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Huff KA, Nayak SP, Ahmad I, DiGeronimo R, Hair A, Kim JH, Markel T, Piazza A, Reber K, Roberts J, Sharma J, Sullivan K, Ahmad KA, Yanowitz T, Premkumar MH. Patterns of lipid-injectable emulsion use in neonatal intensive care units across the United States: A multi-institution survey. JPEN J Parenter Enteral Nutr 2023; 47:51-58. [PMID: 35689505 DOI: 10.1002/jpen.2422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/28/2022] [Accepted: 06/07/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Lipid-injectable emulsions (ILEs) are a necessity for neonates dependent on parenteral nutrition (PN). In this manuscript, we describe the patterns of ILE use in neonatal intensive care units (NICUs) in the United States (US). METHODS An electronic survey was sent to 488 NICUs across the US between December 2020 and March 2021. Survey fields included availability and utilization of various ILE in neonates. RESULTS The response rate was 22% (107 out of 488). Soybean oil ILE (SO-ILE) and soybean oil, medium-chain triglycerides, olive oil, fish oil ILE (SO, MCT, OO, FO-ILE) had similar availability (87% vs 86%, respectively), and SO, MCT, OO, FO-ILE was more commonly used (SO-ILE, 71% vs SO, MCT, OO, FO-ILE, 86%). Fish oil-ILE (FO-ILE) was used by 55% of centers. SO-ILE was most frequently used with PN and needs <4 weeks without cholestasis (79%). The most common reason for SO, MCT, OO, FO-ILE use was cholestasis (71%). ILE minimization was used by 28% of SO-ILE and 22% of SO, MCT, OO, FO-ILE users; 95% of these centers restrict SO, MCT, OO, FO-ILE to doses ≤2 g/kg/day. Twenty-two percent of centers started FO-ILE at direct bilirubin of >5 mg/dl. CONCLUSION The results of this survey reveal significant variability in ILE usage across the US. Lipid minimization with SO, MCT, OO, FO-ILE and initiation of FO-ILE for cholestasis at higher bilirubin thresholds are prevalent. Such reports are crucial for a better understanding of ILE use in the NICU and in future ILE development.
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Affiliation(s)
- Katie A Huff
- Department of Pediatrics, Division of Neonatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sujir Pritha Nayak
- Department of Pediatrics, Division of Neonatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Irfan Ahmad
- Division of Neonatology, Children's Hospitals Orange County, Orange, California, USA
| | - Robert DiGeronimo
- Division of Neonatology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Amy Hair
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Jae H Kim
- Division of Neonatology, Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Troy Markel
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Anthony Piazza
- Division of Neonatal-Perinatal Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kristina Reber
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Jessica Roberts
- Division of Neonatal-Perinatal Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jotishna Sharma
- Department of Pediatrics, Division of Neonatology, University of Missouri - Kansas School of Medicine, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Kevin Sullivan
- Division of Neonatal and Perinatal Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kaashif A Ahmad
- Division of Neonatology, Pediatrix and Obstetrix Specialists of Houston, Houston, Texas, USA
| | - Toby Yanowitz
- Department of Pediatrics, Division of Newborn Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Muralidhar H Premkumar
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
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Raphael BP, Mitchell PD, Carey A, Gura KM, Puder M. One-year Experience With Composite Intravenous Lipid Emulsion in Children on Home Parenteral Nutrition. J Pediatr Gastroenterol Nutr 2021; 72:451-455. [PMID: 33264184 DOI: 10.1097/mpg.0000000000003011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Composite lipid emulsion (CLE) composed of soybean oil, medium-chain triglycerides, olive oil, and fish oil is approved in the US for parenterally fed adults. For stable children discharged on home parenteral nutrition (HPN) without cholestasis (direct bilirubin > 2.0 mg/dL), CLE has theoretical benefits over soybean-based intravenous lipid emulsion due to reduced phytosterol exposure with higher calorie support to permit reduced glucose infusion rates (GIRs), omega-3 supplementation, and supplemental α-tocopherol. METHODS In this prospective, single-center open-label research study, safety and efficacy outcomes were evaluated in patients on HPN younger than 18 years treated with CLE at 1 to 3 g · kg-1 · day-1 over 12 months. The primary outcome was change in anthropometrics and GIRs compared with baseline. Secondary outcomes were changes in fatty acid profiles and liver function and enzyme tests compared with baseline. RESULTS Fifty-seven subjects were treated with a median age of 7 years. The diagnosis was short bowel syndrome in 72%. Change in practice was associated with a decrease in mean GIRs from 17 to 14 mg · kg-1 · h-1 at 4 to 6 months postbaseline and beyond with a coincidental decline in mean arachidonic acid and stable growth parameters. No significant adverse events were noted. CONCLUSIONS CLE was safe and well-tolerated in stable children on HPN at 1 year, but further studies are needed in this population to appreciate long-term outcomes.
