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Kaenkumchorn TK, Lampone O, Huebner K, Cramer J, Karls C. When parenteral nutrition is the answer: The case of pediatric intestinal rehabilitation. Nutr Clin Pract 2024. [PMID: 38961658 DOI: 10.1002/ncp.11179] [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: 02/19/2024] [Revised: 05/09/2024] [Accepted: 06/03/2024] [Indexed: 07/05/2024] Open
Abstract
In pediatric patients with intestinal failure, parenteral nutrition is lifesaving but also has several associated risks. The goals of intestinal rehabilitation include promoting growth, minimizing complications associated with intestinal failure, and reaching enteral autonomy, if possible. Pediatric intestinal rehabilitation programs are interdisciplinary teams that strive to provide optimal care for children dependent on parenteral nutrition. The provision of parenteral nutrition requires close monitoring of patients' growth, nutrition concerns, clinical status, and laboratory parameters. Recent advances in the field of intestinal rehabilitation include new lipid emulsions, considerations regarding enteral feeding, advances in micronutrient provision, and central venous catheter preservation techniques. Challenges in the field remain, including improving overall quality of life with home parenteral nutrition administration and preventing recently recognized complications such as chronic intestinal inflammation.
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Affiliation(s)
- Tanyaporn K Kaenkumchorn
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Olivia Lampone
- Clinical Nutrition, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Kayla Huebner
- Department of Pharmacy, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Jesse Cramer
- Department of Pharmacy, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Catherine Karls
- Clinical Nutrition, Children's Wisconsin, Milwaukee, Wisconsin, USA
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2
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Zafirovska M, Zafirovski A, Rotovnik Kozjek N. Current Insights Regarding Intestinal Failure-Associated Liver Disease (IFALD): A Narrative Review. Nutrients 2023; 15:3169. [PMID: 37513587 PMCID: PMC10385050 DOI: 10.3390/nu15143169] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
Intestinal failure-associated liver disease (IFALD) is a spectrum of liver disease including cholestasis, biliary cirrhosis, steatohepatitis, and gallbladder disease in patients with intestinal failure (IF). The prevalence of IFALD varies considerably, with ranges of 40-60% in the pediatric population, up to 85% in neonates, and between 15-40% in the adult population. IFALD has a complex and multifactorial etiology; the risk factors can be parenteral nutrition-related or patient-related. Because of this, the approach to managing IFALD is multidisciplinary and tailored to each patient based on the etiology. This review summarizes the current knowledge on the etiology and pathophysiology of IFALD and examines the latest evidence regarding preventative measures, diagnostic approaches, and treatment strategies for IFALD and its associated complications.
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Affiliation(s)
- Marija Zafirovska
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
- Association of General Practice/Family Medicine of South-East Europe (AGP/FM SEE), St. Vladimir Komarov No. 40/6, 1000 Skopje, North Macedonia
| | - Aleksandar Zafirovski
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
- General Hospital Jesenice, Cesta Maršala Tita 112, 4270 Jesenice, Slovenia
- Clinical Institute of Radiology, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000 Ljubljana, Slovenia
| | - Nada Rotovnik Kozjek
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
- Department for Clinical Nutrition, Institute of Oncology Ljubljana, Zaloška Cesta 2, 1000 Ljubljana, Slovenia
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3
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Waltz P, Azzuqa A. Nutritional considerations in the neonate. Semin Pediatr Surg 2022; 31:151197. [PMID: 36038219 DOI: 10.1016/j.sempedsurg.2022.151197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Paul Waltz
- Assistant Professor of Surgery, UPMC Childrens Hospital of Pittsburgh, USA.
| | - Abeer Azzuqa
- Associate Professor of Pediatrics, UPMC Childrens Hospital of Pittsburgh, USA
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Nabarrete JM, Pereira AZ, Garófolo A, Seber A, Venancio AM, Grecco CES, Bonfim CMS, Nakamura CH, Fernandes D, Campos DJ, Oliveira FLC, Cousseiro FK, Rossi FFP, Gurmini J, Viani KHC, Guterres LF, Mantovani LFAL, Darrigo LG, Albuquerque MIBPE, Brumatti M, Neves MA, Duran N, Villela NC, Zecchin VG, Fernandes JF. Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: children and adolescents. EINSTEIN-SAO PAULO 2021; 19:eAE5254. [PMID: 34909973 PMCID: PMC8664291 DOI: 10.31744/einstein_journal/2021ae5254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 12/10/2020] [Indexed: 11/28/2022] Open
Abstract
The Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Children and Adolescents was developed by dietitians, physicians, and pediatric hematologists from 10 Brazilian reference centers in hematopoietic stem cell transplantation. The aim was to emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to patient´s nutritional assessment. This consensus is intended to improve and standardize nutrition therapy during hematopoietic stem cell transplantation. The consensus was approved by the Brazilian Society of Bone Marrow Transplantation.
