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Borenstein-Levin L, Haj A, Riskin A, Dinur G, Littner Y, Hochwald O, Kugelman A. Oxygenation Instability during Bolus versus Continuous Feeding among Very Low Birth Weight Premature Infants, Supported by Noninvasive Ventilation: A Randomized Prospective Study. Am J Perinatol 2024; 41:e2341-e2347. [PMID: 37494585 DOI: 10.1055/s-0043-1771257] [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: 07/28/2023]
Abstract
OBJECTIVE This study aimed to compare oxygenation instability, as documented by the oxygen saturation (SpO2) histograms, during bolus (over 30 minutes) versus continuous (over 2 hours) feeding among very low birth weight (VLBW) premature infants, supported with noninvasive ventilation (NIV). STUDY DESIGN This was a randomized prospective study. VLBW infants supported with NIV received three consecutive feeds in a random order of bolus-continuous-bolus or continuous-bolus-continuous. During each feed, 30 minutes and 2 hours histograms were documented. RESULTS Twenty-four infants (birth weight [mean ± standard deviation, SD] 820 ± 168 g, gestational age [mean ± SD] 27.0 ± 1.6 weeks) were included in our study (12 infants started with bolus feeding and 12 with continuous feeding) and 72 histograms were obtained (36 during bolus feeding and 36 during continuous feeding). No differences in mean fraction of inspired oxygen (FiO2), and number of apnea events were observed between the two feeding modes. Oxygenation instability as assessed by time spent in different SpO2 ranges and histogram types (stable or unstable) was comparable during bolus and continuous feedings. Changing feeding mode from bolus to continuous or vice versa did not significantly change the oxygenation instability of the group, though individual infants did show a consistence response to feeding length changes. CONCLUSION Among VLBW infants supported with NIV, oxygenation instability, as documented by SpO2 histograms, was comparable between bolus and continuous feedings. Individual infants may benefit from specific feeding length, and this can be easily demonstrated by the SpO2 histograms. KEY POINTS · Feeding length did not affect oxygenation instability of preterm infants on noninvasive respiratory Support.. · Oxygen saturation histograms allow objective quantification of oxygenation instability at the bedside.. · Individual infants benefit from specific feeding length, as demonstrated by SpO2 histograms..
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Affiliation(s)
- Liron Borenstein-Levin
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ahmad Haj
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Arieh Riskin
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Neonatal Intensive Care Unit, Bnai Zion Medical Center, Haifa, Israel
| | - Gil Dinur
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yoav Littner
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ori Hochwald
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Amir Kugelman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Borenstein-Levin L, Riskin A, Hochwald O, Timstut F, Sendler S, Shoris I, Littner Y, Dinur G, Kugelman A. Continuous versus Bolus Gastric Tube Feeding in Very Low Birth Weight Infants Supported with Noninvasive Respiratory Support: A Randomized, Pilot Study. Am J Perinatol 2024; 41:e394-e399. [PMID: 36096134 DOI: 10.1055/s-0042-1755551] [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: 11/01/2022]
Abstract
OBJECTIVES This study aimed to compare time to full feeding (TFF) between continuous gastric feeding (CGF) and bolus feeding (BF) in very low birth weight (VLBW) infants supported with noninvasive ventilation (NIV) and to evaluate feasibility and identify methodological pitfalls for future large-scale studies. STUDY DESIGN This study is a randomized controlled, prospective, pilot study. VLBW premature infants, supported with NIV, were randomized while still on trophic feeding <20 mL/kg/day to receive feeding over 2 hours of CGF or over 15- to 30-minute BF. The primary outcome was TFF. Analysis was done by intention to treat. RESULTS Overall, 32 infants were included in this analysis, 17 in the CGF group and 15 in the BF group. Infants in the CGF group were significantly younger than the BF group (mean ± standard deviation [SD] gestational age [GA] 26.9 ± 1.2 vs. 28.9 ± 1.5 weeks, respectively). TFF was comparable with median (interquartile range [IQR]) for the two groups, 10.0 (10.0, 19.0) days in the BF group versus 12.0 (9.0, 13.0) days in the CGF group (p = 0.59). Feeding length was not found to significantly affect TFF in multivariate analysis correcting for GA. Groups were comparable in weight gain, gastrointestinal complications, length of NIV, bronchopulmonary dysplasia incidence, and age at discharge. Most infants from both groups (60% of BF and 70% of CGF) required changes in feeding length. CONCLUSION In this pilot study, among VLBW infants supported with NIV, TFF was comparable between the BF and CGF groups. These results should be interpreted with caution due to the small sample size and despite the multivariate analysis correcting for the different GA. Interestingly, most infants required changes in feeding length regardless of their allocation. This feasibility study emphasizes the need for careful attention to randomization and strict feeding protocols including criteria for switching allocation in future large-scale studies aimed at determining the preferred feeding length during NIV in VLBW infants. KEY POINTS · Among infants supported with NIV, length of feeding affects gastric venting.. · BF might increase gastrointestinal reflux, while continuous feeding hinders gastric decompression.. · Among infants supported by NIV, feeding tolerance was comparable between bolus and continuous groups..
