In a previous post, we discussed Total Parenteral Nutrition (TPN) and its indication in the NICU. Here, we will talk about one of TPN’s key ingredients—Lipids—and the most commonly used form—SMOFLipid!
To review, TPN is indicated in neonates when oral or enteral nutrition is not possible, insufficient, or contraindicated. TPN is made of Parenteral Nutrition (PN) + Lipids.
A novel lipid emulsion called SMOFlipid is widely used in the NICU setting. Why? Because it provides an excellent source of essential fatty acids, energy, monounsaturated fatty acids, and omega-3 fatty acids. It is also supplemented with antioxidant α-tocopherol and has a lower, more optimal omega-6:omega-3 ratio. In other words, it is GREAT for your baby!
SMOFlipid is a mixture composed of:
Soybean Oil (SO)—30%
Medium-Chain Triglycerides (MCTs)—30%
From coconut oil or palm kernel oil
Olive Oil (OO)—25
Fish Oil (FO)—15%
Why are these ingredients beneficial?
SO is high in polyunsaturated fatty acids like omega-3s and omega-6s. It's a high source of linoleic acid and α-linolenic acid, as well as bioactive EPA and DHA. During the 3rd trimester of pregnancy is when most of DHA is accumulated, meaning that premature infants are born with a DHA deficit. SO also serves as an excellent anti-inflammatory agent.
MCTs do not accumulate in the liver or adipose tissue and are eliminated quickly from the bloodstream. In addition, they do not impair hepatic function.
OO is high in monounsaturated fatty acids. It is more resistant to oxidative stress from free radicals and is a great source of vitamin E, which is important to prevent cell damage by lipid peroxidation.
FO is rich in α-tocopherol, which helps to prevent the oxidation of fatty acids.
What are the advantages of SMOFlipids?
Rapid clearance from the body
Reduction of the risk of cholestasis
Reduced oxidative stress
Reducesd direct bilirubin
Decreased liver damage
Reduced lipid peroxidation
Provision of essential long-chain polyunsaturated fatty acids (PUFAs) → These are critical in neonatal neurodevelopment and vision!
Increased immune system
Reduced inflammation
May prevent bronchopulmonary dysplasia (BPD)
Administration Instructions
SMOFlipid can be used for central lines or peripheral IVs, depending on the osmolarity of the solution. A higher concentration requires central access. It is important to use a 1.2 micron in-line filter in order to prevent air embolism. Also, a dedicated line for PN must be used, as PN is incompatible with SMOFlipid. The two fluids can and should be infused concurrently into the same vein via a Y-connector located near the infusion site.
NICU nurses, anything that I’m forgetting from the list? Does your NICU use SMOFlipid, too?