Injectable lipid emulsions (ILEs) provide energy, fatty acids, and substrates needed to help promote normal growth and development in children. However, their use is not without concern. There are special considerations concerning the use of these products in this population that differ from those for adults.
The American Society of Parenteral and Enteral Nutrition (ASPEN) recently released safety recommendations for using ILEs in neonates and other pediatric patients.
The paper provides information on the three ILE preparations—Intralipid, Nutrilipid, and Omegaven—that are approved for use in children. The first two products are soybean oil—based, whereas the last formulation is fish oil—based. Two other ILE preparations, one containing a mix of soybean oil, medium-chain triglycerides, olive oil, and fish oil and another one that contains olive and soybean-based oil, are approved only for adults.
While the authors describe a systematic review of ILEs in preterm infants from the Cochrane Neonatal Groupthat did not find statistically significant differences in clinically important outcomes between the agents, they do warn about the development of intestinal failure–associated liver disease (IFALD), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP) stage >3. IFALD, which has previously been referred to as parenteral nutrition–associated liver disease or parenteral nutrition–associated cholestasis, is a multifactorial, serious complication seen in infants and children who are receiving long-term parenteral nutrition, especially if they were born prematurely and/or have had bowel resection resulting in short-bowel syndrome.
IFALD can progress to end-stage liver disease. BPD occurs in premature babies whose lungs are underdeveloped at birth. There are conflicting data on the use of fish oil in this population. ROP is a retinal vasoproliferative disease due to inflammation and oxidative stress seen in preterm babies that is a major cause of blindness.
About 38% of ILE errors occur in this young population and most often involve administration, prescribing, or transcribing processes. ILEs are the most common parenteral-nutrition ingredient associated with pharmaceutical-preparation errors. Prescribing considerations for ILEs are discussed, including patient-specific selection and dosing considerations. Safety precautions pertaining to the order-review process for ILEs include the use of a checklist to ensure that all elements involved in the preparation of the ILE are addressed.
Higher doses of ILEs are utilized in pediatric patients relative to adults to support growth, development, and metabolic need. However, these higher doses can lead to compatibility concerns. The use of total parental admixtures is more common for adults, but they are still used in about one-quarter of pediatric patients. Dosing errors while repackaging ILEs to meet the unique needs of pediatric patients, as well as the risk of contamination during repackaging, pose special challenges to the use of these nutritional supplements in young children.
The paper provides recommendations for monitoring, especially serum triglyceride concentrations, and the role that different formulations can have on triglyceride clearance and fat-overload syndrome. Other conditions to monitor for include essential fatty acid deficiencies, platelet dysfunction and bleeding, and elevations of liver-function tests.
These recommendations provide guidance to pharmacists who compound ILEs for pediatric patients on the safe prescribing, order-review process, preparation, administration, and monitoring of these essential nutritional formulations.
The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.
« Click here to return to Infusion Pharmacy Update.