# Pediatric parenteral nutrition and hydroperoxide toxicity: Evaluation of the effectiveness of photoprotection medical devices

Pierre Nizet, Nicolas Guillard, Lionel Chabaud, Kamel-olivier Sellal, Corinne Lejus-Bourdeau, Laure Simon, Dominique Navas, Emmanuelle Olivier, Johann Clouet, Fabien Lindenberg, et al.

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## ► To cite this version:

Pierre Nizet, Nicolas Guillard, Lionel Chabaud, Kamel-olivier Sellal, Corinne Lejus-Bourdeau, et al. Pediatric parenteral nutrition and hydroperoxide toxicity: Evaluation of the effectiveness of photoprotection medical devices. Photochemistry and Photobiology, 2023, 10.1111/php.13894. hal-04418078

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# Pediatric parenteral nutrition and hydroperoxide toxicity: Evaluation of the effectiveness of photoprotection medical devices

Pierre Nizet, Nicolas Guillard, Lionel Chabaud, Kamel-olivier Sellal, Corinne Lejus-Bourdeau, Laure Simon, Dominique Navas, Emmanuelle Olivier, Johann Clouet, Fabien Lindenberg, et al.

<figure><img src="image_1.png" /></figure>

## ► To cite this version:

Pierre Nizet, Nicolas Guillard, Lionel Chabaud, Kamel-olivier Sellal, Corinne Lejus-Bourdeau, et al. Pediatric parenteral nutrition and hydroperoxide toxicity: Evaluation of the effectiveness of photoprotection medical devices. Photochemistry and Photobiology, 2023, 10.1111/php.13894. hal-04418078

HAL Id: hal-04418078

https://hal.inrae.fr/hal-04418078v1

Submitted on 25 Jan 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
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<figure><img src="image_2.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
# Pediatric parenteral nutrition and hydroperoxide toxicity: Evaluation of the effectiveness of photoprotection medical devices

Pierre Nizet<fnref n="1" />,<fnref n="2" />

Nicolas Guillard<fnref n="1" />

Lionel Chabaud<fnref n="2" />

Kamel-Olivier Sellal<fnref n="1" />

Corinne Lejus-Bourdeau<fnref n="3" />,<fnref n="4" />

Laure Simon<fnref n="5" />

Dominique Navas<fnref n="1" />,<fnref n="2" />

Emmanuelle Olivier<fnref n="1" />

Johann Clouet<fnref n="1" />,<fnref n="2" />

Fabien Lindenberg<fnref n="1" />

Fabien Nativel<fnref n="1" />,<fnref n="2" />

<figure><img src="image_3.png" /></figure>

**Correspondence**

Fabien Nativel, Nantes Université, CHU Nantes, Pharmacie, 5 allée de l'ile Gloriette, Nantes F-44000, France.

Email: fabien.nativel@univ-nantes.fr

**Abstract**

Exposure of parenteral nutrition (PN) to light induces hydroperoxide (HPO) formation whose toxicity, especially in pediatrics, is documented. In this context, we evaluated the efficacy of photoprotection medical devices used in our institution to protect PN from degradation after two different exposures to light. A mixed oil lipid emulsion (Smoflipid®) in standard or opaque syringes and a ternary PN mixture bags (Numetah®) with or without opaque overwrap were exposed for at least 420 min to a xenon lamp. Samples of Smoflipid® in standard or opaque syringes were also exposed for 24 h to conditions reproducing those of a neonatal intensive care unit. The use of opaque syringes for Smoflipid® administration or opaque overwraps for Numetah® administration reduced HPO formation by an average of 14% and 40%, respectively, compared to standard conditions after at least 420 min to a xenon lamp. When Smoflipid® samples were administered with standard or opaque syringes and exposed to a phototherapy lamp, the fold-change in the HPO concentration increased, respectively, by 6.3 or 5.4 at 24 h compared with syringes unexposed to phototherapy lamp. Although the observed differences were non-significant, it nonetheless appears prudent to use photoprotection of PN during administration, particularly in patients with immature or compromised antioxidant capacity.

**KEYWORDS**

lipid peroxidation, medical devices, parenteral nutrition, pediatric, photoprotection

## INTRODUCTION

In neonatal intensive care, preterm newborns often require parenteral nutrition (PN) in the first weeks of life,

in particular, when they are voluntarily exposed to natural or artificial light to prevent neonatal hyperbilirubinemia.<fnref n="1" /> However, exposure of PN to light induces the formation of hydroperoxides (HPO) whose toxicity is already

Pierre Nizet and Nicolas Guillard contributed equally to this work.

<footnote n="1">¹Nantes Université, CHU Nantes, Pharmacie, Nantes, France</footnote>

<footnote n="2">²Nantes Université, UFR des Sciences Pharmaceutiques et Biologiques, Nantes, France</footnote>

<footnote n="3">³Nantes Université, CHU Nantes, Service d'Anesthésie et de Soins Intensifs, Nantes, France</footnote>

<footnote n="4">⁴Nantes Université, Laboratoire Expérimental de Simulation de Médecine Intensive (LE SiMU), Nantes, France</footnote>

<footnote n="5">⁵Nantes Université, CHU Nantes, Service médecine néonatale, Nantes, France</footnote>

<footnote>This is an open access article under the terms of the [Creative Commons Attribution License](https://creativecommons.org/licenses/by/4.0/), which permits use, distribution and reproduction in any medium, provided the original work is properly cited.</footnote>

<footnote>© 2023 The Authors. *Photochemistry and Photobiology* published by Wiley Periodicals LLC on behalf of American Society for Photobiology.</footnote>
# Pediatric parenteral nutrition and hydroperoxide toxicity: Evaluation of the effectiveness of photoprotection medical devices

Pierre Nizet<fnref n="1" />,<fnref n="2" />

Nicolas Guillard<fnref n="1" />

Lionel Chabaud<fnref n="2" />

Kamel-Olivier Sellal<fnref n="1" />

Corinne Lejus-Bourdeau<fnref n="3" />,<fnref n="4" />

Laure Simon<fnref n="5" />

Dominique Navas<fnref n="1" />,<fnref n="2" />

Emmanuelle Olivier<fnref n="1" />

Johann Clouet<fnref n="1" />,<fnref n="2" />

Fabien Lindenberg<fnref n="1" />

Fabien Nativel<fnref n="1" />,<fnref n="2" />

<figure><img src="image_3.png" /></figure>

Correspondence

Fabien Nativel, Nantes Université, CHU Nantes, Pharmacie, 5 allée de l'ile Gloriette, Nantes F-44000, France.

Email: fabien.nativel@univ-nantes.fr

Abstract

Exposure of parenteral nutrition (PN) to light induces hydroperoxide (HPO) formation whose toxicity, especially in pediatrics, is documented. In this context, we evaluated the efficacy of photoprotection medical devices used in our institution to protect PN from degradation after two different exposures to light. A mixed oil lipid emulsion (Smoflipid®) in standard or opaque syringes and a ternary PN mixture bags (Numetah®) with or without opaque overwrap were exposed for at least 420 min to a xenon lamp. Samples of Smoflipid® in standard or opaque syringes were also exposed for 24 h to conditions reproducing those of a neonatal intensive care unit. The use of opaque syringes for Smoflipid® administration or opaque overwraps for Numetah® administration reduced HPO formation by an average of 14% and 40%, respectively, compared to standard conditions after at least 420 min to a xenon lamp. When Smoflipid® samples were administered with standard or opaque syringes and exposed to a phototherapy lamp, the fold-change in the HPO concentration increased, respectively, by 6.3 or 5.4 at 24 h compared with syringes unexposed to phototherapy lamp. Although the observed differences were non-significant, it nonetheless appears prudent to use photoprotection of PN during administration, particularly in patients with immature or compromised antioxidant capacity.

