Micronutrient Supplementation in Preterm Infants Clinical Guideline - V1.0 August 2020 - RCHT
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Micronutrient Supplementation in Preterm
Infants
Clinical Guideline
V1.0
August 2020Summary
START
Was the infant born1. Aim/Purpose of this Guideline
1.1. The vitamin and mineral content of breastmilk (or standard infant formula) is
likely to be insufficient for many preterm infants (1). Breastfed preterm
infants with a birth weight2. The Guidance
2.1. Additional micronutrient supplementation should be considered for all
preterm infants born at less than 34 weeks gestation OR with birth weight
less than 1800g.
2.2. The micronutrient supplements required will vary depending on feed choice.
Recommended doses are specified in the following table:
Unfortified
breastmilk
Nutriprem 1 Full-strength
Half-strength
fortified When to prescribe
fortified
Nutriprem 2 breastmilk
breastmilk
Term formula
10am
Start when tolerating
150ml/kg/day feeds.
Abidec 0.6ml OD 0.3ml OD Not required
Stop at 12 months
corrected
Folic Acid 2pm
Start when tolerating
500mcg OD for 50mcg OD Not required Not required 150ml/kg/day feeds.
DAT++/+++
positive baby
for 8 weeks. Stop at discharge.
1ml Sytron 1ml Sytron 6pm
OD OD Start at day 28.
Iron Not required
(5.5mg elemental (5.5mg elemental Stop at 12 months
iron) iron) corrected
Consider supplementation only if serum
Split doses
phosphate 500
Phosphate
Decision to start/stop
1 mmol/kg/day
based on bloods.
2.3. If an infant is receiving a combination of different feed types, follow the
supplementation guidance for whichever feed is given in the highest
volume.
2.4. Micronutrient supplements should be reviewed every time an infant’s feed is
changed, both as an inpatient and in the community.
2.5. In special circumstances, it may be necessary to refer to the neonatal
dietitian, who will calculate individual micronutrient intake and offer advice
on supplementation.
Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0
Page 4 of 132.6. Include guidance for GP on ongoing supplement prescription requirements
in the Badger discharge summary.
2.7. Parents should be made aware that The Department of Health recommend
that all children aged 6 months to 5 years are given a daily multivitamin
containing A,C and D unless they are taking more than 500ml of formula
milk daily (4).
3. Monitoring compliance and effectiveness
Element to be The prescription of supplements as per recommendations in this
monitored guideline, for inpatients and post-discharge.
Lead Neonatal dietitian
Tool Micronutrient supplementation audit tool – see appendix 4
Please use Excel version available in the Dietetics Neonatal Shared
folder:
S:\TR11\Dietetics\Nut&dt\Specialities\Neonatal\Audit\Micronutrient
supplementation audit tool.xlsx
Frequency Annual audit and report
Reporting Child Health Directorate Audit meetings
arrangements
Acting on The Neonatal Dietitian will work with the paediatricians and
recommendations pharmacists to agree a suitable action plan to address
and Lead(s) recommendations.
Change in Required changes to practice will be identified and actioned within
practice and 3 months of audit. A lead member of the team will be identified to
lessons to be take each change forward where appropriate. Lessons will be
shared shared with all the relevant stakeholders
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement which can be found in the 'Equality,
Inclusion & Human Rights Policy' or the Equality and Diversity website.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0
Page 5 of 13Appendix 1. Governance Information
Micronutrient Supplementation in Preterm Infants
Document Title
Clinical Guideline V1.0
This document replaces (exact
New Document
title of previous version):
Date Issued/Approved: 15 July 2020
Date Valid From: August 2020
Date Valid To: August 2023
Directorate / Department
Neonatal - Georgia Kirwin, Neonatal Dietitian
responsible (author/owner):
Contact details: 01872 252409
This guideline is designed to provide guidance to
neonatal staff and general practitioners on
Brief summary of contents
prescription of micronutrient supplements to
preterm infants.
Neonatal, nutrition, infant feeding, vitamins,
Suggested Keywords:
supplements, micronutrients
RCHT CFT KCCG
Target Audience
Executive Director responsible
Medical Director
for Policy:
Approval route for consultation
Neonatal Guidelines Group
and ratification:
General Manager confirming
Mary Baulch
approval processes
Name of Governance Lead
confirming approval by specialty
Caroline Amukusana
and care group management
meetings
Links to key external standards none
Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0
Page 6 of 131. Uauy R, Koletzko B. Defining the nutritional
needs of preterm infants. In: World Review of
Nutrition and Dietetics. S. Karger AG; 2014.
p. 4–10.
