A national survey of the enteral feeding practices in Canadian neonatal intensive care units

How long does it take to start minimal enteral feeding in preterm Neonates admitted to NICUs in Southern Oromia, Ethiopia?

BACKGROUND

The timely initiation of trophic feeding (TF) is crucial for premature newborns, but challenging due to immaturity, respiratory instability, abdominal distension, resource scarcity, and healthcare worker expertise. Moreover, there is a dearth of information on predictors of full trophic feeding time. Therefore, this retrospective cohort study aimed to investigate the time it takes and its predictors to initiate minimal enteral feeding in preterm neonates in Southern Oromia, Ethiopia.

METHOD

A facility-based retrospective follow up study was conducted among 434 randomly selected preterm neonates admitted to NICU of Bule Hora University Teaching Hospital and Yabello General Hospital from January 1, 2021 to December 30, 2022. Data were extracted by a pretested structured checklist, entered into Epidata 3.1 and then transferred to Stata version 17 for analysis. Kaplan Meier survival curve and log rank test were used to estimate survival time and a statistical comparison respectively. Bivariable and multivariable cox proportional hazard model was fitted to identify predictors of time to initiate TF and their outputs are presented using Adjusted Hazard Ratio (AHR) with 95% Confidence Intervals (CIs).

RESULT

The overall incidence density of TF initiation was reported as 43.6 per 100 neonate-days. Moreover, the median (IQR) time to initiate TF was found to be 2 (1-4) days. Neonates delivered vaginally had a higher likelihood of early TF initiation (AHR: 1.64, CI: 1.26, 2.13), while those born between 32 and 34 weeks (AHR: 0.61, CI: 0.46, 0.81), VLBW neonates (AHR: 0.45, CI: 0.34, 0.60), neonates without KMC (AHR: 0.59, CI: 0.46, 0.79), and those in level II hospitals were less likely to start TF promptly (AHR: 0.78, CI: 0.62, 0.99). Furthermore, neonates with sepsis (AHR: 1.76, CI: 1.36, 2.28) and hypothermia (AHR: 1.51, CI: 1.19, 1.93) had delayed TF initiation.

CONCLUSION

We observed a significant low rate of early TF initiation and higher death rate of preterm newborn in our study as compared to the global. Preterm neonates with lower GA, no KMC, and a VLBW are more likely to have a delayed initiation. Our results highlight that staff training on identifying neonates suitable for TF, and ensuring adequate resources for KMC in all NICU levels should be considered.

Use of Probiotics for Preventing Necrotizing Enterocolitis in Preterm Infants: A Survey of Current Practices Among Indian Neonatologists

OBJECTIVE

Probiotics are known to reduce the risk of necrotizing enterocolitis (NEC≥ Stage II) significantly, as well as all-cause mortality, late-onset sepsis (LOS), and feeding intolerance in preterm infants. Probiotics have been reported to have comparable benefits in high- and low-middle-income countries (LMICs). We aimed to assess the current practices of neonatologists in India for using probiotics in preterm infants.

MATERIAL AND METHODS

A questionnaire created using Survey Monkey's web-based tool was sent to neonatologists in India. Survey forms automatically converted responses into Excel files (Microsoft® Corp., Redmond, WA). Data were analyzed using SPSS (IBM Corp., Armonk, NY).

RESULTS

A total of 615 responses were received from various neonatal intensive care units (NICUs) in India (Level I: 43 (7%), II: 124 (20.8%), III: 448 (72.8%)). Around 431 (70%) of the units had either National Neonatology Forum (NNF) accreditation or IAP fellowships or were affiliated with private or government medical colleges. The remaining 184 (30%) were in private setups. Routine probiotic supplementation (RPS) was provided in 241 (39.1%) of the responding units; 179 (48%) quoted inadequate evidence as the reason for not providing RPS, 125 (33.43%) quoted difficulty in sourcing safe and effective products, whereas others were concerned about adverse effects. Most centers provided RPS for preterm infants <32 weeks and 1500 g at birth. The clinical practice was influenced by the judgment of the attending clinician. Significant variation was noticed in the protocol for RPS.

CONCLUSION

Findings of the survey suggest that approximately 39% of the participating neonatologists in India currently offer RPS for preterm infants. A significant variation exists in the selection of probiotic strains, products, dose, and duration of supplementation. Despite limitations, our findings are useful in guiding clinical practice and further research to optimize the safety and efficacy of RPS for preterm infants.

