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Chan AP, Rostas S, Rogers S, Martin CR, Calkins KL. Parenteral Nutrition in the Neonatal Intensive Care Unit: Intravenous Lipid Emulsions. Clin Perinatol 2023; 50:575-589. [PMID: 37536765 DOI: 10.1016/j.clp.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Intravenous lipid emulsions (ILEs) are a source of nonprotein calories and fatty acids and help promote growth in preterm infants and infants with intestinal failure. An ILE dose and oil source determines its fatty acid, phytosterol, and vitamin E delivery. These factors play a role in the infant's risk for essential fatty acid deficiency and cholestasis, and help modulate inflammation, immunity, and organ development. This article reviews different ILEs and their constituents and their relationship with neonatal health.
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Affiliation(s)
- Alvin P Chan
- Division of Gastroenterology, Department of Pediatrics, David Geffen School of Medicine UCLA, 10833 Le Conte Avenue, MDCC 12-383, Los Angeles, CA 90095, USA
| | - Sara Rostas
- New York-Presbyterian Department of Pharmacy, New York-Presbyterian Hospital/Komansky Children's Hospital, 1283 York Avenue, FL15, New York, NY 10065, USA
| | - Samantha Rogers
- New York-Presbyterian Food & Nutrition Services, New York-Presbyterian Hospital/Weill Cornell Medical Center, 1283 York Avenue, FL15, New York, NY 10065, USA
| | - Camilia R Martin
- Division of Neonatology, Department of Pediatrics, Weill Cornell Medicine, 1283 York Avenue, FL15, New York, NY 10065, USA
| | - Kara L Calkins
- Division of Neonatology & Developmental Biology, Department of Pediatrics, Neonatal Research Center of the UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine UCLA, 1088 Le Conte Avenue, Room B2-375 MDCC, Los Angeles, CA 90095, USA.
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Sjöbom U, Andersson MX, Pivodic A, Lund AM, Vanpee M, Hansen-Pupp I, Ley D, Wackernagel D, Sävman K, Smith LEH, Löfqvist C, Hellström A, Nilsson AK. Modification of serum fatty acids in preterm infants by parenteral lipids and enteral docosahexaenoic acid/arachidonic acid: A secondary analysis of the Mega Donna Mega trial. Clin Nutr 2023; 42:962-971. [PMID: 37120902 PMCID: PMC10512593 DOI: 10.1016/j.clnu.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND & AIM Preterm infants risk deficits of long-chain polyunsaturated fatty acids (LCPUFAs) that may contribute to morbidities and hamper neurodevelopment. We aimed to determine longitudinal serum fatty acid profiles in preterm infants and how the profiles are affected by enteral and parenteral lipid sources. METHODS Cohort study analyzing fatty acid data from the Mega Donna Mega study, a randomized control trial with infants born <28 weeks of gestation (n = 204) receiving standard nutrition or daily enteral lipid supplementation with arachidonic acid (AA):docosahexaenoic acid (DHA) (100:50 mg/kg/day). Infants received an intravenous lipid emulsion containing olive oil:soybean oil (4:1). Infants were followed from birth to postmenstrual age 40 weeks. Levels of 31 different fatty acids from serum phospholipids were determined by GC-MS and reported in relative (mol%) and absolute concentration (μmol l-1) units. RESULTS Higher parenteral lipid administration resulted in lower serum proportion of AA and DHA relative to other fatty acids during the first 13 weeks of life (p < 0.001 for the 25th vs the 75th percentile). The enteral AA:DHA supplement increased the target fatty acids with little impact on other fatty acids. The absolute concentration of total phospholipid fatty acids changed rapidly in the first weeks of life, peaking at day 3, median (Q1-Q3) 4452 (3645-5466) μmol l-1, and was positively correlated to the intake of parenteral lipids. Overall, infants displayed common fatty acid trajectories over the study period. However, remarkable differences in fatty acid patterns were observed depending on whether levels were expressed in relative or absolute units. For example, the relative levels of many LCPUFAs, including DHA and AA, declined rapidly after birth while their absolute concentrations increased in the first week of life. For DHA, absolute levels were significantly higher compared to cord blood from day 1 until postnatal week 16 (p < 0.001). For AA, absolute postnatal levels were lower compared to cord blood from week 4 throughout the study period (p < 0.05). CONCLUSIONS Our data show that parenteral lipids aggravate the postnatal loss of LCPUFAs seen in preterm infants and that serum AA available for accretion is below that in utero. Further research is needed to establish optimal postnatal fatty acid supplementation and profiles in extremely preterm infants to promote development and long-term health. CLINICAL TRIAL REGISTRY ClinicalTrials.gov, identifier: NCT03201588.