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Affiliation(s)
- Juliana Moura Nabarrete
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Andrea Z Pereira
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Adriana Garófolo
- Universidade Federal de São PauloInstituto de Oncologia PediátricaSão PauloSPBrazilInstituto de Oncologia Pediátrica, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Adriana Seber
- Universidade Federal de São PauloSão PauloSPBrazilUniversidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Angela Mandelli Venancio
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Carlos Eduardo Setanni Grecco
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoHospital das ClínicasRibeirão PretoSPBrazilHospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
| | - Carmem Maria Sales Bonfim
- Universidade Federal do ParanáHospital de ClínicasCuritibaSPBrazilHospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Claudia Harumi Nakamura
- Universidade Federal de São PauloInstituto de Oncologia PediátricaSão PauloSPBrazilInstituto de Oncologia Pediátrica, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Daieni Fernandes
- Santa Casa de Misericórdia de Porto AlegrePorto AlegreRSBrazilSanta Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.
| | - Denise Johnsson Campos
- Universidade Federal do ParanáHospital de ClínicasCuritibaSPBrazilHospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Fernanda Luisa Ceragioli Oliveira
- Universidade Federal de São PauloEscola Paulista de MedicinaSão PauloSPBrazilEscola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Flávia Krüger Cousseiro
- Santa Casa de Misericórdia de Porto AlegrePorto AlegreRSBrazilSanta Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.
| | - Flávia Feijó Panico Rossi
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Jocemara Gurmini
- Universidade Federal do ParanáHospital de ClínicasCuritibaSPBrazilHospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Karina Helena Canton Viani
- Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilInstituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Luciana Fernandes Guterres
- Santa Casa de Misericórdia de Porto AlegrePorto AlegreRSBrazilSanta Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.
| | | | - Luiz Guilherme Darrigo
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoHospital das ClínicasRibeirão PretoSPBrazilHospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
| | - Maria Isabel Brandão Pires e Albuquerque
- Instituto Nacional de Câncer José Alencar Gomes da SilvaRio de JaneiroRJBrazilInstituto Nacional de Câncer José Alencar Gomes da Silva - INCA, Rio de Janeiro, RJ, Brazil.
| | - Melina Brumatti
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Mirella Aparecida Neves
- Universidade Federal do ParanáHospital de ClínicasCuritibaSPBrazilHospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Natália Duran
- Hospital de Câncer de BarretosBarretosSPBrazilHospital de Câncer de Barretos, Barretos, SP, Brazil.
| | - Neysimelia Costa Villela
- Hospital de Câncer de BarretosBarretosSPBrazilHospital de Câncer de Barretos, Barretos, SP, Brazil.
| | - Victor Gottardello Zecchin
- Universidade Federal de São PauloInstituto de Oncologia PediátricaSão PauloSPBrazilInstituto de Oncologia Pediátrica, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Juliana Folloni Fernandes
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Hardy G, Wong T, Morrissey H, Anderson C, Moltu SJ, Poindexter B, Lapillonne A, Ball PA. Parenteral Provision of Micronutrients to Pediatric Patients: An International Expert Consensus Paper. JPEN J Parenter Enteral Nutr 2021; 44 Suppl 2:S5-S23. [PMID: 32767589 DOI: 10.1002/jpen.1990] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/04/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Micronutrients (vitamins and trace elements) are essential to all nutrition. For children and neonates who are dependent upon nutrition support therapies for growth and development, the prescribed regimen must supply all essential components. This paper aims to facilitate interpretation of existing clinical guidelines into practical approaches for the provision of micronutrients in pediatric parenteral nutrition. METHODS An international, interdisciplinary expert panel was convened to review recent evidence-based guidelines and published literature to develop consensus-based recommendations on practical micronutrient provision in pediatric parenteral nutrition. RESULTS The guidelines and evidence have been interpreted as answers to 10 commonly asked questions around the practical principles for provision and monitoring of micronutrients in pediatric patients. CONCLUSION Micronutrients are an essential part of all parenteral nutrition and should be included in the pediatric nutrition therapy care plan.
