Low Dose Parenteral Fat for Prevention of Parenteral Nutrition Associated Cholestasis in Preterm Neonates

The goal of the study is to determine if parenteral nutrition-associated cholestasis (PNAC) is related to the amount of parenteral (intravenous) fat administered to premature babies until full enteral nutrition is achieved.

Study Overview

• Status: Completed
• Conditions: Parenteral Nutrition-Associated Liver Disease
• Intervention / Treatment: Other: Intravenous fat emulsion; Other: Restriction of intravenous fat emulsion to 1 gm/kg/d

Detailed Description

In the neonatal intensive care unit, parenteral nutrition is widely used to provide protein, energy, vitamins and minerals to infants who cannot accept enteral feeds.

Intravenous fat emulsion is an important component of parenteral nutrition because of the important caloric supply that it brings, but also for the essential fatty acids (linoleic and linolenic acid) that it provides. Because intravenous fat emulsion is the only supply of essential fatty acids, at least until the enteral feeds are established, there is a minimum of fat that has to be administered with at least 0.25g/kg /day for preterm babies and 0.1g/kg/day for term infants (Lee EJ, 1993). The maximal dose of intravenous fat safe to administer is difficult to determine. Although in larger preterm infants intravenous fat is tolerated well based on measurement of serum triglycerides, there are still question regarding tolerance in extremely low birth weight infants.

Parenteral nutrition has been associated with the development of liver disease-parenteral nutrition associated liver disease (PNALD). PNALD can range from cholestasis and a transient elevation of liver enzymes to more severe forms including fibrosis, liver cirrhosis and hepatic failure. Cholestasis, defined as hyperbilirubinemia with a direct bilirubin above 2 mg/dL or more than 15% of total bilirubin, is a hepatocellular injury of the liver that manifests after the administration of parenteral nutrition for at least two weeks. The mechanism by which the liver injury occurs is unknown and probably multifactorial. Risk factors associated with the development of PNAC include: prematurity, low birth weight, absence of enteral feeds, bacterial sepsis, necrotizing enterocolitis, prolonged use of parenteral nutrition, and multiple surgical procedures on the gastro-intestinal tract. In addition, many of the nutrients contained in parenteral nutrition, have been linked with the development of cholestasis.

Specific factors associated with intravenous fat emulsions that have been related to PNAC include : phytosterols, the rate of administration of the intravenous emulsion, the total amount of fat administered and toxic metabolites of intravenous fat emulsions.

The total amount of lipids was found to be a risk factor for cholestasis in children on long-term parenteral nutrition and decreased amount of fat was recommended for the prevention of this hepatic complication (Colomb V, 2000). In the adult population parenteral lipid intake of less than 1gr/kg of body weight decreased the risk of cholestasis in parenteral nutrition treated patients (Cavicchi, 2000).

Current Nutritional Management for VLBW infants in the NBSCU:

The administration of parenteral nutrition to all the preterm babies with a gestational age less than or equal to 29 weeks' is standard practice in the NBSCU for infants not receiving full enteral nutrition. Fat, as an integral part of the intravenous alimentation, is started in the first day of life at a dose of 0.5 grams/kg/day of an 20% fat emulsion(eg, Lyposyn II, Abbott Laboratories Chicago, IL). The amount of fat is then gradually increased by 0.5-1 grams/kg/day to total amount of 3 grams/kg/day as tolerated. The tolerance is checked by measuring serum triglyceride level the morning after 3 grams/kg/day has been reached for the first time serum triglyceride level ≤200 mg/dl are accepted for infants ≤52 weeks postmenstrual age. If the serum triglyceride level is >200 mg/dL, the intravenous fat emulsion is reduced for 24 hours, then the triglyceride level is checked again to ensure that it has dropped below 200 mg/dL. The fat emulsion is then restarted at 1-1.5 grams/kg/day and the serum triglyceride level is monitored as it is slowly increased.

Enteral nutrition is started initially as minimal enteral feedings, also called non-nutritive feedings, usually by 48±12 hours of age with about 12 ml/kg/day. The feedings are then advanced as tolerated with the goal to reach full enteral nutrition (>120 ml/kg/day) between 14-21days of life. As the enteral volumes reach 1/3, 1/2, and 2/3 of the total daily fluid volume, the rate of administration of the lipid emulsion is decreased in steps (ie, from 2 grams/kg/day to 1.5 to 1.0) , until the intravenous fat emulsion is stopped.

As part of standard NBSCU management guidelines screening of liver function consists of measuring serum direct bilirubin level after the baby has been on TPN for 10 days to two weeks and then biweekly, if PN continues. In addition, if the direct bilirubin level is greater than 2.5mg/dL, then liver enzymes will be checked .

Study Procedure:

All preterm babies with a gestational age less than or equal to 29 weeks' born at YNHH who will receive intravenous fat emulsion as part of their nutrition management are eligible to participate in the study. The parents of these babies will be approached during the first 24 hours of life, regarding the possible participation in the study. After informed consent will be obtained, the subjects will be randomized by YNHH Investigator pharmacy to one of the two groups: intervention (restricted intravenous fat intake) and control (standard intravenous fat intake).

