Probiotics for the treatment of type 2 diabetes: A review of randomized controlled trials.

With the increasing prevalence of type 2 diabetes mellitus (T2DM), there is increased interest in probiotic supplementation for improving glycaemic control. This review evaluates nine randomized controlled trials that tested the effects of probiotics on glycaemic outcomes including fasting plasma glucose, fasting plasma insulin, haemoglobin A1c, and homeostatic model assessment of insulin resistance among adults with T2DM. Based on the evidence reviewed, multistrain probiotics that contain seven million to 100 billion colony forming units of Lactobacillus acidophilus, Streptococcus thermophilus, Lactobacillus bulgaricus, and/or Bifidobacterium lactis administered for 6 to 12 weeks may be efficacious for improving glycaemic control in adults with T2DM. Further research is needed to understand the role of the gut microbiota and the probiotic dose, medium, and duration of exposure that is most effective for disease management.

Body Composition in Adults With Intellectual Disabilities: Implications for Practice.

Health care professionals require increased knowledge of health and disabilities to effectively implement health promotion initiatives at both the individual and group level for adults with intellectual disabilities (ID). The aim of this review is to examine the feasibility, reliability, and validity of various field-based measurements to assess body composition among adults with ID as compared to nondisabled controls. The literature was systematically searched from 1990 to 2017 for primary articles pertaining to the subject matter that were published in the English language and included only individuals ≥18 years of age. 1,989 studies were screened and 8 studies were included for review. Several field-based measurements for body composition are feasible and reliable yet none have been validated for use in adults with ID. Awareness of the various methods for assessing body composition in adults with ID in clinical practice, while simultaneously understanding their limitations, is necessary.

Fistuloclysis: An Interprofessional Approach to Nourishing the Fistula Patient.

BACKGROUND: Enteric fistulas can be classified as enterocutaneous and/or enteroatmospheric. Both are devastating complications of bowel disease, abdominal surgery, and/or open abdomen. Enteric fistulas are associated with a mortality rate varying from 1% to 33%; the main cause of death is sepsis. Coordinated and skillful efforts of an interprofessional team are required in customizing successful treatment regimens appropriate to each patient's unique clinical scenario. CASE STUDY: A 65-year-old white woman experienced an enteroatmospheric fistula patient after ventral hernia repair. Care of this patient was based on the complementary relationship between professionals from 2 disciplines: the wound and ostomy continence nurse (WOC nurse) and the nutrition support registered dietitian/nutritionist. Working together, they developed a comprehensive wound, ostomy, and nutritional plan. Initially, the patient received parenteral nutrition exclusively. After the fistula tract was clearly defined, a feeding tube was placed into the distal limb of the fistula, and she received nourishment via a fistuloclysis (ie, enteral feedings administered via the fistula). A special wound management system was created to contain fistula output while allowing feeding through the distal limb of the fistula. CONCLUSION: Enterocutaneous and enteroatmospheric fistulas originating from the small bowel present a management challenge to the entire healthcare team. WOC nurses are often called upon to meet the challenge of maintaining skin health while promoting dignity and function. Nutrition support via registered dietitian/nutritionists play a critical role in managing the nutrition regimen for these patients. In this case, the use of fistuloclysis met the patient's nutritional needs while avoiding the risks associated with parenteral nutrition.

Impact of standardized feeding guidelines on enteral nutrition administration, growth outcomes, metabolic bone disease, and cholestasis in the NICU.

OBJECTIVES: The objectives of this study were to determine whether the implementation of standardized feeding guidelines (SFGs) in a neonatal intensive care unit had an impact on the administration of enteral nutrition, growth, and bone and liver health. METHODS: This was a retrospective chart review of infants ≤ 32 weeks' gestation and ≤ 1500 g at birth who received enteral nutrition either via traditional care (TC) or via SFGs. The outcomes of the study were to determine the day of life the first enteral feedings were started, the day of life full, fortified enteral feedings were established, the day of life the infant returned to birth weight, the change in weight z score from birth to day of life 30, and the presence of metabolic bone disease and cholestasis. RESULTS: There were 128 infants in the TC group and 125 infants in the SFG group. Based on the Cox regression, no significant differences were found between the 2 groups in the length of time to the first feed (P=0.110; CI 1.03-1.70), in the length of time to full, fortified enteral feedings (P=0.334; CI 0.87-1.44), in the length of time to return to birth weight (P=0.545; CI 0.77-1.28), incidence of metabolic bone disease (P=0.990), or incidence of cholestasis (P=0.926). CONCLUSIONS: This study provides preliminary evidence that SFGs have an effect on enteral nutrition administration, growth, and morbidity for preterm infants. Although the findings were not statistically significant, they are clinically relevant.