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Affiliation(s)
| | - Paul D Mitchell
- Institutional Centers for Clinical and Translational Research
| | | | - Kathleen M Gura
- Division of Gastroenterology, Hepatology and Nutrition
- Department of Pharmacy
| | - Mark Puder
- Department of Surgery and the Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Growth in Infants and Children With Intestinal Failure-associated Liver Disease Treated With Intravenous Fish Oil. J Pediatr Gastroenterol Nutr 2020; 70:261-268. [PMID: 31978030 DOI: 10.1097/mpg.0000000000002551] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Infants with intestinal failure (IF) and IF-associated liver disease (IFALD) are at risk for poor somatic growth because of increased metabolic demands, inadequate intake, intestinal malabsorption, chronic liver disease and other comorbidities. There are limited data on the nutritional adequacy of intravenous fish oil lipid emulsion (FOLE) compared with standard soybean oil lipid emulsion (SOLE) in the setting of intestinal failure. AIMS To describe growth patterns in a large cohort of infants with IFALD treated with FOLE. METHODS We compared growth data from infants enrolled in a single-center, prospective FOLE study to published norms, as well as to a multicenter, historical cohort of infants with IF treated with SOLE. RESULTS One hundred thirty-eight infants with IFALD were treated with FOLE and 108 with SOLE. Compared with normative growth curves from WHO and published preterm data, infants in both groups from 6 to 11 months postmenstrual age exhibited declines in mean weight- and length-for-age z scores. At 24 months postmenstrual age compared with WHO growth data, infants treated with FOLE had a mean (95% confidence interval [CI]) weight-for-age z-score of 0.13 (-0.18 to 0.45) and length-for-age z-score of 0.07 (-0.33 to 0.47). In comparison, at 24 months postmenstrual age, infants treated with SOLE had a mean weight for age z-score of -0.93 (-1.20 to -0.67) and mean length for age z-score of -2.33 (-2.75 to -1.91). Independent predictors of higher weight, length and head circumference z-scores included older postmenstrual age at baseline, fewer central line-associated blood stream infections, resolution of cholestasis, type of intravenous fat emulsion (FOLE vs SOLE) and female sex. CONCLUSIONS Infants with IFALD treated with FOLE showed comparable somatic growth to those treated with SOLE in early infancy, and improved somatic growth up to 24 months of age, supporting its wider use in this patient population.
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Gunnar R, Lumia M, Pakarinen M, Merras-Salmio L. Children With Intestinal Failure Undergoing Intestinal Rehabilitation Are at Risk for Essential Fatty Acid Deficiency. JPEN J Parenter Enteral Nutr 2018; 42:1203-1210. [PMID: 29701873 DOI: 10.1002/jpen.1152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/10/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Essential fatty acid (EFA) status may be compromised during the intestinal failure (IF) rehabilitation. Parenteral lipid restriction is used to treat intestinal failure associated liver disease (IFALD), while the enteral fatty acid (FA) absorption remains limited. We analyzed the FA status among pediatric IF and intestinal insufficiency patients. METHODS We evaluated 49 patients aged 0-18 years attending our nationwide IF referral center. Their serum FA fractions were determined and examined against previous nutrition, parenteral lipid emulsion, and intestinal anatomy data. The patients were divided into 3 subgroups according to their dependence on parenteral nutrition (PN): full enteral (EN) (n = 33), supplemental PN (n = 14) or predominantly PN (n = 20). Trien:tetraen ratio (TTR) ≥0.2 was considered diagnostic for essential fatty acid deficiency (EFAD) and increased risk was suspected if TTR exceeded 0.1. RESULTS We identified 8 (16%) patients with elevated TTR ≥0.1; in 3 of them the ratio exceeded 0.2. Five of these children belonged to supplemental PN group. This group carried the highest incidence of elevated TTR (P = 0.0016), with median TTR at 0.06 (interquartile range 0.03-0.09) and two-thirds of the analyzed TTR ≥0.5. Increased EFAD risk was associated with young age (P = 0.0291), current PN with low parenteral lipid content (P = 0.0003), and short remaining small bowel (P = 0.0013). CONCLUSIONS IF children with supplemental PN carry the highest overall risk for EFAD. Young age, current PN, and short remaining small bowel also increase the risk for EFAD.