2. Lapillonne A, Bronsky J, Campoy C,
Embleton N, Fewtrell M, Fidler Mis N, et al.
Feeding the Late and Moderately Preterm
Infant. J Pediatr Gastroenterol Nutr [Internet].
2019 Aug [cited 2020 Jul 8];69(2):259–70.
Available from:
https://pubmed.ncbi.nlm.nih.gov/31095091/
3. Agostoni ÃC, Buonocore G, Carnielli V, De
Curtis M, Darmaun jj D, Decsi ô T, et al.
Enteral Nutrient Supply for Preterm Infants:
Commentary From the European Society for
Paediatric Gastroenterology, Hepatology,
and Nutrition Committee on Nutrition. 2009
[cited 2020 May 30]; Available from:
Related Documents: www.kindergesundheit.de
4. NHS. Vitamins for children - NHS [Internet].
2018 [cited 2020 Jul 8]. Available from:
https://www.nhs.uk/conditions/pregnancy-
and-baby/vitamins-for-children/
5. Darlow BA, Graham PJ, Rojas-Reyes MX.
Vitamin A supplementation to prevent
mortality and short- and long-term morbidity
in very low birth weight infants. Vol. 2016,
Cochrane Database of Systematic Reviews.
John Wiley and Sons Ltd; 2016.
6. Chinoy A, Mughal MZ, Padidela R. Metabolic
bone disease of prematurity: Causes,
recognition, prevention, treatment and long-
term consequences [Internet]. Vol. 104,
Archives of Disease in Childhood: Fetal and
Neonatal Edition. BMJ Publishing Group;
2019 [cited 2020 Jul 2]. p. F560–6. Available
from: https://fn.bmj.com/content/104/5/F560
Training Need Identified? No
Publication Location (refer to
Policy on Policies – Approvals Internet & Intranet Intranet Only
and Ratification):
Document Library Folder/Sub
Clinical / Neonatal
Folder
Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0
Page 7 of 13Version Control Table
Version Changes Made by
Date Summary of Changes (Name and Job
No
Title)
Georgia Kirwin,
July 2020 V1.0 Initial issue
Neonatal Dietitian
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy for the Development and Management of Knowledge, Procedural and Web
Documents (The Policy on Policies). It should not be altered in any way without the
express permission of the author or their Line Manager.
Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0
Page 8 of 13Appendix 2. Equality Impact Assessment
Section 1: Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed
Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0
Directorate and service area: Is this a new or existing Policy?
Child health directorate - Neonatal New
Name of individual completing EIA Contact details:
Georgia Kirwin, Neonatal Dietitian 01872 252409
1. Policy Aim
Who is the This guideline is designed to provide guidance to neonatal staff
strategy / policy / and general practitioners on prescription of micronutrient
proposal / service supplements to preterm infants.
function aimed at?
2. Policy Objectives
As above
3. Policy Intended
Outcomes
To enable appropriate and consistent micronutrient prescribing for
preterm infants.
4. How will
you measure
See section 3
the outcome?
5. Who is intended
to benefit from the Preterm infants
policy?
6a). Who did you Local External
Workforce Patients Other
consult with? groups organisations
x
Please record specific names of groups:
b). Please list any Neonatal Guidelines Group
groups who have Neonatal dietitians at University Hospitals Bristol and North Bristol
been consulted NHS Trust.
about this procedure.
c). What was the
outcome of the Approved 15 July 2020
consultation?
Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0
Page 9 of 137. The Impact
Please complete the following table. If you are unsure/don’t know if there is a negative impact
you need to repeat the consultation step.
Are there concerns that the policy could have a positive/negative impact on:
Protected
Yes No Unsure Rationale for Assessment / Existing Evidence
Characteristic
Age X
Sex (male, female
non-binary, asexual X
etc.)
Gender
X
reassignment
Race/ethnic Any information provided should be in an
communities accessible format for the parent/carer’s needs –
/groups x i.e. available in different languages if
required/access to an interpreter if required
Disability
(learning disability, Those parent/carers with any identified additional
physical disability, needs will be referred for additional support as
sensory impairment, appropriate - i.e to the Liaison team or for
X
mental health specialised equipment.
problems and some Written information will be provided in a format to
long term health meet the family’s needs e.g. easy read, audio etc
conditions)
Religion/ All staff should be aware of any beliefs that may
other beliefs impact on treatment.
