Necrotizing enterocolitis (NEC) is one of the most significant causes of morbidity and mortality among premature infants. The exact cause is considered multifactorial and related to gastrointestinal immaturity, inflammation and enteral feeding. The role of nutrition is vitally important in NEC. The main modifiable risk factor is the introduction and advancement of enteral feedings. After an infant has recovered from NEC, enteral feeds should be cautiously resumed to prevent injury from prolonged use of parenteral nutrition. The logistics of how, when, and what to feed are somewhat unclear and often depend on the severity of the disease. For patients with an enterostomy, refeeding the distal intestine with the small-intestinal ostomy output may improve bowel growth and prevent long-term complications.

BackgroundPhytosterols in soybean oil (SO) lipids likely contribute to parenteral nutrition-associated liver disease (PNALD) in infants. No characterization of phytosterol metabolism has been done in infants receiving SO lipids.MethodsIn a prospective cohort study, 45 neonates (36 SO lipid vs 9 control) underwent serial blood sample measurements of sitosterol, campesterol, and stigmasterol. Mathematical modeling was used to determine pharmacokinetic parameters of phytosterol metabolism and phytosterol exposure.ResultsCompared to controls, SO lipid-exposed infants had significantly higher levels of sitosterol and campesterol (p<0.01). During SO lipid infusion, sitosterol and campesterol reached half of steady-state plasma levels within 1.5 days and 0.8 days, respectively. Steady-state level was highest for sitosterol (1.68 mg/dL), followed by campesterol (0.98 mg/dL), and lowest for stigmasterol (0.01 mg/dL). Infants born < 28 weeks gestational age had higher sitosterol steady-state levels (p=0.03) and higher area under the curve for sitosterol (p=0.03) during the first 5 days of SO lipid (AUC5) than infants born ≥ 28 weeks gestational age.ConclusionPhytosterols in SO lipid accumulate rapidly in neonates. Very preterm infants receiving SO lipid have higher sitosterol exposure, and may have poorly developed mechanisms of eliminating phytosterols that may contribute to their vulnerability to PNALD.

Background Cyclic parenteral nutrition (PN) is used for both the treatment and prevention of parenteral nutrition-associated liver disease (PNALD). Early initiation of prophylactic cyclic PN may not be well tolerated in young neonates. Our objective was to test the hypothesis that prophylactic cyclic PN initiated prior to the onset of hyperbilirubinemia is associated with younger age at initiation, lower bilirubin levels, and similar rates of adverse events compared to therapeutic cyclic PN initiated after established cholestasis in surgical neonates. Materials and Methods Retrospective review of infants with gastrointestinal disorders requiring surgical intervention who received cyclic PN from 2006 to 2011. Results Of the 43 infants eligible for analysis, 23 received prophylactic and 20 received therapeutic cyclic PN. Infants in both groups were comparable in demographics, surgical diagnoses, and illness severity. At initiation of cyclic PN, infants with prophylactic cyclic PN were significantly younger in chronologic (p = 0.003) and postmenstrual age (p = 0.029). Prophylactic cyclic PN was associated with a significantly lower incidence of hyperbilirubinemia (p = 0.001), lower maximum conjugated bilirubin (p < 0.0001), and lower last checked conjugated bilirubin (p = 0.032) compared to the therapeutic cyclic PN. The incidence of hypoglycemia, hyperglycemia, and hypertriglyceridemia was similar for the two groups. Conclusions There may be a potential benefit to initiating cyclic PN prior to the development of hyperbilirubinemia in surgical neonates. Early initiation of prophylactic cyclic PN does not appear to increase the risk for adverse events.

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Learning Outcome: To learn how skimmed human milk (SHM) can be used in infants with chylothorax to support adequate weight gain and nutrition while receiving human milk.Background: Traditional nutrition management for chylothorax is to limit longchain triglycerides (LCTs) and provide a diet high in medium-chain triglycerides (MCTs). Transition from human milk to formula has been required to provide the ratio of MCT to LCT required to stop the accumulation of chyle. Although SHM may provide the right fat content for a baby with chylothorax, previous studies have shown slow growth in infants receiving SHM.Objective: To demonstrate that infants receiving SHM fortified with high-MCT infant formula will have age appropriate growth without re-accumulation of chyle. Design/Methods: Between 2017 and 2019, term infants with the diagnosis of chylothorax who were previously receiving human milk and transitioned to fortified SHM were monitored for growth and reaccumulation of chyle. Results:The six infants who were prescribed fortified SHM with high-MCT infant formula using standardized recipes did not show reaccumulation of chyle and showed positive weight gain in five of the six study patients. The infants gained a mean weight of 30.5 g/day (±19.5), and their weight z scores improved by a mean of +0.29 (±0.33).Conclusions: Fortified SHM is a safe treatment option that can provide adequate nutrition for the infant with chylothorax to gain weight appropriately for age.

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