Preterm small for gestational age infants are not at higher risk for parenteral nutrition-associated cholestasis

Current Practices, Challenges, and Recommendations in Enteral Nutrition After Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a neonatal disease with high mortality and morbidity. There is a lack of evidence-based recommendations on nutritional rehabilitation following NEC, and much of the current practice is guided by institutional policies and expert opinions. After a diagnosis of NEC, infants are exposed to an extended period of bowel rest and a prolonged course of antibiotics. Recognizing the patient characteristics that predict nutritional tolerance, early initiation of enteral nutrition, minimizing periods of bowel rest and antibiotic exposure, and standardization of dietary practices are the mainstay of post-NEC nutrition.

Intestinal Continuity Alleviates Pediatric Intestinal Failure-Associated Liver Disease

Background

Type I short bowel syndrome (SBS) occurs after a critical reduction in the functional gut mass and resection of intestinal continuity after ileostomy or jejunostomy for necrotizing enterocolitis (NEC), intestinal atresia or other causes. SBS is often accompanied with intestinal failure-associated liver disease (IFALD) who requires long-term parenteral nutrition (PN). Our study aimed to observe the effect of intestinal continuity on the hepatic function of pediatric intestinal failure (IF) patients with type I SBS.

Methods

The pre-and post-anastomosis medical records of 35 pediatric patients with type I SBS from April 2013 to April 2019 were reviewed retrospectively. The average growth (cm/month) in the proximal and distal small bowel lengths was calculated as the growth in intestinal length (cm)/the duration (month) from enterostomy to anastomosis. The changes in hepatic function from enterostomy to anastomosis were evaluated by assessment of hepatic function before anastomosis for 6 weeks and after anastomosis for 4 weeks.

Results

The average growth in proximal intestinal length was 9.3 cm/month (±7.2) in neonates and 2.8 cm/month (1.3, 11.9) in infants and children, and in distal intestinal length was 1.5 cm/month (0, 2.7) in neonates and 0.4 cm/month (0, 1.4) in infants and children. The incidence of IFALD was 28.6% 1 month before anastomosis and 20.0% 1 month after anastomosis (p < 0.05).

Conclusion

In pediatric type I SBS with IFALD, restoration of intestinal continuity may alleviate liver injury. There was an intestinal compensatory effect on the growth in the intestinal length after resection, and better results were seen in neonates in terms of intestinal length growth.

Cholestasis after very preterm birth was associated with adverse neonatal outcomes but no significant long-term liver disease: A population-based study

AIM

To describe outcome linked to neonatal cholestasis in a defined cohort of very preterm infants.

METHODS

Population-based retrospective case-control study of preterm infants, gestational age <30 weeks, surviving for 28 days, in Stockholm County. Cholestasis was defined as conjugated bilirubin ≥30 μmol/L exceeding 20% of total level at least twice and graded as high if exceeding 100 μmol/L. Cholestatic cases were matched on gestational week with two non-cholestatic controls.

RESULTS

The incidence rate of cholestasis was 37/250 (14.8%), with increasing rates in lower gestational weeks. Perinatal factors associated with cholestasis were pre-eclampsia and being born small for gestational age. Cholestatic infants had three times more bronchopulmonary dysplasia and eight times more retinopathy of prematurity. The mortality was 13.5% in cholestatic infants versus 2.7% in controls (P = .040). All deceased cholestatic infants had high-grade cholestasis. No surviving infants developed chronic liver disease by 10 years of age.

CONCLUSION

Cholestasis was common in very preterm infants and linked to disease severity and adverse outcome. Cholestasis may be an independent risk factor for bronchopulmonary dysplasia and retinopathy of prematurity and more severe cholestasis associated with increased mortality. Cholestasis was not associated with chronic liver disease later in childhood.

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

AIM

We aimed to explore risk factors associated with parenteral nutrition-associated cholestasis (PNAC) in very-low-birthweight (VLBW) infants.

METHODS

VLBW infants receiving parenteral nutrition (PN) for at least 14 days were enrolled in a retrospective dual-centre study and divided into two groups chronologically: group A (2000-2007) and group B (2008-2015). The incidence of PNAC and related factors were investigated. We compared the differences between PNAC and non-PNAC groups. A multivariate binary logistic regression analysis was carried out to identify the potential risk factors of PNAC.

