The use of IV fat in neonates

Monitoring and management of hypertriglyceridemia in extremely low birth weight neonates receiving intravenous lipid emulsions: A national survey

AIM

To assess the practice variation of defining, monitoring and managing hypertriglyceridemia (HTG) in extremely low birth weight neonates receiving intravenous lipid emulsions (IVLE).

METHODS

An 8-question survey created via the web survey site Qualtrics was distributed to neonatologists, neonatal nurse practitioners and fellows within the Section of Neonatal-Perinatal Medicine email directory list in the United States and Canada. Survey results were obtained between August and September 2022.

RESULTS

There were 249 respondents from approximately 4000 members within the Section of Neonatal-Perinatal Medicine. Responses were documented as a frequency (percentage) with a margin of error of plus or minus 6.2 %. Most respondents were neonatologists, individuals practicing for >10 years and reported a unit-based policy for IVLE initiation and advancement. The definitions of HTG varied among respondents, with the majority (42.7 %) reporting a defining threshold of >200 mg/dL. Nineteen percent of respondents reported not routinely monitoring serum triglyceride concentrations with variable triglyceride monitoring intervals reported by other survey respondents. Regarding elevated triglyceride concentrations, 19.0 % reported decreasing the IVLE rate and checking triglyceride concentrations until normalization; 14.6 % reported IVLE discontinuation and monitoring triglyceride concentrations until normalization; 61.9 % reported using a combination of the above practices; and 4.4 % reported individualized practices for IVLE management with elevated triglyceride concentrations.

CONCLUSION

This survey demonstrates a high variation in defining, monitoring and managing HTG in extremely low birth weight neonates and emphasizes the need for studies to better guide this practice.

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.

An Evaluation to Establish the Acceptable Serum Triglyceride Levels in Neonates Receiving Intravenous Fat Emulsion Infusion in a Multicenter Retrospective Study

OBJECTIVE

This study aimed to establish neonatal serum triglyceride (TG) level reference ranges during lipid infusion and correlate peak TG with neonatal outcomes.

STUDY DESIGN

This is a retrospective review of 356 neonates with 696 TG measures obtained in four neonatal intensive care units between 2015 and 2017. TG was evaluated collectively to establish a reference range and a threshold limit. To analyze the effects of a higher TG threshold, neonates were categorized by their peak TG: <180 (TG<180), 180 to 400 (TG180-400), and > 400 mg/dL (TG>400). Univariable and multivariable regression models were constructed to compare peak TG to patient characteristic and clinical outcomes.

RESULTS

The frequency of TG > 400 mg/dL was 5% and found only in neonates weighing < 1.5 kg. Neonates in the TG180-400 (n = 91) group were significantly lower in birth weight and gestational age, had lower 5-minute APGAR scores, and had increased ventilatory requirement when compared with neonates in the TG<180 (n = 240) group (all p < 0.001). The TG180-400 group had increased risk of severe intraventricular hemorrhage (p = 0.02) and bronchopulmonary dysplasia (p = 0.03). Elevated TG was associated with mortality (odds ratio [OR]: 14.4, p < 0.001) in univariable analysis, but the relationship weakened (OR: 4.4, p = 0.05) after adjusting for comorbidities in multivariable logistic regression.

CONCLUSION

It is unclear if the adverse outcomes seen in neonates with higher peak TG were due to elevated TG alone, or whether illness severity predicted the increased TG. More prospective studies are needed to further delineate the relationships.