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Affiliation(s)
- Riikka Gunnar
- Department of Gastroenterology, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Pediatric Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Mirka Lumia
- Department of Neonatology, Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Mikko Pakarinen
- Pediatric Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Laura Merras-Salmio
- Department of Gastroenterology, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Pediatric Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, Helsinki, Finland
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Ong ML, Purdy IB, Levit OL, Robinson DT, Grogan T, Flores M, Calkins KL. Two-Year Neurodevelopment and Growth Outcomes for Preterm Neonates Who Received Low-Dose Intravenous Soybean Oil. JPEN J Parenter Enteral Nutr 2018; 42:352-360. [PMID: 29443399 PMCID: PMC5400735 DOI: 10.1177/0148607116674482] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 09/12/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND In some studies, the dose of intravenous soybean oil (SO) has been associated with a decreased incidence of intestinal failure-associated liver disease. The effect of lipid sparing on neurodevelopment (ND) and growth remains unknown. This study investigated the impact of SO dose on ND and growth over the first 2 years of age in preterm neonates. MATERIALS AND METHODS This is a single-site prospective follow-up study. Neonates with a gestational age ≤29 weeks were randomized to low-dose (LOW) or standard-dose (CON) SO. Bayley Scales of Infant Development III and anthropometric measurements were collected at approximately 6, 12, and 24 months corrected gestational age. RESULTS Subjects were premature, with a mean (±SD) gestational age of 28 ± 1 and 27 ± 1 weeks (P = .3) for LOW and CON, respectively. Thirty subjects completed follow-up (LOW = 15, CON = 15). There were no differences for ND and growth outcomes when LOW was compared with CON, with the exception of a higher 12-month follow-up cognitive scaled score in the LOW group (P = .02). CONCLUSION A reduced SO dose did not adversely affect ND or growth in this cohort of preterm neonates. However, larger studies are needed to determine the long-term safety of SO dose reduction before this strategy can be adopted.
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Affiliation(s)
- Margaret L. Ong
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Isabell B. Purdy
- Neonatal Research Center of the UCLA Children’s Discovery and Innovation Institute, Division of Neonatology and Developmental Biology, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Orly L. Levit
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Daniel T. Robinson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tristan Grogan
- Statistics Core, Department of Medicine, University of California, Los Angeles, California, USA
| | - Martiniano Flores
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Kara L. Calkins
- Neonatal Research Center of the UCLA Children’s Discovery and Innovation Institute, Division of Neonatology and Developmental Biology, Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Lam K, Schiano T, Fiel MI, Iyer K. Index Use of Smoflipid in a Tertiary Intestinal Rehabilitation and Transplantation Program. JPEN J Parenter Enteral Nutr 2017; 41:20S-23S. [PMID: 29161210 DOI: 10.1177/0148607117743495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Long-term parenteral nutrition (PN) may be complicated by PN-associated liver disease (PNALD), and some studies suggest an association between the use of soy-based fat emulsions and PNALD development. Patients' liver function typically improves and PNALD resolves after reducing or stopping a soy-based fat emulsion, and thus lipid minimization has been the primary strategy for managing PNALD in many intestinal rehabilitation programs. However, fat emulsions often cannot be stopped entirely, leading some patients to develop PNALD even after lipid reduction strategies have been implemented. Smoflipid emulsion (Kabi-Fresenius, Bad Homburg, Germany), a balanced mixture of soybean oil, medium-chain triglycerides (MCTs), olive oil, and fish oil, was recently approved by the Food and Drug Administration for use in the United States as an equivalent alternative to Intralipid (Baxter Healthcare Corporation, Deerfield, IL). In several pediatric studies, patients who received Smoflipid had significantly lower serum bilirubin levels than those who received Intralipid. In this case report, we present a patient who developed severe PNALD with subsequent resolution after 20 weeks on Smoflipid.
