Observational Study Open Access
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Pediatr. Aug 8, 2016; 5(3): 325-329
Published online Aug 8, 2016. doi: 10.5409/wjcp.v5.i3.325
Significant variations in nutritional supplementation amongst neonates in the United Kingdom
Morris Gordon, Sahira Isaji, Fiona Tyacke
Morris Gordon, Sahira Isaji, Fiona Tyacke, Department of Paediatric, Blackpool Victoria Hospital, Preston FY3 8NR, United Kingdom
Morris Gordon, School of Medicine and Dentistry, University of Central Lancashire, Preston PR1 2HE, United Kingdom
Author contributions: Gordon M conceived the study, supported the analysis and led the write up; Isaji S and Tyacke F jointly performed the data collection, analysis and added to the write up; all authors approved the final manuscript.
Institutional review board statement: The study was reviewed by the local Research and Development/audit Department.
Informed consent statement: Obtained by all participants before telephone participation, all information recorded was anonymous.
Conflict-of-interest statement: Isaji S and Tyacke F have none to declare; Gordon M has received travel grants and educational grants from various companies to attend scientific and educational meetings, including Danone/nutricia, Abbott, Ferring, Casen Fleet, Vifor, Clinova, Tillots, Warner Chiclott, Norgine and Biogaia. They had no involvement in this or any other study.
Data sharing statement: Data is available on request from the author morris@betterprescribing.com.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Morris Gordon, School of Medicine and Dentistry, University of Central Lancashire, HA118, Harrington building, Preston PR1 2HE, United Kingdom. morris@betterprescribing.com
Telephone: +44-7816-687791
Received: January 20, 2016
Peer-review started: January 20, 2016
First decision: April 18, 2016
Revised: May 8, 2016
Accepted: June 27, 2016
Article in press: June 29, 2016
Published online: August 8, 2016

Abstract

AIM: To ascertain United Kingdom adherence to European society of Paediatric Gastroenterology, Hepatology and Nutrition guidance (ESPGHAN).

METHODS: A national cross sectional questionnaire study of neonatal units across England was completed between January and March 2014. All 174 units in the country were attempted to be contacted to complete a telephone survey. This included all level 1, 2 and 3 units. They were initially contacted by phone and asking any senior member of the team about their current practice and procedures. The first ten telephone interviews were completed with two researchers present to ensure consistency of approach. If no response was received or no details were available, one further attempt was made to contact the unit. The results were recorded in a proforma and then collated and entered into a spreadsheet for analysis. Comparison to United Kingdom adherence to ESPGHAN guidance was completed.

RESULTS: Response rate was 53%. There was variation in use of all supplements. The survey collected data from 91 neonatal units (53% response rate). It was found that 10% of neonatal units had no fixed policy on supplements. The protocols regarding supplementation involved predominantly folic acid, vitamin A, vitamin D and iron, with much variation in doses and regimens. The criteria for prescribing supplements was largely based on age (47%) with only 7% using a weight targets to initiate supplements. Summary data regarding the appropriateness of each nutritional supplement for a variety of different weights are presented, as well as comparison to ESPGHAN guidance which suggests issues with both underdoing of Breast Fed infants and overdosing of infants on several artificial formulas which already contain significant amounts of these nutritional elements.

CONCLUSION: There is significant heterogeneity in neonatal policies when prescribing supplements to neonates. National policies which take international guidance into account are recommended.

Key Words: Neonatal, Nutritional additives, Preterm nutrition, Term nutrition, Iron

Core tip: Nutritional supplementation in neonates is common in neonatal units, but there is no clear United Kingdom guidance. This study set out to ascertain United Kingdom practice with a national cross-sectional study with reference to European society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) nutritional guidance. Fifty-five percent of the 174 units in the country were contacted. There was variation in use of all supplements. Comparison to ESPGHAN guidance suggests issues with both underdoing of Breast Fed infants and overdosing of preterm infants on several artificial formulas which already contain significant amounts of nutritional elements. National policies which take international guidance into account are recommended, with similar research needed in other countries.



INTRODUCTION

Nutritional needs of both preterm and term neonates are not the same as older children and are subject to rapid changes. A number of nutritional supplements have been studied in relation to prematurity, notably vitamin A, D, iron and folic acid - these form the basis of supplementation recommendations in neonates. Preterm infants have higher nutrient requirements than term infants but inappropriate or absent supplementation can be detrimental to their health[1]. Preterm infants have a low vitamin A status at birth[1]. Evidence shows vitamin A supplement significantly reduces the risk of chronic lung disease and reduces mortality, however excessive levels can lead to symptoms[2].