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Affiliation(s)
- Ulrika Sjöbom
- Section for Ophthalmology, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Learning and Leadership for Health Care Professionals at the Institute of Health and Care Science at Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
| | - Mats X Andersson
- Department of Biological and Environmental Sciences, University of Gothenburg, Gothenburg, Sweden.
| | - Aldina Pivodic
- Section for Ophthalmology, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Anna-My Lund
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Pediatrics, Lund, Sweden.
| | - Mireille Vanpee
- Department of Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
| | - Ingrid Hansen-Pupp
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Pediatrics, Lund, Sweden.
| | - David Ley
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Pediatrics, Lund, Sweden.
| | - Dirk Wackernagel
- Department of Neonatology, Karolinska University Hospital and Institute, Astrid Lindgrens Children's Hospital, Stockholm, Sweden.
| | - Karin Sävman
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Department of Neonatology, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Lois E H Smith
- The Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Chatarina Löfqvist
- Section for Ophthalmology, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Learning and Leadership for Health Care Professionals at the Institute of Health and Care Science at Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
| | - Ann Hellström
- Section for Ophthalmology, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Anders K Nilsson
- Section for Ophthalmology, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Gillespie TC, Kim ES, Grogan T, Tsui I, Chu A, Calkins KL. Decreased Levels of Erythrocyte Membrane Arachidonic and Docosahexaenoic Acids Are Associated With Retinopathy of Prematurity. Invest Ophthalmol Vis Sci 2022; 63:23. [PMID: 36383353 PMCID: PMC9680586 DOI: 10.1167/iovs.63.12.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Purpose Retinopathy of prematurity (ROP) can lead to blindness. Arachidonic acid (ARA) and docosahexaenoic acid (DHA) regulate retinal inflammation and angiogenesis. The aim of this study was to investigate red blood cell membrane (RBCM) ARA and DHA in preterm infants. Methods This prospective observational study divided infants into groups by ROP severity and RBCM ARA and DHA means and terciles. Results Although the mean ± SD RBCM ARA was different between groups (no ROP, 17.9% ± 0.7%, vs. type 2 ROP, 17.4% ± 0.8%, vs. type 1 ROP, 16.7% ± 1.0%; P < 0.001), the mean RBCM DHA was similar (P = 0.161). Infants with type 1 ROP were more likely to be in the lowest ARA and DHA terciles than in the highest (ARA, 44% vs. 5.6%; DHA, 22% vs. 5.6%). ARA and DHA declined over the first month of life in all ROP groups. At week 1, ARA was lower in the type 1 and type 2 ROP groups compared with the no-ROP group (18% ± 2% and 19% ± 3% vs. 21% ± 2%, respectively; P < 0.05 for all). At week 2, DHA and ARA were lower in the type I ROP group compared with the no-ROP group (3% ± 1% vs. 4% ± 1%, P = 0.03 and 16% ± 1% vs. 19% ± 1%, respectively; P < 0.01). A RBCM ARA% ≥ 17 was associated with a 45% reduction in any ROP. As the estimated 4-week ARA% mean increased by 1%, the odds of ROP decreased by 70% (odds ratio = 0.30; 95% confidence interval, 0.1-0.7). Conclusions Infants with severe ROP have lower ARA and DHA levels than infants without ROP. ARA and DHA may act synergistically to protect against ROP.
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Affiliation(s)
- Tessa C. Gillespie
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States
| | - Esther S. Kim
- Department of Pediatrics, Neonatal Research Center of the UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine, University of California, Los Angeles, and UCLA Mattel Children's Hospital, Los Angeles, California, United States
| | - Tristan Grogan
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States
| | - Irena Tsui
- Department of Ophthalmology, David Geffen School of Medicine, University of California, Los Angeles, and UCLA Mattel Children's Hospital, Los Angeles, California, United States
| | - Alison Chu
- Department of Pediatrics, Neonatal Research Center of the UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine, University of California, Los Angeles, and UCLA Mattel Children's Hospital, Los Angeles, California, United States
| | - Kara L. Calkins
- Department of Pediatrics, Neonatal Research Center of the UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine, University of California, Los Angeles, and UCLA Mattel Children's Hospital, Los Angeles, California, United States
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Gura KM, Calkins KL, Premkumar MH, Puder M. Use of Intravenous Soybean and Fish Oil Emulsions in Pediatric Intestinal Failure-Associated Liver Disease: A Multicenter Integrated Analysis Report on Extrahepatic Adverse Events. J Pediatr 2022; 241:173-180.e1. [PMID: 34695449 DOI: 10.1016/j.jpeds.2021.10.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/17/2021] [Accepted: 10/15/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To compare extrahepatic adverse events during fish oil lipid emulsion (FOLE) or soybean oil lipid emulsion (SOLE) treatment in children with intestinal failure-associated liver disease (IFALD). STUDY DESIGN In this multicenter integrated analysis, bleeding, bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), infections, and signs of lipid emulsion intolerance were compared between FOLE recipients (1 g/kg/d) (n = 189) and historical controls who received SOLE (≤3 g/kg/d) (n = 73). RESULTS When compared with SOLE recipients, FOLE recipients had a lower gestational age (30.5 vs 33.0 weeks; P = .0350) and higher baseline direct bilirubin (DB) (5.8 vs 3.0 mg/dL; P < .0001). FOLE recipients had a decreased incidence of bleeding (P < .0001), BPD (P < .001), ROP (P < .0156), bacterial and fungal infections (P < .0001), and lipid intolerance signs (P < .02 for all). Patients with bleeding vs patients without bleeding had higher baseline DB; the ORs for baseline DB (by mg/dL) and treatment (FOLE vs SOLE) were 1.20 (95% CI: 1.10, 1.31; P ≤ .0001) and 0.22 (95% CI: 0.11, 0.46; P ≤ .0001), respectively. In preterm infants, a higher BPD (P < .0001) and ROP incidence (P = .0071) was observed in SOLE recipients vs FOLE recipients. CONCLUSIONS Children with IFALD who received FOLE had fewer extrahepatic adverse events, including a decreased incidence of bleeding, preterm comorbidities, and lipid intolerance signs compared with children with IFALD who received SOLE. TRIAL REGISTRATION CLINICALTRIALS.GOV: NCT00910104 and NCT00738101.