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Affiliation(s)
- Liron Borenstein-Levin
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Arieh Riskin
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Neonatal Intensive Care Unit, Bnai Zion Medical Center, Haifa, Israel
| | - Ori Hochwald
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Fanny Timstut
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Sofia Sendler
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Irit Shoris
- Neonatal Intensive Care Unit, Bnai Zion Medical Center, Haifa, Israel
| | - Yoav Littner
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Dinur
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Amir Kugelman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Kumar V, Thakur A, Garg P, Kler N. Comparison of Three Modalities of Feeding in Preterm Infants ≤32 Weeks and ≤1,250 G: A Randomized Controlled Trial. Am J Perinatol 2024; 41:e1792-e1799. [PMID: 37059454 DOI: 10.1055/a-2074-1960] [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: 04/16/2023]
Abstract
OBJECTIVE Early establishment of enteral feeds is desirable in very preterm infants, but it may be associated with feeding intolerance. Several feeding methods have been studied with no strong evidence to suggest the preferred feeding method to establish early full enteral feeds. We studied three modalities of feeding in preterm infants ≤32 weeks and ≤1,250 g: continuous infusion (CI), intermittent bolus by infusion (IBI), and intermittent bolus by gravity (IBG) for their effect on time to reach full enteral feeds of 180 mL/kg/d. STUDY DESIGN We randomized 146 infants, 49 infants in each CI and IBI group and 48 infants in the IBG group. In the CI group, feeds were delivered by an infusion pump continuously over 24 hours. In the IBI group, feeds were given every 2 hours and infused over 15 minutes by an infusion pump. In the IBG group, feeds were delivered by gravity over 10 to 30 minutes. The intervention was continued till infants reached direct breast/cup feeds. RESULTS The mean (standard deviation) gestation in CI, IBI, and IBG groups were 28.4 (2.2), 28.5(1.9), and 28.6 (1.8) weeks, respectively. The time to reach full feeds in CI, IBI, and IBG were not significantly different (median [interquartile range]: 13 [10-16], 11.5 [9-17], and 13 [9.5-14.2] d, respectively, p = 0.71). The proportions of infants who developed feeding intolerance in CI, IBI, and IBG were similar (n [%]: 21 [51.2%], 20 [52.6%], and 22 [64.7%], respectively, p = 0.45). There was no difference in necrotizing enterocolitis ≥2 (p = 0.80), bronchopulmonary dysplasia (p = 0.86), intraventricular hemorrhage ≥2 (p = 0.35), patent ductus arteriosus requiring treatment (p = 0.44), retinopathy of prematurity requiring treatment (p = 0.51), and growth parameters at discharge. CONCLUSION In preterm infants, ≤32 weeks of gestation and birth weight ≤1,250 g, there was no difference in time to reach full enteral feeds in the three modalities of feeding. This study is registered with Clinical Trials Registry India (CTRI) and the registration number is CTRI/2017/06/008792. KEY POINTS · Gavage feeding in preterm infants is either continuous or intermittent bolus feeding.. · Intermittent bolus feeding was evaluated in a controlled time by infusion over 15 minutes.. · The time to reach full feeds was comparable for all three methods..
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Affiliation(s)
- Vijay Kumar
- Department of Neonatology, Institute of Medical Sciences and Sum Hospital, Bhubaneswar, Odisha, India
| | - Anup Thakur
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Pankaj Garg
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Neelam Kler
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
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Sallam M, Breuer R, Wrotniak B, Alibrahim O. Necrotizing Enterocolitis Complicating Severe RSV Bronchiolitis in PICU Settings. Clin Pediatr (Phila) 2024:99228241227763. [PMID: 38303673 DOI: 10.1177/00099228241227763] [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] [Indexed: 02/03/2024]
Abstract
This retrospective study aims to analyze the baseline characteristics and factors associated with poor outcomes in patients with necrotizing enterocolitis (NEC) complicating respiratory syncytial virus (RSV) infection. Using the Virtual Pediatric Systems data registry, patients under 2 years admitted to the pediatric intensive care unit (PICU) were screened. Patients with documented RSV infection and NEC, intestinal perforation, noninfectious gastroenteritis/colitis, or pneumatosis intestinalis occurring around the timing of RSV bronchiolitis diagnosis were included. Out of the screened patients, 41 were analyzed. Most patients (93%) were aged 30 days to 2 years, one-third had baseline anatomical cardiac defects, and 20% history of prematurity. Median PICU length of stay was 11.7 days. Seven patients died before hospital discharge. While not statistically significant, nonsurvivors tended to exhibit higher PRISM-3 scores, more acidemia, and lower systolic blood pressure. These findings emphasize the need for cautious assessment of gastrointestinal symptoms in critically ill patients with RSV infection.
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Affiliation(s)
- Mohammad Sallam
- University at Buffalo, Buffalo, NY, USA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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Verma RP, Sahni D, Fogel J. Bolus Feeding Via Gastric Versus Oral Routes in Very Preterm Neonates. JOURNAL OF MOTHER AND CHILD 2024; 28:1-7. [PMID: 38411990 PMCID: PMC10898621 DOI: 10.34763/jmotherandchild.20242801.d-23-00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/01/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND We intend to investigate the association of bolus orogastric tube (BOG) and nipple bottle (N) feedings with postnatal growth in very premature neonates (VPN: gestational age between 28 and 33 weeks). MATERIAL AND METHODS The days of life (DOL) to achieve full combined oral and gastric enteral nutrition (FEN) and attain body weight (BW) of 2200 g (Wt22) and the length of hospitalization (LOH) were retrospectively associated with clinical and BOG and N feeding-related variables via multivariate regression analyses. Correlations were performed to ascertain the strength of associations. RESULTS In a cohort of 127 VPN, FEN demonstrated negative associations with gestational age (GA) and LOH and Wt22 with birth weight (BW). FEN showed positive associations with nil by mouth and intravenous fluid-nutrition days and with DOL to start and achieve full nipple feeding. LOH was associated with days on antibiotics and DOL to start and achieve full nipple feeding. Wt22 was associated with DOL to achieve full nipple feeding. The start day of BOG feeding had no independent associations and weak, highly significant positive correlations with Wt22, LOH, and FEN. CONCLUSION Bolus orogastric tube feeding has no independent implications for postnatal growth, duration of hospitalization, or chronological age to attain full enteral nutrition in VPN unless combined with nipple feeding to provide enteral nutrition. Oral bottle feeding accelerates postnatal catch-up growth and full enteral nutrition acquisition while reducing hospitalization duration. Initiating nipple feeding at 32 weeks of postmenstrual age may be safe in stable VPN. Antibiotic therapy increases hospitalization duration.
