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Elsayed Ramadan OM, Alruwaili MM, Alruwaili AN, Elsharkawy NB, Abdelaziz EM, Zaky ME, Shaban MM, Shaban M. Nursing practice of routine gastric aspiration in preterm infants and its link to necrotizing enterocolitis: is the practice still clinically relevant? BMC Nurs 2024; 23:333. [PMID: 38760751 PMCID: PMC11100149 DOI: 10.1186/s12912-024-01994-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024] Open
Abstract
The practice of routine gastric residual aspiration in preterm infants remains controversial, with conflicting evidence regarding its impact on necrotizing enterocolitis (NEC). As front-line caregivers, nurses play a vital role in gastric aspiration procedures and must be informed by evidence. This quasi-experimental nursing study aimed to assess whether gastric aspiration is clinically relevant in reducing the risk of NEC in preterm infants.A total of 250 preterm infants from two NICUs in Egypt were allocated to the gastric aspiration (n = 125) and non-aspiration (n = 125) groups. Feeding practices, gastric residuals, and incidence/severity of NEC were compared between groups according to modified Bell's criteria. Risk factors were analyzed using multivariate regression. There were no significant baseline differences between the groups. The gastric residual attributes and feeding outcomes did not differ substantially from aspiration. The overall incidence of NEC was 14-15%, with no significant differences in the odds of onset or progression of NEC by stage between the groups. Lower gestational age and birth weight emerged as stronger predictors of NEC. Routine gastric aspiration does not appear to directly prevent or reduce the severity of NEC in this population. Although gastric residuals retain clinical importance, study findings question assumptions that aspiration protects against NEC and informs nursing practice. Evidence-based feeding protocols must continually evolve through ongoing research on modifiable risk factors for this devastating intestinal disease in preterm infants.
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Affiliation(s)
| | | | | | - Nadia Bassuoni Elsharkawy
- College of Nursing, Jouf University, Sakaka, Saudi Arabia, 72388
- Maternal and Newborn Health Nursing Department, Faculty of Nursing, Cairo University, Cairo, Egypt
| | - Enas Mahrous Abdelaziz
- College of Nursing, Jouf University, Sakaka, Saudi Arabia, 72388
- Psychiatric Mental Health Nursing Department, Faculty of Nursing, Cairo University, Cairo, Egypt
| | - Mohammed Elsayed Zaky
- College of Nursing, Jouf University, Sakaka, Saudi Arabia, 72388
- Medical Surgical Nursing Department, Faculty of Nursing, Cairo University, Cairo, Egypt
| | - Marwa Mamdouh Shaban
- Lecturer of Community Health Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt
| | - Mostafa Shaban
- College of Nursing, Jouf University, Sakaka, Saudi Arabia, 72388
- Geriatric Nursing Department, Faculty of Nursing, Cairo University, Cairo, Egypt
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Roberts AG, Younge N, Greenberg RG. Neonatal Necrotizing Enterocolitis: An Update on Pathophysiology, Treatment, and Prevention. Paediatr Drugs 2024; 26:259-275. [PMID: 38564081 DOI: 10.1007/s40272-024-00626-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
Necrotizing enterocolitis (NEC) is a life-threatening disease predominantly affecting premature and very low birth weight infants resulting in inflammation and necrosis of the small bowel and colon and potentially leading to sepsis, peritonitis, perforation, and death. Numerous research efforts have been made to better understand, treat, and prevent NEC. This review explores a variety of factors involved in the pathogenesis of NEC (prematurity, low birth weight, lack of human breast milk exposure, alterations to the microbiota, maternal and environmental factors, and intestinal ischemia) and reports treatment modalities surrounding NEC, including pain medications and common antibiotic combinations, the rationale for these combinations, and recent antibiotic stewardship approaches surrounding NEC treatment. This review also highlights the effect of early antibiotic exposure, infections, proton pump inhibitors (PPIs), and H2 receptor antagonists on the microbiota and how these risk factors can increase the chances of NEC. Finally, modern prevention strategies including the use of human breast milk and standardized feeding regimens are discussed, as well as promising new preventative and treatment options for NEC including probiotics and stem cell therapy.
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Morris M, Bennett S, Drake L, Hetherton MC, Clifton-Koeppel R, Schroeder H, Breault C, Larson K. Multidisciplinary evidence-based tools for improving consistency of care and neonatal nutrition. J Perinatol 2024; 44:751-759. [PMID: 38615125 DOI: 10.1038/s41372-024-01963-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Extrauterine growth restriction from inadequate nutrition remains a significant morbidity in very low birth weight infants. Participants in the California Perinatal Quality Care Collaborative Quality Improvement Collaborative, Grow, Babies, Grow! developed or refined tools to improve nutrition and reduce practice variation. METHOD Five Neonatal Intensive Care Units describe the development and implementation of nutrition tools. Tools include Parenteral Nutrition Guidelines, Automated Feeding Protocol, electronic medical record Order Set, Nutrition Time-Out Rounding Tool, and a Discharge Nutrition Recommendations. 15 of 22 participant sites completed a survey regarding tool value and implementation. RESULTS Reduced growth failure at discharge was observed in four of five NICUs, 11-32% improvement. Tools assisted with earlier TPN initiation (8 h) and reaching full feeds (2-5 days). TPN support decreased by 5 days. 80% of survey respondents rated the tools as valuable. CONCLUSION Evidence and consensus-based nutrition tools help promote standardization, leading to improved and sustainable outcomes.
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Affiliation(s)
- Mindy Morris
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA.
| | | | - Liz Drake
- Children's Hospital Orange County Mission Hospital, Mission Viejo, CA, USA
| | | | | | - Holly Schroeder
- Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Courtney Breault
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Dimmer A, Baird R, Puligandla P. Role of practice standardization in outcome optimization for CDH. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000783. [PMID: 38532942 PMCID: PMC10961560 DOI: 10.1136/wjps-2024-000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/28/2024] [Indexed: 03/28/2024] Open
Abstract
Standardization of care seeks to improve patient outcomes and healthcare delivery by reducing unwanted variations in care as well as promoting the efficient and effective use of healthcare resources. There are many types of standardization, with clinical practice guidelines (CPGs), based on a stringent assessment of evidence and expert consensus, being the hallmark of high-quality care. This article outlines the history of CPGs, their benefits and shortcomings, with a specific focus on standardization efforts as it relates to congenital diaphragmatic hernia management.
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Affiliation(s)
- Alexandra Dimmer
- Harvey E. Beardmore Division of Pediatric Surgery, Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Robert Baird
- Division of Pediatric General and Thoracic Surgery, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Pramod Puligandla
- Harvey E. Beardmore Department of Pediatric Surgery, McGill University, Montreal, Quebec, Canada
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Stanikova A, Jouza M, Bohosova J, Slaby O, Jabandziev P. Role of the microbiome in pathophysiology of necrotising enterocolitis in preterm neonates. BMJ Paediatr Open 2023; 7:e002172. [PMID: 37918941 PMCID: PMC10626796 DOI: 10.1136/bmjpo-2023-002172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/26/2023] [Indexed: 11/04/2023] Open
Abstract
Although necrotising enterocolitis (NEC) is a serious, life-threatening disease, improved neonatal care is increasing the number of survivors with NEC among extremely preterm neonates. Therapy is nevertheless mostly symptomatic and the mortality rate remains high, especially among neonates requiring surgery. Therefore, it is important to focus on preventing the disease and modifiable risk factors. NEC's pathophysiology is multifaceted, with key factors being immaturity of the immune and barrier protective mechanisms of the premature gut and exaggerated proinflammatory reaction to insults like gut hypoxia, enteral nutrition or microbial dysbiosis. The role of the intestinal microbiome in the pathophysiology of NEC has been a subject of research for many years, but to date no specific pathogen or type of dysbiosis has been connected with NEC development. This review assesses current knowledge as to the role of the intestinal microbiota in the pathophysiology of NEC and the possibilities for positively influencing it.
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Affiliation(s)
- Andrea Stanikova
- Department of Neonatology, University Hospital Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Jouza
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Pediatrics, University Hospital Brno, Brno, Czech Republic
| | - Julia Bohosova
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Ondrej Slaby
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
- Department of Biology, University Hospital Brno, Brno, Czech Republic
| | - Petr Jabandziev
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Pediatrics, University Hospital Brno, Brno, Czech Republic
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Rath CP, Athalye-Jape G, Nathan E, Doherty D, Rao S, Patole S. Benefits of routine probiotic supplementation in preterm infants. Acta Paediatr 2023; 112:2352-2358. [PMID: 37505925 DOI: 10.1111/apa.16924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 07/30/2023]
Abstract
AIM We introduced routine probiotic supplementation (RPS) of preterm infants in June 2012. We previously reported that RPS reduced the incidence of necrotising enterocolitis (NEC) and mortality in such infants. In this study, we assessed if the benefits of RPS were sustained for infants in the current era. METHOD We compared the outcomes of preterm infants in recent epoch 3 (RPS, 1st June 2014 to 31st December 2019) versus epoch 2 (RPS, 1st June 2012 to 31st May 2014) and epoch 1 (no RPS, 1st December 2008 to 30th November 2010). Multiple logistic and Cox regression models were used to compare the outcomes. RESULTS There were 645 infants in epoch 1, 712 in epoch 2 and 1715 in epoch 3. Age at full feeds was significantly lower in epoch 3 vs. 2 and epoch 3 vs. 1 in infants <28 weeks of gestation. NEC and late-onset sepsis (LOS) were significantly lower in epoch 3 vs. 1 in infants <28 weeks. LOS and age at full feeds were significantly lower in epoch 3 vs. 2 and epoch 3 vs. 1 in infants with gestation 28 to 32 weeks. CONCLUSION The benefits associated with RPS were sustained during epoch 3.
