More on PNAC

In a previous blog entry (PNAC, PNALD, and IFAC), reduction in intralipids was shown to improve parenteral nutrition associated cholestasis (PNAC).  This change in the use of parenteral nutrition (PN) and others are emphasized in a review article by the American Pediatric Surgical Association (J Ped Surg 2012; 47: 225-40).

This review tries to provide evidence-based guidelines for PNAC with ratings of the evidence for each of their recommendations.

A summary of their findings is given in Figure 1 of the article.  Key points:

  • PN duration is a significant predictor for cholestasis
  • NEC & sepsis both play a role in the development of PNAC
  • Insufficient data to determine if antibiotics used to decrease bacterial translocation/hepatocyte damage may be beneficial
  • Fat emulsion restriction may reduce PNAC without detriment to growth
  • Fish-oil based lipid emulsions are safe and effective for PNAC.  “Despite the promise of Omegaven…the literature is insufficient to provide a recommendation higher than grade C.”  (Grade C= “possibly effective, ineffective, or harmful;” requires at least 2 convincing class III studies [class III studies generally are non-randomized non-blinded studies]).  Information to obtain Omegaven:

http://www.oley.org/documents/How_Physicians_Can_Obtain_Omegaven.pdf
http://www.oley.org/lifeline/PN_Liver_Disease.html

  • Strong evidence that higher initial protein load does not increase the risk of PNAC
  • Strong evidence that trophic feeds are beneficial to reduce PNAC
  • Weak/conflicting evidence that there is any benefit of Aminosyn over Trophamine
  • Weak evidence to support the routine removal of copper or manganese from PN as a prophylactic strategy to prevent PNAC
  • Weak evidence to support prophylactic cycling of PN to reduce PNAC.  There are also concerns about the development of hypoglycemia in preterm infants off of PN
  • Use of CCK is not recommended
  • Oral bile acids may result in improvement
  • Erythromycin may promote motility and facilitate enteral feeds, thereby reducing PNAC

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