Fast food versus slow food in very and extremely low-birthweight infants: speed of feeds is a little more than a gut feeling

Assessment of an umbilical venous catheter dwell-time of 8-14 days versus 1-7 days in very low birth weight infacts (UVC - You Will See): a pilot single-center, randomized controlled trial

BACKGROUND

Umbilical venous catheters (UVCs) are used for central vascular access in preterm infants, but controversy exits with regard to the optimum dwell-time.

PATIENTS AND METHODS

Prospective, randomized controlled trial at a level III University neonatal intensive care unit (NICU), comparing a UVC dwell-time of 1-7 days (control group) to 8-14 days (intervention group) in very low birth weight (VLBW) infants.

PRIMARY OUTCOME PARAMETER

Number of infants requiring additional peripherally inserted central catheters (PICC) after removal of UVC.

SECONDARY OUTCOME PARAMETERS

Total number of central lines (CL = UVC and PICCs) until time point of full enteral feeds (130-160 mL/kg/d), total number of intravenous vascular catheters, number of CL-associated complications (infection, thrombosis/emboli, organ injury, secondary CL dislocation), number of X-rays for assessment of CL positioning, and days of therapy (DOT) (teicoplanin) for CL-associated blood stream infections (CLABSI).

RESULTS

Of 116 patients screened for eligibility, 63 patients were enrolled - control group: 31 infants, mean gestational age (GA) 28⁰ weeks (standard deviation (SD) 2.6 weeks), mean birth weight (BW) 988.9 g (SD 322.0 g); intervention group: 32 infants, mean GA 28⁵ weeks (SD 3.0 weeks), mean BW 1078.9 g (SD 324.6 g). In the control group, 28 infants required additional PICCs versus 16 in the intervention group (p < 0.001); total number of CLs: control group n = 58 versus intervention group n = 28; p < 0.001, and the total number of venous vascular devices was also significantly higher in the control group (109 versus 61; p = 0.04). No significant differences were seen with regard to CL-associated complications (p = 0.09). The number of X-rays for assessment of correct CL-position significantly lower in the intervention group (144 versus 96; p = 0.03). In the intervention group, length of hospital stay was significantly shorter (88.1 (SD: 35.3 days) versus 68.1 (SD: 32.6 days); p = 0.03) and GA significantly lower at discharge from the hospital (40⁴: SD: 3³ weeks) versus 38⁵: SD: 2⁵ weeks; p = 0.02. No differences existed with regard to neonatal morbidities and mortality at 36 weeks gestational age.

CONCLUSIONS

A longer UVC dwell-time of up to 14 days significantly decreased the number of painful invasive vascular procedures and radiation exposure, and shortened the length of the hospital stay. The findings of our pilot study should be confirmed in a larger, multi-center RCT with the primary focus on catheter-associated complications.

Enteral Feeding and Necrotizing Enterocolitis: Does Time of First Feeds and Rate of Advancement Matter?

OBJECTIVE

The aim of the study was to determine if time to initial enteral feeding (EF) and rate of advancement are associated with necrotizing enterocolitis (NEC) or death.

METHODS

Secondary analysis of prospectively collected data of very-low-birth-weight infants (VLBWI: 400--1500 g) born in 26 NEOCOSUR centers between 2000 and 2014.

RESULTS

Among 12,387 VLBWI, 83.7% survived without NEC, 6.6% developed NEC and survived, and 9.6% had NEC and died or died without NEC (NEC/death). After risk adjustment, time to initial EF (median = 2 days) was not associated with NEC; however, delaying it was protective for NEC/death (odds ratio [OR] = 0.96; 95% confidence interval [CI] 0.93--0.99). A slower feeding advancement rate (FAR) was protective for NEC (OR = 0.97; 95% CI = 0.94-0.98) and for NEC/death (OR = 0.98; 95% CI = 0.96-0.99).

CONCLUSIONS

In VLBWI, there was no association between an early initial EF and NEC, although delaying it was associated with less NEC/death. A slower FAR was associated with lower risk of both outcomes.

Gavage Feed Volume Determines the Gastric Emptying Rate in Preterm Infants

OBJECTIVE

Feeding intolerance, manifesting as increased gastric residual, is a common finding in preterm neonates. Little is known about the regulation of gastric emptying early in life and the extent to which this plays a role in the preterm infants' feeding tolerance. The goal of this study was to evaluate clinically stable 28- to 32-week gestation neonates during the first 4 weeks of life and noninvasively determine their gastric emptying rate.

STUDY DESIGN

Ultrasound measurements of gastric milk content volume were obtained from 25 neonates immediately after, 30 and/or 60 minutes following routine gavage feeds. The content emptying rate was calculated from the gastric volume data.

