Clinical trial NCT02357576
Conditions: Cholestasis
Sponsor: University of Michigan
Start date: 2016-05-21; Completion date: 2019-11-08
Enrollment: 22 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Parenteral nutrition-associated cholestasis (PNAC) and liver disease (PNALD) are associated with significant morbidity and mortality in neonates and is felt to be exacerbated by soybean-based lipid emulsions. Much research is currently being directed at identifying ways to reduce this risk. Reduction of the dose of soybean-based lipid given as a component of parenteral nutrition is one possible strategy. In this study we will compare standard dosing of soybean-based lipid (up to 3/kg/day) with a minimized dose (1 g/kg/day) and evaluate for the development of cholestasis and adequate growth between the two groups. Longterm followup will include an assessment of neurodevelopmental outcomes at 12 and 24 months of age.

Funding source - FDA OOPD

Detailed description:

Arms: arm 1: Subjects will receive a minimized dose (1 g/kg/day) of the soybean-based lipid component of parenteral nutrition. arm 2: Subjects will receive the standard dose (up to 3 g/kg/day) of the soybean-based lipid component of parenteral nutrition.
Interventions: intervention 1: Intralipid 20% I.V. Fat Emulsion
Intervention descriptions: intervention 1: None

Protocol documents:
Prot_SAP_000.pdf: 
Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
1
 
 
 
 
 
 
 
 
Clinical Protocol 
 
Study Title: Standard IV lipid dosing compared to IV lipid minimization for the prevention of 
PNAC/PNALD (HUM00075458) 
 
 
 
Sponsor Investigator: Dr. Meghan Arnold 
 
IND: 121287 
 
 
Version 22 JUN 2018 
 
 
 
 
NCT02357576 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
2
 
Study Significance/Background 
Parenteral nutrition (PN) is the intravenous administration of complete and balanced nutrition; it has transformed 
nutritional support for patients who cannot maintain adequate nutrition via the gastrointestinal tract.1  PN is 
associated with a number of significant infectious and metabolic complications including parenteral nutrition-
associated cholestasis (PNAC) which can lead to parenteral nutrition-associated liver disease (PNALD).  Both 
are considered among the most challenging complications associated with prolonged PN administration.  PNAC 
is generally accepted to occur when the direct bilirubin rises above 2 mg/dL after other potential etiologies of 
direct hyperbilirubinemia have been eliminated.2-5  The reported incidence of liver dysfunction in children on long 
term PN in the literature ranges from 7.4% to 84%; this variety is attributed to study heterogeneity – the patient 
population studied, the definition of liver dysfunction used and different risk factors associated with the 
development of liver disease itself.6,7  
 
Well-characterized risk factors for the development of PNAC include prematurity, low birth weight, repeated 
infectious/septic episodes, a lack of enteral feeds, delayed initiation of enteral feeds and the length of time on 
PN.8-10  Progressive PNAC may lead to PNALD as demonstrated by severe liver injury and fibrosis which can 
ultimately lead to death from liver failure if transplantation is not achieved.  The development of PNALD itself is 
associated with increased morbidity and mortality related to recurrent line infections, sepsis, the need for 
repeated hospitalizations and operative procedures, biliary sludge and gallstones, bacterial overgrowth and 
translocation.6,9,11  In a study of surgical neonates, almost one-third died with long-standing PNALD.12  In a more 
recent study of children with short bowel syndrome maintained on long term PN, PNALD was the greatest risk 
factor for mortality.13 
 
Parenteral nutrition is made up of amino acids, dextrose, intravenous fat emulsion (IVFE), micronutrients, fluids, 
and electrolytes.  In addition to the patient-related factors listed above which are known to contribute to the 
development of PNAC, the IVFE component of PN, and specifically soybean-based emulsions, have been shown 
to be an independent causative factor in the development of PNAC.14,15  Soybean-based fat emulsions contain 
high levels of phytosterols which have been shown to impair bile drainage and contribute to hepatobiliary 
dysfunction.16  Given these findings, several strategies have been undertaken to minimize the effects of IVFE on 
the liver; these strategies include soybean-based IVFE reduction or the use of alternative IVFE such as marine 
oil-based emulsions or combination fat emulsions.  Data supporting these approaches, however, have been 
based on retrospective or uncontrolled studies thus limiting the strength of the supporting evidence.  Further, 
soybean based fat emulsions remain the only approved IVFE products for use in pediatric patients in the United 
States. 
 
The standard dosing for IVFE in neonates is 3 g/kg/day.  The development of PNAC while on this dosing regimen 
often leads practitioners to reduce the IVFE dose in an attempt to reverse or keep the liver dysfunction and 
fibrosis from progressing.  The data supporting IVFE reduction (IFER) focus on the efficacy of this modification 
after the first signs of PNAC have developed rather than as a preventative approach.  The benefit of IFER was 
first described in the adult literature in 1982 but it was not until 2000 that a similar approach was reported in a 
pediatric population with severe cholestasis.17,18  In this report by Colomb et al the IVFE component of PN was 
acutely terminated once cholestasis developed (defined as a plasma bilirubin ≥30 µmol/L).  Patients were 
subsequently noted to have a marked decline in bilirubin levels.18  A prospective study by Cober and Teitelbaum 
supported this concept of IFER for the prevention of PNAC progression.19,20  In this single-center study, patients 
who developed PNAC (defined as a direct bilirubin >2.5 mg/dL) on standard soybean-based IVFE at a dose of 
3 g/kg/day were switched to a restricted regimen of IVFE at a dose of 1 g/kg/day twice a week.  These infants 
were then compared to a well-matched historical controls who were maintained on standard IVFE dosing 
regardless of bilirubin level.  Thirty-one patients were included in the study group and were noted to have a 
significant decline in their serum direct bilirubin levels over time when compared to the control group.  
Specifically, the IFER group was found to have a downward trend in bilirubin whereas the standard cohort was 
found to have increased bilirubin levels across study weeks (estimated slope -0.73 mg/dL/week compared to 
0.29 mg/dL/week; p=0.0017).  In addition, the number of patients achieving resolution of PNAC was significantly 
greater in the IFER group compared to the control group (n=13 vs. n=3; p=0.013).  It is important to note that 
eight patients in the IFER group developed mild, reversible essential fatty acid deficiency (EFAD) which was 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
3
defined as a triene:tetraene ratio ≥0.05.  No physical manifestations of EFAD were observed in this group, 
however, and those who developed EFAD had their IVFE dose increased to 1 g/kg/day three times a week.  If 
EFAD persisted the IVFE dose was increased to 2 g/kg/day.  Increased IVFE dosing led to resolution of EFAD 
in all patients.  No significant differences in growth parameters were noted between groups. 
 
A reduction in the dose of soybean-based emulsion has also been studied as a preventative approach.  In a 
study by Nehra and colleagues, neonates requiring long-term parenteral nutrition support, defined as ≥21 days 
of therapy, were divided into two groups:  those receiving IVFE at a dose of 1 g/kg/day (n = 29) and those 
receiving IVFE at doses between 2 and 3 g/kg/day (n=32).21  Groups were then evaluated for the primary 
outcome of the development of cholestasis, defined as a direct bilirubin >2 mg/dL for ≥2 consecutive weeks.  
The incidence of cholestasis was not significantly different between the groups with 15/29 (52%) developing 
cholestasis in the lower IVFE group compared to 14/32 (44%; p=0.61) in the standard IVFE group.  The time to 
cholestasis was also similar between groups.  In this study, once cholestasis developed patients were 
expeditiously transitioned to full enteral feeds or to a marine oil-based fat emulsion.  Limitations of this study 
include its retrospective nature, slight differences between the study groups and unclear indications for the 
different IVFE doses between groups. 
 
A retrospective study was recently published which compared the development of cholestasis in surgical infants 
treated with 1 g/kg/day of IVFE relative to a historical cohort who received standard dosing.22  Starting in 2009 
all surgical neonates at a single center who were expected to require PN for at least 2 weeks were administered 
a soybean-based fat emulsion at a dose of 1 g/kg/day.  A total of 82 infants were treated in this manner and were 
compared to the 132 infants treated with standard dose soybean-based IVFE (2 to 3 g/kg/day) at the same 
institution from 2005 through 2008.  Infants treated with IFER were found to have a significantly lower incidence 
of PNAC (defined as a serum bilirubin ≥2 mg/dL for a minimum of 2 weeks and for at least 2 measurements):  
22% compared to 43% (p=0.003).  IFER was also associated with a reduction in the peak direct bilirubin levels 
observed (p<0.0001).  Overall, infants treated with standard dosing were 1.77 times more likely to develop PNAC 
than those treated with IFER (CI 1.17 – 2.68; p=0.007).  Growth parameters were not different between groups.  
Limitations of this study include its retrospective nature and the lack of data regarding the development of EFAD 
in the IFER group. 
 