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Affiliation(s)
- Rita P. Verma
- Nassau University Medical Center, East Meadow, NY11554, NYC Health+ Hospitals/South Brooklyn Hospital, Coney Island, NY11235
| | - Deepank Sahni
- Nassau University Medical Center, East Meadow, New York, 11554
| | - Joshua Fogel
- Nassau University Medical Center, New York, NY 11210
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Lamireau N, Greiner E, Hascoët JM. Risk factors associated with necrotizing enterocolitis in preterm infants: A case-control study. Arch Pediatr 2023; 30:477-482. [PMID: 37704519 DOI: 10.1016/j.arcped.2023.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 03/06/2023] [Accepted: 07/07/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is the most common life-threatening gastrointestinal emergency in prematurity. The pathophysiology is multifactorial and remains incompletely understood. Early diagnosis and treatment could reduce the risk of mortality and morbidity. We aimed to identify factors associated with NEC in preterm newborns. METHOD This case-control study included all preterm newborns presenting with NEC and managed between January 1, 2009 and December 31, 2018 in the neonatal intensive care unit of Nancy. For each case, two controls were matched according to three criteria: gestational age (WG), date of birth, and mode of delivery. Antenatal, peripartum, and postnatal risk factors prior to NEC were analyzed. RESULTS A total of 292 infants were involved in the study, 113 of whom had NEC. Mean gestational age for newborns with NEC was 29 WG, and mean birth weight, 1340 g. Only early-onset infection was identified as a significant risk factor for NEC (15% vs. 6.6% for infection p<0.04, and 28.3% vs. 16.4% p<0.02 for infection and sepsis, NEC vs. controls, respectively). Late-onset feeding and initial continuous enteral feeding were significantly associated with the occurrence of more severe NEC (p<0.02 and p = 0.03, respectively). CONCLUSION The results of this study are consistent with intestinal dysbiosis being a risk factor for NEC. Early-onset infection was found to be a significant risk factor. Enteral feeding practice may also be associated with NEC.
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Affiliation(s)
- Nathalie Lamireau
- Division of Neonatology, Maternité Régionale Universitaire, CHRU, Nancy, France.
| | - Eva Greiner
- Division of Neonatology, Maternité Régionale Universitaire, CHRU, Nancy, France
| | - Jean-Michel Hascoët
- Division of Neonatology, Maternité Régionale Universitaire, CHRU, Nancy, France; Lorraine University, DevAH 3450, 54500 Vandœuvre-lès-Nancy, France
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Itriago E, Trahan KF, Massieu LA, Garg PM, Premkumar MH. Current Practices, Challenges, and Recommendations in Enteral Nutrition After Necrotizing Enterocolitis. Clin Perinatol 2023; 50:683-698. [PMID: 37536772 DOI: 10.1016/j.clp.2023.04.009] [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: 08/05/2023]
Abstract
Necrotizing enterocolitis (NEC) is a neonatal disease with high mortality and morbidity. There is a lack of evidence-based recommendations on nutritional rehabilitation following NEC, and much of the current practice is guided by institutional policies and expert opinions. After a diagnosis of NEC, infants are exposed to an extended period of bowel rest and a prolonged course of antibiotics. Recognizing the patient characteristics that predict nutritional tolerance, early initiation of enteral nutrition, minimizing periods of bowel rest and antibiotic exposure, and standardization of dietary practices are the mainstay of post-NEC nutrition.
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Affiliation(s)
- Elena Itriago
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Kimberly Fernandez Trahan
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Leonor Adriana Massieu
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Parvesh M Garg
- Wake Forest School of Medicine, Brenner Children's Hospital, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Muralidhar H Premkumar
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
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de Campos VP, Vien I, Marino LV, Lucchese-Lobato F. Translation, cross-cultural adaptation, content validation, and clinical feasibility of the nutritional pathway for infants with congenital heart disease before surgery. J Pediatr (Rio J) 2023; 99:456-463. [PMID: 37060920 PMCID: PMC10492146 DOI: 10.1016/j.jped.2023.02.007] [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: 10/03/2022] [Revised: 02/26/2023] [Accepted: 02/27/2023] [Indexed: 04/17/2023] Open
Abstract
OBJECTIVE The aim of this study is to translate and validate the Nutritional Pathway for Infants with Congenital Heart Disease before Surgery British nutritional protocol into Brazilian Portuguese and test its clinical feasibility for specialized clinicians in Brazilian hospitals. METHOD The translation and validation process followed strict methodological standards over the following steps: 1) initial translation; 2) synthesis; 3) back-translation; 4) expert committee content validation, and pre-test clinical feasibility with 30 health professionals. Data were collected through the Research Electronic Data Capture software data system, and then extracted and analyzed through statistical analysis software. RESULTS The culturally adapted version was considered equivalent to the original. In the first round, 82% agreement was achieved, and after consensus, there was 100% agreement among the experts. Regarding the ease of use of the protocol in clinical practice, the instrument obtained a minimum agreement rate of 93.4% and a 0.92 content validity index. CONCLUSIONS The results indicate that the instrument adapted to Brazilian Portuguese has high content validity, and high reliability among the experts, suggesting a high level of accuracy of the instrument and cultural adaptation for Brazilian culture and medical systems. It was easily understandable by health professionals, as well as simple to apply in clinical practice. The Nutritional protocol for preoperative infants with congenital heart disease can reproduce the outcomes found in the pilot of this instrument carried out in the United Kingdom, which may promote better pre-surgical nutritional status for infants with congenital heart disease in Brazil.
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Affiliation(s)
| | - Isabele Vien
- Institute of Cardiology, University Foundation in Cardiology, Porto Alegre, RS, Brazil
| | - Luise V Marino
- University Hospital Southampton NHS, Foundation Trust (UHSFT), Southampton, UK
| | - Fernanda Lucchese-Lobato
- Institute of Cardiology, University Foundation in Cardiology, Porto Alegre, RS, Brazil; Hospital da Criança Santo Antônio, Irmandade Santa Casa de Misericórdia, Porto Alegre, RS, Brazil; Columbia University Irving Medical Center, Child and Adolescent Psychiatry Division, New York, NY, USA.