Stability of commercial parenteral lipid emulsions repacking to polypropylene syringes

To accommodate small fluid volumes, repackaging of intravenous lipid emulsions is frequently performed in hospitals providing parenteral nutrition to neonates and smaller pediatric patients. The physical stability of lipid commercial parenteral emulsions repacked and stored in polypropylene syringe up to 30 days at room temperature, refrigerator and 40°C was determined to establish options for extended storage. Lipid emulsions in the manufacturers’ original containers were used as references. Commercial lipid emulsions (20% of oil phase), ClinOleic, Intralipid, Smoflipid, Omegaven and Lipofindin LCT/MCT were repackaged under aseptic conditions in polypropylene syringes and stored at 4°C, 25°C and 40°C without light protection. Samples were assayed periodically over 30 days using validated, stability-indicating methods. Lipid emulsions in the manufacturers’ containers stored in the same conditions were as references. Analysis of variance showed differences in the physical parameters due to temperature (p<0.05) and study day (p<0.05) but not the type of the emulsion (p = 0.98). The parenteral lipid emulsions in polypropylene syringe exhibited identical (except Z-avarage at 40°C, t = 30 days) to original containers time-dependent behavior taking into account the mean globule size, pH, and zeta potential measurements. Size of oily droplets of all test conditions remained below the United States Pharmacopeia limits. The results allow safe repacking of commercial lipid emulsion in a syringe, which is a necessary condition for supplying parenteral nutrition using the two-in-one method for newborns. However, longer storage than 12 h of repacked emulsion needs microbiological studies.

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.

Influence of gestational age and birth weight in neonatal cholesterol response to total parenteral nutrition

BACKGROUND

Premature and critically ill infants receiving total parenteral nutrition (TPN) are at risk for dyslipidemia, and altered cholesterol levels in early life may contribute to later cardiovascular risk. Data regarding plasma cholesterol response to TPN in young infants are lacking.

OBJECTIVE

To determine the changes in plasma cholesterol levels during the first week of life in infants receiving TPN and a comparison group of infants who did not receive TPN during routine care.

METHODS

In a prospective, pilot cohort study, 38 neonates (30 TPN vs. 8 No-TPN) underwent serial blood sampling during the first week of life. Gas chromatography-mass spectrometry was used to measure cholesterol in plasma and TPN administered to study participants.

RESULTS

Baseline cholesterol level was similar between groups. In contrast to infants who did not receive TPN, cholesterol levels during the first week of life were significantly higher than baseline in infants receiving TPN (maximum cholesterol response 34% vs. 103% change from baseline, No-TPN vs. TPN, respectively, P = .036). After adjusting for cumulative cholesterol received by infants receiving TPN, maximum cholesterol response remained inversely related to gestational age and birth weight (P < .05).

CONCLUSION

Plasma cholesterol significantly increases during the first week of life in neonates receiving TPN. A higher cholesterol response was induced by TPN in infants of lower gestational age and birth weight.

Safety and efficacy of parenteral fish oil-containing lipid emulsions in premature neonates

OBJECTIVE

The aim of the study was to evaluate the safety and efficacy of fish oil-containing (FO) lipid emulsions that are rich in ω-3 fatty acids for parenteral nutrition in preterm neonates by using data retrieved from randomized controlled trials.

METHODS

We performed a meta-analysis of 8 randomized controlled trials representing 483 premature neonates to compare FO with control (CO) lipid emulsions.

RESULTS

This meta-analysis revealed that the levels of ω-3 fatty acids in the form of docosahexaenoic acid, eicosapentaenoic acid, and arachidonic acid (% of total fatty acids) in plasma were statistically higher in FO groups (mean difference [MD] -0.7%, 95% confidence interval [CI] -1.05 to -0.36, P < 0.001; MD -1.31%, 95% CI -1.40 to -1.21, P < 0.001). The differences were found in red blood cell (RBC) membranes. The levels of arachidonic acid (% of total fatty acids) as ω-6 fatty acid in plasma and red blood cell membranes were significantly lower in FO groups (MD 1.27%, 95% CI 1.12-1.42, P < 0.001) (MD 0.92%, 95% CI 0.12-1.72, P = 0.02). The mean body weight, serum level of bilirubin, triglycerides or C-reactive protein, all-cause mortality, and rate of lipid emulsion-associated complications were, however, not different between FO and CO groups.