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Affiliation(s)
- C P Rath
- Neonatology Directorate, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - G Athalye-Jape
- Neonatology Directorate, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - E Nathan
- Biostatistics, Women and Infants Research Foundation, Subiaco, Western Australia, Australia
- Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, Western Australia, Australia
| | - D Doherty
- Biostatistics, Women and Infants Research Foundation, Subiaco, Western Australia, Australia
- Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, Western Australia, Australia
| | - S Rao
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
- Neonatal Directorate, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - S Patole
- Neonatology Directorate, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
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Salem A, Patel RM. Red Blood Cell Transfusion, Anemia, Feeding, and the Risk of Necrotizing Enterocolitis. Clin Perinatol 2023; 50:669-681. [PMID: 37536771 DOI: 10.1016/j.clp.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality in preterm infants. Severe anemia and red blood cell (RBC) transfusion are associated with gut inflammation and injury in preclinical models and observational studies. However, there is uncertainty about the causal role of these factors in the pathogenesis of NEC. Observational studies have shown that withholding feeding during RBC transfusion may reduce the risk of NEC, although confirmatory data from randomized trials are lacking. In this review, we summarize data on feeding during RBC transfusion and its role in NEC and highlight ongoing randomized trials.
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Affiliation(s)
- Anand Salem
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA
| | - Ravi M Patel
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA.
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8
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Assad M, Jerome M, Olyaei A, Nizich S, Hedges M, Gosselin K, Scottoline B. Dilemmas in establishing preterm enteral feeding: where do we start and how fast do we go? J Perinatol 2023; 43:1194-1199. [PMID: 37169912 DOI: 10.1038/s41372-023-01665-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 03/06/2023] [Accepted: 03/23/2023] [Indexed: 05/13/2023]
Abstract
Beginning and achieving full enteral nutrition is a key step in the care of preterm infants, particularly very low birth weight (VLBW) infants. As is true for many organ system-specific complications of prematurity, the gastrointestinal tract must complete in utero development ex utero while concurrently serving a physiologic role reserved for after completion of full term development. The preterm gut must assume the placental function of the interface between a source of energy, precursors for anabolism, and micronutrients, and the developing infant-through digestion and absorption of milk, instead of directly from the mother via the uteroplacental interface. The benefits of enteral nourishment in preterm infants are counterbalanced by gastrointestinal complications of prematurity: dysmotility leading to difficulty establishing and advancing feeds, and the risk of necrotizing enterocolitis (NEC). Concern for these complications can prolong the need for parenteral nutrition with an associated increase in risk for central line-associated bloodstream infection (CLABSI) and parenteral nutrition (PN)-associated cholestasis or liver disease (PNALD). Thus, a daily issue facing neonatologists caring for preterm infants is how to optimally begin, advance, and reach full enteral nutrition sufficient to satisfy the nutrient, energy, and fluid requirements of VLBW infants while minimizing risk. In this perspective, we provide an overview of the approaches and supporting data for starting and advancing enteral feeds in preterm infants, particularly very low birth weight infants, and we discuss the significant gaps in knowledge that accompany current approaches. This framework recognizes the dilemmas of preterm feeding initiation and advancement and identifies areas of opportunity for further investigation.
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Affiliation(s)
- Maushumi Assad
- Division of Neonatology, Department of Pediatrics, University of Massachusetts T.H.Chan School of Medicine, Worcester, MA, 01655, USA
| | - Maggie Jerome
- Graduate Programs in Human Nutrition, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Amy Olyaei
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Samantha Nizich
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Madeline Hedges
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Kerri Gosselin
- Division of Neonatology, Department of Pediatrics, University of Massachusetts T.H.Chan School of Medicine, Worcester, MA, 01655, USA
| | - Brian Scottoline
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA.
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9
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Riddle S, Karpen H. Special Populations-Surgical Infants. Clin Perinatol 2023; 50:715-728. [PMID: 37536774 DOI: 10.1016/j.clp.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Congenital gastrointestinal disorders and other surgical diagnoses share many common problems: increased nutritional requirements to prevent catabolism, enhance wound healing, and provide optimal growth; impaired motility and altered intestinal flora leading to feeding intolerance requiring long-term parenteral nutrition; gastroesophageal reflux and poor feeding mechanics requiring tube feedings and support; growth failure; poor barrier function and risk of infection; and other long-term sequelae. Consequently, the surgical "at-risk" infant requires specialized nutritional support to meet their increased requirements to ensure adequate growth and meet the increased demands from critical illness.
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Affiliation(s)
- Stefanie Riddle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| | - Heidi Karpen
- Emory University School of Medicine/Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, ECC Room 324, Atlanta, GA 30322, USA
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10
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Salas AA, Travers CP. The Practice of Enteral Nutrition: Clinical Evidence for Feeding Protocols. Clin Perinatol 2023; 50:607-623. [PMID: 37536767 PMCID: PMC10599301 DOI: 10.1016/j.clp.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Establishing full enteral nutrition in critically ill preterm infants with immature gastrointestinal function is challenging. In this article, we will summarize emerging clinical evidence from randomized clinical trials suggesting the feasibility and efficacy of feeding interventions targeting the early establishment of full enteral nutrition. We will also examine trial outcomes of higher volume feedings after the establishment of full enteral nutrition. Only data from randomized clinical trials will be discussed extensively. Future opportunities for clinical research will also be presented.
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Affiliation(s)
- Ariel A Salas
- Division of Neonatology, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, 1700 6th Avenue South Women & Infants Center Suite 9380, Birmingham, AL 35233, USA.
| | - Colm P Travers
- Division of Neonatology, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, 1700 6th Avenue South Women & Infants Center Suite 9380, Birmingham, AL 35233, USA
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Monzon N, Kasahara EM, Gunasekaran A, Burge KY, Chaaban H. Impact of neonatal nutrition on necrotizing enterocolitis. Semin Pediatr Surg 2023; 32:151305. [PMID: 37257267 PMCID: PMC10750299 DOI: 10.1016/j.sempedsurg.2023.151305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Necrotizing enterocolitis (NEC) is the leading cause of morbidity and mortality in preterm infants. NEC is multifactorial and the result of a complex interaction of feeding, dysbiosis, and exaggerated inflammatory response. Feeding practices in the neonatal intensive care units (NICUs) can vary among institutions and have significant impact on the vulnerable gastointestinal tract of preterm infants. . These practices encompass factors such as the type of feeding and fortification, duration of feeding, and rate of advancement, among others. The purpose of this article is to review the data on some of the most common feeding practices in the NICU and their impact on the development of NEC in preterm infants. Data on the human milk bioactive component glycosaminoglycans, specifically hyaluronan, will also be discussed in the context of postnatal intestinal development and NEC prevention.
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Affiliation(s)
- Noahlana Monzon
- Department of Nutritional Sciences, The University of Oklahoma Health Sciences Center, Oklahoma, OKC, 73104
| | - Emma M Kasahara
- Department of Nutritional Sciences, The University of Oklahoma Health Sciences Center, Oklahoma, OKC, 73104
| | - Aarthi Gunasekaran
- Department of Pediatrics, Division of Neonatology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104
| | - Kathryn Y Burge
- Department of Pediatrics, Division of Neonatology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104
| | - Hala Chaaban
- Department of Nutritional Sciences, The University of Oklahoma Health Sciences Center, Oklahoma, OKC, 73104; Department of Pediatrics, Division of Neonatology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104.
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12
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King B, Patel RM. Using Quality Improvement to Improve Value and Reduce Waste. Clin Perinatol 2023; 50:489-506. [PMID: 37201993 DOI: 10.1016/j.clp.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Value is defined as health outcomes achieved per dollar spent. Addressing value in quality improvement (QI) efforts can help optimize patient outcomes while reducing unnecessary spending. In this article, we discuss how QI focused on reducing morbidities frequently reduces costs, and how proper cost accounting can help demonstrate improvements in value. We provide examples of high-yield opportunities for value improvement in neonatology and review the literature associated with these topics. Opportunities include reducing neonatal intensive care admissions for low-acuity infants, sepsis evaluations in low-risk infants, unnecessary total parental nutrition use, and utilization of laboratory and imaging.
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Affiliation(s)
- Brian King
- Department of Pediatrics, University of Pittsburg School of Medicine.
| | - Ravi M Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive, NE, Atlanta, GA 30322, USA
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Fu TT, Arhin M, Schulz A, Ward L, Chapman S, Adamchak A, Kim J. Standardizing Feeding Strategies in Moderately Preterm Infants. RESEARCH SQUARE 2023:rs.3.rs-2520889. [PMID: 36798338 PMCID: PMC9934753 DOI: 10.21203/rs.3.rs-2520889/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objective To evaluate the impact of a standardized feeding protocol and donor breast milk (DBM) provision on clinical outcomes in moderate preterm infants (MPT, 29-33 6/7 weeks gestational age). Study Design A protocol for MPT infants born > 1500 g was implemented clinically to standardize feeding advancements at 30 mL/kg/day. Infants < 33 weeks received DBM. We retrospectively identified 131 and 144 infants born before and after implementation. Clinical data including central venous line (CVL) placement, feeding tolerance, growth, and provision of maternal breast milk (MBM) were collected. Result Number of CVLs, days to full enteral volume (FEV), and MBM provision was unchanged. There was a narrower range of days to FEV post-implementation. Growth metrics were similar between eras. Conclusion Implementation of a feeding protocol for MPT infants is associated with more consistent time to FEV With monitoring and appropriate fortification, DBM use in this population is not associated with worse growth outcomes.
