ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Calcium, phosphorus and magnesium

Literature search timeframe: Publications published after the previous guidelines [[1]Parenteral Nutrition Guidelines Working G, European Society for Clinical N, Metabolism, European Society of Paediatric Gastroenterology H, Nutrition, European Society of Paediatric R Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), supported by the European Society of Paediatric Research (ESPR) – 7. Iron, minerals and trace elements.J Pediatr Gastroenterol Nutr. 2005; 41: S39-S46PubMed Google Scholar] (i.e., from 2004–December 2014), were considered. Some studies published in 2015 or 2016 during the revision process have also been considered. References cited in the previous guidelines are not repeated here, except for some relevant publications; the previous guidelines are cited instead. Type of publications: Original papers, meta-analyses and overviews. Key words: (Parenteral Nutrition or (Infusions, Parenteral)) or (parenteral and nutrition); (calcium or phosphorus or phosphate* or bone or mineralization or magnesium) Age: Child, infant, preterm Language: English.Tabled 1Table: Recommendations for calcium, phosphorus and magnesium in PNR 8.1In infants, children and adolescents on PN appropriate amounts of Ca, P and Mg should be provided to ensure optimal growth and bone mineralization (GPP, strong recommendation)R 8.2The mineral accretion of the fetus, healthy infant, child, and adolescent may be used as a reference for Ca, P and Mg provision (GPP, conditional recommendation)R 8.3In the individual infant appropriate PN should provide a simultaneous slight surplus of Ca, P, and Mg to ensure optimal tissue and bone mineral accretion (GPP, conditional recommendation)R 8.4Ca infusion may be used for prevention and treatment of early neonatal hypocalcaemia that is common and generally not associated with obvious clinical problems such as tetany (GPP, conditional recommendation)R 8.5In preterm infants on PN who were exposed to maternal Mg therapy, Mg intakes need to be adapted to postnatal blood concentrations (LoE 2, RG B, conditional recommendation)R 8.6Acidic solutions packaged in glass vials, such as calcium gluconate, are contaminated with aluminum and should not be used in PN (LoE 3, RG 0, strong recommendation)R 8.7It is recommended to use organic Ca and P salts for compounding of PN solutions to prevent precipitation (GPP, strong recommendation)R 8.8The adequacy of Ca and P intakes in preterm infants can be adjusted until both start being excreted simultaneously with low urine concentrations (>1 mmol/L) indicative of a slight surplus (extrapolated evidence derived from enteral nutrition LoE 2+ studies, RG B, conditional recommendation)R 8.9The recommended parenteral intake for calcium, phosphorus, and magnesium intake in newborns and children on parenteral nutrition in mmol (mg)/kg/d is as follows (LoE 2, 3 and 4, RG 0, conditional recommendation)Tabled 1AgeCa mmol (mg)/kg/dP mmol (mg)/kg/dMg mmol (mg)/kg/dPreterm infants during the first days of life0.8–2.0 (32–80)1.0–2.0 (31–62)0.1–0.2 (2.5–5.0)Growing Premature1.6–3.5 (64–140)1.6–3.5 (50–108)0.2–0.3 (5.0–7.5) infants0–6 m*0.8–1.5 (30–60)0.7–1.3 (20–40)0.1–0.2 (2.4–5)7–12 m0.5 (20)0.5 (15)0.15 (4)1–18 y0.25–0.4 (10–16)0.2–0.7 (6–22)0.1 (2.4) Open table in a new tab *Includes term newborns.R 8.10In preterm infants with intrauterine growth restriction on PN careful monitoring of the plasma phosphate concentration within the first days of life is required to prevent severe hypophosphataemia that can result in muscle weakness, respiratory failure, cardiac dysfunction, and death (LoE 3, RG 0, strong recommendation)R 8.11In preterm infants on early PN during the first days of life lower Ca, P and Mg intakes are recommended than in growing stable preterm infants (Table 1) (LoE 2, RG B, conditional recommendation)R 8.12In early PN when calcium and phosphorus intakes are low (Table 1) and protein and energy are optimized it is recommended to use a molar Ca:P ratio below 1 (0.8–1.0) to reduce the incidence of early postnatal hypercalcaemia and hypophosphataemia (LoE 2, RG B, strong recommendation)R 8.13In infants and children on PN regular monitoring of the individual alkaline phosphatase, Ca, P and Mg serum concentrations and Ca and P urine concentrations is required (Extrapolated evidence from LoE 2 and 3 studies, RG 0, strong recommendation)R 8.14In infants and children on long term PN the risk of metabolic bone disease requires periodic monitoring of Ca, P, vitamin D and bone mineral status (LoE 2 + and 3, RG 0, strong recommendation) Open table in a new tab