## 2 Provision of Energy and Macronutrients in Pediatric Patients on PN
### Effects on Growth and Nutritional Status  
In studies evaluating the effects of PN with SMOFlipid, administered in doses up to 3 g lipids /kg BW/day for 2 to 9 weeks to hospitalized pediatric patients of all age groups, no significant differences in weight gain or parameters of growth as compared to SO-ILE [88; 101; 110] or SO/MCT-ILE [100; 107] were reported (see Table 1), indicating that SMOFlipid is at least equally as effective as SO-ILE for supporting adequate growth. Several studies evaluated the effects of long-term HPN with SMOFlipid on growth parameters (see Table 1). [PERSON] et al. found that after receiving SMOFlipid for more than 6 months, highly PN-dependent children (median age 5.8 years) on HPN showed normal body weight and height relative to growth charts for healthy children. After an extended PN duration of 2.4 years, growth parameters between patients still receiving PN with SMOFlipid and those weaned from PN did not show any significant differences and were consistent with normal growth rates [15]. [PERSON] et al. retrospectively evaluated growth parameters in children on HPN from the initiation of SMOFlipid up to 1.5 years postSMOFlipid initiation and found slight increases in body mass index (BMI) z-scores over this period that were, however, not significant [94]. In newborn infants with IF receiving PN with SMOFlipid (2-3 g lipids/kg BW/day) for an average of 421 days, [PERSON] et al. reported significantly improved weight z-scores after 3 and 6 months compared to historic controls receiving SO-ILE. Anthropometric parameters including weight, height, and head circumference remained within the normal range with both ILEs [99]. [PERSON] et al. conducted a prospective multicenter study including pediatric patients of all age groups receiving HPN with SMOFlipid or OO/SO-ILE (median lipid dose 1.3 g/kg BW/day) for a mean duration of 22 and 21 months, respectively [92]. Median Z-scores of weight, height, or BMI for age were not statistically significant between groups [92]. The authors concluded that both ILEs ensured adequate growth, despite the lower plasma levels of ARA seen in this study. PN with a Pediatric Amino Acid Solution for Newborn Infants, Infants/Toddlers, Children, and Adolescents--Clinical Experience  
Vaminolact is a pediatric amino acid solution providing essential (49%) and non-essential (51%) amino acids in a pattern similar to human milk (Figure 2). The amino acid composition of Vaminolact has a special focus on amino acids that are critical for pediatric patients (Table 2). It supplies adequate amounts of cysteine and tyrosine to compensate for the insufficient synthetic capacity in newborn and young infants. Moreover, it provides higher amounts of arginine to account for reduced intestinal synthesis and lower amounts of methionine, phenylalanine, valine, and isoleucine to account for the lack of intestinal \"first-pass\" metabolism [54; 55; 56]. This helps to avoid plasma amino acids imbalances in pediatric patients receiving PN. Figure 2: Amino acid supply to infants with human milk* or Vaminolact. *derived from WHO, 2007 [114], and [PERSON], 1997 [115]. There are no data available for supporting the use of adult amino acid solutions such as Vamin(r) (Fresenius [PERSON], Bad Homburg, Germany) in infants, toddlers, children, and adolescents. As a matter of fact, even for those designed for neonatology according to the value of amino acid solutions, there is no worry regarding their use in infants/toddlers, children, and adolescents. The literature reports valuable data supporting the safety and efficiency of these pediatric amino acid mixtures in the short as well as long term (Table 1). Moreover, Vaminolact supplies taurine, an amino acid that may be conditionally essential in pediatric patients requiring long-term PN [68; 116]. Taurine deficiency during the neonatal period may result in retinal dysfunction [117], as well as long-term neurodevelopmental impairment [118].