KEYWORDS

lipid peroxidation, medical devices, parenteral nutrition, pediatric, photoprotection

INTRODUCTION

In neonatal intensive care, preterm newborns often require parenteral nutrition (PN) in the first weeks of life,

in particular, when they are voluntarily exposed to natural or artificial light to prevent neonatal hyperbilirubinemia.<fnref n="1" /> However, exposure of PN to light induces the formation of hydroperoxides (HPO) whose toxicity is already

Pierre Nizet and Nicolas Guillard contributed equally to this work.

<footnote n="1">¹Nantes Université, CHU Nantes, Pharmacie, Nantes, France</footnote>

<footnote n="2">²Nantes Université, UFR des Sciences Pharmaceutiques et Biologiques, Nantes, France</footnote>

<footnote n="3">³Nantes Université, CHU Nantes, Service d'Anesthésie et de Soins Intensifs, Nantes, France</footnote>

<footnote n="4">⁴Nantes Université, Laboratoire Expérimental de Simulation de Médecine Intensive (LE SiMU), Nantes, France</footnote>

<footnote n="5">⁵Nantes Université, CHU Nantes, Service médecine néonatale, Nantes, France</footnote>

<footnote>This is an open access article under the terms of the [Creative Commons Attribution License](https://creativecommons.org/licenses/by/4.0/), which permits use, distribution and reproduction in any medium, provided the original work is properly cited.</footnote>

<footnote>© 2023 The Authors. *Photochemistry and Photobiology* published by Wiley Periodicals LLC on behalf of American Society for Photobiology.</footnote>
documented.²⁻⁵ In vivo, these HPO diffuse into the cells and form free radicals in the presence of metal ions that can react with molecular species (proteins, lipids, and DNA), leading to dysregulation of the inflammatory response, cell death, and tissue injury.⁶⁻⁸ When patient's antioxidant systems are immature, the toxicity of these oxygen-rich HPO is high and can lead to various complications such as bronchopulmonary dysplasia, necrotizing enterocolitis, and retinopathy.⁹ In addition, the appearance of these HPO in the mixtures clearly changes the quality of the administered PN.¹⁰

In September 2019, the French agency ANSM (Agence Nationale de Sécurité des Médicaments et des produits de santé) addressed a safety information to healthcare professionals and emphasized the obligation to protect PN bags that contain amino acids and/or lipids from light during their administration, especially, in newborns and children under 2 years of age.¹¹ However, no practical information has been provided regarding the administration modalities nor the technical characteristics of the photoprotection medical devices (MD) to be used in hospital.

Complete photoprotection of PN admixtures refers to implementing light-protective measures during the multiple steps of the PN process: (1) sterile compounding in the pharmacy, (2) transport and delivery to the patient care area, and (3) administration to the patient.¹² Several studies have evaluated the clinical impact of some photoprotection MD,⁴,¹³⁻¹⁵ but to our knowledge, no recent study has evaluated the effectiveness of the MD in association with HPO concentration formed in PN. In this study, we focused on the photoprotective MD of parenteral nutrition during administration in connection with the ANSM information safety.

The objective of this study was to evaluate the concentration of HPO with and without use of photoprotection MD referenced in our institution (1) after deliberate light overexposure of PN, and (2) during a realistic scenario in a hospital context.

# MATERIALS AND METHODS

## Materials

Lipid emulsion (Smoflipid®, 200mg/mL), a mixture of water and oil comprising four different types of lipids: soybean oil, olive oil, fish oil, and medium chain triglycerides, was purchased from Fresenius Kabi (Uppsala, Sweden). Ternary mixture (Numetah® G16%), indicated for use in newborns and children under 2 years of age and marketed as a tri-compartment bag and composed of a 50% dextrose monohydrate solution, a 12.5% lipid emulsion (80% olive oil and 20% soybean oil), and a 5.9% amino acid solution containing electrolytes, was purchased from Baxter (Deerfield, USA). Photoprotection MD tested were (1)

50-mL opaque syringes (ref. 300,869, Becton Dickinson, San Jose, USA) which are used to protect lipid emulsion, and (2) opaque overwraps (ref. 29,866, Bexen Medical, Hernani, Spain) which used to protect ternary mixture bags. According to the technical data of manufacturer, opaque syringes and opaque overwraps are capable of absorbing 90% of radiation between 290 and 450 nm. Fifty-milliliter standard syringes (ref 300,865) also purchased from Becton Dickinson were used as control MD.

## Induction of lipid peroxidation after deliberate light overexposure of the mixed oil lipid emulsion and ternary mixture

Smoflipid® samples in standard and opaque syringes, as well as Numetah® G16% bags protected or not from light by overwraps, were exposed to light from a filtered xenon lamp (λ=300-800nm - Power=250mW) in a Suntest CPS+® (Atlas, Elancourt, France) to mimic the radiation and temperature of the sun in midsummer (Figure 1). No vitamins or trace elements were added to the samples tested. Smoflipid® syringes (standard or opaque) were exposed for 480min and Numetah® G16% bags (with or without overwrap) were exposed for 420min. For the Smoflipid® conditions, samples were collected after 180 and 480min of exposure to filtered xenon lamps. For the Numetah® G16% conditions, samples were collected at the following times: 30, 60, 90, 120, 180, 240, 300, 360, and 420min. The results are expressed as the lipid peroxidation concentration ratio obtained between the light overexposure condition and the light non-exposure condition (control group). The experiment was performed using three different batches of Smoflipid® and two different batches of Numetah® G16% and in triplicate for each condition.

## Induction of lipid peroxidation during a realistic scenario in a hospital context

Samples of Smoflipid® in standard and opaque syringes were exposed to high-intensity blue light-emitting diodes (λ=400-550nm - Power=4mW/cm²) in the experimental simulation laboratory located at the Faculty of Pharmacy of Nantes University. These conditions were chosen to as closely as possible mimic those of parenteral nutrition administration to premature newborns in a neonatal intensive care unit (Figure 2). The syringes were placed on an electric syringe pump (Vial Pilot A2, Fresenius Kabi) in the incubator. A Leddybloo® phototherapy lamp (Mediprema, Tauxigny-Saint-Bauld, France) was installed above the incubator as in clinical practice for 24h. The study of lipid peroxidation was then performed after the following exposure times: 0, 2, 4, 6, 8, and 24h according to the 2018 guidelines
documented.²⁻⁵ In vivo, these HPO diffuse into the cells and form free radicals in the presence of metal ions that can react with molecular species (proteins, lipids, and DNA), leading to dysregulation of the inflammatory response, cell death, and tissue injury.⁶⁻⁸ When patient's antioxidant systems are immature, the toxicity of these oxygen-rich HPO is high and can lead to various complications such as bronchopulmonary dysplasia, necrotizing enterocolitis, and retinopathy.⁹ In addition, the appearance of these HPO in the mixtures clearly changes the quality of the administered PN.¹⁰

In September 2019, the French agency ANSM (Agence Nationale de Sécurité des Médicaments et des produits de santé) addressed a safety information to healthcare professionals and emphasized the obligation to protect PN bags that contain amino acids and/or lipids from light during their administration, especially, in newborns and children under 2 years of age.¹¹ However, no practical information has been provided regarding the administration modalities nor the technical characteristics of the photoprotection medical devices (MD) to be used in hospital.