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Affiliation(s)
- Gil Hardy
- Ipanema Research Trust, Auckland, New Zealand
| | - Theodoric Wong
- Consultant Pediatric Gastroenterologist, Women's and Children's Hospital, Birmingham, UK
| | - Hana Morrissey
- School of Pharmacy and Pharmaceutical Science, Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
| | - Collin Anderson
- Pharmacy, Intermountain Healthcare Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Sissel J Moltu
- Department of Neonatology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Brenda Poindexter
- Department of Pediatrics, Cincinnati Children's Hospital and Medical Centre, Cincinnati, Ohio, USA
| | | | - Patrick A Ball
- School of Pharmacy and Pharmaceutical Science, Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
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Leite HP, Koch Nogueira PC, Uchoa KMCB, Carvalho de Camargo MF. Copper Deficiency in Children With Intestinal Failure: Risk Factors and Influence on Hematological Cytopenias. JPEN J Parenter Enteral Nutr 2019; 45:57-64. [PMID: 31637763 DOI: 10.1002/jpen.1728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 09/24/2019] [Accepted: 10/01/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND We investigated to what extent serum copper influences hemoglobin (Hb), neutrophil, and platelet counts and the factors associated with serum copper in children with intestinal failure (IF) who have their micronutrient status monitored according to a standard protocol. METHODS Children with IF admitted to a pediatric intestinal rehabilitation program and receiving home parenteral nutrition (PN) were followed up prospectively. Patients received vitamins and multi-trace elements (TEs) as part of the PN. Copper, iron, zinc, vitamin A, and cobalamin serum levels were routinely monitored at 3-month intervals or monthly when a deficiency was detected. Complete blood counts were performed biweekly. Repeated-measures analyses were used to estimate the effect of explanatory variables on the outcomes. RESULTS Thirteen children with a median time receiving PN of 16.6 months were included. An average of 7 copper measurements per patient were performed; 53.8% of patients had a low serum level at least twice during the follow-up. Eight patients with cholestasis had TEs of PN discontinued. In the multivariable analysis, copper was not associated with Hb levels; an increase of 10 µg/dL in serum copper resulted in an increase of 240/mm3 (95% confidence interval [CI], 18.0-30.1) neutrophils and of 8429/mm3 (95% CI, 466-1219) platelets (P < .001). Time of PN without copper, direct bilirubin levels, and ostomy were associated with lower serum copper. CONCLUSION The increase in serum copper was associated with significant increases in neutrophil and platelet counts. Time without copper in PN, cholestasis, and having an ostomy negatively influenced copper status.
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Affiliation(s)
- Heitor Pons Leite
- Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Paulo Cesar Koch Nogueira
- Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil.,Center for Intestinal Rehabilitation, Hospital Samaritano de São Paulo, São Paulo, São Paulo, Brazil
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Adler A, Worley S, Radhakrishnan K. Increased Needs for Copper in Parenteral Nutrition for Children in the Neonatal Intensive Care Unit With an Ostomy. Nutr Clin Pract 2019; 35:724-728. [PMID: 31270844 DOI: 10.1002/ncp.10365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Copper (Cu) is an essential trace element, with deficiency causing anemia, neutropenia, and other abnormalities. Cu is mainly absorbed in the small intestine. Patients with intestinal failure or jejunostomy have increased Cu losses and require additional Cu supplementation in parenteral nutrition (PN). The American Society for Clinical Nutrition standards for trace element recommendations in PN, including Cu, were created in 1988, and the American Society for Parenteral and Enteral Nutrition currently follows the same recommendations. METHODS Patients admitted to the neonatal intensive care unit for surgical intervention resulting in an ostomy (ileal or jejunal) were included in this retrospective study. Patients received PN support with Cu dosed individually, rather than in a multi-trace element package. Cu and ostomy output were analyzed daily. Serum Cu was obtained 2 months postsurgical intervention. RESULTS Out of the 7 patients enrolled, 71% had low serum Cu. Weekly mean Cu intake for all 7 patients ranged from 5.3 to 154.8 μg/kg/day from enteral and parenteral sources, with individual mean weekly Cu intake ranging from 18.9 to 74.4 μg/kg/day from surgical intervention to 2 months post-surgery. Patients' weekly ostomy outputs ranged from 0 mL/kg/day to 77.2 mL/kg/day, with individual mean weekly output ranging from 3.7 to 41.6 mL/kg/day. CONCLUSION Providing 20 μg/kg/day of Cu in PN to neonates with ostomies is insufficient to prevent Cu deficiency. Further studies are warranted to determine an optimal dosage of parenteral Cu to prevent Cu deficiency.