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Yavanoglu Atay F, Bozkurt O, Sahin S, Bidev D, Sari FN, Uras N. A Comparison of Slow Infusion Intermittent Feeding versus Gravity Feeding in Preterm Infants: A Randomized Controlled Trial. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1389. [PMID: 37628387 PMCID: PMC10453490 DOI: 10.3390/children10081389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/01/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND The transition to full enteral feeding is important for ensuring adequate growth in preterm infants. AIMS The aim of this study was to investigate the effects of two different intermittent feeding methods on the transition to full enteral feeding in preterm infants. STUDY DESIGN A prospective, randomized controlled study was conducted in a neonatology and perinatology center. SUBJECTS Preterm infants with a gestational age between 24 + 0/7 and 31 + 6/7 were included in this study. They were divided into two groups: the SIF (slow infusion feeding) group and the IBF (intermittent bolus feeding) group. In the SIF group, feed volumes were administered over one hour using an infusion pump through an orogastric tube, with feeding occurring every three hours. The IBF group received enteral feeding using a gravity-based technique with a syringe through an orogastric tube, completed within 10 to 30 min. OUTCOME MEASURES The primary outcome was the achievement of full enteral feeding and the occurrence of feeding intolerance. RESULTS A total of 103 infants were enrolled in the study (50 in SIF and 53 in IBF). The time to achieve full enteral feeding did not differ significantly between the two groups (p = 0.20). The SIF group had significantly fewer occurrences in which gastric residual volume exceeded 50% (p = 0.01). Moreover, the SIF group had a significantly shorter duration of non-per-oral (NPO) status than the IBF group (p = 0.03). CONCLUSIONS It is our contention that the use of the SIF method as an alternative feeding method is appropriate for infants with feeding intolerance and those at high risk of feeding intolerance.
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Affiliation(s)
- Funda Yavanoglu Atay
- Department of Pediatrics, Division of Neonatology, Umraniye Training and Research Hospital, 34764 Istanbul, Türkiye
| | - Ozlem Bozkurt
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Kocaeli University, 41380 Izmit, Türkiye
| | - Suzan Sahin
- Department of Pediatrics, Division of Neonatology, Buca Seyfi Demirsoy Training and Research Hospital, Izmir Democracy University, 35140 Izmir, Türkiye
| | - Duygu Bidev
- Neonatal Care Intensive Unit, Koru Sincan Hospital, 06934 Ankara, Türkiye
| | - Fatma Nur Sari
- Department of Pediatrics, Division of Neonatology, Ankara City Hospital, 06800 Ankara, Türkiye
| | - Nurdan Uras
- Department of Pediatrics, Division of Neonatology, Faculty of Medicine, Istinye University, 34517 Istanbul, Türkiye
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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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Ackley D, Wang H, D'Angio CT, Meyers J, Young BE. Human milk-derived fortifiers are linked with feed extension due to Hypoglycemia in infants <1250 g or <30 weeks: a matched retrospective chart review. J Perinatol 2023; 43:624-628. [PMID: 36991141 PMCID: PMC10717733 DOI: 10.1038/s41372-023-01654-z] [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: 10/12/2022] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To investigate differences in hypoglycemia and extended feed prescriptions among premature infants provided bovine-derived human milk fortifiers (Bov-fort) with mother's milk or formula vs human milk-derived human milk fortifiers (HM-fort) with mother's milk or donor human milk. STUDY DESIGN This was a retrospective chart review (n = 98). Infants receiving HM-fort were matched with infants receiving Bov-fort. Blood glucose values and feed orders were retrieved from the electronic medical record. RESULTS Prevalence of ever having blood glucose <60 mg/dL was 39.1% in the HM-fort group vs. 23.9% in the Bov-fort group (p = 0.09). Blood glucose ≤45 mg/dL occurred in 17.4% of HM-fort vs 4.3% in Bov-fort (p = 0.07). Feeds were extended for any reason in 55% of HM-fort vs. 20% of Bov-fort (p < 0.01). Feed extension due to hypoglycemia occurred in 24% of HM-fort vs. 0% of Bov-fort (p < 0.01). CONCLUSION Predominately HM-based feeds are associated with feed extension due to hypoglycemia. Prospective research is warranted to elucidate underlying mechanisms.
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Affiliation(s)
- Danielle Ackley
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Hongyue Wang
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Carl T D'Angio
- Division of Neonatology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Jeffrey Meyers
- Division of Neonatology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Bridget E Young
- Division of Pediatric Allergy and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Embleton ND, Jennifer Moltu S, Lapillonne A, van den Akker CHP, Carnielli V, Fusch C, Gerasimidis K, van Goudoever JB, Haiden N, Iacobelli S, Johnson MJ, Meyer S, Mihatsch W, de Pipaon MS, Rigo J, Zachariassen G, Bronsky J, Indrio F, Köglmeier J, de Koning B, Norsa L, Verduci E, Domellöf M. Enteral Nutrition in Preterm Infants (2022): A Position Paper From the ESPGHAN Committee on Nutrition and Invited Experts. J Pediatr Gastroenterol Nutr 2023; 76:248-268. [PMID: 36705703 DOI: 10.1097/mpg.0000000000003642] [Citation(s) in RCA: 59] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To review the current literature and develop consensus conclusions and recommendations on nutrient intakes and nutritional practice in preterm infants with birthweight <1800 g. METHODS The European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee of Nutrition (CoN) led a process that included CoN members and invited experts. Invited experts with specific expertise were chosen to represent as broad a geographical spread as possible. A list of topics was developed, and individual leads were assigned to topics along with other members, who reviewed the current literature. A single face-to-face meeting was held in February 2020. Provisional conclusions and recommendations were developed between 2020 and 2021, and these were voted on electronically by all members of the working group between 2021 and 2022. Where >90% consensus was not achieved, online discussion meetings were held, along with further voting until agreement was reached. RESULTS In general, there is a lack of strong evidence for most nutrients and topics. The summary paper is supported by additional supplementary digital content that provide a fuller explanation of the literature and relevant physiology: introduction and overview; human milk reference data; intakes of water, protein, energy, lipid, carbohydrate, electrolytes, minerals, trace elements, water soluble vitamins, and fat soluble vitamins; feeding mode including mineral enteral feeding, feed advancement, management of gastric residuals, gastric tube placement and bolus or continuous feeding; growth; breastmilk buccal colostrum, donor human milk, and risks of cytomegalovirus infection; hydrolyzed protein and osmolality; supplemental bionutrients; and use of breastmilk fortifier. CONCLUSIONS We provide updated ESPGHAN CoN consensus-based conclusions and recommendations on nutrient intakes and nutritional management for preterm infants.