Complete photoprotection of PN admixtures refers to implementing light-protective measures during the multiple steps of the PN process: (1) sterile compounding in the pharmacy, (2) transport and delivery to the patient care area, and (3) administration to the patient.¹² Several studies have evaluated the clinical impact of some photoprotection MD,⁴,¹³⁻¹⁵ but to our knowledge, no recent study has evaluated the effectiveness of the MD in association with HPO concentration formed in PN. In this study, we focused on the photoprotective MD of parenteral nutrition during administration in connection with the ANSM information safety.

The objective of this study was to evaluate the concentration of HPO with and without use of photoprotection MD referenced in our institution (1) after deliberate light overexposure of PN, and (2) during a realistic scenario in a hospital context.

# MATERIALS AND METHODS

## Materials

Lipid emulsion (Smoflipid®, 200mg/mL), a mixture of water and oil comprising four different types of lipids: soybean oil, olive oil, fish oil, and medium chain triglycerides, was purchased from Fresenius Kabi (Uppsala, Sweden). Ternary mixture (Numetah® G16%), indicated for use in newborns and children under 2 years of age and marketed as a tri-compartment bag and composed of a 50% dextrose monohydrate solution, a 12.5% lipid emulsion (80% olive oil and 20% soybean oil), and a 5.9% amino acid solution containing electrolytes, was purchased from Baxter (Deerfield, USA). Photoprotection MD tested were (1)

50-mL opaque syringes (ref. 300,869, Becton Dickinson, San Jose, USA) which are used to protect lipid emulsion, and (2) opaque overwraps (ref. 29,866, Bexen Medical, Hernani, Spain) which used to protect ternary mixture bags. According to the technical data of manufacturer, opaque syringes and opaque overwraps are capable of absorbing 90% of radiation between 290 and 450 nm. Fifty-milliliter standard syringes (ref 300,865) also purchased from Becton Dickinson were used as control MD.

## Induction of lipid peroxidation after deliberate light overexposure of the mixed oil lipid emulsion and ternary mixture

Smoflipid® samples in standard and opaque syringes, as well as Numetah® G16% bags protected or not from light by overwraps, were exposed to light from a filtered xenon lamp (λ=300-800nm - Power=250mW) in a Suntest CPS+® (Atlas, Elancourt, France) to mimic the radiation and temperature of the sun in midsummer (Figure 1). No vitamins or trace elements were added to the samples tested. Smoflipid® syringes (standard or opaque) were exposed for 480min and Numetah® G16% bags (with or without overwrap) were exposed for 420min. For the Smoflipid® conditions, samples were collected after 180 and 480min of exposure to filtered xenon lamps. For the Numetah® G16% conditions, samples were collected at the following times: 30, 60, 90, 120, 180, 240, 300, 360, and 420min. The results are expressed as the lipid peroxidation concentration ratio obtained between the light overexposure condition and the light non-exposure condition (control group). The experiment was performed using three different batches of Smoflipid® and two different batches of Numetah® G16% and in triplicate for each condition.

## Induction of lipid peroxidation during a realistic scenario in a hospital context

Samples of Smoflipid® in standard and opaque syringes were exposed to high-intensity blue light-emitting diodes (λ=400-550nm - Power=4mW/cm²) in the experimental simulation laboratory located at the Faculty of Pharmacy of Nantes University. These conditions were chosen to as closely as possible mimic those of parenteral nutrition administration to premature newborns in a neonatal intensive care unit (Figure 2). The syringes were placed on an electric syringe pump (Vial Pilot A2, Fresenius Kabi) in the incubator. A Leddybloo® phototherapy lamp (Mediprema, Tauxigny-Saint-Bauld, France) was installed above the incubator as in clinical practice for 24h. The study of lipid peroxidation was then performed after the following exposure times: 0, 2, 4, 6, 8, and 24h according to the 2018 guidelines
<figure><img src="image_4.png" /><figcaption>**FIGURE 1** Induction of lipid peroxidation after deliberate light overexposure of the mixed oil lipid emulsion and ternary mixture vs unexposed conditions. Two independent experiments were performed to assess lipid peroxidation based on the quantification of their degradation products. Indeed, mixed oil lipid emulsion and ternary mixture were exposed to filtered xenon lamps (λ = 300–800 nm – Power = 250 mW) in a Suntest CPS + ® for a maximum of 480 min. Lipid peroxidation was determined by using the Peroxide Assay kit®. The experiments were performed in triplicate for each condition.</figcaption></figure>

of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN).¹⁶ The results are expressed as the lipid peroxidation concentration ratio obtained between the blue light-exposure condition and the light non-exposure condition (control group). The experiment was performed using three different batches of Smoflipid® and in triplicate for each condition.

## Evaluation of lipid peroxidation by measurement of the concentration of their degradation products (or hydroperoxides, HPO)

After dilution of the samples in a solvent composed of methanol/dichloromethane (80%/20%, v/v), HPO formation was determined using a Peroxide Assay kit® (# MAK311,

Sigma-Aldrich, Saint-Louis, USA) following the manufacturer's instructions. Briefly, this method is based on the chromogenic Fe³⁺-xylenol orange reaction.¹⁷⁻¹⁹ The chromophore generated absorbs at 585 nm in spectrophotometry after 30 min of incubation at room temperature. The measured absorbance, using a Spectra Max® 190 UV/visible microplate reader (Molecular Devices), is proportional to the concentration of HPO in the sample.

## Statistical analysis

GraphPad 8® software was used for all statistical analyses. Results are reported as means ± the standard error of the mean. A two-way unpaired ANOVA test was used followed by a Tukey's post-test, with *p*-values adjusted for multiple comparisons, to compare (1) the HPO concentration in
<figure><img src="image_4.png" /><figcaption>**FIGURE 1** Induction of lipid peroxidation after deliberate light overexposure of the mixed oil lipid emulsion and ternary mixture vs unexposed conditions. Two independent experiments were performed to assess lipid peroxidation based on the quantification of their degradation products. Indeed, mixed oil lipid emulsion and ternary mixture were exposed to filtered xenon lamps (λ = 300–800 nm – Power = 250 mW) in a Suntest CPS + ® for a maximum of 480 min. Lipid peroxidation was determined by using the Peroxide Assay kit®. The experiments were performed in triplicate for each condition.</figcaption></figure>

of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN).¹⁶ The results are expressed as the lipid peroxidation concentration ratio obtained between the blue light-exposure condition and the light non-exposure condition (control group). The experiment was performed using three different batches of Smoflipid® and in triplicate for each condition.

## Evaluation of lipid peroxidation by measurement of the concentration of their degradation products (or hydroperoxides, HPO)

After dilution of the samples in a solvent composed of methanol/dichloromethane (80%/20%, v/v), HPO formation was determined using a Peroxide Assay kit® (# MAK311,

Sigma-Aldrich, Saint-Louis, USA) following the manufacturer's instructions. Briefly, this method is based on the chromogenic Fe³⁺-xylenol orange reaction.¹⁷⁻¹⁹ The chromophore generated absorbs at 585 nm in spectrophotometry after 30 min of incubation at room temperature. The measured absorbance, using a Spectra Max® 190 UV/visible microplate reader (Molecular Devices), is proportional to the concentration of HPO in the sample.