RESULTS

A total of 387 VLBW infants (53 in group A and 334 in group B) were enrolled in the study. The total incidence of PNAC was 6.7%, 9.4% in group A and 6.3% in group B. The dosage of amino acid (P = 0.009), glucose (P = 0.006), PN calories (P = 0.021) and the ratio of glucose/fat (P = 0.014) were significantly higher in group B than in group A. Non-protein energy to nitrogen ratio (P = 0.017) was lower in group B. Birthweight was significantly lower in the PNAC group than in the non-PNAC group (P = 0.021). Subgroup analysis showed that gestational age and duration of PN were significantly different between the PNAC and non-PNAC groups (P < 0.05). Logistic regression showed that prolonged duration of PN (≥43 days) (odds ratio 3.155, 95% confidence interval 1.009-9.861, P = 0.048) was an independent risk factor of PNAC.

CONCLUSIONS

For VLBW infants, prolonged duration of PN is a risk factor for the development of PNAC. PNAC may be prevented by weaning off PN as early as possible in VLBW infants.

Small Proportion of Low-Birth-Weight Infants With Ostomy and Intestinal Failure Due to Short-Bowel Syndrome Achieve Enteral Autonomy Prior to Reanastomosis

BACKGROUND

It is challenging to provide optimum nutrition in low-birth-weight (LBW) infants with short-bowel syndrome (SBS) and ostomy. This study aims to evaluate the clinical course of LBW infants with SBS and ostomy in response to enteral feeds, recognize characteristics associated with achievement of enteral autonomy prior to reanastomosis, and evaluate associated short-term outcomes.

METHODS

A retrospective analysis of 52 LBW neonates with intestinal failure (IF) caused by SBS and ostomy treated in a neonatal intensive care unit from 2012 to 2018 was performed. Clinical characteristics and short-term outcomes were studied in relation to the location of the ostomy and the success with enteral feeding achieved prior to reanastomosis.

RESULTS

Of the 52 infants with SBS, jejunostomy, ileostomy, and colostomy were present in 9, 40, and 3 infants, respectively. Fourteen (26.92%) infants achieved enteral autonomy transiently, and 7 (13.46%) sustained until reanastomosis. All 9 infants with jejunostomy were parenteral nutrition dependent, compared with 22 with ileostomy and none with colostomy (P = 0.002). Infants who achieved enteral autonomy showed lower incidence of cholestasis (P = 0.038) and better growth velocity (P = 0.02) prior to reanastomosis.

CONCLUSIONS

A minority of LBW infants with SBS and ostomy achieved enteral autonomy prior to reanastomosis. Distal ostomy (ileostomy and colostomy), reduced cholestasis, and better growth were associated with achievement of enteral autonomy. Our report highlights the challenges in establishing enteral autonomy in LBW infants with IF and ostomy, and the feasibility of that approach in a minority of patients, with tangible benefits.

Intestinal failure-associated liver disease (IFALD): insights into pathogenesis and advances in management

Premature infants and children with intestinal failure (IF) or short bowel syndrome are susceptible to intestinal failure-associated liver disease (IFALD, previously referred to as parenteral nutrition-associated liver disease, or PNALD). IFALD in children is characterized by progressive cholestasis and biliary fibrosis, and steatohepatitis in adults, and is seen in individuals dependent upon prolonged administration of PN. Many factors have been proposed as contributing to the pathogenesis of IFALD. In recent years, the focus has been on the potential synergistic roles of the intestinal microbiome, increased intestinal permeability, activation of hepatic innate immune pathways, and the use of intravenous soybean-oil-based intravenous lipid emulsions (SO-ILE). In vitro and in vivo studies have identified stigmasterol, a component of the plant sterols present in SO-ILE, as playing an important role. Although various strategies have been adopted to prevent or reverse IFALD, most suffer from a lack of strong evidence supported by well-designed, prospective clinical trials with clearly defined endpoints. Reduction in the amount of SO-ILEs or replacement with non-SO-ILEs has been shown to reverse IFALD although safety and long-term effectiveness have not been studied. Medical and surgical modalities to increase intestinal adaptation, advance enteral feedings, and prevent central line bloodstream infections are also important preventative strategies. There is a continued need to conduct high-quality, prospective trials with clearly define outcome measures to ascertain the potential benefits of these strategies.

