Oxidation of parenteral lipid emulsion by ambient and phototherapy lights: potential toxicity of routine parenteral feeding

Pediatric parenteral nutrition and hydroperoxide toxicity: Evaluation of the effectiveness of photoprotection medical devices

Exposure of parenteral nutrition (PN) to light induces hydroperoxide (HPO) formation whose toxicity, especially in pediatrics, is documented. In this context, we evaluated the efficacy of photoprotection medical devices used in our institution to protect PN from degradation after two different exposures to light. A mixed oil lipid emulsion (Smoflipid®) in standard or opaque syringes and a ternary PN mixture bags (Numetah®) with or without opaque overwrap were exposed for at least 420 min to a xenon lamp. Samples of Smoflipid® in standard or opaque syringes were also exposed for 24 h to conditions reproducing those of a neonatal intensive care unit. The use of opaque syringes for Smoflipid® administration or opaque overwraps for Numetah® administration reduced HPO formation by an average of 14% and 40%, respectively, compared to standard conditions after at least 420 min to a xenon lamp. When Smoflipid® samples were administered with standard or opaque syringes and exposed to a phototherapy lamp, the fold-change in the HPO concentration increased, respectively, by 6.3 or 5.4 at 24 h compared with syringes unexposed to phototherapy lamp. Although the observed differences were non-significant, it nonetheless appears prudent to use photoprotection of PN during administration, particularly in patients with immature or compromised antioxidant capacity.

Administering Parenteral Nutrition in the Neonatal Intensive Care Unit: Logistics, Existing Challenges, and a Few Conundrums

Use of parenteral nutrition (PN) in the neonatal intensive care unit (NICU) requires evaluating the need for central venous catheters, potential drug incompatibilities, unintentional exposures, and suboptimal energy and nutrient intake during the transition to full enteral nutrition. Risks of photooxidation reactions in PN components, refeeding syndrome, and excess early amino acid intake should prompt the reevaluation of routine practices. The goal of this paper is to review the practicalities, challenges, and conundrums of administering PN in the NICU.

Macronutrients and Micronutrients in Parenteral Nutrition for Preterm Newborns: A Narrative Review

Preterm neonates display a high risk of postnatal malnutrition, especially at very low gestational ages, because nutritional stores are less in younger preterm infants. For this reason nutrition and growth in early life play a pivotal role in the establishment of the long-term health of premature infants. Nutritional care for preterm neonates remains a challenge in clinical practice. According to the recent and latest recommendations from ESPGHAN, at birth, water intake of 70-80 mL/kg/day is suggested, progressively increasing to 150 mL/kg/day by the end of the first week of life, along with a calorie intake of 120 kcal/kg/day and a minimum protein intake of 2.5-3 g/kg/day. Regarding glucose intake, an infusion rate of 3-5 mg/kg/min is recommended, but VLBW and ELBW preterm neonates may require up to 12 mg/kg/min. In preterm infants, lipid emulsions can be started immediately after birth at a dosage of 0.5-1 g/kg/day. However, some authors have recently shown that it is not always possible to achieve optimal and recommended nutrition, due to the complexity of the daily management of premature infants, especially if extremely preterm. It would be desirable if multicenter randomized controlled trials were designed to explore the effect of early nutrition and growth on long-term health.

ASPEN lipid injectable emulsion safety recommendations part 2: Neonate and pediatric considerations

Lipid injectable emulsions (ILEs) are complex pharmaceutical formulations intended as a source of energy and fatty acids for parenteral nutrition (PN) therapy. Part 1 of this series addressed issues associated with and safety recommendations pertaining to adult ILE use. Part 2 addresses ILE safety in neonatal and pediatric patients. Considerations for ILE use in the neonatal and pediatric populations differ from those of adults. For example, these patients often require higher doses compared with adult counterparts to support growth, development, and daily metabolic needs. ILE is also frequently administered as a separate infusion as opposed to in a total nutrient admixture owing to compatibility and stability issues and limitations to intravenous access in the neonatal and pediatric populations. ILE is the most frequent PN ingredient associated with PN errors occurring in the administration, prescribing, and transcribing processes. Concerns exist with use of in-line filters and repackaging of commercial products for infusion. ILE use in neonatal and pediatric patients has been associated with both minor and major adverse effects, which most often occur with doses exceeding manufacturer recommendations. Gaps in ILE best practices for neonatal and pediatric patients predispose to errors in the PN use system. This paper describes safe-use considerations for ILE products available in the United States in neonatal and pediatric patients, including indications, prescribing, order review, preparation, administration, and monitoring. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Recommendations for photoprotection of parenteral nutrition for premature infants: An ASPEN position paper

Although crucial in improving health outcomes in the preterm infants, parenteral nutrition (PN) is not without risk, especially if handled improperly. A growing body of evidence suggests that components of PN admixtures, including lipid injectable emulsions (ILEs), are susceptible to degradation, including oxidation when exposed to light (ie, photo-oxidation), resulting in the production of reactive oxygen species. Infants, especially those born preterm, are considered more susceptible to consequences of oxidative stress than children and adults. Oxidative stress is associated with bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, and intestinal failure-associated liver disease. The American Society for Parenteral and Enteral Nutrition (ASPEN) assembled a working group to provide recommendations on clinical practice surrounding photoprotection of PN.This Position Paper reviews the scientific literature on the formation of quantifiable peroxides and other degradation products when PN admixtures and ILEs are exposed to light and reports adverse clinical outcomes in premature infants exposed to PN. Recommendations for photoprotection of PN admixtures and ILEs are provided, as well as the challenges in achieving complete photoprotection with the equipment, supplies, and materials currently available in the US. ASPEN and the authors understand that the full implementation of complete photoprotection may not currently be feasible given current product availability; recommendations provided in this paper serve to represent the goal to which to strive as well as to highlight the importance of product availability to achieve these practices. This paper has been approved by the ASPEN Board of Directors.

Lichtschutz für Lösungen zur parenteralen Ernährung von Säuglingen und Kindern bis zum Alter von 2 Jahren

Das Bundesinstitut für Arzneimittel und Medizinprodukte (BfArM) empfahl im Rote-Hand-Brief vom 02.09.2019: „Während der Verabreichung an Neugeborene und Kinder unter 2 Jahren sollen entsprechend zugelassene Arzneimittel zur parenteralen Ernährung (PE), die Aminosäuren und/oder Fettemulsionen enthalten, vor Licht geschützt werden (Behältnisse und Infusionsbestecke)“.

Ziel dieser Stellungnahme ist es, evidenzbasierte Empfehlungen zum Lichtschutz für Lösungen zu parenteraler und heimparenteraler Ernährung bei Säuglingen und Kindern bis zum Alter von 2 Jahren zu geben.