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Affiliation(s)
- Andrea Adler
- Pediatric Nutrition Support, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Sarah Worley
- Quantitative Health Sciences, Learner Research Institute, Cleveland, Ohio, USA
| | - Kadakkal Radhakrishnan
- Department of Pediatric Gastroenterology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
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Zemrani B, McCallum Z, Bines JE. Trace Element Provision in Parenteral Nutrition in Children: One Size Does Not Fit All. Nutrients 2018; 10:E1819. [PMID: 30469420 PMCID: PMC6266164 DOI: 10.3390/nu10111819] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 11/16/2018] [Accepted: 11/18/2018] [Indexed: 12/16/2022] Open
Abstract
Routine administration of trace elements is recognised as a standard of care in children requiring parenteral nutrition. However, there is a lack of global consensus regarding trace elements provision and dosing in pediatric parenteral nutrition. This review provides an overview of available evidence regarding trace elements supply and posology in parenteral nutrition in neonates and children. Trace elements provision in children should be tailored to the weight and clinical condition of the child with emphasis on those at risk of toxicity or deficiency. Based on current evidence, there is a need to review the formulation of commercial solutions that contain multiple-trace elements and to enable individual trace elements additives to be available for specific indications. Literature supports the removal of chromium provision whereas manganese and molybdenum supplementation are debated. Preterm neonates may have higher parenteral requirements in iodine, selenium and copper than previously recommended. There is growing support for the routine provision of iron in long-term parenteral nutrition. Further studies on trace elements contamination of parenteral nutrition solutions are needed for a range of trace elements.
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Affiliation(s)
- Boutaina Zemrani
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, 3052 Melbourne, Australia.
| | - Zoe McCallum
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, 3052 Melbourne, Australia.
- Department of Pediatrics, University of Melbourne, 3010 Melbourne, Australia.
| | - Julie E Bines
- Clinical Nutrition Unit, Department of Gastroenterology and Clinical Nutrition, The Royal Children's Hospital, 3052 Melbourne, Australia.
- Department of Pediatrics, University of Melbourne, 3010 Melbourne, Australia.
- Murdoch Children's Research Institute, 3052 Melbourne, Australia.
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9
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ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Iron and trace minerals. Clin Nutr 2018; 37:2354-2359. [PMID: 30078716 DOI: 10.1016/j.clnu.2018.06.949] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/26/2022]
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10
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Gupta K, Wang H, Amin SB. Copper Supplementation in Premature Infants With Parenteral Nutrition-Associated Cholestasis. Nutr Clin Pract 2018. [PMID: 29529337 DOI: 10.1002/ncp.10053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The aim of this study was to evaluate the effect of intermittent parenteral copper supplementation (IPC) on serum copper status and biochemical and hematological measures of copper toxicity and deficiency in premature infants with parenteral nutrition (PN)-associated cholestasis (PNAC). We performed a prospective nested observational study in premature infants with PNAC who received IPC after the development of PNAC. Infants with chromosomal disorders, TORCH (toxoplasmosis, parvovirus, syphilis, rubella, cytomegalovirus, herpes, human immunodeficiency virus) infection, metabolic disorder, and/or surgical abnormality of the hepatobiliary system were excluded. Serum copper concentrations were measured once every 2-4 weeks while receiving PN; 24 premature infants were studied. The mean gestational age (GA) of infants was 28.6 ± 4.7 weeks. On regression analysis, there was no significant association between IPC and serum copper concentration (coefficient 2.72, 95% CI: -27 to 32; P = .84) after controlling for GA, gender, and baseline copper intake before PNAC. There was no significant association of IPC with alanine and aspartate transaminases levels (hepatotoxicity) and platelet count, hematocrit, white blood cell count, and neutrophil count (measures of copper deficiency) after controlling for confounders. GA and postmenstrual age were independently and positively associated with serum copper concentration after controlling for confounders on regression analyses. Thus, IPC in premature infants with PNAC does not influence copper status and is not associated with biochemical and hematological measures of copper deficiency and/or toxicity. Serum copper concentration in premature infants with PNAC receiving IPC is determined by the degree of prematurity and postmenstrual age.
