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Parenteral nutrition-associated conjugated hyperbilirubinemia in hospitalized infants
Catherine J Klein1, Mary Revenis, Mary Ravenis
1Bionutrition Research Program, Children's National Medical Center, and Department of Pediatrics, School of Washington, DC, USA. cklein@cnmc.org
Insights
Parenteral nutrition-associated conjugated hyperbilirubinemia (PNAC) affects premature infants, with duration of PN being a key risk factor. Transitioning to enteral feeding is the most effective treatment for this serious condition.
Area of Science:
- Neonatology
- Pediatric Gastroenterology
- Clinical Nutrition
Background:
- Parenteral nutrition-associated conjugated hyperbilirubinemia (PNAC) is a significant complication in infants receiving parenteral nutrition (PN).
- Defined as direct bilirubin ≥2 mg/dL, PNAC can lead to severe morbidity and increased mortality, especially with bilirubin levels >10 mg/dL.
- The exact causes of PNAC remain poorly understood, hindering effective prevention and treatment strategies.
Purpose of the Study:
- To systematically review the histopathology of PNAC.
- To analyze prospective, randomized, controlled trials in hospitalized infants.
- To summarize the prevalence, risk factors, clinical presentation, and treatment options for PNAC in neonatal intensive care units.
Main Methods:
- Systematic literature search for histopathology data and clinical trials.
- Review of animal studies linking soy oil emulsion in PN to hyperbilirubinemia.
- Analysis of risk factors, clinical presentation, and treatment outcomes in infants.
Main Results:
- Animal studies indicate PN with soy oil emulsion exacerbates hyperbilirubinemia, particularly with overfeeding.
- The duration of PN is the most consistent risk factor for PNAC in infants.
- Transitioning to full enteral feeding and discontinuing PN is the only established effective treatment.
Conclusions:
- PNAC is a serious condition in premature infants requiring careful management.
- Further research into lipid sources, motility agents, and trace element preparations is warranted.
- Early transition to enteral feeding is crucial for managing and potentially preventing PNAC.
Abstract:
Parenteral nutrition-associated conjugated hyperbilirubinemia (PNAC), commonly defined as direct bilirubin ≥2 mg/dL (34.2 μmol/L), is primarily a pediatric disease with premature infants being the most susceptible. Severe morbidity and increased mortality are associated with bilirubin >10 mg/dL (171.0 μmol/L). The lack of knowledge regarding the cause of PNAC has stymied development of prevention and treatment strategies. A systematic search of published reports was conducted to provide data on histopathology of PNAC and to review prospective, randomized, controlled trials in hospitalized infants. In experiments of young animals, parenteral nutrition (PN) with and without soy oil emulsion is directly linked to hyperbilirubinemia, and the effects are exaggerated by overfeeding. In infants, the most consistently reported risk factor for PNAC is the duration of PN. The only known effective modality is the transition to full enteral feeding and discontinuation of PN. Emerging clinical research is evaluating the role of lipid source (soy vs fish) and motility agents, such as erythromycin. Different trace element preparations are associated with varying severity of cholestasis, a finding that also deserves more study. This article reviews the prevalence, risk factors, clinical presentation, and treatment options for PNAC in neonatal intensive care units.
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