Prevention and Treatment of Intestinal Failure-Associated Liver Disease in Children

Intestinal failure-associated liver disease (IFALD) is a threatening complication for children on long-term parenteral nutrition because of intestinal failure. When progressive and intractable, it may jeopardize intestinal rehabilitation and lead to combined liver and intestinal transplantation. The institution of dedicated intestinal failure centers has dramatically decreased the incidence of such complication. IFALD may rapidly fade away if very early management aimed at preventing progression to end-stage liver disease is provided. In this review, we address the etiology and risk factors of IFALD in order to introduce pillars of prevention (nutritional management and catheter-related infections control). The latest evidence of therapeutic strategies, such as medical and surgical treatments, is also discussed.

Rapid determination and conversion study of 5-hydroxymethylfurfural and its derivatives in glucose injection

5-HMF and two identified additional derivatives (II, III) in glucose injection were rapidly separated in less than 7 min for the first time by our normal phase high performance liquid chromatography. The results were more precise than the method adopted by pharmacopeias.

Predictive Value of the Aspartate Aminotransferase to Platelet Ratio Index for Parenteral Nutrition-Associated Cholestasis in Premature Infants With Intestinal Perforation

BACKGROUND

Parenteral nutrition-associated cholestasis (PNAC) is a major cause of morbidity and mortality in premature infants. Early predictors of PNAC would have clinical value. We sought to evaluate risk factors and liver function testing as predictors of PNAC in premature infants with intestinal perforation.

METHODS

Medical records of infants with a gestational age <34 weeks, birth weight <2000 g, and intestinal perforation due to either necrotizing enterocolitis or spontaneous intestinal perforation were reviewed. We analyzed clinical data and the maximum values of the aspartate aminotransferase (AST) to platelet ratio index (APRI), alanine aminotransferase (ALT), AST to ALT ratio, and total bilirubin (TB).

RESULTS

Sixty infants were identified, 17 infants with PNAC and 43 infants without PNAC. Sepsis, time to initiation of enteral feeds after perforation, and duration of PN were associated with PNAC. Within 2 weeks following intestinal perforation, APRI, ALT, and TB each differed significantly between infants who later developed PNAC and those that did not. The best APRI cut-point was 0.4775 within 2 weeks after perforation (area under the receiver operating characteristic curve, 0.90; positive predictive value, 85%; and negative predictive value, 87%); the cut-point for ALT was 13.5 (0.90, 85%, 84%), and the cut-point for TB was 3.55 (0.82, 69%, 83%), respectively, at 2 weeks after perforation. AST to ALT ratio did not differ between groups.

CONCLUSIONS

APRI and ALT had reasonable predictive value for PNAC in premature infants with intestinal perforation, with the APRI the best predictor within 2 weeks after perforation.

Pediatric intestinal failure-associated liver disease

PURPOSE OF REVIEW

The goal of this review is to provide updates on the definition, pathophysiology, treatment, and prevention of intestinal failure-associated liver disease (IFALD) that are relevant to care of pediatric patients.

RECENT FINDINGS

Current literature emphasizes the multifactorial nature of IFALD. The pathogenesis is still largely unknown; however, molecular pathways have been identified. Key to these pathways are proinflammatory cytokines involved in hepatic inflammation and bile acids synthesis such as Toll-like receptor 4 and farnesoid X receptor, respectively. Research for prevention and treatment is aimed at alleviating risk factors associated with IFALD, principally those associated with parental nutrition. Multiple nutrients and amino acids are relevant to the development of IFALD, but lipid composition has been the primary focus. Lipid emulsions with a lower ratio of omega-6-to-omega-3 polyunsaturated fatty acids (FAs) appear to improve bile flow and decrease intrahepatic inflammation. Long-term consequences of these alternative lipid emulsions are yet to be determined.

