Calcium and Phosphorous in Pediatric Parenteral Nutrition

Abstract

Calcium (Ca) and phosphorus (P) are essential for various systemic functions, including bone mineralization. Adequate provision of Ca and P in pediatric parenteral nutrition (PN) solutions is necessary for skeletal growth and for the prevention of metabolic bone disease. The provision of adequate doses of Ca and P in pediatric PN solutions is complicated by the increased needs in preterm and term infants, solubility limitations, and venous access. Clinicians should be aware of the evidence that supports the optimal use of Ca and P in pediatric PN solutions, including studies that have evaluated dosing and solubility. The aim of this article is to review relevant literature and practices for the use of these two minerals in pediatric PN solutions. The vitamin D endocrine system, a critical component for Ca homeostasis and bone mineralization, is discussed, as well as clinical manifestations of metabolic bone disease and methods for its prevention, assessment, and treatment in pediatric patients receiving PN.

Solubility of calcium gluconate and sodium glycerophosphate in infant parenteral nutrition solutions

“…Preterm infants need high amount of calcium and phosphorus during their first year of life or until they reach approximately 10-12 kg in weight for enhancing bone mineralization and preventing abnormal growth (Marks & Crill, 2004). The European Society of Infant Gastroenterology, Hepatology and Nutrition and the European Society for Clinical Nutrition and Metabolism (The ESPGHAN/ESPEN) recommends that growing newborn infants should receive 1.3-3.0 mM calcium/kg/day and 1.0-2.3 mM phosphorus/kg/day, with a calcium-to-phosphorus (Ca:P) ratio (mole/mole) in the range of 1.3-1.7 (Koletzko et al, 2005;Ribeiro et al, 2009).…”

“…Therefore it is important to increase calcium and phosphate amounts in PN prescription for neonates. However, practical solubility factors relevant to the safe administration of calcium and phosphate are concerned (Marks & Crill, 2004).…”

“…Separate infusions of calcium and phosphate solutions are alternative methods to achieve requirement of the infant patient but they resulted in hyperphosphatemia and hypocalcemia during phosphate infusion and hypercalcemia and hypophosphatemia during calcium infusion (Marks & Crill, 2004;Pereira-da-Silva et al, 2003). To avoid this mineral imbalance, calcium phosphate admixture is still required.…”

“…The fetus accumulates 3.00-3.75 mM/kg/day of calcium and 2.25-2.75 mM/kg/day of phosphorus in bone, teeth and soft tissue during the third trimester, a period of rapid skeletal mineralization (Marks & Crill, 2004). Therefore, inadequate calcium supplementation in preterm infants results in rickets and bone fractures.…”

“…Concentration of amino acid: the concentration of amino acids affects the pH of solution (Marks & Crill, 2004;Migaki et al, 2012). Amino acid solution has Jackson, Eggert, Fitzgerald, & Cash, 2011;Newton & Driscoll, 2008).…”