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Affiliation(s)
- Kathleen M Gura
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pharmacy (KG), Boston Children's Hospital, Boston, MA; Department of Surgery and the Vascular Biology Program (MPU), Boston Children's Hospital, Boston, MA.
| | - Kara L Calkins
- Department of Pediatrics, Division of Neonatology & Developmental Biology, Neonatal Research Center of the UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine at UCLA, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Muralidhar H Premkumar
- Baylor College of Medicine, Section of Neonatology, Department of Pediatrics, Texas Children's Hospital, Houston, TX
| | - Mark Puder
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pharmacy (KG), Boston Children's Hospital, Boston, MA; Department of Surgery and the Vascular Biology Program (MPU), Boston Children's Hospital, Boston, MA
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Álvarez P, Ramiro-Cortijo D, Montes MT, Moreno B, Calvo MV, Liu G, Esteban Romero A, Ybarra M, Cordeiro M, Clambor Murube M, Valverde E, Sánchez-Pacheco A, Fontecha J, Gibson R, Saenz de Pipaon M. Randomized controlled trial of early arachidonic acid and docosahexaenoic acid enteral supplementation in very preterm infants. Front Pediatr 2022; 10:947221. [PMID: 36090567 PMCID: PMC9452757 DOI: 10.3389/fped.2022.947221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate changes in blood long-chain polyunsaturated fatty acid (LCPUFA) and oxylipin concentrations in very preterm infants from birth to 36 weeks' postmenstrual age (WPA) after providing an emulsified arachidonic acid (ARA):docosahexaenoic acid (DHA) supplement at two different concentrations. STUDY DESIGN This prospective, randomized trial assigned infants to receive a supplement (1) 80:40 group (80 mg/kg/day ARA and 40 mg/kg/day DHA, n = 9) or (2) 120:60 group (120 mg/kg/day ARA and 60 mg/kg/day DHA, n = 9). Infants received supplement daily from birth until 36 WPA. At baseline, 21 days of life and 36 WPA, the LCPUFAs were measured in plasma by gas chromatography/mass spectrophotometry. Additionally, LCPUFAs and oxylipins were analyzed in whole blood by ultra-high-performance liquid chromatography-tandem mass spectrometry. Furthermore, a sample of oral mucosa was obtained to analyze single-nucleotide polymorphism located in the FADS1 gene by PCR. RESULTS Gestational age was similar between groups (80:40 = 28+6 [27+3; 30+3] completed weeks+days ; 120:60 = 29+6 [27+3; 30+5] completed weeks+days , p = 0.83). At 36 WPA, the change in plasma ARA was significantly different between groups (80:40 group = 0.15 [-0.67; 0.69] %nmol, 120:60 = 1.68 [1.38; 3.16] %nmol, p = 0.031). In whole blood, the levels of ARA-derived oxylipins (5-, 8-, 9-, 11-, 15-HETE and 8,9-EET) and EPA-derived oxylipins (18-HEPE) significantly increase from baseline to 36 WPA in the 120:60 group than the 80:40 group. CONCLUSION Supplementation at high doses (120:60 mg/kg/day) increased levels of ARA, and EPA- and ARA-derived oxylipins compared to low doses (80:40 mg/kg/day). Differences were detected in EPA metabolites without a significant increase in plasma DHA.
