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Neu J, Ashley P, Chowdhary V, Lampland A, Porcelli P, Rothstein R, Slancheva B, Kronström A, Rastad J, Strömberg S, Thuresson M. Progression of Enteral Feeding Volumes in Extremely Low Birth Weight Infants in the "Connection Trial". Am J Perinatol 2024; 41:e2717-e2726. [PMID: 37683670 DOI: 10.1055/s-0043-1774314] [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: 09/10/2023]
Abstract
OBJECTIVE Investigate daily feeding volumes and their association with clinical variables in the early postnatal care of premature infants of the "Connection Trial." STUDY DESIGN A total of 641 infants of 510 to 1,000-g birth weight (BW, mean: 847 g) and mean 27 weeks' gestational age at birth (GA) were analyzed for total daily enteral (TDE) feeding volumes of 10, 20, 40, 80, and 120 mL/kg/d and their association with 24 clinical variables. Uni- and multivariable Cox regression models were used to calculate hazard ratios (HR) with 95% confidence intervals as a measure of the chance of reaching each of the TDE volumes. RESULTS Daily feeding volumes were highly variable and the median advancement from 10 to 120 mL/kg/d was 11 mL/kg/d. Univariable analyses showed the lowest chance (HR, 0.22-0.81) of reaching the TDE volumes for gastrointestinal (GI) serious adverse events (SAEs), GI perforation, GI obstruction, and necrotizing enterocolitis, as well as respiratory SAEs, persistent ductus arteriosus, and hypotension. Each GA week, 100-g BW, and point in 5-minute Apgar score at birth associated with 8 to 20% increased chance of reaching the TDE volumes. Multivariable analyses showed independent effects for BW, GA, Apgar score, GI SAEs, abdominal symptoms/signs, respiratory SAEs, days on antibiotics, and hypotension. CONCLUSION This observational analysis demonstrates the variable and cautious progression of enteral feedings in contemporary extremely low BW infants and the extent to which clinical variables associate with this progression. KEY POINTS · Total feedings of 10 and 120 mL/kg/d were reached at median 4 and 14 day of age, respectively, and at a daily increase of 11 mL/kg.. · Each incremental GA week, 100-g BW, and point in 5-minute Apgar score associated with 8 to 20% increased chance of reaching enteral feedings of 10 to 120 mL/kg/d.. · Progression of enteral feeding associated with several clinical events and was slower than advocated in common feeding protocols..
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Affiliation(s)
- Josef Neu
- Department of Pediatrics, University of Florida Health Shands Children's Hospital, Gainesville, Florida
| | - Patricia Ashley
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Vikas Chowdhary
- Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Andrea Lampland
- Department of Neonatology, Children's Minnesota St. Paul Clinic, Saint Paul, Minnesota
| | - Peter Porcelli
- Department of Pediatrics, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Robert Rothstein
- Department of Pediatrics, Baystate Children's Hospital, Springfield, Massachusetts
| | - Boriana Slancheva
- Department of Neonatology, Medical University of Sofia, Sofia, Bulgaria
| | | | - Jonas Rastad
- Infant Bacterial Therapeutics Inc., Stockholm, Sweden
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Imam ZO, Nabwera HM, Tongo OO, Andang’o PEA, Abdulkadir I, Ezeaka CV, Ezenwa BN, Fajolu IB, Mwangome MK, Umoru DD, Akindolire AE, Otieno W, Olwala M, Nalwa GM, Talbert AW, Abubakar I, Embleton ND, Allen SJ. Time to full enteral feeds in hospitalised preterm and very low birth weight infants in Nigeria and Kenya. PLoS One 2024; 19:e0277847. [PMID: 38457475 PMCID: PMC10923414 DOI: 10.1371/journal.pone.0277847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/18/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Preterm (born < 37 weeks' gestation) and very low birthweight (VLBW; <1.5kg) infants are at the greatest risk of morbidity and mortality within the first 28 days of life. Establishing full enteral feeds is a vital aspect of their clinical care. Evidence predominantly from high income countries shows that early and rapid advancement of feeds is safe and reduces length of hospital stay and adverse health outcomes. However, there are limited data on feeding practices and factors that influence the attainment of full enteral feeds among these vulnerable infants in sub-Saharan Africa. AIM To identify factors that influence the time to full enteral feeds, defined as tolerance of 120ml/kg/day, in hospitalised preterm and VLBW infants in neonatal units in two sub-Saharan African countries. METHODS Demographic and clinical variables were collected for newborns admitted to 7 neonatal units in Nigeria and Kenya over 6-months. Multiple linear regression analysis was conducted to identify factors independently associated with time to full enteral feeds. RESULTS Of the 2280 newborn infants admitted, 484 were preterm and VLBW. Overall, 222/484 (45.8%) infants died with over half of the deaths (136/222; 61.7%) occurring before the first feed. The median (inter-quartile range) time to first feed was 46 (27, 72) hours of life and time to full enteral feeds (tFEF) was 8 (4.5,12) days with marked variation between neonatal units. Independent predictors of tFEF were time to first feed (unstandardised coefficient B 1.69; 95% CI 1.11 to 2.26; p value <0.001), gestational age (1.77; 0.72 to 2.81; <0.001), the occurrence of respiratory distress (-1.89; -3.50 to -0.79; <0.002) and necrotising enterocolitis (4.31; 1.00 to 7.62; <0.011). CONCLUSION The use of standardised feeding guidelines may decrease variations in clinical practice, shorten tFEF and thereby improve preterm and VLBW outcomes.
