A provocative article (J Pediatr 2014; 165: 274-9) examines supplementation of enteral fat/fish oil in premature infants as a mechanism to reduce parenteral nutrition associated cholestasis (PNAC). While the study’s limitations will prevent any dramatic conclusions, the article and associated editorial (pgs 226-27) do make several useful points.
Before discussing the limitations, the design of the study:
Infants were block randomized (block size of 8) into either a control group or treatment group. While both groups received conventional PN, the treatment group received supplemental enteral fat as microlipid and fish oil after tolerating enteral feeds at 20 mL/kg/d. Microlipid was started at 1 g/kg/d and advanced up to 2.5 g/kg/d; coinciding with microlipid increases, parenteral intralipid was decreased. Fish oil was started at 0.2 g every 12 hours and was advanced to a maximum of 0.5 g every 6 hours. The two fish oil products were Major Fish Oil 500 (Major Pharmaceuticals) and Rugby Sea Omega 50 (Rugby Laboratories).
The limitations include the following:
- Small cohort of 18 patients in each arm
- Due to the smell of fish oil, the study could not truly be blinded which introduces potential bias
- Only 7 of the 36 patients could be considered to have short bowel syndrome as most of the infants had small amounts of intestine resected
- Advancement of enteral feedings were halted if stoma output reached 20 mL/kg/d. The editorialists note that 40 mL/kg/d would be more typical. Thus, in both the treatment group and the control group, there was significant opportunity to reduce PN by more aggressive enteral nutrition advancement.
With these limitations in mind, there authors were able to show that supplemental fat (with fish oil) was associated with less parenteral intravenous lipid, and reduced conjugated bilirubin prior to anastomosis. However, there was no significant difference in PN duration. Growth parameters were similar prior to anastomosis, but improved in the treatment group after anastomosis.
In the editorial, it is noted that “enteral feeding with a high-fat diet has been demonstrated to enhance structural features of resection-associated adaptation, the underlying mechanisms for this phenomenon are still presently unknown.”
Take-home message: Enteral fat/fish oil supplementation helped decrease parenteral intravenous lipids in this study. More broadly, advancing enteral nutrition by accepting higher ostomy outputs is likely the best strategy to avoid PNAC and other PN-associated complications.
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