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Affiliation(s)
- Patricia Álvarez
- Department of Neonatology, La Paz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - David Ramiro-Cortijo
- Department of Physiology, Faculty of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - María Teresa Montes
- Department of Neonatology, La Paz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Bárbara Moreno
- Department of Neonatology, La Paz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - María V Calvo
- Food Lipid Biomarkers and Health Group, Instituto de Investigación en Ciencias de la Alimentación (CIAL, CSIC-UAM), Madrid, Spain
| | - Ge Liu
- South Australian Health and Medical Research Institute, SAHMRI Women and Kids, Adelaide, SA, Australia
| | - Ana Esteban Romero
- Department of Neonatology, La Paz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Marta Ybarra
- Department of Neonatology, La Paz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Malaika Cordeiro
- Department of Neonatology, La Paz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Marina Clambor Murube
- Department of Biochemistry, Instituto de Investigaciones Biomédicas Alberto Sols (CSIC-UAM), Madrid, Spain
| | - Eva Valverde
- Department of Neonatology, La Paz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Aurora Sánchez-Pacheco
- Department of Biochemistry, Instituto de Investigaciones Biomédicas Alberto Sols (CSIC-UAM), Madrid, Spain
| | - Javier Fontecha
- Food Lipid Biomarkers and Health Group, Instituto de Investigación en Ciencias de la Alimentación (CIAL, CSIC-UAM), Madrid, Spain
| | - Robert Gibson
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA, Australia.,School of Agriculture, Food and Wine, The University of Adelaide, Adelaide, SA, Australia
| | - Miguel Saenz de Pipaon
- Department of Neonatology, La Paz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
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Alshaikh BN, Reyes Loredo A, Knauff M, Momin S, Moossavi S. The Role of Dietary Fats in the Development and Prevention of Necrotizing Enterocolitis. Nutrients 2021; 14:145. [PMID: 35011027 PMCID: PMC8746672 DOI: 10.3390/nu14010145] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/21/2021] [Accepted: 12/26/2021] [Indexed: 11/18/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is a significant cause of mortality and morbidity in preterm infants. The pathogenesis of NEC is not completely understood; however, intestinal immaturity and excessive immunoreactivity of intestinal mucosa to intraluminal microbes and nutrients appear to have critical roles. Dietary fats are not only the main source of energy for preterm infants, but also exert potent effects on intestinal development, intestinal microbial colonization, immune function, and inflammatory response. Preterm infants have a relatively low capacity to digest and absorb triglyceride fat. Fat may thereby accumulate in the ileum and contribute to the development of NEC by inducing oxidative stress and inflammation. Some fat components, such as long-chain polyunsaturated fatty acids (LC-PUFAs), also exert immunomodulatory roles during the early postnatal period when the immune system is rapidly developing. LC-PUFAs may have the ability to modulate the inflammatory process of NEC, particularly when the balance between n3 and n6 LC-PUFAs derivatives is maintained. Supplementation with n3 LC-PUFAs alone may have limited effect on NEC prevention. In this review, we describe how various fatty acids play different roles in the pathogenesis of NEC in preterm infants.
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Affiliation(s)
- Belal N Alshaikh
- Neonatal Nutrition and Gastroenterology Program, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2T9, Canada
| | - Adriana Reyes Loredo
- Neonatal Nutrition and Gastroenterology Program, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2T9, Canada
| | - Megan Knauff
- Nutrition Services, Alberta Health Services, Calgary, AB T2N 2T9, Canada
| | - Sarfaraz Momin
- Neonatal Nutrition and Gastroenterology Program, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2T9, Canada
| | - Shirin Moossavi
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2T9, Canada
- International Microbiome Centre, Cumming School of Medicine, Health Sciences Centre, University of Calgary, Calgary, AB T2N 2T9, Canada
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Frazer LC, Martin CR. Parenteral lipid emulsions in the preterm infant: current issues and controversies. Arch Dis Child Fetal Neonatal Ed 2021; 106:676-681. [PMID: 33514630 PMCID: PMC8319211 DOI: 10.1136/archdischild-2020-319108] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/24/2020] [Accepted: 01/14/2021] [Indexed: 12/14/2022]
Abstract
Parenteral lipid emulsions are a necessary component of nutrition for extremely low gestational age newborns until adequate levels of enteral intake are established. Historically, Intralipid, a 100% soybean oil emulsion, has filled this role. Newer multicomponent lipid emulsions containing a mixture of other oils, including olive oil and fish oil, are now available as options, although the regulatory approval for use in neonates varies worldwide. When dosed at currently published recommendations, each of these lipid emulsions meets total fat and energy requirements without a risk of essential fatty acid deficiency. Thus, when choosing which lipid emulsion to provide, the answer must be based on the metabolic differences induced as a result of these fatty acid-rich emulsions and whether the emulsions provide a health advantage or pose a health risk. The questions of induced fatty acid profiles, health benefit and health risk are discussed sequentially for multicomponent lipid emulsions. Despite the growing acceptance of multicomponent lipid emulsions, there is concern regarding changes in blood fatty acid levels and potential health risk without strong evidence of benefit. There remains no ideal parenteral lipid emulsion option for the preterm infant. Standardising future animal and human studies in lipid delivery with the inclusion of lipid metabolism data will iteratively provide answers to inform the optimal lipid emulsion for the preterm infant.
