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Cholestasis of parenteral nutrition — Clinical Guidelines

Overview

Cholestasis of parenteral nutrition (PN) refers to the impairment of bile flow and secretion during PN therapy, often leading to complications such as jaundice, liver dysfunction, and increased risk of infections. 22

Diagnosis

Clinical signs include jaundice, pruritus, and elevated liver enzymes (ALT, AST, ALP, GGT). 22

Laboratory tests: Elevated bilirubin levels, abnormal liver function tests. 22

Imaging: Ultrasound or MRI may show hepatomegaly or biliary abnormalities. 22

Monitoring: Regular assessment of PN lipid levels and lipid emulsion adjustments. 22

Management

Adjust PN Composition: Reduce lipid content or switch to specialized lipid emulsions (e.g., SMOF). 22

Supplemental Therapies: Ursodeoxycholic acid (UDCA) may be considered to improve bile flow. 22

Monitoring and Support: Frequent monitoring of liver function tests and clinical status. 22

Infection Control: Vigilant surveillance for and management of infections due to compromised immune status. 22

Special Populations

Pediatrics: Careful monitoring of growth and development alongside PN adjustments is crucial. 22

Comorbidities: Patients with pre-existing liver conditions require heightened vigilance and tailored PN formulations. 22

Key Recommendations

Regularly monitor liver function tests and bilirubin levels to detect cholestasis early. (Evidence: Moderate 22)

Adjust PN lipid content or switch to safer lipid emulsions like SMOF to mitigate cholestatic risk. (Evidence: Moderate 22)

Consider adjunct therapy with UDCA for patients showing signs of cholestasis. (Evidence: Weak 22)

Implement stringent infection control measures due to increased vulnerability in PN-dependent patients. (Evidence: Expert opinion 22)

References

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Journal of the Academy of Nutrition and Dietetics 2023. link 6 Kenney EL, Tucker K, Plummer RS, Mita C, Andreyeva T. The Child and Adult Care Food Program and young children's health: a systematic review. Nutrition reviews 2023. link 7 Earnesty D, Mphwanthe G, Rau K, Weatherspoon L. A Qualitative Study: Perceived Barriers and Facilitators to Nutrition Standard Adherence by In-home Childcare Providers. Journal of the Academy of Nutrition and Dietetics 2022. link 8 McIsaac JD, MacQuarrie M, Barich R, Morris S, Turner JC, Rossiter MD. Responsive . International journal of environmental research and public health 2022. link 9 Dev DA, Padasas I, Hillburn C, Stage VC, Dzewaltowski DA. Ecological Approach to Family-Style, Multilevel Child Care Intervention: Formative Evaluation Using RE-AIM Framework. Journal of nutrition education and behavior 2022. link 10 Searle BE, Staton SS, Littlewood R, Thorpe K. Associations between food provision and feeding practices in socially disadvantaged childcare centres. Appetite 2022. link 11 Brennan SF, Lavelle F, Moore SE, Dean M, McKinley MC, McCole P et al.. Food environment intervention improves food knowledge, wellbeing and dietary habits in primary school children: Project Daire, a randomised-controlled, factorial design cluster trial. The international journal of behavioral nutrition and physical activity 2021. link 12 Tsai MM, Frongillo EA, Ritchie LD, Woodward-Lopez G, Au LE. Factor Analysis Reduces Complex Measures of Nutrition Environments in US Elementary and Middle Schools into Cohesive Dimensions in the Healthy Communities Study. The Journal of nutrition 2021. link 13 Assunção R, Boué G, Alvito P, Brazão R, Carmona P, Carvalho C et al.. Risk-Benefit Assessment of Cereal-Based Foods Consumed by Portuguese Children Aged 6 to 36 Months-A Case Study under the RiskBenefit4EU Project. Nutrients 2021. link 14 Mulligan C, Jawad A, Kent MP, Vanderlee L, L'Abbé MR. Stakeholder interactions with the federal government related to Bill S-228 and marketing to kids in Canada: a quantitative descriptive study. CMAJ open 2021. link 15 Mori S, Asakura K, Sasaki S, Nishiwaki Y. Relationship between maternal employment status and children's food intake in Japan. Environmental health and preventive medicine 2021. link 16 Holmberg Fagerlund B, Helseth S, Andersen LF, Småstuen MC, Glavin K. The use of a communication tool about diet at the child health centre: A cluster randomized controlled trial. Nursing open 2020. link 17 Hamner HC, Moore LV. Dietary quality among children from 6 months to 4 years, NHANES 2011-2016. The American journal of clinical nutrition 2020. link 18 Yoong SL, Grady A, Wiggers JH, Stacey FG, Rissel C, Flood V et al.. Child-level evaluation of a web-based intervention to improve dietary guideline implementation in childcare centers: a cluster-randomized controlled trial. The American journal of clinical nutrition 2020. link 19 Santoso MV, Kerr RB, Hoddinott J, Garigipati P, Olmos S, Young SL. Role of Women's Empowerment in Child Nutrition Outcomes: A Systematic Review. Advances in nutrition (Bethesda, Md.) 2019. link 20 Gichuru W, Ojha S, Smith S, Smyth AR, Szatkowski L. Is microfinance associated with changes in women's well-being and children's nutrition? A systematic review and meta-analysis. BMJ open 2019. link 21 Lutz LJ, Gaffney-Stomberg E, Karl JP, Hughes JM, Guerriere KI, McClung JP. Dietary Intake in Relation to Military Dietary Reference Values During Army Basic Combat Training; a Multi-center, Cross-sectional Study. Military medicine 2019. link 22 Eum S, Ock M, Lee S, Kim H. Adverse events and concurrent medications associated with parenteral nutrition use. Basic & clinical pharmacology & toxicology 2019. link 23 Bailey RL, Catellier DJ, Jun S, Dwyer JT, Jacquier EF, Anater AS et al.. Total Usual Nutrient Intakes of US Children (Under 48 Months): Findings from the Feeding Infants and Toddlers Study (FITS) 2016. The Journal of nutrition 2018. link 24 Welker EB, Jacquier EF, Catellier DJ, Anater AS, Story MT. Room for Improvement Remains in Food Consumption Patterns of Young Children Aged 2-4 Years. The Journal of nutrition 2018. link 25 Anater AS, Catellier DJ, Levine BA, Krotki KP, Jacquier EF, Eldridge AL et al.. The Feeding Infants and Toddlers Study (FITS) 2016: Study Design and Methods. The Journal of nutrition 2018. link 26 Seward K, Wolfenden L, Finch M, Wiggers J, Wyse R, Jones J et al.. Improving the implementation of nutrition guidelines in childcare centres improves child dietary intake: findings of a randomised trial of an implementation intervention. Public health nutrition 2018. link 27 Ghisolfi J, Fantino M, Turck D, de Courcy GP, Vidailhet M. Nutrient intakes of children aged 1-2 years as a function of milk consumption, cows' milk or growing-up milk. Public health nutrition 2013. link 28 Royo-Bordonada MA, Gorgojo L, Martín-Moreno JM, Garcés C, Rodríguez-Artalejo F, Benavente M et al.. Spanish children's diet: compliance with nutrient and food intake guidelines. European journal of clinical nutrition 2003. link 29 . Issues in infant and toddler nutrition. The journal of family health care 2002. link

Cholestasis of parenteral nutrition