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Affiliation(s)
| | | | | | - Chris H P van den Akker
- the Department of Pediatrics - Neonatology, Amsterdam UMC - Emma Children's Hospital, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Virgilio Carnielli
- Polytechnic University of Marche and Division of Neonatology, Ospedali Riuniti, Ancona, Ancona, Italy
| | - Christoph Fusch
- the Department of Pediatrics, Nuremberg General Hospital, Paracelsus Medical School, Nuremberg, Germany
- the Division of Neonatology, Department of Pediatrics, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Konstantinos Gerasimidis
- the Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Johannes B van Goudoever
- Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Nadja Haiden
- the Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Silvia Iacobelli
- the Réanimation Néonatale et Pédiatrique, Néonatologie - CHU La Réunion, Saint-Pierre, France
| | - Mark J Johnson
- the Department of Neonatal Medicine, University Hospital Southampton NHS Trust, Southampton, UK
- the National Institute for Health Research Biomedical Research Centre Southampton, University Hospital Southampton NHS Trust and University of Southampton, Southampton, UK
| | - Sascha Meyer
- the Department of General Paediatrics and Neonatology, University Hospital of Saarland, Homburg, Germany
| | - Walter Mihatsch
- the Department of Pediatrics, Ulm University, Ulm, Germany
- the Department of Health Management, Neu-Ulm University of Applied Sciences, Neu-Ulm, Germany
| | - Miguel Saenz de Pipaon
- the Department of Pediatrics-Neonatology, La Paz University Hospital, Autonoma University of Madrid, Madrid, Spain
| | - Jacques Rigo
- the Neonatal Unit, University of Liège, CHR Citadelle, Liège, Belgium
| | - Gitte Zachariassen
- H.C. Andersen Children's Hospital, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Jiri Bronsky
- the Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Flavia Indrio
- the Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Jutta Köglmeier
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Barbara de Koning
- the Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lorenzo Norsa
- the Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIIII, Bergamo, Italy
| | - Elvira Verduci
- the Department of Health Sciences, University of Milan, Milan, Italy
- the Department of Paediatrics, Ospedale dei Bambini Vittore Buzzi, Milan, Italy
| | - Magnus Domellöf
- the Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
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Three-hourly versus two-hourly feeding interval in stable preterm infants: an updated systematic review and meta-analysis of randomized controlled trials. Eur J Pediatr 2022; 181:2075-2086. [PMID: 35147747 DOI: 10.1007/s00431-022-04405-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/09/2022] [Accepted: 01/31/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Evidence from randomized controlled trials (RCTs) suggests that three-hourly feeding is safe and might help achieve full feeds earlier in preterm infants. We systematically compared the benefits and harms of three-hourly and two-hourly feeding schedules in preterm infants. We searched electronic databases (MEDLINE, CINAHL, Embase, Web of Science, and Scopus) and trial registries until November 16, 2021, for RCTs comparing the two feeding schedules. We did a random-effects meta-analysis using RevMan 5.4 software. The primary outcome was the incidence of stage II or III necrotizing enterocolitis (NEC). Other outcomes were the incidence of any stage NEC, mortality, time to full enteral feeds, and hospital stay. Six trials (872 participants) are included. There was no significant difference in the incidence of stage II/III NEC (3 trials; 530 participants; RR 1.39; 95% CI: 0.53, 3.65; I2 - 0%, low certainty), and any stage NEC (5 studies; 767 participants; RR 0.98; 95% CI: 0.53, 1.82; I2 -0%, very low certainty) between three and two-hourly feeding groups. There was no difference in achieving full feeds (5 trials; 755 participants; MD: - 0.0 days; 95% CI: - 0.32, 0.31, low certainty) or other outcomes. On subgroup analysis, neonates with birthweight < 1000 g and in the three-hourly feeding regime achieved full enteral feeds slower than those in the two-hourly feeding group (1 trial; 84 participants; MD: 2.9 days, 95% CI: 1.16, 4.64, low certainty). CONCLUSION In stable preterm infants (1000-1500 g), three-hourly feeding can be followed safely. In infants < 1000 g, there is insufficient evidence to advise on an optimal feeding interval, although a 2-h interval might be preferable.Prospero Registration Number: CRD42021246568. WHAT IS KNOWN • Most of the units follow two-hourly feeding schedules without any evidence. • Recent trials suggest that the three hourly feeding schedules can be safely followed in stable preterm infants. WHAT IS NEW • Low certainty evidence suggests that three-hourly feeding is safe in stable preterm infants (1000-1500 grams). • In infants with birthweight <1000 grams, two-hourly feeding may be considered as it was associated with a shorter time to full feeds in subgroup analysis.
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Optimal Nutrition Parameters for Neonates and Infants with Congenital Heart Disease. Nutrients 2022; 14:nu14081671. [PMID: 35458233 PMCID: PMC9029500 DOI: 10.3390/nu14081671] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023] Open
Abstract
Congenital heart defects are known causes of malnutrition. Optimal nutritional management is paramount in improving short and long-term prognosis for neonates and infants with congenital heart malformations, as current strategies target preoperative and postoperative feeding requirements. Standardized enteral and/or parenteral feeding protocols, depending on the systemic implications of the cardiac defect, include the following common practices: diagnosing and managing feeding intolerance, choosing the right formula, and implementing a monitoring protocol. The latest guidelines from the American Society for Parenteral and Enteral Nutrition and the European Society of Paediatric and Neonatal Intensive Care, as well as a significant number of recent scientific studies, offer precious indications for establishing the best feeding parameters for neonates and infants with heart defects.