Severe vitamin C deficiency associated with continuous renal replacement therapy: A case report.

Hypovitaminosis C is prevalent in critically ill patients. Continuous renal replacement therapy (CRRT) clears vitamin C, increasing the risk for vitamin C deficiency. However, recommendations for vitamin C supplementation in critically ill patients receiving CRRT vary widely, from 250 mg/day to 12 g/day. This case report describes a patient who developed a severe vitamin C deficiency after prolonged CRRT despite receiving ascorbic acid (450 mg/day) supplementation in her parenteral nutrition. This report summarizes recent research investigating vitamin C status in critically ill patients receiving CRRT, discusses the patient case, and provides recommendations for clinical practice. In critically ill patients receiving CRRT, the authors of this manuscript suggest providing at least 1000 mg/day of ascorbic acid to prevent vitamin C deficiency. Baseline vitamin C levels should be checked in patients who are malnourished and/or have other risk factors for vitamin C deficiency, and vitamin C levels should be monitored thereafter every 1-2 weeks.

Variation in metabolic demand following severe pediatric traumatic brain injury: A case review.

A traumatic brain injury (TBI) is one of the most common pediatric traumas among children in the United States. Appropriate nutrition support, including the initiation of early enteral nutrition, within the first 48 h after injury is crucial for children with a TBI. It is important that clinicians avoid both underfeeding and overfeeding, as both can lead to poor outcomes. However, the variable metabolic response to a TBI can make determining appropriate nutrition support difficult. Because of the dynamic metabolic demand, indirect calorimetry (IC) is recommended, instead of predictive equations, to measure energy requirements. Although IC is suggested and ideal, few hospitals have the technology available. This case review discusses the variable metabolic response, identified using IC, in a child with a severe TBI. The case report highlights the ability of the team to meet measured energy requirements early, even in the setting of fluid overload. It also highlights the presumed positive impact of early and appropriate nutrition provision on the patient's clinical and functional recovery. Further research is needed to investigate the metabolic response to TBIs in children and the impact optimal feedings based on the measured resting energy expenditure have on clinical, functional, and rehabilitation outcomes.

Association between underweight status or low body mass index and the risk of developing superior mesenteric artery syndrome following scoliosis corrective surgery in pediatric patients: a review of the literature.

Superior mesenteric artery (SMA) syndrome is the compression of the third portion of the duodenum between the abdominal aorta and the superior mesenteric artery. Although multifactorial, the most frequent cause of SMA syndrome is significant weight loss and cachexia often induced by catabolic stress. SMA syndrome resulting from scoliosis surgery is caused by a reduction of the aortomesenteric angle and distance. Risk factors include rapid weight loss, malnutrition, and a rapid reduction in the mesenteric fat pad and are the most common causes of a decrease in the aortomesenteric angle and distance. Surgically lengthening the vertebral column can also lead to a reduction of the aortomesenteric distance, therefore, has been identified as a risk factor unique to spinal surgery. Despite a reported decline in SMA syndrome cases due to improved surgical techniques, duodenal compression is still a risk and remains a life-threatening complication of scoliosis surgery. This article is a cumulative review of the evidence of being underweight or having a low body mass index as risk factors for developing SMA syndrome following surgical scoliosis instrumentation and correction.

Development of a bronchopulmonary dysplasia nutrition focused physical examination tool: A modified Delphi study.

OBJECTIVE: The objectives of this study were to identify factors impacting nutrition needs in infants and children with bronchopulmonary dysplasia (BPD). A modified Delphi approach to obtain consensus among pediatric registered dietitian nutritionists (RDNs) was used to create a BPD-specific nutrition focused physical examination (NFPE) tool. STUDY DESIGN: RDNs, recruited through pediatric nutrition professional associations, completed a survey rating proposed NFPE components on a Likert scale of 1-5 allowing open-ended responses in a two-round Delphi. Responses were analyzed, deidentified, and results were returned to panelists for in-round feedback. Consensus was defined a priori as 75% agreement for usefulness or relevance ± 1 standard deviation. RESULTS: Six domains (anthropometrics, body composition, development, gastrointestinal, respiratory, and physical signs) and 38 components achieved consensus. CONCLUSION: Components for an evidence-based tool to enhance nutrition assessment in infants and children with BPD were identified with consensus agreement by an expert panel of 19 pediatric RDNs.