Nutrition of the preterm infant with persistent ductus arteriosus: existing evidence and practical implications

The persistence of a patent ductus arteriosus (PDA) is a common condition in preterm infants with a prevalence inversely proportional to gestational age. PDA is associated with mild-to-severe gastrointestinal complications such as feeding intolerance, gastrointestinal perforation, and necrotizing enterocolitis, which represent a major challenge for the nutritional management in preterm infants. In this context, the Section on Nutrition, Gastroenterology and Metabolism and the Circulation Section of the European Society for Pediatric Research have joined forces to review the current knowledge on nutritional issues related to PDA in preterm infants. The aim of the narrative review is to discuss the clinical implications for nutritional practice. Because there is little literature on postnatal nutrition and PDA in preterm infants, further research with well-designed studies on this topic is urgently needed. Guidelines should also be developed to clearly define the implementation and course of enteral nutrition and the target nutritional intake before, during, and after pharmacologic or surgical treatment of PDA, when indicated. IMPACT: Persistent ductus arteriosus (PDA) is associated with gastrointestinal complications such as feeding intolerance, gastrointestinal perforation, and necrotizing enterocolitis, which pose a major challenge to the nutritional management of preterm infants. In PDA infants, fluid restriction may lead to inadequate nutrient intake, which may negatively affect postnatal growth and long-term health. The presence of PDA does not appear to significantly affect mesenteric blood flow and splanchnic oxygenation after enteral feedings. Initiation or maintenance of enteral nutrition can be recommended in infants with PDA.

Re-feeding versus discarding gastric residuals to improve growth in preterm infants

BACKGROUND

Routine monitoring of gastric residuals in preterm infants on tube feeds is a common practice in neonatal intensive care units used to guide initiation and advancement of enteral feeding. There is a paucity of consensus on whether to re-feed or discard the aspirated gastric residuals. While re-feeding gastric residuals may aid in digestion and promote gastrointestinal motility and maturation by replacing partially digested milk, gastrointestinal enzymes, hormones, and trophic substances, abnormal residuals may result in vomiting, necrotising enterocolitis, or sepsis.

OBJECTIVES

To assess the efficacy and safety of re-feeding when compared to discarding gastric residuals in preterm infants.  SEARCH METHODS: Searches were conducted in February 2022 in Cochrane CENTRAL via CRS, Ovid MEDLINE and Embase, and CINAHL. We also searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

We selected RCTs that compared re-feeding versus discarding gastric residuals in preterm infants.

DATA COLLECTION AND ANALYSIS

Review authors assessed trial eligibility and risk of bias and extracted data, in duplicate. We analysed treatment effects in individual trials and reported the risk ratio (RR) for dichotomous data and the mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We found one eligible trial that included 72 preterm infants. The trial was unmasked but was otherwise of good methodological quality. Re-feeding gastric residual may have little or no effect on time to regain birth weight (MD 0.40 days, 95% CI -2.89 to 3.69; 59 infants; low-certainty evidence), risk of necrotising enterocolitis stage ≥ 2 or spontaneous intestinal perforation (RR 0.71, 95% CI 0.25 to 2.04; 72 infants; low-certainty evidence), all-cause mortality before hospital discharge (RR 0.50, 95% CI 0.14 to 1.85; 72 infants; low-certainty evidence), time to establish enteral feeds ≥ 120 mL/kg/d (MD -1.30 days, 95% CI -2.93 to 0.33; 59 infants; low-certainty evidence), number of total parenteral nutrition days (MD -0.30 days, 95% CI -2.07 to 1.47; 59 infants; low-certainty evidence), and risk of extrauterine growth restriction at discharge (RR 1.29, 95% CI 0.38 to 4.34; 59 infants; low-certainty evidence). We are uncertain as to the effect of re-feeding gastric residual on number of episodes of feed interruption lasting for ≥ 12 hours (RR 0.80, 95% CI 0.42 to 1.52; 59 infants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

We found only limited data from one small unmasked trial on the efficacy and safety of re-feeding gastric residuals in preterm infants. Low-certainty evidence suggests re-feeding gastric residual may have little or no effect on important clinical outcomes such as necrotising enterocolitis, all-cause mortality before hospital discharge, time to establish enteral feeds, number of total parenteral nutrition days, and in-hospital weight gain. A large RCT is needed to assess the efficacy and safety of re-feeding of gastric residuals in preterm infants with adequate certainty of evidence to inform policy and practice.