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Affiliation(s)
- Zainab O. Imam
- Massey Street Children’s Hospital, Lagos Island, Lagos, Nigeria
| | - Helen M. Nabwera
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Alder Hey Children’s Hospital NHS Trust, Liverpool, United Kingdom
| | - Olukemi O. Tongo
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | | | - Isa Abdulkadir
- Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Nigeria
| | - Chinyere V. Ezeaka
- College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Paediatrics, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Beatrice N. Ezenwa
- College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Paediatrics, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Iretiola B. Fajolu
- College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Paediatrics, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Martha K. Mwangome
- Department of Clinical Research, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Dominic D. Umoru
- Department of Paediatrics, Maitama District Hospital, Maitama, Abuja, Nigeria
| | | | - Walter Otieno
- Maseno University, Maseno, Kenya
- Department of Paediatrics, Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya
| | - Macrine Olwala
- Department of Paediatrics, Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya
| | - Grace M. Nalwa
- Maseno University, Maseno, Kenya
- Department of Paediatrics, Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya
| | - Alison W. Talbert
- Department of Clinical Research, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ismaela Abubakar
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Nicholas D. Embleton
- Department of Paediatrics, Newcastle University, Newcastle upon Tyne, United Kingdom
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Stephen J. Allen
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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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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MARQUES PC, ROCHA G, FLOR-DE-LIMA F, GUIMARÃES H. Extrauterine growth restriction at discharge in very-low-birth weight infants: a retrospective study in a level III neonatal intensive care unit. Minerva Pediatr (Torino) 2022; 74:553-561. [DOI: 10.23736/s2724-5276.18.05253-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Luo L, Liu X, Yu H, Luo M, Jia W, Dong W, Lei X. Red blood cell transfusions post diagnosis of necrotizing enterocolitis and the deterioration of necrotizing enterocolitis in full-term and near-term infants: a propensity score adjustment retrospective cohort study. BMC Pediatr 2022; 22:211. [PMID: 35428277 PMCID: PMC9012001 DOI: 10.1186/s12887-022-03276-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 04/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background Necrotizing enterocolitis (NEC) is one of serious gastrointestinal inflammatory diseases in newborn infants, with a high morbidity and mortality. Red blood cell transfusion (RBCT) plays a controversial and doubtful role in the treatment of NEC. In present study, we aim to analyze the association between RBCT and the deterioration of NEC. Methods This was a retrospective cohort study of near-term and full-term infants with a confirmed diagnosis of Bell’s stage II NEC between Jan 1, 2010 and Jan 31, 2020. The maternal and infant baseline characteristics, treatment information and laboratory test for each case were collected. The eligible subjects were divided into two groups based on receiving RBCT post NEC diagnosis or not. The propensity score was used to eliminate potential bias and baseline differences. A multivariate logistic regression model was used to adjust the propensity score and calculate the odds ratio (OR) and 95% confidential interval (CI) of RBCT for the deterioration of NEC. Results A total of 242 infants were included in this study, 60 infants had a history of RBCT post NEC diagnosis, and 40 infants deteriorated from Bell’s stage II to stage III. By adjusting the propensity score, RBCT post NEC diagnosis was associated with an increased risk for NEC deteriorating from stage II to III (adjusted OR 6.06, 95%CI 2.94–12.50, P = 0.000). Conclusions NEC infants who required RBCT post NEC diagnosis were more likely to deteriorate from stage II to III in full-term and near-term infants. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03276-4.