A review of the efficacy of appetite stimulating medications in hospitalized adults.

BACKGROUND: The majority of evidence on efficacy of appetite-stimulating medications is limited to specific populations and the outpatient treatment setting. However, hospitalized adults remain at risk for poor appetite and inadequate intake. METHOD: The purpose of this review was to assess recent evidence on the efficacy of dronabinol, megestrol acetate, and mirtazapine (used to stimulate appetite) on promoting change in intake; somatic symptoms, such as appetite and nausea; and weight change during hospital stay. The population was limited to hospitalized adults or adults who demonstrated a need for appetite stimulation during hospitalization. RESULTS: Of the 382 articles screened, four met inclusion criteria (one randomized control trial, two retrospective cohort studies, and one retrospective case series). Based on the studies included, these appetite stimulants have limited efficacy on improving appetite and meal intake. There was no significant change in weight. CONCLUSION: Current data lack standardization, generalizability, and comparability, and higher quality evidence is needed before conclusions can be identified on the efficacy of dronabinol, megestrol acetate, and mirtazapine in the inpatient setting.

Nutritional Supplement Use and Athletic Characteristics among a Sample of NCAA Division I and Division III Student-Athletes.

Due to documented adverse events, understanding the prevalence of nutritional supplements commonly used by athletes is essential. This cross-sectional study used data from a web-based survey conducted in February-March 2022. Participants were Division I (DI) and Division III (DIII) student-athletes of the National Collegiate Athletic Association (NCAA). Chi-square tests were conducted to identify the differences in the prevalence of demographic and athletic characteristics between the divisions. Multivariable odds ratios and 95% confidence intervals were calculated using logistic regression adjusting for potential confounders to determine the predictors of supplement usage. A total of 247 NCAA student-athletes (72.5% Division I, 27.5% Division III) completed the survey, yielding a 24.5% response rate. There were no significant differences between nutritional supplementation and NCAA divisions. Instead, all student-athletes used supplements regardless of division. There were significant differences in race, ethnicity, sports dietitian access, name, image, and likeness (NIL), advisement to consume NS, and knowledge of NS between the divisions (all P-values < 0.01). Unadjusted regression models showed that being in an upper-level academic standing was associated with higher odds of using sports food and ergogenic supplements than student-athletes with a lower-level academic standing. However, multivariable logistic regression analysis revealed that none of the demographic and athletic characteristics significantly affected supplement usage. Allocating resources for access to sports dietitians and supplement education for all divisions may benefit student-athletes knowledge and safety.

Energy requirements for critically ill patients with COVID-19.

Early reports suggested that predictive equations significantly underestimate the energy requirements of critically ill patients with coronavirus disease 2019 (COVID-19) based on the results of indirect calorimetry (IC) measurements. IC is the gold standard for measuring energy expenditure in critically ill patients. However, IC is not available in many institutions. If predictive equations significantly underestimate energy requirements in severe COVID-19, this increases the risk of underfeeding and malnutrition, which is associated with poorer clinical outcomes. As such, the purpose of this narrative review is to summarize and synthesize evidence comparing measured resting energy expenditure via IC with predicted resting energy expenditure determined via commonly used predictive equations in adult critically ill patients with COVID-19. Five articles met the inclusion criteria for this review. Their results suggest that many critically ill patients with COVID-19 are in a hypermetabolic state, which is underestimated by commonly used predictive equations in the intensive care unit (ICU) setting. In nonobese patients, energy expenditure appears to progressively increase over the course of ICU admission, peaking at week 3. The metabolic response pattern in patients with obesity is unclear because of conflicting findings. Based on limited evidence published thus far, the most accurate predictive equations appear to be the Penn State equations; however, they still had poor individual accuracy overall, which increases the risk of underfeeding or overfeeding and, as such, renders the equations an unsuitable alternative to IC.

Timing of oral intake after esophagectomy: A narrative review of the literature and case report.

