- nutrition
• Stacy E. Rustico, Andrew C. Calabria, Samuel J. Garber, Metabolic bone disease of
prematurity, Journal of Clinical & Translational Endocrinology, 2014; Vol 1: 85-91
3. Supporting relevant trust guidelines
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a. Scope
This guideline in relevant to all staff caring for babies across neonatal intensive care, transitional care and maternity.
b. Purpose
i. This guidelines aims to facilitate a common approach to the management of babies admitted under neonatal care. At times deviation from the guideline may be necessary, this should be documented and is the responsibility of the attending consultant.
ii. This guideline is subject to regular review to ensure ongoing evidence based practice.
c. Duties and Responsibilities
All healthcare professionals responsible for the care of newborn infants in NICU are duty bound to ensure good practice with regards to this guideline.
d. Approval and Ratification
This guideline will be approved and ratified by the Neonatal Guidelines Group.
e. Dissemination and Implementation
i. This guideline will be uploaded to the trust intranet ‘Neonatal Guidelines’ page and thus available for common use.
ii. This guideline will be shared as part of ongoing education within the Neonatal Unit for both medical and nursing staff.
iii. All members of staff are invited to attend and give comments on the guideline as part of the ratification process.
f. Review and Revision Arrangements
a. This policy will be reviewed on a 5 yearly basis. b. If new information comes to light prior to the review date, an earlier review will
be prompted. c. Amendments to the document shall be clearly marked on the document control
sheet and the updated version uploaded to the intranet. Minor amendments will be ratified through the Neonatal Guidelines Group. A minor amendment would consist of no major change in process, and includes but is not limited to, amendments to documents within the appendices.
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Neonatal Guidelines Group
Methodology
A brief account of how the likely effects of the policy was assessed (to include race and ethnic origin, disability, gender, culture, religion or belief, sexual orientation, age)
The data sources and any other information used The consultation that was carried out (who, why and how?)
Discussed at open guidelines meeting
Key Findings
Describe the results of the assessment Identify if there is adverse or a potentially adverse impacts for any equalities groups
No evidence of discrimination
No evidence of discrimination
Recommendations
State recommended changes to the proposed policy as a result of the impact assessment Where it has not been possible to amend the policy, provide the detail of any actions that have
been identified Describe the plans for reviewing the assessment
Fit for purpose
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h. Document Checklist
To be completed (electronically) and attached to any document which guides practice when submitted to the appropriate committee for approval or ratification.
Title of the document: Prevention and management of metabolic bone disease of prematurity
Policy (document) Author: Vennila Ponnusamy
Yes/No/ Unsure/NA
1. Title Is the title clear and unambiguous? Y
Is it clear whether the document is a guideline, policy, protocol or standard?
Y
Y
Is the purpose of the document clear? Y Are the intended outcomes described? Y Are the statements clear and unambiguous? Y 3. Development Process
Is there evidence of engagement with stakeholders and users?
Y
Who was engaged in a review of the document (list committees/ individuals)?
Neonatal guidelines committee (multidisciplinary). Wider stakeholder consultation prior to meeting.
Has the policy template been followed (i.e. is the format correct)?
Y
4. Evidence Base
Is the type of evidence to support the document identified explicitly?
Y
NA
Y
If appropriate, have the joint human resources/staff side committee (or equivalent) approved the document?
NA
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Comments
Is there an outline/plan to identify how this will be done?
Y
Does the plan include the necessary training/support to ensure compliance?
Y
7. Process for Monitoring Compliance
Are there measurable standards or KPIs to support monitoring compliance of the document?
8. Review Date
2022
9. Overall Responsibility for the Document
Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation?
Y
10. Equality Impact Assessment (EIA) Has a suitable EIA been completed? Y
Committee Approval (Neonatal Guidelines Committee)
If the committee is happy to approve this document, please complete the section below, date it and return it to the Policy (document) Owner
Name of Chair S. Edwards Date 14 November 2019
Ratification by Management Executive (if appropriate)
If the Management Executive is happy to ratify this document, please complete the date of ratification below and advise the Policy (document) Owner
Date: n/a
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