Preterm infants are susceptible to developing iron deficiency, particularly more premature infants and those being exclusively breastfed without supplementation. As iron plays a role in various tissue functions this would support the need supplementation in preterm infants[3]. Vitamin D is needed for bone health and low levels can cause rickets and seizures secondary to low calcium[4]. Folic acid is used for the prevention of anaemia of prematurity. Levels are high at birth but fall rapidly in the first few weeks of life more notably in the lowest birthweight neonates[5].

Nutritional supplements are almost ubiquitous for infants admitted to United Kingdom neonatal units. Compositions of vitamin supplements vary, for example, Dalavit and Abidec are both commonly used, but Dalavit contains nearly 4 times the amount of vitamin A[1] as Abidec. Doses of supplements should be adjusted according to the type of milk the infant is receiving. Breast milk is best for preterm and low birth weight babies - better long term health outcomes have been well documented, but higher doses of supplements or the addition of fortifiers is required in order to reach the recommended daily intake of vitamins and minerals.

There are currently no national guidelines on nutritional supplementation, but local protocols exist based on growth and nutrition studies and guidance provided by expert groups[6]. The aim of this study was to establish current practices in neonatal supplementation in neonatal units across England[6] and to compare these dosing regimens to guidance provided by European society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)[7].

MATERIALS AND METHODS

A national cross sectional questionnaire study of Neonatal units across England was conducted between January and March 2014[6]. This included all level 1, 2 and 3 units. They were initially contacted by phone and asking any senior member of the team about their current practice and procedures. Eligible staff included senior nurses, advanced neonatal nurse practitioners and senior medical staff.

Firstly, the existence of a local policy was established. Then, details of the supplements used, their brands, dosing, criteria for initiation and the impact of gestational age, weight and feeding type were recorded.

The first ten telephone interviews were completed with two researchers present to ensure consistency of approach and then further interviews were conducted by either researcher. If no response was received or no details were available, one further attempt was made to contact the unit.

The results were recorded in a proforma and then collated and entered into a spreadsheet for analysis. Comparison to ESPGHAN guidance was completed.

RESULTS

The survey collected data from 91 neonatal units (53% response rate), with a representative sample of hospital size and level of neonatal care achieved[6]. It was found that 10% of neonatal units had no fixed policy on supplements. The protocols regarding supplementation involved predominantly folic acid, vitamin A, vitamin D and iron.

In regards to folic acid, when supplementing expressed breast milk (EBM), 36% of hospitals prescribed 50 μg of folic acid daily, whilst 37% of units prescribed no folic acid. For remaining units, the dose varied from 50 μg daily to 1 mg weekly of folic acid.

Similar results were obtained when looking at the vitamins A and D data. Dalavit and Abidec doses varied in each hospital. Two units had no fixed regime and was based on which supplement (Dalavit or Abidec) was available at the time of prescribing.

When considering iron supplementation[7], over 65% of units prescribed iron supplementation with various feeds types whereas 27% did not supplement with iron at all. Doses across the different units varied between 0.5 mL sytron once daily to 2.5 mL twice daily. Forty-six percent of units recognised that no additional iron supplementation is needed for babies receiving preterm formula. The criteria for prescribing supplements was largely based on age (47%) with only 7% of units interviewed using a weight based set of criteria to initiate supplements. A small number of hospitals had no fixed criteria, and certain hospitals (24%) used both age and weight.

Summary data regarding the appropriateness of each nutritional supplement for a variety of different weights are presented in Figure 1. Table 1 demonstrates the amount of each of the supplements that are delivered purely through feeding with breast milk, fortified breast milk and with a variety of artificial milks.