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Affiliation(s)
| | - Maame Arhin
- Cincinnati Children's Hospital Medical Center
| | | | - Laura Ward
- Cincinnati Children's Hospital Medical Center
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Impact of a Standardized Nutrition Bundle Including Donor Human Milk on Hospital Outcomes in Very Low Birth-Weight (VLBW) Infants in a Safety-Net Hospital. Adv Neonatal Care 2022; 22:503-512. [PMID: 36413779 DOI: 10.1097/anc.0000000000000974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Standardized protocols have been shown to reduce clinical practice variation and improve patient outcomes. PURPOSE To measure the impact of a standardized nutrition bundle inclusive of donor human milk (DHM) on hospital outcomes of very low birth-weight (VLBW) infants in a safety-net hospital. METHODS The study used the Model for Improvement methodology to drive improvement in practice. Outcome measures consisted of necrotizing enterocolitis (NEC), mortality, growth at 36 weeks' postmenstrual age and discharge, as well as volume and type of milk consumption during hospitalization. FINDINGS NEC rate decreased from 16.67% in the control group to 6.78% in the standardized nutrition bundle group (P = .07). Similarly, there was significant reduction in mortality with the bundled intervention (15.6% in the control group vs 1.6% in the nutrition bundle group; P = .006). Time to first (15 vs 27.5 hours of life; P < .001) and full-volume enteral feeding (8.5 vs 10 days; P = .086) were reduced in the standardized nutrition bundle group compared with the control group. The human milk volume almost doubled with the intervention. IMPLICATIONS FOR PRACTICE Our standardized nutrition bundle protocol inclusive of DHM resulted in lower NEC rates and reduced mortality. The implementation of the DHM program proved to be cost-effective and saved lives. Our findings may help guide development of a structured approach to nutrition protocols inclusive of DHM that can be adapted by other units located in safety-net hospitals. IMPLICATIONS FOR RESEARCH Future research on ethnic and racial barriers to access and affordability of DHM is warranted and much needed.
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Ahmad I, Premkumar MH, Hair AB, Sullivan KM, Zaniletti I, Sharma J, Nayak SP, Reber KM, Padula M, Brozanski B, DiGeronimo R, Yanowitz TD. Variability in antibiotic duration for necrotizing enterocolitis and outcomes in a large multicenter cohort. J Perinatol 2022; 42:1458-1464. [PMID: 35760891 DOI: 10.1038/s41372-022-01433-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 05/01/2022] [Accepted: 06/09/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To evaluate variability in antibiotic duration for necrotizing enterocolitis (NEC) and associated clinical outcomes. STUDY DESIGN Five-hundred ninety-one infants with NEC (315 medical; 276 surgical) were included from 22 centers participating in Children's Hospitals Neonatal Consortium (CHNC). Multivariable analyses were used to determine predictors of variability in time to full feeds (TFF) and length of stay (LOS). RESULTS Median (IQR) antibiotic duration was 12 (9, 17) days for medical and 17 (14, 21) days for surgical NEC. Wide variability in antibiotic use existed both within and among centers. Duration of antibiotic therapy was associated with longer TFF in both medical (OR 1.04, 95% CI [1.01, 1.05], p < 0.001) and surgical NEC (OR 1.02 [1, 1.03] p = 0.046); and with longer LOS in medical (OR 1.03 [1.02, 1.04], p < 0.001) and surgical NEC (OR 1.01 [1.01, 1.02], p = 0.002). CONCLUSION Antibiotic duration for both medical and surgical NEC remains variable within and among high level NICUs.
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Affiliation(s)
| | | | - Amy B Hair
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Kevin M Sullivan
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Jotishna Sharma
- University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | | | - Kristina M Reber
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Michael Padula
- University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Dufendach KR, Navarro-Sainz A, Webster KL. Usability of human-computer interaction in neonatal care. Semin Fetal Neonatal Med 2022; 27:101395. [PMID: 36457213 DOI: 10.1016/j.siny.2022.101395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
While a goal for Electronic Health Record (EHR) technologies was to improve quality, efficiency, and safety, the usability of EHRs has remained poor. The relation to patient harm and user satisfaction cannot be ignored. Optimization of EHR usability is imperative to improving the outcomes for critically ill patients, especially neonates who are at the extremes of physiologic variability. Further development and integration of metadata with predictive modeling and clinical protocols can support provider decision making, increase efficiency and safety, and reduce clinician burnout. This paper reviews EHR usability and identifies opportunities to improve the EHR specific to neonatal care.
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Affiliation(s)
- Kevin R Dufendach
- Department of Pediatrics, University of Cincinnati College of Medicine, USA; Perinatal Institute, Cincinnati Children's Hospital Medical Center, USA; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, USA.
| | | | - Kristen Lw Webster
- Patient Safety, Regulatory, & Accreditation, James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, USA
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17
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Gomez J, Wardell D. Nurse-Driven Interventions for Improving ELBW Neurodevelopmental Outcomes. J Perinat Neonatal Nurs 2022; 36:362-370. [PMID: 36288443 DOI: 10.1097/jpn.0000000000000695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Survival rates for extremely low-birth-weight (ELBW) infants are improving as neurodevelopmental impairment (NDI) rates stay stable, thereby increasing the overall number of infants with NDI. Although there are many determinants of NDI in this population, nutritional factors are of interest because they are readily modifiable in the clinical setting. Nurses can influence nutritional factors such as improving access to human milk feeding, using growth monitoring, establishing feeding policies, implementing oral care with colostrum, facilitating kangaroo care, and providing lactation education for the mother. All of these measures assist in leading to a decrease in NDI rates among ELBW infants.
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Affiliation(s)
- Jessica Gomez
- Section of Neonatology, Department of Pediatrics, The University of Texas Health Science Center at Houston, Houston (Ms Gomez); and Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston (Dr Wardell)
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18
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Advancements in neonatology through quality improvement. J Perinatol 2022; 42:1277-1282. [PMID: 35368024 DOI: 10.1038/s41372-022-01383-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 11/09/2022]
Abstract
In the past 3 decades, quality improvement methodology has often been employed in medicine to improve patient outcomes. Neonatal medicine has seen an increase in publications using improvement science to ensure the application of potentially better practices to decrease complications and increase survival without major disability. This article reviews quality improvement studies that have impacted neonatal mortality and morbidity, as well as specific disease processes including bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and retinopathy of prematurity. Using improvement science, studies have substantially reduced neonatal mortality and the major complications of preterm birth.
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Early erythropoietin for preventing necrotizing enterocolitis in preterm neonates - an updated meta-analysis. Eur J Pediatr 2022; 181:1821-1833. [PMID: 35122138 DOI: 10.1007/s00431-022-04394-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/20/2021] [Accepted: 01/23/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Previous systematic reviews suggest reduction in necrotizing enterocolitis (NEC) among preterm infants supplemented with erythropoietin (EPO). We aimed to update our 2018 systematic review in this field considering the evidence accumulated over the last 3 years. Randomized controlled trials (RCTs) reporting the effect of early EPO supplementation vs placebo/no EPO supplementation on any stage NEC in preterm infants were included. Fixed effect model was used for meta-analysis. Trial sequential analysis (TSA) was conducted to verify the effects of EPO on NEC after accounting for repeated significance testing. A total of 22 RCTs (n = 5359) were included, of which six were new (n = 2541 additional preterm infants) in comparison to our previous systematic review. EPO significantly decreased the risk of any stage NEC (232/2669 (8.7%) vs 313/2690 (11.6%); RR: 0·76; TSA adjusted 95% CI (0·64, 0·90); p = 0·0008, number needed to treat (NNT) = 34). The risk of definite NEC (≥ Stage II) was also significantly reduced by EPO administration (105/2219 (4.7%) vs 141/2246 (6.3%); RR: 0.77; 95% CI (0.61, 0.98); p = 0.03, NNT: 62). However, the results for definite NEC were no longer significant on sensitivity analyses that included (a) only double-blind RCTs and (b) only prospectively registered trials. The quality of evidence was deemed moderate-to-low for the reported outcomes. CONCLUSION There is moderate to low-quality evidence that early prophylactic EPO reduces any stage and ≥ Stage II NEC in preterm neonates. Prospectively registered, adequately powered, double-blind RCTs are required to confirm these findings. WHAT IS KNOWN • Experimental studies have shown that erythropoietin (EPO) has gastrointestinal trophic effects. • Systematic reviews have shown that early treatment with EPO may decrease the risk of gut injury in preterm or low birth weight infants. WHAT IS NEW • Early EPO supplementation significantly reduced the incidence of any stage NEC and definite NEC in preterm infants < 34 weeks of gestation. • EPO had no significant effect on definite NEC in the analyses that included only double-blinded and prospectively registered RCTs. How might it impact clinical practice in the foreseeable future? • Early prophylactic EPO can be recommended for NEC prevention if its benefits are consistently demonstrated in adequately powered randomized trials with a low risk of bias.