SUMMARY

IFALD remains the greatest contributor of mortality in patients with intestinal failure. Many factors contribute to its development, namely, alterations in the gut microbiome, sepsis, and lack of enteral intake. Novel combinations of lipid formulations are promising alternatives to purely soy-based formulas to reduce cholestasis.

Bone fracture in severe small-for-gestational-age, extremely low birth weight infants: A single-center analysis

INTRODUCTION

Bone fracture is a complication of extremely low birth weight infants (ELBWIs). This study aimed to analyze risk factors for bone fracture in a population of severe small-for-gestational-age (SGA) ELBWIs.

METHODS

We retrospectively studied data from ELBWIs with a birth weight <1000g and <-2 standard deviations (SDs) born at the National Center for Child Health and Development, Japan, from 2013 to 2015. Infants were divided into fracture and control groups. Serum calcium (Ca) and phosphorus (P) levels, perinatal factors, and previously reported risk factors were analyzed.

RESULTS

Of 25 cases of severe SGA ELBWIs, 5 cases of bone fracture were identified. Gestational age was 27.7±2.2, 29.1±2.6weeks (mean difference [MD] -1.4, 95% confidence interval [CI]: -4.0, -1.2, p=0.280), birth weight (BW) 448±105, 673±216g (MD -225, 95% CI: -433, -17, p=0.036) and BW-SD -4.1±0.1, -3.4±0.8 (MD -0.8, 95% CI: -1.5, -0.02, p=0.045) in the fracture and control groups, respectively. Minimums of serum Ca and P were 6.6±1.4, 8.1±0.8mg/dl (MD -1.5, 95% CI: -2.5, -0.6), p=0.003) and 2.3±0.6, 3.5±1.1mg/dl (MD -1.2, 95% CI: -2.2, -0.1, p=0.027) in the fracture and control groups, respectively.

CONCLUSION

Lower BW and BW-SD were possible risk factors for bone fracture. Hypocalcemia and hypophosphatemia may also contribute to the condition.

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

BACKGROUND

The pathogenesis of parenteral nutrition-associated cholestasis (PNAC) has not been clarified. The objective of this study was to explore the incidence of PNAC in premature infants without surgery and to identify associated risk factors.

MATERIALS AND METHODS

Premature neonates who received parenteral nutrition (PN) at least 14 days were included in a retrospective, dual-center study. Cholestasis was diagnosed as conjugated bilirubin ≥2 mg/dL. Infants with metabolic liver disease, cyanotic congenital heart disease, congenital syphilis, hepadnaviridae infection, and those who underwent surgery were excluded. Infants were divided into 3 groups chronologically: group A (2000-2004, n = 50), group B (2005-2009, n = 283), and group C (2010-2014, n = 741). A case-controlled study was conducted by comparing infants with PNAC to those without PNAC.

RESULTS

Of 1074 premature neonates, PNAC was confirmed in 53 infants (4.93%). There were 6.8% very low birth weight (BW) infants and 20.0% extremely low BW infants who developed PNAC. The incidence of PNAC decreased slightly during 2000-2014 (8.0%, 6.4%, and 4.2% in groups A, B, and C, respectively). Compared with those without PNAC, infants with PNAC (n = 53) had significantly younger gestational age, lower BW, longer PN duration, and higher rate of sepsis. Logistic regression showed male sex, PN duration ≥43 days, and sepsis were statistically correlated with PNAC.

CONCLUSIONS

Prolonged duration (≥43 days), male sex, and sepsis are probably independent risk factors for developing PNAC in premature neonates.

Aggressive nutrition in extremely low birth weight infants: impact on parenteral nutrition associated cholestasis and growth

Background

Parenteral nutrition associated cholestasis (PNAC) is a frequently observed pathology in extremely low birth weight (ELBW) infants. Its pathogenesis is determined by the composition and duration of parenteral nutrition (PN) as well as the tolerance of enteral feeds (EF). “Aggressive” nutrition is increasingly used in ELBW infants to improve postnatal growth. Little is known about the effect of “aggressive” nutrition on the incidence of PNAC. We analyzed the influence of implementing an “aggressive” nutritional regimen on the incidence of PNAC and growth in a cohort of ELBW infants.