In the first known study of its kind, Rollins et al recently published pilot data of a prospective, randomized trial 
comparing IFER to standard IVFE dosing in surgical neonates.23  In this study 28 surgical patients ≥26 weeks 
gestation anticipated to require PN for at least 2 weeks were randomized to reduced (1 g/kg/day) or standard (3 
g/kg/day) IVFE.  Because this was a feasibility study it was not powered to detect significant differences between 
the groups.  Despite this limitation, infants who received the reduced dose were observed to have lower overall 
direct bilirubin levels (p=0.04).  Subjects randomized to standard dosing had a 13-fold higher median increase 
in total bile acids compared to a 2-fold increase in the reduced group (p=0.02).  While weight z-scores increased 
more in the standard group (p=0.006), average weight gain was similar between the groups (23.7 g/day in the 
standard group and 20.8 g/day in the reduced group).  No patient in the reduced IVFE group developed clinical 
or laboratory-proven EFAD which was assessed using triene:tetraene ratios. 
 
These studies of IFER reveal important but occasionally conflicting findings relevant to the administration of a 
reduced dose of IVFE and its effect on the prevention and treatment of PNAC.  Each study has limitations and 
because of their occasionally differing conclusions, questions remain regarding the optimal dose of IVFEs to 
promote growth and optimize brain development while preventing the development of PNAC and its progression 
to irreversible liver disease.  These questions include the optimal dose of IVFE, the timing of the initiation of 
IFER, short- and long-term outcomes related to IFER as well as the safety associated with this treatment 
approach.  These questions will be best answered in a well-designed prospective study that randomizes patients 
to IFER and standard dosing in order to evaluate the effectiveness of this strategy in maintaining adequate 
growth while reducing the development of PNAC and without leading to EFAD. 
 
Essential fatty acids are known to be important for neurodevelopment. Specifically, docosahexaenoic acid 
(DHA), arachidonic acid (AA), eicosapentaenoic acid (EPA), and long-chain polyunsaturated fatty acids are 
important for neural development and visual development within the first year of life.24  The essential fatty acids 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
4
linoleic and alpha-linolenic acids are converted to AA and DHA and are typically provided through enteral nutrition 
(e.g. breast milk or enteral formulas).  However, for PN-dependent patients, essential fatty acids must be 
provided through IVFEs. The optimal dose and type of IVFE is a topic of current investigation, and the effects of 
exogenous supplementation via the intravenous or enteral route on the developing brain have not been 
determined.25  The balance between providing these essential nutrients during infancy and preventing the 
development of PNAC has led to concerns regarding the possible effects on neurodevelopment.  In a recent pilot 
study completed at The University of Michigan, the association between IFER treatment and poor 
neurodevelopmental outcomes was evaluated.26  Of the IFER-related variables analyzed (mean IVFE dose, 
IFER duration, and development of EFAD), none were found to be predictive of poor neurodevelopmental 
outcomes.  However, this pilot study was retrospective in nature, relied on parent-reported outcomes, and was 
limited by small sample size.  Further data is needed to confirm the effects of early IFER on neurodevelopmental 
outcomes.  
 
 
Primary Hypothesis 
IVFE reduction (IFER) during the administration of neonatal parenteral nutrition will lead to a significant decrease 
in the rate of rise of direct bilirubin (mg/dL/week) when compared to standard therapy. 
 
Secondary Hypotheses 
1. The time to development of PNAC, when present, will be longer with IFER when compared to standard 
IVFE therapy. 
2. IFER will not be associated with a significant increase in failure to thrive (as assessed by growth 
parameters) or the development of essential fatty acid deficiency (EFAD) when compared to standard 
IVFE therapy. 
3. Neurodevelopmental outcomes (NDOs), when assessed at 12 and 24 months of corrected gestational 
age, will be similar for those treated with IFER and standard IVFE therapy. 
 
Specific Aims 
1. To determine whether neonates and infants receiving PN with IFER (1 g/kg/day) will have lower rates of 
rise of direct bilirubin compared to those receiving standard IVFE therapy (3 g/kg/day)  
2. To compare the time to development of PNAC in neonates and infants receiving PN with IFER (1 
g/kg/day) compared to those receiving PN with standard IVFE administration (3 g/kg/day)  
3. To determine if IFER results in normal growth and essential fatty acid (EFA) parameters by measuring 
weight, length, head circumference (weekly) and EFA profiles (every 2 weeks in the IFER group) during 
the treatment period.  
4. To compare NDOs at 12 and 24 months of corrected gestational (2 weeks) age of those treated with 
IFER with those treated with standard IVFE doses using a combination of neurodevelopmental screening 
tools (e.g. Bayley Scales of Infant Development, MacArthur Communicative Development Inventory, etc.) 
aimed at capturing several developmental domains such as motor, cognition, speech and language, 
sensory, and behavior. 
 
Study Definitions 
Subjects will be considered “on treatment” from the time of randomization until 7 days after PN has been 
discontinued, but not to exceed a total of 84 days.  Subjects will be considered “on study” until they 
complete their neurodevelopmental testing at 24 months corrected gestational age (2 weeks). 
 
Study Design 
This is a multi-institution, prospective, randomized study evaluating IVFE dose reduction on the development of 
PNAC as a proxy measure of PNALD in neonates requiring prolonged PN.  The definition of PNAC will be that 
used predominantly in the literature – a direct bilirubin level of ≥2 mg/dL, documented on two occasions 1 week 
apart, in patients who have required parenteral nutrition for more than 2 weeks.  Eligible neonates will be 
randomized into two treatment arms:  standard IVFE administration (3 g/kg/day) or IVFE reduction (IFER) 
(1 g/kg/day).  A total of 60 subjects (30 subjects per arm) will be included in the study. The study will evaluate 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
5
short- and long-term outcomes of this strategy.  In the short-term, infants will be followed for up to 12 weeks for 
the development of PNAC.  If a subject’s PN is discontinued before 12 weeks, and if they remain in the hospital, 
follow-up data will be collected for an additional 7 days but not beyond a total of 84 days. Only standard-of-care 
data will be collected during these 7 days. No procedures will be performed for the purpose of this study during 
these 7 days. In the long-term, subjects’ neurodevelopmental outcomes will be assessed at 12 and 24 months 
corrected gestational age (2 weeks).   
 
Primary outcome measure:  
1. The rate of rise of direct bilirubin as a function of time (mg/dL/week) between the two groups over 12 
weeks or until the subject has been off of PN for >7 days, whichever comes first.   
 
Secondary outcome measures  
1. Initial 12 week period: 
a. The incidence of PNAC (direct bilirubin ≥2 mg/dL) and severe PNAC (direct bilirubin ≥4 mg/dL in 
subjects on parenteral nutrition for at least 2 weeks) 
b. The time to development of PNAC and severe PNAC 
c. The peak total and direct bilirubin levels  
d. The incidence of EFAD   
e. Adequacy of growth as evaluated by z-scores for weight, height, and head circumference  
f. Other safety measures assessed during the initial 12 week period will include adverse events 
(e.g., episodes of sepsis and catheter-related blood stream infections). 
2. Long-term follow-up: 
Neurodevelopmental assessments will include:  
a. At 12 months corrected gestational age (2 weeks): 
i. Bayley Scales for Infant and Toddler Development (BSID-III) 
b. At 24 months corrected gestational age (2 weeks): 
i. Bayley Scales for Infant and Toddler Development (BSID-III) 
ii. MacArthur-Bates Communicative Development Inventories (CDI) 
iii. Brief Infant Toddler Social Emotional Assessment (BITSEA) 
iv. Gross Motor Function Classification System (GMFCS) 
v. Behavioral Assessment System for Children-Second Edition (BASC2) 
 
Study Arms: 
Study Arm 1 (Standard IVFE dosing):  Subjects in the standard IVFE dosing arm (3 g/kg/day) will be on 
treatment for a total of 12 weeks or until the subject has been off of parenteral nutrition for >7 days, or if 
they are discharged from the hospital, whichever comes first. 
 
Study Arm 2 (IFER dosing):  Subjects in the IFER dosing arm (1 g/kg/day) will be on treatment for a total 
of 12 weeks or until the subject has been off parenteral nutrition for >7 days, or if they are discharged 
from the hospital, whichever comes first. 
 
