What is the recommended dose of vitamin A (Vit A) for preterm newborn babies?

Vitamin A Requirements in Preterm Newborn Babies

Recommended Dosage

Preterm infants on parenteral nutrition should receive 700-1500 IU/kg/day (or 227-455 µg/kg/day) of vitamin A, administered with lipid emulsion rather than water-based solutions. 1, 2

This recommendation is based on the ESPGHAN/ESPEN/ESPR/CSPEN 2018 guidelines, which represent the most authoritative guidance for preterm infant vitamin supplementation. 1

Route of Administration Matters

Parenteral Administration

• Vitamin A must be given with lipid emulsion, not glucose-amino acid solutions, as more than 60% is lost when administered in water-based preparations. 1, 2
• Light-protecting tubing provides only marginal additional benefit beyond lipid emulsion delivery. 1
• Neonatal-specific parenteral multivitamin preparations should be used; adult formulations containing propylene glycol and polysorbate are contraindicated due to toxicity risk. 3

Intramuscular Supplementation for Chronic Lung Disease Prevention

• The landmark NICHD trial demonstrated that 5000 IU administered intramuscularly three times per week for 4 weeks reduces chronic lung disease and death in extremely low birth weight infants. 4
• This regimen (equivalent to approximately 2143 IU/day) resulted in 1 additional infant surviving without chronic lung disease for every 14-15 infants treated. 4
• Alternative dosing regimens have been studied: once-weekly dosing (15,000 IU) worsened vitamin A deficiency, while higher doses (10,000 IU three times weekly) showed no additional benefit over the standard regimen. 5, 1
• The intramuscular route is painful and requires 12 injections over 4 weeks, which affects acceptability. 1

Enteral Supplementation

• For preterm infants tolerating feeds, 5000 IU/day enterally can safely correct vitamin A deficiency without causing toxicity. 6
• This approach achieves similar plasma retinol and retinol-binding protein levels as intramuscular supplementation by day 32 of life. 6

Clinical Benefits and Target Populations

Primary Benefits

• Reduces death or oxygen requirement at one month of age in infants <1500g. 1
• Decreases oxygen requirement at 36 weeks postmenstrual age, particularly in infants <1000g. 1
• Shows trend toward reduced retinopathy of prematurity incidence. 1
• No effect on patent ductus arteriosus closure, nosocomial sepsis, or intraventricular hemorrhage. 1

High-Risk Populations Requiring Supplementation

Infants with the following conditions have increased risk of vitamin A deficiency and may benefit from supplementation: 1, 2

• Sepsis or HIV infection
• Burns or mechanical ventilation
• Steroid use
• Hepatobiliary dysfunction or renal failure
• Hemato-oncological conditions
• Protein-energy malnutrition or zinc deficiency

Monitoring Vitamin A Status

Deficiency Thresholds

• Serum retinol <200 µg/L (0.7 µmol/L) indicates deficiency in very low birth weight infants. 1, 2
• Serum retinol <100 µg/L (0.35 µmol/L) indicates severe deficiency with depleted liver stores. 2
• Additional markers include retinol-binding protein <2.5 mg/dL and relative dose response >10%. 1, 5

Monitoring Recommendations

• Routine monitoring of vitamin A levels is not recommended except for infants on long-term parenteral nutrition. 3, 2
• The ESPGHAN guidelines specifically state that routine vitamin concentration monitoring is unnecessary for most preterm infants. 3

Critical Safety Considerations

Narrow Therapeutic Window

Vitamin A has a relatively narrow window between deficiency and toxicity, requiring careful dosing. 1, 2

Acute Toxicity (>150,000 µg)

• Increased intracranial pressure
• Headache, nausea, vomiting
• Vertigo, blurred vision
• Muscular incoordination 1, 2

Chronic Toxicity (approximately 30,000 µg/day)

• Bone abnormalities (malformations, fractures)
• Dermatitis, alopecia
• Ataxia, muscle pain
• Pseudotumor cerebri
• Hepatocellular necrosis
• Hyperlipidemia 1, 2

Toxicity Monitoring

• Toxicity can be established by measuring retinyl-ester levels. 1
• In clinical trials using the standard intramuscular regimen, possible toxicity was seen in <5% of infants. 5
• No toxicity was observed with 5000 IU/day enteral supplementation. 6

Practical Implementation Algorithm

For preterm infants on parenteral nutrition:

1. Start vitamin A at 700-1500 IU/kg/day mixed with lipid emulsion from day 2 of life. 1, 7
2. Use neonatal-specific parenteral vitamin preparations. 3
3. Continue until adequate enteral intake is established. 1

For extremely low birth weight infants (<1000g) with significant lung disease:

1. Consider intramuscular supplementation: 5000 IU three times weekly for 4 weeks. 4
2. Weigh benefits (modest reduction in chronic lung disease) against pain of 12 injections. 1
3. Decision depends on local incidence of chronic lung disease and institutional values. 1

For preterm infants tolerating enteral feeds:

1. Provide 5000 IU/day enterally as early as feeds are tolerated. 6
2. This safely corrects deficiency without requiring painful injections. 6

Common Pitfalls to Avoid

• Administering vitamin A in glucose-amino acid solutions rather than lipid emulsion, resulting in >60% loss of the vitamin. 1, 2
• Using adult multivitamin formulations in neonates, which contain toxic additives. 3
• Delaying vitamin A supplementation beyond the first days of life, as preterm infants have minimal hepatic stores at birth. 1, 8
• Assuming standard enteral intake (1500 IU/day) is adequate for preterm infants, as this dose does not readily reverse deficiency. 6
• Over-monitoring vitamin A levels in stable infants not on long-term parenteral nutrition. 3, 2