Therefore, the purpose of this study will be to determine if PNAC is related to the amount of parenteral fat administered to premature babies until full enteral nutrition is reached.

• Study Type: Interventional
• Enrollment (Actual): 136
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Connecticut
    • New Haven, Connecticut, United States, 06520-8064
      • Yale University School of Medicine

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 12 hours to 2 days (Child)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Preterm infants less than or equal to 29 weeks' gestation
• Age less than 48 hours

Exclusion Criteria:

• Congenital intrauterine infection, known to be associated with liver involvement and cholestasis
• Known structural liver abnormalities that are associated with cholestasis
• Known genetic disorders: trisomy 21, trisomy 13 and trisomy 18
• Inborn errors of metabolism
• Infants meeting the criteria for terminal illness (eg, pH < 6.8 > 2 hours)
• Inability to obtain informed consent

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: 3 gm/kg/day intravenous lipid emulsion	Other: Intravenous fat emulsion; An infusion of intravenous fat will start at 0.5 grams/kg on the first day of life, with increments of 0.5 -1.0 grams/kg every day, until a total dose of 3 grams/kg is reached.
Experimental: Intravenous Fat Emulsion-restricted	Other: Restriction of intravenous fat emulsion to 1 gm/kg/d; Intravenous fat will be started at 0.5 grams/kg on the first day of life and then increase to a dose of 1gram/kg/day the next day. There will be no further increase in the amount of intravenous fat.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
The Presence of Cholestasis at Age of 28 Days or When Full Enteral Nutrition is Achieved, Whichever is Longer.	28 days of age or when full enteral nutrition is acheived, whichever is longer

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mortality Rate- Death Rate Before Discharge From the Hospital		Discharge from the Newborn ICU
Incidence of Bronchopulmonary Dysplasia (BPD)		36 weeks PMA or discharge home,whichever comes first
Incidence of Necrotizing Enterocolitis (NEC)		At discharge from Newborn ICU
Incidence of Retinopathy of Prematurity (ROP)		At discharge from Newborn ICU
Late Onset Sepsis	Bloodstream infection, defined as a positive blood culture obtained after 72 hours of life.	At the discharge from Newborn ICU
Length of Stay	Defines time to discharge or death.	At discharge from Newborn ICU/death
Anthropometric Measurements(Body Weight)	Change in body weight measurement reported in g/week	At age of 28 days and at discharge
Anthropometric Measurements(Length)	Change in body length measurement reported in cm/week	At age of 28 days and at discharge
Anthropometric Measurements(Head Circumference)	Change in head circumference measurement reported in cm/week	At age of 28 days and at discharge

Collaborators and Investigators

• Sponsor: Yale University
• Collaborators: University of California, Los Angeles; Northwestern University Feinberg School of Medicine
• Investigators: Principal Investigator: Richard A Ehrenkranz, MD, Yale University

Publications and helpful links

General Publications

• Colomb V, Jobert-Giraud A, Lacaille F, Goulet O, Fournet JC, Ricour C. Role of lipid emulsions in cholestasis associated with long-term parenteral nutrition in children. JPEN J Parenter Enteral Nutr. 2000 Nov-Dec;24(6):345-50. doi: 10.1177/0148607100024006345.
• Lee EJ, Simmer K, Gibson RA. Essential fatty acid deficiency in parenterally fed preterm infants. J Paediatr Child Health. 1993 Feb;29(1):51-5. doi: 10.1111/j.1440-1754.1993.tb00440.x.
• Boyd GW. An investigation of the prolonged pressor response to renin in the nephrectomized rat. Clin Sci Mol Med Suppl. 1976 Dec;3:151s-153s. doi: 10.1042/cs051151s.

Study record dates

Study Major Dates

• Study Start: June 1, 2009
• Primary Completion (Actual): November 1, 2012
• Study Completion (Actual): January 1, 2013

Study Registration Dates

• First Submitted: December 23, 2009
• First Submitted That Met QC Criteria: January 14, 2010
• First Posted (Estimate): January 15, 2010

Study Record Updates

• Last Update Posted (Estimate): October 28, 2014
• Last Update Submitted That Met QC Criteria: October 27, 2014
• Last Verified: October 1, 2014

More Information

Terms related to this study

• Keywords: Very low birth weight infants; PNAC; Parenteral nutrition associated liver disease; Direct bilirubin; Intravenous fat emulsion
• Additional Relevant MeSH Terms: Digestive System Diseases; Biliary Tract Diseases; Bile Duct Diseases; Liver Diseases; Cholestasis; Pharmaceutical Solutions; Parenteral Nutrition Solutions; Soybean oil, phospholipid emulsion; Fat Emulsions, Intravenous
• Other Study ID Numbers: HIC# 0902004803