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Blackmer AB, Partipilo ML. Three-in-one parenteral nutrition in neonates and pediatric patients: risks and benefits. Nutr Clin Pract 2015; 30:337-43. [PMID: 25857309 DOI: 10.1177/0884533615580596] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Parenteral nutrition (PN) is a life-sustaining therapy designed to deliver essential nutrients to patients unable to meet nutrition needs via the enteral route. PN may be delivered via a 2-in-1 system (one solution containing amino acids, dextrose, electrolytes, vitamins, minerals, and fluids and one solution containing intravenous fat emulsions [IVFEs]) or via a 3-in-1 system (all nutrients mixed in one container). Although the use of 3-in-1 PN solutions is not necessarily therapeutically advantageous, certain benefits may exist such as the potential to reduce the risk of contamination due to decreased manipulations; ease of administration, particularly in the home care setting; possible cost savings; and reduced IVFE wastage. However, the incorporation of IVFE in 3-in-1 solutions also presents unique risks for the neonatal and pediatric population such as decreased stability, increased lipid globule size, decreased sterility and the potential for increased microbial growth/infectious complications, the need to use a larger filter size, precipitation and compatibility risks, and an increased chance of catheter occlusion. This review outlines the unique issues and challenges to be considered when formulating neonatal and pediatric 3-in-1 PN admixtures. While 3-in-1 PN solutions may be advantageous for certain pediatric populations, specifically those dependent on home PN, the risks do not outweigh the benefits in neonatal patients, and use should be avoided in this population.
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Affiliation(s)
- Allison Beck Blackmer
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - M Luisa Partipilo
- University of Michigan Health Systems, Ann Arbor, Michigan C. S. Mott Children's and Women's Hospital, Ann Arbor, Michigan
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The natural history of cirrhosis from parenteral nutrition-associated liver disease after resolution of cholestasis with parenteral fish oil therapy. Ann Surg 2015; 261:172-9. [PMID: 24374535 DOI: 10.1097/sla.0000000000000445] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To determine the natural history of cirrhosis from parenteral nutrition-associated liver disease (PNALD) after resolution of cholestasis with fish oil (FO) therapy. BACKGROUND Historically, cirrhosis from PNALD resulted in end-stage liver disease, often requiring transplantation for survival. With FO therapy, most children now experience resolution of cholestasis and rarely progress to end-stage liver disease. However, outcomes for cirrhosis after resolution of cholestasis are unknown and patients continue to be considered for liver/multivisceral transplantation. METHODS Prospectively collected data were reviewed for children with cirrhosis because of PNALD who had resolution of cholestasis after treatment with FO from 2004 to 2012. Outcomes evaluated included need for liver/multivisceral transplantation, mortality, and the clinical progression of liver disease. RESULTS Fifty-one patients with cirrhosis from PNALD were identified, with 76% demonstrating resolution of cholestasis after FO therapy. The mean direct bilirubin decreased from 6.4 ± 4 mg/dL to 0.2 ± 0.1 mg/dL (P < 0.001) 12 months after resolution of cholestasis, with a mean time to resolution of 74 days. None of the patients required transplantation or died from end-stage liver disease. Pediatric End-Stage Liver Disease scores decreased from 16 ± 4.6 to -1.2 ± 4.6, 12 months after resolution of cholestasis (P < 0.001). In children who remained PN-dependent, the Pediatric End-Stage Liver Disease score remained normal throughout the follow-up period. CONCLUSIONS Cirrhosis from PNALD may be stable rather than progressive once cholestasis resolves with FO therapy. Furthermore, these patients may not require transplantation and show no clinical evidence of liver disease progression, even when persistently PN-dependent.