Der Bundesverband Deutscher Krankenhausapotheker, die Ernährungskommission der Deutschen Gesellschaft für Kinder- und Jugendmedizin, die Ernährungskommission der Österreichischen Gesellschaft für Kinder und Jugendheilkunde und die Arbeitsgemeinschaft Chronisches Darmversagen der Gesellschaft für Pädiatrische Gastroenterologie und Ernährung empfehlen in Übereinstimmung mit den internationalen Empfehlungen zur pädiatrischen parenteralen Ernährung der Fachgesellschaften ESPGHAN, ESPEN, ESPR und CSPEN: 1. Parenterale Nährlösungen, die Fette und/oder Vitamine enthalten, sind während der Applikation durch geeignete Maßnahmen vor Licht zu schützen. 2. Parenterale Nährlösungen, die keine Fette und/oder Vitamine enthalten (z. B. Lösungen mit Aminosäuren, Glucose, Elektrolyten oder Spurenelementen) bedürfen keines speziellen Lichtschutzes. 3. Bei heimparenteraler Ernährung können im Hinblick auf die kindlichen Bedürfnisse normale Spiralleitungen verwendet werden, solange lichtschützende Spiralleitungen nicht verfügbar sind.

Parenteral Nutrition and Oxidant Load in Neonates

Neonates with preterm, gastrointestinal dysfunction and very low birth weights are often intolerant to oral feeding. In such infants, the provision of nutrients via parenteral nutrition (PN) becomes necessary for short-term survival, as well as long-term health. However, the elemental nutrients in PN can be a major source of oxidants due to interactions between nutrients, imbalances of anti- and pro-oxidants, and environmental conditions. Moreover, neonates fed PN are at greater risk of oxidative stress, not only from dietary sources, but also because of immature antioxidant defences. Various interventions can lower the oxidant load in PN, including the supplementation of PN with antioxidant vitamins, glutathione, additional arginine and additional cysteine; reduced levels of pro-oxidant nutrients such as iron; protection from light and oxygen; and proper storage temperature. This narrative review of published data provides insight to oxidant molecules generated in PN, nutrient sources of oxidants, and measures to minimize oxidant levels.

Enteral and parenteral nutrition considerations in pediatric patients

PURPOSE

Current clinical practice guidelines on management of enteral nutrition (EN) and parenteral nutrition (PN) in pediatric patients are reviewed.

SUMMARY

The provision of EN and PN in pediatric patients poses many unique considerations and challenges. Although indications for use of EN and PN are similar in adult and pediatric populations, recommended EN and PN practices differ for pediatric versus adult patients in areas such as selection of EN and PN formulations, timing of EN and PN initiation, advancement of nutrition support, and EN and PN goals. Additionally, provision of EN and PN to pediatric patients poses unique compounding and medication administration challenges. This article provides a review of current EN and PN best practices and special nutrition considerations for neonates, infants, and other pediatric patients.

CONCLUSION

The provision of EN and PN to pediatric patients presents many unique challenges. It is important for pharmacists to keep current with pediatric- and neonatal-specific guidelines on nutritional management of various disease states, as well as strategies to address compounding and medication administration challenges, in order to optimize EN and PN outcomes.

Photoprotection But Not N-acetylcysteine Improves Intestinal Blood Flow and Oxidation Status in Parenterally Fed Piglets

OBJECTIVES

The purpose of the present study was to determine if protecting parenteral nutrition solutions from ambient light and supplementing with N-acetylcysteine (NAC) improves mesenteric blood flow, gut morphology, and oxidative status of parenterally fed neonates.

METHODS

Neonatal Yucatan miniature piglets (n = 23, 7-11 days old) were surgically fitted with central venous catheters and an ultrasonic blood flow probe around the superior mesenteric artery. Piglets were fed continuously for 7 days either light-protected (LP) or light-exposed (LE) complete parenteral nutrition that was enriched with either NAC or alanine (ALA).

RESULTS

There were no differences in body weight or overall gut morphology among groups after 7 days. Plasma concentrations of NAC were greater and total homocysteine lower in NAC- versus ALA-supplemented pigs on day 7 (N-acetylcysteine: 94 vs 7 μmol/L; P < 0.001; homocysteine: 14 versus 21 μmol/L; P < 0.005); plasma total glutathione was not affected. Hepatic lipid peroxidation was reduced by 25% in piglets that received LP parenteral nutrition (P < 0.05). The mesenteric artery blood flow decreased in all pigs between days 2 and 6 (P < 0.001) because of parenteral feeding. Photoprotection alone (LP-ALA) attenuated the decrease in mesenteric blood flow to 66% of baseline on day 6 compared with LE-ALA (37%; P < 0.05) and LP-NAC pigs (43%; P = 0.062); LE-NAC piglets had intermediate reductions in blood flow (55%).

CONCLUSIONS

Photoprotection of parenteral nutrition solutions is a simple, effective method to attenuate decline in blood flow to the gut and hepatic lipid peroxidation, which are both commonly associated with parenteral feeding.

Parenteral nutrition and oxidant stress in the newborn: A narrative review

There is strong evidence that oxidant molecules from various sources contaminate solutions of parenteral nutrition following interactions between the mixture of nutrients and some of the environmental conditions encountered in clinical practice. The continuous infusion of these organic and nonorganic peroxides provided us with a unique opportunity to study in cells, in vascular and animal models, the mechanisms involved in the deleterious reactions of oxidation in premature infants. Potential clinical impacts of peroxides infused with TPN include: a redox imbalance, vasoactive responses, thrombosis of intravenous catheters, TPN-related hepatobiliary complications, bronchopulmonary dysplasia and mortality. This is a narrative review of published data.

Glutathione Supplementation of Parenteral Nutrition Prevents Oxidative Stress and Sustains Protein Synthesis in Guinea Pig Model

Peroxides contaminating parenteral nutrition (PN) limit the use of methionine as a precursor of cysteine. Thus, PN causes a cysteine deficiency, characterized by low levels of glutathione, the main molecule used in peroxide detoxification, and limited growth in individuals receiving long-term PN compared to the average population. We hypothesize that glutathione supplementation in PN can be used as a pro-cysteine that improves glutathione levels and protein synthesis and reduces oxidative stress caused by PN. One-month-old guinea pigs (7–8 per group) were used to compare glutathione-enriched to a non-enriched PN, animals on enteral nutrition were used as a reference. PN: Dextrose, amino acids (Primene), lipid emulsion (Intralipid), multivitamins, electrolytes; five-day infusion. Glutathione (GSH, GSSG, redox potential) and the incorporation of radioactive leucine into the protein fraction (protein synthesis index) were measured in the blood, lungs, liver, and gastrocnemius muscle. Data were analysed by ANOVA; p < 0.05 was considered significant. The addition of glutathione to PN prevented the PN-induced oxidative stress in the lungs and muscles and supported protein synthesis in liver and muscles. The results potentially support the recommendation to add glutathione to the PN and demonstrate that glutathione could act as a biologically available cysteine precursor.