Methods

ELBW infants were nourished using a “conservative” (2005–6; n = 77) or “aggressive” (2007–9; n = 85) nutritional regimen that differed in the composition of PN after birth as well as the composition and timing of advancement of EFs. We analyzed the incidence of PNAC (conjugated bilirubin > 1.5 mg/dl (25 µmol/l)) corrected for confounders of cholestasis (i.e., NEC and/or gastrointestinal surgery, sepsis, birth weight, Z-score of birth weight, time on PN and male sex), growth until discharge (as the most important secondary outcome) and neonatal morbidities.

Results

The incidence of PNAC was significantly lower during the period of “aggressive” vs. “conservative “nutrition (27% vs. 46%, P < 0.05; adjusted OR 0.275 [0.116–0.651], P < 0.01). Body weight (+411g), head circumference (+1 cm) and length (+1 cm) at discharge were significantly higher. Extra-uterine growth failure (defined as a Z-score difference from birth to discharge lower than −1) was significantly reduced for body weight (85% vs. 35%), head circumference (77% vs. 45%) and length (85% vs. 65%) (P < 0.05). The body mass index (BMI) at discharge was significantly higher (11.1 vs. 12.4) using “aggressive” nutrition and growth became more proportionate with significantly less infants being discharged below the 10th BMI percentile (44% vs. 9%), while the percentage of infants discharged over the 90th BMI percentile (3% vs. 5%) did not significantly increase.

Discussion

“Aggressive” nutrition of ELBW infants was associated with a significant decrease of PNAC and marked improvement of postnatal growth.

Italian guidelines for the management and treatment of neonatal cholestasis

Hyperbilirubinemia is a frequent condition affecting newborns during the first two weeks of life and when it lasts more than 14 days it is defined as prolonged jaundice. This condition requires differential diagnosis between the usually benign unconjugated hyperbilirubinemia and the pathological conjugated hyperbilirubinemia, that is mainly due to neonatal cholestasis. It is important that the diagnosis of neonatal cholestasis be well-timed to optimize its management, prevent worsening of the patient’s outcome, and to avoid premature, painful, expensive, and useless tests. Unfortunately, this does not always occur and, therefore, the Task Force on Hyperbilirubinemia of the Italian Society of Neonatology presents these shared Italian guidelines for the management and treatment of neonatal cholestasis whose overall aim is to provide a useful tool for its assessment for neonatologists and family pediatricians.

Incidence and Risk Factors of Parenteral Nutrition-Associated Cholestasis in Omani Neonates: Single centre experience

OBJECTIVES

Parenteral nutrition-associated cholestasis (PNAC) is one of the most challenging complications of prolonged parenteral nutrition (PN) in neonates. There is a lack of research investigating its incidence in newborn infants in Oman and the Arab region. Therefore, this study aimed to assess the incidence of PNAC and its risk factors in Omani neonates.

METHODS

This retrospective study took place between January and April 2014. All neonates who received PN for ≥14 days during a four-year period (June 2009 to May 2013) at the neonatal intensive care unit (NICU) in Sultan Qaboos University Hospital, Muscat, Oman, were enrolled.

RESULTS

A total of 1,857 neonates were admitted to the NICU over the study period and 135 neonates (7.3%) received PN for ≥14 days. Determining the incidence of PNAC was only possible in 97 neonates; of these, 38 (39%) had PNAC. The main risk factors associated with PNAC were duration of PN, duration of enteral starvation, gastrointestinal surgeries, blood transfusions and sepsis. Neonates with PNAC had a slightly higher incidence of necrotising enterocolitis in comparison to those without PNAC.

CONCLUSION

This study found a PNAC incidence of 39% in Omani neonates. There were several significant risk factors for PNAC in Omani neonates; however, after logistic regression analysis, only total PN duration remained statistically significant. Preventive strategies should be implemented in NICUs so as to avoid future chronic liver disease in this population.

Parenteral Nutrition-Associated Cholestasis in Premature Infants: Role of Macronutrients

PURPOSE

To evaluate whether intravenous lipid (IL) intake is associated with the development of parenteral nutrition-associated cholestasis (PNAC) in infants younger than 32 weeks gestational age (GA).