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Preservation of biochemical liver function with low-dose soy-based lipids in children with intestinal failure-associated liver disease. J Pediatr Gastroenterol Nutr 2015; 60:375-7. [PMID: 25714580 PMCID: PMC4341952 DOI: 10.1097/mpg.0000000000000609] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Intestinal failure-associated liver disease (IFALD) contributes to significant morbidity in pediatric patients with intestinal failure (IF); however, the use of parenteral nutrition (PN) with a fish oil-based intravenous (IV) emulsion (FO) has been associated with biochemical reversal of cholestasis and improved outcomes. Unfortunately, FO increases the complexity of care: because it can be administered only under Food and Drug Administration compassionate use protocols requiring special monitoring, it is not available as a 3-in-1 solution and is more expensive than comparable soy-based IV lipid emulsion (SO). Because of these pragmatic constraints, a series of patient families were switched to low-dose (1 g kg(-1) day(-1)) SO following biochemical resolution of cholestasis. The present study examines whether reversal of cholestasis and somatic growth are maintained following this transition. METHODS The present study is a chart review of all children with IFALD who switched from FO to SO following resolution of cholestasis. Variables are presented as medians (interquartile ranges). Comparisons were performed using the Wilcoxon signed-rank test. RESULTS Seven patients ages 25.9 (16.2-43.2) months were transitioned to SO following reversal of cholestasis using FO. At a median follow-up of 13.9 (4.3-50.1) months, there were no significant differences between pretransition and post-transition serum alanine and aspartate aminotransferases, direct bilirubin, and weight-for-age z scores. Because of recurrence of cholestasis, 1 patient was restarted on FO after 4 months on SO. CONCLUSIONS Biochemical reversal of IFALD and growth were preserved after transition from FO to SO in 6 of 7 (86%) patients. Given the challenges associated with the use of FO, SO may be a viable alternative in select patients with home PN.
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Ng K, Stoll B, Chacko S, Saenz de Pipaon M, Lauridsen C, Gray M, Squires EJ, Marini J, Zamora IJ, Olutoye OO, Burrin DG. Vitamin E in New-Generation Lipid Emulsions Protects Against Parenteral Nutrition-Associated Liver Disease in Parenteral Nutrition-Fed Preterm Pigs. JPEN J Parenter Enteral Nutr 2015; 40:656-71. [PMID: 25596209 DOI: 10.1177/0148607114567900] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 12/13/2014] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Parenteral nutrition (PN) in preterm infants leads to PN-associated liver disease (PNALD). PNALD has been linked to serum accumulation of phytosterols that are abundant in plant oil but absent in fish oil emulsions. HYPOTHESIS Whether modifying the phytosterol and vitamin E composition of soy and fish oil lipid emulsions affects development of PNALD in preterm pigs. METHODS We measured markers of PNALD in preterm pigs that received 14 days of PN that included 1 of the following: (1) Intralipid (IL, 100% soybean oil), (2) Intralipid + vitamin E (ILE, d-α-tocopherol), (3) Omegaven (OV, 100% fish oil), or (4) Omegaven + phytosterols (PS, β-sitosterol, campesterol, and stigmasterol). RESULTS Serum levels of direct bilirubin, gamma glutamyl transferase, serum triglyceride, low-density lipoprotein, and hepatic triglyceride content were significantly lower (P < .05) in the ILE, OV, and PS compared to IL. Hepatic cholesterol 7-hydroxylase and organic solute transporter-α expression was lower (P < .05) and portal plasma FGF19 higher in the ILE, OV, and PS vs IL. Hepatic expression of mitochondrial carnitine palmitoyltransferase 1A and microsomal cytochrome P450 2E1 fatty acid oxidation genes was higher in ILE, OV, and PS vs IL. In vivo (13)C-CDCA clearance and expression of pregnane X receptor target genes, cytochrome P450 3A29 and multidrug resistance-associated protein 2, were higher in ILE, OV, and PS vs IL. CONCLUSIONS α-tocopherol in Omegaven and added to Intralipid prevented serum and liver increases in biliary and lipidemic markers of PNALD in preterm piglets. The addition of phytosterols to Omegaven did not produce evidence of PNALD.