Regioisomer-independent quantification of fatty acid oxidation products by HPLC-ESI-MS/MS analysis of sodium adducts

Despite growing acknowledgement of the role of oxidized fatty acids (oxFA) as cellular signaling molecules and in the pathogenesis of disease, developing methods to measure these species in biological samples has proven challenging. Here we describe a novel method utilizing HPLC-ESI-MS/MS to identify and quantify multiple full-length oxFA species in a regioisomer-independent manner without the need for time-consuming sample preparation or derivatization. Building on recent progress in the characterization of FA and their oxidation products by MS/MS, we employed positive-ion ionization by measuring sodium adducts in conjunction with Differential Energy Qualifier Ion Monitoring to unequivocally verify the presence of the hydroperoxide, hydroxide, and ketone oxidation products of linoleic and arachidonic acid. Our HPLC method achieved separation of these oxidized species from their unoxidized counterparts while maintaining regioisomer-independent elution, allowing quantification over a 5 log10 range with a lower limit of quantification of 0.1 picomoles. With a simple sample preparation and a runtime as low as 11 minutes, our method allows the rapid and facile detection and measurement of full-length oxFA in biological samples. We believe this approach will allow for new insight and further investigation into the role of oxFA in metabolic disease.

Adult Consequences of Extremely Preterm Birth: Cardiovascular and Metabolic Diseases Risk Factors, Mechanisms, and Prevention Avenues

Extremely preterm babies are exposed to various sources of injury during critical stages of development. The extremely preterm infant faces premature transition to ex utero physiology and undergoes adaptive mechanisms that may be deleterious in the long term because of permanent alterations in organ structure and function. Perinatal events can also directly cause structural injury. These disturbances induce morphologic and functional changes in their organ systems that might heighten their risks for later adult chronic diseases. This review examines the pathophysiology of programming of long-term health and diseases after preterm birth and associated perinatal risk factors.

Evolution of Fatty Acid Profile and Lipid Oxidation During Enteral Formula Storage

BACKGROUND

Enteral formulas can be stored for up to 2 years. Fat oxidation during storage can lead to the loss of nutritive value and generation of toxic products such as lipid peroxides.

METHODS

Two standard enteral formulas were stored for short periods at high temperatures (1-4 weeks at 32-55 degrees C) or for long periods at low temperatures (12-36 weeks at 4 degrees C, 20 degrees C, or 30 degrees C). The present study included the assessment of lipid oxidation by measuring related fluorescent compounds and the evolution of fatty acids profile.

RESULTS

Enteral formula fat was oxidized under all assayed conditions, including storage at 4 degrees C. The loss of essential fatty acids (linoleic and linolenic acids) was always higher when time and temperature were increased. The omega6/omega3 ratio was increased by storage from 5.6 to 7.8, which could exacerbate the inflammatory response in critically ill patients. Fluorescence intensity increased with time and temperature of storage and was correlated with the decrease in essential fatty acids (lineal correlation between -0.9416 and -0.9996).

CONCLUSIONS

Enteral formula fat was oxidized during storage, leading to a loss of nutritional value. These formulas should be stored under refrigeration to minimize this loss. Finally, fluorescence measurement proved to be a fast and easy method to assess fat oxidation status.

ESPGHAN Committee on Nutrition Position Paper. Intravenous Lipid Emulsions and Risk of Hepatotoxicity in Infants and Children: a Systematic Review and Meta-analysis

The aim of the present article was to perform a systematic review with meta-analysis of available scientific evidence regarding the role of different intravenous lipid emulsions (ILE) in the pathogenesis of cholestasis and parenteral nutrition-associated liver disease. A systematic review of the literature (up to March 2015) identified 23 randomized controlled trials (RCTs). Of these, 17 were performed in preterm infants or critically ill neonates with a short duration of intervention, 2 in older children with short-term use (following surgery or bone marrow transplantation), 1 in neonates with long-term use, and 3 in infants and children receiving long-term parenteral nutrition (PN). Meta-analysis showed no differences in the rate of cholestasis or bilirubin levels associated with short-term use of different ILEs. Because of high heterogeneity of the long-term studies no meta-analysis could be performed. Available studies found that the use of multicomponent fish oil (FO)-containing ILE compared with pure soya bean oil (SO), ILE-reduced liver enzymes, and bilirubin levels in noncholestatic children on long-term PN and one other RCT found that FO-based ILE-reversed cholestasis in a proportion of patients. The ESPGHAN Committee on Nutrition concludes that there is no evidence of a difference in rates of cholestasis or bilirubin levels between different ILE for short-term use in neonates. The use of multicomponent FO-containing ILE may contribute to a decrease in total bilirubin levels in children with IF on prolonged PN. Well-designed RCTs are, however, lacking and long-term effects have not been determined.

p38/p53/miR-200a-3p feedback loop promotes oxidative stress-mediated liver cell death

Although our previous studies have provided evidence that oxidative stress has an essential role in total parenteral nutrition (TPN)-associated liver injury, the mechanisms involved are incompletely understood. Here, we show the existence of crosstalk between the miR-200 family of microRNAs and oxidative stress. The members of the miR-200 family are markedly enhanced in hepatic cells by hydrogen peroxide (H2O2) treatment. The upregulation of miR-200-3p in turn modulates the H2O2-mediated oxidative stress response by targeting p38α. The enhanced expression of miR-200-3p mimics p38α deficiency and promotes H2O2-induced cell death. Members of the miR-200 family that are known to inhibit the epithelial to mesenchymal transition (EMT) are induced by the tumor suppressor p53. Here, we show that p53 phosphorylation at Ser 33 contributes to H2O2-induced miR-200s transcription. In addition, we show that p38α can directly phosphorylate p53 at serine 33 upon H2O2 exposure. Thus, we suggest that in liver cells, the oxidative stress-induced, p38α-mediated phosphorylation of p53 at Ser33 is essential for the functional regulation of oxidative stress-induced miR-200 transcription by p53. Collectively, our data indicate that the p53-dependent expression of miR-200a-3p promotes cell death by inhibiting a p38/p53/miR-200 feedback loop.

Intestinal failure-associated liver disease: a position paper of the ESPGHAN Working Group of Intestinal Failure and Intestinal Transplantation

Intestinal failure-associated liver disease is the most prevalent complication affecting children with intestinal failure receiving long-term parenteral nutrition. This paper reviews the definition, diagnostic criteria, pathogenesis, and risk factors. The authors discuss the role of enteral nutrition, parenteral nutrition, and its components, especially lipid emulsions. The authors also discuss the surgical treatment, including intestinal transplantation, its indications, technique, and results, and emphasise the importance of specialised intestinal failure centres.