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20
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A quality improvement initiative to standardize time to initiation of enteral feeds after non-surgical necrotizing enterocolitis using a consensus-based guideline. J Perinatol 2022; 42:522-527. [PMID: 35091710 DOI: 10.1038/s41372-022-01324-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/01/2021] [Accepted: 01/14/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Recent evidence demonstrates that earlier feeding may be beneficial after non-surgical necrotizing enterocolitis (NEC). We aimed to decrease time to reach full enteral feeds by 20% post-NEC by standardizing time to reinitiate feeds. METHODS We implemented a consensus-based guideline for earlier feeding post-NEC. Outcome measures included days to initiate enteral feeds and reach full enteral feeds. Central venous line days and length of stay were also evaluated. Balancing measures were NEC recurrence and post-NEC stricture. Statistical analysis used process control methodology and standard comparison statistical testing. RESULTS Average days infants with Stage II NEC began feeding decreased from 9.4 to 5.1 days and average days to reach full feeds was decreased by 35% from 24.0 to 15.7 days. We observed no change in our balancing measures. CONCLUSION A multidisciplinary consensus-based NEC earlier feeding guideline decreased time to reach full enteral feeds and reduced central line days without adverse events.
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21
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Swanson JR, Hair A, Clark RH, Gordon PV. Spontaneous intestinal perforation (SIP) will soon become the most common form of surgical bowel disease in the extremely low birth weight (ELBW) infant. J Perinatol 2022; 42:423-429. [PMID: 35177793 DOI: 10.1038/s41372-022-01347-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 12/12/2022]
Abstract
Recent data have revealed declines in the prevalence rates of NEC over the last decade in premature infants. In contrast, SIP has either remained steady or risen during the same epoch. These trends are consistent with our knowledge of the clinical arena. The ability to discern SIP contamination within NEC datasets has slowly improved. Additionally, quality improvement efforts are being utilized to reduce NEC through stewardship of antibiotics, acid inhibitors, central lines and blood products, as well as optimization of human milk diets. These forces are moving us to a new era, where NEC will no longer be the dominant surgical intestinal disease of the extremely preterm neonate. Indeed, in the extremely low birth weight (ELBW) population, SIP may already be the most prevalent reason for abdominal surgery. In this perspective, the reader will find supporting data and references for these assertions as well as predictions for the future.
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Affiliation(s)
- Jonathan R Swanson
- Division of Neonatology, University of Virginia Children's Hospital, Charlottesville, VA, USA.
| | - Amy Hair
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, USA
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22
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Nesterenko TH, Baliga N, Swaintek S, Abdelatif D, Aly H, Mohamed MA. The impact of a multifaceted quality improvement program on the incidence of necrotizing enterocolitis in very low birth weight infants. Pediatr Neonatol 2022; 63:181-187. [PMID: 34933821 DOI: 10.1016/j.pedneo.2021.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/27/2021] [Accepted: 10/07/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a multifactorial gastrointestinal disease which mostly occurs in very low birth weight (VLBW) infants. In addition to decreasing gestational age (GA) or birth weight (BW), artificial formula, delayed initiation or rapidly advanced feeding, severe anemia and systemic infections were associated with NEC. Several studies demonstrated that breast milk, standardized feeding advancement regimens and treatment of anemia are associated with less incidence of NEC. It is not known if including all these interventions in one multifaceted program will lead to significant reduction in NEC. METHODS The NICU team at The George Washington University Hospital created a multifaceted interdisciplinary quality improvement project to tackle several aspects of NEC prevention that addressed researched risk factors for NEC. The program was made of four quality improvement protocols: 1) Standardized Structured Feeding Program, 2) Feeding Intolerance Management Algorithm, 3) Enteral Osmolality Control Tool, and 4) Packed Red Blood Cell (RBC) Standardized Transfusion Protocol. This time-series, quasi experimental study design examined the differences in the incidence of NEC between infants with BW < 1500 g who were admitted to the GW Hospital NICU before and after the program implementation. RESULTS Data from 408 VLBW infants were included in the study. Although not statistically significant, there was a decreasing trend of NEC incidence in the post-implementation group (n = 199) compared to the pre-implementation group (n = 209), (3.5% vs. 5.3%, p = 0.88). The trend in the incidence of NEC declined further after the introduction of RBC transfusion protocol which was introduced ten month after starting the other elements of the program. CONCLUSION Integration of the multifaceted quality improvement program may be associated with a decline in the occurrence of NEC. Further analysis with a larger sample size is required to determine if the changes seen are statistically significant.
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Affiliation(s)
- Tetyana H Nesterenko
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Nita Baliga
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Sarah Swaintek
- Department of Food and Nutrition, The George Washington University Hospital, Washington, DC, USA
| | - Dinan Abdelatif
- Department of Obstetrics and Gynecology, The George Washington University, Washington, DC, USA
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Mohamed A Mohamed
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA.
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23
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Tsao PC. Effect of a multifaceted quality improvement program on the incidence of necrotizing enterocolitis in infants with very low birth weight. Pediatr Neonatol 2022; 63:107-108. [PMID: 35246372 DOI: 10.1016/j.pedneo.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 02/18/2022] [Accepted: 02/18/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Pei-Chen Tsao
- Division of Neonatology and Pediatric Intensive Care, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Pediatrics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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24
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Abstract
Appropriate nutrition is essential for optimal development and growth of preterm infants. Infants less than 25 weeks corrected gestational age are frequently the most difficult group for which to provide adequate nutrition due to minimal energy stores and high fluid losses. Nutrient delivery becomes an integral, but also very challenging part in their management. Early administration of intravenous nutrients provides a critical bridge to full enteral nutrition. However, enteral feeding is challenging due to immaturities of the intestinal tract, feeding intolerance and the risk of catastrophic gastrointestinal disease such as necrotizing enterocolitis (NEC). Decreased gastric acid production, increased gut permeability, reduced immunoglobulins, immature intestinal epithelia and a decreased mucin barrier all contribute to weakness to gastrointestinal insult. This review aims to illustrate the importance of enteral feeding and the common challenges and approaches in the nutrition of infants born at this age.
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Affiliation(s)
- Laura Patton
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Diomel de la Cruz
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA.
| | - Josef Neu
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
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25
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Oda A, Mizuno K. Questionnaire survey on donor human milk programs targeting NICUs in Japan. Pediatr Int 2022; 64:e15344. [PMID: 36410722 DOI: 10.1111/ped.15344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/15/2022] [Accepted: 08/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Since 2019, neonatal intensive care units (NICUs) with access to human milk banks (HMBs) have increased in Japan. In this study, using a questionnaire survey, we explored an understanding of the purpose, status, and problems of donor human milk (DHM) use and the status of enteral nutrition (EN) in very-low-birthweight infants (VLBWIs) in NICUs with access to HMBs. METHODS A questionnaire was sent to 47 NICUs that had access to HMBs. Participants were surveyed from the begining of January to the end of February 2022. RESULTS In total, 37 of 47 (78.9%) NICUs responded to the questionnaire. The most common indications for DHM were gestational age of less than 28 weeks (78.3%) and birthweight of less than 1500 g (100%). Informed consent was obtained from the physicians and most parents accepted DHM. All NICUs responded that EN for VLBWIs should start ideally within 24 h of birth, but in reality, nine NICUs (25%) and 18 NICUs (50%) began EN within 12 and 24 h of birth, respectively. Additionally, seven of the nine NICUs that started EN within 12 h after birth routinely used DHM for VLBWIs. For infants with birthweights of 1000-1499 g, it was not uncommon to start EN within 24 h of birth with formula milk. CONCLUSION All NICUs responded that the indication for DHM was very-low birthweight and that such infants would receive health benefits from DHM. In Japan, there is a trend of starting EN early in VLBWIs. Accessibility to HMB may be important for starting EN within 24 h of birth.
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Affiliation(s)
- Ayaka Oda
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Katsumi Mizuno
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
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26
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Clinical Presentation and Multifactorial Pathogenesis of Necrotizing Enterocolitis in the Preterm Infant. Adv Neonatal Care 2021; 21:349-355. [PMID: 33958518 DOI: 10.1097/anc.0000000000000880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a serious infection of the bowel wall induced by multiple pathological factors, which include inflammation and tissue invasion with bacteria known to cause severe infections. NEC is now understood to be several disease processes under one umbrella. The most common form occurs in premature infants and can exert significant impacts to preterm morbidity and mortality. PURPOSE This narrative review describes current knowledge of the clinical presentation and pathophysiology of NEC in premature infants. METHODS/SEARCH STRATEGY A review of literature was conducted using key words in PubMed and CINAHL with preference for years 2015 to 2020. FINDINGS/RESULTS Several converging and interrelated factors including characteristics of the premature intestinal mucosa, gut ischemia, dysregulation of the microbiome, enteral feeding, and genetics create an environment where NEC is more likely to occur. IMPLICATIONS FOR PRACTICE To recognize and diagnose NEC in preterm infants, an understanding of underlying factors that create an optimal environment for disease acquisition in premature infants is essential. IMPLICATIONS FOR RESEARCH Prevention of NEC remains the most important strategy for decreasing morbidity and mortality. Multiple areas of potential study exist for NEC pathophysiology including those that consider how the factors discussed in this review are interrelated and how each particular pathway can be optimized to prevent the onset of NEC.
