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[Lillian Parker]

Despite a lack of evidence support omitting or reducing trace element in PNALD

· Check serum Copper levels prior to reducing or omitting trace elements dose to avoid producing a Copper deficiency, even if the direct serum bilirubin level is ≥2.0 mg/dL.

· Maintain an initial dose of 20 mcg/kg/d of copper in PN despite the development of cholestasis (majority of the pediatric trace element available in market contain 20 mcg/ml dose is 1 ml/kg), with monitoring of serum Copper levels .

· Manganese deficiency has not been reported; it may be relatively safe to discontinue Manganese in PN for a short period of time when cholestasis develops, despite a lack of evidence support for this practice.

· Obtain serum Copper and whole-blood Manganese levels at regular intervals (following 2 weeks of PN and monthly thereafter), regardless of bilirubin levels. This practice should decrease a patient’s chance of developing a Copper deficiency or Manganese toxicity while providing more appropriate, individualized parenteral doses.

· Since there is no sufficient data on the proper dose adjustment of trace elements, to decide whether to reduce or omit trace elements is a patient specific. If short PN expected then checking level will increase cost and with no major benefits. Therefore, majority of practitioner will reduce or omit trace elements.