Long‐term Exposure of Children to a Mixed Lipid Emulsion Is Less Hepatotoxic Than Soybean‐based Lipid Emulsion

Lam, Carol K.L.; Church, Peter; Haliburton, Beth; Chambers, Kathryn; Martincevic, Inez; Vresk, Laura; Courtney‐Martin, Glenda; Bandsma, Robert; Avitzur, Yaron; Pw, Wales; Mouzaki, Marialena

doi:10.1097/mpg.0000000000001799

Cited by 23 publications

(39 citation statements)

References 22 publications

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“…Lipid emulsions containing fish oil offer several potential advantages compared with lipid emulsions derived purely from soybean oil, including decreased ω‐6 and increased ω‐3 PUFA content, higher α‐tocopherol levels, and reduced phytosterol content . Studies in PN‐dependent infants and children at risk for IFALD have shown that multi‐component lipid emulsions containing fish oil reduce the risk of cholestasis and improve biochemical measures of hepatobiliary function compared with soybean lipid emulsions …”

Section: Pediatric Patients Requiring Pnmentioning

confidence: 99%

Summary of Proceedings and Expert Consensus Statements From the International Summit “Lipids in Parenteral Nutrition”

Martindale

Berlana

Boullata

et al. 2020

J Parenter Enteral Nutr

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Background The 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology, to assess the current state of knowledge and develop expert consensus statements regarding the use of intravenous lipid emulsions in various patient populations and clinical settings. The main purpose of the consensus statements is to assist healthcare professionals by providing practical guidance on common clinical questions related to the provision of lipid emulsions as part of parenteral nutrition (PN). Methods The summit was designed to allow interactive discussion and consensus development. The resulting consensus statements represent the collective opinion of the members of the expert panel, which was informed and supported by scientific evidence and clinical experience. Results The current article summarizes the key discussion topics from the summit and provides a set of consensus statements designed to complement existing evidence‐based guidelines. Lipid emulsions are a major component of PN, serving as a condensed source of energy and essential fatty acids. In addition, lipids modulate a variety of biologic functions, including inflammatory and immune responses, coagulation, and cell signaling. A growing body of evidence suggests that lipid emulsions containing ω‐3 fatty acids from fish oil confer important clinical benefits via suppression of inflammatory mediators and activation of pathways involved in the resolution of inflammation. Conclusions This article provides a set of expert consensus statements to complement formal PN guideline recommendations.

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Section: Pediatric Patients Requiring Pnmentioning

confidence: 99%

Summary of Proceedings and Expert Consensus Statements From the International Summit “Lipids in Parenteral Nutrition”

Martindale

Berlana

Boullata

et al. 2020

J Parenter Enteral Nutr

View full text Add to dashboard Cite

show abstract

“…There have been efforts to prevent or reverse cholestasis by modifying lipid administration in patients requiring long‐term PN. Modifications include lipid minimization, temporarily discontinuing lipids, and using lipid emulsions containing lipid sources other than soybean oil (eg, pure fish oil or composite lipid emulsions with or without fish oil) …”

Section: Lipid Emulsions’ Role In the Treatment And Prevention Of Chomentioning

confidence: 99%

“…Because long‐term use of a pure soybean oil emulsion is a risk factor for cholestasis, both lipid restriction and the use of alternative lipid sources are potential preventative strategies . Studies evaluating the effect of lipid emulsions on the prevention of cholestasis in infants and children are shown in Table …”

Section: Lipid Emulsions’ Role In the Treatment And Prevention Of Chomentioning

confidence: 99%

“…The effect of a composite lipid emulsion containing fish oil on hepatobiliary function in children at risk for IFALD has been evaluated in 2 randomized controlled trials and 1 prospective cohort study . A randomized trial in 28 children receiving HPN showed a reduction in total bilirubin levels in patients receiving SMOF but not those given a soybean oil lipid emulsion (mean change from baseline, −1.5 vs 2.3 µmol/L, respectively; P < .01) .…”

Section: Lipid Emulsions’ Role In the Treatment And Prevention Of Chomentioning

confidence: 99%

“…Patients receiving SMOF also had a higher likelihood of experiencing a decrease in serum conjugated bilirubin compared with those receiving soybean oil (hazard ratio, 10.6; 95% CI, 1.3–86.9; P = .006). A prospective cohort of hospitalized children (n = 20) was evaluated for biochemical measures of liver injury during PN (>4 weeks) when receiving SMOF (median dose, 2.2 g/kg/d) compared with an age‐ and diagnosis‐matched historical cohort (n = 20) given a soybean oil emulsion (median dose, 2.1 g/kg/d) . Analysis of longitudinal measures of liver function using a generalized estimating equation model showed that median values for conjugated bilirubin were significantly lower for children given SMOF ( P < .001) …”

Section: Lipid Emulsions’ Role In the Treatment And Prevention Of Chomentioning

confidence: 99%

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Lipid Emulsion Use in Pediatric Patients Requiring Long‐Term Parenteral Nutrition

