ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Lipids

Tabled 1Table: Recommendations for the use of intravenous lipid emulsionsR 4.1In paediatric patients, intravenous lipid emulsions (ILE) should be an integral part of parenteral nutrition (PN) either exclusive or complementary to enteral feeding. (LoE 1−, RG A, strong recommendation for)R 4.2In preterm infants, lipid emulsions can be started immediately after birth and no later than on day two of life and for those in whom enteral feeding has been withdrawn, they can be started at time of PN initiation. (LoE 1−, RG A, strong recommendation for)R 4.3In preterm and term infants, parenteral lipid intake should not exceed 4 g/kg/day. (LoE 4, GPP, conditional recommendation for)R 4.4In children, parenteral lipid intake should be limited to a maximum of 3 g/kg/day. (LoE 3–4, RG 0, conditional recommendation for)R 4.5In order to prevent essential fatty acids (EFA) deficiency in preterm infants a lipid emulsion dosage providing a minimum linoleic acid (LA) intake of 0.25 g/kg/day can be given. This lipid emulsion dosage ensures an adequate intake of linolenic acid (LNA) with all lipid emulsions currently registered for paediatric use. (LoE 2−, RG 0, strong recommendation for)R 4.6In order to prevent EFA deficiency in term infants and in children a lipid emulsion dosage providing a minimum LA intake of 0.1 g/kg/day can be given, which also provides an adequate intake of LNA with all ILEs currently registered for paediatric use. (LoE 3–4, RG 0, conditional recommendation for)R 4.7In preterm infants, newborns and older children on short term PN, pure soybean oil (SO) ILEs may provide less balanced nutrition than composite ILEs. For PN lasting longer than a few days, pure SO ILEs should no longer be used and composite ILEs with or without fish oil (FO) should be the first choice treatment (LoE 1−, RG A, conditional recommendation for)R 4.8In preterm infants, ILEs should be protected by validated light-protected tubing. (LoE 1−, RG B, strong recommendation for)R 4.9In infants and children, 20% ILEs should be the first choice treatment (LoE 1−, RG B, strong recommendation for)R 4.10In newborns including preterm infants, routine use of ILEs should be continuous over 24 h (LoE 2++, RG B, conditional recommendation for)R 4.11If cyclic PN is used, for example for home PN children, ILEs should usually be given over the same duration as the other PN components. (LoE 4, GPP, strong recommendation for)R 4.12In paediatric patients, heparin should not be given with lipid infusion on a routine basis. (LoE 3–4, GPP, conditional recommendation for)R 4.13Carnitine supplementation may be considered in paediatric patients expected to receive PN for more than 4 weeks or in premature infants on an individual basis (LoE 3–4, GPP, conditional recommendation for)R 4.14In critically ill paediatric patients, ILE should be an integral part of PN. Composite ILEs with or without FO may be used as the first choice treatment. Available evidence raises the important question on the best timing to provide parenteral nutrition support in critically ill children, but do not allow to differentiate potential effects on outcomes of the timing of introducing parenteral lipid supply (LoE 4, GPP, conditional recommendation for)R 4.15In paediatric patients with sepsis, more frequent monitoring of plasma triglyceride concentration and dose adjustment in case of hyperlipidaemia are recommended. ILE dosage may be reduced but lipid supply may generally be continued at least in amounts supplying the minimal EFA requirements (LoE 4, GPP, conditional recommendation for)R 4.16Case reports have suggested the use of ILEs as a possible antidote for the treatment of drug toxicity in children, which however is not based on well-designed trials (LoE 3–4, GPP, conditional recommendation for)R 4.17In patients with severe unexplained thrombocytopaenia, serum triglyceride concentrations should be monitored and a reduction of parenteral lipid dosage may be considered. (LoE 3–4, GPP, conditional recommendation for)R 4.18As part of measures to reverse IFALD in paediatric patients, a discontinuation of SO ILE, a reduction of other ILE dosage and/or the use of composite ILE with FO, should be considered along with the treatment and management of other risk factors (LoE 2+, RG B, strong recommendation for)R 4.19The use of pure FO ILE is not recommended for general use in paediatric patients but may be used for short-term rescue treatment in patients with progression to severe IFALD, based on case reports. (LoE 3–4, GPP, conditional recommendation for)R 4.20Markers of liver integrity and function, and triglyceride concentrations in serum or plasma should be monitored regularly in patients receiving ILEs, and more frequently in cases with a marked risk for hyperlipidaemia (e.g. patients with high lipid or glucose dosage, sepsis, catabolism, extremely low birth weight infants) (LoE 2−, RG B, strong recommendation for)R 4.21Reduction of the dosage of ILEs can be considered if serum or plasma triglyceride concentrations during infusion exceed 3 mmol/L (265 mg/dL) in infants or 4.5 mmol/L (400 mg/dL) in older children (LoE 4, GPP, conditional recommendation for) Open table in a new tab Literature search timeframe: The references cited in the previous guidelines [[1]Koletzko B. Goulet O. Hunt J. Krohn K. Shamir R. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), supported by the European Society of Paediatric Research (ESPR).J Pediatr Gastroenterol Nutr. 2005; 41: S1-S87Crossref PubMed Google Scholar] are not repeated here, except for some relevant publications, and only the previous guidelines are cited instead. All publications published after the previous guidelines (i.e., from January 2004 to December 2014), have been considered for the first draft of this manuscript. Randomized controlled trials (RCTs), review articles, prospective studies and meta-analyses published in 2015 and 2016, during the revision process, have also been considered. Type of publications: Original papers, meta-analyses and reviews. Language: English Key words: Parenteral nutrition, lipid/fat emulsions, paediatric, fatty acids, LC-PUFA, IFALD, PNALD, cholestasis.