Fish oil emulsion for reversal of intestinal failure-associated liver disease in preterm infants: Three case reports and review of literature

BACKGROUND Prolonged parenteral nutrition (PN) is a major risk factor for intestinal failure-associated liver disease (IFALD), particularly in preterm infants. Plant-derived lipid emulsions, rich in phytosterols and ω-6 fatty acids, are considered key contributors. Fish oil lipid emulsions (FO-ILE) have emerged as a potential therapeutic alternative; however, the optimal dose for balancing efficacy and safety remains uncertain. CASE SUMMARY We report three preterm infants (gestational age, 31-36+2 weeks) with severe IFALD who were transitioned from soybean oil-based or multi-oil emulsions to FO-ILE. Fish oil was administered at a dose of 2 g/kg/day, a dosing approach for which limited data are available in this population. Prior to the transition, peak direct bilirubin (DB) levels ranged from 191.9 μmol/L to 356 μmol/L, with one patient exhibiting severe cholestasis and marked hepatosplenomegaly. Following 29-63 days of treatment, DB levels decreased to 30.7-89.9 μmol/L, resulting in a faster DB decline than that observed with the conventional 1 g/kg/day dosage. Full enteral feeding was achieved after 69-105 days of PN. The regimen was well tolerated, with no evidence of essential fatty acid deficiency, growth impairment, or bleeding complications. CONCLUSION FO-ILE up to 2 g/kg/day was well tolerated and improved liver function, which supports further investigation in PN-dependent infants.