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Affiliation(s)
- Lauren C Frazer
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Camilia R Martin
- Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA .,Division of Translational Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Frost BL, Patel AL, Robinson DT, Berseth CL, Cooper T, Caplan M. Randomized Controlled Trial of Early Docosahexaenoic Acid and Arachidonic Acid Enteral Supplementation in Very Low Birth Weight Infants. J Pediatr 2021; 232:23-30.e1. [PMID: 33358843 DOI: 10.1016/j.jpeds.2020.12.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/09/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine feasibility of providing a concentrated emulsified long-chain polyunsaturated fatty acids (LCPUFA) supplement to very low birth weight infants, and to evaluate blood LCPUFA concentrations at 2 and 8 weeks of study supplementation. STUDY DESIGN This prospective, randomized, double-blind, placebo-controlled trial randomized infants to receive (1) LCPUFA-120 (a supplement of 40 mg/kg/day docosahexaenoic acid [DHA] and 80 mg/kg/day arachidonic acid [ARA]; DHA:ARA at 1:2 ratio), (2) LCPUFA-360 (a supplement of 120 mg/kg/day DHA and 240 mg/kg/day ARA), or (3) sunflower oil (placebo control). Infants received supplement daily for 8 weeks or until discharge, whichever came first. Whole blood LCPUFA levels (wt%; g/100 g) were measured at baseline, 2 weeks, and 8 weeks. RESULTS Infants were 28 weeks of gestation (IQR, 27-30 weeks of gestation) and weighed 1040 g (IQR, 910-1245 g). At 2 weeks, the change in blood DHA (wt%) from baseline differed significantly among groups (sunflower oil, n = 6; -0.63 [IQR, -0.96 to -0.55]; LCPUFA-120: n = 12; -0.14 [IQR, -0.72 to -0.26]; LCPUFA-360, n = 12; 0.46 [IQR, 0.17-0.81]; P = .002 across groups). Change in blood ARA (wt%) also differed by group (sunflower oil: -2.2 [IQR, -3.9 to -1.7]; LCPUFA-120: 0.1 [IQR, -2.1 to 1.1] vs LCPUFA-360: 2.9 IQR, 1.5 to 4.5]; P = .0002). Change from baseline to 8 weeks significantly differed between groups for DHA (P = .02) and ARA (P = .003). CONCLUSIONS Enteral LCPUFA supplementation supported higher blood DHA by 2 weeks. LCPUFA supplementation at 360 mg of combined DHA and ARA is likely necessary to reduce declines as well as allow increases in whole blood concentrations in the first 8 weeks of life. TRIAL REGISTRATION Clinicaltrials.gov: NCT03192839.
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Affiliation(s)
- Brandy L Frost
- Department of Pediatrics, NorthShore University HealthSystem, Evanston, IL; Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL.
| | - Aloka L Patel
- Department of Pediatrics, Rush University Medical Center, Chicago, IL
| | - Daniel T Robinson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Carol Lynn Berseth
- Clinical Research, Department of Medical Affairs, Mead Johnson Nutrition, Evansville, IN
| | - Timothy Cooper
- Clinical Research, Department of Medical Affairs, Mead Johnson Nutrition, Evansville, IN
| | - Michael Caplan
- Department of Pediatrics, NorthShore University HealthSystem, Evanston, IL; Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL
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Frost BL, Caplan MS. Can Fish Oil Reduce the Incidence of Necrotizing Enterocolitis by Altering the Inflammatory Response? Clin Perinatol 2019; 46:65-75. [PMID: 30771820 DOI: 10.1016/j.clp.2018.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Necrotizing enterocolitis (NEC) is a devastating bowel necrosis that predominantly affects preterm infants and is characterized by an imbalance toward a proinflammatory state. Fish oil or omega-3 long-chain polyunsaturated fatty acids have the potential to modulate inflammation. In this article, the authors examine the evidence in support of fish oil supplementation to alter the inflammatory response and potentially reduce the risk of NEC.
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Affiliation(s)
- Brandy L Frost
- Department of Pediatrics, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, 2650 Ridge Avenue, Walgreen Building Suite 1505, Evanston, IL 60201, USA.
