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Response to Letter to the Editor from Kunal Gupta MBBS, MD: Is SMOF lipid emulsion better than soy-based lipid emulsion for low birth weight preterm neonates?

Journal of Perinatology volume 40, pages 544–545 (2020)Cite this article

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We thank Dr Gupta for his remarks on our recently published paper, “Multicomponent lipid emulsion (LE) vs soy-based LE for very low birth weight preterm neonates: a pre–post comparative study” [1]. We respond to Dr Gupta’s questions in an itemized fashion, below. However, the core theme of his questioning pertains to interpretations and conclusions drawn from a pre–post study and whether these may be rationalized as conclusive of efficacy. We wish to stress that we did not suggest in our manuscript the existence of cause and effect relationships. Rather, we strictly reported associations that are prone to residual confounding and would thus need a randomized trial to prove efficacy.

  1. (1)

    Enteral feeds, parenteral nutrition (PN)-induced cholestasis, and osteopenia: We agree it is possible that the reduced times to reach full enteral feeds and regain birth weight, reduced duration of PN, and reduced duration of intravenous LE with SMOF (soybean oil-medium chain triglycerides-olive oil-fish oil)–LE may be due to early initiation of enteral feeds. It was for this reason that we indicated we cannot claim these effects were due to the use of SMOF lipids. This same rationale applies to decreased odds of PN-induced cholestasis and osteopenia in the SMOF–LE group. In addition regarding cholestasis, we have not analyzed cholestasis only in neonates who received >4 weeks of PN, as the number of eligible neonates would be very small. We are presenting our study as a hypothesis-generating study that will need to be tested in a randomized controlled trial.

  2. (2)

    Lipid interruptions: Lipid interruptions were due to high serum triglyceride level. In our unit, we use serum triglyceride level for monitoring lipid tolerance. If the serum level is >1.2 gm/L, we stop lipids until the next day (16–18 h approximately). Unfortunately, we cannot report these data as we did not collect the full set of serum triglyceride levels.

  3. (3)

    Retinopathy of prematurity (ROP): Except for the cesarean section rate, baseline maternal and infant demographic and clinical characteristics were statistically similar in both study groups. Although the cesarean section rate was statistically significantly higher in the SMOF–LE vs the Intralipid group (P value 0.02), we do not think this is a risk factor for retinopathy. Previous studies have reported conflicting results for this association [2]. The rate of chronic lung disease also did not differ significantly between groups. Regarding erythropoietin and blood transfusions, we did not use erythropoietin in our study groups, and we did not account for blood transfusions because results from studies evaluating the presence or treatment of anemia as risk factors for ROP have been inconsistent [3]. In addition, blood transfusions were at the discretion of the attending neonatologists on service; however, in general our group follows restrictive transfusion policies.

Enteral feeds, parenteral nutrition (PN)-induced cholestasis, and osteopenia: We agree it is possible that the reduced times to reach full enteral feeds and regain birth weight, reduced duration of PN, and reduced duration of intravenous LE with SMOF (soybean oil-medium chain triglycerides-olive oil-fish oil)–LE may be due to early initiation of enteral feeds. It was for this reason that we indicated we cannot claim these effects were due to the use of SMOF lipids. This same rationale applies to decreased odds of PN-induced cholestasis and osteopenia in the SMOF–LE group. In addition regarding cholestasis, we have not analyzed cholestasis only in neonates who received >4 weeks of PN, as the number of eligible neonates would be very small. We are presenting our study as a hypothesis-generating study that will need to be tested in a randomized controlled trial.

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References

  1. Torgalkar R, Dave S, Shah J, Ostad N, Kotsopoulos K, Unger S, et al. Multi-component lipid emulsion vs soy-based lipid emulsion for very low birth weight preterm neonates: a pre-post comparative study. J Perinatol. 2019;39:1118–24.

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  2. Abdel HA, Mohamed GB, Othman MF. Retinopathy of prematurity: a study of incidence and risk factors in NICU of Al-Minya University Hospital in Egypt. J Clin Neonatol. 2012;1:76–81.

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  3. Kim SJ, Port AD, Swan R, Campbell JP, Chan RP, Chiang MF. Retinopathy of prematurity: a review of risk factors and their clinical significance. Surv Ophthalmol. 2018;63:618–637.

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Authors and Affiliations

  1. Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada

    Ranjit Torgalkar & Prakesh S. Shah

  2. Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada

    Prakesh S. Shah

  3. Department of Pediatrics, University of Toronto, Toronto, ON, Canada

    Prakesh S. Shah

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  1. Ranjit Torgalkar
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Correspondence to Prakesh S. Shah.

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Torgalkar, R., Shah, P.S. Response to Letter to the Editor from Kunal Gupta MBBS, MD: Is SMOF lipid emulsion better than soy-based lipid emulsion for low birth weight preterm neonates?. J Perinatol 40, 544–545 (2020). https://doi.org/10.1038/s41372-020-0591-7

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