Routine monitoring of gastric residual for prevention of necrotising enterocolitis in preterm infants

BACKGROUND

Routine monitoring of gastric residual in preterm infants on gavage feeds is a common practice used to guide initiation and advancement of feeds. It is believed that an increase in or an altered gastric residual may be predictive of necrotising enterocolitis (NEC). Withholding monitoring of gastric residual may take away the early indicator and thus may increase the risk of NEC. However, routine monitoring of gastric residual as a guide, in the absence of uniform standards, may lead to unnecessary delay in initiation and advancement of feeds and hence might result in a delay in establishing full enteral feeds. This in turn may increase the duration of total parenteral nutrition (TPN) and central venous line usage, increasing the risk of associated complications. Furthermore, delays in establishing full enteral feeds increase the risk of extrauterine growth restriction and neurodevelopmental impairment.

OBJECTIVES

• To assess the efficacy and safety of routine monitoring versus no monitoring of gastric residual in preterm infants • To assess the efficacy and safety of routine monitoring of gastric residual based on two different criteria for interrupting feeds or decreasing feed volume in preterm infants SEARCH METHODS: We conducted searches in Cochrane CENTRAL via CRS, Ovid MEDLINE, Embase and CINAHL in February 2022. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs), quasi- and cluster-RCTs.

SELECTION CRITERIA

We selected RCTs that compared routine monitoring versus no monitoring of gastric residual and trials that used two different criteria for gastric residual to interrupt feeds in preterm infants.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, risk of bias and extracted data. We analysed treatment effects in individual trials and reported risk ratio (RR) for dichotomous data, and mean difference (MD) for continuous data, with respective 95% confidence intervals (CI). We calculated the number needed to treat for an additional beneficial/harmful outcome (NNTB/NNTH) for dichotomous outcomes with significant results. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included five studies (423 infants) in this updated review. Routine monitoring versus no routine monitoring of gastric residual in preterm infants Four RCTs with 336 preterm infants met the inclusion criteria for this comparison. Three studies were performed in infants with birth weight of < 1500 g, while one study included infants with birth weight between 750 g and 2000 g. The trials were unmasked but were otherwise of good methodological quality. Routine monitoring of gastric residual:  - probably has little or no effect on the risk of NEC (RR 1.08, 95% CI 0.46 to 2.57; 334 participants, 4 studies; moderate-certainty evidence); - probably increases the time to establish full enteral feeds (MD 3.14 days, 95% CI 1.93 to 4.36; 334 participants, 4 studies; moderate-certainty evidence); - may increase the time to regain birth weight (MD 1.70 days, 95% CI 0.01 to 3.39; 80 participants, 1 study; low-certainty evidence);  - may increase the number of infants with feed interruption episodes (RR 2.21, 95% CI 1.53 to 3.20; NNTH 3, 95% CI 2 to 5; 191 participants, 3 studies; low-certainty evidence);  - probably increases the number of TPN days (MD 2.57 days, 95% CI 1.20 to 3.95; 334 participants, 4 studies; moderate-certainty evidence); - probably increases the risk of invasive infection (RR 1.50, 95% CI 1.02 to 2.19; NNTH 10, 95% CI 5 to 100; 334 participants, 4 studies; moderate-certainty evidence); - may result in little or no difference in all-cause mortality before hospital discharge (RR 2.14, 95% CI 0.77 to 5.97; 273 participants, 3 studies; low-certainty evidence). Quality and volume of gastric residual compared to quality of gastric residual alone for feed interruption in preterm infants One trial with 87 preterm infants met the inclusion criteria for this comparison. The trial included infants with 1500 g to 2000 g birth weight.  Using two different criteria of gastric residual for feed interruption: - may result in little or no difference in the incidence of NEC (RR 5.35, 95% CI 0.26 to 108.27; 87 participants; low-certainty evidence);  - may result in little or no difference in time to establish full enteral feeds (MD -0.10 days, 95% CI -0.91 to 0.71; 87 participants; low-certainty evidence); - may result in little or no difference in time to regain birth weight (MD 1.00 days, 95% CI -0.37 to 2.37; 87 participants; low-certainty evidence); - may result in little or no difference in number of TPN days (MD 0.80 days, 95% CI -0.78 to 2.38; 87 participants; low-certainty evidence); - may result in little or no difference in the risk of invasive infection (RR 5.35, 95% CI 0.26 to 108.27; 87 participants; low-certainty evidence); - may result in little or no difference in all-cause mortality before hospital discharge (RR 3.21, 95% CI 0.13 to 76.67; 87 participants; low-certainty evidence).  - we are uncertain about the effect of using two different criteria of gastric residual on the risk of feed interruption episodes (RR 3.21, 95% CI 0.13 to 76.67; 87 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Moderate-certainty evidence suggests routine monitoring of gastric residual has little or no effect on the incidence of NEC. Moderate-certainty evidence suggests monitoring gastric residual probably increases the time to establish full enteral feeds, the number of TPN days and the risk of invasive infection. Low-certainty evidence suggests monitoring gastric residual may increase the time to regain birth weight and the number of feed interruption episodes, and may have little or no effect on all-cause mortality before hospital discharge. Further RCTs are warranted to assess the effect on long-term growth and neurodevelopmental outcomes.