All subjects will be maintained at their assigned dosing regimen for the duration of the treatment period (12 
weeks) or until they are transitioned off of PN for >7 days, are discharged or until the direct bilirubin is ≥2.5 mg/dL 
for 2 consecutive weeks, whichever occurs first.  Data will be collected for the duration of the study for those 
subjects who remain on parenteral nutrition for the full 12 weeks.  For those who transition off of PN prior to the 
end of the 12 week period, data will be collected for 7 days after termination of PN if the subject remains in the 
hospital.  The clinical course of these subjects who wean off PN prior to 12 weeks will continue to be monitored 
according to standards of practice.  If serum direct bilirubin reaches a level of ≥2.5 mg/dL for 2 consecutive 
weeks during the course of the treatment, subjects will be transitioned to an IVFE dose of 1 g/kg/day three days 
per week.  Those who remain cholestatic at the termination of their treatment period will be evaluated on a 
monthly basis for the persistence or resolution of cholestasis.  This will be done by obtaining monthly liver 
function tests and bilirubin fractions for 6 months. 
 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
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Overview of Study Design: 
 
 
Inclusion Criteria 
Study subjects will be neonates and infants who are ≥28 weeks corrected gestational age at the time of 
enrollment who are parenteral nutrition naïve (<72 hours of PN exposure prior to randomization) and whose 
direct bilirubin has never been >2 mg/dL with at least one of the following diagnoses: 
1. Meconium ileus and peritonitis 
2. Gastroschisis 
3. Omphalocele >4 cm in diameter or with liver herniated outside of the abdominal cavity 
4. Necrotizing enterocolitis requiring surgical intervention (drain placement, laparotomy, bowel resection) 
5. Volvulus 
6. Intestinal atresia with >50% bowel loss as defined by bowel length nomogram (Figure 1) 
 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
7
 
 
 
This population was selected because of their high risk for developing PNAC due to their underlying disease 
process and limited ability to tolerate enteral feeds.  Using this group of subjects will allow for sufficient data to 
be obtained with the fewest number of subjects over the shortest period of time. 
 
No preference will be given to sex, race or ethnic background during the enrollment of subjects into the study. 
 
Exclusion Criteria 
1. Birthweight <1kg  
2. A metabolic pathway defect which is associated with liver dysfunction in the neonatal period including: 
hereditary fructose intolerance, galactosemia due to transferase deficiency and neonatal tyrosinemia, 
and/or disorders of lipid metabolism 
3. A history of hepatic insufficiency as defined by either a biopsy with cirrhosis and/or a marked aberration 
in synthetic function (defined by elevated prothrombin time (INR ≥2.0) with no evidence of a systemic 
coagulopathy and no administration of an anticoagulant) 
4. Primary or secondary liver disease, including hepatitis, as defined by either an elevated prothrombin time 
(INR ≥2.0)or elevation of liver function tests (AST and ALT) greater than twice the upper limit of the age-
adjusted norm  
5. Congenital obstruction of the hepatobiliary tree (e.g. biliary atresia, choledochal cyst) 
6. History of PNAC or a direct bilirubin >2 mg/dL at any time prior to enrollment/randomization 
7. Renal failure (as defined by a creatinine >1.5 mg/dL) 
8. Use of extracorporeal membrane oxygenation (ECMO), as hemolysis from the ECMO circuit may cause 
a mixed hyperbilirubinemia unrelated to the development of PNAC 
9. Documented active infection which may be communicable, including infectious hepatitis or human 
immunodeficiency virus 
10. Previous receipt of choleretic agents (e.g. ursodiol, phenobarbital, cholecystokinin).  This is done in order 
to avoid the use of an agent which may reduce cholestasis and the development of PNAC. 
11. Current administration of phenobarbital or other barbiturates 
12. No infant with a congenital or acquired anomaly which will require major cardiovascular surgery 
13. Major congenital or chromosomal anomaly 
14. Hypoxic ischemic encephalopathy 
Figure 1.  Nomogram estimating normal 
small bowel length based on height at the 
time of surgery.26  


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
8
15. Congenital defect of the brain 
16. Major seizure disorder 
 
Removal from Study Protocol After Initiation of Study 
The following criteria may require study removal: 
1. Parent or guardian request for removal 
2. Transfer to a non-study hospital 
3. Development of multiple nutritional problems which are unable to be managed (e.g. more than mild 
undernutrition, irreversible undernutrition, hyperglycemia, or hypertriglyceridemia refractory to 
intervention)  
      4.   At the discretion of the PI 
 
Informed Consent 
Informed consent will be obtained from the parents or legal guardian of the child.  Consent will be obtained in 
person whenever possible.  In the rare circumstance that a parent or legal guardian cannot be present in person, 
consent will be obtained via telephone.  We expect this to be an unusual occurrence as subjects can be 
randomized up to 72 hours after PN initiation. 
 
Randomization 
Subjects will be randomized within 72 hours of PN initiation.  Stratified, equal within-center randomization will be 
performed after consent is obtained.  Group assignment will be determined by a random permutation of blocks 
of randomly determined sizes of 2 or 4.  Randomization will be stratified based on gestational age (<32 and ≥32 
weeks gestation).  Enrollment and randomization will occur as early as feasible after identification of subjects 
who meet eligibility criteria.  Randomization MUST occur within 72 hours of PN initiation to minimize the number 
of days of PN prior to treatment group assignment.  All subjects will be treated according to standard 
management until consent is obtained and randomization occurs.  Once randomization occurs the PN dose the 
subject is currently on may change based on group assignment. 
 
Blinding 
Subject’s family members, the statistical team and those administering the neurodevelopmental tests will be 
blinded to treatment assignment.  Blinding of families and those evaluating neurodevelopmental outcomes is 
particularly important as these are subjective assessments which we do not want to be biased by the treatment 
assignment.  Adequacy of blinding will be assessed at the end of the initial 12 week treatment period by asking 
parents which treatment arm they believe the subject has been assigned to.  Assessment of the adequacy of 
blinding will be performed and changes made if blinding of parents is deemed to be suboptimal.  It is not possible 
to blind the inpatient care team and the investigators as the remainder of the PN formulation (dextrose, protein) 
must be adjusted to deliver adequate caloric needs to the subjects based on their IVFE treatment assignment.  
The lack of blinding during this phase of the study will not influence the short-term outcomes as they are discrete 
measurements that cannot be biased by subjectivity. 
 
Standardization of Parenteral Nutrition Across Study Centers 
The following guidelines for parenteral nutrition administration have been established to provide uniformity 
among study sites.  Each site will follow these guidelines. 
 
Energy 
Total caloric delivery will range between 100-120 Kcal/kg/day when PN is the only source of calories 
Total non-protein caloric delivery will not exceed 100 Kcal/kg/day when PN is the only source of calories 
 
Carbohydrate 
Dextrose infusion rate (DIR) will be increased in the following manner, provided there is no aberration in the 
serum glucose levels: 
Day 1 
DIR 4-8 mg/kg/min 
Day 2 and beyond 
Advancement of DIR by 1-2 mg/kg/min per day to a goal of 11-18 mg/kg/min 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
9
 
For study subjects 0-30 days old the maximum DIR will be 16 mg/kg/min 
For study subjects >30 days old the maximum DIR will be18 mg/kg/min 
 
If hyperglycemia develops (defined as serum glucose >150 mg/dL), subjects will be managed in accordance with 
standard guidelines28 
1. Confirmatory point of care glucose test performed  
2. If confirmatory glucose >150 mg/dL, the DIR will be reduced daily in increments of 1-2 mg/kg/min as 
tolerated until the serum glucose normalizes 
3. Insulin will only be administered if hyperglycemia has not been controlled by adjusting the DIR 
 
Protein 
Protein, in the form of neonatal IV amino acids solutions, will be initiated on the first day of PN at the highest 
delivery possible based on the following ranges: 
Body weight: 
<1.5 kg 
1.5 – 2.5 kg 
>2.5 kg 
Protein Needs (g/kg): 
3.4 – 4 
3.2 – 3.8 
2 – 3 
 
If protein is not able to be initiated at the goals indicated above, protein will be advanced over the first 2-3 days 
of PN administration to reach specified goals. 
 
In order to maintain uniformity in the PN administered between study centers, formulations will use neonatal-
specific amino acid solutions that contain supplementation with taurine, glutamic acid and aspartic acid, all of 
which are not routinely contained in conventional adult crystalline amino acid infusions.  Uniformity of amino acid 
solutions is particularly important because a lack of taurine may have a role in the development of PNAC.29,30  
Ensuring that all infants receive this amino acid formulation will ensure uniformity between centers. 
 
IVFE 
Standard Arm:  IVFE to begin at 1 g/kg/day on the first day of PN and advance by 0.5-1 g/kg/day to a maximum 
of 3 g/kg/day. 
 
IFER arm:  IVFE administration to begin and remain at 1 g/kg/day for the duration of the study unless inadequate 
weight gain/growth occurs and/or the subject develops EFAD. 
 
