Nutritional value and requirements of vitamins for the premature infant

The recommended oral intake of vitamins A,K, thiamin, riboflavin, niacin, pyridoxine, pantothenic acid, vitamin B12, and biotic by preterm infants is the same as that recommended for full term infants. All preterm, as well as term infants should receive at least 1mg vitamin K at birth

The International committee on Nutrition recommends that daily multivitamin supplements be given when enteral feedings are established, The most appropriate supplements are those that contain the National Research Council's recommended Dietary Allowance (NRC-RDA) of vitamins A, C, D, E and B complex. Be aware that liquid multivitamin drops for infants do not contain folic acid. The committee of Nutrition suggests that the NRC-RDA of folate can be added to the multivitamin preparation in the hospital pharmacy.

Vitamin C
There have been conflicting reports on the need for high ascorbic acid intakes in preterm infants to enhance the activity of hepatic hydroxyphenylpyruvic acid oxidase and to lower blood tyrosine and urinary tyrosine metabolites levels, Some investigators have reported no detrimental effects of transient neonatal tyrosinemia, but one study reported a lowering of I.Q values at 7 to 8 years of age in affected children.

Due to the uncertainties, there have not been consistent recommendations regarding vitamin C supplementation. Although the Nutrition Committee of the Canadian Paediatric Society recommended Vitamin C supplements for preterm infants in 1976, it did not do so in 1981. Zeigler and co-workers recommended an intake of 60mg vitamin C per day by preterm infants. Due to the absence of compelling evidence for a high vitamin C requirement in preterm infants, the Academy's Committee on Nutrition does not recommend a supplement in addition to the 35 mg in the daily oral multivitamin mixture.

Vitamin D
The role of vitamin D deficiency in the development of the osteopenia and rickets of small premature infants is uncertain. Although some investigators have suggested that some small premature infants have a high vitamin D metabolites, others have found that preterm infants given a high calcium formula plus 600 to 700 IU Vitamin D per day did show normal serum 25-OH-Vitamin D levels and calcium retentions similar to the fetal retention rate.

The prevention of severe bone disease in preterm infants appears to rely on both supplemental oral calcium and phosphorus and at least 500IU vitamin D per day. The latter can be achieved by giving vitamin D in the formula. There is no evidence that administration of the active Vitamin D metabolites, 25-OH-Vitamin D or 1,25-(OH)2-Vitamin D, is necessary or advisable.

Vitamin E
The requirement for vitamin E, alpha-tocopherol, in the small premature infant is higher than that of the term infant because fat absorption is limited. The signs of vitamin E deficiency in the preterm infant include a mild anemia and mild generalized edema. Vitamin E deficiency is exacerbated by a high iron intake which interferes with vitamin E absorption and vitamin E-mediated stabilization of the erythrocyte cell membrane, as well as by high intake of polyunsaturated fatty acids which leads to a higher vitamin E requirement.

The recommended intake of vitamin E is 0.7 IU vitamin E (0.5mg alpha-tocopherol) per 100Kcal and at least 1.0 IU vitamin E per gram of linoleic acid. In addition, it has been suggested that the preterm infant receives 5 to 25 IU of supplemental vitamin E per day because of concerns about the adequacy of its intestinal absorption.

Folic Acid
Although clinical deficiency of folic acid is unusual, many preterm infants show laboratory evidence of folate deficiency by hyper-segmentation of their neutrophils. Although a dose of 20 Uig folate per day to pretem infants does not prevent low serum folate levels after 2 weeks, 50ig is effective, and Dallman has suggested that preterm infants weighing less than 2000g receive this amount. Be aware that the usual liquid multivitamin preparations for infants do not contain folic acid.

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