## 2 Provision of Energy and Macronutrients in Pediatric Patients on PN
### Amino Acids
These pediatric amino acid mixtures provide more essential and less non-essential amino acids. Specificities of these mixtures such as Vaminolact or Primene([PERSON], France) are nowadays well established. An amino acid that should be included in pediatric amino acid solutions is taurine. Plasma, platelet, and urinary taurine levels have been shown to be significantly decreased in children on long-term HPN compared to those in normal children of a similar age [67]. It has even been suggested that taurine may be conditionally essential in pediatric patients on long-term PN [68]. ESPGHAN/ESPEN/ESPR guidelines [50] recommend that amino acid solutions for infants and children should contain taurine, a recommendation that is based on data indicating that adequate taurine may prevent cholestasis in newborn infants. Factors affecting solubilities of calcium and phosphate in neonatal PN solutions containing the new amino acid formulation were examined [69; 70]. Nowadays, these \"pediatric amino acid mixtures\" are widely used for children and adolescents on short- as well as for long-term PN. PN with a Composite Fish Oil Containing Lipid Emulsion in Newborn Infants, Infants/Toddlers, Children, and Adolescents--Clinical Experience  
SMOFlipid is a composite ILE containing SO (30%), MCTs (30%), OO (25%), and FO (15%), and is supplemented with alpha-tocopherol (200 mg/L) to counteract lipid peroxidation and oxidative stress [22]. A key feature of SMOFlipid is its specific fatty acid pattern resulting from the combination of these four different oils. In comparison to SO, SO/MCT, or OO/SO-based ILEs, the pattern is more similar to human umbilical cord blood and breast milk, respectively, with regard to proportions of saturated fatty acids,monousaturated fatty acids, EFAs, and the omega-3 PUFAs EPA and DHA (Figure 1) [71; 72; 73]. Such a balanced fatty acid supply is of relevance, especially for newborn infants, to maintain plasma and tissue fatty acid patterns equivalent to those seen in breast-fed infants [31]. Several randomized clinical trials have been performed in very-low-birth-weight infants comparing SO-based ILEs and SMOFlipid [76; 77; 78; 79; 80; 81]. In these studies, growth was not different between groups, but those who received SMOFlipid had higher circulating EPA and DHA levels in both plasma and red blood cells (RBCs). Moreover, liver function tests (ALAT, ASAT, GGT, alkaline phosphatase) are less modified in those receiving FO-based ILEs. In numerous clinical trials conducted on term newborn infants, infants and toddlers, older children, and adolescents, SMOFlipid provided as a component of PN has been evaluated in comparison to other types of ILEs, especially SO-based ILEs, in terms of effects on plasma and tissue fatty acid patterns, inflammation and infections, cholestasis and liver function, growth and nutritional status, as well as EFA status (see Table 1). Figure 1: Fatty acid pattern of lipid emulsions vs. human umbilical cord blood and human breast milk. Compiled from * [PERSON], 2011 [74], ** [PERSON] et al., 2012 [73], *** [PERSON] et al., 2016 [75], § [PERSON] et al., 2010 [48], and § [PERSON] et al., 2005 [2]. \begin{table}
\begin{tabular}{c c c c c c c c c} \hline \hline
**Study** & **Design** & **Patients** & **Patients** & **Patients** & **Control** & **PN Lipid Dose** & **In Line with** & **ENPIGHAN** & **PN Duration** & **Main Outcomes and** **Conclusions** \\  & **Patients** (N) & **Age at Inclusion** & & & & & & & SMOF vs. SO: \\  & & & & & & & & & Overall \\  & & & & & & & & & - & 3.8 days (\(p<0.001\)). \\ [PERSON] et al., & & & Hospitalized infants and & & & & & & - & Lower risk of urinary \\
2023 [82] & Retrospective & & \begin{tabular}{c} Hospitalized infants and \\ (redders), children, median (Okt) age \\ 3.0 (0.9-11.0) years \\ \end{tabular}  & SMOF (n = 478) & SO (n = 206) & n.a. & n.a. & \ \begin{tabular}{c} SO: 9.0 (4, 25) \\ (4, 19) days \\ \end{tabular}