Evaluation of a Trace Element Dosing Protocol During Trace Element Product Shortages

Purpose: Trace element supplementation in parenteral nutrition (PN) is critically important to prevent deficiency. Our institution has dosed traces individually, rather than using multitrace products, to optimize supplementation (copper, zinc, selenium), while avoiding accumulation (chromium, manganese). Due to PN product shortages, we began using a neonatal multitrace product in late 2011. Since no pediatric multitrace products contain selenium, we instituted an intermittent dosing protocol to prolong supply. The objective of this study was to evaluate trace element concentrations with this dosing protocol.

Methods: Neonatal multitrace element product (chromium 0.85 mcg/mL, copper 0.1 mg/mL, manganese 25 mcg/mL, zinc 1.5 mg/mL) was dosed at 0.2 mL/kg/day. Additional zinc was supplemented daily via single-entity product. In patients receiving PN > 1 month, selenium was supplemented (4 mcg/kg < 2.5 kg; 5 mcg/kg ≥ 2.5 kg) on Monday, Wednesday, and Friday. This was a retrospective chart review of trace element concentrations in infants receiving this protocol over an 8-week period. 

Results: Seven infants (34.1±3.9; range 27-38 weeks gestational age and 3.2±0.8; range 2.2-4.5 kg during the evaluation period) had diagnoses of necrotizing enterocolitis (n=3), gastroschisis (n=3), and volvulus (n=1). Baseline selenium concentrations were assessed in 5 patients (25.6±9.9; range 10-35 mcg/L), with 1 having a concentration below normal limits (16-71 mcg/L). All 7 patients had selenium concentrations within normal limits at the end of the evaluation period (40.6±14.5; range 20-45 mcg/L). Copper concentrations assessed in 2 patients were within normal limits. Manganese concentrations, assessed at the end of the evaluation period in 4 patients, were all above normal threshold of 1.1 mcg/L (median 3.25; range 1.7-12.8). Three of these 4 patients had elevated direct bilirubin (2.3±0.6; 1.8-3 mg/dL).

Conclusions: An intermittent selenium dosing protocol resulted in maintained concentrations within normal limits. Infants receiving multitrace element products accumulate manganese and should be monitored accordingly.