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Enteral Feeding and Necrotizing Enterocolitis: Does Time of First Feeds and Rate of Advancement Matter? J Pediatr Gastroenterol Nutr 2021; 72:763-768. [PMID: 33587409 DOI: 10.1097/mpg.0000000000003069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the study was to determine if time to initial enteral feeding (EF) and rate of advancement are associated with necrotizing enterocolitis (NEC) or death. METHODS Secondary analysis of prospectively collected data of very-low-birth-weight infants (VLBWI: 400--1500 g) born in 26 NEOCOSUR centers between 2000 and 2014. RESULTS Among 12,387 VLBWI, 83.7% survived without NEC, 6.6% developed NEC and survived, and 9.6% had NEC and died or died without NEC (NEC/death). After risk adjustment, time to initial EF (median = 2 days) was not associated with NEC; however, delaying it was protective for NEC/death (odds ratio [OR] = 0.96; 95% confidence interval [CI] 0.93--0.99). A slower feeding advancement rate (FAR) was protective for NEC (OR = 0.97; 95% CI = 0.94-0.98) and for NEC/death (OR = 0.98; 95% CI = 0.96-0.99). CONCLUSIONS In VLBWI, there was no association between an early initial EF and NEC, although delaying it was associated with less NEC/death. A slower FAR was associated with lower risk of both outcomes.
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28
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[Clinical guidelines for the diagnosis and treatment of neonatal necrotizing enterocolitis (2020)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021. [PMID: 33476530 DOI: 10.7499/j.issn.1008-8830.2011145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease of neonates, especially of preterm infants, with high morbidity and mortality. The surviving infants may have digestive tract and neurological sequelae. Therefore, the prevention and treatment of NEC are of great significance in improving survival rate and survival quality of neonates. To provide evidence-based recommendations for management of NEC, the guidelines were developed based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the current domestic and overseas studies.
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Moschino L, Duci M, Fascetti Leon F, Bonadies L, Priante E, Baraldi E, Verlato G. Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection. Nutrients 2021; 13:nu13020340. [PMID: 33498880 PMCID: PMC7910892 DOI: 10.3390/nu13020340] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.
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MESH Headings
- Enterocolitis, Necrotizing/complications
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/prevention & control
- Enterocolitis, Necrotizing/surgery
- Failure to Thrive/prevention & control
- Humans
- Infant
- Infant Nutritional Physiological Phenomena
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/prevention & control
- Infant, Premature, Diseases/surgery
- Intestines/surgery
- Short Bowel Syndrome/etiology
- Short Bowel Syndrome/prevention & control
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Affiliation(s)
- Laura Moschino
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Elena Priante
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Giovanna Verlato
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
- Correspondence: ; Tel.: +39-0498211428
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30
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Chandran S, Anand AJ, Rajadurai VS, Seyed ES, Khoo PC, Chua MC. Evidence-Based Practices Reduce Necrotizing Enterocolitis and Improve Nutrition Outcomes in Very Low-Birth-Weight Infants. JPEN J Parenter Enteral Nutr 2020; 45:1408-1416. [PMID: 33296087 DOI: 10.1002/jpen.2058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/25/2020] [Accepted: 12/02/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in preterm infants. Survivors may suffer both short- and long-term morbidities. Current evidence suggests that the incidence of NEC can be reduced by standardizing the care delivery in addressing key risk factors including an altered gut microbiome, use of formula milk, hyperosmolar feeds, and unrestricted use of high-risk medications METHODS: Since 2014, the department has a workgroup who analyzed all cases of NEC within a month of diagnosis to identify preventable risk factors. Existing evidence-based quality improvement strategies were revised and new ones were implemented sequentially over the next 4 years. These strategies include (1) a standardized feeding protocol, (2) early initiation of enteral feeding using human milk, (3) optimization of the osmolality of preterm milk feeds using standardized dilution guidelines for additives, and (4) promotion of healthy microbiome by use of probiotics, early oral care with colostrum and by restricting high-risk medications and prolonged use of empirical antibiotics RESULTS: Baseline characteristics of the patients including sex, gestational age, and birth weight were similar during the study period. After implementing the evidence-based practices successively over 4 years, the incidence of NEC in very- low birth-weight (VLBW) infants dropped from 7% in 2014 to 0% (P < .001) in 2018. The duration of parenteral nutrition, use of central line, and days to full feeds were also reduced significantly (P < .05) CONCLUSION: Adopting evidence-based best practices resulted in a significant decrease in the incidence of NEC and improved the nutrition outcomes in VLBW infants.
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Affiliation(s)
- Suresh Chandran
- Department of Neonatology, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technical University, Singapore
| | - Amudha Jayanthi Anand
- Department of Neonatology, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technical University, Singapore
| | - Victor Samuel Rajadurai
- Department of Neonatology, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technical University, Singapore
| | - Ehsan Saffari Seyed
- Lee Kong Chian School of Medicine, Nanyang Technical University, Singapore.,Center for Quantitative Medicine, Office of Clinical Science, Duke University-National University of Singapore Medical School, Singapore
| | - Poh Choo Khoo
- Department of Neonatology, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technical University, Singapore
| | - Mei Chien Chua
- Department of Neonatology, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technical University, Singapore
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31
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Abstract
Although risk for necrotizing enterocolitis (NEC) is often presented from the perspective of a premature infant's vulnerability to nonmodifiable risk factors, in this paper we describe the evidence and present recommendations to manage modifiable risks that are amenable to clinical actions. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, we present recommendations in the context of their supporting evidence in a way that balances risks (e.g. potential harm, cost) and benefits. Across the prenatal, intrapartum, early and late clinical course, strategies to limit NEC risk in premature infants are presented. Our goal is to summarize modifiable NEC risk factors, grade the evidence to offer quality improvement (QI) targets for healthcare teams and offer a patient-family advocate's perspective on how to engage parents to recognize and reduce NEC risk.
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32
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Abstract
Necrotizing enterocolitis (NEC) accounts for 10% of deaths in neonatal intensive care units. Several causal mechanisms are likely to lead to a final common disease phenotype. This article summarizes recent data on NEC following red blood cell (RBC) transfusion, with a focus on the most recent literature and ongoing trials. It highlights potential mechanisms from preclinical and human physiologic studies. It also discusses the role of feeding during RBC transfusion and the risk of NEC. Ongoing randomized trials will provide important data on how liberal or conservative approaches to RBC transfusion influence the risk of NEC.
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Mizuno K, Shimizu T, Ida S, Ito S, Inokuchi M, Ohura T, Okumura A, Kawai M, Kikuchi T, Sakurai M, Sugihara S, Suzuki M, Takitani K, Tanaka D, Mushiake S, Yoshiike N, Kodama H, Okada K, Tsutsumi C, Hara M, Hanawa Y, Kawakami K, Inomata H, Oguni T, Bito Y, Uchida K, Sugiyama A. Policy statement of enteral nutrition for preterm and very low birthweight infants. Pediatr Int 2020; 62:124-127. [PMID: 32026585 PMCID: PMC7065204 DOI: 10.1111/ped.14067] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/03/2019] [Accepted: 11/14/2019] [Indexed: 12/30/2022]
Abstract
For preterm and very low birthweight infants, the mother's own milk is the best nutrition. Based on the latest information for mothers who give birth to preterm and very low birthweight infants, medical staff should encourage and assist mothers to pump or express and provide their own milk whenever possible. If the supply of maternal milk is insufficient even though they receive adequate support, or the mother's own milk cannot be given to her infant for any reason, donor human milk should be used. Donors who donate their breast milk need to meet the Guideline of the Japan Human Milk Bank Association. Donor human milk should be provided according to the medical needs of preterm and very low birthweight infants, regardless of their family's financial status. In the future, it will be necessary to create a system to supply an exclusive human milk-based diet (EHMD), consisting of human milk with the addition of a human milk-derived human milk fortifier, to preterm and very low birthweight infants.
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Affiliation(s)
- Katsumi Mizuno
- Director Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Toshiaki Shimizu
- Director Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Shinobu Ida
- Chair Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Setsuko Ito
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Mikako Inokuchi
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Toshihiro Ohura
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Akihisa Okumura
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Masanobu Kawai
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Toru Kikuchi
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Motoichiro Sakurai
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Shigetaka Sugihara
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Mitsuyoshi Suzuki
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Kimitaka Takitani
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Daisuke Tanaka
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Sotaro Mushiake
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Nobuo Yoshiike
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Hiroko Kodama
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Kazuo Okada
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Chiharu Tsutsumi
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Mitsuhiko Hara
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Yoshio Hanawa
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Kazue Kawakami
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Hiroaki Inomata
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Tatsuya Oguni
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Yuko Bito
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Keiichi Uchida
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
| | - Akihide Sugiyama
- Board Committee on Nutrition, The Child Health Consortium of Japan, Tokyo, Japan
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Patel EU, Wilson DA, Brennan EA, Lesher AP, Ryan RM. Earlier re-initiation of enteral feeding after necrotizing enterocolitis decreases recurrence or stricture: a systematic review and meta-analysis. J Perinatol 2020; 40:1679-1687. [PMID: 32683411 PMCID: PMC7368613 DOI: 10.1038/s41372-020-0722-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/04/2020] [Accepted: 07/07/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the effects of earlier vs. later re-initiation of enteral feeds after necrotizing enterocolitis (NEC). STUDY DESIGN We reviewed the literature to assess timing of enteral feeding after NEC using fixed effects models. RESULTS Three studies met inclusion criteria; no randomized trials. After removal of Bell's Stage I infants, the earlier refeeding group (<5-7 or median 4 days) included 79 infants and later refeeding group (≥5-7 or median 10 days) included 119 infants. Pooled analysis revealed earlier re-initiation reduced the incidence in the composite outcome of recurrent NEC and/or post-NEC stricture (OR = 0.27; 95% Cl = 0.10-0.75; p = 0.012). Individually, NEC recurrence (pooled OR = 0.34; 95% Cl = 0.09-1.29; p = 0.112) or stricture (OR = 0.34; 95% Cl = 0.09-1.26; p = 1.06) did not differ between groups. CONCLUSIONS There was no increase in negative outcomes with earlier refeeding after NEC. Earlier initiation of enteral feeds resulted in a significantly lower risk for the combined outcome of recurrent NEC and/or post-NEC stricture.
