OBJECTIVE: The objective of this study was to determine if outcomes at our neonatal intensive care units (NICUs) since we began using calcium chloride (CaCl2) as our preferred calcium additive in order to reduce aluminum (Al) exposure are within expected outcome ranges for NICUs in the U.S. where calcium gluconate in glass vials (CaGlu-Gl) has been the preferred additive.
STUDY DESIGN: A retrospective study of very low birth weight infants born between January 1, 2000 and December 31, 2014. Outcomes in two intensive care units (NICUs) using CaCl2 were compared to all U.S. NICUs in the Vermont Oxford Network. Primary outcomes were chronic lung disease (CLD), percent requiring supplemental oxygen at 28 days, and mortality excluding early deaths (MEED). The incidence of IV infiltrates of all admissions to the study NICUs in 2013-2014 was compared to the literature.
RESULTS: The incidence of CLD and those requiring oxygen at 28 days were 24.0% vs 28.6% and 46.2% vs 51.8% for the study NICUs compared to all U.S. NICUs, respectively (both p < 0.0001). The MEED was 8.7% vs 10.3% (p < 0.002). All major morbidities were lower at the study NICUs. The incidence of infiltrates was lower than that in the literature.
CONCLUSION: The use of CaCl2 was not associated with any detectable adverse effects. Calcium chloride appears to be a safe alternative to the use of CaGlu-Gl based upon studies of clinical outcomes.
BishopNJ, MorleyR, DayJP, LucasA. Aluminum neurotoxicity in preterm infants receiving intravenous-feeding solutions. N Eng J Med1997;336(22):1557–61.
2.
FewtrellMS, BishopNJ, EdmondsCJ, IsaacsEB, LucasA. Aluminum exposure from parenteral nutrition in preterm infants: Bone health at 15-year follow-uPediatrics2009;124:1372–9.
3.
FreyOR, MeierL. Polyethylene vials of calcium gluconate reduce aluminum contamination of TPN. Ann Pharmacother2000;34:811–2.
4.
PironiL, ZolessiC, RuggeriE, PaganelliF, PizzoferratoA, MiglioliM. Bone turnover in short-term and long-term home parenteral nutrition for benign disease. Nutrition2000;16:272–7.
5.
BohrerD, do NascimentoPC, BinottoR, BeckerE, PomblumS. Contribution of the raw material to the aluminum contamination in parenterals. JPEN J Parenter Enteral Nutr2002;26:382–8.
6.
MigakiEA, MelhartBJ, DewarCJ, HustonRK. Calcium chloride and sodium phosphate in neonatal parenteral nutrition containing Trophamine: Precipitation studies and aluminum content. JPEN J Parenter Enteral Nutr2012;36:470–5.
7.
DriscollDF, NewtonDW, BistrianBR. Potential hazards of precipitation associated with calcium chloride in parenteral nutrition admixtures: Response to Migaki et al. JPEN J Parenter Enteral Nutr2012;36:497–8.
8.
HustonRK, MigakiEA. Issues concerning the safety of calcium chloride in neonatal parenteral nutrition: Response to the letter from Drs Driscoll, Newton, and Bistrian. JPEN J Parenter Enteral Nutr2012;36:498–500.
9.
NewtonDW, DriscollDF. Calcium and phosphate compatibility: Revisited again. Am J Health-Syst Pharm2008;65:73–80.
10.
HillSE, HeldmanLS, GooEDH, WhippoPE, PerkinsonJC. Fatal microvascular pulmonary emboli from precipitation of a total nutrient admixture solution. JPEN J Parenter Enteral Nutr1996;20:81–7.
11.
ShayDK, FannLM, JarvisWR. Respiratory distress and sudden death associated with receipt of a peripheral parenteral nutrition admixture. Infect Control Hosp Epidemiol1997;18:814–7.
12.
Food and Drug Administration. Aluminum in large and small volume parenterals used in total parenteral nutrition; amendment; delay in effective date. Fed Reg2002;67:70691–2.
13.
MirtalloJ, CanadaT, JohnsonD, et al. Safe practices for parenteral nutrition. JPEN J Parenter Enteral Nutr2004;28:S39–70.
14.
KaempfJW, ZupancicJAF, WangL, GrunkemeierGL. A risk-adjusted, composite outcomes score and resource utilization metrics for very low-birth-weight infants. JAMA Pediatrics2015;169:459–65.
15.
PatelAL, EngstromJL, MeierPP, KimuraRE. Accuracy of methods for calculating postnatal growth velocity for extremely low birth weight infants. Pediatrics2005;116:1466–7.
Hernandez-SanchezA, Tejada-GonzalezPM. Aluminum in parenteral nutrition: A systematic review. Eur J Clin Nutr2013;67:230–8.
18.
NehraD, CarlsonSJ, FallonEM, KalishB, PotemkinAK, GuraKM, et al. A. S.P.E.N. clinical guidelines: Nutrition support of neonatal patients at risk for metabolic bone disease. JPEN J Parenter Enteral Nutr2013;37:570–98.
19.
PooleRL, SchiffS, HintzSR, WongA, MackenzieN, KernerJA. Aluminum content of parenteral nutrition: Measured versus calculated levels. JPGN2010;50:208–11.
20.
HenryRS, JurgensRJJr, SturgeonR, AthanikarN, WelcoA, Van LeuvenM. Compatibility of calcium chloride and calcium gluconate with sodium phosphate in a mixed TPN solution. Am J Hosp Pharm1980;37:673–4.
21.
HustonRK, ChristensenJM, KarnprachaC, et al. Calcium chloride in neonatal parenteral nutrition: Compatibility studies using laser methodology. PLoS One2014;5;9(9):e106825. doi: 10.1371/journal.pone.0106828.
22.
HustonRK, ChristensenJM, AlshahraniSM, et al. Calcium chloride in neonatal parenteral nutrition solutions with and without added cysteine: Compatibility studies using laser and micro-flow imaging methodology. PLoS One2015;28;10(8):e0136894.