Understanding triglyceride levels related to intravenous fat administration

Lipid is an essential macronutrient in parenteral nutrition (PN) support. intravenous (IV) lipid provides essential fatty acids and a concentrated calorie source. Preterm infants are at risk for essential fatty deficiency early in life. Lipid administration is associated with some risks, and there are guidelines for administration to minimize complications. Lipid emulsions in the United States are derived from soybean oil. Outside of the United States, lipid emulsions made from fish oil or combinations of fish, soybean, olive, and medium-chain triglycerides (MCTs) are under investigation for improved tolerance, lower plasma lipid levels, and improved fatty acid profiles, all of which are considered beneficial. Triglyceride levels are an important measurement to assess patient tolerance.

Fat emulsion given to very low-birthweight infants increases urinary L-FABP

BACKGROUND

In premature infants, many factors influence the function of renal tubules, such as asphyxia, respiratory disorders, use of high-concentration oxygen, hypotension, and drug treatment. When tubular ischemia and oxidative stress develop due to renal microcirculatory pathology, urinary L-type fatty acid-binding protein (L-FABP) level increases.

METHODS

Urinary L-FABP level was measured over time in very low-birthweight infants (VLBWI), and the effect of fat emulsion on L-FABP level was investigated. Thirty-one VLBWI were divided into two groups with regard to treatment with fat emulsion: the lipid group (n = 20) and the control group (n = 11). Urinary L-FABP was measured before (0-3 days of age), during (7-14 days of age), and after fat emulsion treatment (21-28 days of age) in the two groups.

RESULTS

Median urinary L-FABP level before treatment was 459 ng/mgCr (range, 22.7-5100 ng/mgCr; mean, 1067 ± 1570 ng/mgCr) and 797 ng/mgCr (range, 69-3900 ng/mgCr; mean, 1066 ± 1188 ng/mgCr) in the lipid and control groups, respectively, showing no significant difference. Median urinary L-FABP level was 624 ng/mgCr (range, 50-2050 ng/mgCr; mean ± SD, 799 ± 655 ng/mgCr) and 273 ng/mgCr (range, 31-987 ng/mgCr; mean ± SD, 359 ± 323 ng/mgCr) at 7-14 days of age, respectively, showing that the level was significantly higher in the lipid group. At 21-28 days of age, the median level was 462 ng/mgCr (range, 49-1867 ng/mgCr; mean ± SD, 557 ± 534 ng/mgCr) and 130 ng/mgCr (range, 20-993 ng/mgCr; mean ± SD, 290 ± 329 ng/mgCr), respectively, showing that L-FABP level tended to be higher in the lipid group.

CONCLUSIONS

Fat emulsion treatment induced a significant increase in urinary L-FABP level, suggesting that fat emulsion affected the proximal tubule in VLBWI.

Inhibition of hepatic methionine adenosyltransferase by peroxides contaminating parenteral nutrition leads to a lower level of glutathione in newborn Guinea pigs

Premature newborn infants on total parenteral nutrition (TPN) are at risk of oxidative stress because of peroxides contaminating TPN and low glutathione level. Low cysteine availability limits glutathione synthesis. In this population, the main source of cysteine derives from the hepatic conversion of methionine. The first enzyme of this conversion, methionine adenosyltransferase (MAT), contains redox-sensitive cysteinyl residues. We hypothesize that inhibition of MAT by peroxides contaminating TPN leads to a lower availability of cysteine for glutathione synthesis. At 3 days of life, animals were fitted with a jugular catheter for intravenous infusion. Four groups were compared by ANOVA (P<0.05): (1) Control, without surgery, fed regular chow; (2) Sham, fitted with an obstructed catheter, fed orally regular chow; (3) TPN, fed exclusively TPN (dextrose, amino acids, fat, vitamins) containing 350 μM peroxides; (4) H2O2, fed regular chow orally and infused with 350 μM H2O2. Four days later, MAT activity and glutathione in liver and blood were lower in TPN and H2O2 groups. The redox potential was more oxidized in blood and liver of the TPN group. In conclusion, peroxides generated in TPN inhibit methionine adenosyltransferase activity with, among consequences, a low level of glutathione and a more oxidized redox potential.

Influence of shielding TPN from photooxidation on the number of early blood transfusions in ELBW premature neonates

OBJECTIVES

The smallest premature neonates often receive blood transfusions early in life. Nonrestrictive transfusion policies are linked to deleterious outcomes. Exposure of total parenteral nutrition (TPN) to ambient light generates oxidation products associated with haemolysis in vitro. Shielding TPN from light limits oxidation. Our hypothesis was protecting TPN from light decreases haemolysis and therefore the need for early blood transfusions.

METHODS

Comparison of haemolysis between animals fed enterally and those receiving TPN, and exploratory case-control retrospective analysis of transfusion counts in premature infants receiving light-exposed or light-protected TPN. The statistical analysis was analysis of variance and longitudinal binomial regression model adjusting for potential covariables of transfusion counts.

RESULTS

In animals, TPN is associated with higher (P<0.05) haemolysis compared with enteral feeds; photoprotection induces lower peroxide load with no effect on the level of haemolysis. In premature infants, light-exposed (n=76) or light-protected (n=57) populations exhibited similar clinical characteristics. Initial haematocrit, gestational age, and index of disease severity had a significant effect on the number of transfusions. When adjusting for these covariables, photoprotection was no longer significant.

CONCLUSIONS

Even though peroxides are associated in vitro with haemolysis, shielding TPN from light to reduce infused peroxides does not significantly decrease the need for early transfusions in premature infants.

Antioxidant therapies for Alzheimer's disease

Alzheimer's disease (AD) is the most common neurodegenerative disease featuring progressive impairments in memory, cognition, and behavior and ultimately leads to death. The histopathological changes of Alzheimer's disease include neuronal and synaptic loss, formation of extracellular senile plaques and intracellular neurofibrillary tangles in brain. Multiple lines of evidence indicate that oxidative stress not only strongly participates in an early stage of Alzheimer's disease prior to cytopathology, but plays an important role in inducing and activating multiple cell signaling pathways that contribute to the lesion formations of toxic substances and then promotes the development of Alzheimer's disease. Many years of studies show that antioxidant therapies have enjoyed general success in preclinical studies. Therefore, this paper mainly focuses on the recent developments of common used antioxidant therapies for Alzheimer's disease and thus provides indications for future potential antioxidant therapeutic strategies of neurodegenerative diseases.

Lipid peroxidation in all-in-one admixtures for preterm neonates: impact of amount of lipid, type of lipid emulsion and delivery condition

AIM

To evaluate the effect of lipid emulsion composition and delivery condition on lipid peroxidation in typical all-in-one parenteral admixtures for preterm neonates.

METHODS

Malonedialdehyde (MDA) concentrations were assessed in different all-in-one admixtures. We evaluated the effects of fat blend (three lipid emulsions) and the amount of lipids, as well as the effects of protecting bags and/or tubing from ambient light and storage for 72 h. MDA was measured by liquid chromatography/mass spectrometry.