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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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16
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Savarino G, Carta M, Cimador M, Corsello A, Giuffrè M, Schierz IAM, Serra G, Corsello G. Necrotizing enterocolitis in the preterm: newborns medical and nutritional Management in a Single-Center Study. Ital J Pediatr 2021; 47:226. [PMID: 34775993 PMCID: PMC8591939 DOI: 10.1186/s13052-021-01180-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/26/2021] [Indexed: 11/10/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is a typical disorder of preterm newborns, with a high mortality and morbidity rate. The therapeutic and nutritional management of disease depends on several factors. Its prognosis is linked, in addition to the severity of the disease and the need for surgery, to a correct enteral feeding in these patients. This study aims to identify the clinical characteristics of 18 patients with NEC, evaluating the different therapeutic paths undertaken, the type of formula used and the survival rate of this population. Average time of enteral nutrition before the NEC onset was 11,3 ± 11,6 days, with an average fasting period since the onset of 24 ± 18.9 days. 77.8% of patients received surgery and resumed enteral nutrition 17.7 ± 17.9 days after the intervention. The overall survival rate of our cohort was 55.5%. More prospective studies are needed to evaluate the long-term outcomes of survived children with NEC.
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Affiliation(s)
- Giovanni Savarino
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy.
| | - Maurizio Carta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy
| | - Marcello Cimador
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy
| | | | - Mario Giuffrè
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy
| | - Ingrid Anne Mandy Schierz
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy
| | - Gregorio Serra
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy
| | - Giovanni Corsello
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy
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17
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Veldscholte K, Cramer ABG, Joosten KFM, Verbruggen SCAT. Intermittent fasting in paediatric critical illness: The properties and potential beneficial effects of an overnight fast in the PICU. Clin Nutr 2021; 40:5122-5132. [PMID: 34461586 DOI: 10.1016/j.clnu.2021.07.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 12/30/2022]
Abstract
Although evidence for the superiority of continuous feeding over intermittent feeding is lacking, in most paediatric intensive care units (PICU) artificial feeding is administered continuously for 24 h per day. Until now, studies in PICU on intermittent feeding have primarily focused on surrogate endpoints such as nutritional intake and gastro-intestinal complaints and none have studied the effects of an extended fasting period. Intermittent fasting has been proven to have many health benefits in both animal and human studies. The observed beneficial effects are based on multiple metabolic and endocrine changes that are presumed crucial in critical illness as well. One key element is the transition to ketone body metabolism, which, among others, contributes to the stimulation of several cellular pathways involved in stress resistance (neuro)plasticity and mitochondrial biogenesis, and might help preserve brain function. Secondly, the fasting state stimulates the activation of autophagy, a process that is crucial for cellular function and integrity. Of the different intermittent fasting strategies investigated, time-restricted feeding with a daily extended fasting period appears most feasible in the PICU. Moreover, planning the fasting period overnight could help maintain the circadian rhythm. Although not investigated, such an overnight intermittent fasting strategy might improve the metabolic profile, feeding tolerance and perhaps even have beneficial effects on tissue repair, reperfusion injury, muscle weakness, and the immune response. Future studies should investigate practical implications in critically ill children and the optimal duration of the fasting periods, which might be affected by the severity of illness and by age.
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Affiliation(s)
- Karlien Veldscholte
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Arnout B G Cramer
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Koen F M Joosten
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sascha C A T Verbruggen
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands.
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18
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Sadrudin Premji S, Chessell L, Stewart F. Continuous nasogastric milk feeding versus intermittent bolus milk feeding for preterm infants less than 1500 grams. Cochrane Database Syst Rev 2021; 6:CD001819. [PMID: 34165778 PMCID: PMC8223964 DOI: 10.1002/14651858.cd001819.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Milk feedings can be given via nasogastric tube either intermittently, typically over 10 to 20 minutes every two or three hours, or continuously, using an infusion pump. Although the theoretical benefits and risks of each method have been proposed, their effects on clinically important outcomes remain uncertain. OBJECTIVES: To examine the evidence regarding the effectiveness of continuous versus intermittent bolus tube feeding of milk in preterm infants less than 1500 grams. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 7) in the Cochrane Library; Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions; and CINAHL (Cumulative Index to Nursing and Allied Health Literature) on 17 July 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs and quasi-RCTs comparing continuous versus intermittent bolus nasogastric milk feeding in preterm infants less than 1500 grams. DATA COLLECTION AND ANALYSIS Two review authors independently assessed all trials for relevance and risk of bias. We used the standard methods of Cochrane Neonatal to extract data. We used the GRADE approach to assess the certainty of evidence. Primary outcomes were: age at full enteral feedings; feeding intolerance; days to regain birth weight; rate of gain in weight, length and head circumference; and risk of necrotising enterocolitis (NEC). MAIN RESULTS We included nine randomised trials (919 infants) in this updated Cochrane Review. One study is awaiting classification. Seven of the nine included trials reported data from infants with a maximum weight of between 1000 grams and 1400 grams. Two of the nine trials included infants weighing up to 1500 grams. Type(s) of milk feeds varied, including