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Abstract
PURPOSE OF REVIEW Infants of women with diabetes are at risk for specific morbidities including congenital anomalies, abnormalities of fetal growth, neonatal hypoglycemia, electrolyte abnormalities, polycythemia, hyperbilirubinemia, and respiratory distress syndrome. Recent studies have shed light on long-term outcomes of these infants and presented advances in treatment. The purpose of this review is to outline the most common neonatal morbidities affecting infants of women with diabetes, the pathophysiology and prevalence of these conditions, and contemporary approaches to treatment. RECENT FINDINGS Recent investigative findings have led to advances in treatment approaches for these infants, particularly regarding risks of neonatal hypoglycemia. Optimizing maternal glycemic control during pregnancy is imperative to improving infant outcomes. However, on a population level, maternal diabetes still poses significant risks to the infant. Timely and appropriate treatment of infants of women with diabetes is imperative to decrease short- and long-term morbidity.
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Affiliation(s)
- Sydney Peters
- Tufts University, 419 Boston Avenue, Medford, MA, USA
| | - Chloe Andrews
- Department of Newborn Medicine, Brigham & Women's Hospital, 75 Francis St, Boston, MA, USA
| | - Sarbattama Sen
- Department of Newborn Medicine, Brigham & Women's Hospital, 75 Francis St, Boston, MA, USA.
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.
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Fabrizio V, Shabanova V, Taylor SN. Factors in Early Feeding Practices That May Influence Growth and the Challenges that Arise in Growth Outcomes Research. Nutrients 2020; 12:nu12071939. [PMID: 32629763 PMCID: PMC7399918 DOI: 10.3390/nu12071939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/19/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022] Open
Abstract
Growth in preterm infants is associated with improved outcomes during both the initial hospitalization and long-term. A single center investigation evaluated preterm infant in-hospital growth trajectory and how it related to early nutritional practices as a way to identify areas for quality improvement. Infants born <34 weeks’ gestational age and with discharge at or prior to 40 weeks’ gestational age were included and were divided into quartiles based on their change in weight z-score through hospitalization. Early nutritional factors were compared between the lowest and highest growth quartiles. Although the highest growth quartile experienced less days of parenteral nutrition and higher enteral caloric density in the first week, as the data was analyzed, potential statistical pitfalls became apparent. Therefore, the aim of this study was to investigate selection bias and cohort effect related to both the inclusion criteria for this cohort as well as the inherent challenges in comparison of preterm infant growth trajectories by standard fetal growth charts.
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Affiliation(s)
- Veronica Fabrizio
- Connecticut Children’s, Division of Neonatology, Hartford, CT 06106, USA
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT 06032, USA
- Correspondence:
| | - Veronika Shabanova
- Department of Pediatrics, Yale School of Medicine, New Haven, CT 06443, USA; (V.S.); (S.N.T.)
| | - Sarah N. Taylor
- Department of Pediatrics, Yale School of Medicine, New Haven, CT 06443, USA; (V.S.); (S.N.T.)