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Affiliation(s)
- Kenneth Ng
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara Stoll
- USDA/ARS Children's Nutrition Research Center, Houston, Texas, USA
| | - Shaji Chacko
- USDA/ARS Children's Nutrition Research Center, Houston, Texas, USA
| | | | | | - Matthew Gray
- Department of Animal and Poultry Science, University of Guelph, Guelph, Ontario, Canada
| | - E James Squires
- Department of Animal and Poultry Science, University of Guelph, Guelph, Ontario, Canada
| | - Juan Marini
- USDA/ARS Children's Nutrition Research Center, Houston, Texas, USA
| | - Irving J Zamora
- Texas Children's Hospital, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Oluyinka O Olutoye
- Texas Children's Hospital, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Douglas G Burrin
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA USDA/ARS Children's Nutrition Research Center, Houston, Texas, USA
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Dickerson RN, Kumpf VJ, Rollins CJ, Frankel EH, Kraft MD, Canada TW, Crill CM. Significant publications for pharmacy nutrition support practice in 2013. Hosp Pharm 2014; 49:717-30. [PMID: 25477597 DOI: 10.1310/hpj4908-717] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To assist the pharmacy clinician engaged in nutrition support in staying current with the most pertinent literature. METHODS Several experienced board-certified clinical pharmacists in nutrition support compiled a list of publications published in 2013 that they considered to be important to their practice. The citation list was compiled into a Web-based survey whereby pharmacist members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), GI-Liver-Nutrition Practice Research Network of the American College of Clinical Pharmacy, and the Pharmacy and Pharmacology Section of the Society of Critical Care Medicine were asked to rank each article according to level of importance in their practice. RESULTS A total of 30 articles were identified by the author group. Thirty-six participants responded to the survey. The top-ranked papers by participants from the Web-based survey were reviewed by the authors. Due to its high level of importance, the parenteral nutrition safety consensus recommendations article, to be published in 2014 by A.S.P.E.N., was also reviewed. CONCLUSION It is recommended that the informed pharmacist, who is engaged in nutrition support therapy, be familiar with the majority of these publications.
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Affiliation(s)
- Roland N Dickerson
- Professor of Clinical Pharmacy, University of Tennessee College of Pharmacy , Memphis, Tennessee
| | - Vanessa J Kumpf
- Clinical Specialist, Nutrition Support, Center for Human Nutrition, Vanderbilt University Medical Center , Nashville, Tennessee
| | - Carol J Rollins
- Clinical Coordinator, Nutrition Support Team, The University of Arizona Medical Center , Tucson, Arizona
| | - Eric H Frankel
- Neonatal Clinical Lead & Metabolic Support Service Clinical Pharmacist, Truman Medical Center Hospital Hill , Kansas City, Missouri
| | - Michael D Kraft
- Assistant Director, Education and Research, Department of Pharmacy Services, University of Michigan Hospitals and Health Centers , Ann Arbor, Michigan
| | - Todd W Canada
- Clinical Pharmacy Services Manager, University of Texas, MD Anderson Cancer Center , Houston, Texas
| | - Catherine M Crill
- Associate Professor of Clinical Pharmacy and Pediatrics, University of Tennessee College of Pharmacy and Medicine , Memphis, Tennessee
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Josephson J, Turner JM, Field CJ, Wizzard PR, Nation PN, Sergi C, Ball RO, Pencharz PB, Wales PW. Parenteral Soy Oil and Fish Oil Emulsions. JPEN J Parenter Enteral Nutr 2014; 39:677-87. [DOI: 10.1177/0148607114556494] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 10/01/2014] [Indexed: 11/17/2022]
Affiliation(s)
| | - Justine M. Turner
- Department of Pediatrics, University of Alberta, Edmonton, Canada
- Department of Agricultural Food and Nutritional Science, University of Alberta, Edmonton, Canada
| | - Catherine J. Field
- Department of Agricultural Food and Nutritional Science, University of Alberta, Edmonton, Canada
| | | | - Patrick N. Nation
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Canada
| | - Consolato Sergi
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Canada
| | - Ronald O. Ball
- Department of Agricultural Food and Nutritional Science, University of Alberta, Edmonton, Canada
| | - Paul B. Pencharz
- Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Departments of Pediatrics and Nutritional Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W. Wales
- Department of Pediatrics, University of Alberta, Edmonton, Canada
- Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Departments of Pediatrics and Nutritional Sciences, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment, Hospital for Sick Children, Toronto, Ontario, Canada