METHODS

A retrospective matched case-control study (1:1) was performed including infants younger than 32 weeks GA admitted to the neonatal intensive care unit within 48 hours after birth. Infants with a chromosomal disorder, TORCH infection (toxoplasmosis, syphilis, rubella, cytomegalovirus, herpes, human immunodeficiency virus, and parvovirus), metabolic disorder, and/or surgical abnormality of the hepatobiliary system were excluded. Infants with PNAC (direct bilirubin 2 mg/dL or higher) comprised the case group, while infants without PNAC comprised the control group. Duration of parenteral nutrition, intravenous fluid intake on the day of development of PNAC, and GA were used as matching criteria.

RESULTS

A total of 46 subjects were studied. Daily average intravenous dextrose (ID) intake was significantly higher in infants with PNAC compared with infants without PNAC (12.72 ± 2.5 g/kg/d and 10.64 ± 2.1 g/kg/d, respectively, P = .004). On comparison of receiver operating characteristic curves, the area under the curve for ID intake (0.74) was significantly higher (P = .01) compared with the area under the curve for IL intake (0.59) and intravenous protein (IP) intake (0.52). On logistic regression, daily ID intake was associated with PNAC (odds ratio 1.7; 95% CI, 1.04-2.9, P = .03) after controlling for daily IP and IL intake.

CONCLUSIONS

ID intake may be associated with the development of PNAC in premature infants. Our findings suggest that limiting ID intake may be more useful than limiting IL intake in reducing the incidence of PNAC in premature infants.

Clinical manifestations and prognosis of long-term parenteral nutrition induced cholestasis in neonates

AIM: To explore the clinical manifestations and prognosis of parenteral nutrition induced cholestasis (PNIC).

METHODS: One hundred and two newborns receiving continuous parenteral nutrition (PN) ≥ 14 d from January 2010 to December 2013 were divided into either a PNIC group (n = 42) or a non-PNIC group (n = 60). PNAC onset time, duration and hepatic injury were compared between the two groups.

RESULTS: PNIC occurred 3.4 wk ± 1.5 wk after PN administration, and its mean duration was 13.4 wk ± 5.2 wk. The maximum total bilirubin was 198.9 μmol/L ± 95.8 μmol/L, and the direct bilirubin was 137.1 μmol/L ± 64.3 μmol/L. In the PNIC group, 77.8% (28/36) suffered from hepatic injury. Hepatic injury occurred 6.5 wk ± 2.9 wk after PN administration, and lasted for 9.6 wk ± 5.2 wk. Multiple linear regression analysis showed that the severity of cholestasis was positively correlated with the duration of PN (r = 0.287, P < 0.05).

CONCLUSION: The prognosis of PNIC was favorable. To reduce the incidence of PNIC, long-term PN and infections should be avoided, enteral feeding should be started early and the PN formula should be improved.

The effect of 5 intravenous lipid emulsions on plasma phytosterols in preterm infants receiving parenteral nutrition: a randomized clinical trial

BACKGROUND

Elevated plasma phytosterol concentrations are an untoward effect of parenteral nutrition (PN) with vegetable oil-based lipid emulsions (LEs). Phytosterols are elevated in neonatal cholestasis, but the relation remains controversial.

OBJECTIVE

The objective was to study the effect of 5 LEs on plasma phytosterols in preterm infants.

DESIGN

One hundred forty-four consecutive admitted preterm infants (birth weight: 500-1249 g) were studied. Patients were randomly assigned to receive 1 of 5 different LEs: S [100% soybean oil (SO)], MS [50% medium-chain triglycerides (MCTs) and 50% SO], MSF (50% MCTs, 40% SO, and 10% fish oil (FO)], OS (80% olive oil and 20% SO), or MOSF (30% MCTs, 25% olive oil, 30% SO, and 15% FO). Phytosterols in the LEs and in plasma (on postnatal day 7 and day 14) were measured by gas chromatography-mass spectrometry.