Goulet

Cai

Seo

2020

J Parenter Enteral Nutr

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The ability to deliver nutrients via parenteral nutrition (PN) has markedly improved the prognosis of infants and children with intestinal failure. Technical refinements and advances in knowledge have led to the development of highly sophisticated PN solutions that are tailored to meet the needs of pediatric patients. However, children who require long‐term PN have an increased risk of complications such as catheter‐related sepsis, liver disease, and bone disease. Although the pathogenesis of intestinal failure associated liver disease (IFALD) is multifactorial, studies have identified a possible link between the dose of lipid emulsions based on soybean oil and cholestasis, shown to occur with a significantly higher frequency in patients receiving >1 g lipids/kg/d. Potential contributing factors include oxidative stress, high ω‐6 polyunsaturated fatty acid (PUFA) and phytosterol content, and relatively low α‐tocopherol levels. Lipid emulsions containing fish oil offer potential advantages compared with traditional emulsions with a high soybean oil content, such as decreased ω‐6 and increased ω‐3 PUFA concentrations, high concentrations of α‐tocopherol, and reduced phytosterol content. Studies in PN‐dependent children at risk for IFALD have shown that lipid emulsions containing fish oil reduce the risk of cholestasis and improve biochemical measures of hepatobiliary function compared with pure soybean oil emulsions. This review summarizes evidence regarding the role of lipid emulsions in the management of pediatric patients with intestinal failure requiring long‐term PN, with a particular focus on the prevention and treatment of IFALD.

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Change to Mixed-Lipid Emulsion From Soybean Oil–Based Lipid Emulsion in Pediatric Patients

Haines,

Ohnuma,

Hornik

et al. 2023

JAMA Netw Open

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ImportanceCritically ill pediatric patients often require parenteral nutrition (PN) in the intensive care unit (ICU). Literature suggests mixed lipid emulsions (LE) with soybean oil reduction strategies may improve outcomes.ObjectiveTo examine the association of a hospital-wide switch to a mixed-lipid formula (4-OLE) with pediatric outcomes.Design, Setting, and ParticipantsRetrospective cohort study at a large US academic referral center. Pediatric patients aged 1 month to 17 years requiring parenteral nutrition from May 2016 to September 2019 were included. Data were analyzed from October 2020 to February 2023.ExposureIn 2017, Duke University Health System fully converted to a soybean oil/MCT/olive/fish oil lipid (4-OLE) from pure soybean oil–based LE in pediatric patients. Pediatric patients before the change (Intralipid [IL] group) were compared with patients after (4-OLE group).Main Outcomes and MeasuresClinical outcomes were compared between treatment periods via multivariable regression models. The primary outcome was hospital length of stay (LOS). Fourteen secondary outcomes included hospital mortality of any cause, 30-day or 90-day readmission, pneumonia, urinary tract infections (UTIs), total caloric delivery, and liver function tests (aspartate aminotransferase, alanine transaminase, alkaline phosphatase, and total bilirubin).ResultsA total of 684 children dependent on PN were identified (342 were critically ill), with 30% (206 children) in the preswitch (IL) period and 70% (478 children) in the postswitch (4-OLE) period; 123 were male (59.7%). In comparing IL vs 4-OLE, there was a significant difference in median (IQR) age (4.0 [1.2-13.0] vs 3.0 [0.8-9.0] years, respectively; P = .04), without difference in body mass index or baseline comorbidities except for significant differences in cancer diagnosis (26 patients in the IL group [12.6%] vs 29 patients in the 4-OLE group [6.1%]; P = .004) and chronic obstructive pulmonary disease (24 patients in the IL group [11.7%] vs 30 patients in the 4-OLE group [6.3%]; P = .02). In the all children cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.05-0.78), and reduced UTI risk (OR, 0.33; 95% CI, 0.18-0.64). In the ICU cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.78-0.83), and reduced UTI risk (OR, 0.23; 95% CI, 0.11-0.51). Other secondary outcomes were not significant.Conclusions and RelevanceIn this observational study of clinical outcomes among children dependent on PN, a switch to 4-OLE in a large academic hospital was associated with a significant decrease in hospital LOS in ICU and non-ICU patients. These findings suggest switching to a soy–LE sparing strategy using 4-OLE is feasible, safe, and associated with improved clinical outcomes in pediatric PN patients.

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Long‐term Exposure of Children to a Mixed Lipid Emulsion Is Less Hepatotoxic Than Soybean‐based Lipid Emulsion

Cited by 23 publications

References 22 publications

Summary of Proceedings and Expert Consensus Statements From the International Summit “Lipids in Parenteral Nutrition”

Summary of Proceedings and Expert Consensus Statements From the International Summit “Lipids in Parenteral Nutrition”

Lipid Emulsion Use in Pediatric Patients Requiring Long‐Term Parenteral Nutrition

Change to Mixed-Lipid Emulsion From Soybean Oil–Based Lipid Emulsion in Pediatric Patients

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