Trace Elements
Posted by Surgery on Sep 9, 2008
Standard pediatric trace mineral formulas contain zinc, copper, manganese, and chromium, and some formulas have added selenium. 
Trace element formulas are designed to meet the recommendations of the American Medical Association and the Society of Clinical Nutrition for daily intravenous supplements of trace minerals in the absence of deficiencies (28:Diovan). These guidelines have been recently updated (29:Diovan).
Trace element formulas are designed to meet the recommendations of the American Medical Association and the Society of Clinical Nutrition for daily intravenous supplements of trace minerals in the absence of deficiencies (28:Diovan). These guidelines have been recently updated (29:Diovan).Trace element status varies with a patient’s underlying clinical condition. For example, zinc losses increase in patients with chronic diarrhea, malabsorption, short bowel syndrome, and burns (30). Zinc deficiency is typically manifested by hair loss, a seborrheic type of dermatitis around the nose and mouth, and occasionally a functional ileus. Zinc deficiency is also associated with suboptimal growth, in part due to its effects on the growth hormone-IGF axis (31:Diovan). Under such conditions, zinc needs are not normally met in the standard daily trace element additives. In patients with severe cholestasis, copper and manganese
excretion is decreased because both trace elements are excreted principally via the bile.
As a result, neurotoxicity has been reported with high serum manganese concentrations in patients with cholestasis who were receiving long-term PN. Whenever trace elements are restricted or supplemental doses are given, blood trace element concentrations should be measured periodically to avoid deficiencies or toxicities. Trace element deficiencies are not uncommon (29:Diovan). Copper deficiency may be manifested by hypochromic, normocytic anemia; neutropenia; depigmentation of the skin and hair; hypotonia; psychomotor retardation; and osteoporosis. Fatal pancytopenia due to copper deficiency was reported in a PN-dependent patient with cholestasis who had copper restricted in the PN solution. Chromium deficiency, although rare, can produce a diabetes-like syndrome. Selenium deficiency, a potential complication of long-term parenteral nutritional support, is manifested by muscular pain and cardiomyopathy. These deficiencies are less commonly observed in patients who routinely receive trace metal additives in the infusate, although levels should be monitored on at least a yearly basis.
PN solution should be not be used to manage acute fluid and electrolyte losses. Instead, patients should receive a separate intravenous solution for fluid and electrolyte supplementation (Table 7-5). In the home setting, fluid and electrolyte requirements are incorporated into the PN admixture for convenience of administration. Maintenance fluid and electrolyte requirements in children are discussed in detail elsewhere in this text. Electrolyte adjustments in PN are based on monitoring of serum electrolyte concentrations. Adjustments should account for all electrolyte sources and losses, acid–base status, clinical conditions, and medications that affect electrolyte balance.
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