[ Vol. 10 No. 2 ] (May - August 2009 )
PN-Related cholestasis in infants - preventable and/or treatable?

Frederick Schwenk
MayoClinic College of Medicine, Rochester, M N, USA


Cholestatic liver disease with prolonged administration of PN is more common in infants and children than in adults. The etiology of PN-related cholestasis is unclear, but is likely to be multifactorial. While numerous treatment options have been suggested, the problem continues to plague practitioners treating infants with long-term PN.

Current fat emulsions used in PN are made from soybean/safflower or soybean oils and are rich in omega-6 fatty acids. An alternative to these products has recently become available. The alternative is a fish oil-based fat emulsion which contains omega-3 fatty acids, as well as the omega-6 fatty acid, arachidonic acid. Because animal studies using fish oil-based emulsions have been shown to prevent and reverse steatosis, this product has now been used in infants on long-term PN.

A recent report described the use of this emulsion in 18 infants with short bowel syndrome who had developed cholestasis while receiving soybean emulsion. Their clinical course was compared to 21 historical controls. In this compassionate use protocol, the only fat source the infants received was the fish oil-based fat emulsion administered at a rate of 1 gram per kilogram body weight per day. The results were dramatic. In those infants where cholestasis was reversed, the mean time it took for reversal of cholestasis was 9.4 weeks in the fish oil-based emulsion group compared to 44.1 weeks in the soybean emulsion group (p < 0.002). Seven of 21 infants receiving soybean emulsion died vs only 2 of the infants on the fish-oil emulsion. Use of the fish oil-based emulsion was not associated with essential fatty acid deficiency, hypertriglyceridemia, coagulopathy, an increased infection rate, or growth delay.

The mechanism by which the fish oil-based emulsion was able to reverse cholestasis is unclear. Whatever the mechanism, the recent data suggests a new treatment option for TP-related cholestasis in infants. On going studies will also help to address whether this product might prevent the development of cholestasis in this patient population.


PENSA 2009

“Energizing Nutrition Support Practice for Life”
June 5-7 2009, Shangri-La Hotel, Kuala Lumpur, Malaysia 
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