What are the safest multivitamin alternatives for preterm newborns?

Safest Multivitamin Alternatives for Preterm Newborns

Preterm infants should receive neonatal-specific parenteral multivitamin preparations designed for their unique needs, NOT term infant oral multivitamins like A to Z, Bevon, or Zincovit, as adult and term infant formulations containing propylene glycol and polysorbate additives are contraindicated due to potential toxicity. 1, 2

Why Term Infant Multivitamins Are Unsafe for Preterm Infants

• Adult and term infant formulations are explicitly not recommended for preterm infants because they contain propylene glycol and polysorbate additives that pose toxicity risks in this vulnerable population. 1, 2

• Preterm infants have fundamentally different physiologic capacities compared to term infants: they have low lipid stores, low stores of fat-soluble vitamins, low levels of protein and lipoprotein transport, and less adaptive capacity to handle high or low vitamin doses. 1, 3

• Very low birth weight infants (<1500g) may show marked elevations of some vitamins when given inappropriate formulations, increasing risk of toxicity. 3

Recommended Safe Alternatives for Preterm Infants

For Parenteral Nutrition (Hospital Setting)

• Neonatal-specific parenteral multivitamin preparations should be used with weight-based dosing according to ESPGHAN/ESPEN/ESPR/CSPEN guidelines. 1

• Specific weight-based doses for preterm infants include:

  • Vitamin A: 700-1500 IU/kg/day 1, 2
  • Vitamin D: 200-1000 IU/day or 80-400 IU/kg/day 2
  • Vitamin E: 2.8-3.5 mg/kg/day 2
  • Vitamin C: 15-25 mg/kg/day 2
  • Vitamin K: 10 μg/kg/day 2
  • B vitamins at specific weight-based doses 2

• Vitamins should be added to lipid emulsions whenever possible to increase vitamin stability and reduce losses, particularly for vitamin A which has substantial losses when given with water-soluble solutions. 1

For Enteral Feeding (Post-Discharge or Stable Preterm Infants)

• Preterm-specific formulas (not standard term infant formulas) are enriched with appropriate amounts of vitamins, minerals, and trace elements designed for preterm infant needs. 4

• Post-discharge formulas (PDFs) specifically designed for preterm infants with faltering growth contain more energy (73 kcal/100 mL), protein (1.9 g/100 mL), minerals, vitamins, and trace elements than term formulas. 4

• For breastfed preterm infants, vitamin D supplementation at 400 IU/day should be provided starting in the first days of life. 2, 5

• All newborns, including preterm infants, must receive vitamin K at birth to prevent life-threatening vitamin K deficiency bleeding. 2, 3

Critical Safety Principles

• Preterm infants require daily vitamin administration when on parenteral nutrition, with lipid-soluble vitamins given simultaneously with lipid emulsions (except vitamin K, which can be given weekly). 1

• Routine monitoring of vitamin concentrations is not recommended except for vitamin D, unless infants are on long-term parenteral nutrition (weeks) where monitoring may be needed based on clinical indications. 1

• Multivitamin preparations at recommended doses have been used without apparent harmful effects in clinical practice for decades, but this safety record applies to neonatal-specific preparations, not term infant products. 1, 3

Common Pitfalls to Avoid

• Never use term infant oral multivitamin drops (like A to Z, Bevon, or Zincovit) in preterm infants as substitutes for neonatal-specific preparations. 1, 2

• Avoid assuming that "more is better" – preterm infants need precise weight-based dosing, not arbitrary high doses. 3

• Do not overlook that preterm infants require supplementation until they reach at least 2000 grams body weight or a caloric intake of 300 kcal/day. 2

• Remember that the primary cause of rickets in premature infants is calcium and phosphorus deficiency, not vitamin D deficiency, so comprehensive mineral supplementation is essential. 5