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Fu TT, Arhin M, Schulz AT, Gardiner A, Chapman S, Adamchak A, Ward LP, Kim JH. Standardizing feeding strategies for preterm infants born greater than 1500 grams. Pediatr Res 2024:10.1038/s41390-024-03483-y. [PMID: 39152334 DOI: 10.1038/s41390-024-03483-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/18/2024] [Accepted: 08/01/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Use of standardized feeding protocols and donor breast milk (DBM) have been studied primarily in infants born <1500 g and not examined exclusively in infants born >1500 g. METHODS In this retrospective pre-post-implementation cohort study, we evaluated a protocol for preterm infants born >1500 g that was implemented clinically to standardize feeding advancements at 30 mL/kg/day, with infants born <33 weeks eligible to receive DBM. We compared placement of peripherally inserted central catheters for parenteral nutrition, feeding tolerance, growth, and maternal milk provision in the 18 months before/after implementation. The association between DBM intake and growth was evaluated using multivariable linear regression. RESULTS We identified 133 and 148 eligible infants pre/post-implementation. Frequency of peripherally inserted central catheters and rate of maternal milk provision was not statistically different. While there was no difference in median days to full enteral volume, there was a narrower distribution post-implementation (p < 0.001). Growth was similar between eras, but each 10% increase in DBM was associated with 1.0 g/d decrease in weight velocity (p < 0.001). CONCLUSIONS A feeding protocol for preterm infants >1500 g is associated with more consistent time to full enteral volume. Further investigation is needed to clarify DBM's impact on growth in this population. IMPACT Despite practice creep, no study has examined the use of standardized feeding protocols or pasteurized donor breast milk exclusively in infants >1500 g. A feeding protocol in this population may achieve full enteral feedings more consistently. With appropriate fortification, donor breast milk can support adequate growth in infants born >1500 g but warrants further study.
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Affiliation(s)
- Ting Ting Fu
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Maame Arhin
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ashley T Schulz
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Abigail Gardiner
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stacie Chapman
- University of Cincinnati Medical Center, Compass One, Cincinnati, OH, USA
| | - Abigail Adamchak
- University of Cincinnati Medical Center, Compass One, Cincinnati, OH, USA
| | - Laura P Ward
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jae H Kim
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
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2
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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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3
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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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4
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Nicolas CT, Carter SR, Martin CA. Impact of maternal factors, environmental factors, and race on necrotizing enterocolitis. Semin Perinatol 2023; 47:151688. [PMID: 36572622 DOI: 10.1016/j.semperi.2022.151688] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Necrotizing enterocolitis (NEC) is a complex disease with a multifactorial etiology. As the leading cause of intestinal morbidity and mortality among premature infants, many resources are being dedicated to neonatal care and molecular targets in the newborn intestine. However, NEC is heavily influenced by maternal and perinatal factors as well. Given its nature, preventive approaches to NEC are more likely to improve outcomes than new treatment strategies. Therefore, this review focuses on maternal, environmental, and racial factors associated with the development of NEC, with an emphasis on those that may be modifiable to decrease the incidence of the disease.
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Affiliation(s)
- Clara T Nicolas
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Stewart R Carter
- Department of Surgery, Division of Pediatric Surgery, University of Louisville School of Medicine, Louisville, KY, United States
| | - Colin A Martin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States; Department of General and Thoracic Surgery, Children's of Alabama, Birmingham, AL, United States.
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5
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Vallant N, Haffenden V, Peatman O, Khan H, Lee G, Thakkar H, Yardley I. Outcomes for necrotising enterocolitis (NEC) in babies born at the threshold of viability: a case-control study. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001583. [PMID: 36645754 PMCID: PMC9717317 DOI: 10.1136/bmjpo-2022-001583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 11/03/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The threshold for active management of babies born prematurely in the UK is currently 22 weeks. The optimal management strategy for necrotising enterocolitis (NEC) in babies born at or near this threshold remains unclear. AIM To review our institutional experience of babies born <24 weeks diagnosed with NEC, identify risk factors for NEC, and compare outcomes with a control cohort. METHODS All infants born <24 weeks gestation January 2015-December 2021 were identified. Babies diagnosed with NEC were defined as cases and babies with no NEC diagnosis as controls. Patient demographics, clinical features, complications and outcomes were extracted from the medical record and compared between cases and controls. RESULTS Of 56 babies, 31 (55.3%) were treated for NEC. There was no difference in NEC-specific risk factors between cases and controls. 17 babies (30.4%) underwent surgery, of these, 11/17 (64.7%) presented with a C reactive protein rise and 11/17 (64.7%) a fall in platelet count. Pneumatosis intestinalis (3/17 (17.7%)) or pneumoperitoneum (3/17 (17.7%)) were present in only a minority of cases. Abdominal ultrasound demonstrated intestinal perforation in 8/8 cases. The surgical complication rate was 5/17 (29.4%). There was no difference in the incidence of intraventricular haemorrhage, periventricular leukomalacia and survival to discharge between the groups. CONCLUSIONS The diagnosis of NEC in infants born <24 weeks gestation is challenging with inconsistent clinical and radiological features. Ultrasound scanning is a useful imaging modality. Mortality was comparable regardless of a diagnosis of NEC. Low gestational age is not a contraindication to surgical intervention in NEC.