Esophagectomy, a treatment modality for esophageal cancer, is associated with high rates of morbidity, the most common being anastomotic leaks and pulmonary complications. The current standard of care for nutrition support after esophagectomy includes a period of nothing by mouth with enteral nutrition support via jejunostomy tube owing to the concern of increasing the risk of anastomotic leak as a result of early postoperative oral intake. However, the optimal timing of oral diet initiation remains controversial. This narrative review presents a patient who incurred an anastomotic leak following esophagectomy after initiation of oral intake on postoperative day 5 and evaluates the current literature on the timing of oral diet initiation after esophagectomy. A systematic literature search was performed to assess current evidence evaluating early oral diet (EOD) initiation after esophagectomy. Over the past 5 years, 11 studies have evaluated the impact of EOD initiation after esophagectomy in comparison with a conventional feeding regimen, including a period of nothing by mouth with enteral or parenteral nutrition support. The available evidence suggests that EOD initiation does not increase rates of complications after esophagectomy. However, the evidence is limited by the lack of a standardized definition of what constitutes EOD initiation, patient selection bias, variations in nutrition support provided in the studies, and lack of statistical analyses evaluating the impact of potential confounding variables. Additional research with larger, high-quality randomized controlled trials is needed to determine the optimal timing of diet initiation after esophagectomy.

Family Systems Cultural and Resilience Dimensions to Consider in Nutrition Interventions: Exploring Preschoolers' Eating and Physical Activity Routines During COVID-19.

OBJECTIVE: To describe the weight-related family functioning of racial minority families with low income using family systems theory as an interpretive framework. DESIGN: Primarily a qualitative study with interviews plus; descriptive demographics, anthropometrics, a family functioning measure, and food insecurity screening. SETTING: Telephone interviews with families of preschool-aged children in an urban setting. PARTICIPANTS: Primary caregivers of preschool-aged children. PHENOMENON OF INTEREST: Cultural impacts on family systems. ANALYSIS: Interviews were audio-recorded, transcribed verbatim, and loaded into NVivo 12 for thematic analysis. Descriptive statistics. RESULTS: The 23 participants were mothers and 2 maternal grandmothers. Seventy-four percent were African American, most children were normal weight (n = 15, 65%), mean family function scores were high, and more than half the families were at risk for food insecurity (n = 13, 56%). Acculturation and intergenerational eating-related cultural dimensions were discerned as the overarching themes influencing family cohesion. Family cohesion appeared to have helped the families adapt to the impact of coronavirus disease 2019. CONCLUSIONS AND IMPLICATIONS: Cultural dimensions such as acculturation and intergenerational influences appeared to be associated with social cohesion and family functioning around weight-related behaviors for these families. These findings add cultural and family resilience dimensions to family systems theory in nutrition interventions.

Anthropometric Outcomes of Children and Adolescents Using Telehealth with Weight Management Interventions Compared to Usual Care: A Systematic Review and Meta-analysis.

Objective:This systematic review and meta-analysis evaluated the effect of telehealth (TH) weight management interventions compared to usual care on anthropometric outcomes in children and adolescents with overweight and obesity.Methods: Comprehensive searches were conducted identifying randomized controlled trials (RCTs) published between January 1, 2005 and June 1, 2019. Studies using a web-based, smartphone or email TH intervention in children between 2-18 years of age were included. Outcome measures of interest included body mass index (BMI) z-score, BMI percentile, waist circumference (WC) and waist-to-hip-ratio (WHR). The Grade Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to rate strength of evidence (SOE) and a random-effects meta-analysis was performed when five or more RCTs reported the same outcome.Results: Thirteen RCTs met the inclusion criteria for the systematic review. Random effects meta-analysis of 10 RCTs detected a small effect for TH interventions compared to usual care in reducing BMI z-score (pooled net change in BMI z-score = -0.04; 95% CI -0.07, 0.00: I2 = 12%). No significant differences were found between groups for other outcomes. Strength of evidence ratings were low or very low in part due to concerns with heterogeneity in study designs, intervention durations, ages of participants, the type of TH used and risk of bias (ROB) of included studies.Conclusions: There is a low strength of evidence that TH had a small effect on anthropometric outcomes compared to usual care. Future RCTs should be well designed to minimize clinical heterogeneity and ROB. Studies of longer intervention duration with adequate, statistically powered analyses should be conducted.Key teaching pointsStudies using TH with pediatric weight management interventions may be effective to improve health of children with overweight and obesity.Future RCTs should consider clinical heterogeneity of study design for setting, age-group of children, preferences for type of TH and ROB.Studies that include children with severe obesity (<95th%) may need more sensitive outcome measures.Studies of longer duration are needed to better understand long-term weight management success.