X
Information on Halal/Kosher suitability of
supplements has been requested
Marriage and civil
partnership X
Pregnancy and
maternity X
Sexual orientation
(bisexual, gay, X
heterosexual, lesbian)
If all characteristics are ticked ‘no’, and this is not a major working or service
change, you can end the assessment here as long as you have a robust rationale
in place.
I am confident that section 2 of this EIA does not need completing as there are no highlighted
risks of negative impact occurring because of this policy.
Name of person confirming result of initial
Georgia Kirwin, Neonatal Dietitian
impact assessment:
If you have ticked ‘yes’ to any characteristic above OR this is a major working or
service change, you will need to complete section 2 of the EIA form available here:
Section 2. Full Equality Analysis
For guidance please refer to the Equality Impact Assessments Policy (available
from the document library) or contact the Human Rights, Equality and Inclusion
Lead debby.lewis@nhs.net
Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0
Page 10 of 13Appendix 3. Supporting Information The micronutrients that may need supplementing in preterm infants are as follows: Vitamin A: Plays a role in vision, growth, healing, reproduction, cell differentiation and immune function; also important in fetal lung cell differentiation and surfactant synthesis (1). Cochrane review suggested vitamin A supplementation slightly reduced the risk of death and chronic lung disease at 36 weeks corrected age (5). Unfortified breastmilk or term formula will not provide sufficient vitamin A to meet preterm requirements defined by ESPGHAN (3). Appropriate levels of vitamin A are routinely included in breastmilk fortifier, infant multivitamin preparations and preterm formulas. B and C vitamins: There is little capacity for storage of these water-soluble vitamins within the body; preterm infants will quickly develop deficiencies without regular intake. Preterm infants are likely to have particularly high requirements for B vitamins due to their high metabolic rate and rapid tissue turnover (1). Unfortified breastmilk will not provide sufficient B and C vitamins to meet preterm requirements defined by ESPGHAN (3). Appropriate levels of B and C vitamins are routinely included in term formula (excepting Niacin), breastmilk fortifier, Abidec and preterm formulas. Vitamin D: Plays a role in the absorption of calcium and phosphate, and is therefore important in bone metabolism. 400IU/day (10mcg) is thought to be appropriate to maintain serum vitamin D levels and avoid the risks associated with excessive intake (1). However, ESPGHAN recommend 20-25mcg/day, based on evidence suggesting many infants are already vitamin D deficient at birth, due to maternal deficiency (3). Preterm formulas contain relatively low concentrations of vitamin D, to avoid toxicity with high intakes. All infants, except those receiving breastmilk fortifier, will need supplementation with a vitamin D-containing multivitamin preparation e.g. Abidec. Folate: In preterm infants, folate demands of growth outstrip intake from unfortified breastmilk, which may contribute to folate deficiency. However, there is little evidence that low folate levels contribute to anemia of prematurity (1,3). Preterm formulas and breastmilk fortifier will provide adequate folic acid to meet ESPGHAN requirements, but infants receiving term formulas or unfortified breastmilk will need supplementation. It is not included in infant multivitamin preparations eg Abidec. Iron: Preterm infants are born with lower iron stores than term infants, due to iron accretion occurring in the third trimester. Losses through phlebotomy also decrease iron levels. Risks of iron depletion include anaemia and poor neurodevelopment. Risks of excess supplementation include poor growth and increased infection risk. Uauy and Koletzko (1) recommend commencing supplementation at 2 weeks in infants with birth weight
Phosphate:
Accretion of phosphate in the third trimester occurs at a rate of 50–65 mg/kg/day.
Phosphate absorption varies from 60-95% in preterm infants – this variation accounts
for the wide variety in intake recommendations from various professional bodies (1).
Human milk fortifier, added to the breast milk, and preterm formulae are designed to
provide increased calcium and phosphorus requirements for preterm infants. There is
a lack of evidence to support routine supplementation of oral phosphate in preterm
infants (6). On commencing phosphate supplements, infants may need calcium
supplementation to maintain an appropriate calcium to phosphate ratio.
Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0
Page 12 of 13Appendix 4. Audit Tool
Please use Excel version available in the Dietetics Neonatal Shared folder -
S:\TR11\Dietetics\Nut&dt\Specialities\Neonatal\Audit\Micronutrient supplementation audit tool.xlsx
Patient no Birth weight Gestation at birth Time point at audit Outcome - Abidec Outcome - Folic acid Outcome - Iron Outcome - Phosphate
Micronutrient Supplementation in Preterm Infants Clinical Guideline V1.0
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