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Affiliation(s)
- Ekta U. Patel
- Department of Pediatrics (Neonatology), Shawn Jenkins Children’s Hospital, Charleston, SC USA
| | - Dulaney A. Wilson
- grid.259828.c0000 0001 2189 3475Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC USA
| | - Emily A. Brennan
- grid.259828.c0000 0001 2189 3475Medical University of South Carolina Libraries, Charleston, SC USA
| | - Aaron P. Lesher
- Department of Surgery (Pediatric Surgery), Shawn Jenkins Children’s Hospital, Charleston, SC USA
| | - Rita M. Ryan
- grid.415629.dDepartment of Pediatrics (Neonatology), Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, OH USA
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Wertheimer F, Arcinue R, Niklas V. Necrotizing Enterocolitis: Enhancing Awareness for the General Practitioner. Pediatr Rev 2019; 40:517-527. [PMID: 31575803 DOI: 10.1542/pir.2017-0338] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Necrotizing enterocolitis (NEC) has been recognized for well over 5 decades yet remains the most common life-threatening surgical emergency in the newborn. The incidence of NEC has decreased steadily in preterm and very-low-birthweight infants over several decades and is typically uncommon in term newborns and infants with a birthweight greater than 2,500 g. Evidence accumulating during the past decade, however, suggests that practitioners should consider NEC in this broader subset of term infants with chromosomal and congenital anomalies complicated by heart or gastrointestinal defects when signs and symptoms of feeding intolerance, abdominal illness, or sepsis are present. The short- and long-term consequences of NEC are devastating in all infants, and although early disease recognition and treatment are essential, promoting human milk feeding as a primary modality in prevention is critical. This article highlights our current understanding of the pathophysiology, the clinical presentation, the risk factors for NEC in term infants compared with premature infants, and the treatment of NEC and discusses strategies in the prevention of NEC. Finally, we review the long-term consequences of NEC and the importance of primary care practitioners in the long-term care of infants after hospitalization for NEC.
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Affiliation(s)
- Fiona Wertheimer
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Los Angeles, CA.,Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Roxanne Arcinue
- Keck School of Medicine, University of Southern California, Los Angeles, CA.,Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - Victoria Niklas
- Prolacta Bioscience Inc, Duarte, CA, and Department of Pediatrics, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
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Relationship of Necrotizing Enterocolitis Rates to Adoption of Prevention Practices in US Neonatal Intensive Care Units. Adv Neonatal Care 2019; 19:321-332. [PMID: 30893097 DOI: 10.1097/anc.0000000000000592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Applying quality improvement methods has reduced necrotizing enterocolitis (NEC) in some neonatal intensive care units (NICUs) by 40% to 90%. PURPOSE This study was conducted to (1) examine relationships between adoption of prevention practices using the NEC-Zero adherence score and NEC rates, and (2) describe implementation strategies NICUs use to prevent NEC. METHODS A descriptive cross-sectional correlational study was completed among US quality improvement-focused NICUs. Relationships of the NEC-Zero adherence score to NEC rates were examined. Subgroup analyses explored relationships of a human milk adherence subscore and differences between high NEC rate (≥8%) and low NEC rate (≤2%) NICUs. RESULTS NICUs (N = 76) ranged in size from 18 to 114 beds. The mean adherence score was 7.3 (standard deviation = 1.7; range, 3-10). The 10-point adherence score was not related to the NEC rate. The human milk subscore related to lower NEC rates (Rho = -0.26, P = .049), as was colostrum for oral care (Rho = -0.27, P = .032). The units that used a feeding protocol showed higher NEC rates (Rho = 0.27, P = .03), although very few addressed the use of effective implementation strategies to track adherence or to ensure consistency among clinicians. The units that used colostrum for oral care were more likely to adopt strategies to limit inappropriate antibiotic exposure (Rho = 0.34, P = .003). IMPLICATIONS FOR PRACTICE Broader use of evidence-based implementation strategies could bolster delivery of NEC prevention practices. Maternal lactation support is paramount. IMPLICATIONS FOR RESEARCH Future studies are needed to identify how individual clinicians deliver prevention practices, to find the extent to which this relates to overall delivery of prevention, and to study effects of bundles on NEC outcomes.
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Growth, Feeding Tolerance and Metabolism in Extreme Preterm Infants under an Exclusive Human Milk Diet. Nutrients 2019; 11:nu11071443. [PMID: 31248006 PMCID: PMC6683272 DOI: 10.3390/nu11071443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/18/2019] [Accepted: 06/24/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND For preterm infants, human milk (HM) has to be fortified to cover their enhanced nutritional requirements and establish adequate growth. Most HM fortifiers are based on bovine protein sources (BMF). An HM fortifier based on human protein sources (HMF) has become available in the last few years. The aim of this study is to investigate the impact of an HMF versus BMF on growth in extremely low birth weight (ELBW, <1000 g) infants. METHODS This was a retrospective, controlled, multicenter cohort study in infants with a birthweight below 1000 g. The HMF group received an exclusive HM diet up to 32+0 weeks of gestation and was changed to BMF afterwards. The BMF group received HM+BMF from fortifier introduction up to 37+0 weeks. RESULTS 192 extremely low birth weight (ELBW)-infants were included (HMF n = 96, BMF n = 96) in the study. After the introduction of fortification, growth velocity up to 32+0 weeks was significantly lower in the HMF group (16.5 g/kg/day) in comparison to the BMF group (18.9 g/kg/day, p = 0.009) whereas all other growth parameters did not differ from birth up to 37+0 weeks. Necrotizing enterocolitis (NEC) incidence was 10% in the HMF and 8% in the BMF group. CONCLUSION Results from this study do not support the superiority of HFM over BMF in ELBW infants.
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Bajaj M, Lulic-Botica M, Hanson A, Natarajan G. Feeding during transfusion and the risk of necrotizing enterocolitis in preterm infants. J Perinatol 2019; 39:540-546. [PMID: 30723281 DOI: 10.1038/s41372-019-0328-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 12/07/2018] [Accepted: 01/15/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the effect of withholding feeds during transfusion on transfusion associated acute gut injury (TRAGI). STUDY DESIGN Data were collected on 125 preterm infants before and after the practice of withholding feeds for 12-24 h during transfusion was instituted. Logistic regression was used to examine effects of withholding feeds on TRAGI rates. RESULTS A total of 19 (15%) infants developed NEC; 6/19 (32%) had TRAGI. Postnatal hydrocortisone use was associated with TRAGI (OR 8.97; 95% CI 1.17-68.46, p = 0.034). There was no difference in NEC rates (15.8 vs. 14.7%) and the proportions (22.2 vs. 40%) of TRAGI in the two time periods before and after instituting the standardized feeding regimen and practice of holding feeds during transfusion. CONCLUSION No significant decrease was noted in the rates of TRAGI after feeds were withheld during transfusion. Further studies are warranted to explore the relationship between feeds during transfusion and NEC.
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Affiliation(s)
- Monika Bajaj
- Carman and Ann Department of Pediatrics, Department of Pediatrics, Hutzel Women's Hospital, 3980 John R Rd, Detroit, MI, 48201, USA.
| | | | - Amber Hanson
- Department of Pharmacy, Wayne State University, Detroit, MI, 48201, USA
| | - Girija Natarajan
- Carman and Ann Department of Pediatrics, Department of Pediatrics, Hutzel Women's Hospital, 3980 John R Rd, Detroit, MI, 48201, USA
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39
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Sahin S, Gozde Kanmaz Kutman H, Bozkurt O, Yavanoglu Atay F, Emre Canpolat F, Uras N, Suna Oguz S, Underwood MA. Effect of withholding feeds on transfusion-related acute gut injury in preterm infants: a pilot randomized controlled trial. J Matern Fetal Neonatal Med 2019; 33:4139-4144. [PMID: 30890001 DOI: 10.1080/14767058.2019.1597844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Several retrospective studies have reported an increase in necrotizing enterocolitis (NEC) during the 48 h following red blood cell (RBC) transfusion. Whether withholding enteral feeding during transfusion decreases the risk of transfusion-associated acute gut injury (TRAGI) in preterm infants is unclear.Study design and methods: In this pilot study, 112 preterm infants with gestational age ≤32 weeks and/or birth weight ≤1500 g were randomly assigned to withholding (NPO) or continuance of feeding (FED) during RBC transfusion. Primary outcome measure was development of NEC (stage ≥ 2) within 72 h of a transfusion and the change in abdominal circumference.Results: One hundred fifty-four transfusion episodes (74 NPO and 80 FED) were analyzed. Demographic characteristics were found to be similar in both groups. There was no difference in rates of NEC (0 versus 3.4%; p = .49) between the NPO and FED groups. The incidence of feeding intolerance was higher in the FED group; however, it was statistically insignificant (1.9 versus 6.8%, p = .36). Abdominal circumference remained similar in both groups in all three consecutive days following transfusion (p>.05).Conclusion: This pilot study does not support withholding feedings during transfusion but is not adequately powered to test the hypothesis that NPO decreases NEC rates. Adequately powered well-designed multicenter trials are still required.