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Affiliation(s)
- Natalie Vallant
- Department of Paediatric Surgery, Evelina London Children's Healthcare, London, UK
| | - Verity Haffenden
- Department of Paediatric Surgery, Evelina London Children's Healthcare, London, UK
| | - Oliver Peatman
- Department of Neonatal and Perinatal Medicine, Evelina London Children's Healthcare, London, UK
| | - Hammad Khan
- Department of Neonatal and Perinatal Medicine, Evelina London Children's Healthcare, London, UK
| | - Geraint Lee
- Department of Neonatal and Perinatal Medicine, Evelina London Children's Healthcare, London, UK
| | - Hemanshoo Thakkar
- Department of Paediatric Surgery, Evelina London Children's Healthcare, London, UK
| | - Iain Yardley
- Department of Paediatric Surgery, Evelina London Children's Healthcare, London, UK.,Faculty of Life Sciences and Medicine, King's College, London, UK
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6
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Aurora M, Keyes ML, Acosta JG, Swartz K, Lombay J, Ciaramitaro J, Rudnick A, Kelleher C, Hally S, Gee M, Madhavan V, Roumiantsev S, Cummings BM, Nelson BD, Lerou PH, Matute JD. Standardizing the Evaluation and Management of Necrotizing Enterocolitis in a Level IV NICU. Pediatrics 2022; 150:189570. [PMID: 36164852 PMCID: PMC10026590 DOI: 10.1542/peds.2022-056616] [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] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outcomes. This quality improvement project aimed to decrease variation in the evaluation and management of NEC in a Level IV NICU. METHODS A multidisciplinary team investigated institutional variation in NEC management and developed a standardized guideline and electronic medical record tools to assist in evaluation and management. Retrospective baseline data were collected for 2 years previously and prospectively for 3.5 years after interventions. Outcomes included the ratio of observed-to-expected days of antibiotics and nil per os (NPO) on the basis of the novel guidelines and the percentage of cases treated with piperacillin/tazobactam. Balancing measures were death, surgery, and antifungal use. RESULTS Over 5.5 years, there were 124 evaluations for NEC. Special cause variation was noted in the observed-to-expected antibiotic and NPO days ratios, decreasing from 1.94 to 1.18 and 1.69 to 1.14, respectively. Piperacillin/tazobactam utilization increased from 30% to 91%. There were no increases in antifungal use, surgery, or death. CONCLUSIONS Variation in evaluation and management of NEC decreased after initiation of a guideline and supporting electronic medical record tools, with fewer antibiotic and NPO days without an increase in morbidity or mortality. A quality improvement approach can benefit patients and decrease variability, even in diseases with limited evidence-based standards.
