Parenteral Nutritional Support 161
3
should always be a minimum linoleic acid intake
to prevent essential fatty acid deficiency (pre-
term infants: ≥ 0.25 g linoleic acid/kg per day;
term infants/children: ≥ 0.1 g/kg per day). In ne-
onates requiring PN, lipids can start on day 1 of
life and should start no later than day 3. In young
infants, lipids should be administered continu-
ously over ∼ 24 h.
During phototherapy, validated light-protect-
ed tubing for lipid emulsions is recommended to
decrease hydroperoxide formation. Lipid emul-
sions have no demonstrable effect on hyperbili-
rubinaemia. There is no firm evidence on adverse
effects in severe acute respiratory failure, but
avoiding high lipid dosages in these patients ap-
pears prudent. In severe, progressive PN-associ-
ated cholestasis, a decrease in or transient inter-
ruption of intravenous lipids should be consid-
ered.
Commercial lipid emulsions based on soy-
bean oil, or mixtures of olive and soybean oils or
of medium-chain triglycerides and soybean oil,
as well as mixed emulsions with fish oil are con-
sidered safe and are registered for paediatric pa-
tients in many countries around the world. In a
meta-analysis of randomized controlled trials in
VLBWI, the use of mixed emulsions without
and with fish oil showed a 25% lower risk of sep-
sis than the use of 100% soybean oil emulsions
[6]. In v iew of t hese data a nd concerns on a n im-
balanced fatty acid composition and an appar-
ently high risk of liver damage, the use of lipid
emulsions based only on soybean oil has been
discouraged in young infants, and these emul-
sions are not preferred for use in paediatric pa-
tients [2].
O t h e r A s p e c t s
Vitamins and minerals should be supplied with
all PN and provided over several days. Cyclical
PN (over ∼ 8–14 h/day) should be considered
from the age of 3–6 months onwards [2, 4].
Individualized prescriptions of paediatric PN
are widely used, but standard PN solutions are
suitable for many paediatric patients with ade-
quate monitoring and the possible addition of
electrolytes/nutrients. They can improve the
quality and safety of PN and reduce costs [7].
The risks of PN are best reduced by limiting its
amount and duration combined with persistent
attempts to increase the amount of enteral feed-
ings as tolerated. Rather than enteral starvation,
minimal enteral feeds should be given whenever
possible, and experienced paediatricians and di-
eticians should be involved.Conclusions- PN is an essential and often life-saving treat-
ment for infants and children who cannot be
adequately fed orally or enterally - PN should only be used when all alternative
options have been explored, including ade-
quate care, specialized EN and artificial feed-
ing devices - PN can induce severe adverse effects. The risk
is reduced by a meticulous approach, estab-
lishment of a multidisciplinary nutrition sup-
port team, avoidance of unbalanced or exces-
sive substrate supplies, strict hygiene measures
to reduce catheter infections, concomitant
minimal enteral feeding and forceful enhance-
ment of enteral feeding where possible to lim-
it the amount and duration of PN
References 1 Agostoni C, Axelson I, Colomb V, Gou-
let O, Koletzko B, Michaelsen KF, Puntis
JW, Rigo J, Shamir R, Szajewska H,
Turck D: The need for nutrition support
teams in pediatric units: a commentary
by the ESPGHAN Committee on Nutri-
tion. J Pediatr Gastroenterol Nutr 2005;
41: 8–11.Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 158–162
DOI: 10.1159/000375190