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Affiliation(s)
- Kwai Lam
- 1 Intestinal Rehabilitation & Transplantation Program, Mount Sinai Medical Center, New York, New York, USA
| | - Thomas Schiano
- 1 Intestinal Rehabilitation & Transplantation Program, Mount Sinai Medical Center, New York, New York, USA
| | - Maria Isabel Fiel
- 2 Department of Pathology, Mount Sinai Medical Center, New York, New York, USA
| | - Kishore Iyer
- 1 Intestinal Rehabilitation & Transplantation Program, Mount Sinai Medical Center, New York, New York, USA
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Al-Shahwani NH, Sigalet DL. Pathophysiology, prevention, treatment, and outcomes of intestinal failure-associated liver disease. Pediatr Surg Int 2017; 33:405-411. [PMID: 28028560 DOI: 10.1007/s00383-016-4042-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Intestinal failure-associated liver disease (IFALD) remains a serious problem in the treatment of infants with nutritional problems and short bowel syndrome. METHODS A review of the recent literature from 2010 to 2016, concentrating on articles related to the pathophysiology of IFALD and to outcomes of novel nutritional and pharmacological therapies for neonatal cholestasis in the post-surgical neonate. RESULTS The pathophysiology of IFALD relates to an increase sensitivity of the neonatal liver to cholestasis in the non-fed state; prolonged cholestasis almost inevitably results in liver damage which will progress from fibrosis to cirrhosis. Clinically discerned risk factors include premature birth, inflammation, sepsis, disruption of the enterohepatic circulation by creation of a proximal stoma, and the duration and type of parenteral nutritional support. Within the hepatocyte, the regulatory enzyme farsanoid receptor X (FXR) appears to play a pivotal role in the development of cholestasis. Recent studies have shown that its activity is suppressed by sepsis, and by plant phytosterols found in soy-based lipid preparations. This paradigm is reflected in the emerging consensus for the care of post-surgical neonates, which is based around a multi-disciplinary team approach. Using an algorithm-driven approach, an appropriate balance between caloric support and prevention of IFALD can be achieved. CONCLUSIONS Further prospective studies are required to further refine the optimal sequence of use of these therapies and the long-term effects on neurological development and hepatic function. However, with optimal care, the number of IF patients progressing to end-stage liver disease because of IFALD should be very low.
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Affiliation(s)
| | - David L Sigalet
- Chair of Surgery, Sidra Medical and Research Center, PO Box 26999, Doha, Qatar.
- Surgery, Weill Cornell Medicine, New York, NY, USA.
- Surgery, Weill Cornell Medicine, Doha, Qatar.
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Cohran VC, Prozialeck JD, Cole CR. Redefining short bowel syndrome in the 21st century. Pediatr Res 2017; 81:540-549. [PMID: 27997531 DOI: 10.1038/pr.2016.265] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 10/30/2016] [Indexed: 12/12/2022]
Abstract
In 1968, Wilmore and Dudrick reported an infant sustained by parenteral nutrition (PN) providing a potential for survival for children with significant intestinal resections. Increasing usage of TPN over time led to some patients developing Intestinal Failure Associated Liver Disease (IFALD), a leading cause of death and indication for liver/intestinal transplant. Over time, multidisciplinary teams called Intestinal Rehabilitation Programs (IRPs) began providing meticulous and innovative management. Usage of alternative lipid emulsions and lipid minimization strategies have resulted in the decline of IFALD and an increase in long-term and transplant-free survival, even in the setting of ultrashort bowel (< 20 cm). Autologous bowel reconstructive surgeries, such as the serial tapering enteroplasty procedure, have increased the likelihood of achieving enteral autonomy. Since 2007, the number of pediatric intestinal transplants performed has sharply declined and likely attributed to the newer innovations healthcare. Recent data support the need for changes in the listing criteria for intestinal transplantation given the overall improvement in outcomes. Over the last 50 y, the diagnosis of short bowel syndrome has changed from a death sentence to one of hope with a vast improvement of quality of life and survival.
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Affiliation(s)
- Valeria C Cohran
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Joshua D Prozialeck
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Conrad R Cole
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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