Parenteral nutrition-associated cholestasis and growth pre- and post-SMOFlipid introduction in neonates and infants with intestinal failure in Edmonton

Background: SMOFlipid was made available for use in pediatric parenteral nutrition (PN) in Canada, since 2013. While it is thought to have anti-cholestatic properties, data remains limited, including growth outcomes. We aimed to determine if infants receiving SMOFlipid had significantly lower rates of PN-associated cholestasis (PNAC) and improved growth compared to conventional Intralipid.

Methods: We conducted a retrospective cohort analysis. Patients (≤1 year old) with intestinal failure (PN ≥6 weeks) at the Stollery Children’s and Royal Alexander hospitals (2010-2018) were identified. Non-parametric tests were used to compare PNAC (conjugated bilirubin (CB) ≥34 umol/L) and growth.

Results: 1777 patients were reviewed; 36 infants (21 SMOFlipid, 15 Intralipid) were included. There were no significant differences in SMOFlipid vs. Intralipid median CB at baseline (29 vs. 6.5 umol/L), six weeks (9 vs. 5 umol/L), PN cessation (3 vs. 4 umol/L), or peak CB (29 vs. 16umol/L). At PN cessation, the proportion of PNAC decreased from 37% to 16% for SMOFlipid and remained stable from 8% to 10% for Intralipid. There were no differences in growth z-scores (p>0.05) in either the SMOFlipid or Intralipid group. There was a non-significant difference with higher head circumference z-scores given SMOFlipid compared to Intralipid at both six weeks (-0.93 vs. -2.8) and three months (-0.41 vs. -2.3) (p>0.05).

Conclusions: Despite significantly longer PN duration and a trend towards higher baseline CB, overall rates of PNAC decreased with use of SMOFlipid. Non-significant improvement in head circumferences and less time spent in low lipid dose ranges raises the possibility that either the better calorie delivery or fatty acid composition of SMOFlipid may support neurodevelopment, although future research is needed.