CONCLUSIONS

The level of docosahexaenoic acid is efficiently improved by FO lipid emulsions. The changes observed in eicosapentaenoic acid and arachidonic acid, and the associated safety issue, however, remain to be clarified. Any clinical benefit or detrimental effect of using FO in premature neonates cannot be demonstrated by the present study.

Three-in-one parenteral nutrition in neonates and pediatric patients: risks and benefits

Parenteral nutrition (PN) is a life-sustaining therapy designed to deliver essential nutrients to patients unable to meet nutrition needs via the enteral route. PN may be delivered via a 2-in-1 system (one solution containing amino acids, dextrose, electrolytes, vitamins, minerals, and fluids and one solution containing intravenous fat emulsions [IVFEs]) or via a 3-in-1 system (all nutrients mixed in one container). Although the use of 3-in-1 PN solutions is not necessarily therapeutically advantageous, certain benefits may exist such as the potential to reduce the risk of contamination due to decreased manipulations; ease of administration, particularly in the home care setting; possible cost savings; and reduced IVFE wastage. However, the incorporation of IVFE in 3-in-1 solutions also presents unique risks for the neonatal and pediatric population such as decreased stability, increased lipid globule size, decreased sterility and the potential for increased microbial growth/infectious complications, the need to use a larger filter size, precipitation and compatibility risks, and an increased chance of catheter occlusion. This review outlines the unique issues and challenges to be considered when formulating neonatal and pediatric 3-in-1 PN admixtures. While 3-in-1 PN solutions may be advantageous for certain pediatric populations, specifically those dependent on home PN, the risks do not outweigh the benefits in neonatal patients, and use should be avoided in this population.

Hypertriglyceridemia in extremely low birth weight infants receiving lipid emulsions

OBJECTIVE

To determine the prevalence of high TG levels in extremely low birth weight (ELBW) infants and what the risk factors are for high TG levels.

STUDY DESIGN

We performed a prospective observational study of triglyceride concentrations in extremely low birth weight infants receiving lipid infusions. Lipid infusions were begun at 0.5 grams/kg/day at age one day and the dose advanced by 0.5 grams/kg/day. Triglyceride concentrations were drawn when the dose reached 1 and 2 grams/kg/day. We compared infants with normal triglyceride levels (≤200 mg/dl) with those with elevated triglyceride levels (>200 mg/dl) with univariate and multivariate analysis.

RESULTS

There were 75 infants included in the analysis. Twenty (26.7% , 95% CI = 16.6-36.7%) had triglyceride levels >200 mg/dl. On multiple logistic regression analysis, lower birth weight was associated with the risk of an elevated triglyceride level. Triglyceride levels >200 mg/dl did not predict future mortality or morbidity.

CONCLUSION

Elevated TG levels occur commonly in ELBW infants and are associated with a lower birth weight.

Preeclampsia, prematurity and cardiovascular health in adult life

Investigations into how perinatal growth and intrauterine environment may 'programme' risk of later cardiovascular disease have been ongoing for over two decades. One of the more recent outcomes of these studies is the observation that certain pregnancy-related conditions, such as preterm birth, have an unusually large impact on the long-term cardiovascular health of the offspring. In the present paper, we review the current literature of how preterm birth affects the long-term cardiovascular structure and function of the offspring, considering three major areas of investigation: firstly, outlining the long-term cardiovascular phenotypic changes in preterm-born individuals; secondly, investigating factors related to preterm birth that may be modifying cardiovascular phenotype, such as preeclampsia, perinatal interventions, and physiological disturbances; and thirdly, the expected clinical relevance of these cardiovascular changes. This review discusses the importance of continued research focused on the mechanistic understanding of these cardiovascular alterations in order to develop specific primary prevention strategies.

Microbial Growth in Neonatal Intravenous Fat Emulsion Administered Over 12 Versus 24 Hours

OBJECTIVES

To determine whether an extended infusion time (24 hours) of intravenous fat emulsion is associated with an increase in microbial growth, versus a shorter infusion time (12 hours).