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Affiliation(s)
- Kunal Gupta
- Division of Neonatology, Department of Pediatrics, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Hongyue Wang
- Department of Biostatistics, University of Rochester Medical Center, Rochester, New York, USA
| | - Sanjiv B Amin
- Division of Neonatology, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
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El-Koofy N, Fouad HM, Fahmy ME, Helmy H, Shaker O, El-Karaksy HM, Mohsen N. Copper concentrations in Egyptian infants with cholestasis: A single center study. Arab J Gastroenterol 2018. [PMID: 29523470 DOI: 10.1016/j.ajg.2018.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND STUDY AIMS Hepatobiliary cholestatic disorders produce excess copper (Cu) retention in the liver, which is toxic and may cause hepatitis, fulminant hepatic failure, cirrhosis and death. In this study, we measured hepatic Cu and tested its correlation with serum Cu (S. Cu) and serum ceruloplasmin (S. ceruloplasmin) in cholestatic infants. PATIENTS AND METHODS 41 cholestatic infants were enrolled as cases and 11 healthy infants as control subjects. S. Cu and S. ceruloplasmin were done for all infants and hepatic Cu was measured in the liver specimen in cases. RESULTS Cases were 63.5% males with their age ranging between 1 and 7 months, while control subjects were 45.5% males with an age range between 3 and 18 months. Among cases, 41.5% had biliary atresia and 58.5% had intrahepatic cholestasis. Cholestatic infants had significantly higher levels of S. Cu and S. ceruloplasmin than control subjects and their hepatic Cu concentration was significantly higher than literature control. Infants with biliary atresia showed higher levels of Cu indices, with no statistical significance. Serum and hepatic Cu levels positively correlated with each other and with S. ceruloplasmin. Results of ROC curve showed that S. Cu was highly sensitive and specific for predicting hepatic Cu concentration at cut-off 181 μg/dl. CONCLUSION Serum and hepatic Cu concentrations were markedly elevated in patients with cholestasis and positively correlated with each other and with S. ceruloplasmin. S. Cu level can predict hepatic Cu concentration.
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Affiliation(s)
- Nehal El-Koofy
- Department of Paediatrics, Cairo University, Cairo, Egypt
| | - Hanan M Fouad
- Department of Paediatrics, Hepatology and Tropical Medicine Research Institute, Cairo, Egypt.
| | - Mona E Fahmy
- Department of Paediatrics, Research Institute of Ophthalmology, Cairo, Egypt
| | - Heba Helmy
- Department of Paediatrics, Cairo University, Cairo, Egypt
| | - Olfat Shaker
- Department of Biochemistry, Cairo University, Cairo, Egypt
| | | | - Nabil Mohsen
- Department of Paediatrics, Cairo University, Cairo, Egypt
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12
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Nucci AM, Ellsworth K, Michalski A, Nagel E, Wessel J. Survey of Nutrition Management Practices in Centers for Pediatric Intestinal Rehabilitation. Nutr Clin Pract 2017; 33:528-538. [PMID: 28731841 DOI: 10.1177/0884533617719670] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Nutrition management of pediatric intestinal failure (IF) requires interdisciplinary coordination of parenteral nutrition (PN) and enteral nutrition (EN) support. Nutrition strategies used by specialists in pediatric intestinal rehabilitation to promote gut adaptation and manage complications have not been previously summarized. METHODS A practice survey was distributed to members of the dietitian subgroup of the American Society for Parenteral and Enteral Nutrition Pediatric Intestinal Failure Section. The survey included 24 open-ended questions related to PN and enteral feeding strategies, nutrition management of PN-associated liver disease, and laboratory monitoring. RESULTS Dietitians from 14 centers completed the survey. Management components for patients at risk for cholestasis were consistent and included fat minimization, trace element modification, avoiding PN overfeeding, and providing EN. Parenteral amino acid solutions designed for infants/young children are used in patients <1 or 2 years of age. Trace minerals are dosed individually in 10 of 14 centers. Eleven centers prescribe a continuous infusion of breast milk or elemental formula 1-2 weeks after resection while 3 centers determine the formula type by the extent of resection. Most (86%) centers do not have a protocol for initiating oral/motor therapy. Laboratory panel composition varied widely by center. The selection and frequency of use depended on clinical variables, including cholestatic status, exclusive vs partial PN dependence, postrepletion verification vs routine monitoring, intestinal anatomy, and acuity of care. CONCLUSION EN and PN management strategies are relatively consistent among U.S. centers. Collaborative initiatives are necessary to define better practices and establish laboratory monitoring guidelines.
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Affiliation(s)
| | | | - Austin Michalski
- University of Michigan, C.S. Mott Children's Hospital, Grand Rapids, Michigan, USA
| | - Emily Nagel
- Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Jackie Wessel
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Abstract
Management of pediatric intestinal failure has evolved in recent decades, with improved survival since the advent of specialized multidisciplinary intestinal failure centers. Though sepsis and intestinal failure associated liver disease still contribute to mortality, we now have growing data on the long-term outcomes for this population. While intestinal adaptation and parenteral nutrition weaning is most rapid during the first year on parenteral support, achievement of enteral autonomy is possible even after many years as energy and protein requirements decline dramatically with age. Intestinal transplant is an option for patients experiencing complications of long-term parenteral nutrition who are expected to have permanent intestinal failure, but outcomes are hindered by immunosuppression-related complications. Much of the available data comes from single center retrospective reports, with variable inclusion criteria, intestinal failure definitions, and follow-up durations; this limits the ability to analyze outcomes and identify best practices. As most children now survive long-term, the focus of management has shifted to the avoidance and management of comorbidities, support of normal growth and development, and optimization of quality of life for these medically and surgically complex patients.