human milk (either mother's own milk or pasteurised donor human milk), preterm formula, or mixed feeding regimens. In some instances, preterm formula was initially diluted. Earlier studies also used water to initiate feedings. We judged six trials as unclear or high risk of bias for random sequence generation. We judged four trials as unclear for allocation concealment. We judged all trials as high risk of bias for blinding of care givers, and seven as unclear or high risk of bias for blinding of outcome assessors. We downgraded the certainty of evidence for imprecision, due to low numbers of participants in the trials, and/or wide 95% confidence intervals, and/or for risk of bias. Continuous compared to intermittent bolus (nasogastric and orogastric tube) milk feeding Babies receiving continuous feeding may reach full enteral feeding almost one day later than babies receiving intermittent feeding (mean difference (MD) 0.84 days, 95% confidence interval (CI) -0.13 to 1.81; 7 studies, 628 infants; low-certainty evidence). It is uncertain if there is any difference between continuous feeding and intermittent feeding in terms of number of days of feeding interruptions (MD -3.00 days, 95% CI -9.50 to 3.50; 1 study, 171 infants; very low-certainty evidence). It is uncertain if continuous feeding has any effect on days to regain birth weight (MD -0.38 days, 95% CI -1.16 to 0.41; 6 studies, 610 infants; low-certainty evidence). The certainty of evidence is low and the 95% confidence interval is consistent with possible benefit and possible harm. It is uncertain if continuous feeding has any effect on rate of gain in weight compared with intermittent feeding (standardised mean difference (SMD) 0.09, 95% CI -0.27 to 0.46; 5 studies, 433 infants; very low-certainty evidence). Continuous feeding may result in little to no difference in rate of gain in length compared with intermittent feeding (MD 0.02 cm/week, 95% CI -0.04 to 0.08; 5 studies, 433 infants; low-certainty evidence). Continuous feeding may result in little to no difference in rate of gain in head circumference compared with intermittent feeding (MD 0.01 cm/week, 95% CI -0.03 to 0.05; 5 studies, 433 infants; low-certainty evidence). It is uncertain if continuous feeding has any effect on the risk of NEC compared with intermittent feeding (RR 1.19, 95% CI 0.67 to 2.11; 4 studies, 372 infants; low-certainty evidence). The certainty of evidence is low and the 95% confidence interval is consistent with possible benefit and possible harm. AUTHORS' CONCLUSIONS Although babies receiving continuous feeding may reach full enteral feeding slightly later than babies receiving intermittent feeding, the evidence is of low certainty. However, the clinical risks and benefits of continuous and intermittent nasogastric tube milk feeding cannot be reliably discerned from current available randomised trials. Further research is needed to determine if either feeding method is more appropriate for the initiation of feeds. A rigorous methodology should be adopted, defining feeding protocols and feeding intolerance consistently for all infants. Infants should be stratified according to birth weight and gestation, and possibly according to illness.
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Affiliation(s)
| | | | - Fiona Stewart
- Cochrane Children and Families Network, c/o Cochrane Pregnancy and Childbirth, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
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Gastric Volume Changes in Preterm Neonates during Intermittent and Continuous Feeding-GRV and Feeding Mode in Preterm Neonates. CHILDREN-BASEL 2021; 8:children8040300. [PMID: 33920800 PMCID: PMC8071189 DOI: 10.3390/children8040300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 11/17/2022]
Abstract
Background: We aimed to evaluate gastric volume changes during intermittent milk feeds (IMF) and continuous milk feeds (CMF) in very premature neonates (VPN), with gastric residual volume (GRV) based on antral cross-sectional area (ACSA) measurements and to examine if there were differences in GRV between the two feeding methods. Methods: A randomized prospective clinical trial with crossover design was conducted in 31 preterm neonates (gestational age < 30 weeks). Gastric volume was assessed twice in each neonate (during IMF and CMF feeding), at 7 specific time points during a 2-h observation period by measuring ACSA changes via the ultrasound (U/S) method. Results: There was a significantly different pattern of gastric volume changes between the two feeding methods. GRV, expressed as the median percentage of ACSA measurement at 120 min relative to the higher ACSA measurement during IMF, was found to be 3% (range 0–25%) for IMF and 50% (range 15–80%) for CMF. Neonates fed with IMF had a shorter mean gastric emptying time compared to those fed with CMF (p = 0.0032). No signs of feeding intolerance were recorded in either group during the period of observation. Conclusions: Our results showed that gastric volume changes and gastric emptying time in VPN, based on ACSA measurement changes, depend on the milk feeding method. No gastrointestinal complications/adverse events were noted with GRV up to 80% with CMF.
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20
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Bolus versus continuous feeding regimens post gastrostomy tube placement in children. J Pediatr Surg 2021; 56:717-720. [PMID: 33023750 DOI: 10.1016/j.jpedsurg.2020.09.004] [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: 04/23/2020] [Revised: 08/30/2020] [Accepted: 09/06/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND/PURPOSE Owing to the frequency of gastrostomy tube placement in children and the numerous regimens used to start feeds after placement we attempted to see if it matters if the initial feeds after a gastrostomy tube placement are provided in a bolus or continuous manner. METHODS Using a prospective randomized trial, children were randomized to initial bolus or continuous chimney feeding after gastrostomy tube placement. Feeding tolerance and complications related to the gastrostomy tube were collected for 4 weeks after placement. RESULTS Demographics were similar in the two groups. Times to goal feeds were similar in both groups, but in the first two weeks more feeding modifications were required in the bolus group. Other than the rate of leakage during the second week after placement which occurred more in the bolus group, all other clinical outcomes were similar in the two groups. CONCLUSIONS Other than minor, clinically insignificant differences noted above, the method of initial feeding after a gastrostomy tube placement does not affect feeding tolerance or gastrostomy tube complication in the first month after placement. LEVEL OF EVIDENCE Therapeutic, level II.
