Injectable Multivitamin (MVI) Dosing
For pediatric patients on parenteral nutrition, injectable multivitamins should be dosed according to age and weight-based recommendations from the 2018 ESPGHAN/ESPEN guidelines, while for adults, the standard dose is 10 mL of MVI-12 daily added to the parenteral nutrition solution. 1
Pediatric Dosing (Based on 2018 ESPGHAN/ESPEN Guidelines)
The dosing is stratified by age group with specific recommendations for each vitamin component:
Preterm Infants:
- Vitamin A: 700-1500 IU/kg/day (227-455 mcg/kg/day)
- Vitamin D: 200-1000 IU/day or 80-400 IU/kg/day
- Vitamin E: 2.8-3.5 mg/kg/day (maximum 11 mg/day)
- Vitamin K: 10 mcg/kg/day
- Vitamin C: 15-25 mg/kg/day
- B-vitamins: Weight-based dosing (see term infant dosing below) 1
Term Infants (up to 12 months):
- Vitamin A: 150-300 mcg/kg/day or 2300 IU/day (697 mcg/day)
- Vitamin D: 400 IU/day or 40-150 IU/kg/day
- Vitamin E: 2.8-3.5 mg/kg/day (maximum 11 mg/day)
- Vitamin K: 10 mcg/kg/day
- Vitamin C: 15-25 mg/kg/day
- Thiamine (B1): 0.35-0.50 mg/kg/day
- Riboflavin (B2): 0.15-0.2 mg/kg/day
- Pyridoxine (B6): 0.15-0.2 mg/kg/day
- Niacin: 4-6.8 mg/kg/day
- Vitamin B12: 0.3 mcg/kg/day
- Pantothenic acid: 2.5 mg/kg/day
- Biotin: 5-8 mcg/kg/day
- Folic acid: 56 mcg/kg/day 1
Children and Adolescents (1-18 years):
- Vitamin A: 150 mcg/day
- Vitamin D: 400-600 IU/day
- Vitamin E: 11 mg/day
- Vitamin K: 200 mcg/day
- Vitamin C: 80 mg/day
- Thiamine: 1.2 mg/day
- Riboflavin: 1.4 mg/day
- Pyridoxine: 1.0 mg/day
- Niacin: 17 mg/day
- Vitamin B12: 1 mcg/day
- Pantothenic acid: 5 mg/day
- Biotin: 20 mcg/day
- Folic acid: 140 mcg/day 1
Adult Dosing
The standard adult dose is 10 mL of MVI-12 (or equivalent adult multivitamin formulation) added daily to the parenteral nutrition solution. 2, 3 This formulation now includes 150 mcg of vitamin K per the FDA requirements, eliminating the need for separate weekly vitamin K injections. 3
Critical Administration Considerations
Timing of Addition:
Add the MVI to the parenteral nutrition solution immediately before infusion rather than 24 hours in advance, as ascorbic acid degrades significantly when standing in solution. 2
Lipid-Soluble Vitamins:
Fat-soluble vitamins (A, D, E, K) should be administered with lipid emulsion whenever possible to reduce losses and improve stability. 1 Vitamin A losses are particularly high (up to 70%) when given in water-soluble solutions.
Monitoring:
- Routine vitamin level monitoring is not recommended except for vitamin D in long-term parenteral nutrition patients 1
- For patients on long-term PN (weeks to months), monitor based on clinical indications
- In neonates, inadequate MVI can cause biochemical abnormalities mimicking inherited metabolic disorders 4
Important Caveats
Vitamin E upper limits: While the recommended dose for children under 11 years is 11 mg/day, higher doses from combined lipid emulsions and multivitamins have been used without apparent harm and may provide hepatoprotective benefits. 1
Cost considerations: While daily dosing is standard, one small study suggested three-times-weekly dosing prevented clinical deficiency in stable home PN patients, though this requires further validation before routine implementation. 5
Shortage situations: During MVI shortages, prioritize thiamine, riboflavin, pyridoxine, and biotin supplementation, as deficiencies of these B-vitamins develop most rapidly and can cause severe metabolic derangements. 4