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Affiliation(s)
- Megan Aurora
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors contributed equally to this work
| | - Madeline L Keyes
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- Harvard Neonatal-Perinatal Medicine Fellowship Program, Boston, Massachusetts
- These authors contributed equally to this work
| | | | | | - Jesiel Lombay
- Divisions of aNewborn Medicine
- Departments of Pediatrics
| | | | | | | | | | - Michael Gee
- Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | - Paul H Lerou
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors co-supervised this work
| | - Juan D Matute
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors co-supervised this work
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7
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Burge KY, Gunasekaran A, Makoni MM, Mir AM, Burkhart HM, Chaaban H. Clinical Characteristics and Potential Pathogenesis of Cardiac Necrotizing Enterocolitis in Neonates with Congenital Heart Disease: A Narrative Review. J Clin Med 2022; 11:3987. [PMID: 35887751 PMCID: PMC9320426 DOI: 10.3390/jcm11143987] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 12/10/2022] Open
Abstract
Neonates with congenital heart disease (CHD) are at an increased risk of developing necrotizing enterocolitis (NEC), an acute inflammatory intestinal injury most commonly associated with preterm infants. The rarity of this complex disease, termed cardiac NEC, has resulted in a dearth of information on its pathophysiology. However, a higher incidence in term infants, effects on more distal regions of the intestine, and potentially a differential immune response may distinguish cardiac NEC as a distinct condition from the more common preterm, classical NEC. In this review, risk factors, differentiated from those of classical NEC, are discussed according to their potential contribution to the disease process, and a general pathogenesis is postulated for cardiac NEC. Additionally, biomarkers specific to cardiac NEC, clinical outcomes, and strategies for achieving enteral feeds are discussed. Working towards an understanding of the mechanisms underlying cardiac NEC may aid in future diagnosis of the condition and provide potential therapeutic targets.
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Affiliation(s)
- Kathryn Y. Burge
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (K.Y.B.); (A.G.); (M.M.M.)
| | - Aarthi Gunasekaran
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (K.Y.B.); (A.G.); (M.M.M.)
| | - Marjorie M. Makoni
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (K.Y.B.); (A.G.); (M.M.M.)
| | - Arshid M. Mir
- Department of Pediatrics, Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA;
| | - Harold M. Burkhart
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA;
| | - Hala Chaaban
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (K.Y.B.); (A.G.); (M.M.M.)
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8
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王 琳, 赵 小, 刘 辉, 邓 丽, 梁 红, 段 思, 杨 依, 张 华. [Evidence-based standardized nutrition protocol can shorten the time to full enteral feeding in very preterm/very low birth weight infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:648-653. [PMID: 35762431 PMCID: PMC9250396 DOI: 10.7499/j.issn.1008-8830.2202121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 05/06/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To investigate whether evidence-based standardized nutrition protocol can facilitate the establishment of full enteral nutrition and its effect on short-term clinical outcomes in very preterm/very low birth weight infants. METHODS A retrospective analysis was performed on the medical data of 312 preterm infants with a gestational age of ≤32 weeks or a birth weight of <1 500 g. The standardized nutrition protocol for preterm infants was implemented in May 2020; 160 infants who were treated from May 1, 2019 to April 30, 2020 were enrolled as the control group, and 152 infants who were treated from June 1, 2020 to May 31, 2021 were enrolled as the test group. The two groups were compared in terms of the time to full enteral feeding, the time to the start of enteral feeding, duration of parenteral nutrition, the time to recovery to birth weight, the duration of central venous catheterization, and the incidence rates of common complications in preterm infants. RESULTS Compared with the control group, the test group had significantly shorter time to full enteral feeding, time to the start of enteral feeding, duration of parenteral nutrition, and duration of central venous catheterization and a significantly lower incidence rate of catheter-related bloodstream infection (P<0.05). There were no significant differences between the two groups in the mortality rate and the incidence rate of common complications in preterm infants including grade II-III necrotizing enterocolitis (P>0.05). CONCLUSIONS Implementation of the standardized nutrition protocol can facilitate the establishment of full enteral feeding, shorten the duration of parenteral nutrition, and reduce catheter-related bloodstream infection in very preterm/very low birth weight infants, without increasing the risk of necrotizing enterocolitis.
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Affiliation(s)
| | | | | | | | | | | | | | - 华岩 张
- 费城儿童医院 及宾夕法尼亚大学佩雷尔曼医学院新生儿科,美国宾夕法尼亚州费城
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9
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Berken JA, Chang J. Neurologic consequences of neonatal necrotizing enterocolitis. Dev Neurosci 2022; 44:295-308. [PMID: 35697005 DOI: 10.1159/000525378] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 05/24/2022] [Indexed: 11/19/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is a severe gastrointestinal disease of the premature infant with high mortality and morbidity. Children who survive NEC have been shown to demonstrate neurodevelopmental delay, with significantly worse outcomes than from prematurity alone. The pathways leading to NEC-associated neurological impairments remain unclear, limiting the development of preventative and protective strategies. This review aims to summarize the existing clinical and experimental studies related to NEC-associated brain injury. We describe the current epidemiology of NEC, reported long-term neurodevelopmental outcomes among survivors, and proposed pathogenesis of brain injury in NEC. Highlighted are the potential connections between hypoxia-ischemia, nutrition, infection, gut inflammation, and the developing brain in NEC.