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Affiliation(s)
- Brenna S Fullerton
- Department of Surgery, Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Fegan 3, Boston, MA 02115
| | - Charles R Hong
- Department of Surgery, Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Fegan 3, Boston, MA 02115
| | - Tom Jaksic
- Department of Surgery, Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Fegan 3, Boston, MA 02115.
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14
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Finch CW. Review of trace mineral requirements for preterm infants: what are the current recommendations for clinical practice? Nutr Clin Pract 2014; 30:44-58. [PMID: 25527182 DOI: 10.1177/0884533614563353] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Inadequate nutrient stores at birth are an inevitable consequence of being born prematurely. Preterm infants also have high nutrient requirements, which increase with earlier gestational ages. As a result, early nutrition intervention is required to prevent further deficits that, if not corrected, can affect growth and long-term outcomes. Preterm infants often require several weeks of parenteral nutrition (PN) support, which includes trace mineral supplementation. Trace minerals are considered essential nutrients, unable to be synthesized in the human body. Deficiencies of trace minerals have been reported, yet evidence-based guidelines for assessment and supplementation have not been clearly defined. Food and Drug Administration-approved parenteral trace mineral intake guidelines are more than 30 years old. In an effort to more clearly define trace mineral supplementation and monitoring guidelines for preterm infants, a review of literature was performed with the purpose to (1) summarize trace mineral roles in preterm infants, (2) describe clinical signs of deficiency and toxicity, and (3) present intake recommendations and considerations for preterm infants based on current available literature. Review of literature was completed using PubMed and Cochrane databases to find relevant studies specific to trace mineral requirements for preterm infants, trace mineral supplementation of PN, human milk fortifiers, and preterm infant formulas. Review of literature supports that trace mineral depletion can lead to clinical compromise in preterm infants; therefore, suggesting that every effort be made to ensure adequate provision of trace minerals is given to preterm infants. Practical considerations for the clinical nutrition management of preterm infants were also identified in this review.
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Copper-induced alterations in rat brain depends on route of overload and basal copper levels. Nutrition 2014; 30:96-106. [PMID: 24290605 DOI: 10.1016/j.nut.2013.06.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 06/11/2013] [Accepted: 06/12/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Copper (Cu) is widely used in industry for the manufacture of a vast range of goods including Cu-intrauterine devices (IUDs), electronic products, agrochemicals, and many others. It is also one of the trace elements essential to human health in the right measure and is used as a parenteral supplement in patients unable to ingest food. Elevated Cu levels have been found in the plasma of women using Cu-IUDs and in farmers working with Cu-based pesticides. However, possible alterations due to Cu overload in the brain have been poorly studied. Therefore, the aim of this study was to investigate the effects of Cu administration on rat brain in Cu-sufficient and Cu-deficient animals fed on semi-synthetic diets with different doses of Cu (7 or 35 ppm). METHODS We aimed to investigate the effects of Cu administration using two routes of administration: oral and intraperitoneal (IP). Male Wistar rats were feeding (one month) a complete (7 ppm) or a deficient (traces) Cu diets subdivided into three categories oral-, intraperitoneal- (or both) supplemented with copper carbonate (7 to 35 ppm). Cu content in plasma, brain zones (cortex and hippocampus), antioxidant enzyme activities, and protease systems involved in programmed cell death were determined. RESULTS The results show that Cu levels and the concentration of Cu in plasma and brain were dose-dependent and administration route-dependent and demonstrated a prooxidative effect in plasma and brain homogenates. Oxidative stress biomarkers and antioxidative enzyme activity both increased under Cu overload, these effects being more noticeable when Cu was administered IP. Concomitantly, brain lipids from cortex and hippocampus were strongly modified, reflecting Cu-induced prooxidative damage. A significant increase in the activities of calpain (milli- and micro-) and caspase-3 activity also was observed as a function of dose and administration route. CONCLUSION The findings of this study could be important in evaluating the role of Cu in brain metabolism and neuronal survival.