## Statistical analysis

GraphPad 8® software was used for all statistical analyses. Results are reported as means ± the standard error of the mean. A two-way unpaired ANOVA test was used followed by a Tukey's post-test, with *p*-values adjusted for multiple comparisons, to compare (1) the HPO concentration in
<figure><img src="image_5.png" /><figcaption>**FIGURE 2** Induction of lipid peroxidation during a realistic scenario in a hospital context. (A) Mixed oil lipid emulsion was exposed to Leddybloo® phototherapy lamp for 24 h. Lipid peroxidation was determined by using the Peroxide Assay kit®. The experiments were performed in triplicate for each condition; (B) Representative picture of the assembly used in the experimental simulation laboratory located in the Faculty of Pharmacy in Nantes in order to reproduce the conditions of administration of mixed oil lipid emulsion in a neonatal intensive care room (1: Leddybloo® phototherapy lamp; 2: electric syringe pump; 3: incubator with low fidelity mannequin).</figcaption></figure>

standard or opaque syringes after exposure of Smoflipid® to filtered xenon lamps; (2) the HPO concentration in Numetah® G16% bags protected or not from light by over-wraps after exposure of bags to filtered xenon lamps; (3) the HPO concentration in standard or opaque syringes after exposure of Smoflipid® to high-intensity blue light-emitting diodes during a realistic scenario in a hospital context.

## RESULTS

### Hydroperoxide formation after deliberate light overexposure of mixed oil lipid emulsion and ternary mixture to filtered xenon lamps

In vitro, quantification of the HPO concentration ratio in Smoflipid® samples revealed an increase in lipid

peroxidation when the Smoflipid® was exposed to light from a filtered xenon lamp in a standard syringe (1.7-fold at 180 min and 2.2-fold at 480 min) or an opaque syringe (1.4-fold at 180 min and 1.9-fold at 480 min) compared to a control group (Figure 3A). The use of opaque syringes for the administration of Smoflipid® reduced HPO formation by an average of 20% at 180 min after exposure to light from a xenon lamp (and by an average of 14% after 480 min) compared to the use of standard syringes (Figure 3A).

Quantification of the average HPO concentration ratio in Numetah® G16% revealed a difference in lipid peroxidation when the Numetah® G16% was exposed to light from a filtered xenon lamp and not protected or protected with opaque overwraps compared with an unexposed condition, with increases of 4.4-fold and 2.3-fold, respectively, at 180 min and 8.1-fold and 4.9-fold, respectively, at 420 min (Figure 3B). The use of opaque overwraps during the administration of Numetah® G16% reduced HPO
<figure><img src="image_5.png" /><figcaption>**FIGURE 2** Induction of lipid peroxidation during a realistic scenario in a hospital context. (A) Mixed oil lipid emulsion was exposed to Leddybloo® phototherapy lamp for 24 h. Lipid peroxidation was determined by using the Peroxide Assay kit®. The experiments were performed in triplicate for each condition; (B) Representative picture of the assembly used in the experimental simulation laboratory located in the Faculty of Pharmacy in Nantes in order to reproduce the conditions of administration of mixed oil lipid emulsion in a neonatal intensive care room (1: Leddybloo® phototherapy lamp; 2: electric syringe pump; 3: incubator with low fidelity mannequin).</figcaption></figure>

standard or opaque syringes after exposure of Smoflipid® to filtered xenon lamps; (2) the HPO concentration in Numetah® G16% bags protected or not from light by over-wraps after exposure of bags to filtered xenon lamps; (3) the HPO concentration in standard or opaque syringes after exposure of Smoflipid® to high-intensity blue light-emitting diodes during a realistic scenario in a hospital context.

## RESULTS

### Hydroperoxide formation after deliberate light overexposure of mixed oil lipid emulsion and ternary mixture to filtered xenon lamps

In vitro, quantification of the HPO concentration ratio in Smoflipid® samples revealed an increase in lipid

peroxidation when the Smoflipid® was exposed to light from a filtered xenon lamp in a standard syringe (1.7-fold at 180 min and 2.2-fold at 480 min) or an opaque syringe (1.4-fold at 180 min and 1.9-fold at 480 min) compared to a control group (Figure 3A). The use of opaque syringes for the administration of Smoflipid® reduced HPO formation by an average of 20% at 180 min after exposure to light from a xenon lamp (and by an average of 14% after 480 min) compared to the use of standard syringes (Figure 3A).

Quantification of the average HPO concentration ratio in Numetah® G16% revealed a difference in lipid peroxidation when the Numetah® G16% was exposed to light from a filtered xenon lamp and not protected or protected with opaque overwraps compared with an unexposed condition, with increases of 4.4-fold and 2.3-fold, respectively, at 180 min and 8.1-fold and 4.9-fold, respectively, at 420 min (Figure 3B). The use of opaque overwraps during the administration of Numetah® G16% reduced HPO
<figure><img src="image_6.png" /><figcaption>**FIGURE 3** Hydroperoxide formation after deliberate overexposure of mixed oil lipid emulsion and ternary mixture to light from a filtered xenon lamp. (A) Mixed oil lipid emulsion samples contained in standard and opaque syringes and (B) a ternary mixture protected or not from light by opaque overwrap were, respectively, exposed during 480 min or 420 min to filtered xenon lamps (λ = 300–800 nm – Power = 250 mW). Then, lipid peroxidation was determined by using the Peroxide Assay kit® (N = 3, n = 3). These results were expressed as an HPO concentration ratio obtained between the light overexposure condition to the light non-exposure condition.</figcaption></figure>

formation by an average of 48% after 180 min of exposure to light from a xenon lamp (and by an average of 40% after 420 min) compared to the condition where the Numetah® G16% samples were not protected (Figure 3B).

Even if the overall results of this experiment are not statistically significant, a tendency toward reduction of HPO formation under these conditions using this photoprotection MD was shown over time.

## Hydroperoxide formation after exposure of mixed oil lipid emulsion to high-intensity blue light during a realistic scenario in a hospital context

These conditions used above do not reflect what happens in real conditions, especially because newborns are more often exposed to a high-intensity blue light from a phototherapy lamp, it is, therefore, essential to evaluate the effectiveness of these photoprotection MD during a realistic scenario in a hospital context.

During the 24-h phototherapy session in the experimental simulation laboratory, the mean concentration of HPO in standard Smoflipid® syringes was 233±86 µM at 2h, 347±12 µM at 4h, 848±140 µM at 8h, and 1610±421 µM at 24h. The mean concentration HPO in opaque Smoflipid® syringes was 242±93 µM at 2h, 320±97 µM at 4h, 626±92 µM at 8h, and 1230±346 µM at 24h (data not shown).