METHODS

Samples were collected from intravenous fat emulsions (n=132), from intravenous fat emulsions prepared in the current 24-hour infusion method (n=55), and from intravenous fat emulsions prepared in the twice-daily (12-hour infusion) method (n=55). In addition, samples were collected from pharmacy (n=22) to test for possible contamination.

RESULTS

No growth was observed in either arm of the study.

CONCLUSIONS

Current Kern Medical Center policy of preparation and administration of neonatal intensive care unit intravenous fat emulsion is safe and effective in regard to microbial growth.

Dose of intravenous lipids and rate of bacterial clearance in preterm infants with blood stream infections

BACKGROUND

Intravenous lipid emulsion (IVLE) is an integral part of the total parenteral nutrition (TPN) regimen in neonates. The use of IVLE during sepsis is the subject of controversy because it may interfere with phagocytosis of microbes by macrophages and may lead to significant hypertriglyceridemia.

OBJECTIVE

This paper aims to study the rate of clearance of bacteria in relation to dose of IVLE administered to preterm infants with blood stream infections (BSIs).

METHODS

Preterm infants (mean gestational age ± SD, 32.0 ± 2.5 weeks) with culture-proven BSI and receiving TPN were randomized to two groups. The first group (n = 22) was given the usual dose of IVLE according to a standard protocol (starting from 0.5 g kg(-1) day(-1) and gradually increased by 1 g kg(-1) day(-1) to a maximum of 3.5 g kg(-1) day(-1)); in the second group (n = 20), IVLE were restricted at a dose of 1 g kg(-1) day(-1). Samples for blood cultures were withdrawn every 24 h until a negative culture was obtained. CRP was measured daily until its normalization. Serum triglycerides were monitored daily.

RESULTS

The rate of bacterial clearance was significantly more rapid in the restricted-dose IVLE group compared to the standard-dose group [72 (48-120) versus 144 (72-168) h, p = 0.001]. Daily weight increment was significantly greater in the standard-dose IVLE group compared to the restricted-dose IVLE group [25 (6.9-31.9) versus 0.9 (-3.3-11.7) g, p = 0.0001]. The duration of antibiotic use was significantly reduced in the restricted-dose IVLE group compared with the standard-dose IVLE group (10.0 ± 4.5 vs 14.9 ± 5.1 days; p = 0.003). The durations of TPN, mechanical ventilation, and hospitalization were not significantly different between groups.

CONCLUSIONS

Restriction of the dose of IVLE to 1 g kg(-1) day(-1) in preterm infants with BSI is associated with earlier negative blood cultures and reduced duration of antibiotic therapy but was associated with a lower daily weight increments.

Short-term use of parenteral nutrition with a lipid emulsion containing a mixture of soybean oil, olive oil, medium-chain triglycerides, and fish oil: a randomized double-blind study in preterm infants

BACKGROUND

For premature neonates needing parenteral nutrition (PN), a balanced lipid supply is crucial. The authors hypothesized that a lipid emulsion containing medium-chain triglycerides (MCTs) and soybean, olive, and fish oils would be as safe and well tolerated as a soybean emulsion while beneficially influencing the fatty acid profile.

METHODS

Double-blind, controlled study in 53 neonates (<34 weeks' gestation) randomized to receive at least 7 days of PN containing either an emulsion of MCTs and soybean, olive, and fish oils or a soybean oil emulsion. Target lipid dosage was 1.0 g fat/kg body weight [BW]/d on days 1-3, 2 g/kg BW/d on day 4, 3 g/kg BW/d on day 5, and 3.5 g/kg BW/d on days 6-14.

