Incidence and risk factors of parenteral nutrition‐associated cholestasis in surgical very low birth weight infants

Objectives Surgical intervention for necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP), and meconium‐related ileus (MRI) is frequently complicated by parenteral nutrition‐associated cholestasis (PNAC). This study aimed to determine the incidence and identify risk factors of PNAC in very low birth weight (VLBW) infants following gastrointestinal surgery. Methods We conducted a retrospective review of medical records for VLBW infants who underwent gastrointestinal surgery between January 2012 and December 2020. PNAC was defined as direct bilirubin ≥2.0 mg/dL persisting for two postoperative weeks while on PN. Results Among 61 VLBW patients who underwent surgery for NEC, SIP, or MRI, 30 (49%) developed PNAC. The median duration of PN until PNAC onset was 6 weeks, and 70% developed cholestasis within 8 weeks of PN initiation. Intestinal failure was present in 79% of the cohort and was significantly more frequent in infants with PNAC. Inability to achieve full enteral feeding within 6 weeks was independently associated with PNAC. Despite routine use of SMOFlipid, PNAC incidence remained substantial. Among infants with severe cholestasis (direct bilirubin ≥6 mg/dL), switching to fish oil monotherapy rarely resulted in reversal. Conclusion PNAC developed early and frequently in surgical VLBW infants despite SMOFlipid use and was strongly associated with intestinal failure and inability to achieve full enteral feeding. Early feeding progression appears to reflect overall disease severity and may represent an important clinical marker for PNAC risk.