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21
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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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22
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中国医师协会新生儿科医师分会循证专业委员会. [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; 23:1-11. [PMID: 33476530 PMCID: PMC7818154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 12/09/2020] [Indexed: 11/11/2023]
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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Affiliation(s)
- 中国医师协会新生儿科医师分会循证专业委员会
- 唐军, 女, 教授, 四川大学华西第二医院儿科/出生缺陷与相关妇儿疾病教育部重点实验室, ; 封志纯, 男, 教授, 解放军总医院第七医学中心附属八一儿童医院NICU, ; 母得志, 男, 教授, 四川大学华西第二医院儿科/出生缺陷与相关妇儿疾病教育部重点实验室,
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Ma Y, Cheng J, Liu L, Chen K, Fang Y, Wang G, Zhu J, Chen L. Intermittent versus continuous enteral nutrition on feeding intolerance in critically ill adults: A meta-analysis of randomized controlled trials. Int J Nurs Stud 2020; 113:103783. [PMID: 33161333 DOI: 10.1016/j.ijnurstu.2020.103783] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/12/2020] [Accepted: 09/27/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Enteral formula delivery strategy is an important part of enteral nutrition. We aimed to synthesize up-to-date studies to clarify the effects of intermittent versus continuous feeding on feeding intolerance during enteral nutrition in critically ill adults. DESIGN A meta-analysis of randomized controlled trials. DATA SOURCES Embase, PubMed, Information Sciences Institute Web of Science, CINAHL EBSCO, Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, China National Knowledge Infrastructure databases were searched from inception to 17th of June 2020. REVIEW METHODS The Cochrane "risk of bias" tool was used to assess the quality of individual studies, and the quality of each outcome was assessed by GRADE approach. Fixed or random effect meta-analysis was used pending the presence of heterogeneity. Dichotomous data synthesis was presented as risk ratio and 95% confidence interval, and quantitative data synthesis was shown as mean difference and 95% confidence interval. RESULTS Fourteen trials with 1025 critically ill adults were included in the meta-analysis. We found that intermittent feeding could significantly increase the occurrence of feeding intolerance (risk ratio = 1.64, 95% confidence interval = 1.23 to 2.18, P < 0.001) compared with continuous feeding, as well as the incidence of high gastric volume (risk ratio = 3.62, 95% confidence interval = 1.43-9.12, P = 0.006) and aspiration (risk ratio = 3.29, 95% confidence interval = 1.18-9.16, P = 0.02) in > 1-week trial duration, while constipation rate was reduced in intermittent feeding group (risk ratio = 0.66, 95% confidence interval = 0.45-0.98, P = 0.04). Patients in intermittent feeding group received more calories compared with continuous feeding group (mean difference = 184.81, 95% confidence interval = 56.61-313.01, P = 0.005). The quality of all evidence synthesis was "low" or "very low". CONCLUSIONS In critically ill adults, continuous feeding was associated with lower overall incidence of feeding intolerance, especially in high gastric volume and aspiration. However, decreased constipation incidence and more calorie intake were observed in intermittent feeding group. Because quality of the synthesized evidence was "low" or "very low", there is considerable uncertainty about this estimate.
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Affiliation(s)
- Yuanyuan Ma
- 75th Army Group Hospital, Dali, Yunnan, China
| | - Jun Cheng
- 75th Army Group Hospital, Dali, Yunnan, China
| | - Liang Liu
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Kexi Chen
- 75th Army Group Hospital, Dali, Yunnan, China
| | - Yuli Fang
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, Liaoning, China; Department of Basic Nursing, School of Nursing, Army Medical University, Chongqing, China
| | | | - Jingci Zhu
- Department of Basic Nursing, School of Nursing, Army Medical University, Chongqing, China
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Ye J, Chen H, Zhang HG. Continuous versus intermittent bolus milk feeding in preterm infants: a meta-analysis. J Int Med Res 2020. [PMCID: PMC7498975 DOI: 10.1177/0300060520950981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives To analyze the evidence comparing the benefits and risks of continuous versus
intermittent milk feeding in low birth weight (LBW) infants. Methods Three electronic databases were searched and screened to identify randomized
controlled trials of continuous and intermittent milk feeding of LBW infants
up to October 2016. Results Eight trials were included in this meta-analysis. Continuous feeding had no
effect on days to full feeds and time to regain birth weight. There were no
significant differences in the number of apneas, invasive ventilation,
changes in body length, occipitofrontal circumference, skinfold thickness,
and total protein, and in the number of stools between the two feeding
strategies. Continuous feeding was associated with higher gastric residual
volume, noninvasive ventilation, weight gain, increase in bilirubin, and
longer nil by mouth. There were no significant differences in adverse events
and confounders between the two feeding strategies. Conclusions Continuous milk feeding was superior to intermittent feeding in LBW infants
in terms of weight gain. However, continuous feeding was also associated
with increased nil by mouth duration, increased bilirubin, increased
noninvasive support, and increased gastric residuals. Continuous feeding
thus confers advantages in terms of weight gain, but also has disadvantages
compared with bolus feeding.
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Affiliation(s)
- Juan Ye
- Department of Neonatology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hong Chen
- Department of Pediatrics, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hong-Gang Zhang
- Department of Anesthesiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Ou J, Courtney CM, Steinberger AE, Tecos ME, Warner BW. Nutrition in Necrotizing Enterocolitis and Following Intestinal Resection. Nutrients 2020; 12:nu12020520. [PMID: 32085587 PMCID: PMC7071274 DOI: 10.3390/nu12020520] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 12/25/2022] Open
Abstract
This review aims to discuss the role of nutrition and feeding practices in necrotizing enterocolitis (NEC), NEC prevention, and its complications, including surgical treatment. A thorough PubMed search was performed with a focus on meta-analyses and randomized controlled trials when available. There are several variables in nutrition and the feeding of preterm infants with the intention of preventing necrotizing enterocolitis (NEC). Starting feeds later rather than earlier, advancing feeds slowly and continuous feeds have not been shown to prevent NEC and breast milk remains the only effective prevention strategy. The lack of medical treatment options for NEC often leads to disease progression requiring surgical resection. Following resection, intestinal adaptation occurs, during which villi lengthen and crypts deepen to increase the functional capacity of remaining bowel. The effect of macronutrients on intestinal adaptation has been extensively studied in animal models. Clinically, the length and portion of intestine that is resected may lead to patients requiring parenteral nutrition, which is also reviewed here. There remain significant gaps in knowledge surrounding many of the nutritional aspects of NEC and more research is needed to determine optimal feeding approaches to prevent NEC, particularly in infants younger than 28 weeks and <1000 grams. Additional research is also needed to identify biomarkers reflecting intestinal recovery following NEC diagnosis individualize when feedings should be safely resumed for each patient.
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Affiliation(s)
- Jocelyn Ou
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA;
| | - Cathleen M. Courtney
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Allie E. Steinberger
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Maria E. Tecos
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Brad W. Warner
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
- Correspondence: ; Tel.: 314-454-6022
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