| | - Michael S Caplan
- Department of Pediatrics, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, 2650 Ridge Avenue, Walgreen Building Suite 1505, Evanston, IL 60201, USA
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10
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ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Lipids. Clin Nutr 2018; 37:2324-2336. [DOI: 10.1016/j.clnu.2018.06.946] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/24/2022]
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Smith SL, Rouse CA. Docosahexaenoic acid and the preterm infant. Matern Health Neonatol Perinatol 2017; 3:22. [PMID: 29238605 PMCID: PMC5725938 DOI: 10.1186/s40748-017-0061-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/24/2017] [Indexed: 12/20/2022] Open
Abstract
Docosahexaenoic acid (DHA) is a long chain poly-unsaturated fatty acid (LCPUFA) that has a role in the cognitive and visual development, as well as in the immune function of newborns. Premature infants are typically deficient in DHA for several reasons, to include fetal accretion of DHA that typically occurs during the third trimester. These premature infants are reliant on enteral sources of DHA, most commonly through breast milk. The DHA content in breast milk varies in direct correlation with maternal DHA intake and mothers consuming a Western diet typically have lower levels of DHA in their breast milk. Maternal DHA supplementation and direct supplementation of DHA to the infant has been tried successfully but there are still conflicting results on the optimal dosage and method of delivery of DHA to the infant. This has led to inconsistent results in trials evaluating the effects of DHA supplementation to the preterm infant in terms of cognitive and immunological outcomes. While short-term benefits have been seen in several studies, long-term benefits are not consistent. Future studies continue to be needed to optimize DHA intake in our premature infants.
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Affiliation(s)
- Stephanie L Smith
- Uniformed Services University of Health Sciences, 4301 Jones Bridge, Bethesda, MD 20814 USA
| | - Christopher A Rouse
- Uniformed Services University of Health Sciences, 4301 Jones Bridge, Bethesda, MD 20814 USA.,Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20814 USA
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12
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Fares S, Sethom MM, Hammami MB, Cheour M, Feki M, Hadj-Taieb S, Kacem S. Postnatal RBC arachidonic and docosahexaenoic acids deficiencies are associated with higher risk of neonatal morbidities and mortality in preterm infants. Prostaglandins Leukot Essent Fatty Acids 2017; 126:112-116. [PMID: 29031388 DOI: 10.1016/j.plefa.2017.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 09/12/2017] [Accepted: 09/19/2017] [Indexed: 01/03/2023]
Abstract
Arachidonic (AA) and docosahexaenoic (DHA) acids are essential for the health and development of the neonate. Red blood cell (RBC) fatty acids were analyzed in 583 very low birth weight (VLBW) infants and 274 term infants using capillary gas chromatography. VLBW infants exhibited significantly lower RBC AA (13.0 ± 0.89 vs. 13.5 ± 0.98) and DHA (3.77 ± 0.60 vs. 3.80 ± 0.62), but higher n6:n3 ratio (3.97 ± 0.46 vs. 3.63 ± 0.37) than term infants. In VLBW infants, DHA was lower in those born with small for gestational age (3.69 ± 0.57 vs. 3.86 ± 0.58) and those who suffered from neonatal sepsis (3.73 ± 0.60 vs. 3.86 ± 0.55). Both AA and DHA were significantly lower in infants who developed respiratory distress syndrome or intraventricular hemorrhage, and those who died during the hospital stay. VLBW infants had lower postnatal RBC AA and DHA levels than term infants did. These deficits are associated with higher risk of neonatal morbidities and mortality.
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Affiliation(s)
- S Fares
- Université de Tunis El Manar, Faculté de Médecine de Tunis, CHU La Rabta, Laboratoire de Biochimie, LR99ES11, 1007 Jebbari, Tunis, Tunisia.
| | - M M Sethom
- Université de Tunis El Manar, Faculté de Médecine de Tunis, CHU La Rabta, Laboratoire de Biochimie, LR99ES11, 1007 Jebbari, Tunis, Tunisia
| | - M B Hammami
- Université de Tunis El Manar, Faculté de Médecine de Tunis, CHU La Rabta, Laboratoire de Biochimie, LR99ES11, 1007 Jebbari, Tunis, Tunisia
| | - M Cheour
- Centre de Maternité et de Néonatologie de Tunis, Service de Néonatologie, 1007 Jebbari, Tunis, Tunisia
| | - M Feki
- Université de Tunis El Manar, Faculté de Médecine de Tunis, CHU La Rabta, Laboratoire de Biochimie, LR99ES11, 1007 Jebbari, Tunis, Tunisia
| | - S Hadj-Taieb
- Université de Tunis El Manar, Faculté de Médecine de Tunis, CHU La Rabta, Laboratoire de Biochimie, LR99ES11, 1007 Jebbari, Tunis, Tunisia
| | - S Kacem
- Centre de Maternité et de Néonatologie de Tunis, Service de Néonatologie, 1007 Jebbari, Tunis, Tunisia
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Abstract
Fatty acids are critical nutrient regulators of intracellular signaling and influence key pathways including inflammatory responses, hemostasis as well as central nervous system development and function. Preterm birth interrupts the maternal-fetal transfer of essential fatty acids including docosahexaenoic and arachidonic acids, which occurs during the third trimester. Postnatal deficits of these nutrients accrue in preterm infants during the first week and they remain throughout the first months. Due to the regulatory roles of these fatty acids, such deficits contribute an increased risk of developing prematurity-related morbidities including impaired growth and neurodevelopment. The fatty acid contents of parenteral and enteral nutrition are insufficient to meet current recommendations. This chapter summarizes the regulatory roles of fatty acids, current recommendations and limitations of parenteral and enteral nutrition in meeting these recommendations in preterm infants. Suggested areas for research on the roles of fatty acids in preterm infant health are also provided.
