Introduction: The soy-based lipid component of parenteral nutrition (PN) is a known contributing factor to intestinal failure associated liver disease (IFALD). Although effective in reducing hepatotoxicity, lipid minimization (LM) protocols predispose to essential fatty acid deficiency (EFAD). SMOFlipid (soybean oil, medium-chain triglycerides, olive oil, fish oil) was FDA approved for adult patients with intestinal failure (IF) in the United States in 2016 and contains a more favorable ratio of omega-3 to omega-6 fatty acids compared to Intralipid (IL). We reviewed our experience with SMOFlipid in pediatric patients with IF.

Methods: A retrospective chart review was conducted on pediatric patients with IF at our Center who switched from IL to SMOFlipid between 2016-2017. We reviewed data before and 3-6 months after initiation of SMOFlipid (demographics, IF etiology, PN components, liver biochemistry tests, fatty acid profiles, growth parameters, micronutrient labs, abdominal ultrasound and liver histology).

Results: Sixteen eligible patients were included in this analysis (median age: 4 years, range: 4 months-10 years, 50% male). After switching to SMOFlipid, the mean fat component of PN increased (0.4 g/kg/day vs. 1 g/kg/day, P<0.001), glucose infusion rate (GIR) decreased (16.3 mg/kg/min vs. 11.4 mg/kg/min, P=0.01), serum α-tocopherol levels increased (6.8 mg/L vs. 9.2 mg/L, P=0.01), EFAD improved (mean triene:tetraene 0.07 vs. 0.04, P<0.001), and growth improved (mean BMI/Weight:Length Z-score 0.11 vs. 0.95, P=0.03). There was some improvement in liver biochemistry tests, despite increased lipid administration. Two patients had resolution of abnormal sonographic findings, and one patient had histologically-proven resolution of hepatic steatosis and fibrosis. The average cost was $2.70/day for IL and $14.40/day for SMOFlipid (P<0.001). SMOFlipid was not discontinued in any of the patients and no adverse effects were observed.

Conclusion: An increased dose of a balanced lipid emulsion was associated with improved EFAD, improved growth, decreased GIR and increased serum α-tocopherol levels, while not worsening IFALD. Although the daily cost of SMOFlipid is higher than IL, the benefits offered by its better anti-inflammatory profile may prove to outweigh the higher cost. Based on our single-center experience, we recommend the routine use of SMOFlipid in pediatric patients with IF to avoid the potentially harmful effects associated with IL and LM protocols.