RESULTS

Three hundred and sixty samples were collected from 114 admixtures. Neither the type of lipid (p = 0.43) nor the interaction between light and type of lipid (p = 0.49) had any influence on final MDA concentrations, but the increase in MDA concentration at 24 h (T(24)) was related to light exposure (p < 0.001). The increase in MDA concentration was related to the increase in lipid amount in the admixture at T(0) (r = 0.77) and T(24) (r = 0.86). MDA concentrations in solutions stored for 72 h showed no significant increase, with no difference between the three lipid emulsions (p = 0.69).

CONCLUSION

All-in-one admixtures may be interesting for the parenteral nutrition of preterm neonates. Protection from light and restricting the amount of lipid to what is required for appropriate energy provision are essential to limit lipid peroxidation.

Inflammatory response in preterm infants is induced early in life by oxygen and modulated by total parenteral nutrition

The i.v. lipid emulsion (LIP) is a source of oxidants, which may stimulate inflammation. Coadministration of parenteral multivitamins (MVP) with LIP prevents lipid peroxidation in light-exposed total parenteral nutrition (TPN). We hypothesized that this modality of TPN administration affects systemic inflammation, which may be modulated by exposure to oxygen. Premature infants were allocated to three TPN regimens: control regimen - MVP coadministered with amino acid/dextrose exposed to ambient light, LIP provided separately (n = 9) - LIP+MVP light exposed (LE): MVP coadministered with light-exposed LIP (n = 9) - LIP+MVP light protected (LP): MVP coadministered with light-protected LIP (n = 8). In LE and LP, amino acid/dextrose was provided separately. On reaching full TPN, infants were sampled for IL-6 and IL-8 in plasma and the redox potential of glutathione in whole blood (E, mV). Data were compared (ANOVA) in infants exposed to low (<0.25) versus high (> or =0.25) FiO2. Patients (mean +/- SD: birth weight 797 +/- 172 g; GA 26 +/- 1 wk) had similar clinical characteristics in TPN groups. Cytokine levels correlated positively (p < 0.01) with FiO2 and E. High FiO2 stimulated an increase (p < 0.01) in cytokines in control regimen, whereas these markers remained unaffected by oxygen in the LE and LP groups. The choice of a TPN admixture may have important consequences on the systemic inflammatory response triggered by an oxidant stress.

Egg yolk peptides up-regulate glutathione synthesis and antioxidant enzyme activities in a porcine model of intestinal oxidative stress

Long-term oxidative stress in the gastrointestinal tract can lead to the development of chronic intestinal disorders. Many food-derived antioxidants are effective in vitro, but the variable reports of in vivo efficacy and the pro-oxidant nature of some antioxidants necessitate alternative strategies for the reduction of in vivo oxidative stress. Compounds that up-regulate the production of endogenous antioxidants such as glutathione (GSH) and antioxidant enzymes provide novel approaches for the restoration of redox homeostatis. Egg yolk peptides (EYP) prepared from Alcalase and protease N digestion of delipidated egg yolk proteins were found to exhibit antioxidative stress properties. The effect of EYP supplementation was examined in a hydrogen peroxide-induced human colon cell line and in an animal model of intestinal oxidative stress. EYP significantly reduced the pro-inflammatory cytokine, IL-8, in Caco-2 cells. In piglets given intraperitoneal infusions of hydrogen peroxide, EYP treatment increased GSH and gamma-glutamylcysteine synthetase mRNA expression and activity, significantly increased antioxidant enzyme activities, in particular catalase and glutathione S-transferase activities, and reduced protein and lipid oxidation in the duodenum, jejunum, ileum, and colon. Furthermore, EYP boosted the systemic antioxidant status in blood by increasing the GSH concentration in red blood cells. These results suggest that EYP supplementation is a novel strategy for the reduction of intestinal oxidative stress.

Ascorbylperoxide contaminating parenteral nutrition perturbs the lipid metabolism in newborn guinea pig

The light exposure of parenteral nutritive solutions generates peroxides such as H(2)O(2) and ascorbylperoxide [2,3-diketo-4-hydoxyperoxyl-5,6-dihydroxyhexanoic acid]. This absence of photoprotection is associated with higher plasma triacylglycerol (TG) concentration in premature infants and oxidative stress and H(2)O(2)-independent hepatic steatosis in animals. We hypothesized that ascorbylperoxide is the active agent leading to high TG. The aim was to investigate the role of ascorbylperoxide in glucose and lipid metabolism in an animal model of neonatal parenteral nutrition. Three-day-old guinea pigs received through a catheter in the jugular solutions containing dextrose plus 0, 90, 225, or 450 microM ascorbylperoxide. After 4 days, blood and liver were sampled and treated for determinations of TG, cholesterol, markers of oxidative stress (redox potential of glutathione and F(2alpha)-isoprostane), and activities and protein levels of acetyl-CoA carboxylase (ACC), glucokinase, and phosphofructokinase (PFK). Ascorbylperoxide concentration was measured in urine on the last day. Data were compared by analysis of variance (p < 0.05). Plasma TG and cholesterol and hepatic PFK activity increased (200% of control), whereas ACC activity decreased (66% of control) in the function of the amount of ascorbylperoxide infused. Both markers of oxidative stress were higher in animals receiving the highest amounts of ascorbylperoxide. The logarithmic relations between urinary ascorbylperoxide and plasma TG (r(2) = 0.69) and hepatic PFK activity (r(2) = 0.26) were positive, whereas they were negative with ACC activity (r(2) = 0.50). In conclusion, ascorbylperoxide contaminating parenteral nutrition stimulates glycolysis, allowing higher availability of substrates for lipid synthesis. The logarithmic relation between urinary ascorbylperoxide and plasma TG suggests a very low efficient concentration.

Early life events, sex, and arterial blood pressure in critically ill infants

OBJECTIVE

To determine whether photo-protecting total parenteral nutrition in preterm infants influences arterial blood pressure differently according to gender. Blood pressure is influenced by complex mechanisms of vasomodulation. Oxidants are mediators and effectors in such reactions. Shielding total parenteral nutrition from light contributes to decrease the generation of peroxides. Girls may be better protected against an oxidant load than boys. We questioned whether shielding total parenteral nutrition may have cardiovascular effects that are influenced by gender.

DESIGN

A post hoc subgroup analysis of the effect of shielding parenteral nutrition from light.

SETTING

Neonatal intensive care unit.

SUBJECTS

Preterm infants <1000 g with indwelling arterial catheters who received light exposed (n = 20) or light protected (n = 20) parenteral nutrition.

INTERVENTIONS

Invasive monitoring, total parenteral nutrition.