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Worthington P, Balint J, Bechtold M, Bingham A, Chan LN, Durfee S, Jevenn AK, Malone A, Mascarenhas M, Robinson DT, Holcombe B. When Is Parenteral Nutrition Appropriate? JPEN J Parenter Enteral Nutr 2017; 41:324-377. [PMID: 28333597 DOI: 10.1177/0148607117695251] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.
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Affiliation(s)
| | - Jane Balint
- 2 Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | | | - Angela Bingham
- 4 University of the Sciences, Philadelphia, Pennsylvania, USA
| | | | - Sharon Durfee
- 6 Central Admixture Pharmacy Services, Inc, Denver, Colorado, USA
| | | | | | - Maria Mascarenhas
- 9 The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel T Robinson
- 10 Ann & Robert H. Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Beverly Holcombe
- 11 American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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Guthrie G, Premkumar M, Burrin DG. Emerging Clinical Benefits of New-Generation Fat Emulsions in Preterm Neonates. Nutr Clin Pract 2017; 32:326-336. [PMID: 28129045 DOI: 10.1177/0884533616687500] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Soybean oil-based intravenous fat emulsions (IVFEs) have been the predominant parenteral nutrition IVFE used in the United States for neonates over the past 45 years. Even though this emulsion has proven useful in supplying infants with energy for growth and essential fatty acids, there have been concerns over its composition in the development of several morbidities, ranging from sepsis to liver disease, bronchopulmonary dysplasia, and impaired neurodevelopment and growth. The exact mechanisms that drive these morbidities in preterm infants are multifactorial, but potential contributors include high ω-6 (n-6) fatty acid composition, low docosahexaenoic acid and antioxidant supplementation, and the presence of potentially harmful nonnutritive components (eg, phytosterols). To address these issues, new-generation IVFEs with various types and amounts of fat have been developed containing greater amounts of the medium-chain fatty acids, long-chain polyunsaturated fatty acid, docosahexaenoic acid, lower concentrations of ω-6 polyunsaturated fatty acids, supplemental vitamin E, and low or negligible amounts of phytosterols. This review examines the clinical outcomes associated with different morbidities of parenteral nutrition in neonates who have received either soybean oil-based or new-generation IVFEs and addresses whether the proposed benefits of new-generation IVFEs have improved outcomes in the neonatal population.
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Affiliation(s)
- Gregory Guthrie
- 1 USDA/ARS Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Muralidhar Premkumar
- 2 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Douglas G Burrin
- 1 USDA/ARS Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Early docosahexaenoic and arachidonic acid supplementation in extremely-low-birth-weight infants. Pediatr Res 2016; 80:505-10. [PMID: 27356083 DOI: 10.1038/pr.2016.118] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/07/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Extremely-low-birth-weight (ELBW) infants accrue large deficits in docosahexaenoic acid (DHA) and arachidonic acid (ARA) and require improved supplementation strategies. We hypothesized that once daily DHA+ARA drops applied to buccal mucosa will increase blood levels. METHODS Thirty ELBW infants were randomized to receive DHA 20 mg/kg/d + ARA 40 or 60 mg/kg/d + ARA 120 mg/kg/d or placebo within 72 h of age for 8 wk duration. Red blood cell phospholipid levels of DHA (primary) and ARA (secondary) were measured at 2 and 8 wk of age. RESULTS Twenty-eight survivors with a median birth weight of 806 g completed dosing and sampling. Red blood cell levels were similar between the three groups at 2 wk (DHA: 4.62 wt% (interquartile range (IQR) 4.1-5.5) for all, P = 0.29 between groups; ARA: 21.1 wt% (IQR 18.78-22.6) for all, P = 0.41 between groups) and 8 wk (DHA: 6.0 wt% (IQR 5.1-7.1) for all, P = 0.57 between groups; ARA: 20.1 wt% (IQR 18.3-23.1) for all, P = 0.63 between groups). DHA in all infants showed a median increase of 31% from 2 to 8 wk (P < 0.04). ARA levels did not significantly change over time (P > 0.6). CONCLUSION Daily buccal DHA and ARA supplements did not affect fatty acid levels in ELBW infants.