Hypertriglyceridemia 
If hypertriglyceridemia develops (serum triglycerides (TG)>250 mg/dL), subjects will be managed as follows: 
1. Repeat laboratory measure to confirm diagnosis 
2. Screen for carnitine deficiency (if present, supplement as appropriate) 
3. If confirmatory TG >250 mg/dL, then: 
 
TG 250-400 mg/dL 
AND glucose >150 
mg/dL 
TG 250-400 mg/dL 
AND glucose ≤150 
mg/dL 
TG ≥400 mg/dL AND 
glucose >150 mg/dL 
TG >400 mg/dL AND 
glucose ≤150 mg/dL 
1. Decrease DIR by 
1-2 mg/kg/min as 
tolerated until 
serum glucose 
normalizes 
2. Decrease current 
IVFE infusion by 
50% for the 
remainder of the 
current infusion 
1. Decrease current 
IVFE infusion by 
50% for the 
remainder of the 
current infusion 
2. Hold IVFE x 48 
hours and repeat 
TG level* 
1. Decrease DIR by 
1-2 mg/kg/min as 
tolerated until 
serum glucose 
normalizes 
2. Discontinue current 
IVFE infusion 
3. Hold IVFE x 48 
hours and repeat 
TG level* 
1. Discontinue current 
IVFE infusion 
2. Hold IVFE x 48 
hours and repeat 
TG level* 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
10
3. Hold IVFE x 48 
hours and repeat 
TG level* 
* Upon repeat TG level: 
1. If TG are <250 mg/dL:  restart IVFE at 50% of previous dose 
2. If TG are ≥250 mg/dL:  continue to hold IVFE infusion and repeat TG level every 48 hours until <250 
mg/dL.  If IVFE is held for ≥7 days with continued TG levels ≥250 mg/dL, restart IVFE at 0.5 g/kg/day  
 
Essential Fatty Acid Deficiency (EFAD) 
The detection of EFAD will be assisted by a biochemist and expert in the area of lipid biology. 
 
The IVFE dose will be adjusted if subjects develop EFAD.  EFAD will be defined by the development of any of 
the following: 
1. Clinical evidence of EFAD deficiency (i.e. scaly skin)31,32  
2. Triene:tetraene ratio of >0.20 
3. Arachidonic acid (ARA), (EPA) and/or docosahexaenoic acid (DHA) levels below normal as defined by 
Mayo Laboratory reference ranges 
 
In the presence of EFAD, the IVFE dose will be increased in 0.5 g/kg/day increments based on biweekly essential 
fatty acid profiles until resolved.  
 
Cycled Parenteral Nutrition 
Study subjects will not receive cycled parenteral nutrition (i.e. parenteral nutrition administered over less than 24 
hours per day) during the study period, as cycled PN has been shown to decrease the development of PNAC 
and may represent a confounder.33,34 
 
Adjustment of Parenteral Nutrition if Inadequate Weight Gain Occurs  
(Lipid Restricted Group Only) 
 
Subjects with inadequate weight gain that cannot be attributed to other physiologic causes (e.g. low urine sodium, 
low hematocrit, insufficient respiratory support) will be managed according to the protocol described below. 
 
Indicators of acute and chronic malnutrition will be assessed using z-scores.35  For the purposes of the initial 12 
weeks, subjects will only be assessed for acute malnutrition as chronic malnutrition occurs after 3 months.  Z-
scores will be obtained using the Peditools.org calculator (https://peditools.org/).  Fenton scores36 will be used 
for infants born <37 weeks gestation, until 50 weeks gestation, at which time the WHO scores will be used, using 
corrected gestational age.  WHO scores37 will be used for infants born at ≥37 weeks gestation.  Z-scores will be 
documented for birth anthropometrics.  Z-scores will be assessed at 1 month of age and weekly thereafter 
(allowing 1 month before reassessment to account for natural weight loss at birth in addition to weight loss from 
acute illness at birth).  Z-scores for all anthropometrics will be followed, however, the z-score for weight-for-age 
will be used as the primary assessment for acute malnutrition and will be used to prompt intervention.  If 
intervention is required, PN will be adjusted as described in Table 1. 
 
Table 1. PN Adjustments Based on Change in Z-score (after 1 month of age)  
Decrease in z-score by 0.5 standard 
deviation (SD) (17 percentiles decrease) 
from birth 
Increase DIR by 2 mg/kg/min (as clinically 
tolerated) 
 
Maximum DIR for study subjects 0 – 30 days 
old:  16 mg/kg/min 
Maximum DIR for study subjects >30 days 
old:  18 mg/kg/min 
Decrease in z-score by 1 SD (34 
percentiles decrease) from birth  
1. Increase DIR by 2 mg/kg/min (as 
clinically tolerated) 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
11
a. Maximum DIR for study subjects 
0 – 30 days old:  16 mg/kg/min 
b. Maximum DIR for study subjects 
>30 days old:  18 mg/kg/min 
 
2. If Z-score is not improving in response to 
increase in DIR after 1 week, or if DIR is 
already at max of 18 mg/kg/min, 
increase IVFE by 0.5 g/kg/day to a 
maximum of 1.5 g/kg/day 
3. If poor weight gain continues and 
consideration is being made to increase 
the lipid dose to 2 g/kg/day the 
coordinating center must be contacted to 
determine if the subject should be 
withdrawn. 
Decrease in z-score by 2 SD from birth x2 
consecutive measurements separated by 7 
days or Lipids need to be increased to >1.5 
g/kg/d d/t poor growth 
Subject deemed to have growth failure, 
prompting exit from study in order to allow for 
liberalization of the IVFE dose to promote 
adequate growth 
 
 
Data Collection 
1. Demographic information 
2. Birth weight, gestational age 
3. Weight, gestational age at the time of enrollment/randomization, and weekly thereafter 
4. Inclusion diagnosis 
5. Number of septic episodes according to standard definitions38 
6. Use of choleretic medications 
a. Ursodiol 
b. Cholecystokinin 
c. Phenobarbital 
7. Nutritional data 
a. Parenteral nutrition data 
i. IVFE dose 
ii. Dextrose infusion rate 
iii. Total calories and % calories obtained via PN 
b. Enteral nutrition data 
i. Total calories and % calories being obtained via enteral route 
ii. % calories obtained via breast milk 
8. Growth parameters (whenever possible, obtain all growth measurements on the same day of the week) 
i. Weight (with z-score) weekly  (every 7 days ± 2 days) 
ii. Height (with z-score) weekly (every 7 days ± 2 days) 
iii. Head circumference (with z-score) weekly  (every 7 days ± 2 days) 
9. Additional safety data to be obtained from human subjects is summarized below, indicating any key 
differences in frequency of monitoring between the two groups: 
Laboratory Parameter 
Frequency (+24 hours)* 
Fractionated bilirubin panel (includes 
total, indirect, and direct bilirubin) 
One time weekly (Monday) 
 
Serum bile acids (total) 
One time monthly (every 4th Monday on treatment)  
 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
12
Point of care or serum glucose 
measures 
- Daily for the first 5 days of PN, then twice weekly (Monday, 
Thursday) 
- Confirmatory test if serum glucose is >150 mg/dL on electrolyte 
panel 
Serum Triglycerides 
One time weekly (Monday) 
Essential Fatty Acid Profile 
IFER Group:  Every 2 weeks (Thursday) 
Standard Group:  At the time of restriction of IVFE to 1 g/kg/day 
three days per week, then every 2 weeks (Thursday) 
Comprehensive metabolic panel 
Twice weekly (Monday, Thursday) 
Magnesium level 
Twice weekly (Monday, Thursday) 
Phosphorus level 
Twice weekly (Monday, Thursday) 
Complete blood count 
One time weekly (Monday) 
* Lab draw volumes will be below each institution’s daily limits  
 
Definition of Sepsis 
Sepsis will be defined in a standard manner using the following criteria (Table 2):38 
 
The presence of at least two of the following four criteria in the presence of or as a result of suspected or 
proven infection: 
1. Core temperature of >38.5C or <36C 
2. Tachycardia, defined as a mean heart rate >2 SD above normal for age in the absence of external 
stimulus, chronic drugs, or painful stimuli; or otherwise unexplained persistent elevation over 0.5 to 4 
hour time period OR for children <1 year old:  bradycardia, defined as a mean heart rate <10th percentile 
for age in the absence of external vagal stimulus, beta-blocker drugs, or congenital heart disease, or 
otherwise unexplained persistent depression over 0.5 hour time period 
3. Mean respiratory rate >2 SD above normal for age or mechanical ventilation for an acute process not 
related to underlying neuromuscular disease or the receipt of general anesthesia 
4. Leukocyte count elevated or depressed for age or >10% immature neutrophils 
 
Table 2.  Age specific criteria for the criteria listed above; adapted.38 
Age 
Tachycardia 
(bpm) 
Bradycardia 
(bpm) 
Respiratory 
Rate 
(breaths/min) 
Leukocyte 
Count 
Leukocytes 
x 
103/mm3 
Systolic Blood 
Pressure 
(mmHg) 
0 days – 1 week 
>180 
<100 
>50 
>34 
<65 
1 week – 1 month 
>180 
<100 
>40 
>19.5 or <5 
<75 
1 month – 1 year 
>180 
<90 
>34 
>17.5 or <5 
<100 
 
 
Monitoring and Follow Up of Subjects 
Monitoring during the 12 week treatment period includes the amount and type of parenteral and enteral nutrition 
(total calories, expressed as kcal/kg/day, and amounts of parenteral protein and IVFE, expressed as g/kg/day, 
type of enteral formula (e.g. breast milk, formula). Clinical diagnoses, clinical occurrences other than adverse 
events, clinical complications, and drugs listed on the medication form will be recorded. If a patient goes home 
on PN prior to the end of 12 weeks from randomization, data will be collected according to standards of that 
institution.  
 
