Demographic and nutritional factors associated with prolonged cholestatic jaundice in the premature infant

Abstract

Objective: The primary aim of this study was to determine if an association exists between amino-acid levels and development of cholestasis. The secondary aim of our amino-acid dose comparison trial was to identify factors associated with the development of prolonged cholestatic jaundice.Study Design: We compared demographic characteristics and amino-acid levels in neonates who developed cholestasis with those who did not. Parenteral-associated cholestatic liver disease was defined as a direct serum bilirubin above 5 mg per 100 ml any time during the first 28 days after birth in neonates with no history of biliary atresia or viral hepatitis. We obtained filter paper blood spots for amino acid and acylcarnitine measurements on the day of randomization and days 7 and 28 of age to identify a profile of values that could be used to identify neonates with evidence of abnormal liver function. Result:We enrolled 122 neonates in our study; 13 (10.7%) developed cholestasis. Neonates who developed cholestasis were more immature, had lower birth weight, were exposed to parenteral nutrition for a longer period, had a higher cumulative dose of amino acids, were less often on enteral nutrition by day 7 of age, more often had a patent ductus arteriosus and severe intraventricular hemorrhage and were more commonly treated with steroids by 28 days of age. Amino acid and acylcarnitine values were not different for the two groups on the day of randomization. On day 7 (parenteral phase of nutrition), blood urea nitrogen, citrulline, histidine, methionine and succinyl carnitine were higher, and serine, glutamate and thyroxine levels were lower in the neonates who developed cholestasis than in who did not. Conclusion:Cholestasis remains an important complication of parenteral nutrition, and several clinical and biochemical factors may be helpful in identifying high-risk patients.

Intestinal Failure–Associated Liver Disease

“…Higher dextrose intake also increased the prevalence of cholestasis (68)(69)(70). High cumulative infusion of amino acids may be associated with development of IFALD in children, although a definitive relation has not been demonstrated.…”

Parenteral nutrition–associated cholestasis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

“…Steinbach et al [56] examined factors associated with PN administration that may be associated with the development of cholestasis in a cohort of 122 neonates on PN. The authors found that neonates developing PNAC were exposed to PN for a longer period of time, received a higher dose of parenteral amino acids, and were less often on enteral nutrition by the seventh day of life.…”

Outcome on home parenteral nutrition for benign intestinal failure: A review of the literature and benchmarking with the European prospective survey of ESPEN

“…89 Most of the data on children have been derived from studies of hospitalized premature or newborn infants. An increased risk of IF/PNALD was associated with young gestational age, 90 91,103 An appropriate PN regimen is also important as high parenteral energy intake, 88,95,104 use of a soybean-based lipid emulsion at a dose of >1 g/kg, 53 dextrose infusion >7 mg/ kg/min, 84,105 high amino acid load in premature infants, 90 as well as deficiency of transsulfuration pathway products, most notably choline, 106 have been reported to favour the development of IF/ PNALD. The use of lipid emulsion with a low content of omega-6 fatty acids is recommended both in preventing and treating IF/ PNALD.…”