Moreover, when Smoflipid® samples were administered with standard syringes and exposed to phototherapy light, the HPO concentration increased compared with syringes unexposed to phototherapy light, with increases of 0.9-fold at 2h, 1.4-fold at 4h, 3.6-fold at 8h, and 6.3-fold at 24h. When Smoflipid® samples were administered with opaque syringes and exposed to phototherapy light, the HPO concentration increased compared with syringes unexposed to phototherapy light, with increases of 0.9-fold at 2h, 1.2-fold at 4h, 2.5-fold at 8h, and 5.4-fold at 24h (Figure 4). Under these conditions, the photoprotection MD did not appear to significantly reduce the amount of HPO produced over time.
<figure><img src="image_6.png" /><figcaption>**FIGURE 3** Hydroperoxide formation after deliberate overexposure of mixed oil lipid emulsion and ternary mixture to light from a filtered xenon lamp. (A) Mixed oil lipid emulsion samples contained in standard and opaque syringes and (B) a ternary mixture protected or not from light by opaque overwrap were, respectively, exposed during 480 min or 420 min to filtered xenon lamps (λ = 300–800 nm – Power = 250 mW). Then, lipid peroxidation was determined by using the Peroxide Assay kit® (N = 3, n = 3). These results were expressed as an HPO concentration ratio obtained between the light overexposure condition to the light non-exposure condition.</figcaption></figure>

formation by an average of 48% after 180 min of exposure to light from a xenon lamp (and by an average of 40% after 420 min) compared to the condition where the Numetah® G16% samples were not protected (Figure 3B).

Even if the overall results of this experiment are not statistically significant, a tendency toward reduction of HPO formation under these conditions using this photoprotection MD was shown over time.

**Hydroperoxide formation after exposure of mixed oil lipid emulsion to high-intensity blue light during a realistic scenario in a hospital context**

These conditions used above do not reflect what happens in real conditions, especially because newborns are more often exposed to a high-intensity blue light from a phototherapy lamp, it is, therefore, essential to evaluate the effectiveness of these photoprotection MD during a realistic scenario in a hospital context.

During the 24-h phototherapy session in the experimental simulation laboratory, the mean concentration of HPO in standard Smoflipid® syringes was 233±86 µM at 2h, 347±12 µM at 4h, 848±140 µM at 8h, and 1610±421 µM at 24h. The mean concentration HPO in opaque Smoflipid® syringes was 242±93 µM at 2h, 320±97 µM at 4h, 626±92 µM at 8h, and 1230±346 µM at 24h (data not shown).

Moreover, when Smoflipid® samples were administered with standard syringes and exposed to phototherapy light, the HPO concentration increased compared with syringes unexposed to phototherapy light, with increases of 0.9-fold at 2h, 1.4-fold at 4h, 3.6-fold at 8h, and 6.3-fold at 24h. When Smoflipid® samples were administered with opaque syringes and exposed to phototherapy light, the HPO concentration increased compared with syringes unexposed to phototherapy light, with increases of 0.9-fold at 2h, 1.2-fold at 4h, 2.5-fold at 8h, and 5.4-fold at 24h (Figure 4). Under these conditions, the photoprotection MD did not appear to significantly reduce the amount of HPO produced over time.
DISCUSSION

According to the guidelines of the ESPGHAN, pediat-
ric PN is used in hospitals when conventional or enteral
feeding is not possible in patients due to impaired or im-
mature gastrointestinal function.¹⁶ Several types of PN
used in hospitals: (1) mixed oil lipid emulsions; (2) binary
mixtures, composed of dextrose monohydrate and amino
acids, which can used in combination with a mixed oil
lipid emulsion; (3) ternary mixtures composed of dextrose
monohydrate, amino acids, and a lipid emulsion. These
mixtures can be supplemented with vitamins, trace ele-
ments, and sometimes electrolytes within validated phar-
maceutical limits. In our institution, it is important to note
that no supplementation is added directly into the PN bag
in order to limit microbiological risk. However, they are
added in a Y-site using an extender. Like all health prod-
ucts, PN must be stored under optimal conditions (light,
temperature), in particular mixed oil lipid emulsions and
ternary mixture, due to their high polyunsaturated fatty
acid composition. These fatty acids are a major source of
HPO production during their administration as a result of
their oxidation by radical oxygen species.

Even if, in the majority of living organisms, where all
antioxidant systems interact with each other, the toxicity
of HPO has not yet been fully proven, the toxicity of HPO
has been documented in cellular and tissue models since
the 90s. The toxicity of HPO contributes to a decrease in
the intracellular adenosine triphosphate content, which is
essential for providing energy for metabolic reactions,²⁰⁻²²
decreases endothelial cell viability,²³,²⁴ and interferes with
eicosanoid production.²³ In isolated organs from rat and
rabbit, HPO-containing solutions have previously been
shown to affect organ function by increasing pulmo-
nary vascular permeability,²⁵,²⁶ decreasing myocardial

contractility, and reducing coronary responsiveness.²⁷
Other animal studies have also shown that HPO admin-
istration can increase cell apoptosis, cause liver damage,
steatosis,⁸ and increase cholestasis, and can lead to the
development of pulmonary fibrosis.²⁸ Thus, exogenous
administration of HPO from PN directly to patients also
leads to various clinical complications.⁷,²⁹,³⁰ Preterm new-
borns, who are fed exclusively by regular PN during the
first days or weeks of life, preterm newborns are partic-
ularly susceptible to these administered HPO.⁵,³¹ Indeed,
during their administration, the exposure of PN to light
sources is one of the main causes of the formation of
HPO.³² In this context, we wished to verify that photopro-
tection MD used in neonatal intensive care units was as-
sociated with a reduction of HPO load formed during the
administration of PN.

For the determination of HPO, we chose a colorimet-
ric method based on the chromogenic Fe³⁺-xylenol orange
reaction. This method, that requires oxidation of ferrous
ions in the presence of a ferric ion indicator xylenol, was
described as a reference method for the determination of
HPO by Wolff et al.¹⁷ The main advantage of this method
is that it does not require pretreatment of the samples, un-
like chromatographic or spectroscopic methods.³³

We used a qualified Suntest CPS+® to assess the intrin-
sic photostability characteristics of PN caused by solar ra-
diation in a short period of time based on its xenon lamp.
This technique is recommended by the International
Council for Harmonization of Technical Requirements
(ICH) for the registration of pharmaceuticals for human
use for bench testing of photostability. The use of a
Suntest CPS+® allowed us to accelerate the photodegra-
dation of PN, validate the method of evaluation of lipid
peroxidation, and begin to evaluate the photoprotection
performance of the selected MD under conditions of light

<figure><img src="image_7.png" /><figcaption>**FIGURE 4** Hydroperoxide formation after exposure of mixed oil lipid emulsion to high-intensity blue light during a realistic scenario in a hospital context. Mixed oil lipid emulsion samples contained in standard and opaque syringes were exposed for 24 h to high-intensity blue light (λ = 400–550 nm – Power = 4 mW/cm²) in conditions that reproduce those of a neonatal intensive care room. Then, lipid peroxidation was determined by using the Peroxide Assay kit® (N = 3, n = 3). These results were expressed as an HPO concentration ratio obtained between the blue light exposure condition to the light non-exposure condition.</figcaption></figure>
DISCUSSION

According to the guidelines of the ESPGHAN, pediat-
ric PN is used in hospitals when conventional or enteral
feeding is not possible in patients due to impaired or im-
mature gastrointestinal function.¹⁶ Several types of PN
used in hospitals: (1) mixed oil lipid emulsions; (2) binary
mixtures, composed of dextrose monohydrate and amino
acids, which can used in combination with a mixed oil
lipid emulsion; (3) ternary mixtures composed of dextrose
monohydrate, amino acids, and a lipid emulsion. These
mixtures can be supplemented with vitamins, trace ele-
ments, and sometimes electrolytes within validated phar-
maceutical limits. In our institution, it is important to note
that no supplementation is added directly into the PN bag
in order to limit microbiological risk. However, they are
added in a Y-site using an extender. Like all health prod-
ucts, PN must be stored under optimal conditions (light,
temperature), in particular mixed oil lipid emulsions and
ternary mixture, due to their high polyunsaturated fatty
acid composition. These fatty acids are a major source of
HPO production during their administration as a result of
their oxidation by radical oxygen species.