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Blackmer AB, Warschausky S, Siddiqui S, Welch KB, Horn K, Wester A, Warschausky M, Teitelbaum DH. Preliminary findings of long-term neurodevelopmental outcomes of infants treated with intravenous fat emulsion reduction for the management of parenteral nutrition-associated cholestasis. JPEN J Parenter Enteral Nutr 2014; 39:34-46. [PMID: 25293944 DOI: 10.1177/0148607114551965] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Parenteral nutrition-associated cholestasis (PNAC) is linked with the administration of soybean-based intravenous fat emulsion (IVFE). IVFE reduction (IFER) may be an effective management strategy for PNAC; however, long-term associated neurodevelopmental outcomes (NDOs) for infants undergoing IFER have not been measured previously. This single-institution, prospective study examined the risk for negative NDOs and key predictors of NDOs associated with IFER. METHODS Patients (2-5 years) treated with soybean-based IFER as neonates underwent NDO measurements, including Ages and Stages Questionnaires-3 (ASQ-3), Parents' Evaluations of Developmental Status (PEDS), and Behavior Assessment System for Children, Second Edition Preschool, Parent (BASC-2 PRS-P). The relationship between NDOs and predictive variables was evaluated. RESULTS A total of 25 children had a complete PEDS survey, and 17 were found to be "not at risk." The BASC-2 PRS-P evaluation (n = 18 patients) showed that all 4 composite domains fell within the normative developmental range, and 67%-89% of patients were observed to be "typically developing." For the primary outcome measure, ASQ-3, 82.4%-94.4% of patients were "not at risk." Logistical regression analyses were performed to examine risk factors contributing to negative NDOs. Of children completing all NDO studies, IFER-related variables (eg, development of essential fatty acid deficiency, duration of IFER, and mean IVFE dose) were not found to be predictors of adverse NDOs. CONCLUSIONS This study represents the first report of NDOs in pediatric patients treated with IFER. IFER-treated patients score within the normative range most of the time. IFER-related variables were not found to be associated with negative NDOs. The results set the stage for a larger, multicenter, prospective study.
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Affiliation(s)
- Allison B Blackmer
- Department of Clinical, Social and Administrative Sciences, University of Michigan College of Pharmacy, Ann Arbor Department of Pharmacy Services, University of Michigan Health System, Ann Arbor
| | - Seth Warschausky
- Department of Physical Medicine and Rehabilitation, University of Michigan Health System, Ann Arbor
| | - Sabina Siddiqui
- Department of Surgery, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor
| | | | - Karolyn Horn
- College of Pharmacy, University of Michigan, Ann Arbor
| | - Ashley Wester
- College of Pharmacy, University of Michigan, Ann Arbor
| | - Micah Warschausky
- Department of Physical Medicine and Rehabilitation, University of Michigan Health System, Ann Arbor
| | - Daniel H Teitelbaum
- Department of Surgery, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor
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58
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Mortensen M, Williamson N, Davis C, Kanyu Hsu E, Javid PJ, Horslen S. Iodine Deficiency in a Parenteral Nutrition–Dependent Adolescent With Intestinal Pseudo-Obstruction. JPEN J Parenter Enteral Nutr 2014; 40:730-3. [DOI: 10.1177/0148607114551799] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 08/19/2014] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Cheryl Davis
- Seattle Children’s Hospital, Seattle, Washington
| | - Evelyn Kanyu Hsu
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, Seattle, Washington
- University of Washington School of Medicine, Seattle
| | - Patrick J. Javid
- Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Washington
- Department of Surgery, University of Washington School of Medicine, Seattle
| | - Simon Horslen
- University of Washington School of Medicine, Seattle
- Liver and Intestinal Transplantation, Seattle Children’s Hospital, Seattle, Washington
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Levit OL, Calkins KL, Gibson LC, Kelley-Quon L, Robinson DT, Elashoff DA, Grogan TR, Li N, Bizzarro MJ, Ehrenkranz RA. Low-Dose Intravenous Soybean Oil Emulsion for Prevention of Cholestasis in Preterm Neonates. JPEN J Parenter Enteral Nutr 2014; 40:374-82. [PMID: 24963025 DOI: 10.1177/0148607114540005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/16/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Premature infants depend on intravenous fat emulsions to supply essential fatty acids and calories. The dose of soybean-based intravenous fat emulsions (S-IFE) has been associated with parenteral nutrition (PN)-associated liver disease. This study's purpose was to determine if low-dose S-IFE is a safe and effective preventive strategy for cholestasis in preterm neonates. MATERIALS AND METHODS This is a multicenter randomized controlled trial in infants with a gestational age (GA) ≤29 weeks. Patients <48 hours of life were randomized to receive a low (1 g/kg/d) or control dose (approximately 3 g/kg/d) of S-IFE. The primary outcome was cholestasis, defined as a direct bilirubin ≥15% of the total bilirubin at 28 days of life (DOL) or full enteral feeds, whichever was later, after 14 days of PN. Secondary outcomes included growth, length of hospital stay, death, and major neonatal morbidities. RESULTS In total, 136 neonates (67 and 69 in the low and control groups, respectively) were enrolled. Baseline characteristics were similar for the 2 groups. When the low group was compared with the control group, there was no difference in the primary outcome (69% vs 63%; 95% confidence interval, -0.1 to 0.22; P = .45). While the low group received less S-IFE and total calories over time compared with the control group (P < .001 and P = .03, respectively), weight, length, and head circumference at 28 DOL, discharge, and over time were not different (P > .2 for all). CONCLUSION Compared with the control dose, low-dose S-IFE was not associated with a reduction in cholestasis or growth.