RESULTS

Test emulsion vs control, mean ± SD: baseline triglyceride concentrations were 0.52 ± 0.16 vs 0.54 ± 0.19 mmol/L and increased similarly in both groups to 0.69 ± 0.38 vs 0.67 ± 0.36 on day 8 of treatment (P = .781 for change). A significantly higher decrease in total and direct bilirubin vs baseline was seen in the test group compared with the control group P < .05 between groups). In plasma and red blood cell phospholipids, eicosapentaenoic acid and docosahexaenoic acid were higher, and the n-6/n-3 fatty acid ratio was lower in the test group (P < .05 vs control).

CONCLUSIONS

The lipid emulsion, based on a mixture of MCTs and soybean, olive, and fish oils, was safe and well tolerated by preterm infants while beneficially modulating the fatty acid profile.

Short-term exposure to exogenous lipids in premature infants and long-term changes in aortic and cardiac function

OBJECTIVE

Intravenous lipid use is associated with an acute hyperlipidemia, but long-term consequences have not been studied. We investigated whether elevated lipids in humans during the critical period of preterm neonatal life have a long-term impact on aortic and myocardial function relevant to adult disease.

METHODS AND RESULTS

We followed up 102 subjects born prematurely and now aged 23 to 28 years. Eighteen received intravenous lipids as neonates and were matched to controls with equivalent perinatal characteristics. Global and regional aortic stiffness and left ventricular function were assessed by cardiovascular magnetic resonance. Those who received intravenous lipids had greater aortic stiffness in early adulthood (P=0.0002), with greater stiffness in the abdominal aorta (P=0.012). The relationship was graded according to the elevation in neonatal cholesterol induced by intravenous lipids (P<0.0001) but not other metabolic parameters altered by the infusion. Peak systolic circumferential strain was also reduced in the lipid group (P=0.006), which, again, was proportional to neonatal cholesterol level (P<0.01).

CONCLUSIONS

Aortic and myocardial function in young adulthood is associated with intralipid exposure during neonatal life for preterm infants, in a graded manner related to the rise in cholesterol. Circulating cholesterol during critical developmental periods may have long-term impacts on the human cardiovascular system.

Effect of free fatty acids on bilirubin-albumin binding affinity and unbound bilirubin in premature infants

BACKGROUND

The author has previously shown that intravenous lipid intake may be associated with an increase in unbound bilirubin in infants < or =28 weeks gestational age. The objective of this study was to evaluate whether this increase in unbound bilirubin is mediated by free fatty acids and to examine the secondary effect of free fatty acids on bilirubin-albumin binding affinity.

METHODS

A prospective study was conducted to include 26 infants < or =32 weeks gestational age with indirect hyperbilirubinemia and receiving intravenous lipids during the first 10 postnatal days. Blood samples were collected for unbound bilirubin, binding affinity, and free fatty acid measurement at varying intravenous lipid intakes (1-3 g/kg/d). Regression analyses were performed to evaluate the roles of free fatty acids and binding affinity as mediators.

RESULTS

Intravenous lipid intake was significantly associated with an increase in free fatty acids and unbound bilirubin in infants < or =28 weeks but not >28 weeks gestational age. In infants < or =28 weeks gestational age, each unit increase in free fatty acids was significantly associated with a decrease in binding affinity, which was significantly associated with an increase in unbound bilirubin.

CONCLUSIONS

In infants < or =28 weeks gestational age, intravenous lipid intake may be associated with an increase in unbound bilirubin, and this is mediated by an increase in free fatty acids and a secondary decrease in binding affinity. In infants >28 weeks gestational age, higher intravenous lipid intake may be used because it is unassociated with increases in free fatty acids and unbound bilirubin.

Safety and efficacy of a lipid emulsion containing a mixture of soybean oil, medium-chain triglycerides, olive oil, and fish oil: a randomised, double-blind clinical trial in premature infants requiring parenteral nutrition

OBJECTIVES

Safety, tolerability, and efficacy of a novel lipid emulsion containing a mixture of soybean oil, medium-chain triglycerides, olive oil, and fish oil (SMOFlipid 20%) with reduced n-6 fatty acids (FA), increased monounsaturated and n-3 FA, and enriched in vitamin E were evaluated in premature infants compared with a soybean oil-based emulsion.

