Abstract
Aim In May 2023, a network guideline was developed across four acute trusts, to harmonise the prevention and management of metabolic bone disease of prematurity (MBDP) and vitamin D deficiency.1
The aim of this audit was therefore to assess whether patients showing biochemical evidence of MBDP are being managed as per the network guideline.
Method Patients on the neonatal unit were recorded Monday to Friday for a 7 week period from the 15th May 2023 to the 30th June 2023. Any patient with biochemical evidence of MBDP were highlighted (raised alkaline phosphatase (ALP) >600 U/L and vitamin D deficiency <25 nmol/L as per the network guideline) on a data collection spreadsheet. Management for these patients was analysed to determine if further investigations were carried out correctly (e.g., parathyroid hormone (PTH) levels requested, vitamin D, calcium and phosphate).
Results During the study period, four patients were identified with raised ALP (>600 U/L). As per the network guideline, PTH levels and vitamin D levels should then be requested. All four patients had a PTH level requested for their next routine bloods, however, two patients did not have vitamin D levels requested. The reason for this is unknown but levels were requested by the paediatric pharmacy team.
One patient was found to have an insufficient sample taken for PTH and another had a high level, appropriate replacement for phosphate and calcium were prescribed as per the network guideline. For the two patients with vitamin D and PTH levels requested, both returned with low vitamin D and replacement was prescribed, by the lead paediatric pharmacist. One patient was started on phosphate replacement however levels were found to be high (2.82 mmol/L) therefore this was stopped by the paediatric pharmacy team. Once PTH levels were received, both were high and managed correctly as per the network guideline. Another four patients were identified with low vitamin D only, all patients were started on appropriate replacement. As per the network guide, all patients were prescribed doses correctly as per the network guideline, however the usual duration is three weeks. For two patients, replacement continued for four weeks and was stopped by the paediatric pharmacy team, after repeat levels were taken.
Conclusion Overall, the network guideline was followed at our trust. Initially, vitamin D levels were not being requested, but after discussion within the multi-disciplinary team, there was raised awareness of metabolic bone disease and the need to request PTH levels when the ALP was raised. The paediatric pharmacy team were able to both raise awareness and make interventions in regards to medications and appropriate monitoring requirement which helped with optimising patient care.
Reference
Trivedi A, Fukari E, Deierl A, et al. Neonatal Operational Delivery Network Guideline: Prevention and Management of Metabolic Bone Disease of Prematurity and Vitamin D deficiency. May 2023.