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Affiliation(s)
- Jonathan A Berken
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jill Chang
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA,
- Division of Neonatal-Perinatal Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA,
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10
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Nesterenko TH, Baliga N, Swaintek S, Abdelatif D, Aly H, Mohamed MA. The impact of a multifaceted quality improvement program on the incidence of necrotizing enterocolitis in very low birth weight infants. Pediatr Neonatol 2022; 63:181-187. [PMID: 34933821 DOI: 10.1016/j.pedneo.2021.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/27/2021] [Accepted: 10/07/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a multifactorial gastrointestinal disease which mostly occurs in very low birth weight (VLBW) infants. In addition to decreasing gestational age (GA) or birth weight (BW), artificial formula, delayed initiation or rapidly advanced feeding, severe anemia and systemic infections were associated with NEC. Several studies demonstrated that breast milk, standardized feeding advancement regimens and treatment of anemia are associated with less incidence of NEC. It is not known if including all these interventions in one multifaceted program will lead to significant reduction in NEC. METHODS The NICU team at The George Washington University Hospital created a multifaceted interdisciplinary quality improvement project to tackle several aspects of NEC prevention that addressed researched risk factors for NEC. The program was made of four quality improvement protocols: 1) Standardized Structured Feeding Program, 2) Feeding Intolerance Management Algorithm, 3) Enteral Osmolality Control Tool, and 4) Packed Red Blood Cell (RBC) Standardized Transfusion Protocol. This time-series, quasi experimental study design examined the differences in the incidence of NEC between infants with BW < 1500 g who were admitted to the GW Hospital NICU before and after the program implementation. RESULTS Data from 408 VLBW infants were included in the study. Although not statistically significant, there was a decreasing trend of NEC incidence in the post-implementation group (n = 199) compared to the pre-implementation group (n = 209), (3.5% vs. 5.3%, p = 0.88). The trend in the incidence of NEC declined further after the introduction of RBC transfusion protocol which was introduced ten month after starting the other elements of the program. CONCLUSION Integration of the multifaceted quality improvement program may be associated with a decline in the occurrence of NEC. Further analysis with a larger sample size is required to determine if the changes seen are statistically significant.
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Affiliation(s)
- Tetyana H Nesterenko
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Nita Baliga
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Sarah Swaintek
- Department of Food and Nutrition, The George Washington University Hospital, Washington, DC, USA
| | - Dinan Abdelatif
- Department of Obstetrics and Gynecology, The George Washington University, Washington, DC, USA
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Mohamed A Mohamed
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA.
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11
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Vohr BR, McGowan EC, Brumbaugh JE, Hintz SR. Overview of Perinatal Practices with Potential Neurodevelopmental Impact for Children Affected by Preterm Birth. J Pediatr 2022; 241:12-21. [PMID: 34673090 DOI: 10.1016/j.jpeds.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 09/27/2021] [Accepted: 10/15/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Betty R Vohr
- Department of Pediatrics, Alpert Medical School of Brown University and Women & Infants Hospital, Providence, RI.