PATIENTS AND METHODS

Sixty (30/30) premature neonates (age 3-7 days, gestational age ≤ 34 weeks, birth weights 1000-2500 g) received parenteral nutrition (PN) with either SMOFlipid 20% (study group) or a conventional lipid emulsion (Intralipid 20%, control group) for a minimum of 7 up to 14 days. Lipid supply started at 0.5 g · kg body weight(-1) · day(-1) on day 1 and increased stepwise (by 0.5 g) up to 2 g · kg body weight(-1) · day(-1) on days 4 to 14. Safety and efficacy parameters were assessed on days 0, 8, and 15 if PN was continued.

RESULTS

Adverse events, serum triglycerides, vital signs, local tolerance, and clinical laboratory did not show noticeable group differences, confirming the safety of study treatment. At study end, γ-glutamyl transferase was lower in the study versus the control group (107.8 ± 81.7 vs 188.8 ± 176.7 IU/L, P < 0.05). The relative increase in body weight (day 8 vs baseline) was 5.0% ± 6.5% versus 5.1% ± 6.6% (study vs control, not significant). In the study group, an increase in n-3 FA in red blood cell phospholipids and n-3:n-6 FA ratio was observed. Plasma α-tocopherol (study vs control) was increased versus baseline on day 8 (26.35 ± 10.03 vs 3.67 ± 8.06 μmol/L, P < 0.05) and at study termination (26.97 ± 18.32 vs 8.73 ± 11.41 μmol/L, P < 0.05).

CONCLUSIONS

Parenteral infusion of SMOFlipid was safe and well tolerated and showed a potential beneficial influence on cholestasis, n-3 FA, and vitamin E status in premature infants requiring PN.

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

OBJECTIVE

To identify a risk profile for harmful medication errors in the neonatal intensive care unit (NICU).

STUDY DESIGN

A retrospective cross-sectional study on NICU medication error reports submitted to MEDMARX between 1 January 1999, and 31 December 2005. The Rao-Scott modified chi(2) test was used for analysis.

RESULT

6749 NICU medication error reports were submitted by 163 health-care facilities. Administering errors accounted for approximately one half of errors, and human factors were the most frequently cited cause of error. Patient age was not associated with an increased likelihood of an error being harmful (P=0.11). Error reports involving Institute for Safe Medication Practices (ISMP) High-Alert Medications, occurring in the prescribing phase of medication processing, or involving equipment/delivery device failures were more likely to be harmful (P< or =0.05).

CONCLUSION

Risk factors for harmful medication error reports include use of ISMP High-Alert Medications, the prescribing phase of the medication use process, and failure of equipment/delivery devices.

State of the art review: Intravenous fat emulsions: Current applications, safety profile, and clinical implications

OBJECTIVE

To review the current state of the science regarding intravenous fat emulsions (IVFEs), with an emphasis on their safety profile.

DATA SOURCES

Articles were identified via a search of the MEDLINE database, including publications from 1979 to December 2009, using a search string that included the terms parenteral nutrition, lipid emulsion, fat emulsion, IVFE, safety, adverse effect, neonate intralipid, and terms describing a range of specific adverse events (AEs) such as pancreatitis.

STUDY SELECTION AND DATA EXTRACTION

We selected articles that allowed us to compare the results of clinical trials involving delivery of medications via IVFEs with the historical use and effects of IVFEs in parenteral nutrition, with an emphasis on AEs. We focused on 2 drugs in current use that are administered intravenously in lipid emulsions: propofol and clevidipine.

