SP9 How to manage patients with a food allergy who need parenteral nutrition
Authors: Morris Stephen 
Published: June 2023

Introduction

Food allergies are commonly encountered in children and young persons in the UK.1This is problematic for healthcare providers who need to use medicines that are derived from food sources. One example is parenteral nutrition (PN), which contain lecithin as an emulsifying agent which is derived from eggs.

Using PN in patients with food allergies is listed as a contra-indication according to the marketing authorisation of a commonly used formulation.2The aim of this abstract is to describe how we approached challenging a patient with a known food allergy.

Situation

The patient was a 2-year-old who was admitted to critical care with acute liver failure. They were fluid overloaded, had gut failure and were not tolerating enteral feeding. His parents reported anaphylactic reactions to eggs and nuts in the past that had been confirmed by a specialist paediatrician in allergies.

As per local protocol, parenteral nutrition was started on day 5 of intensive care admission. Initially, with an aqueous component only (glucose, amino acids, electrolytes, and water-soluble vitamins) to avoid using lipids. Attempts to remove fluid by haemofiltration were complicated by a life-threatening allergic reaction to the filtration circuit.

By day 7 the patient remained on trophic enteral feeds and was still fluid restricted. Their nutrition target was 770kcal but only 400kcal were being given, i.e. 50% of requirements. The multidisciplinary team agreed it would be in the child’s best interest to start lipid. This is due to the higher calorie content of lipid (10kcal/gram) compared to glucose (4kcal/gram) and that the lipid could be administered without increasing the fluid intake.

After consultation with the family, a plan was agreed to start lipid. Lipid was prepared at a dose of 1gram/kg/day and started during the day shift with medical support available, at a nominal rate of 1mL/hour. After six hours, this was increased to the target rate of 2ml/hour. No immediate reactions were observed, and the lipid was titrated to 3grams/kg/day over the next few days. On day 9, Vitlipid Infant® was also added, and no reaction was seen.

By day 20 enteral feeds were establish and PN stopped. No reactions were observed even after several weeks.

Learning points

We could only find one case report of a child with food allergies receiving PN.3Despite the potential for a reaction, the mechanism by which this may occur is still unclear. The ingredients used in the lipid component of PN are purified and they do not contain proteins that may be associated with causing allergic reactions. For example, egg lecithin is a phospholipid which is composed only of fatty acid chains, glycerol and choline.

In conclusion, our experience has demonstrated that it is possible to challenge a food allergy when parenteral nutrition is required in critical care. It is important to include the family in devising a treatment plan as there may be an idiosyncratic reaction regardless of how carefully the PN is introduced.

References

Loh W, Tang M. The epidemiology of food allergy in the global context.Int J Environ Res Public Health.2018;18:2043.

Baxter Healthcare Ltd. Numeta G19% emulsion for infusion. [Internet]. Surrey, UK. Electronic Medicines Compendium. cited 17th June 2022]. Available from: https://www.medicines.org.uk/emc/product/7399/smpc

Lunn M, Fausnight T. Hypersensitivity to total parenteral nutrition fat-emulsion component in an egg-allergic child.Pediatrics.2011;128:1025-1028.