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Very low birth weight infants receive full enteral nutrition within 2 postnatal weeks. J Perinatol 2020; 40:1849-1856. [PMID: 32994536 PMCID: PMC7522453 DOI: 10.1038/s41372-020-00819-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 07/30/2020] [Accepted: 09/10/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Identify whether an enteral nutrition goal of reaching full feeds by 7 postnatal days for infants 1-1.5 kg and by 14 postnatal days for infants <1 kg was feasible and its associated outcomes. STUDY DESIGN Very low birth weight infant cohort admitted in the first postnatal day and categorized as either Epoch 1 or Epoch 2, 12 months before and after implementation of a revised feeding protocol were compared. RESULT In Epoch 2, 83% infants born 1-1.5 kg and 77% infants born <1 kg reached full feeds by 7 and 14 days compared to 26% and 25%, respectively in Epoch 1 (p < 0.0001). Central line and parental nutrition days were significantly lower in Epoch 2 compared to Epoch 1 with sustained and potentially improved infant growth. CONCLUSION An evidence-based advancement feeding protocol was associated with achieving full feeds within the first 2 postnatal weeks for very low birth weight infants.
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Hussain A, Rehman A, Fatima N. Comparison of volume and frequency advancement feeding protocols in very low birth weight neonates. Pak J Med Sci 2018; 34:78-81. [PMID: 29643883 PMCID: PMC5857034 DOI: 10.12669/pjms.341.14092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To determine the outcomes in very low birth weight (VLBW) neonates receiving volume advancement versus frequency advancement feeding protocols. Methods: This controlled clinical trial was conducted in Children Hospital Multan within duration of 6 months from February 2017 to August 2017. VLBW neonates having weight < 1500 g at the time of birth were included. The protocol for frequency advancement (FA) group was to give 1 ml/kg human or pre-formula milk after every 8 hours and in volume advancement (VA) group after every 3 hours initially. After three days, in FA group duration of feeds was decreased gradually from 8 to 2 hours and feed volume of 10 ml.kg-1.day-1 until full-recommended dose of feeding i.e. 150 ml.kg-1.day-1 reached. While in VA group, volume of 20 ml.kg-1.day-1 was given until full-recommended dose of feeding reached. Days to achieve full feed, weight gain, and length of hospital stay were primary study outcomes. Results: Baseline weight of neonates was 1148 (111) grams in VA 1179 (106) grams in FA groups (p-value 0.18). In VA group, full feed was achieved in 11.04 (2.38) days versus 15.76 (2.48) days in FA group (P-value <0.001). Duration of IV fluid therapy were 13.5 (8.4) days in FA group versus 9.4 (7.6) in VA group (p-value <0.001). Moreover weight gain at the end of feeding protocol was significantly higher in VA group 1440 (78) grams versus 1284 (99) grams in FA group (P-value <0.001). Necrotizing entero-colitis occurred in only one neonate that was belonging to volume advancement group. Conclusion: Volume advancement (VA) feeding is better as compared to frequency advancement (FA) feeding in very low birth weight neonates.
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Affiliation(s)
- Afaq Hussain
- Dr. Afaq Hussain, FCPS (Paeds Med), Trainee, Children Hospital Complex and the Institute of Child Health, Multan, Pakistan
| | - Abdur Rehman
- Dr. Abdur Rehman, FCPS (Paeds Med) FCPS (Neonatal Paeds Med), Assistant Professor and Head of Neonatal ICU, Children Hospital Complex and the Institute of Child Health, Multan, Pakistan
| | - Nazia Fatima
- Dr. Nazia Fatima, FCPS (Paeds Med), Trainee, Children Hospital Complex and the Institute of Child Health, Multan, Pakistan
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