What is the purpose of parenteral multivitamins (intravenous vitamins)?

From the Guidelines

Parenteral multivitamins are strongly recommended for pediatric patients who cannot meet their nutritional needs through oral or enteral routes, particularly those on total parenteral nutrition (TPN), as stated in the espghan/espen/espr/cspen guidelines on pediatric parenteral nutrition: vitamins 1.

Key Recommendations

• The guidelines recommend that infants and children receiving PN should receive parenteral vitamins, with water and lipid soluble vitamins added to the lipid emulsion or a mixture containing lipids to increase vitamin stability 1.
• Vitamins should be administered daily, if possible, with lipid-soluble vitamins given simultaneously to lipid emulsions, and vitamin K given weekly 1.
• The optimal doses and infusion conditions for vitamins in infants and children have not been established, but the guidelines provide recommended doses based on expert opinion, as outlined in Table 1 of the guidelines 1.

Dosage and Administration

• The recommended doses for parenteral supply of fat-soluble and water-soluble vitamins for preterm infants, infants, and children are outlined in Table 1 of the guidelines, including:
  • Vitamin A: 700-1500 IU/kg/day for preterm infants, 150-300 ug/kg/day for infants, and 150 ug/day for children and adolescents 1.
  • Vitamin D: 200-1000 IU/day for preterm infants, 400 IU/day for infants, and 400-600 IU/day for children and adolescents 1.
  • Vitamin E: 2.8-3.5 mg/kg/day for preterm infants and infants, and 11 mg/day for children and adolescents 1.
  • Vitamin K: 10 ug/kg/day for preterm infants and infants, and 200 ug/day for children and adolescents 1.

Monitoring and Adjustments

• Routine monitoring of vitamin concentrations is not recommended, except for vitamin D, which should be monitored periodically in patients on long-term PN 1.
• Dosage adjustments may be necessary for patients with renal or hepatic impairment, and individualized monitoring and adjustments should be made based on clinical indications 1.

Importance of Parenteral Multivitamins

• Parenteral multivitamins are crucial for preventing deficiencies in critically ill patients, particularly water-soluble vitamins which are not stored in large amounts in the body 1.
• Fat-soluble vitamins (A, D, E, K) should be monitored in patients with malabsorption or cholestasis, and regular laboratory monitoring of vitamin levels is recommended for patients on long-term parenteral nutrition to ensure adequate supplementation and prevent toxicity 1.

From the Research

Parenteral Multivitamin Requirements

• The requirement for parenteral multivitamins in patients receiving total parenteral nutrition (TPN) has been studied extensively 2, 3, 4.
• A study from 1977 found that administration of 1.1 ml of Multi-Vitamin Infusion (MVI) solution supplemented with additional vitamins maintained normal or higher than normal levels of some vitamins, but resulted in less-than-normal levels of others 2.
• Another study from 1987 found that standard parenteral vitamin therapy led to marginal improvement in abnormally low pre-TPN vitamin levels, and that a higher repletion dose resulted in a significantly greater percent increase in some vitamin levels 3.
• A consensus paper from 2019 emphasized the importance of micronutrients, including vitamins, in parenteral nutrition and provided practical guidance on their prescription, administration, and monitoring 4.

Frequency of Administration

• A study from 2002 investigated whether patients who received parenteral nutrition with MVI three times per week instead of daily developed clinical manifestations of vitamin deficiency, and found that none of the patients showed such manifestations 5.
• This study suggested that using MVI three days a week instead of daily could substantially reduce the cost of treatment and might reduce the risk of infections for these patients 5.
• However, the optimal frequency of administration of parenteral multivitamins is not clearly established and may depend on individual patient needs and circumstances 2, 3, 4.

Clinical Considerations

• Parenteral nutrition is a complex prescription that requires careful consideration of the patient's nutritional needs and the potential risks and benefits of different components, including multivitamins 6.
• The provision of micronutrients, including vitamins, is critical to preventing deficiency and maintaining optimal nutrition status in patients receiving parenteral nutrition 4.
• Clinicians should be aware of the potential for abnormal vitamin levels in patients receiving TPN and should monitor and adjust the parenteral multivitamin regimen as needed 2, 3.