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MacKay M, Mulroy CW, Street J, Stewart C, Johnsen J, Jackson D, Paul I. Assessing Copper Status in Pediatric Patients Receiving Parenteral Nutrition. Nutr Clin Pract 2014; 30:117-21. [DOI: 10.1177/0884533614538457] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Mark MacKay
- Primary Children’s Hospital, Salt Lake City, Utah
| | | | | | | | - Jake Johnsen
- Primary Children’s Hospital, Salt Lake City, Utah
| | | | - Irasema Paul
- Primary Children’s Hospital, Salt Lake City, Utah
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Abstract
A recent review of macronutrients in parenteral nutrition (PN) in the NICU population summarized the carbohydrate, protein, and fat nutrients in PN.1 The purpose of this article is to review the other nutrients in PN that are important for growth and homeostasis including minerals or electrolytes, vitamins, and trace elements. Although the macronutrients contribute more dramatically to adequate nutrition and growth, the other components in PN have significant impact on use of macronutrients as well as targeted organ and cellular function.
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Abstract
PURPOSE OF REVIEW Since the 1970s, it has been known that the supplementation of trace elements with parenteral nutrition is required in order to avoid the clinical manifestations of their deficiencies. However, the correct level of requirements of these trace elements, particularly in paediatrics, has provided some debate. The recent developments might help revise some of the current recommendations, particularly in short-term parenteral nutrition provision. RECENT FINDINGS Parenterally fed preterm neonates require routine addition of zinc. Provision of chromium and manganese in parenteral nutrition should be limited, particularly for short-term patients. Newer parenteral iron preparations provide the opportunity for a safer and larger dose of administration. SUMMARY Clinicians should prescribe according to the individual requirements and revise the routine practice of providing 'all in one' parenteral trace elements preparations, as these products do not reflect or allow tailored provision in paediatrics and may increase the risk of toxicity.
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Affiliation(s)
- Theodoric Wong
- Department of Gastroenterology and Hepatology, Royal Children's Hospital, Herston, Queensland, Australia.
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Abstract
Intestinal failure-associated liver disease (IFALD), a serious complication occurring in infants, children, and adults exposed to long-term parenteral nutrition (PN), causes a wide-spectrum of disease, ranging from cholestasis and steatosis to fibrosis and eventually cirrhosis. Known host risk factors for IFALD include low birth weight, prematurity, short bowel syndrome, and recurrent sepsis. The literature suggests that components of PN may also play a part of the multifactorial pathophysiology. Because some intravenous lipid emulsions (ILEs) may contribute to inflammation and interfere with bile excretion, treatment with ILE minimization and/or ILEs composed primarily of omega-3 fatty acids can be helpful, but requires careful monitoring for growth failure and essential fatty acid deficiency (EFAD). Data from randomized controlled trials are awaited to support widespread use of these approaches. Other IFALD treatments include cycling PN, ursodeoxycholic acid, sepsis prevention, photoprotection, and polyvinylchloride-free tubing. Management and prevention of IFALD remains a clinical challenge.
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Affiliation(s)
- Bram P Raphael
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Marquardt ML, Done SL, Sandrock M, Berdon WE, Feldman KW. Copper deficiency presenting as metabolic bone disease in extremely low birth weight, short-gut infants. Pediatrics 2012; 130:e695-8. [PMID: 22869833 DOI: 10.1542/peds.2011-1295] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Copper deficiency can cause bone lesions in infants, which might be confused with child abuse. Two extremely low birth weight preterm infants had complicated medical courses requiring prolonged parenteral nutrition for short-gut syndrome, which led to the development of cholestasis. Both had spent their entire lives in the hospital. They had been on prolonged ventilator support for chronic lung disease. They developed signs of copper deficiency between 5 and 6 months of age, initially raising child abuse concerns. Musculoskeletal discomfort led to the recognition of radiographic findings of metabolic bone disease. Included were osteoporosis, metaphyseal changes, and physeal disruptions. Copper levels were low; both low copper parenteral nutrition and gut losses from refeeding diarrhea likely contributed to their deficiency. Therapeutic supplementation with copper corrected their deficits and clinical and radiologic findings. The information from these cases, in particular, their radiologic findings, indicate the need to monitor copper status in at-risk premature infants. These findings may aid prevention and earlier recognition of copper deficiency. Their specific radiologic and clinical findings should aid differentiation of such children from abused infants.
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Affiliation(s)
- Michelle L Marquardt
- Department of Pediatrics-Graduate Medical Education, Seattle Children’s Hospital, The University of Washington School of Medicine, Seattle, Washington, USA
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Dembinski K, Gargasz AE, Dabrow S, Rodriguez L. Three distinct cases of copper deficiency in hospitalized pediatric patients. Clin Pediatr (Phila) 2012; 51:759-62. [PMID: 22584540 DOI: 10.1177/0009922812446743] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although copper deficiency is a rare occurrence in the developed world, attention should be given to the proper supplementation of minerals to at-risk pediatric patients. This study presents 3 distinct cases of copper deficiency in hospitalized patients aged 14 months, 6 years, and 12 years. Two patients had short bowel syndrome, requiring prolonged parenteral nutrition or complex intravenous fluid supplementation. The third patient was severely malnourished. Copper deficiency manifested in all of our patients as either microcytic anemia or pancytopenia with myelodysplastic syndrome. Copper deficiency is an important diagnosis to be considered in patients with prematurity, parenteral nutrition dependency, malabsorption, and/or those with malnutrition. More studies are needed to establish appropriate amounts of copper supplementation to replenish copper stores in deficient patients.
