Parenteral Nutrition Associated Cholestasis Is Earlier, More Prolonged and Severe in Small for Gestational Age Compared with Appropriate for Gestational Age Very Low Birth Weight Infants

Abstract

PurposeWe hypothesized that parenteral nutrition associated cholestasis (PNAC) would be more severe in small for gestational age (SGA) compared with appropriate for gestational age (AGA) very low birth weight (VLBW) infants.Materials and MethodsSixty-one VLBW infants were diagnosed as PNAC with exposure to parenteral nutrition with elevation of direct bilirubin ≥2 mg/dL for ≥14 days. Twenty-one SGA infants and 40 AGA infants matched for gestation were compared.ResultsCompared with AGA infants, PNAC in SGA infants was diagnosed earlier (25±7 days vs. 35±14 days, p=0.002) and persisted longer (62±36 days vs. 46±27 days, p=0.048). Severe PNAC, defined as persistent elevation of direct bilirubin ≥4 mg/dL for more than 1 month with elevation of liver enzymes, was more frequent in SGA than in AGA infants (61% vs. 35%, p=0.018). The serum total bilirubin and direct bilirubin levels during the 13 weeks of life were significantly different in SGA compared with AGA infants. SGA infants had more frequent (76% vs. 50%, p=0.046), and persistent elevation of alanine aminotransferase.ConclusionThe clinical course of PNAC is more persistent and severe in SGA infants. Careful monitoring and treatment are required for SGA infants.

Retrospective Dual‐Center Study of Parenteral Nutrition–Associated Cholestasis in Premature Neonates: 15 Years' Experience

“…The idea of sex differences in PNAC has not yet reached a consensus among researchers. For instance, Albers et al 22 showed that male sex may predispose neonate surgical patients to PNAC, and similar results were reported by Jolin‐Dahel et al 2 However, male sex is not identified as a risk factor in many other studies 3 , 8 , 10 , 30 …”

“…PNAC is a recognized predictor of mortality and significantly life‐threatening events in infants on long‐term PN 17 ; its etiology is not well understood. Despite several risk factors being proposed, there are controversies over whether some are independent factors, such as small for GA, 3 , 6 , 10 low BW, 18 , 19 young GA, 2 , 7 , 19 – 21 and male sex 2 , 10 , 22 . In this retrospective study, after univariate analyses, sepsis, male sex, longer PN duration, lower BW, younger GA, more daily calorie intake, and higher dose of lipids and amino acids were indicated to be potentially associated with PNAC.…”

“…Parenteral nutrition–associated cholestasis (PNAC) is a major complication of PN in neonates and one of the most challenging problems for neonatal practitioners 1 . PNAC pathogenesis may be multifactorial, and a number of risk factors have been recognized to be attributed to PNAC, such as prolonged administration of PN, low birth weight (BW), prematurity, severe infections, PN components, total caloric overloading, enzyme deficiencies, genetic causes, anatomic factors, absence of enteral feeding, small for gestational age, male sex, and intestinal resection 1 – 13 …”

Risk factors of parenteral nutrition‐associated cholestasis in very‐low‐birthweight infants

“…First, the PN duration (23 days, range: 18-32 days) of the PNAC group was shorter than previous studies. 1,[14][15][16][17] Second, infants in our study received lower doses of lipids (1.5 g/kg/day, range: 1.2-1.8 g/kg/day), 1,[16][17][18] as well as glucose (8.8 g/kg/day, range: 7.1-10.7 g/kg/day) ,1,19,20 which have been reported to be independent risk factors for PNAC. 1,7,14,18 Finally, we excluded infants who underwent surgery, who have a higher risk of developing PNAC.…”

Parenteral nutrition therapy for neonates: Experience in a tertiary care centre in Sri Lanka

“…Hence, duration of PN should be as short as possible or at least partial enteral feeding should be started as early as possible to minimize the adverse effects and to reduce NEC and death 11 . There are many suggested risks associated with PN such as cholestasis and liver disease, venous thrombosis, metabolic changes such as hypoglycaemia and hyponatraemia especially in babies who are small for gestational age or preterm 12,13 .…”