Fish oil intravenous fat emulsion monotherapy and essential fatty acid requirements
Bibliographic record
Abstract
We have read with great interest the review article, “Essential fatty acid deficiency in parenteral nutrition: Historical perspective and modern solutions, a narrative review” by Wolff et al. We recently reviewed this literature to evaluate fish-oil intravenous lipid emulsion (FO-ILE) monotherapy in our pediatrics and preterm neonates with intestinal failure associated liver disease. We would like to the potential for calculation errors using Table 2. This table provides examples for calculating the minimum lipid volume needed to prevent essential fatty acid deficiency (EFAD) in a patient, based on age, type of lipid emulsion used, and minimal linoleic acid (LA) intake according to European Society of Paediatric Gastroenterology, Hepatology and Nutrition/European Society for Parenteral and Enteral Nutrition/European Society of Paediatric Research/Chinese Society of Parenteral and Enteral Nutrition joint guidelines.1 Sample calculations from Table 2 state that 10% (0.1 g fat/ml) FO-ILE contains 0.1 g LA/ml when, in fact, it only contains 0.0031 g LA/ml, according to product monograph by Fresenius Kabi pharmaceutical company.2 For a premature infant of 1.5 kg receiving FO-ILE monotherapy, instead of the 15 ml calculation result in Table 2, the minimum fat volume to prevent EFAD would be 121 ml (0.25 g LA/kg × 1.5 kg ÷ 0.0031 g LA/ml), which represents 8 g/kg/day of FO-ILE. This amount is impossible to achieve, considering that the maximum labeled dose of FO-ILE is 1 g/kg/day, with some studies having used doses no higher than 1.5 g/kg/day.3 In comparison, the minimum dose of soybean-oil intravenous lipid emulsions (SO-ILE) and mixed-oil emulsions (soybean oil, medium-chain triglycerides, olive oil, fish oil-intravenous lipid emulsion [SO,MCT,OO,FO-ILE] or OO,SO-ILE) to prevent EFAD for this infant are 0.5 g/kg/day and 1.4 g/kg/day, respectively. The recommended fat dose of these emulsions for premature infants is 3 g/kg/day.4 Therefore, it seems that minimal LA intake can be achieved with SO-ILE,OO,SO-ILE and SO,MCT,OO,FO-ILE but not with FO-ILE monotherapy, which may raise concerns among clinicians treating these patients. A team recently proposed to redefine EFAD because there is no published case report of EFAD in pediatrics on FO-ILE monotherapy.5 We would like to highlight that patients who were treated with FO-ILE monotherapy in published literature also received a proportion of their energy requirements by enteral nutrition, which may have protected them from EFAD. Also, monitoring of EFAD in these patients was conducted with triene/tetraene ratio, which is probably an unreliable marker, as discussed by Wolff and al in their article. Until more is known about minimal requirement of LA downstream metabolites or their minimal plasma levels to prevent EFAD, we believe that FO-ILE monotherapy should be used with caution in premature infants and also in term infants and pediatrics not receiving a substantial proportion of their energy requirements by enteral nutrition. Anne-Sophie Otis drafted the manuscript and all authors critically revised the manuscript, agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript. The authors thank Anne-Sophie Otis (Neonatal Intensive Care Unit Pharmacist), Flavie Pettersen-Coulombe (Pediatric Surgery and Parenteral Nutrition Pharmacist), and Emile Demers (Pediatric Gastroenterology Pharmacist) at CHU Sainte-Justine, Montréal, Canada, for their valuable clinical support and contributions to this study. None declared.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.007 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.001 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.002 | 0.007 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; both teacher heads agree on what is shown here.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".