Cannabinoid use for appetite stimulation and weight gain in cancer care: Does recent evidence support an update of the European Society for Clinical Nutrition and Metabolism clinical guidelines?

Cannabinoids have been used medicinally for thousands of years. Clinical trials support their use for treatment of chemotherapy-induced nausea and vomiting and HIV- and AIDS-related anorexia. Cancer anorexia cachexia syndrome (CACS) is a common debilitating condition and is associated with poor prognosis. The 2016 European Society for Parenteral and Enteral Nutrition clinical guidelines on nutrition in cancer patients concluded that "there are insufficient consistent clinical data to recommend cannabinoids to improve taste disorders or anorexia in cancer patients." The increased attention that cannabinoids have received in recent years warrants an updated evaluation of the literature on this topic, as practitioners are likely to encounter cancer patients interested in cannabinoid use. A systematic literature search was performed to assess the current body of evidence concerning cannabinoid use for the stimulation of appetite and oral intake by cancer patients. Over the past 20 years, 6 randomized controlled trials have evaluated the impact of cannabinoids on appetite-related outcomes in oncology patients in comparison with a control group or placebo. Based on this literature, cannabinoids do not appear to improve appetite, oral intake, weight, chemosensory function, or appetite-related quality of life. Limitations of the literature include small sample sizes, lack of adjustment for confounding variables, and difficulties conducting true placebo-controlled trials with a drug that may result in psychoactive side effects. Further exploration of the impact of cannabinoid use on CACS by using large, well-designed clinical trials is needed.

The associations between pediatric weight status and cystic fibrosis-related diabetes status and health-related quality of life among children and young adults with cystic fibrosis: A systematic review.

BACKGROUND: Cystic fibrosis (CF) is a life-shortening genetic disease, yet life expectancy has recently increased, shifting the focus to disease management and health-related quality of life (HRQoL). Identification of clinical factors, such as weight status and CF-related diabetes (CFRD), that are associated with HRQoL can inform clinicians about the patient's health perception. The goal of this systematic review was two prong: identify the association of pediatric weight status and HRQoL and determine how CFRD status impacts HRQoL. METHODS: A systematic review of published research was conducted following the methodology in the Cochrane Handbook on Systematic Reviews for Interventional Studies. Results were reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses. Risk of bias was assessed using the National Heart Lung & Blood Institute tool. A meta-analysis was not performed due to variability of the inclusion/exclusion criteria, differences in outcome reporting, and insufficient primary outcome data to pool. RESULTS: Nine studies met inclusion criteria (n = 6 explored weight status and n = 3 studied CFRD), for a total of 1585 subjects (CFRD cases = 87). Pediatric weight status was positively associated with HRQoL, most commonly the Body Image and Eating Disturbance domains. CFRD was negatively associated with HRQoL, specifically the Treatment Burden and Weight domains. CONCLUSIONS: Based on the limited data available, improved pediatric weight status appears to increase HRQoL while a CFRD diagnosis appears to decrease HRQoL. More research is needed to fully understand the role of these clinical factors on HRQoL, especially with life expectancy increasing among those with CF.

Weight Gain and Growth After Fundoplication in the Pediatric Patient: A Case Report in the Pediatric Patient With Cystic Fibrosis and Literature Review.

Gastroesophageal reflux (GER) is common among infants, but when symptoms become troublesome, that is defined as gastroesophageal reflux disease (GERD). Making a diagnosis of GERD is difficult because there is no gold standard. GERD can be especially problematic for infants with cystic fibrosis (CF). There are signs and symptoms (ie, malnutrition, recurring aspiration pneumonias, refusal to eat, wheezing, coughing, and asthma) in addition to invasive and noninvasive methods used to determine a diagnosis. The treatments for GERD span from nonpharmacological to surgical, with a laparoscopic Nissen fundoplication being the gold standard of surgical intervention. Although surgical interventions have been demonstrated to reduce symptoms associated with GERD, there is little known about the weight/growth-related outcomes. This case report discusses an infant with CF and GERD requiring multiple interventions and ultimately a laparoscopic Nissen fundoplication and the weight changes from presurgery to postsurgery. The case report is expanded upon with a structured literature review of fundoplication and growth studies. There were 4 available studies that assessed changes in weight/growth before and after fundoplication among children with GERD. Because of the heterogeneity of the nutrition outcomes used, the weight/growth benefits after fundoplication are unclear at this time. Further research in needed to assess the nutrition outcomes among patients with GERD requiring fundoplication.