RESULTS

Gastric emptying rate was not postnatal age-dependent, was significantly higher at 30 minutes, whenever compared with 60-minute postfeed and directly proportional to the feed volume. At any postnatal age, the gastric emptying rate was at least 6-fold greater, when comparing the lowest and highest average stomach content volumes.

CONCLUSIONS

The gastric emptying rate of preterm infants is content volume-dependent and unrelated to the postnatal age. Given the present findings, further investigation on the gastric residual of preterm infants receiving larger than currently administered feed volumes at the initiation of enteral nutrition, is warranted.

[Parenteral nutrition in premature babies with a birth weight <1500g: a systematic single-center analysis and comparison with current guidelines]

BACKGROUND

Parenteral and enteral nutrition are essential for both growth and development of preterm infants. Based on the results of many studies, the rate of nutritional growth and the amount of substrate delivered parenterally are under debate.

OBJECTIVE

The main aim of this study was to assess parenteral nutrition in very and extremely immature preterm infants, i.e. very low birth weight (VLBW, birth weight <1500g) and extremely low birth weight (ELBW, birth weight <1000g) neonates, and to compare the amount of parenterally delivered substrate in our neonatal intensive care unit (NICU) to current German guidelines.

METHODS

Retrospective audit at our tertiary NICU at the University Children's Hospital of Saarland, Homburg, Germany between 1 January 2009 and 31 December 2010.

RESULTS

In total, 100 premature neonates were included. The mean gestational age was 29.6 weeks (range 24.4-34.1 weeks) and the mean birth weight was 1119 g ± 260 g (range 570 g-1490 g). Comparing the amount of fluids, glucose, amino acids, lipids and kcals with the current guidelines of the German Society for Nutritional Medicine in preterm infants, only glucose was adequately given; however, a substantial number of weight-dependent (more often in ELBW neonates) episodes of hyperglycemia requiring insulin treatment were also seen. During the first 3 weeks of life a substantial drop in body weight, length and head circumference occurred in our study cohort. In contrast, at 2 years corrected age, catch-up growth was seen in our cohort with anthropometric data now comparable to healthy term infants. Using the Bayley II test for developmental outcome assessment, at 2 years corrected age 78.6% (33/42) of infants demonstrated normal development.

CONCLUSIONS

This retrospective data analysis demonstrated inadequate provision of parenteral nutrition in our NICU, which was often not in line with current German guidelines. This was associated with inadequate growth in our cohort, most notably during the first 3 weeks of life; however, implementation of current guidelines is impeded by metabolic disturbances in this cohort, most notably in ELBW neonates. Whether adherence to published guidelines will result in better early ex utero growth, and whether this normalized growth pattern will translate into better long-term outcome on a metabolic and neurological level, remains unclear.

A retrospective study on the effects of exclusive donor human milk feeding in a short period after birth on morbidity and growth of preterm infants during hospitalization

The risks and benefits of feeding preterm formula (PF) versus donor human milk (DHM) in preterm infants are uncertain, and studies evaluating the efficacy of DHM to the morbidities and growth of preterm infants in the neonatal intensive care unit are confused by the need for milk fortification. We aimed to determine and compare the outcome of short-term morbidities in neonatal intensive care unit and growth between premature infants fed exclusively DHM only until a volume of 130 mL/kg/d of enteral feeding was achieved and infants fed with a PF mix after birth. The data of 132 infants with low birth weight of <1500 g and gestational age of less than 32 weeks were considered. Ninety infants were analyzed, of which 86 were discharged alive. The DHM group (n = 36) was made up of infants who were fed exclusively with DHM, whereas the PF group (n = 54) consisted of infants who were fed with a combination of PF and either DHM or human milk, until a volume of 130 mL/kg/d of enteral feeding was achieved. Once feeding in the DHM group progressed to volumes greater than 130 mL/kg/d, infants were fed fortified DHM and PF alternately. One infant (2.8%) in the DHM group had late-onset sepsis or necrotizing enterocolitis compared with 21 (38.9%) in the PF group (adjusted odds ratio 0.05, 95% confidence interval 0.01-0.41); 13 (36.1%) infants in the DHM group had bronchopulmonary dysplasia compared with 38 (70.4%) in the PF group (odds ratio 0.18, 95% confidence interval 0.05-0.41). Although the DHM group demonstrated a comparatively lower rate of weight gain, head circumference increment, and height increment from birth to the age at which an enteral feeding volume of 130 mL/kg/d was achieved, there were no significant differences in these values at 36 weeks' postmenstrual age between both groups.