Infants completing the initial 12 week period will be monitored according to the institution’s standard of care 
during the remainder of their hospitalization.  Subjects who are cholestatic at the termination of the initial 12 
week period will be followed with monthly LFTs and bilirubin fractions to assess for resolution or progression of 
PNAC.  These monthly labs draws will continue for 6 months.  If patients remain cholestatic, a referral for further 
gastrointestinal workup will be made. 
 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
13
 
 
Among subjects not followed for cholestasis, a final morbidity and mortality assessment will be made, by phone, 
6 months after completion of the initial phase of the study.  To ensure that follow-up is achieved after the infant 
is discharged and for attaining the neurodevelopmental follow-up at 12 and 24 months of age, a contact sheet 
will be held by the study coordinator which will contain the names, addresses and phone numbers of all 
participants. 
 
Neurodevelopmental Outcome Measures 
After the initial 12 week treatment period, study subjects from both treatment arms will be evaluated at 12 months 
and 24 months (corrected age) in order to assess the influence of early IFER treatment on neurodevelopmental 
outcomes.  Early outcome assessments are typically conducted at a corrected age of approximately 24 months.39  
Recommended outcome domains have included motor, cognition, speech and language, sensory and other 
disabilities.  Developmental assessments typically involve a medical examination, direct assessment with an 
instrument such as the Bayley Scales of Infant Development (Bayley-III) and developmental survey instruments.  
While there is evidence that a number of common survey screens lack validity when conducted below 15 months 
of age,40 by 24 months of age specific survey instruments have been shown to be reliable and valid measures 
of behavioral risks.40-44  For the purposes of this study the 12 month assessment is included to examine the 
possibility with our target population of very early identification of developmental lags and predictors of risk.  
These assessments are crucial in order to investigate whether an association exists between reducing the dose 
of IVFE during a critical period of growth and brain development (i.e. the neonatal and infant period) with long-
term neurodevelopmental outcomes.   
 
Bayley Scales of Infant and Toddler Development (BSID-III):45 The BSID-III is designed to assess developmental 
functioning of infants and toddlers, ages 1 month to  42 months. The instrument includes five distinct scales, of 
which three scales and associated subscales are utilized for the purposes of this study:  cognitive, language 
(receptive and expressive communication) and motor (fine motor and gross motor).  
 
The MacArthur-Bates Communicative Development Inventories (CDI):46  The MacArthur-Bates CDI is the most 
widely used parent report measure of language development.  The CDI includes two versions: Words and 
Gestures for ages 8-16 months and Words and Sentences for children ages 16-30 months.  Scores are reported 
as percentiles compared to age-standardized norms. 
 
Brief Infant Toddler Social Emotional Assessment (BITSEA):43,44,47  The 42-item BITSEA is a parent report 
measure of social-emotional and behavior problems in children ages 1-3.  The Problem Index includes 
internalizing, externalizing and dysregulation problems.  The internalizing scale has items that assess 
depression, anxiety and negative emotionality.  
 
Gross Motor Function Classification System (GMFCS):48,49  The GMFCS is a five level classification system that 
assess the gross motor function of children with and at risk for cerebral palsy, from infancy through age 12.  It 
differentiates children into one of five levels of functioning, based on the child’s current gross motor ability, 
limitations in function, and need for assistive technology.  
 
Behavior Assessment System for Children – Second Edition Preschool, Parent (BASC-2 Preschool Parent’s 
version):50  The BASC-2 PRS-P is a 134 item questionnaire that assesses psychological status and adaptive 
behavior.  The parent/caregiver rates the occurrence of behaviors using a 4-point rating scale. The profile yields 
eight clinical scales (hyperactivity, aggression, anxiety, depression, somatization, atypicality, withdrawal and 
attention problems) and four adaptive scales (adaptability, social skills, activities of daily living and functional 
communication) as well as four composite scores (externalizing problems, internalizing problems, adaptive skills 
and the Behavioral Symptoms Index).  
 
These neurodevelopmental tools will be evaluated on the following schedule: 
12 month follow-up 
24 month follow-up 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
14
BSID-III 
BSID-III, CDI, BITSEA, GMFS, BASC-2 
 
We recognize that neurodevelopmental outcomes may be influenced by other factors that extend beyond early 
interventions during the neonatal and infant periods.  Such factors may include duration of parenteral nutrition, 
duration of IFER, mean IVFE dose, percent nutrition obtained via the enteral route compared to the parenteral 
route, type of enteral intake (i.e. breast milk), the development of essential fatty acid deficiency, as well as early 
intervention programs, attendance at daycare/preschool, and socioeconomic status.  As such, we will evaluate 
study subjects every 6 months ( 30 days) and collect the following data, which will be used in final statistical 
analyses to evaluate predictive variables on neurodevelopmental outcomes: 
1. Current parenteral and enteral nutrition parameters 
2. Current IVFE dose/mean IVFE dose over course of previous 6 months 
3. Essential fatty acid profiles (if available, according to each institution’s standard of care), evaluating for 
development of essential fatty acid deficiency 
4. Attendance at early intervention programs and/or daycare/preschool 
 
Monitoring for Adverse Events  
The study coordinator and investigators at each site will monitor for adverse reactions. Although generally very 
well-tolerated, the administration of PN with Intralipid® 20% is associated with a number of adverse events.   
 
 
Determination of Expectedness: 
Adverse events will be classified as expected or unexpected. Expected adverse events include those listed in 
the clinical protocol, the package insert for PN with Intralipid® 20%, and those events listed in the informed 
consent document. 
 
These may include, but are not limited to: 
1. Line complications including: 
a. Catheter-related blood stream infection (CRBSI) 
i. Defined as:  A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) 
or umbilical catheter (UC) was in place for >2 calendar days on the date of event, with day 
of device placement being Day 1, and a CL or UC was in place on the date of event or the 
day before.  If a CL or UC was in place for >2 calendar days and then removed, the LCBI 
criteria must be fully met on the day of discontinuation or the next day51,52 
ii. This is in distinction to a catheter-related blood stream infection (CRBSI) whose definition 
requires removal of the catheter51 
b. Need for catheter replacement 
2. Hyperglycemia > 300 mg/dL 
3. Hypertriglyceridemia >400 mg/dL 
4. Development of essential fatty acid deficiency  
5. Moderate undernutrition (decreased in z-score by >2 standard deviations) to severe undernutrition 
(decreased in z-score by >3 standard deviations) 
6. Thrombophlebitis  
7. Hypercoagulopathy 
8. Thrombocytopenia (platelet count <50 k/mm3) 
 
 
Determination of Relatedness: 
 
Generally, the definition of an adverse event could include worsening of a pre-existing condition and investigators 
could be asked to make the distinction between exacerbation of a pre-existing condition and an event related to 
the study protocol when recording and reporting adverse event. However, due to the nature of the population 
being studied, the typical effects of the underlying condition may not yet be present at Baseline.  
 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
15
Based on clinical information, an adverse event will be determined by the site PI to be definitely not related, 
unlikely to be related, possibly related, definitely related or insufficient information to Intralipid® 20% 
administration or other study procedures. Usual effects from the subject’s condition that are considered by the 
site PI to be not related to Intralipid® 20% administration or other study procedures will be noted in the 
subjects’ medical records but will not be recorded or reported as an adverse event for this study. Examples 
include emesis, reflux and pain due to an expected surgery/procedure. 
 
 
Adverse Event Reporting 
All adverse events that occur from the time of consent until the patient completes 12 weeks of TPN or has been 
off TPN for 7 days, whichever comes first will be assessed for expectedness and relatedness and recorded in 
the subject’s study binder. 
 
Only adverse events considered to be possibly related to Intralipid® 20% administration or other study 
procedures will be reported to the sponsor, the IRB, the FDA, and the DSMB.  
 
 
Severe Adverse Event Reporting 
Although no serious adverse reactions are anticipated, study participants will be monitored, and any such events 
will be recorded and reported to the appropriate regulatory committees. These include: 
 
Death while on the study 
 
Any study-related event that prolongs hospitalization 
 
Any study-related event that requires an operative procedure 
 
Mortality will be defined as a death occurring at any time during the child’s admission to the hospital. The cause 
of death, autopsy findings and whether the subject was on study drug at the time of death will also be recorded. 
 