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Affiliation(s)
- Suzan Sahin
- Department of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - H Gozde Kanmaz Kutman
- Department of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Ozlem Bozkurt
- Department of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Funda Yavanoglu Atay
- Department of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - F Emre Canpolat
- Department of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Nurdan Uras
- Department of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - S Suna Oguz
- Department of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Mark A Underwood
- Davis Children's Hospital, University of California, Sacramento, CA, USA
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40
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Abstract
Multicenter groups have reported reductions in the incidence of necrotizing enterocolitis (NEC) among preterm infants over the past 2 decades. These large-scale prevalence studies have coincided with reports from multicenter consortia and single centers of modifications in practice using quality-improvement techniques aimed at either reducing NEC risk specifically or reducing risk of mortality and multiple morbidities associated with extreme prematurity. The modifications in practice have been based on mechanistic studies, epidemiologic association data, and clinical trials. Recent reports from centers modifying practice to reduce NEC are reviewed and select modified/modifiable practices discussed.
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Affiliation(s)
- C Michael Cotten
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke University School of Medicine, Box 2739 DUMC, Durham, NC 27710, USA.
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41
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Murthy S, Parker PR, Gross SJ. Low rate of necrotizing enterocolitis in extremely low birth weight infants using a hospital-based preterm milk bank. J Perinatol 2019; 39:108-114. [PMID: 30291318 DOI: 10.1038/s41372-018-0235-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/16/2018] [Accepted: 09/10/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We examined the effect of two strategies to prevent necrotizing enterocolitis (NEC) in extremely low birth weight (ELBW) infants-adherence to a standardized feeding protocol and use of a hospital-based milk bank to provide exclusive preterm human milk feedings. STUDY DESIGN We conducted a single-center observational study from 2010 to 2015. Infants received preterm human milk, initially trophic feeds from days 7 to 14 after birth, followed by advancement of 15 mL/kg/day to reach a goal of 180 mL/kg/day. Fortification was used selectively for weight gain < 15 g/kg/day. We determined the incidence of NEC, other morbidities, and growth. RESULTS The cohort included 398 ELBW infants who survived to day 14 without congenital anomalies. Mean gestational age was 26.2 ± 1.9 weeks. Maternal milk was used as the sole feeding in 62% of infants; preterm donor milk was used solely or as supplement in 29%. Full feeds were reached at a median of 27 (IQR 23, 33) days. Four infants (1%) developed NEC. CONCLUSION Use of standardized feedings with a hospital-based milk bank is associated with an incidence of NEC lower than previously reported.
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Affiliation(s)
- Swati Murthy
- Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY, USA.,Department of Neonatology, Crouse Hospital, Syracuse, NY, USA
| | - Pamela R Parker
- Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY, USA.,Department of Neonatology, Crouse Hospital, Syracuse, NY, USA
| | - Steven J Gross
- Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY, USA. .,Department of Neonatology, Crouse Hospital, Syracuse, NY, USA.
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42
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Abstract
Enteral feeding and composition play a chief role in the prevention and treatment of necrotizing enterocolitis (NEC). In the face of decades of research on this fatal disease, the exact mechanism of disease is still poorly understood. There is established evidence that providing mother's own breast milk and standardization of feeding regimens leads to a decreased risk for NEC. More recent studies have focused on the provision of donor human milk or an exclusive human milk diet in the endeavor to prevent NEC while still maintaining adequate nutrition to the premature infant. There is growing literature on the provision of specific human milk components and its effect on the incidence of NEC.
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Affiliation(s)
- Diomel de la Cruz
- University of Florida, Department of Pediatrics, Division of Neonatology, Gainesville, FL, USA.
| | - Catalina Bazacliu
- University of Florida, Department of Pediatrics, Division of Neonatology, Gainesville, FL, USA
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43
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Abstract
Necrotizing enterocolitis (NEC) is the most common serious gastrointestinal morbidity in preterm infants. A number of risk factors for NEC have been reported in the literature. With the exception of decreasing gestational age, decreasing birth weight and formula feeding, there is disagreement on the importance of reported risk factors with uncertain causality. Causal risk factors may be observed at any time before the onset of NEC, including prior to an infant's birth. The purpose of this review is to examine the existing literature and summarize risk factors for NEC. This review may be helpful in understanding the epidemiology of NEC and inform the measurement and assessment of risks factors for NEC in research studies and quality improvement projects.
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Affiliation(s)
- Allison Thomas Rose
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Ravi Mangal Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Gephart SM, Moore EF, Fry E. Standardized Feeding Protocols to Reduce Risk of Necrotizing Enterocolitis in Fragile Infants Born Premature or with Congenital Heart Disease: Implementation Science Needed. Crit Care Nurs Clin North Am 2018; 30:457-466. [PMID: 30447806 DOI: 10.1016/j.cnc.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although a unit-adopted standardized feeding protocol (SFP) for neonates is standard of care, implementation strategies for SFPs vary across neonatal and pediatric intensive care. Besides improving growth and reducing feeding interruptions, SFPs reduce risk for necrotizing enterocolitis in infants with heart disease or born premature. The purpose of this article is to bridge the gap between recommended and actual care using SFPs.
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Affiliation(s)
- Sheila M Gephart
- Community and Health Systems Science, College of Nursing, The University of Arizona, PO Box 210203, Tucson, AZ 85721, USA.
| | - Emily F Moore
- Regional cardiology program, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Emory Fry
- Cognitive Medical Systems, 9444 Waples Street, Suite 300, San Diego, CA 92121, USA
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Faraday C, Hamad S, Jones KD, Sim K, Cherian S, James A, Godambe S, New HV, Kroll JS, Clarke P. Characteristics and incidence of transfusion-associated necrotizing enterocolitis in the UK. J Matern Fetal Neonatal Med 2018; 33:398-403. [PMID: 29945481 DOI: 10.1080/14767058.2018.1494147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background and aims: The etiology of necrotizing enterocolitis (NEC) is unclear and postulated as being multifactorial. It has been suggested that one causative factor is the transfusion of packed red blood cells (PRBCs) leading to the disease entity commonly referred to as transfusion-associated NEC (TANEC). TANEC has been reported in North America but its incidence has not been formally investigated in the UK. Our aims were to identify the incidence of NEC and TANEC in tertiary-level UK neonatal units and to describe characteristics of TANEC cases.Materials and methods: Using strict case definitions for NEC and TANEC, we undertook a retrospective review to estimate the incidence of TANEC cases occurring in four UK tertiary-level centers during a 38-month period.Results: Of 8007 consecutive neonatal admissions of all gestations to the four centers, 68 babies went on to develop NEC and all affected infants were of very low birth weight (VLBW); 34 of these had previously received a transfusion of PRBCs but did not fit the diagnostic criteria for TANEC, whereas 15 (22%) of the 68 babies with NEC qualified as TANEC cases. UK cases occurred at an earlier postnatal age than cases reported in multiple large North American series and were of a lower birth weight.Conclusions: We have confirmed the presence of TANEC in the UK VLBW neonatal population. Its incidence lies within the wide range described in previous reports of this phenomenon globally, though with some local variation in characteristics. Further work is needed to clarify causation, pathophysiology, and possible mechanisms of prevention of TANEC.
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Affiliation(s)
- Christopher Faraday
- Neonatal Unit, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Sheima Hamad
- Neonatal Unit, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Kelsey D Jones
- Neonatal Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Kathleen Sim
- Department of Medicine, Section of Paediatrics, Imperial College, London, UK
| | - Shobha Cherian
- Neonatal Unit, University Hospital of Wales, Cardiff, UK
| | - Anitha James
- Neonatal Unit, Royal Gwent Hospital, Newport, UK
| | - Sunit Godambe
- Neonatal Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Helen V New
- NHS Blood and Transplant/Department of Haematology, Imperial College, London, UK
| | - J Simon Kroll
- Department of Medicine, Section of Paediatrics, Imperial College, London, UK
| | - Paul Clarke
- Neonatal Unit, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
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Reducing time to initiation and advancement of enteral feeding in an all-referral neonatal intensive care unit. J Perinatol 2018; 38:936-943. [PMID: 29740193 DOI: 10.1038/s41372-018-0110-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 03/08/2018] [Accepted: 03/14/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Decrease time to enteral feeding initiation and advancement. STUDY DESIGN In our all-referral neonatal intensive care unit, we developed an evidence-based guideline addressing feeding initiation and advancement. During 6 months before and 7 months after guideline implementation, we measured time to initiate feeding, time to 100 ml/kg/day of feeding, gastric residual measurement frequency, and incidence of necrotizing enterocolitis (balancing measure). RESULT Two hundred twenty-three infants were studied. Time from admission to feeding initiation was shorter after guideline implementation (mean 0.5 days [95% CI: 0.4-0.7] vs. 1.1 days [95% CI: 0.7-1.5], p = 0.01). Time from admission to 100 ml/kg/day feeding was also shorter (3.6 days [95% CI: 2.8-4.4] vs. 6.2 days [95% CI: 4.4-8.1], p = 0.01). After guideline implementation, routine gastric residual measurements were discontinued. CONCLUSION After implementation of an enteral feeding guideline, which included discontinuation of routine gastric residual assessment, we observed a faster initiation of enteral feeding and shorter time to reach 100 ml/kg/day.