| | - Elisabeth C McGowan
- Department of Pediatrics, Alpert Medical School of Brown University and Women & Infants Hospital, Providence, RI
| | - Jane E Brumbaugh
- Children's Center of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA
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12
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Young L, Oddie SJ, McGuire W. Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants. Cochrane Database Syst Rev 2022; 1:CD001970. [PMID: 35049036 PMCID: PMC8771918 DOI: 10.1002/14651858.cd001970.pub6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Enteral feeding for very preterm or very low birth weight (VLBW) infants is often delayed for several days after birth due to concern that early introduction of feeding may not be tolerated and may increase the risk of necrotising enterocolitis. Concerns exist, however, that delaying enteral feeding may diminish the functional adaptation of the gastrointestinal tract and prolong the need for parenteral nutrition with its attendant infectious and metabolic risks. OBJECTIVES To determine the effects of delayed introduction of progressive enteral feeds on the risk of necrotising enterocolitis, mortality and other morbidities in very preterm or VLBW infants. SEARCH METHODS Search strategies were developed by an information specialist in consultation with the review authors. The following databases were searched in October 2021 without date or language restrictions: CENTRAL (2021, Issue 10), MEDLINE via OVID (1946 to October 2021), Embase via OVID (1974 to October 2021), Maternity and Infant Care via OVID (1971 to October 2021), CINAHL (1982 to October 2021). We also searched for eligible trials in clinical trials databases, conference proceedings, previous reviews, and reference lists of retrieved articles. SELECTION CRITERIA Randomised controlled trials that assessed the effects of delayed (four or more days after birth) versus earlier introduction of progressive enteral feeds on necrotising enterocolitis, mortality and other morbidities in very preterm or VLBW infants. DATA COLLECTION AND ANALYSIS Two review authors separately evaluated trial risk of bias, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of evidence for effects on necrotising enterocolitis, mortality, feed intolerance, and invasive infection. MAIN RESULTS We included 14 trials in which a total of 1551 infants participated. Potential sources of bias were lack of clarity on methods to generate random sequences and conceal allocation in half of the trials, and lack of masking of caregivers or investigators in all of the trials. Trials typically defined delayed introduction of progressive enteral feeds as later than four to seven days after birth and early introduction as four days or fewer after birth. Infants in six trials (accounting for about half of all of the participants) had intrauterine growth restriction or circulatory redistribution demonstrated by absent or reversed end-diastolic flow velocities in the fetal aorta or umbilical artery. Meta-analyses showed that delayed introduction of progressive enteral feeds may not reduce the risk of necrotising enterocolitis (RR 0.81, 95% confidence interval (CI) 0.58 to 1.14; RD -0.02, 95% CI -0.04 to 0.01; 13 trials, 1507 infants; low-certainty evidence due risk of bias and imprecision) nor all-cause mortality before hospital discharge (RR 0.97, 95% CI 0.70 to 1.36; RD -0.00, 95% CI -0.03 to 0.03; 12 trials, 1399 infants; low-certainty evidence due risk of bias and imprecision). Delayed introduction of progressive enteral feeds may slightly reduce the risk of feed intolerance (RR 0.81, 95% CI 0.68 to 0.97; RD -0.09, 95% CI -0.17 to -0.02; number needed to treat for an additional beneficial outcome = 11, 95% CI 6 to 50; 6 trials, 581 infants; low-certainty evidence due to risk of bias and imprecision) and probably increases the risk of invasive infection (RR 1.44, 95% CI 1.15 to 1.80; RD 0.10, 95% CI 0.04 to 0.15; number needed to treat for a harmful outcome = 10, 95% CI 7 to 25; 7 trials, 872 infants; moderate-certainty evidence due to risk of bias). AUTHORS' CONCLUSIONS: Delaying the introduction of progressive enteral feeds beyond four days after birth (compared with earlier introduction) may not reduce the risk of necrotising enterocolitis or death in very preterm or VLBW infants. Delayed introduction may slightly reduce feed intolerance, and probably increases the risk of invasive infection.
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Affiliation(s)
- Lauren Young
- Department of Neonatal Medicine, Trevor Mann Baby Unit, Royal Alexandra Children's Hospital, Brighton, UK
| | - Sam J Oddie
- Bradford Neonatology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
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13
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An Interdisciplinary Approach to Reducing NEC While Optimizing Growth: A 20-Year Journey. Adv Neonatal Care 2021; 21:433-442. [PMID: 34510070 DOI: 10.1097/anc.0000000000000929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) and postnatal growth restriction are significant clinical dilemmas that contribute to short- and long-term morbidities for the most premature infants. PURPOSE After a rise in NEC rates in a regional neonatal intensive care unit (NICU), improvement practices were implemented by an interdisciplinary quality improvement (QI) work group whose focus was initially on nutrition and growth. QI work was refocused to address both NEC and growth concurrently. METHODS Through various QI initiatives and with evolving understanding of NEC and nutrition, the work group identified and implemented multiple practices changes over 2-decade time span. A standardized tool was used to review each case of NEC and outcomes were continually tracked to guide QI initiatives. LOCAL FINDINGS Focused QI work contributed to a significant reduction in NEC rates from 16.2% in 2007 to 0% in 2018 for inborn infants. Exclusive human milk diet was a critical part of the success. Postnatal growth outcomes initially declined after initial NEC improvement work. Improvement work that focused jointly on NEC and nutrition resulted in improved growth outcomes without impacting NEC. IMPLICATIONS FOR PRACTICE Use of historical perspective along with evolving scientific understanding can guide local improvement initiatives. Work must continue to optimize lactation during NICU hospitalization. More research is needed to determine impact of care practices on gastrointestinal inflammation including medication osmolality, probiotics, and noninvasive respiratory support.