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Affiliation(s)
- Orly L Levit
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Kara L Calkins
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
| | - L Caroline Gibson
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Lorraine Kelley-Quon
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Daniel T Robinson
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David A Elashoff
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Tristan R Grogan
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Ning Li
- Department of Biomathematics, University of California, Los Angeles, California
| | - Matthew J Bizzarro
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Richard A Ehrenkranz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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Enteral nutrition and total parenteral nutrition components in the course of total parenteral nutrition-associated cholestasis in neonatal necrotizing enterocolitis. Surgery 2014; 156:578-83. [PMID: 24962191 DOI: 10.1016/j.surg.2014.04.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 04/15/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Newborns with necrotizing enterocolitis (NEC) are at high risk for the development of total parenteral nutritional-associated cholestasis (TPNAC). Patients with NEC were evaluated to determine risk factors for development of TPNAC and predictors of resolution. We hypothesized that there are additional factors relating to the timing of enteral nutrition or TPN components that effect development and persistence of TPNAC in patients with NEC that may be altered to decrease the chance of progression to liver failure. METHODS This was a retrospective chart review of NEC patients from 2001 to 2010. TPNAC was defined as direct bilirubin ≥2 mg/dL, the level used for cholestasis in neonatal studies relating to TPNAC. RESULTS Of 178 patients with NEC, 96 developed TPNAC, and in 27 TPNAC had resolved by discharge. Days of TPN did not affect TPNAC resolution by discharge (P = 1.0). TPNAC was less likely to occur in patients with body weights >1,500 g, enteral nutrition within the first week of life, no infection, fewer TPN days, and lesser hospital stay (P < .01). There were many factors affecting resolution of cholestasis. Enteral nutrition within 6 days of birth decreased development of TPNAC (P < .01), and resumption of enteral nutrition within 3 weeks after NEC diagnosis increased the resolution of cholestasis (P < .01). No component of TPN was important for the development or resolution of cholestasis. CONCLUSION Of the factors that effect development and resolution of TPNAC in NEC, the ones that we can alter include early enteral feeds and surveillance for infection.
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Abstract
Although parenteral nutrition (PN) is life-sustaining, it is associated with many complications including parenteral nutrition-associated liver disease (PNALD) and central line-associated bloodstream infections (CLASBIs), which carry a high morbidity and mortality and impose a burden on the health care system. Evidence has emerged that the dose and composition of intravenous lipid products may alter the incidence of PNALD. However, other patient and PN-related factors, such as prematurity, birth weight, and gastrointestinal anatomy and function, are important. To improve neonatal care, future research on optimizing the content of PN and decreasing the incidence IFALD and CLASBIs is required.
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Affiliation(s)
- Kara L Calkins
- Division of Neonatology and Developmental Biology, Department of Pediatrics, Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Robert S Venick
- Division of Gastroenterology, Department of Pediatrics, Mattel Children's Hospital, University of California, 10833 Le Conte Avenue, MDCC, Los Angeles, Los Angeles, CA 90095-1752, USA
| | - Sherin U Devaskar
- Division of Neonatology and Developmental Biology, Department of Pediatrics, Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA, USA
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Nandivada P, Carlson SJ, Chang MI, Cowan E, Gura KM, Puder M. Treatment of parenteral nutrition-associated liver disease: the role of lipid emulsions. Adv Nutr 2013; 4:711-7. [PMID: 24228202 PMCID: PMC3823519 DOI: 10.3945/an.113.004770] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Parenteral nutrition is a life-saving therapy for infants with intestinal failure. However, long-term parenteral nutrition carries the risk of progressive liver disease. Substantial data has implicated components of parenteral soybean oil in the pathogenesis of parenteral nutrition-associated liver disease (PNALD). Elevated serum concentrations of phytosterols, an abundance of omega-6 polyunsaturated fatty acids, and a relative paucity of α-tocopherol have been associated with the risk of cholestasis and hepatic injury observed in PNALD. Currently available treatment strategies include the reduction of the dose of administered parenteral soybean oil and/or the replacement of parenteral soybean oil with alternative parenteral lipid emulsions. The purpose of this review is to provide an overview of the pathogenetic mechanisms associated with the development of PNALD and the data evaluating currently available treatment strategies.