RESULTS

Patients in the S group had significantly higher total phytosterol intakes than did the other study groups. On PN days 7 and 14, plasma phytosterol concentrations were highest in the S group and lowest in the MOSF group. Despite similar β-sitosterol intakes between the MS and MSF groups, plasma concentrations were significantly lower in the MSF than in the MS group. Only 3 patients (2.1%) developed cholestasis: 1 in the MS, 1 in the MSF, and 1 in the MOSF group. No cases of cholestasis were observed in the S and OS groups.

CONCLUSIONS

In uncomplicated preterm infants receiving routine PN, we found a correlation between phytosterol intake and plasma phytosterol concentrations; however, cholestasis was rare and no difference in liver function at 6 wk was observed.

Incidence, prevention, and treatment of parenteral nutrition-associated cholestasis and intestinal failure-associated liver disease in infants and children: a systematic review

BACKGROUND

Cholestasis is a significant life-threatening complication in children on parenteral nutrition (PN). Strategies to prevent/treat PN-associated cholestasis (PNAC) and intestinal failure-associated liver disease (IFALD) have reached moderate success with little supporting evidence. Aims of this systematic review were (1) to determine the incidence of PNAC/IFALD in children receiving PN for ≥ 14 days and (2) to review the efficacy of measures to prevent/treat PNAC/IFALD.

METHODS

Of 4696 abstracts screened, 406 relevant articles were reviewed, and studies on children with PN ≥ 14 days and cholestasis (conjugated bilirubin ≥ 2 mg/dL) were included. Analyzed parameters were (1) PNAC/IFALD incidence by decade and by PN length and (2) PNAC/IFALD prevention and treatment (prospective studies).

RESULTS

Twenty-three articles (3280 patients) showed an incidence of 28.2% and 49.8% of PNAC and IFALD, respectively, with no evident alteration over the last decades. The incidence of PNAC was directly proportional to the length of PN (from 15.7% for PN ≤ 1 month up to 60.9% for PN ≥ 2 months; P < .0001). Ten studies on PNAC met inclusion criteria. High or intermediate-dose of oral erythromycin and aminoacid-free PN with enteral whey protein gained significant benefits in preterm neonates (P < .05, P = .003, and P < .001, respectively). None of the studies reviewed met inclusion criteria for treatment.

CONCLUSIONS

The incidence of PNAC/IFALD in children has no obvious decrease over time. PNAC is directly correlated to the length of PN. Erythromycin and aminoacid-free PN with enteral whey protein have shown to prevent PNAC in preterm neonates. There is a lack of high-quality prospective studies, especially on IFALD.

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

PURPOSE

We 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 METHODS

Sixty-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.

RESULTS

Compared 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.

CONCLUSION

The clinical course of PNAC is more persistent and severe in SGA infants. Careful monitoring and treatment are required for SGA infants.

Risk factors for developing transient neonatal cholestasis

OBJECTIVES

To describe the incidence and the characteristics of neonatal cholestasis in a cohort of patients with known risk factors and to investigate additional risk factors.

METHODS

A prospective observational study conducted between April 2008 and 2009 involved all neonates admitted in the neonatal ward. They were divided into high- and low-risk groups for cholestasis. The high-risk group included preterm birth <34  weeks of gestation, small for gestational age (SGA), parenteral nutrition (PN) >7 days, abdomino-pelvic or thoracic surgery. Bilirubinemia was weekly measured in the high-risk group.

RESULTS

Of the 460 newborns studied, 234 were included in the high-risk group and 226 in the low-risk group. Cholestasis developed in 32 patients (13.7%) in the high-risk group at mean (SD) age of 14.7 (12.9) days; all were receiving PN. None of the patients in the low-risk group developed cholestasis. An analysis was carried out in the 207 patients in the high-risk group who received PN. The odds ratio (OR) for developing cholestasis was 2.3 [1.1-5.0] and 5.6 [2.5-12.5] for SGA or surgical patients, respectively. Cholestasis was associated with neonatal severe conditions, longer PN duration, and more intravenous macronutrients' intakes. In multivariate analysis, SGA and neonatal surgery were strong independent risk factors for cholestasis, with OR (95% confidence interval [95% CI]) of 4.4 [1.6-12.5] and 4.6 [1.7-12.3], respectively.