Even if, in the majority of living organisms, where all
antioxidant systems interact with each other, the toxicity
of HPO has not yet been fully proven, the toxicity of HPO
has been documented in cellular and tissue models since
the 90s. The toxicity of HPO contributes to a decrease in
the intracellular adenosine triphosphate content, which is
essential for providing energy for metabolic reactions,²⁰⁻²²
decreases endothelial cell viability,²³,²⁴ and interferes with
eicosanoid production.²³ In isolated organs from rat and
rabbit, HPO-containing solutions have previously been
shown to affect organ function by increasing pulmo-
nary vascular permeability,²⁵,²⁶ decreasing myocardial

contractility, and reducing coronary responsiveness.²⁷
Other animal studies have also shown that HPO admin-
istration can increase cell apoptosis, cause liver damage,
steatosis,⁸ and increase cholestasis, and can lead to the
development of pulmonary fibrosis.²⁸ Thus, exogenous
administration of HPO from PN directly to patients also
leads to various clinical complications.⁷,²⁹,³⁰ Preterm new-
borns, who are fed exclusively by regular PN during the
first days or weeks of life, preterm newborns are partic-
ularly susceptible to these administered HPO.⁵,³¹ Indeed,
during their administration, the exposure of PN to light
sources is one of the main causes of the formation of
HPO.³² In this context, we wished to verify that photopro-
tection MD used in neonatal intensive care units was as-
sociated with a reduction of HPO load formed during the
administration of PN.

For the determination of HPO, we chose a colorimet-
ric method based on the chromogenic Fe³⁺-xylenol orange
reaction. This method, that requires oxidation of ferrous
ions in the presence of a ferric ion indicator xylenol, was
described as a reference method for the determination of
HPO by Wolff et al.¹⁷ The main advantage of this method
is that it does not require pretreatment of the samples, un-
like chromatographic or spectroscopic methods.³³

We used a qualified Suntest CPS+® to assess the intrin-
sic photostability characteristics of PN caused by solar ra-
diation in a short period of time based on its xenon lamp.
This technique is recommended by the International
Council for Harmonization of Technical Requirements
(ICH) for the registration of pharmaceuticals for human
use for bench testing of photostability. The use of a
Suntest CPS+® allowed us to accelerate the photodegra-
dation of PN, validate the method of evaluation of lipid
peroxidation, and begin to evaluate the photoprotection
performance of the selected MD under conditions of light

<figure><img src="image_7.png" /><figcaption>**FIGURE 4** Hydroperoxide formation after exposure of mixed oil lipid emulsion to high-intensity blue light during a realistic scenario in a hospital context. Mixed oil lipid emulsion samples contained in standard and opaque syringes were exposed for 24 h to high-intensity blue light (λ = 400–550 nm – Power = 4 mW/cm²) in conditions that reproduce those of a neonatal intensive care room. Then, lipid peroxidation was determined by using the Peroxide Assay kit® (N = 3, n = 3). These results were expressed as an HPO concentration ratio obtained between the blue light exposure condition to the light non-exposure condition.</figcaption></figure>
overexposure. After 8 h of light exposure of mixed oil lipid emulsion and 7 h of light exposure of ternary mixture, we noted a tendency toward decreased HPO production in PN samples when administered with photoprotection MD vs control groups.

The second part of the work consisted of testing opaque syringe administration under “real” conditions close to clinical practice during phototherapy sessions performed in neonatal intensive care units. Indeed, Leddybloo® phototherapy lamps are used for the treatment of hyperbilirubinemia in neonates. They expose the whole body to intense light and act by interaction of the light with the bilirubin located in the skin, transforming it into photoderivatives directly eliminated in the stools and urine.34–36 The hepatic stage of bilirubin transformation, which limits its elimination, is thus largely bypassed.37 Therefore, to reproduce the conditions of administration of mixed oil lipid emulsion in a neonatal intensive care room, we created a realistic scenario using a low-fidelity mannequin in an incubator that was exposed for 24 h to the high-intensity blue light of a Leddybloo® phototherapy lamp. After 24 h of exposure of mixed oil lipid emulsion, we noted a tendency toward decreased HPO in the mixed oil lipid emulsion samples when administered with photoprotection MD (opaque syringe) compared to the standard syringe.

Although the results were not significantly different, our study suggests that the use of an opaque syringe for the administration of mixed oil lipid emulsion and a photoprotective overwrap for the administration of ternary mixture appears to limit the increase in HPO concentration under conditions of overexposure to light or under conditions that closely mimic clinical situations.

However, it is important to note that these HPO could also be generated during the storage of PN. Thus, vigilance is required to ensure that these products are protected from light. Given the recent recommendations of American Society for Parenteral and Enteral Nutrition (ASPEN),38 other types of MD, that we did not test in this study, could be used, such as opaque tubing, for example, when administering PN to further limit light exposure of PN components during administration.

## Limitations

Although this study appears to demonstrate a benefit of photoprotection MD during the administration of PN, it does not demonstrate a direct clinical benefit in subjects receiving PN. This study only evaluated partial photoprotection rather than complete photoprotection. Therefore, it appears essential to repeat these experiments on a larger scale with complete photoprotection. Indeed, our

experiment was only repeated three times. Multiplication of these experiments could allow a significant relative difference to be discerned between the photoprotection and the non-photoprotection conditions. Only a prospective randomized clinical trial could determine whether photoprotection of PN during the multiple steps of the PN process (and not just the administration) could benefit the vital prognosis of the most immature neonates by measuring, for example, the concentration of HPO excreted in the urine. Finally, in addition to light, other meteorological factors that we did not measure in this study could act on lipid peroxidation, such as temperature and hygrometry during PN administration.

## CONCLUSION

Although, under our tested conditions, the use of photoprotection DMs is associated with a non-significant reduction in HPO concentration, this empirical approach (no standards or specifications) appears to be a necessary option for slowing down HPO exposure in neonates during NP administration, as indicated in the ANSM safety information.

## CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

## ORCID

Fabien Nativel https://orcid.org/0000-0001-5917-1996

## REFERENCES

1. Mehta NM, Skillman HE, Irving SY, et al. Guidelines for the provision and assessment of nutrition support therapy in the pediatric critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. *J PARENTE Parenteral Enteral Nutr.* 2017;41(5):706-742.

2. Lavoie JC, Bélanger S, Spalinger M, Chessex P. Admixture of a multivitamin preparation to parenteral nutrition: the major contributor to in vitro generation of peroxides. *Pediatrics*. 1997;99(3):E6.

3. Neuzil J, Darlow BA, Inder TE, Sluis KB, Winterbourn CC, Stocker R. Oxidation of parenteral lipid emulsion by ambient and phototherapy lights: potential toxicity of routine parenteral feeding. *J Pediatr.* 1995;126(5 Pt 1):785-790.

4. Bassiouny MR, Almarsafawy H, Abdel-Hady H, Nasef N, Hammad TA, Aly H. A randomized controlled trial on parenteral nutrition, oxidative stress, and chronic lung diseases in preterm infants. *J Pediatr Gastroenterol Nutr.* 2009;48(3):363-369.

