USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, and *Texas Children's Hospital, Houston, Texas, U.S.A.
Since the end of 1996 there has been a shortage of multivitamins available for intravenous use, particularly in the United States. The cause of the shortage has been related to disruptions in production (Nutr Clin Prac 1998;13:295-7). Discontinuation of MVI (Schein Pharmaceuticals, Florham Park, NJ) production increased demand unexpectedly for other intravenous vitamin products. Unfortunately, at nearly the same time the maker of MVI-12 and MVI-Pediatric (Astra USA, Westborough, MA) experienced production problems because of technical difficulties at the manufacturing plant (Centeon, King of Prussia, PA). Fujisawa USA (Deerfield, IL), the original makers of MVC, also experienced shortages because of the resulting increased demand for their product.
This report is an update of the situation and provides some suggestions as to how to deal with the shortage. More information is available through the American Society of Parenteral and Enteral Nutrition (ASPEN) web site at http://www.clinnutr.org. Although the shortage is not as severe as last year, no one is sure when the problem will be over.
The need for attendance to vitamin administration in parenteral nutrition is underlined by reports of vitamin deficiencies and a death due to thiamin deficiency during the shortage. In our experience, the greatest threat is to patients who rely on home total parenteral nutrition, because their vitamin solutions are not made by in-house facilities. We have identified instances in which the vitamins, although ordered, were not included in the total parenteral nutrition solution. The outside pharmacy was not able to obtain them and failed to notify the ordering physician of the problem.
During the shortage, three points should be emphasized: 1) MVI-Pediatric should be used for pediatric patients less than 12 years of age; 2) use of MVI-Pediatric should be reserved for pediatric patients who are most in need (i.e., preterm infants and those most dependent on long-term total parenteral nutrition for their health); and 3) multivitamins should be given enterally whenever possible, although it may be necessary to give more than the recommended daily allowance to account for malabsorption.
The preshortage recommendation for MVI-Pediatric was 1.5 mL/d for infants who weighed less than 1 kg; 3.25 mL/d for infants who weighed 1 to 3 kg; and 5 mL/d for patients who weighed 3 kg or more and were at least 11 years old. The preshortage recommendation for MVI-12 was 10 mL/d plus vitamin K (MVI-12 does not contain vitamin K, so it must be added separately).
An alternative for MVI-Pediatric is Cernevit (imported by Baxter, Deerfield, IL from France). However, Cernevit does not contain vitamin K. Using 0.8 mL · kg-1 · d-1 up to a maximum of 2.5 mL/d with the addition of 80 µg/d of vitamin K for infants who weigh 2.5 kg or less and 200 µg/d for infants who weigh more than 2.5 kg very roughly approximates the vitamin dosages in MVI-Pediatric.
The only option available in situations in which neither supplies of MVI-Pediatric nor Cernevit are adequate is to use lower doses of these preparations. Preparations for adults should not be used in preterm infants because adult preparations contain propylene glycol and there is concern regarding its potential toxicity in this age group (Pediatrics 1987;79:622-6).
The options for children over 11 years of age are greater because of the larger number of alternative products available. None of these products contain vitamin K. The standard is 10 mL/d of MVI-12 plus vitamin K (200 µg/d). Three alternatives are available. The dose of Cernevit is 5 mL/d plus vitamin D (200 µg/d). A dose of 10 mL/d of Multi-12 (Sabex, Boucherville, Quebec, Canada) also requires the addition of vitamin K (200 µg/d). MVC (American Pharmaceutical Partners, Santa Monica, CA) requires particular care. The dose is 2.5 mL/d (or 5 mL 3 times a week), but the following also must be provided: vitamin K (200 µg/d), folic acid (0.4-1.0 mg/d), vitamin B12 (cyanocobalamin, 100 µg monthly), and over the long term, biotin (although no parenteral preparation is available).
With all these alternatives it is important to be vigilant for signs of deficiency. The ASPEN web site contains a list of vitamin deficiency signs and symptoms. Additional information also can be obtained from the manufacturers: Astra (800-225-4803), Baxter (888-229-0001), American Pharmaceutical Partners (800-386-1300), and Sabex (800-361-3062). ASPEN includes a lengthy legal disclaimer regarding this conundrum. It boils down to a physician using her or his best judgment and individualizing to best meet the patient's needs.
Robert J. Shulman, MD
Sarah M. Phillips, MS, RD
Stephanie Maciejewski, PharmD
USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, and Texas Children's Hospital, Houston, Texas, U.S.A.