MEASUREMENTS AND MAIN RESULTS

Arterial blood pressure was recorded hourly and compared between light exposed and light protected over the first week of life; timed average maximum velocity (m/s) was measured in the superior mesenteric artery by Doppler; presence of ductus arteriosus was documented by cardiac ultrasound. Data were analyzed by analysis of variance. No differences were noted between light exposed and light protected in clinical determinants that may influence blood pressure. There was an interaction (p < .01) between gender and total parenteral nutrition on blood pressure. In girls (n = 17), systolic and diastolic blood pressures were higher (p < .01) and heart rate lower (p < .01) during light exposed. There was no effect on BP observed in boys (n = 23). The linear correlation between timed average maximum velocity and systolic blood pressure was positive (p < .05). There was no echocardographic difference in hemodynamic variables between boys (n = 21) and girls (n = 9) who had a patent ductus.

CONCLUSION

Failure to shield total parenteral nutrition from light results in higher blood pressure in a selected population of critically ill female infants. This information adds to our understanding of the multiple determinants involved in optimizing arterial blood pressure in a critical care environment.

Influence of the calcium concentration in the presence of organic phosphorus on the physicochemical compatibility and stability of all-in-one admixtures for neonatal use

BACKGROUND

Preterm infants need high amounts of calcium and phosphorus for bone mineralization, which is difficult to obtain with parenteral feeding due to the low solubility of these salts. The objective of this study was to evaluate the physicochemical compatibility of high concentrations of calcium associated with organic phosphate and its influence on the stability of AIO admixtures for neonatal use.

METHODS

Three TPN admixture formulas were prepared in multilayered bags. The calcium content of the admixtures was adjusted to 0, 46.5 or 93 mg/100 ml in the presence of a fixed organic phosphate concentration as well as lipids, amino acids, inorganic salts, glucose, vitamins and oligoelements at pH 5.5. Each admixture was stored at 4 degrees C, 25 degrees C or 37 degrees C and evaluated over a period of 7 days. The physicochemical stability parameters evaluated were visual aspect, pH, sterility, osmolality, peroxide formation, precipitation, and the size of lipid globules.

RESULTS

Color alterations occurred from the first day on, and reversible lipid film formation from the third day of study for the admixtures stored at 25 degrees C and 37 degrees C. According to the parameters evaluated, the admixtures were stable at 4 degrees C; and none of them presented precipitated particles due to calcium/phosphate incompatibility or lipid globules larger than 5 mum, which is the main parameter currently used to evaluate lipid emulsion stability. The admixtures maintained low peroxide levels and osmolarity was appropriate for parenteral administration.

CONCLUSION

The total calcium and calcium/phosphorus ratios studied appeared not to influence the physicochemical compatibility and stability of AIO admixtures.

Effects of light exposure on total parenteral nutrition and its implications in the neonatal population

Total parenteral nutrition (TPN) is a necessary form of nutrition in neonates with functional or anatomical disruption of the digestive tract. However, laboratory and human investigation have shown that exposure of the TPN solution to light causes the formation of peroxides and other degradation products that are quantifiable in experimental TPN solutions, laboratory animals, and neonates. Premature neonates are at a higher risk for the development and progression of peroxide damage due to their relative lack of antioxidant and free radical scavenger reserves. Furthermore, cell damage seen in a number of neonatal disease states is exacerbated by the presence of peroxides that are generated via intrinsic pathologic processes and from exogenous sources such as TPN. Numerous studies show that the formation of TPN photodegradation products can be slowed or prevented by the application of various light protection mechanisms. While it is not yet known if minimizing TPN associated photodegradation byproducts has a significant direct effect on preventing or mitigating the overall clinical course of some neonatal disease states, it is becoming increasingly clear that light protecting TPN can avoid specific metabolic complications in neonatal patients. It is prudent to implement mechanisms that prevent photodegradation of TPN components from the manufacturer source to the point of patient administration.

Shielding parenteral nutrition from light: does the available evidence support a randomized, controlled trial?

BACKGROUND

Exposure of total parenteral nutrition to ambient light induces the generation of peroxides, creating oxidant stress, which potentially compounds complications of prematurity. Photograph protection of total parenteral nutrition reduces the peroxide load and has been shown to be associated with nutritional and biochemical benefits in animals and humans. It is unclear whether this reduction in peroxides from total parenteral nutrition leads to a reduction in the complications of prematurity, such as bronchopulmonary dysplasia. Our hypothesis was that shielding total parenteral nutrition from ambient light is linked to clinical benefits.

OBJECTIVE

The purpose of this work was to determine whether photograph protection of total parenteral nutrition (light protected), as compared with no photoprotection (light exposed), reduces the occurrence of bronchopulmonary dysplasia or death in preterm infants.

METHODS

The Canadian Neonatal Network provided data for infants born in 2006 at <28 weeks' gestation admitted to level 3 NICUs in Canada. A retrospective analysis was performed comparing bronchopulmonary dysplasia and death in infants who received light-exposed or light-protected parenteral nutrition. Data were analyzed by using logistic regression models. RESULTS. Thirteen NICUs offered partial light-protected (total parenteral nutrition bag only, intravenous tubing exposed) and 13 offered light-exposed parenteral nutrition; not a single NICU offered complete light-protected parenteral nutrition (total parenteral nutrition bag plus intravenous tubing). The incidence of bronchopulmonary dysplasia or death was 66% with light-protected (n = 428) vs 59% with light-exposed (n = 438) parenteral nutrition.

CONCLUSIONS

Partial photograph protection of total parenteral nutrition was not associated with a reduction in bronchopulmonary dysplasia or death as compared with no photograph protection; this relationship is confounded by covariates with strong associations with bronchopulmonary dysplasia. Partial photograph protection of total parenteral nutrition solutions confers no clinical benefit, while consuming valuable resources. A randomized, controlled trial is justified to determine whether there is a true "cause-and-effect" relationship between complete photoprotection of total parenteral nutrition and bronchopulmonary dysplasia or death.

Influence of lung oxidant and antioxidant status on alveolarization: role of light-exposed total parenteral nutrition

Parenteral multivitamins (MVP) are linked to the generation of peroxides, which cause oxidant injury in lungs associated with alveolar remodelling linked to lung disease of prematurity. This study was to investigate the relationship between alveolar development and lung oxidant-antioxidant status as modulated by the mode of administration of multivitamins with total parenteral nutrition (TPN). Four groups of guinea pig pups received parenteral nutrition differing by 1) mode of MVP admixture: with amino acid solution (AA-MVP) or lipid emulsion (LIP-MVP); 2) light exposure: TPN exposed (LE) or shielded from light (LP). After 2 or 4 days of TPN, vitamins C and E, 8-isoprostaneF2alpha and alveolarization index were determined in lungs and GSSG/GSH in lungs and blood. Exposure to light and the mode of MVP admixture did not influence vitamin E and isoprostane levels. Blood glutathione redox potential was more oxidized in LE and LIP-MVP groups after 4-day infusions, whereas lung redox potential was more reduced in LE groups. LP and LIP-MVP had a beneficial effect, with higher number of alveoli. Globally, results indicate that in this model, alveolarization and modifications in lung redox potential are two independent events induced by light exposed TPN.