Effect of early initiation of enteral nutrition on short-term clinical outcomes of very premature infants: A national multicenter cohort study in China

OBJECTIVES

The management of enteral nutrition in very preterm infants (VPIs) is still controversial, and there is no consensus on the optimal time point after birth at which enteral nutrition can be started. The aim of this study was to investigate the effect of early initiation of enteral nutrition on the short-term clinical outcomes of VPIs.

METHODS

Data of infants (n = 2514) born before 32 wk of gestation were collected from 28 hospitals located in seven different regions of China. Based on whether enteral feeding was initiated within or after 24 h since birth, the infants were divided into an early initiation of enteral feeding (EIEF) group and a delayed initiation of enteral feeding (DIEF) group.

RESULTS

Compared with the DIEF group, the EIEF group was more likely to tolerate enteral nutrition and had less need for parenteral nutrition (all P < 0.05). The EIEF group was associated with lower incidence rates of feeding intolerance, extrauterine growth restriction (EUGR), and late-onset sepsis (LOS) (all P < 0.05). There was no significant difference in the incidence of necrotizing enterocolitis (NEC) (Bell stage ≥2) between the two groups (P = 0.118). The multivariate logistic regression analysis revealed that EIEF was a protective factor against EUGR (odds ratio [OR], 0.621; 95% confidence interval [CI], 0.544-0.735; P < 0.001), feeding intolerance (OR, 0.658; 95% CI, 0.554-0.782; P < 0.001), and LOS (OR, 0.706; 95% CI, 0.550-0.906; P = 0.006).

CONCLUSIONS

Early initiation of enteral feeding was associated with less frequency of feeding intolerance, EUGR, and LOS, and it may shorten the time to reach total enteral feeding without increasing the risk of NEC.

Benefits of a Standardized Enteral Feeding Protocol on the Nutrition and Health Outcomes of Very Low Birth Weight Preterm Infants

Purpose: To compare nutrition and health outcomes before and after implementing a standardized enteral feeding protocol on nutrition and health outcomes in very low birth weight preterm infants.Methods: A retrospective chart review was performed evaluating preterm infants, born less than 34 weeks gestation and weighing less than 1500 g, before and after the implementation of a standardized enteral feeding protocol. Outcomes included weaning of parenteral nutrition, initiation and advancement of enteral feeds, initiation of human-milk fortifier (HMF), change in weight z-score and neonatal morbidities.Results: Fifty-six infants (30 in pre-group, 26 in post-group) met the inclusion criteria. Infants in the standardized enteral feeding protocol group started enteral feeds earlier (p = 0.039) and received full HMF fortification at lower weights (p = 0.033) than those in the pre-group. Fewer days on continuous positive airway pressure (p = 0.021) and lower rates of bronchopulmonary dysplasia (p = 0.018) were also observed in the post-group. Weaning of parenteral nutrition and weight z-score were not significantly different between groups. There were no differences in other morbidities.Conclusion: Study results suggest that adopting a standardized enteral feeding protocol may promote early initiation of enteral feeds and fortification.