Neonatal Intensive Care Drug Manual

Goal: Aim for the upper end of the recommended range to prevent fractures and clinical symptoms of osteopenia: Ca and P of around 4-4.5 mmol/kg/day. Adjust the mineral intake with a goal of achieving a slight excess of urinary mineral excretion: Urinary calcium ≥1.2mmol/L and phosphate ≥0.4 mmol/L.¹⁴

Example: 150 ml/kg/day of mature preterm EBM contains: Ca 1 mmol/kg/day and P 0.6 mmol/kg/day. 150 ml/kg/day preterm EBM+24kcal HMF contains: Ca 4.5 mmol/kg/day and P 2.7 mmol/kg/day.

ORAL preparation during NICU stay: Sodium dihydrogen phosphate Phebra IV is the preferred preparation for oral administration due to its low osmolality.

ORAL preparation at discharge or stable neonates: Phosphate-Sandoz tablets can be used.
American Academy of Pediatrics Committee on nutrition 2013 Guidelines on management for Enterally Fed Preterm Infants With Radiologic Evidence of Rickets: 1. Maximize nutrient intake. 2. If no further increases in these can be made, add elemental calcium and phosphorus as tolerated. Usually beginning at 20 mg/kg per day of elemental calcium and 10–20 mg/kg per day elemental phosphorus and increasing, as tolerated, usually to a maximum of 70–80 mg/kg per day of elemental calcium and 40–50 mg/kg per day elemental phosphorus. May consider targeting 25-OH-D concentration of >20 ng/mL (50 nmol/L).⁸ However, breast milk content of phosphorus is variable and harder to estimate the intakes accurately. A more pragmatic approach suggested by our consensus group: start with P 0.5-1.0 mmol/kg/day in divided doses and increase as tolerated to a maximum of P 3 mmol/kg/day.
Efficacy and safety

An ideal oral form of phosphate for use in preterm infants does not exist. Administering the intravenous preparations orally can be considered, because they are lower in osmolarity than are commercially available phosphorus-containing liquids. For example, potassium dihydrogen phosphate provides 31 mg of elemental phosphorus per millimole. A dose of 10 to 20 mg/kg per day of elemental phosphorus is reasonable and will likely resolve hypophosphataemia in most preterm infants.⁸

It is recommended to separate oral doses from calcium and antacids containing agents such as aluminium hydroxide, calcium or magnesium salts, as these may reduce the bioavailability of phosphate. Oral phosphate may combine with calcium in the milk, reducing its absorption. It is recommended to avoid giving phosphate with milk.

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