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47
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Olsen SL, Park ND, Tracy K, Younger D, Anderson B. Implementing Standardized Feeding Guidelines, Challenges, and Results. Neonatal Netw 2018; 37:218-223. [PMID: 30567919 DOI: 10.1891/0730-0832.37.4.218] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this article was to develop standardized nutritional guidelines that would promote increased growth velocity (GV) in premature infants. DESIGN Evidence-based standardized nutritional guidelines were developed. Guidelines included total parenteral nutrition advancement; enteral feeding advancement; and a bedside nurse gastric residual management algorithm. Staff education was given. Guideline compliance was measured. Nutritional intake and daily weights were recorded. SAMPLE Infants of birth weight <1,500 grams who were admitted to the NICU before day of life four. MAIN OUTCOME VARIABLE Increase in GV from 12 to 15 g/kg/d. RESULTS Growth velocity was unchanged. Compliance to the nutritional guidelines was 70 percent. No difference was seen in length of stay. Rate of necrotizing enterocolitis was decreased.
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Ananthan A, Balasubramanian H, Rao S, Patole S. Clinical Outcomes Related to the Gastrointestinal Trophic Effects of Erythropoietin in Preterm Neonates: A Systematic Review and Meta-Analysis. Adv Nutr 2018; 9:238-246. [PMID: 29767696 PMCID: PMC5952937 DOI: 10.1093/advances/nmy005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 01/11/2018] [Indexed: 01/01/2023] Open
Abstract
Erythropoietin (EPO) plays an important role in the development and maturation of the gastrointestinal tract. Recombinant EPO (rEPO) has been used to prevent anemia of prematurity. The gastrointestinal trophic effects of EPO may reduce feeding intolerance and necrotizing enterocolitis (NEC) in preterm neonates. The aim of this systematic review of randomized controlled trials (RCTs) was to evaluate the effects of rEPO on clinical outcomes such as feeding intolerance, stage II or higher NEC, any stage NEC, sepsis, retinopathy of prematurity, and bronchopulmonary dysplasia in preterm neonates. Twenty-five RCTs (intravenous: 13; subcutaneous: 10; enteral: 2; n = 4025) were eligible for inclusion. Meta-analysis of data from 17 RCTs (rEPO compared with placebo) with the use of a fixed-effects model showed no significant effect of rEPO on stage II or higher NEC (RR: 0.87; 95% CI: 0.64, 1.19; P = 0.39). Meta-analysis of data from 25 RCTs (rEPO compared with placebo) showed that rEPO significantly decreased the risk of any stage NEC [cases/total sample: 120/2058 (5.83%) compared with 146/1967 (7.42%); RR: 0.77; 95% CI: 0.61, 0.97; P = 0.03]. Only one RCT reported on time to full feedings. Meta-analysis of data from 15 RCTs showed a significant reduction in late-onset sepsis after rEPO administration (RR: 0.81; 95% CI: 0.71, 0.94; P = 0.004). Meta-analysis of 13 RCTs showed no significant effect of rEPO on mortality, retinopathy of prematurity, and bronchopulmonary dysplasia. Prophylactic rEPO had no effect on stage II or higher NEC, but it reduced any stage NEC, probably by reducing feeding intolerance, which is often labeled as stage I NEC. Adequately powered RCTs are required to confirm these findings.
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Affiliation(s)
- Anitha Ananthan
- Department of Neonatology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India,Address correspondence to AA (e-mail: )
| | | | - Shripada Rao
- Department of Neonatal Pediatrics, Princess Margaret Hospital for Children, Perth, Western Australia, Australia,Center for Neonatal Research and Education, University of Western Australia, Perth, Australia
| | - Sanjay Patole
- Center for Neonatal Research and Education, University of Western Australia, Perth, Australia,Department of Neonatal Pediatrics, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
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Salas AA, Li P, Parks K, Lal CV, Martin CR, Carlo WA. Early progressive feeding in extremely preterm infants: a randomized trial. Am J Clin Nutr 2018; 107:365-370. [PMID: 29529231 PMCID: PMC6692650 DOI: 10.1093/ajcn/nqy012] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 01/11/2018] [Indexed: 11/13/2022] Open
Abstract
Background Due to insufficient evidence, extremely preterm infants (≤28 wk of gestation) rarely receive early progressive feeding (small increments of feeding volumes between 1 and 4 d after birth). We hypothesized that early progressive feeding increases the number of full enteral feeding days in the first month after birth. Objective The aim of this study was to determine the feasibility and efficacy of early progressive feeding in extremely preterm infants. Design In this single-center randomized trial, extremely preterm infants born between September 2016 and June 2017 were randomly assigned to receive either early progressive feeding without trophic feeding (early feeding group) or delayed progressive feeding after a 4-d course of trophic feeding (delayed feeding group). Treatment allocation occurred before or on feeding day 1. The primary outcome was the number of full enteral feeding days in the first month after birth. Secondary outcomes were death, necrotizing enterocolitis (NEC), culture-proven sepsis, growth percentiles at 36 wk postmenstrual age, use of parenteral nutrition, and need for central venous access. Results Sixty infants were included (median gestational age: 26 wk; mean ± SD birth weight: 832 ± 253 g). The primary outcome differed between groups (median difference favoring the early feeding group: +2 d; 95% CI: 0, 3 d; P = 0.02). Early progressive feeding reduced the use of parenteral nutrition (4 compared with 8 d; P ≤ 0.01) and the need for central venous access (9 compared with 13 d; P ≤ 0.01). The outcome of culture-proven sepsis (10% compared with 27%; P = 0.18), restricted growth (weight, length, and head circumference <10th percentile) at 36 wk postmenstrual age (25% compared with 50%; P = 0.07), and the composite outcome of NEC or death (27% compared with 20%; P = 0.74) did not differ between groups. Conclusion Early progressive feeding increases the number of full enteral feeding days in extremely preterm infants. This trial was registered at www.clinicaltrials.gov as NCT02915549.
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Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, School of Medicine; and Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Peng Li
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Kelli Parks
- Department of Pediatrics, School of Medicine; and Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Charitharth V Lal
- Department of Pediatrics, School of Medicine; and Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Camilia R Martin
- Department of Neonatology and Division of Translational Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Waldemar A Carlo
- Department of Pediatrics, School of Medicine; and Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
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Dako J, Buzzard J, Jain M, Pandey R, Groh-Wargo S, Shekhawat P. Slow enteral feeding decreases risk of transfusion associated necrotizing enterocolitis. J Neonatal Perinatal Med 2018; 11:231-239. [PMID: 29843272 DOI: 10.3233/npm-181773] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Necrotizing Enterocolitis (NEC) is a multifactorial condition where PRBC transfusion is associated with necrotizing enterocolitis (TANEC) in about a third of all cases of NEC. We have investigated the role of feeding practices in incidence of TANEC. We sought to compare infants diagnosed with TANEC versus infants diagnosed with classic NEC and investigated the effects of a standardized slow enteral feeding (SSEF) protocol on TANEC incidence as well as the effects of SSEF on growth of infants with NEC. METHODS We conducted a retrospective cohort study, where medical records of infants born in a tertiary care neonatal intensive care unit (level IIIb) from January 1997 to May 2014 with birth weight < 1500 grams and gestational age≤34 weeks with NEC stage IIa or greater according to the modified Bell's staging were reviewed. RESULTS During the study period, 111 infants developed NEC, and 41/111 (37%) were diagnosed with TANEC. Infants with TANEC were smaller, more premature, had higher SNAPPE scores and were more anemic prior to transfusion compared with infants with 'classic NEC'. The severity of NEC did not differ between the two groups, however, infants with TANEC had worse outcomes and longer NICU stays. Introduction of SSEF protocol, led to a significant decrease in TANEC. There was no difference in weight and head circumference of infants in the two groups at 2 years corrected age. CONCLUSION SSEF led to a significant reduction in the incidence of TANEC without impairing growth at 2 years corrected age.
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MESH Headings
- Blood Transfusion/methods
- Enteral Nutrition/methods
- Enterocolitis, Necrotizing/etiology
- Enterocolitis, Necrotizing/physiopathology
- Enterocolitis, Necrotizing/therapy
- Female
- Gestational Age
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/physiopathology
- Infant, Premature, Diseases/therapy
- Infant, Very Low Birth Weight
- Male
- Retrospective Studies
- Risk Factors
- Transfusion Reaction
- Treatment Outcome
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Affiliation(s)
- J Dako
- Department of Pediatrics, Division of Neonatology, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - J Buzzard
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - M Jain
- Department of Pediatrics, Division of Neonatology, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - R Pandey
- Department of Pediatrics, Division of Neonatology, University of Texas Health Science Center at Houston, TX, USA
| | - S Groh-Wargo
- Department of Pediatrics, Division of Neonatology, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - P Shekhawat
- Department of Pediatrics, Division of Neonatology, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
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