We see many cases of severe heart failure in infants due to "wet beriberi" -- thiamine (vitamin B1) deficiency at our hospital in northern Laos. These exclusively breastfed babies present in extremis, usually with mothers with neurologic symptoms as well, at about 2-4 months of age.
I'm looking for some help from the collective wisdom of the community about what the proper dose of acute thiamine supplementation should be. From what I can gather from the recent literature:
2015: 90% survival in northern Laos using a dose of 50 mg by IM or slow IV injection -- no information is given about subsequent doses -- retrospective chart review study
2014: 100% survival in Cambodia using a dose of 100 mg IM for 3 days -- this seems to be the purest study since the data was collected prospectively using rigorous strict case definitions, including blood thiamine testing and very importantly included both baseline and follow-up echocardiography which showed marked improvement
2010: 100% survival in India using a dose of 75 mg IM BID for 5 days -- also a very pure study with the data collected prospectively and fairly strict enrollment criteria used and echo abnormalities also improved
2016 MSF Guidelines for severe cases of acute beriberi: "50 mg by IM injection every 8 hours for a few days then change to oral route (10 mg once daily)"
Any suggestions on optimal dosing? Even after we do provide thiamine (currently we use 50 mg IM followed by 3 days of 25 mg IV), we find the children are still quite tenuous for a few days. The thiamine is relatively cheap for us here so cost is probably not an issue when considering the range of doses that are showing up in the literature.
Thanks for any help or insights.
Hi Indi
I haven't any direct experience of treating wet beri beri, so this is thinking rather than experience.
To me the key thing is to differentiate the acute treatment of a high mortality risk condition from filling up the limited body stores. So the approach depends on when deaths occur. From your description, it sounds like a majority in the first 24h, but interested to hear if later, also an information on post-hospital discharge mortality.
I found a very useful review by Hiffler (MSF) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4906235/ and accompanying commentary https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5237637/ Looking at your references and this review, its clear that there is no real evidence base, but importantly, very high doses are regarded as safe. In the Indian ref you quote, 75 mg of intramuscular thiamine twice a day for 5 days was used to treat breast-fed infants under 6 months of age presenting with cardiac failure: https://academic.oup.com/tropej/article/56/4/284/1650751 The MSF initial dose is the same, split over 3 times a day.
In a child with a significant immediate mortality risk and poor peripheral perfusion, the first dose slow IV (if that can be done) rather than IM may be appropriate. The review authors propose a therapeutic challenge of 100 mg of thiamine in acute severe illness, but may be thinking of bigger children. In your age group of 2-4m, 50mg as per MSF seems more appropriate. Switching to oral depending on response also seems sensible.
You have probably thought of all this already. Sounds like you are well placed to report a case series if you alter policy and then do a trial to answer these. important questions.
all the best
Jay
Answered:
5 years ago