CONCLUSIONS

Transient neonatal cholestasis is a complication of PN. SGA and neonatal surgery are additional risk factors. There is no evidence to limit intravenous protein intakes in preterm.

Randomized controlled trial of early parenteral nutrition cycling to prevent cholestasis in very low birth weight infants

OBJECTIVES

To compare the incidence of cholestasis in very low birth weight infants receiving cycled versus continuous parenteral nutrition, and to determine factors that predispose to parenteral nutrition-associated cholestasis (PNAC).

STUDY DESIGN

Preterm infants weighing ≤ 1250 g (n = 70) at birth were randomly assigned within the first 5 postnatal days to either cycle (n = 34) or continuous (n = 36) parenteral nutrition. Liver function tests were obtained at baseline, and sequentially thereafter. Cholestasis was defined as direct bilirubin >2 mg/dL. Infants with major congenital anomalies, congenital hepatic disease, clinically apparent congenital viral infection, and those who required major abdominal surgery were excluded.

RESULTS

The incidence of PNAC was similar in the 2 groups (cycle 32% vs continuous 31%; P = 1.0). Bilirubin and transaminases were similar in both groups by repeated measures of ANOVA. Gestational age, birth weight, and Apgar scores were significantly lower, and Clinical Risk Index for Babies II scores were significantly higher in infants who developed PNAC. Using backward selection logistic regression, bronchopulmonary dysplasia, duration of parenteral nutrition, and days to full enteral nutrition emerged as factors independently associated with PNAC.

CONCLUSIONS

Early prophylactic parenteral nutrition cycling in very low birth weight infants in this study did not reduce cholestasis. Time to full feedings is a significant predictor for PNAC in very low birth weight infants. Preterm infants with bronchopulmonary dysplasia are more likely to have PNAC as a comorbidity. The Clinical Risk Index for Babies II score may help identify those preterm infants who might benefit from future prospective prevention trials.

Parenteral nutrition-associated cholestasis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

OBJECTIVE

The aim of this study was to review evidence-based data addressing key clinical questions regarding parenteral nutrition-associated cholestasis (PNAC) and parenteral nutrition-associated liver disease (PNALD) in children.

DATA SOURCE

Data were obtained from PubMed, Medicine databases of the English literature (up to October 2010), and the Cochrane Database of Systematic Reviews.

STUDY SELECTION

The review of PNAC/PNALD has been divided into 4 areas to simplify one's understanding of the current knowledge regarding the pathogenesis and treatment of this disease: (1) nonnutrient risk factors associated with PNAC, (2) PNAC and lipid emulsions, (3) nutritional (nonlipid) considerations in the prevention of PNAC, and (4) supplemental medications in the prevention and treatment of PNAC.

RESULTS

The data for each topic area relevant to the clinical practice of pediatric surgery were reviewed, evaluated, graded, and summarized.

CONCLUSIONS

Although the conditions of PNAC and PNALD have been well recognized for more than 30 years, only a few concrete associations and treatment protocols have been established.

Lipids for parenteral nutrition in neonates

PURPOSE OF REVIEW

In neonatal intensive care units, the interest and scope for research in the field of intravenous lipids has significantly widened in recent years. This brief review covers the advances in this field in the last 2 years.

RECENT FINDINGS

These include a significant amount of research in evaluating safety and efficacy of novel lipid emulsions that include olive oil or fish oil. Short-term studies involving novel lipid emulsions have documented safety and benefits in terms of reduced inflammation and lipid peroxidation. Fish oil-based lipid emulsions have also been used to prevent and treat parenteral nutrition-induced cholestasis. Other areas of progress include stability studies of all-in-one parenteral nutrition mixtures including lipid emulsions for neonates.

SUMMARY

Since the first soybean oil-based lipid emulsions were introduced 50 years ago, progress has been made in understanding the composition, dose and clinical effects of parenteral lipids in neonatal patients. However there is a paucity of data in terms of definitive head-to-head trials of different novel lipid emulsions evaluating short-term as well as long-term clinically important outcomes including neurodevelopment. Future research is required to determine long-term benefits of novel lipid emulsions for neurological outcome and effects on the immune system.