5. Karthigesu K, Bertolo RF, Brown RJ. Parenteral nutrition and oxidant load in neonates. *Nutrients*. 2021;13(8):2631.

6. Lunec J. Free radicals: their involvement in disease processes. *Ann Clin Biochem.* 1990;27(Pt 3):173-182.

7. Vitetta L, Linnane AW. Endocellular regulation by free radicals and hydrogen peroxide: key determinants of the inflammatory response. *Inflammopharmacology*. 2014;22(2):69-72.
overexposure. After 8 h of light exposure of mixed oil lipid emulsion and 7 h of light exposure of ternary mixture, we noted a tendency toward decreased HPO production in PN samples when administered with photoprotection MD vs control groups.

The second part of the work consisted of testing opaque syringe administration under “real” conditions close to clinical practice during phototherapy sessions performed in neonatal intensive care units. Indeed, Leddybloo® phototherapy lamps are used for the treatment of hyperbilirubinemia in neonates. They expose the whole body to intense light and act by interaction of the light with the bilirubin located in the skin, transforming it into photoderivatives directly eliminated in the stools and urine.34–36 The hepatic stage of bilirubin transformation, which limits its elimination, is thus largely bypassed.37 Therefore, to reproduce the conditions of administration of mixed oil lipid emulsion in a neonatal intensive care room, we created a realistic scenario using a low-fidelity mannequin in an incubator that was exposed for 24 h to the high-intensity blue light of a Leddybloo® phototherapy lamp. After 24 h of exposure of mixed oil lipid emulsion, we noted a tendency toward decreased HPO in the mixed oil lipid emulsion samples when administered with photoprotection MD (opaque syringe) compared to the standard syringe.

Although the results were not significantly different, our study suggests that the use of an opaque syringe for the administration of mixed oil lipid emulsion and a photoprotective overwrap for the administration of ternary mixture appears to limit the increase in HPO concentration under conditions of overexposure to light or under conditions that closely mimic clinical situations.

However, it is important to note that these HPO could also be generated during the storage of PN. Thus, vigilance is required to ensure that these products are protected from light. Given the recent recommendations of American Society for Parenteral and Enteral Nutrition (ASPEN),38 other types of MD, that we did not test in this study, could be used, such as opaque tubing, for example, when administering PN to further limit light exposure of PN components during administration.

## Limitations

Although this study appears to demonstrate a benefit of photoprotection MD during the administration of PN, it does not demonstrate a direct clinical benefit in subjects receiving PN. This study only evaluated partial photoprotection rather than complete photoprotection. Therefore, it appears essential to repeat these experiments on a larger scale with complete photoprotection. Indeed, our

experiment was only repeated three times. Multiplication of these experiments could allow a significant relative difference to be discerned between the photoprotection and the non-photoprotection conditions. Only a prospective randomized clinical trial could determine whether photoprotection of PN during the multiple steps of the PN process (and not just the administration) could benefit the vital prognosis of the most immature neonates by measuring, for example, the concentration of HPO excreted in the urine. Finally, in addition to light, other meteorological factors that we did not measure in this study could act on lipid peroxidation, such as temperature and hygrometry during PN administration.

## CONCLUSION

Although, under our tested conditions, the use of photoprotection DMs is associated with a non-significant reduction in HPO concentration, this empirical approach (no standards or specifications) appears to be a necessary option for slowing down HPO exposure in neonates during NP administration, as indicated in the ANSM safety information.

## CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

## ORCID

Fabien Nativel https://orcid.org/0000-0001-5917-1996

## REFERENCES

1. Mehta NM, Skillman HE, Irving SY, et al. Guidelines for the provision and assessment of nutrition support therapy in the pediatric critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. *J PARENTE Parenteral Enteral Nutr.* 2017;41(5):706-742.

2. Lavoie JC, Bélanger S, Spalinger M, Chessex P. Admixture of a multivitamin preparation to parenteral nutrition: the major contributor to in vitro generation of peroxides. *Pediatrics*. 1997;99(3):E6.

3. Neuzil J, Darlow BA, Inder TE, Sluis KB, Winterbourn CC, Stocker R. Oxidation of parenteral lipid emulsion by ambient and phototherapy lights: potential toxicity of routine parenteral feeding. *J Pediatr.* 1995;126(5 Pt 1):785-790.

4. Bassiouny MR, Almarsafawy H, Abdel-Hady H, Nasef N, Hammad TA, Aly H. A randomized controlled trial on parenteral nutrition, oxidative stress, and chronic lung diseases in preterm infants. *J Pediatr Gastroenterol Nutr.* 2009;48(3):363-369.

5. Karthigesu K, Bertolo RF, Brown RJ. Parenteral nutrition and oxidant load in neonates. *Nutrients*. 2021;13(8):2631.

6. Lunec J. Free radicals: their involvement in disease processes. *Ann Clin Biochem.* 1990;27(Pt 3):173-182.

7. Vitetta L, Linnane AW. Endocellular regulation by free radicals and hydrogen peroxide: key determinants of the inflammatory response. *Inflammopharmacology*. 2014;22(2):69-72.
8. Chessex P, Lavoie JC, Rouleau T, et al. Photooxidation of parenteral multivitamins induces hepatic steatosis in a neonatal Guinea pig model of intravenous nutrition. *Pediatr Res.* 2002;52(6):958-963.

9. Weinberger B, Laskin DL, Heck DE, Laskin JD. Oxygen toxicity in premature infants. *Toxicol Appl Pharmacol.* 2002;181(1):60-67.

10. Hoff DS, Michaelson AS. Effects of light exposure on total parenteral nutrition and its implications in the neonatal population. *J Pediatr Pharmacol Ther JPPT.* 2009;14(3):132-143.

11. ANSM. Information de sécurité—Nutrition parentérale: les produits. ANSM [Internet]. Accessed January 13, 2022. https://ansm.sante.fr/informations-de-securité/nutrition-parenteral-e-les-produits-doivent-etre-proteges-de-la-lumiere-pour-redui-re-les-risques-deffets-indesirables-graves-chez-les-nouveaunes-prematures

12. Lavoie JC, Chessex P. Parenteral nutrition and oxidant stress in the newborn: a narrative review. *Free Radic Biol Med.* 2019;142:155-167.

13. Harrison A, Khashu M, Friel J, Lavoie JC, Chessex P. Variations in metabolic response to TPN are influenced more by sex than by light exposure. *J Pediatr Gastroenterol Nutr.* 2007;45(5):577-581.

14. Chessex P, Watson C, Kaczala GW, et al. Determinants of oxidant stress in extremely low birth weight premature infants. *Free Radic Biol Med.* 2010;49(9):1380-1386.

15. Clauss C, Tack V, Macchiarulo M, et al. Light protection of parenteral nutrition, cholestasis, and other prematurity-related morbidities in premature infants. *Front Pediatr.* 2022;10:900068.

16. Puntis JWL, Hojsak I, Ksiazyk J, et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Organisational aspects. *Clin Nutr.* 2018;37(6 Part B):2392-2400.

17. Wolff SP. Ferrous ion oxidation in presence of ferric ion indicator xylenol orange for measurement of hydroperoxides. *Methods Enzymol.* 1994;1:182-189.