Elimination of Fermentable Carbohydrates to Reduce Gastrointestinal Symptoms in Pediatric Patients With Irritable Bowel Syndrome: A Narrative Review.

Irritable bowel syndrome (IBS) is classified as a functional gastrointestinal (GI) disorder characterized by abdominal pain, bloating, and changes in bowel function. Although the pathophysiology of IBS is incompletely understood, fermentable carbohydrates are implicated as a potential cause of symptoms. An elimination diet, such as a low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet, represents a potential intervention for reducing GI symptoms in patients with IBS. The role of fermentable carbohydrates in symptom onset is well studied in adult patients with IBS; however, less research exists in the pediatric population. This review sought to explore evidence for the role of dietary fermentable carbohydrate elimination to reduce GI symptoms (abdominal pain, stool changes, abdominal bloating) in children and adolescents (4-19 years of age) diagnosed with IBS based on Rome III or IV criteria. Five studies of neutral to positive quality rating were identified and analyzed using the Academy of Nutrition and Dietetics Evidence Analysis Process. These studies demonstrate that dietary elimination of fermentable carbohydrates, such as through a low-FODMAP diet, reduces the severity of 1 or more GI symptoms in about one-quarter to one-half of pediatric patients with IBS. Patients without improvement are considered "nonresponders" and may require an alternative intervention. More research is needed to establish the best way to identify patients who would respond to elimination diets vs other IBS treatment strategies.

Nutrition Assessment and Intervention in a Pediatric Patient with Angelman Syndrome: A Case Presentation Highlighting Clinical Challenges and Evidence-Based Solutions.

BACKGROUND: Angelman syndrome (AS) is a rare disorder of genetic imprinting which results in intellectual and developmental disability. It meets criteria of a disorder of neurologic impairment. A deletion in the long arm of chromosome 15 (del 15q11.2-q13) is responsible for about 70% of cases of AS (deletion genotype). SUMMARY: There is a paucity of evidence to allow algorithmic nutrition assessment and intervention in pediatric patients with AS. Therefore, our objective is to use a case presentation to provide an example of nutrition assessment and intervention in a pediatric patient with the deletion genotype of AS and then highlight common challenges to providing evidenced-based nutrition care. For the highlighted challenges, we suggest evidence-based solutions to provide a resource for clinicians who may encounter similar challenges in clinical practice. Key Messages: There are genotype-phenotype correlations in AS that can help guide clinicians regarding nutritionally relevant clinical characteristics and corresponding interventions that are patient specific. The deletion genotype in AS is associated with multiple characteristics that are relevant to nutrition care and may also be different and/or more severe than characteristics seen in other AS genetic mechanisms. There is also overlap in certain nutritionally relevant clinical characteristics between AS and other conditions, including Prader-Willi syndrome, autism spectrum disorders, and disorders of neurological impairment like cerebral palsy. Clinicians can utilize nutrition resources related to these conditions to expand the scope of relevant resources available.

Case Report: Transitioning to a Mixed-Oil Intravenous Lipid Emulsion in an Adult Patient Receiving Home Parenteral Nutrition.

A potential risk of long-term parenteral nutrition (PN) is intestinal failure-associated liver disease (IFALD). One recommendation for mitigating risk is limiting the fat dose to reduce the harmful effects of the ω-6 fatty acids, which are the main ingredient in traditional fats. SMOFlipid (SMOF) (Kabi-Fresenius, Bad Homburg, Germany) is a combination of soybean oil, medium-chain triglycerides, olive oil, and fish oil emulsion. This fat source may alleviate the risk of IFALD and improve liver function tests. A patient with a long history of PN reliance and IFALD is presented in this case report. After 4 months on SMOF, total and direct bilirubin levels improved.