warnings and cautions
5 WARNINGS AND PRECAUTIONS Risk of Aluminum Toxicity: Aluminum may reach toxic levels with prolonged administration. Monitor aluminum levels in at risk patients ( 5.1 ) Allergic Reactions: to thiamine may occur ( 5.2 ) Hypervitaminosis A: Patients with renal failure or liver disease may be at higher risk ( 5.3 ) Decreased Anticoagulant Effect of Warfarin: Periodically monitor prothrombin time ( 5.4 ) Interferes with Megaloblastic Anemia Diagnosis: Avoid use during testing for this disorder ( 5.5 ) Risk of Vitamin Deficiencies or Excesses : Monitor blood vitamin concentrations ( 5.6 ) False Negative Urine Glucose Tests: May occur due to vitamin C ( 5.7 ) Risk of Vitamin E Toxicity: Additional oral and parenteral vitamin E may result in elevated vitamin E blood concentrations in infants ( 5.8 ) Low Vitamin A Levels : Monitor vitamin A levels ( 5.9 ) Risk of E- Ferol Syndrome: due to polysorbates ( 5.10 ) 5.1 Aluminum Toxicity M.V.I. Pediatric contains aluminum, up to 42 mcg/L that may be toxic. Aluminum may reach toxic levels with prolonged parenteral administration in patients with renal impairment. Premature neonates are particularly at risk because their kidneys are immature, and they require large amounts of calcium and phosphate solutions, which contain aluminum. Patients with impaired kidney function, including premature neonates, who receive parenteral levels of aluminum at greater than 4 to 5 micrograms per kg per day, accumulate aluminum at levels associated with central nervous system and bone toxicity. Tissue loading may occur at even lower rates of administration. To prevent aluminum toxicity, periodically monitor aluminum levels with prolonged parenteral administration of M.V.I. Pediatric. 5.2 Allergic Reactions to Thiamine Allergic reactions such as urticaria, shortness of breath, wheezing and angioedema have been reported following intravenous administration of thiamine, an ingredient in M.V.I. Pediatric. There have been rare reports of anaphylaxis following intravenous doses of thiamine. No fatal anaphylaxis reactions associated with M.V.I. Pediatric have been reported. 5.3 Hypervitaminosis A Hypervitaminosis A, manifested by nausea, vomiting, headache, dizziness, and blurred vision, has been reported in patients with renal failure receiving 1.5 mg per day retinol and in patients with liver disease. Therefore, supplementation of patients with renal failure and patients with liver diseases with vitamin A, an ingredient found in M.V.I. Pediatric, should be undertaken with caution [ see Use in Specific Populations (8.6 , 8.7) ]. Blood levels of Vitamin A should be monitored periodically. 5.4 Decreased Anticoagulant Effect of Warfarin M.V.I. Pediatric contains Vitamin K, which may decrease the anticoagulant effect of warfarin. In patients who are on warfarin anticoagulant therapy receiving M.V.I. Pediatric, prothrombin time/INR should be periodically monitored to determine if the dose of warfarin needs to be adjusted. 5.5 Interference with Diagnosis of Megaloblastic Anemia M.V.I. Pediatric contains folic acid and cyanocobalamin, which can mask serum deficits of folic acid and cyanocobalamin in patients with megaloblastic anemia. Avoid the use of M.V.I. Pediatric in patients with suspected or diagnosed megaloblastic anemia prior to blood sampling for the detection of the folic acid and cyanocobalamin deficiencies. 5.6 Potential to Develop Vitamin Deficiencies or Excesses In patients receiving parenteral multivitamins, such as with M.V.I. Pediatric, blood vitamin concentrations should be periodically monitored to determine if vitamin deficiencies or excesses are developing. M.V.I. Pediatric may not correct long-standing specific vitamin deficiencies. The administration of additional doses of specific vitamins may be required [ see Dosage and Administration (2.2) ]. 5.7 Interference with Urine Glucose Testing M.V.I. Pediatric contains Vitamin C, which is also known as ascorbic acid. Ascorbic acid in the urine may cause false negative urine glucose determinations. 5.8 Vitamin E Overdose in Infants Receiving Additional Vitamin E Additional vitamin E supplementation of patients receiving M.V.I Pediatric may result in elevated blood concentrations of vitamin E and potential vitamin E toxicity in infants. Avoid additional oral or parenteral doses of vitamin E in infants. A daily dose of M.V.I. Pediatric contains adequate concentrations of vitamin E required to achieve normal blood levels of vitamin E. 5.9 Risk of Low Vitamin A Levels Vitamin A may adhere to plastic, resulting in lower vitamin A concentrations after administration of M.V.I. Pediatric. Therefore, blood vitamin A concentrations should be periodically monitored and the administration of additional therapeutic doses of Vitamin A may be required, especially in low birth weight infants. 5.10 Risk of E-Ferol syndrome E-Ferol syndrome, manifested by thrombocytopenia, renal dysfunction, hepatomegaly, cholestasis, ascites, hypotension and metabolic acidosis, has been reported in low-birth weight infants following administration of polysorbates, which are found in M.V.I. Pediatric. No E-Ferol syndrome associated with M.V.I. Pediatric has been reported.