Hepatic secretory obstruction with total parenteral nutrition in the infant.

Transient hepatic secretory obstruction manifested primarily by chemical evidence of cholestasis with a conjugated bilirubin above 2.0 mg/100 ml occurred in eight of 19 neonates and infants receiving total parenteral nutrition. The incidence of cholestasis was greater in the premature than full-term infant. Prospective determinations of conjugated bilirubin and 5' nucleotidase are essential to detecting cholestasis before jaundice becomes obvious. These tests are more sensitive than serum alkaline phosphatase which normally rises after birth and during periods of accelerated osteoblastic activity. Preliminary data indicate that the 5' nucleotidase is the most sensitive indicator of secretory obstruction and may become elevated in patients with a normal direct bilirubin. The etiology of hepatic cholestasis during total parenteral nutrition is unknown but is presumed to be caused by interference with hepatocellular enzymes controlling bile secretion; immaturity of these enzyme systems increases the risk of secretory obstruction.