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Affiliation(s)
- Karolina Dembinski
- Department of Pediatrics, University of South Florida, Tampa, FL 33606, USA.
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Corkins MR, Martin VA, Szeszycki EE. Copper Levels in Cholestatic Infants on Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2012; 37:92-6. [DOI: 10.1177/0148607112443069] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Mark R. Corkins
- Indiana University School of Medicine, Indianapolis, Indiana
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Burjonrappa SC, Miller M. Role of trace elements in parenteral nutrition support of the surgical neonate. J Pediatr Surg 2012; 47:760-71. [PMID: 22498394 DOI: 10.1016/j.jpedsurg.2012.01.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 01/11/2012] [Accepted: 01/11/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) has transformed the outcome for neonates with surgical problems in the intensive care unit. Trace element supplementation in PN is a standard practice in many neonatal intensive care units. However, many of these elements are contaminants in PN solutions, and contamination levels may, in themselves, be sufficient for normal metabolic needs. Additional supplementation may actually lead to toxicity in neonates whose requirements are small. METHODS An electronic search of the MEDLINE, Cochrane Collaboration, and SCOPUS English language medical databases was performed for the key words "trace elements," "micro-nutrients," and "parenteral nutrition additives." Studies were categorized based on levels of evidence offered, with randomized controlled trials and meta-analyses accorded the greatest importance at the apex of the data pool and case reports and animal experiments the least importance. Articles were reviewed with the primary goal of developing uniform recommendations for trace element supplementation in the surgical neonate. The secondary goals were to review the physiologic role, metabolic demands, requirements, losses, deficiency syndromes, and toxicity symptoms associated with zinc, copper, chromium, selenium, manganese, and molybdenum supplementation in PN. RESULTS Zinc supplementation must begin at initiation of PN. All other trace elements can be added to PN 2 to 4 weeks after initiation. Copper and manganese need to be withheld if the neonate develops PN-associated liver disease. The status of chromium supplementation is currently being actively debated, with contaminant levels in PN being sufficient in most cases to meet neonatal requirements. Selenium is an important component of antioxidant enzymes with a role in the pathogenesis of neonatal surgical conditions such as necrotizing enterocolitis and bronchopulmonary dysplasia. Premature infants are often selenium deficient, and early supplementation has shown a reduction in sepsis events in this age group. CONCLUSION Appropriate supplementation of trace elements in surgical infants is important, and levels should be monitored. In certain settings, it may be more appropriate to individualize trace element supplementation based on the predetermined physiologic need rather than using bundled packages of trace elements as is the current norm. Balance studies of trace element requirements should be performed to better establish clinical recommendations for optimal trace element dosing in the neonatal surgical population.
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Affiliation(s)
- Sathyaprasad C Burjonrappa
- Department of Nutrition and Pediatrics, Maimonides Infants and Children's Hospital, Brooklyn, NY 11219, USA.
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Abstract
PURPOSE OF REVIEW Copper is an essential trace mineral but both deficiency and toxicity need to be avoided. Copper is regulated via excretion by the biliary system and caution was recommended when administered in patients with cholestasis. Recent clinical reports indicate that despite the cholestasis, copper should not be withheld from parenteral nutrition. RECENT FINDINGS Transporters involved in regulating copper levels have been identified. This explains the processes that regulate copper levels and the diseases that result from transporter defects. Monitoring copper ideally requires a liver biopsy but there are reports that in infants serum copper levels correlate with the liver copper. The published cautions about copper in cholestatic patients on parenteral nutrition led to the removal of copper from the solutions. Subsequently, multiple reports of clinical copper deficiency developing in these patients including infants were published. Newer literature indicates no elevation in infant copper levels despite normal copper parenteral nutrition supplementation in the presence of cholestasis. SUMMARY Copper is essential and levels are regulated in response to an individual's needs. The liver excretion of copper is the primary regulating method but clinically cholestasis does not result in elevated levels in infants. The best clinical approach to parenteral nutrition copper is careful monitoring even in the presence of cholestasis.
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Affiliation(s)
- Mark R Corkins
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
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