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NOTE LIST

Lipid Emulsions in Premature Infants

Increase risk of cholestasis/ Parenteral Nutrition Associated Liver Disease (PNALD)

  • Due to immaturity of biliary / bile acid homeostasis
  • Susceptible to frequent sepsis
  • Need for long PN to optimise nutrition

More prone to bronchopulmonary dysplasia, ROP & NEC

  • They have reduced antioxidant enzyme activity
  • Inflammatory response is immature/ dysregulated
  • Lack of fatty acids – EPA/DHA – neurocognitive functions
  • Reduces pro-inflammatory precursors
  • Reduces mediators of oxidative stress
  • Absence of phytosterols
  • Presence of EPA/DHA

Evidence: Lipid Emulsions in Premature Infants

a) 38 prems receiving SMOF vs Intralipid [Skouroliakou2010]

  • Significantly reduced

b) RCTs 34 prems in 7day trial [Deshpande 2014]

  • Lower oxidative stress in prems receiving SMOF compared to Olive lipid emulsion

 

  • 337 prems [
  • Receiving a 1:1 mixture of Olive+Fish oil [n=152]
  • Control : cohort group only Olive oil  [n=185]
  • Significant decrease ROP requiring laser therapy
    • 7.5% vs 27% p=0.023

a) RDBC 103 prems [51 soya vs 52 olive] [Wang 2014]

  • No difference incidence of PNAC

b) 2 year cohort 518 prems [ 250 soya & 268 olive] [Teng 2015]

  • No significant difference incidence of cholestasis [14.8%vs12.7%]

 

a) 337prems comparing Olive+Fish vs Olive

  • Decrease incidence of cholestasis [0.66% vs 4.86% p=0.025] [Deshpande 2014]

b) 5 SBS prems given Olive+Fish & stopped soya bean oil

  • All had resolution of cholestasis

c)57 infants [GA 28 weeks] with PNALD

  • Given fish oil – 82.5% resolution median 35 days

a) Effects of Phytosterols intakes on Plasma phytosterol over 14 day PN  [Savini, etal. Am J Clin Nutr 2013; 98:312]

  • 3g/kg/day lipid
  • PN 1 hour after birth
  • Minimal Enteral Nutrition [Human Milk]
  • D14 PN has 50% Enteral nutrition

Randomly assigned 144 premature infants to 5 different lipid emulsions

  1. Soya [n=30]
  2. Soya+MCT [n=30]
  3. 3. Soya+MCT+Fish [n=27]
  4. Soya+Olive [n=29]
  5. Soya+MCT+Olive+Fish [n=28]

Results:

  • No significant difference at 6 weeks
    • Liver function and BPD, NEC & growth
  • Plasma phytosterols significantly greater in Soya group
  • BUT SMOF group significantly lower compared to SO group
  • Only 3 had cholestasis
  • No association between phytosterols & abnormal LFTs at 6 weeks

Majority [80%] DHA accumulates during last trimester

1. RCT [Vlaardingerbroek, etal.jpgn 2014:58:417] 

  • 3g/kg/lipid
  • Minimal EN
  • Mean duration of PN 12days
  • 96 VLBW
  • 48 Intralipid vs 48 SMOF

Results

  • Lipid classes – cholesterol, TGs and phospholipids did not differ
  • D6 and D14 – EPA/DHA was significantly higher in study group
  • Phytosterols were lower in study group
  • Growth: Median time to regain BW was 8 days
  • Discharge weight was higher in study group 

2. Meta-analysis of 8 RCTs  [Zhao, Y.etal. JPGN 2015;60:708]

  • 486 prems – increased levels fatty acids [DHA/EPA] with Fish Oil