Omegaven as Alternative Parenteral Fat Nutrition

An intermediate population, Investigational New Drug study, to provide an alternate
intravenous fat nutrition, Omegaven®, to help improve liver function while providing adequate
nutrition for critically ill infants with parenteral nutrition associated cholestasis

Inclusion Criteria:

- Greater than 14 days old

- Has parenteral nutrition associated cholestasis defined as at least 2 consecutive
direct bilirubin >2 mg/dL with anatomical or functional short gut (OR >4 mg/dL if
intact intestine) obtained at least 1 week apart with a ratio of direct: total
bilirubin > 0.4

- Patient is parenteral nutrition dependent (unable to meet nutritional needs solely by
enteral nutrition) and are expected to require parenteral nutrition for at least 3
more weeks

- Patient has not responded to other therapeutic approaches for parenteral
nutrition-associated liver disease such as : cycling of parenteral nutrition, avoiding
overfeeding, reduction/removal of copper and manganese from parenteral nutrition,
advancement of enteral feeding, and use of Ursodiol

- Patient has been on at least 2 weeks of SMOFLIPIDs with no improvement or worsening of
direct bilirubin levels

- Signed patient informed consent

- The patient is expected to have a reasonable possibility of survival

- No other known etiology of cholestasis other than parenteral nutrition-associated
liver disease at the time of Omegaven® initiation

Exclusion Criteria:

- Known causes of cholestasis other than parenteral nutrition-associated liver disease
including but not limited to Hepatitis C, Cystic fibrosis, biliary atresia, and alpha
1 antitrypsin deficiency are present, prior to Omegaven® initiation

- Known fish or egg allergy

- Any of the contraindications to use of Omegaven®:

1. Active new infection at the time of initiation of Omegaven®

2. Hemodynamic instability

3. Recent use of medications with associated risk of bleeding, including NSAIDs

4. Active coagulopathy or bleeding

5. Platelet counts persistently under 30,000 despite transfusions

6. Unstable hyperglycemia

7. Impaired lipid metabolism (triglycerides >1000 mg/dL) while on 1 g/kg/day or less
of Intralipid

8. History of severe hemorrhagic disorders (ie. hemophilia, Von Willebrand disease,
etc.)

9. Unstable diabetes mellitus

10. Collapse and shock

11. Stroke/ Embolism

12. Cardiac infarction within the last 3 months

13. Undefined coma status