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Nandivada P, Carlson SJ, Cowan E, Chang MI, Gura KM, Puder M. Role of parenteral lipid emulsions in the preterm infant. Early Hum Dev 2013; 89 Suppl 2:S45-9. [PMID: 23998451 DOI: 10.1016/j.earlhumdev.2013.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Parenteral nutrition (PN) is necessary for infants unable to receive adequate calories enterally due to prematurity, decreased bowel length, or functional intestinal disorders. While PN can be life saving, its use is associated with significant risks of sepsis from catheter-associated infections and progressive liver dysfunction from prolonged use. The preterm infant population is at highest risk for these complications due to the presence of multiple comorbidities and immaturity of the biliary system. Strong data has implicated parenteral lipids in the multifactorial pathogenesis of PN-associated liver disease (PNALD). However, lipids are essential in early infant development, particularly in the neurocognitive development of preterm infants. Substitution of the lipid source from soybean oil to fish oil has emerged as a safe and efficacious treatment of PNALD, with marked improvements in morbidity and mortality. Knowledge of the developmental needs and physiologic limitations of preterm infants is crucial to optimizing parenteral lipid administration to nurture growth, and minimize and treat associated complications. The purpose of this review is to provide an overview of lipid requirements of the preterm infant and discuss the role of parenteral lipid emulsions in the management of PNALD and other diseases of prematurity.
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Affiliation(s)
- Prathima Nandivada
- Boston Children's Hospital, Department of Surgery and Vascular Biology Program, 300 Longwood Avenue, Fegan 3, Boston, MA, USA
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64
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Diamond IR, Grant RC, Feldman BM, Tomlinson GA, Pencharz PB, Ling SC, Moore AM, Wales PW. Expert Beliefs Regarding Novel Lipid-Based Approaches to Pediatric Intestinal Failure–Associated Liver Disease. JPEN J Parenter Enteral Nutr 2013; 38:702-10. [DOI: 10.1177/0148607113494213] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Accepted: 05/26/2013] [Indexed: 11/16/2022]
Affiliation(s)
- Ivan R. Diamond
- Group for Improvement of Intestinal Function and Treatment (GIFT)
- Child Health Evaluative Sciences Program, Hospital for Sick Children, Toronto, Canada
- Department of Surgery
- Department of Health Policy Management and Evaluation
| | - Robert C. Grant
- Group for Improvement of Intestinal Function and Treatment (GIFT)
- Child Health Evaluative Sciences Program, Hospital for Sick Children, Toronto, Canada
- Department of Surgery
| | - Brian M. Feldman
- Child Health Evaluative Sciences Program, Hospital for Sick Children, Toronto, Canada
- Department of Health Policy Management and Evaluation
- Department of Pediatrics
- Department of Medicine
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - George A. Tomlinson
- Department of Health Policy Management and Evaluation
- Department of Medicine
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Paul B. Pencharz
- Group for Improvement of Intestinal Function and Treatment (GIFT)
- Department of Pediatrics
| | - Simon C. Ling
- Group for Improvement of Intestinal Function and Treatment (GIFT)
- Department of Pediatrics
| | - Aideen M. Moore
- Group for Improvement of Intestinal Function and Treatment (GIFT)
- Child Health Evaluative Sciences Program, Hospital for Sick Children, Toronto, Canada
- Department of Health Policy Management and Evaluation
- Department of Pediatrics
| | - Paul W. Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT)
- Child Health Evaluative Sciences Program, Hospital for Sick Children, Toronto, Canada
- Department of Surgery
- Department of Health Policy Management and Evaluation
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