DATA SYNTHESIS

Clearance of the fat particles in IVFEs is mediated by the enzyme lipoprotein lipase. AEs are more likely if the rate or duration of IVFE administration exceeds the enzyme's clearance capacity. AEs are also more likely after administration of a 10% IVFE formulation than a 20% formulation, because the higher concentration of free phospholipid in the 10% formulation interferes with lipoprotein lipase activity. AEs can be reduced by administering IVFEs at a dosage < or = 2.5 g/kg/day and at a rate < or = 0.11 g/kg/h. The anesthetic agent propofol, which is formulated in a 10% IVFE, has been used clinically for 25 years. Typical AEs associated with propofol use include infection, high plasma triglyceride concentrations, and pancreatitis. Recent clinical trials involving clevidipine, which is formulated in a 20% IVFE, have demonstrated a low rate of lipid-related AEs.

CONCLUSIONS

The results of this review demonstrate that IVFEs are well tolerated when administered in accordance with guideline recommendations.

Pediatric parenteral nutrition: putting the microscope on macronutrients and micronutrients

Parenteral nutrition can be a life-saving therapy, but its benefits need to be balanced with a unique set of risks and complications. Methods of practice vary because there is a dearth of research in the area of pediatric parenteral nutrition. This article reviews the available literature on parenteral nutrition in children and provides suggestions on prevention and management of parenteral nutrition-associated liver disease. Some of the issues discussed in this article include glucose infusion rates, cycling of parenteral nutrition, copper and manganese toxicity, and the provision of glutamine, selenium, and carnitine.

Intravenous lipid and bilirubin-albumin binding variables in premature infants

BACKGROUND

The lipid intake at which a significant bilirubin-displacing effect occurs as a function of gestational age (GA) is unclear.

OBJECTIVE

To determine the effect of gradual increase in IL intake from 1.5 to 3 g/kg per day on bilirubin-albumin binding variables as a function of GA in premature infants with indirect hyperbilirubinemia.

METHODS

Infants of 24 to 33 weeks' gestation at birth who received IL (20% Intralipid [Fresenius Kabi, Uppsala, Sweden]) doses of 1.5, 2, 2.5, and 3 g/kg per day over 4 consecutive days were prospectively evaluated. The blood samples were drawn twice at least 8 hours apart on each IL intake to measure total serum bilirubin and free bilirubin by the peroxidase test. The highest free bilirubin on each IL intake, the corresponding total serum bilirubin, and serum albumin were used to calculate the bilirubin/albumin binding constant or binding affinity.

RESULTS

Sixty-two infants (median GA: 28 weeks) were studied during the first 10 days of life. None of the subjects had culture-proven sepsis, had triglyceride levels of >2.05 mmol/L, or were receiving steroids. Infants were grouped in 2-week GA intervals. The cumulative frequency of elevated free bilirubin concentration (>or=90th percentile or B(f) >or= 32 nmol/L) as a function of IL intake was inversely related to GA and was significantly different among 2-week GA groups. There was significant decrease in binding affinity and increase in free bilirubin concentration with higher IL intake for <or=28 week but not for >28 week GA groups.

CONCLUSIONS

The IL intake may be associated with a significant fall in the binding affinity of bilirubin for plasma protein and a concomitant increase in free bilirubin concentration in premature infants. The lipid intake at which this occurs depends on GA.

Neonatal nutrition: a brief review

BACKGROUND

With increasing survival of extremely premature infants, emphasis is now focused on the quality of these survivors' lives. Possibly the most important factor in the premature's ability to survive in the NICU and thrive is the ability to replicate in utero growth through enteral and parenteral nutrition.

DATA SOURCES

Current literature and review articles were retrieved from PubMed and personal files of the authors.

RESULTS

The use and complications of the various components of total parenteral nutrition (TPN) were reviewed. The composition of appropriate enteral feeds for the premature was reviewed as was the difficulties associated with the establishment of adequate enteral feeds in the premature infants.

CONCLUSIONS

Early initiation of amino acids in TPN and timely increases in the components of TPN can improve the caloric intake of prematures. Enteral feeds, particularly of breast milk, may be started within the first few days of life in all but hemodynamically unstable prematures. Newer lipid preparations show promise in reversing the hepatic damage of TPN associated cholestatic jaundice.