Iatrogenic environmental hazards in the neonatal intensive care unit

Premature infants in the neonatal intensive care unit (NICU) face many illnesses and complications. Another potential source of iatrogenic disease is the NICU environment. Research in this area, however, is limited.

Variations in metabolic response to TPN are influenced more by sex than by light exposure

BACKGROUND

Failure to protect total parenteral nutrition (TPN) solutions from ambient light induces the generation of peroxides, which contributes to the oxidation of several amino acids. We hypothesized that photo-protection improves the metabolic response to TPN.

AIM

To study the effects of photo-protecting TPN on urinary nitrogen and vitamin C excretion and to evaluate in premature infants the influence of sex.

PATIENTS AND METHODS

Premature infants were randomized to receive from birth light-exposed (LE) or light-protected (LP) TPN. Upon reaching full TPN, parenteral nutrient intakes were correlated with normalized urinary nitrogen and vitamin C concentrations.

RESULTS

No differences were observed between LE and LP. However, sex-related differences were observed in nitrogen and vitamin C handling. In boys, 50% of the nitrogen loss was explained by parenteral amino acid intake, whereas in girls, no correlation was found. The inverse correlation observed between intake and urinary excretion only in girls suggests a state of greater vitamin C utilization in girls.

CONCLUSIONS

These results demonstrate that sex-related differences in nitrogen/protein metabolism reported during enteral nutrition are seen during TPN as well. Sex is an important variable that will need to be taken into account in future studies evaluating the potential clinical effects of photo-protecting TPN.

In preterm neonates, is the risk of developing bronchopulmonary dysplasia influenced by the failure to protect total parenteral nutrition from exposure to ambient light?

Light-exposed total parenteral nutrition (TPN) generates peroxides that contribute to an oxidant load. Shielding TPN from light protects against lung remodelling. In preterm infants, photoprotection of TPN is associated with a 30% reduction in bronchopulmonary dysplasia in a post-hoc analysis. This analysis provides justification for a randomized controlled trial.

The use of IV fat in neonates

IV fat emulsion (IVFE) is an integral part of the parenteral nutrition (PN) regimen in neonates. It provides a concentrated isotonic source of calories and prevents or reverses essential fatty acid deficiency. Continuous administration of IV fat with PN regimens prolongs the viability of peripheral IV lines in infants who might have limited venous access. IVFE must be administered separately from the PN solution in neonates. The acidic pH of a PN solution is necessary for maximum solubility of calcium and phosphorus. If fat emulsion is added to the PN solution, as is done in 3-in-1 (total nutrient admixture) solutions, the high amount of calcium and phosphorus needed by these infants may result in an unseen precipitate with serious consequences. Continuous fat infusion over 24 hours is the preferred method in neonates. The administration rate of 0.15 g/kg/hour for IVFE in the neonate should not be exceeded. Essential fatty acid deficiency can be prevented in neonates by providing IVFE in a dose of 0.5-1.0 g/kg/day. Carnitine is not routinely required to metabolize IVFE in the neonate. Infants should receive 20% lipid emulsion to improve clearance of triglycerides and cholesterol. Serum triglyceride levels should be maintained at <150-200 mg/dL in neonates. There are concerns about potential adverse effects of early administration of IV fat in very-low-birth-weight infants weighing <800 g. We hold the IV fat dose at 1.0-1.5 g/kg/day until the second week of life in infants <30 weeks gestation.

Total parenteral nutrition-related gastroenterological complications

Total parenteral nutrition is a life saving therapy for patients with chronic gastrointestinal failure, being an effective method for supplying energy and nutrients when oral or enteral feeding is impossible or contraindicated. Clinical epidemiological data indicate that total parenteral nutrition may be associated with a variety of problems. Herein we reviewed data on the gastroenterological tract regarding: (i) total parenteral nutrition-related hepatobiliary complications; and (ii) total parenteral nutrition-related intestinal complications. In the first group, complications may vary from mildly elevated liver enzyme values to steatosis, steatohepatitis, cholestasis, fibrosis and cirrhosis. In particular, total parenteral nutrition is considered to be an absolute risk factor for the development of biliary sludge and gallstones and is often associated with hepatic steatosis and intrahepatic cholestasis. In general, the incidence of total parenteral nutrition-related hepatobiliary complications has been reported to be very high, ranging from 20 to 75% in adults. All these hepatobiliary complications are more likely to occur after long-term total parenteral nutrition, but they seem to be less frequent, and/or less severe in patients who are also receiving oral feeding. In addition, end-stage liver disease has been described in approximately 15-20% of patients receiving prolonged total parenteral nutrition. Total parenteral nutrition-related intestinal complications have not yet been adequately defined and described. Epidemiological studies intended to define the incidence of these complications, are still ongoing. Recent papers confirm that in both animals and humans, total parenteral nutrition-related intestinal complications are induced by the lack of enteral stimulation and are characterised by changes in the structure and function of the gut. Preventive suggestions and therapies for both these gastroenterological complications are reviewed and reported in the present review.

Photoprotection of parenteral nutrition enhances advancement of minimal enteral nutrition in preterm infants

BACKGROUND

Light exposure of TPN generates peroxides which induce vasoconstriction. Mesenteric vasoconstriction may affect feeding tolerance. Since photo-protection of TPN decreases peroxide generation, we hypothesized that shielding TPN from light may improve the establishment of minimal enteral nutrition in preterm infants.

METHODS

Infants were randomized to TPN being light exposed (LE) or protected (LP) from birth. Feeding volumes were monitored through 7 days of life in those initiated on minimal enteral nutrition (MEN). Comparisons between LP and LE were performed by ANOVA.

RESULTS

Daily increments and cumulative volumes of enteral feeds (mL/kg birth weight/d) during the first week of life were significantly higher in LP (n = 18) than LE (n = 19).

CONCLUSION

Photo-protection of parenteral nutrition enhances advancement of MEN in preterm infants. Further research is needed to substantiate these findings and determine whether this confers long-term nutritional advantages.

Influence of early postnatal nutritional management on oxidative stress and antioxidant defence in extreme prematurity

The increased survival of infants born at mid-gestation in the last decade is associated with significant oxygen free radical-mediated morbidities. Resuscitation with 100% oxygen, oxidant load from parenteral nutrition fluids, and oxidant stress inherent to the systemic inflammatory state subsequent to infection and tissue injury are all contributory.

CONCLUSION

Improving early postnatal protein nutrition and the formulation of parenteral nutrition fluids would potentially reduce the oxidative stress and enhance the antioxidant defence of extremely premature newborns.