All adverse events will be graded as follows in their relation to IFER:  definitely not related, unlikely to be related, 
possibly related, definitely related or insufficient information.  All cases rated as possibly or definitely related will 
be defined as an SAE. These SAEs will be reported to the University of Michigan Sponsor-Investigator within 48 
hours. The site PI will be contacted immediately and the case will be evaluated for reporting to IRB, FDA and 
study termination, if deemed necessary. Each clinical site will report SAEs to their local IRB as per their standard 
reporting policy. As per 21 CFR 312.32(c), the sponsors will also notify FDA and all participating investigators in 
an IND safety report of any adverse experience associated with the use of the drug that is both serious and 
unexpected. 
 
Data Safety Monitoring Board 
An independent data safety monitoring committee will be established to monitor the study for safety and to 
determine if a statistical difference has been achieved between the two groups for the primary outcome measure 
at interim data analyses.  The data safety monitoring committee will review the data at the halfway point of the 
study to assess the safety and efficacy of the study to that point.  If safety issues are revealed the study 
investigators and each site’s IRB will be notified immediately.  The data safety monitoring committee will also 
ensure that adverse events are promptly reported to the FDA, and all participating investigators will be notified 
as well of any adverse experience associated with the use of the drug that is both serious and unexpected. 
 
Sample Size Determination 
The sample size was calculated for the primary outcome (rate of rise of direct bilirubin) using previously published 
data as well as our clinical experience.22,23  We have assumed that the mean bilirubin levels at baseline, 4 weeks, 
8 weeks and 12 weeks in the standard dosing group (2-3 g/kg/day) will be 0.55 mg/dL, 1 mg/dL, 1.5 mg/dL and 
2 mg/dL corresponding to a slope of 0.125 mg/dL/week over 12 weeks.  The standard deviation of the bilirubin 
measures at each of these four time points is 1.  Likewise, we have estimated that the mean bilirubin levels at 
baseline, 4 weeks, 8 weeks and 12 weeks in the minimization group (1 g/kg/day) will be 0.45 mg/dL, 0.5 mg/dL, 
0.45 mg/dL and 0.5 mg/dL (a slope of roughly zero).  The standard deviation of the bilirubin measurements at 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
16
each of these four time points is 1.  The correlation of any two adjacent measures on the same individual is 0.5.  
This correlation drops to 0.354 between baseline and 8 weeks and to 0.25 between baseline and 12 weeks. 
 
Using the above assumptions, a sample size of 15 subjects per group using a repeated measures ANOVA will 
have 85% power to detect the change in slopes as being significant at the 0.05 level, 79% power to detect a 
difference in means overall between groups and 88% power to detect the general change in means over time 
across the two groups.  When the sample size is increased to 20 subjects per group, the above power numbers 
increase to 95%, 90% and 96%, respectively.  If 30 subjects are recruited per group this design will allow for a 
33% attrition rate by twelve weeks as we expect that not all patients will require PN for the full 12 weeks of the 
initial study period.  Thus, we will recruit a minimum of 30 subjects per group to ensure adequate power to detect 
our primary outcome measure. 
 
Of the secondary outcomes, sample size was also calculated for the incidence of cholestasis.  Assuming an 
incidence of 50% in the standard group and an incidence of 10% in the minimization group, with alpha = 0.05 
and power of 80%, a sample size of 23 is required for each group.  Regarding the other secondary outcomes, 
our sample size is large enough to allow for establishing trends which may then highlight avenues for future 
research. 
 
Planned Statistical Analysis 
All data analysis will be directed and performed by a statistician through the Center for Statistical Consultation 
and Research at the University of Michigan (http://cscar.research.umich.edu/about/).  Data will be analyzed using 
SAS software release 9.3 for Windows (Copyright, SAS Institute Inc., SAS and all other SAS Institute Inc. product 
of service names are registered trademarks or trademarks of SAS Institute Inc., Cary, NC, USA).  All study 
subjects will be included in the statistical analysis in an intent-to-treat manner.     
 
Descriptive statistics using standard statistical tests (e.g. Student’s t-test, paired sample t-test, Wilcoxon rank 
sums tests, Fisher’s exact tests, Chi-square test, McNemar’s test, etc.) will be used throughout the statistical 
analysis of data.  Logistic regression will be used to compare differences between groups. Because septicemia 
can exacerbate PNAC, we will include the incidence of septicemia as a covariate in our analysis. Septic episodes 
will be defined as positive cultures or clinical presentation consistent with sepsis during the 7 day period 
corresponding to the subject’s weekly bilirubin value.  The number of septic episodes will be accounted for using 
a Poisson regression analysis (or possibly a negative binomial regression if there is more variability than 
expected for a Poisson distribution), with the total time on PN as an offset, allowing us to compare the rate of 
occurrence of septic episodes in the two groups.  
 
Primary Outcome Measure 
The primary outcome measure – change in direct bilirubin as a function of time (mg/dL/week) between the two 
groups – will be evaluated using a linear mixed model analysis to compare the slope of total bilirubin levels 
between the standard and reduced groups. This model will allow us to examine the degree of variability between 
subjects in the rate of change over time, and will take this variability into account in the model by including a 
random effect for the slope of time for each subject as well as a random intercept for each subject.   
 
Secondary Outcome Measures 
1. Time to PNAC (direct bilirubin ≥2 mg/dL) and time to severe PNAC (direct bilirubin ≥4 mg/dL) 
The time to development of a first occurrence of PNAC and of severe PNAC will be evaluated using survival 
analysis.  Initially, we will compare the two groups using Kaplan-Meier curves, but the eventual analysis will 
take into account important covariates, such as development of sepsis, average IVFE dose and percentage 
of calories from enteral feeds using a Cox proportional hazards survival analysis.  We will test whether the 
proportional hazards assumption is met for the analysis by including an interaction term between treatment 
group and time to see if any differences between the groups are consistent or increase/decrease over time.  
The effect of important time-varying covariates (e.g., septic episodes) can also be taken into account using a 
Cox model.  
 
2. Level of peak total and direct bilirubin 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
17
These measures will be compared between the two treatment groups using a linear mixed model.   
 
3. Incidence of PNAC, severe PNAC, and EFAD 
The number of occurrences of each of these outcomes will be compared using either a Poisson regression 
model or a negative binomial model if the variance in these counts is greater than expected for a Poisson 
distribution.  We will also include the time on TPN as an offset, so that we can compare the rates of occurrence 
of each of these outcomes for the two treatment groups. These regression models will be adjusted for the 
covariates such as development of sepsis, average IVFE dose, and percentage of enteral feeds.  
 
4. Adequacy of growth as evaluated by z-scores for weight, height and head circumference 
The z-scores for each of these measures will be compared between the two treatment groups using a linear 
mixed model.  For normally growing infants, we would expect that there would not be a trend in z-scores 
because we would expect them to maintain their curve.  However, for the subjects in this study, there may be 
a loss in z-score over time due to inadequate growth.  The slopes of the changes in these z-scores over time 
will be compared between the two treatment arms.  A random intercept will be included for each subject to 
allow for individual variability in average values as well as a random slope to allow for variability in the rate of 
change over time across subjects.  Important covariates, such as gestational age (<32 weeks gestation vs. 
≥32 weeks gestation) and birth weight will also be used as covariates in this analysis.  
 
5. Neurodevelopmental Outcomes  
Bayley Scales of Infant and Toddler Development (BSID-III):45  Raw scores are converted to composite and 
subscale scores using age-standardized norms.  Scale composite average internal consistency reliability 
coefficients range from .91 to .93 with subtest reliability ranging from .86 to .91.  Validity-related studies 
indicate relatively high correlations (.72-.79) with the Wechsler Preschool and Primary Scale of Intelligence – 
Third Edition (WPPSI-III)53 and with the Preschool Language Scale – Fourth Edition (PLS-4)(.71-.83).54 
 
The MacArthur-Bates Communicative Development Inventories (CDI):46  The MacArthur-Bates CDI is the 
most widely used parent report measure of language development.  The CDI includes two versions:  Words 
and Gestures (ages 8-16 months) and Words and Sentences (ages 16-30 months).  Scores are reported as 
percentiles compared to age-standardized norms. 
 
Brief Infant Toddler Social Emotional Assessment (BITSEA):44,47,55  Dichotomous scores are generated based 
on cut-off scores, which identify subjects to be at risk. Internal consistency coefficients range from.80 to.82.  
Test-retest reliability is acceptable at .80-.85.  Recent evidence identifies the BITSEA as the best short tool 
for early detection of psychosocial problems in two-year olds.40 
 
Gross Motor Function Classification System (GMFCS):48,56  Interrater reliability is 0.75 and both content and 
predictive validity are well-demonstrated in child and adult populations. 56-58 
 
Behavior Assessment System for Children – Second Edition Preschool, Parent Preschool Parent’s version 
(BASC-2 PRS-P):50  Limited construct validation data indicate strong correlations with similar scale scores.  
Primary measurements from the BASC-2 including the Adaptive Behavior Composite and the Behavior 
Symptoms Index will be reported as T-scores and as percentiles.  Secondary analyses will be conducted on 
the subscales.  
 