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Bridges KM, Pereira-da-Silva L, Tou JC, Ziegler J, Brunetti L. Bone metabolism in very preterm infants receiving total parenteral nutrition: do intravenous fat emulsions have an impact? Nutr Rev 2015; 73:823-36. [DOI: 10.1093/nutrit/nuv035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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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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Larsen BMK, Field CJ, Leong AY, Goonewardene LA, Van Aerde JE, Joffe AR, Clandinin MT. Pretreatment with an intravenous lipid emulsion increases plasma eicosapentanoic acid and downregulates leukotriene b4, procalcitonin, and lymphocyte concentrations after open heart surgery in infants. JPEN J Parenter Enteral Nutr 2013; 39:171-9. [PMID: 24121184 DOI: 10.1177/0148607113505326] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The effect of providing a lipid emulsion containing medium-chain triglyceride (MCT), soybean oil, and fish oil in critically ill infants is not widely studied. This study investigated lipid emulsion effects on plasma phospholipids and immune biomarkers. MATERIALS AND METHODS Thirty-two infants undergoing cardiopulmonary bypass (CPB) and dependent on parenteral nutrition (PN) were randomized to receive either soybean oil (control, n = 16) or a 50:40:10 mixture of MCT, soybean oil, and fish oil (treatment, n = 16). PN was administered for 3 days preoperatively and 10 days postoperatively. Fatty acids, procalcitonin (PCT), leukotriene B4 (LTB4), and lymphocytes were quantified at baseline, before surgery, and days 1, 7 and 10 after surgery. RESULTS PCT was significantly lower in the treatment vs control group 1 day postoperatively (P = .01). The treatment group exhibited a lower ω-6 to ω-3 ratio (P = .0001) and a higher ω-3 concentration at all postoperative study periods (P = .001). Treatment resulted in higher (P < .05) plasma phospholipid eicosapentaenoic acid (EPA) on days 7 and 10, while α-linolenic acid, arachidonic acid, and docosahexaenoic acid remained constant. An increase in plasma phospholipid EPA concentration was associated with a decrease in plasma phospholipid LTB4 concentration (P < .05). On postoperative day 10, treatment infants with high Pediatric Risk of Mortality III scores exhibited a 45% lower lymphocyte concentration (P < .05). CONCLUSION These findings suggest that treating infants undergoing CPB with a lipid emulsion containing ω-3 improves fatty acid status and results in a lower inflammatory response after surgery. Overall, this alternative ω-3-enriched lipid emulsion may benefit clinical outcomes of critically ill infants after cardiac surgery.
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Affiliation(s)
- Bodil M K Larsen
- Nutrition Service, Alberta Health Services, Edmonton, Alberta, Canada Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Catherine J Field
- Alberta Institute for Human Nutrition, University of Alberta, Edmonton, Alberta, Canada Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Amanda Y Leong
- Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, Alberta, Canada
| | | | - John E Van Aerde
- Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Ari R Joffe
- Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Michael T Clandinin
- Alberta Institute for Human Nutrition, University of Alberta, Edmonton, Alberta, Canada Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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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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Calkins KL, Dunn JCY, Shew SB, Reyen L, Farmer DG, Devaskar SU, Venick RS. Pediatric intestinal failure-associated liver disease is reversed with 6 months of intravenous fish oil. JPEN J Parenter Enteral Nutr 2013; 38:682-92. [PMID: 23894176 DOI: 10.1177/0148607113495416] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 05/24/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Studies have suggested that when intravenous (IV) soybean oil (SO) is replaced with fish oil (FO), direct hyperbilirubinemia is more likely to resolve. The necessary duration of FO has not been established. This study seeks to determine if 24 weeks of FO is an effective and safe therapy for intestinal failure-associated liver disease (IFALD). MATERIALS AND METHODS This is a clinical trial using patients with IFALD between the ages of 2 weeks and 18 years. SO was replaced with FO (1 g/kg/d) in 10 patients who were receiving most of their calories from parenteral nutrition (PN). Patients were compared with 20 historic controls receiving SO. SO for both groups was prescribed by the primary medical team at variable doses. The primary outcome was time to reversal of cholestasis. Secondary outcomes were death, transplant, and full enteral feeds. Safety measurements included growth, essential fatty acid deficiency, and laboratory markers to assess bleeding risk. RESULTS The Kaplan-Meier method estimated that 75% in the FO group would experience resolution of cholestasis by 17 weeks vs 6% in the SO group (P < .0001). When compared with the SO group, the FO group had decreased serum direct bilirubin concentrations at weeks 8 (P = .03) and 12, 16, 20, and 24 weeks (P < .0001). Although length z score at the end of the study increased in the FO group compared with baseline (P = .03), there were no significant differences in other outcomes. CONCLUSIONS A limited duration of FO appears to be safe and effective in reversing IFALD.
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Affiliation(s)
- Kara L Calkins
- Department of Pediatrics, Division of Neonatology and Developmental Biology, Neonatal Research Center
| | | | | | | | | | - Sherin U Devaskar
- Department of Pediatrics, Division of Neonatology and Developmental Biology, Neonatal Research Center
| | - Robert S Venick
- Department of Surgery Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine, Mattel Children's Hospital UCLA, University of California, Los Angeles
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