Table 1 Nutritional content of breast milk and artificial formulae (brand names of United Kingdom formula preparations used)[5].
Type of feed (based on 180 mL of feed)Vitamin A (μgRE)Vitamin D (μg)Folic acid (μg)Iron (mg)
EBM1040.07 μg/kg per day90.126
EBM + 2 × 2.2 g Nutriprem (C and G) Breast Milk Fortifier5229.1 μg/kg per day63Neg
EBM + 2 × 2 g SMA BMF48613.68 μg/kg per day54Neg
SMA gold Prem 13336.1 μg/kg per day522.5
SMA Gold Prem 21802.7 μg/kg per day272.16
C and G Nutriprem 16505.4 μg/kg per day632.9
C and G Nutriprem 21803.06 μg/kg per day362.16
C and G 197.22.16 μg/kg per day23.40.954
Aptamil 197.22.16 μg/kg per day23.40.954
SMA 11192.2 μg/kg per day19.81.2
HiPP 11262.16 μg/kg per day180.9
Neocate LCP100.82.16 μg/kg per day15.841.8
ESPGHAN recommendation400-1000 µg RE/kg per day20-25 μg/d35-100 µg/kg per day2-3 mg/kg per day (from 2-6 wk)
Figure 1
Figure 1 Dosing range results for various nutritional supplements. EBM: Expressed breast milk.
DISCUSSION

Dosing of all nutritional additives varied greatly across the country[6]. Only a small proportion of units actually achieved dosing within ESPGHAN recommended limits in all supplements[7]. More than 80% of units are in-fact overdosing smaller infants iron potentially causing toxicity.

In general, overdosing of supplements was seen in smaller babies. Larger babies are more commonly receiving doses within the recommended limits. However, the criterion was seen to be based on either birth weight, gestational age or both. ESPGHAN recommends that the infant’s dry weight should be used when calculating the dose of supplements[5]. This would mean weighing the baby on a regular basis and adjusting doses accordingly. This practice was not being done in any unit surveyed; doses calculated from birth seem to remain static until discontinued.

Whilst there is clearly no national policy on this issue, there are local networks that carry guidance. Whilst it was outside the scope of this study to investigate these in great detail, the local network in Greater Manchester included a total of 8 units surveyed. Not only did the dose of vitamin A vary but units were also using different brands. Supplementing with folic acid was completely absent in one hospital but the use of iron was consistent. This highlights that current practice is clearly leading to massive variations in both strategy and outcome for babies. With such wide variation in dosing and differing criteria for initiation there is great potential for causing harm to infants, from either insufficient or excessive supplementation. Consistent dosing and one policy for all feed types are also not ideal and can put smaller babies in particular at risk.

Table 1 highlights certain dosing issues that could become tenants of a national policy. It is clear that neonates on preterm formula generally do not need further vitamin A, folic acid or iron supplementation, but require vitamin D. Neonates on EBM will require all additional supplementation, but those on fortifier will only require iron supplements. It seems that iron supplementation is not indicated for any babies on artificial formulas, as changing requirements have been considered in the changing constituents of preterm vs term formulations. It is also important to assess whether the supplements need to continue on discharge as both requirements and content of formulas change with age.

These principles and the huge variation in practical prescribing that have been highlighted by this study support the need for a standardised supplementation regime based on available evidence, with arrangements to update regular to consider changes in artificial formulas and fortification. This will allow the nutritional needs of infants to be met in an appropriate and safe manner. Further research is indicated to assess if similar problems exists in other countries.

There is significant heterogeneity in neonatal policies when prescribing supplements to neonates. National policies which take international guidance into account are recommended. Further research is indicated to assess if similar problems exists in other countries.

COMMENTS
Background

Nutritional requirements amongst preterm and term neonates differ from older infants and change rapidly. Preterm infants have higher nutrient requirements than term infants but inappropriate or absent supplementation can be detrimental to their health.

Research frontiers

There are currently no national guidelines on nutritional supplementation, although there is international guidance from ESPGHAN.

Innovations and breakthroughs

This study confirms that despite international guidance that is evidence informed, practice across the country does not align to this or any prescribed guidance. Indeed, practice varies significantly and this potential means neonates may be under or overdosing on supplements.

Applications

It is advised that readers consider the evidence base of their local guidance and how this compares to national and international guidance.

Terminology

ESPGHAN: European society of Paediatric Gastroenterology, Hepatology and Nutrition.

Peer-review

In the paper, the authors present a useful and interesting study regarding nutritional supplementation in preterm babies in the United Kingdom.

Footnotes

Manuscript source: Invited manuscript

Specialty type: Pediatrics

Country of origin: United Kingdom

Peer-review report classification

Grade A (Excellent): A

Grade B (Very good): B

Grade C (Good): C

Grade D (Fair): 0

Grade E (Poor): 0

P- Reviewer: Al-Haggar M, Classen CF, Yu ZW S- Editor: Qiu S L- Editor: A E- Editor: Wu HL

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