For the comparison of the two treatment arms across time for neurological measures that are approximately 
continuous, a linear mixed model will be used with a repeated measures covariance structure.  The best 
covariance structure will be chosen based on a comparison of the Akaike Information Criterion (AIC) and Bayes 
Information Criterion (BIC).  This will allow us to adjust for correlated measures within a subject and possibly for 
unequal variances across times points and across groups.  Each measure will be compared between the groups 
at each time point, controlling for important demographic variables, such as gestational age, diagnosis, bilirubin 
(total and direct), as well as a time-varying covariate for development of essential fatty acid deficiency.  
Importantly, we will also evaluate the influence of three IFER-related variables on neurodevelopmental 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
18
outcomes:  mean IVFE dose, duration of IFER and the development of essential fatty acid deficiency.  Since 
total and direct bilirubin are expected to be highly collinear, we will use only one of these predictors and compare 
the models using AIC and BIC to decide which is a better predictor of the particular outcome being assessed. 
   
A logistic regression with Generalized Estimating Equations (GEE) approach will be used to compare the binary 
outcomes between groups.  
 
Intent to Treat 
All statistical analyses will be performed using an intent to treat approach. 
 
Potential Confounding Variables: 
Nutritional intake:  Differences in nutritional intake alter the risk of PNAC as any amount of enteral nutrition has 
been shown to enhance rehabilitation.59  Infants able to tolerate even trophic amounts of enteral calories will be 
at decreased risk compared to those than those who are completely PN-dependent.  Every attempt will be made 
to standardize enteral feeding advancement.  This will be possible because of the relatively homogeneous nature 
of the subjects enrolled and their similar expected ability to tolerate enteral feeds.  Statistical analyses will 
account for variations in enteral intake.  Overfeeding may result in hepatic steatosis that can also worsen PNAC, 
therefore all subjects will follow a strict guideline for PN administration.  Additionally, the administration of breast 
milk, which contains proteins necessary for optimal brain development, may be a confounding variable and will 
be accounted for in the final data analysis.  PN duration (with or without IFER) may also affect 
neurodevelopmental outcomes and will be included as a covariate in the statistical analysis.  
 
Variation in IVFE dose:  The IVFE dose may vary depending on the clinical status of the subject (e.g. elevated 
TG, EFAD, direct bilirubin ≥2.5 mg/dL, nutritional and/or fluid status).  Every attempt will be made to maintain 
dosing within the assigned treatment arm.  Based on previous experience using IFER at the University of 
Michigan, hypertriglyceridemia and EFAD are exceedingly rare occurrences, therefore, the IVFE dose is not 
expected to be adjusted frequently based on these findings.  Statistical analysis will account for differences in 
IVFE dose by using the mean IVFE dose as well as the duration of IVFE/IFER as a covariate. 
 
Critical medical incidences:  As differences in the degree of medical illness between groups may adversely affect 
the development of PNAC, a number of complications will be examined as secondary outcome measures 
including sepsis and mortality rates as well as days in the neonatal intensive care unit.   
 
Occurrence of sepsis:  Because sepsis may lead to increased levels of direct bilirubin and may worsen PNAC, 
the occurrence of sepsis is being recorded and a marker of morbidity. 
 
 


