Version May 2024
Dietary supplement: Oral: 1 capsule/tablet daily.
Parenteral nutrition, maintenance requirement:
Note: Parenteral nutrition ordering requires advanced knowledge of nutrient and other metabolic requirements and should only be prescribed by clinicians trained in assessment and order writing for parenteral nutrition (ASPEN [Guenter 2015]).
Standard daily manganese requirement : IV: Elemental manganese 55 mcg daily as component of parenteral nutrition; adjust daily dose based on serum manganese and clinical considerations (ASPEN 2019).
There are no dosage adjustments provided in the manufacturer's labeling. Use caution; manganese chloride solution for injection contains aluminum.
There are no dosage adjustments provided in the manufacturer's labeling. Use caution; dose may need to be discontinued in patients who develop signs and symptoms of hepatobiliary disease (eg, cholestasis, cirrhosis).
Use with caution and initiate at the lower end of dosage range; refer to adult dosing.
(For additional information see "Manganese: Pediatric drug information")
Note: Dosing presented as mcg/kg/day and mcg/day; use caution.
Parenteral nutrition (PN) additive, maintenance requirement: Note: Manganese contamination is common with other PN products (eg, sodium phosphate, magnesium sulfate), which decreases or eliminates the need for routine supplementation; some experts suggest that additional supplementation is likely unnecessary (ASPEN [Corkins 2015]; ASPEN [Mirtallo 2004]; ESPGHAN/ESPEN/ESPR/CSPEN [Domellöf 2018]; Olson 2019; Srikrishnaraj 2021).
ASPEN recommendations:
Infant and Children weighing ≤40 kg: IV: 1 mcg/kg/day; maximum daily dose: 55 mcg/day (ASPEN 2020; ASPEN [Corkins 2015]; ASPEN [Mirtallo 2004]).
Children and Adolescents weighing >40 kg: IV: 40 to 100 mcg/day (ASPEN 2020; ASPEN [Corkins 2015]; ASPEN [Mirtallo 2004]).
ESPGHAN/ESPEN/ESPR/CSPEN recommendations: Infants, Children, and Adolescents: IV: ≤1 mcg/kg/day; maximum daily dose: 50 mcg/day (Domellöf 2018).
There are no dosage adjustments provided in the manufacturer's labeling. Use caution; manganese chloride solution for injection contains aluminum.
There are no dosage adjustments provided in the manufacturer's labeling. Use caution; dose may need to be decreased or withheld in patients with hepatobiliary disease.
There are no adverse reactions listed in the manufacturer's labeling.
There are no contraindications listed within the manufacturer's US labeling.
Canadian labeling: Hypersensitivity to manganese or any component of the formulation.
Concerns related to adverse effects:
• Neurotoxicity: Neuropsychiatric symptoms, including dysarthria, halting gait, mask-face, memory changes, mood changes, parkinsonian-like tremors, and seizures, have primarily been reported in patients on long-term therapy receiving higher than recommended doses and in association with cholestatic liver disease due to accumulation of manganese in the basal ganglia; has also been reported in patients on recommended doses with normal blood manganese concentrations. Symptoms usually resolved over weeks to months after discontinuation of therapy but may not completely resolve.
Disease-related concerns:
• Hepatobiliary disease: Use with caution in patients with hepatobiliary disorders (eg, cholecystitis, cirrhosis); may increase risk of manganese brain deposits and neurotoxicity, especially in patients on long-term therapy or higher than recommended dosages. Consider discontinuation of therapy in patients that develop signs or symptoms of hepatobiliary disease until clinical evaluation is complete.
Dosage form specific issues:
• Aluminum: The parenteral product may contain aluminum; toxic aluminum concentrations may be seen with high doses, prolonged use, or renal dysfunction. Premature neonates are at higher risk due to immature renal function and aluminum intake from other parenteral sources. Parenteral aluminum exposure of >4 to 5 mcg/kg/day is associated with CNS and bone toxicity; tissue loading may occur at lower doses (Federal Register 2002). See manufacturer's labeling.
Other warnings/precautions:
• Appropriate use: Parenteral: Due to its highly acidic pH (pH 2.0), direct IV or IM injection is contraindicated; may result in severe tissue damage. Use only in conjunction with an admixture program.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Intravenous, as chloride:
Generic: Elemental manganese 0.1 mg/mL (10 mL)
Solution, Intravenous, as sulfate [preservative free]:
Generic: Elemental manganese 0.1 mg/mL (10 mL [DSC])
Tablet, Oral, as chelated:
Mangimin: Elemental manganese 10 mg [DSC] [corn free, rye free, wheat free]
Generic: Elemental manganese 50 mg
Tablet, Oral, as gluconate:
Generic: 50 mg [elemental manganese 5.7 mg]
Yes
Solution (Manganese Chloride Intravenous)
0.1 mg/mL (per mL): $4.07
Tablets (Manganese Gluconate Oral)
50 mg (per each): $0.06
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Intravenous, as sulfate:
Micro-Mn: Elemental manganese 0.1 mg/mL (10 mL)
Oral: May be administered with a meal.
IV: Do not administer IM or by direct IV injection; must be diluted in parenteral nutrition solution prior to administration (volume of fluid ≥100 mL). Acidic pH of the solution may cause tissue irritations and it is hypotonic.
Parenteral: Not for direct IV or IM injection; must be diluted in parenteral nutrition solution prior to administration; acidic pH of the solution may cause tissue irritation and it is hypotonic.
Dietary supplementation: Trace element added to parenteral nutrition to prevent manganese deficiency; orally as a dietary supplement.
Manganese sulfate may be confused with magnesium sulfate
None known.
There are no known significant interactions.
Animal reproduction studies have not been conducted. Manganese crosses the placenta and can be detected in placental tissue and cord blood (Osada 2002).
Manganese is found in breast milk. Normal concentrations of manganese in human milk are generally lower than cow's milk or those found in food sources, but absorption from human milk is higher (IOM 2004).
Dietary adequate intake (IOM 2001):
1 to 6 months: 0.003 mg/day.
7 to 12 months: 0.6 mg/day.
1 to 3 years: 1.2 mg/day.
4 to 8 years: 1.5 mg/day.
9 to 13 years:
Males: 1.9 mg/day.
Females: 1.6 mg/day.
14 to 18 years:
Males: 2.2 mg/day.
Females: 1.6 mg/day.
>18 years:
Males: 2.3 mg/day.
Females: 1.8 mg/day.
Pregnancy: 2 mg/day.
Lactation: 2.6 mg/day.
Manganese whole blood level if manganese excess or toxicity is suspected (ESPEN [Berger 2022]).
Whole blood: 4 to 15 mcg/L (SI: 72.8 to 273 nmol/L). Note: Associated with significant variability; correlate with clinical signs/symptoms of manganese deficiency or toxicity (ESPEN [Berger 2022]; IOM 2001; NIH 2021).
Cofactor in many enzyme systems, stimulates synthesis of cholesterol and fatty acids in liver, and influences mucopolysaccharide synthesis
Absorption: Poor.
Distribution: Concentrated in mitochondria of brain, pituitary gland, pancreas, liver, kidney, and bone.
Excretion: Bile (primarily); urine (negligible).
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