18. Jiang ZY, Woollard AC, Wolff SP. Lipid hydroperoxide measurement by oxidation of Fe²⁺ in the presence of xylenol orange. Comparison with the TBA assay and an iodometric method. *Lipids.* 1991;26(10):853-856.

19. Jiang ZY, Hunt JV, Wolff SP. Ferrous ion oxidation in the presence of xylenol orange for detection of lipid hydroperoxide in low density lipoprotein. *Anal Biochem.* 1992;202(2):384-389.

20. Abernathy F, Pacht ER. Alteration of adenosine triphosphate and other nucleotides after sublethal oxidant injury to rat type II alveolar epithelial cells. *Am J Med Sci.* 1995;309(3):140-145.

21. Janero DR, Hreniuk D, Sharif HM. Hydrogen peroxide-induced oxidative stress to the mammalian heart-muscle cell (cardiomyocyte): nonperoxidative purine and pyrimidine nucleotide depletion. *J Cell Physiol.* 1993;155(3):494-504.

22. Crim C, Longmore WJ. Sublethal hydrogen peroxide inhibits alveolar type II cell surfactant phospholipid biosynthetic enzymes. *Am J Phys.* 1995;268(1 Pt 1):L129-L135.

23. Lavoie JC, Chessex P. Gender-related response to a tert-butyl hydroperoxide-induced oxidation in human neonatal tissue. *Free Radic Biol Med.* 1994;16(3):307-313.

24. Lavoie JC, Tremblay A. Sex-specificity of oxidative stress in newborns leading to a personalized antioxidant nutritive strategy. *Antioxid Basel Switz.* 2018;7(4):49.

25. Tate RM, Vanbenthuysen KM, Shasby DM, McMurtry IF, Repine JE. Oxygen-radical-mediated permeability edema and vasoconstriction in isolated perfused rabbit lungs. *Am Rev Respir Dis.* 1982;126(5):802-806.

26. Meiring JJ, Borm PJA, Bagate K, et al. The influence of hydrogen peroxide and histamine on lung permeability and translocation of iridium nanoparticles in the isolated perfused rat lung. *Part Fibre Toxicol.* 2005;2:3.

27. Harrison GJ, Jordan LR, Willis RJ. Deleterious effects of hydrogen peroxide on the function and ultrastructure of cardiac muscle and the coronary vasculature of perfused rat hearts. *Can J Cardiol.* 1994;10(8):843-849.

28. Lavoie JC, Rouleau T, Gagnon C, Chessex P. Photoprotection prevents TPN-induced lung procollagen mRNA in newborn Guinea pigs. *Free Radic Biol Med.* 2002;33(4):512-520.

29. Pitkänen OM, Hallman M, Andersson SM. Correlation of free oxygen radical-induced lipid peroxidation with outcome in very low birth weight infants. *J Pediatr.* 1990;116(5):760-764.

30. Pitkänen OM. Peroxidation of lipid emulsions: a hazard for the premature infant receiving parenteral nutrition? *Free Radic Biol Med.* 1992;13(3):239-245.

31. Gargasz A. Neonatal and pediatric parenteral nutrition. *AACN Adv Crit Care.* 2012;23(4):451-464; quiz 465-466.

32. Mihatsch WA, Koletzko B. Editorial: light shielding of bags and tubing used for parenteral nutrition of infants. *Curr Opin Clin Nutr Metab Care.* 2021;24(3):236-239.

33. Dobarganes MC, Velasco J. Analysis of lipid hydroperoxides. *Eur J Lipid Sci Technol.* 2002;104(7):420-428.

34. Faulhaber FRS, Procianoy RS, Silveira RC. Side effects of phototherapy on neonates. *Am J Perinatol févr.* 2019;36(3):252-257.

35. Woodgate P, Jardine LA. Neonatal jaundice: phototherapy. *BMJ Clin Evid.* 2015;2015:319.

36. Bhutani VK, Wong RJ, Stevenson DK. Hyperbilirubinemia in preterm neonates. *Clin Perinatol.* 2016;43(2):215-232.

37. Cortey A, Pernel H. Efficacité des dispositifs médicaux de photothérapie dans le traitement de l'hyperbilirubinémie du nouveau-né. *IRBM News.* 2014;35(4):105-111.

38. Robinson DT, Ayers P, Fleming B, et al. Recommendations for photoprotection of parenteral nutrition for premature infants: an ASPEN position paper. *Nutr Clin Pract off Publ Am Soc Parenter Enter Nutr.* 2021;36(5):927-941.

**How to cite this article:** Nizet P, Guillard N, Chabaud L, et al. Pediatric parenteral nutrition and hydroperoxide toxicity: Evaluation of the effectiveness of photoprotection medical devices. *Photochem Photobiol.* 2023;00:1-8. doi:10.1111/aph.13894
8. Chessex P, Lavoie JC, Rouleau T, et al. Photooxidation of parenteral multivitamins induces hepatic steatosis in a neonatal Guinea pig model of intravenous nutrition. *Pediatr Res.* 2002;52(6):958-963.

9. Weinberger B, Laskin DL, Heck DE, Laskin JD. Oxygen toxicity in premature infants. *Toxicol Appl Pharmacol.* 2002;181(1):60-67.

10. Hoff DS, Michaelson AS. Effects of light exposure on total parenteral nutrition and its implications in the neonatal population. *J Pediatr Pharmacol Ther JPPT.* 2009;14(3):132-143.

11. ANSM. Information de sécurité—Nutrition parentérale: les produits. ANSM [Internet]. Accessed January 13, 2022. https://ansm.sante.fr/informations-de-securité/nutrition-parenteral-e-les-produits-doivent-etre-proteges-de-la-lumiere-pour-redui-re-les-risques-deffets-indesirables-graves-chez-les-nouveaunes-prematures

12. Lavoie JC, Chessex P. Parenteral nutrition and oxidant stress in the newborn: a narrative review. *Free Radic Biol Med.* 2019;142:155-167.

13. Harrison A, Khashu M, Friel J, Lavoie JC, Chessex P. Variations in metabolic response to TPN are influenced more by sex than by light exposure. *J Pediatr Gastroenterol Nutr.* 2007;45(5):577-581.

14. Chessex P, Watson C, Kaczala GW, et al. Determinants of oxidant stress in extremely low birth weight premature infants. *Free Radic Biol Med.* 2010;49(9):1380-1386.

15. Clauss C, Tack V, Macchiarulo M, et al. Light protection of parenteral nutrition, cholestasis, and other prematurity-related morbidities in premature infants. *Front Pediatr.* 2022;10:900068.

16. Puntis JWL, Hojsak I, Ksiazyk J, et al. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Organisational aspects. *Clin Nutr.* 2018;37(6 Part B):2392-2400.

17. Wolff SP. Ferrous ion oxidation in presence of ferric ion indicator xylenol orange for measurement of hydroperoxides. *Methods Enzymol.* 1994;1:182-189.

18. Jiang ZY, Woollard AC, Wolff SP. Lipid hydroperoxide measurement by oxidation of Fe²⁺ in the presence of xylenol orange. Comparison with the TBA assay and an iodometric method. *Lipids.* 1991;26(10):853-856.

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**How to cite this article:** Nizet P, Guillard N, Chabaud L, et al. Pediatric parenteral nutrition and hydroperoxide toxicity: Evaluation of the effectiveness of photoprotection medical devices. *Photochem Photobiol.* 2023;00:1-8. doi:10.1111/aph.13894