Prescripción y elaboración de nutrición parenteral en los hospitales españoles

OBJECTIVE

To identify habits related to prescription and preparation of parenteral nutrition in Spain and their adequacy to current recommendations.

METHOD

A questionnaire was administered in order to collect information about the characteristics of diets used at each hospital and the way they were prepared. The questionnaire was available through the web page of the Spanish Society of Hospital Pharmacy.

RESULTS

Forty five hospitals answered the questionnaire. More than 90% of the hospitals reported that they used diets with a fixed or standard composition and 66.6% reported that they bought diets available in the market with a defined composition. Fifty seven point five per cent of the hospitals always prepared "all in one" parenteral nutrition and 37.5% prepared them only for adults. A 5% provided the lipids separately, both for adults and for children. Forty five per cent of the hospitals reported that they did not use organophosphates as source of phosphate. Almost 60% alternate the introduction of vitamins and trace elements. Differences were also found regarding the type of lipids provided and the use of filters. Most hospitals used multi-layer bags and photoprotection.

CONCLUSIONS

There is quite a lot of diversity in the patterns of prescription and preparation of parenteral nutrition in our country. Further consensus documents should be written about these topics.

Effect of coadministration of parenteral multivitamins with lipid emulsion on lung remodeling in an animal model of total parenteral nutrition

Exposure of parenteral multivitamin solutions (MVP) to ambient light generates peroxides and vitamin loss, and induces initiation of fibrosis and a reduced alveolar count in an animal model of total parenteral nutrition (TPN). Adding MVP to the lipid moiety of TPN prevents lipid peroxidation and vitamin loss. The aim of the study was to compare modes of delivery of MVP on lung procollagen mRNA and alveolar counts. Three-day-old guinea pig pups were infused continuously with one of three intravenous solutions: 1) control = dextrose; 2) AA + MVP = MVP given with the dextrose + amino-acid moiety, in a "piggyback" setup with a lipid emulsion mixed close to the infusion site; and 3) LIP + MVP = same as AA + MVP, except that MVP is given with the lipid emulsion. After 4 days, lungs were prepared for alveolar count (intercept technique) and for quantification of the procollagen/beta-actin mRNA ratio (initial step of fibrosis). Data were compared by ANOVA. The procollagen mRNA was lower (P < 0.05) in animals receiving LIP + MVP than those with AA + MVP. But the two modes of admixture of MVP had the same effect on the alveolar counts, which were lower (P < 0.01) than controls. The mode of delivery of TPN affects lung remodeling. Although LIP + MVP protects against the initiation of lung fibrosis, the absence of a beneficial effect on alveolar counts suggests that these features of lung remodeling are not caused by a unique component of TPN. Specific roles of peroxides, components of MVP, and light exposure on lung remodeling need to be explored before LIP + MVP can be recommended as an alternative mode of parenteral vitamin delivery.

Early introduction of lipids to parenterally-fed preterm infants

BACKGROUND

Lipids are essential components of parenteral nutrition for preterm infants. Parenteral lipids can be administered through a peripheral vein, and their early introduction offers the potential advantages of increasing energy intake and providing essential fatty acids and fat soluble vitamins. Concerns have been raised about potential adverse effects including chronic lung disease (CLD), increase in pulmonary vascular resistance, impaired pulmonary gas diffusion, bilirubin toxicity, sepsis and free radical stress.

OBJECTIVES

To determine the safety and efficacy of 'early' (</= 5 days after birth) introduction of lipids to parenterally fed preterm infants.

SEARCH STRATEGY

Eligible studies were identified by searching MEDLINE (December 2004), EMBASE 1980 - 2004, Oxford Database of Perinatal Trials, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2004) and CINAHL (December 1982 - December 2004). Abstracts of the Society for Pediatric Research were hand searched from 1980 to 2004 inclusive. No language restrictions were applied.

SELECTION CRITERIA

All randomised or quasi randomised controlled trials comparing 'early' versus 'no early' introduction of lipids to preterm infants.

DATA COLLECTION AND ANALYSIS

Data were sought regarding effects on growth and risk of CLD or death, other respiratory morbidities including duration of respiratory support, duration of supplemental oxygen, the need for home oxygen, pneumothorax (PTX), pulmonary haemorrhage and pulmonary interstitial emphysema (PIE), >/= stage 2 necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), patent ductus arteriosus (PDA), sepsis, intraventricular haemorrhage (IVH), clinically significant thrombocytopenia and significant jaundice. Methodological quality of eligible studies was assessed according to allocation concealment, blinding of intervention, blinding of outcome assessment and completeness of follow up. When appropriate, meta-analysis was conducted to provide a pooled estimate of effect. For categorical data the Typical relative risk (RR), Typical risk difference (RD) and number needed to treat (NNT) with 95% confidence intervals (CI) were calculated. Continuous data were analysed using weighted mean difference (WMD).

MAIN RESULTS

Five studies (n = 397) were included in the review. All studies compared the effectiveness and safety of 'early' introduction versus 'no early' introduction of lipids in preterm infants. The timing of introduction of 'early lipids' ranged from < 12 hours after birth to day five of life. The timing of introduction of lipids in the 'no early' lipid group ranged from day six after birth to day 14 after birth. The initial dose ranged from 0.5 - 1 g/kg/day with gradual daily increments up to a maximum of 2.5 - 3.5 g/kg/day. For the primary outcomes (growth, death and CLD), there was no statistically significant difference between the 'early' lipid and 'no early' lipid groups. Days to regain birth weight: [WMD 0.59 (95% CI -2.41, 3.58); two trials; N = 71]. Rate of weight gain (g/day) during period of hospital stay: [MD -2.40 (95% CI -5.30, 0.50); one trial; N = 129]Death (irrespective of time): [Typical RR 1.04 (95% CI 0.69, 1.56); Typical RD 0.01 (95% CI -0.07, 0.08); five trials; N = 397]Neonatal deaths: [Typical RR 1.35 (95% CI 0.78, 2.34); Typical RD 0.05 (95% CI -0.04, 0.13); four trials; N = 268].CLD: [Typical RR 1.10 (95% CI 0.81, 1.49); Typical RD 0.04 (95% CI -0.09, 0.17); two trials; N = 193]. For the secondary outcomes of other respiratory morbidities including duration of respiratory support, duration of supplemental oxygen, PTX, pulmonary haemorrhage, PIE, NEC, ROP, PDA, sepsis, IVH and significant jaundice, there were no statistically significant differences between 'early' and 'no early' lipid groups.

AUTHORS' CONCLUSIONS

No statistically significant effects of 'early introduction' of lipids on short term nutritional or other clinical outcomes, either benefits or adverse effects, were demonstrated in the studies reviewed. Based on the currently available evidence, 'early' initiation of lipids (</= 5 days after birth) can not be recommended for short term growth or to prevent morbidity and mortality in preterm infants.