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References 
 
1. 
Suita S, Yamanouchi T, Masumoto K, Ogita K, Nakamura M, Taguchi S. Changing profile of parenteral 
nutrition in pediatric surgery: a 30-year experience at one institute. Surgery. 2002;131(1 Suppl):S275–
82. 
2. 
Merritt RJ. Cholestasis associated with total parenteral nutrition. J Pediatr Gastroenterol Nutr. 
1986;5(1):9–22. 
3. 
Kubota A, Okada A, Nezu R, Kamata S, Imura K, Takagi Y. Hyperbilirubinemia in neonates associated 
with total parenteral nutrition. JPEN Journal of parenteral and enteral nutrition. 1988;12(6):602–606. 
4. 
Nanji AA, Anderson FH. Sensitivity and specificity of liver function tests in the detection of parenteral 
nutrition-associated cholestasis. JPEN Journal of parenteral and enteral nutrition. 1985;9(3):307–308. 
5. 
Beath SV, Booth IW, Murphy MS, et al. Nutritional care and candidates for small bowel transplantation. 
Arch Dis Child. 1995;73(4):348–350. 
6. 
Kelly DA. Liver complications of pediatric parenteral nutrition--epidemiology. Nutrition. 1998;14(1):153–
157. 
7. 
Koseesirikul P, Chotinaruemol S, Ukarapol N. Incidence and risk factors of parenteral nutrition-
associated liver disease in newborn infants. Pediatr Int. 2012;54(3):434–436. doi:10.1111/j.1442-
200X.2012.03627.x. 
8. 
Drongowski RA, Coran AG. An analysis of factors contributing to the development of total parenteral 
nutrition-induced cholestasis. JPEN Journal of parenteral and enteral nutrition. 1989;13(6):586–589. 
9. 
Kelly DA. Intestinal failure-associated liver disease: what do we know today? Gastroenterology. 
2006;130(2 Suppl 1):S70–7. doi:10.1053/j.gastro.2005.10.066. 
10. 
Carter BA, Shulman RJ. Mechanisms of disease: update on the molecular etiology and fundamentals of 
parenteral nutrition associated cholestasis. Nat Clin Pract Gastroenterol Hepatol. 2007;4(5):277–287. 
doi:10.1038/ncpgasthep0796. 
11. 
Carter BA, Karpen SJ. Intestinal failure-associated liver disease: management and treatment strategies 
past, present, and future. Semin Liver Dis. 2007;27(3):251–258. doi:10.1055/s-2007-985070. 
12. 
Ginn-Pease ME, Pantalos D, King DR. TPN-associated hyperbilirubinemia: a common problem in 
newborn surgical patients. J Pediatr Surg. 1985;20(4):436–439. 
13. 
Spencer AU, Neaga A, West B, et al. Pediatric short bowel syndrome: redefining predictors of success. 
Ann Surg. 2005;242(3):403–9; discussion 409–12. 
14. 
Moss RL, Amii LA. New approaches to understanding the etiology and treatment of total parenteral 
nutrition-associated cholestasis. YSPSU. 1999;8(3):140–147. 
15. 
Kumpf VJ. Parenteral nutrition-associated liver disease in adult and pediatric patients. Nutr Clin Pract. 
2006;21(3):279–290. 
16. 
Rangel SJ, Calkins CM, Cowles RA, et al. Parenteral nutrition-associated cholestasis: an American 
Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr 
Surg. 2012;47(1):225–240. doi:10.1016/j.jpedsurg.2011.10.007. 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
20
17. 
Allardyce DB. Cholestasis caused by lipid emulsions. Surg Gynecol Obstet. 1982;154(5):641–647. 
18. 
Colomb V, Jobert-Giraud A, Lacaille F, Goulet O, Fournet JC, Ricour C. Role of lipid emulsions in 
cholestasis associated with long-term parenteral nutrition in children. JPEN Journal of parenteral and 
enteral nutrition. 2000;24(6):345–350. 
19. 
Cober MP, Killu G, Brattain A, Welch KB, Kunisaki SM, Teitelbaum DH. Intravenous fat emulsions 
reduction for patients with parenteral nutrition-associated liver disease. J Pediatr. 2012;160(3):421–427. 
doi:10.1016/j.jpeds.2011.08.047. 
20. 
Cober MP, Teitelbaum DH. Prevention of parenteral nutrition-associated liver disease: lipid 
minimization. Curr Opin Organ Transplant. 2010;15(3):330–333. doi:10.1097/MOT.0b013e328338c2da. 
21. 
Nehra D, Fallon EM, Carlson SJ, et al. Provision of a Soy-Based Intravenous Lipid Emulsion at 1 g/kg/d 
Does Not Prevent Cholestasis in Neonates. JPEN Journal of parenteral and enteral nutrition. 
2013;37(4):498–505. doi:10.1177/0148607112453072. 
22. 
Sanchez SE, Braun LP, Mercer LD, Sherrill M, Stevens J, Javid PJ. The effect of lipid restriction on the 
prevention of parenteral nutrition-associated cholestasis in surgical infants. J Pediatr Surg. 
2013;48(3):573–578. doi:10.1016/j.jpedsurg.2012.08.016. 
23. 
Rollins MD, Ward RM, Jackson WD, et al. Effect of decreased parenteral soybean lipid emulsion on 
hepatic function in infants at risk for parenteral nutrition-associated liver disease: A pilot study. J Pediatr 
Surg. 2013;48(6):1348–1356. doi:10.1016/j.jpedsurg.2013.03.040. 
24. 
Belkind-Gerson J, Carreón-Rodríguez A, Contreras-Ochoa CO, Estrada-Mondaca S, Parra-Cabrera MS. 
Fatty Acids and Neurodevelopment. J Pediatr Gastroenterol Nutr. 2008;47(Suppl 1):S7–S9. 
doi:10.1097/MPG.0b013e3181818e3f. 
25. 
Davis-Bruno K, Tassinari MS. Essential fatty acid supplementation of DHA and ARA and effects on 
neurodevelopment across animal species: a review of the literature. Birth Defects Research Part B: 
Developmental and Reproductive Toxicology. 2011;92(3):240–250. doi:10.1002/bdrb.20311. 
26. 
Blackmer AB, Warschausky S, Siddiqui S, et al. Preliminary Findings of Long-Term 
Neurodevelopmental Outcomes of Infants Treated With Intravenous Fat Emulsion Reduction for the 
Management of Parenteral Nutrition-Associated Cholestasis. JPEN Journal of parenteral and enteral 
nutrition. 2014. doi:10.1177/0148607114551965. 
27. 
Struijs M-C, Diamond IR, de Silva N, Wales PW. Establishing norms for intestinal length in children. J 
Pediatr Surg. 2009;44(5):933–938. doi:10.1016/j.jpedsurg.2009.01.031. 
28. 
Arsenault D, Brenn M, Kim S, et al. A.S.P.E.N. Clinical Guidelines: hyperglycemia and hypoglycemia in 
the neonate receiving parenteral nutrition. JPEN Journal of parenteral and enteral nutrition. 
2012;36(1):81–95. doi:10.1177/0148607111418980. 
29. 
Okamoto E, Rassin DK, Zucker CL, Salen GS, Heird WC. Role of taurine in feeding the low-birth-weight 
infant. J Pediatr. 1984;104(6):936–940. 
30. 
Chesney RW. Taurine: is it required for infant nutrition? J Nutr. 1988;118(1):6–10. 
31. 
HANSEN AE, HAGGARD ME, BOELSCHE AN, ADAM DJ, WIESE HF. Essential fatty acids in infant 
nutrition. III. Clinical manifestations of linoleic acid deficiency. J Nutr. 1958;66(4):565–576. 
32. 
Hansen AE, Wiese HF, Boelsche AN, Haggard ME, Adam DJD, Davis H. ROLE OF LINOLEIC ACID IN 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
21
INFANT NUTRITION. Pediatrics. 1963. 
33. 
Nehra D, Fallon EM, Puder M. The prevention and treatment of intestinal failure-associated liver disease 
in neonates and children. Surg Clin North Am. 2011;91(3):543–563. doi:10.1016/j.suc.2011.02.003. 
34. 
Jensen AR, Goldin AB, Koopmeiners JS, Stevens J, Waldhausen JHT, Kim SS. The association of 
cyclic parenteral nutrition and decreased incidence of cholestatic liver disease in patients with 
gastroschisis. J Pediatr Surg. 2009;44(1):183–189. doi:10.1016/j.jpedsurg.2008.10.033. 
35. 
Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-
related definitions. JPEN Journal of parenteral and enteral nutrition. 2013;37(4):460–481. 
doi:10.1177/0148607113479972. 
36. 
Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for 
preterm infants. BMC Pediatr. 2013;13:59. doi:10.1186/1471-2431-13-59. 
37. 
WHO Growth Standards Are Recommended for Use in the US for Infants and Children 0 to 2 Years of 
Age. Centers for Disease Control Available at: http://www.cdc.gov/growthcharts/who_charts.htm. 
Accessed February 2, 2014. 
38. 
Goldstein B, Giroir B, Randolph A, International Consensus Conference on Pediatric Sepsis. 
International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in 
pediatrics. In: Vol 6. 2005:2–8. doi:10.1097/01.PCC.0000149131.72248.E6. 
39. 
Medicine BAOP. Report of a classification of health status at 2 years of age as a perinatal outcome. 1st 
ed. London; 2008. 
40. 
de Wolff MS, Theunissen MHC, Vogels AGC, Reijneveld SA. Three questionnaires to detect 
psychosocial problems in toddlers: a comparison of the BITSEA, ASQ:SE, and KIPPPI. Acad Pediatr. 
2013;13(6):587–592. doi:10.1016/j.acap.2013.07.007. 
41. 
Peralta-Carcelen M, Bailey K, Rector R, Gantz M, NICHD Neonatal Research Network. Behavioral and 
socioemotional competence problems of extremely low birth weight children. J Perinatol. 
2013;33(11):887–892. doi:10.1038/jp.2013.78. 
42. 
Kruizinga I, Jansen W, Mieloo CL, Carter AS, Raat H. Screening accuracy and clinical application of the 
Brief Infant-Toddler Social and Emotional Assessment (BITSEA). PLoS ONE. 2013;8(8):e72602. 
doi:10.1371/journal.pone.0072602. 
43. 
Briggs-Gowan MJ, Carter AS, Irwin JR, Wachtel K, Cicchetti DV. The Brief Infant-Toddler Social and 
Emotional Assessment: screening for social-emotional problems and delays in competence. J Pediatr 
Psychol. 2004;29(2):143–155. 
44. 
Briggs-Gowan MJ, Carter AS, McCarthy K, Augustyn M, Caronna E, Clark R. Clinical validity of a brief 
measure of early childhood social-emotional/behavioral problems. J Pediatr Psychol. 2013;38(5):577–
587. doi:10.1093/jpepsy/jst014. 
45. 
Bayley N. Bayley Scales of Infant and Toddler Development:  Administrative Manuel. 3rd ed. San 
Antonio, TX: Harcourt Assessment; 2006. 
46. 
Fenson L, Marchman V, Thal D, Dale P, Reznick J. MacArthur-Bates Communicative Development 
Inventories:  User Guide and Technical Manual. Baltimore, MD: Brookes; 2007. 
47. 
Briggs-Gowan MJ, Carter AS. Social-emotional screening status in early childhood predicts elementary 


Standard IV lipid dosing compared to IV lipid minimization for the prevention of PNAC/PNALD 
 
 
22
school outcomes. Pediatrics. 2008;121(5):957–962. doi:10.1542/peds.2007-1948. 
48. 
Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a 
system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 
1997;39(4):214–223. 
49. 
Palisano RJ, Hanna SE, Rosenbaum PL, et al. Validation of a model of gross motor function for children 
with cerebral palsy. Phys Ther. 2000;80(10):974–985. 
50. 
Reynolds C, Kamphaus R. Behavior Assessment System for Children. 2nd ed. Circle Pines, MN: AGS 
Publishing; 2004. 
51. 
July 2013 CDC/NHSN Protocol Clarifications. Centers for Disease Control Available at: 
http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf. Accessed November 11, 2013. 
52. 
Guide to the Elimination of Catheter-Related Bloodstream Infections. 2009 ed. Association for 
Professionals in Infection Control and Epidemiology Available at: 
http://www.apic.org/Resource_/EliminationGuideForm/259c0594-17b0-459d-b395-
fb143321414a/File/APIC-CRBSI-Elimination-Guide.pdf. Accessed November 11, 2013. 
53. 
D W. Wechsler Preschool and Primary Scale of Intelligence - Third Edition. San Antonio, TX: The 
Psychological Corporation; 2002. 
54. 
Zimmerman IL, Steiner VG, Pond RE. Preschool Language Scale - Fourth Edition. San Antonio, TX: 
The Psychological Corporation; 2002. 
55. 
Briggs-Gowan MJ. The Brief Infant-Toddler Social and Emotional Assessment: Screening for Social-
Emotional Problems and Delays in Competence. J Pediatr Psychol. 2004;29(2):143–155. 
doi:10.1093/jpepsy/jsh017. 
56. 
Palisano RJ, Hanna SE, Rosenbaum PL, et al. Validation of a Model of Gross Motor Function for 
Children With Cerebral Palsy. Physical …. 2000. 
57. 
Sandström K, Alinder J, Öberg B. Descriptions of functioning and health and relations to a gross motor 
classification in adults with cerebral palsy. Disabil Rehabil. 2004;26(17):1023–1031. 
doi:10.1080/09638280410001703503. 
58. 
Wood E, Rosenbaum P. The Gross Motor Function Classification System for Cerebral Palsy: a study of 
reliability and stability over time. Dev Med Child Neurol. 2007;42(5):292–296. doi:10.1111/j.1469-
8749.2000.tb00093.x. 
59. 
Wessel JJ, Kocoshis SA. Nutritional management of infants with short bowel syndrome. Semin Perinatol. 
2007;31(2):104–111. doi:10.1053/j.semperi.2007.02.009.