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Raduma OS, Jehangir S, Karpelowsky J. The effect of standardized feeding protocol on early outcome following gastroschisis repair: A systematic review and meta-analysis. J Pediatr Surg 2021; 56:1776-1784. [PMID: 34193345 DOI: 10.1016/j.jpedsurg.2021.05.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 04/27/2021] [Accepted: 05/25/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Improved post-operative outcomes following gastroschisis repair are attributed to advancement in perioperative and post-operative care and early enteral feeding. This study evaluates the role of standardized postoperative feeding protocols in gastroschisis. STUDY DESIGN A systematic review and meta-analysis of studies published from January 2000 to April 2019 in MEDLINE, EMBASE, Cochrane Library databases and Google Scholar was conducted. Primary outcomes were duration to full enteral feeding and cessation of parenteral nutrition. Secondary outcomes included days to first enteral feeding, length of stay, compliance, complication and mortality rates. Meta-analysis was done using the RevMan Analysis Statistical Package in Review Manager (Version 5.3) using a random effects model and reported as pooled Risk Ratio and Mean Difference. p-value < 0.05 was considered statistically significant. RESULTS Eight observational cohort studies were identified and their data analyzed. Significant heterogeneity was noted for some outcomes. Standardized feeding protocols resulted in fewer days to first enteral feeding by 3.19 days (95% CI: -4.73, -1.66, p < 0.0001) than non-protocolized feeding, less complication rates, reduced mortality and better compliance to care. The duration of parenteral nutrition and time to full enteral feeding were not significantly affected. CONCLUSION Protocolized feeding post-gastroschisis repair is associated with early initiation of enteral feeding. There is a likelihood of reduced rates of sepsis; shorter duration of parenteral nutrition, length of hospital stay and time to full enteral feeding. However, the latter trends are not statistically significant and will require further studies best accomplished with a prospective randomized trial or more cohort studies.
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Affiliation(s)
- Ochieng Sephenia Raduma
- Department of Surgery, Defence Forces Memorial Hospital, Nairobi, Kenya; Division of Surgery, University of Sydney, NSW, Australia; Division of Child and Adolescent Health, Sydney Medical School, University of Sydney, NSW, Australia
| | - Susan Jehangir
- Department of Paediatric Surgery, The Children's hospital at Westmead, NSW, Australia; Christian Medical College, Vellore, Tamil Nadu, India
| | - Jonathan Karpelowsky
- Division of Surgery, University of Sydney, NSW, Australia; Department of Paediatric Surgery, The Children's hospital at Westmead, NSW, Australia; Division of Child and Adolescent Health, Sydney Medical School, University of Sydney, NSW, Australia.
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15
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Aggarwal R, Plakkal N, Bhat V. Does oropharyngeal administration of colostrum reduce morbidity and mortality in very preterm infants? A randomised parallel-group controlled trial. J Paediatr Child Health 2021; 57:1467-1472. [PMID: 33908117 DOI: 10.1111/jpc.15529] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
AIM To evaluate whether a strategy of oropharyngeal administration of colostrum reduces morbidity and mortality in very preterm infants. METHODS A total of 260 neonates with gestational age 26-31 weeks at birth were randomised between August 2017 and August 2018 to receive 0.2 mL of human milk or placebo respectively via the oropharyngeal route, beginning within 24 h after birth, and continued every 3 h until oral feeds were initiated. The primary outcome was a composite of death, late-onset sepsis (LOS) or necrotising enterocolitis (NEC) in the neonatal period. RESULTS A total of 260 infants (mean gestational age 29.5 weeks, and mean birthweight 1201.7 g) were included in the primary analysis. The composite primary outcome occurred in 43 (33.6%) infants in the colostrum group and 38 infants (29.7%) in the placebo group, and the difference was not statistically significant (P = 0.50). Secondary outcomes including the incidence of death, NEC, LOS, probable sepsis, intraventricular haemorrhage, ventilator-associated pneumonia, retinopathy of prematurity, bronchopulmonary dysplasia, time to full feeds, time to regain birthweight, duration of hospital stay and survival to 6 months without major neurosensory impairment were also comparable between the two groups. CONCLUSION A strategy of oropharyngeal administration of colostrum in very preterm and extremely preterm neonates did not decrease the composite primary outcome of death, LOS or NEC. This finding is consistent with most published literature in the area.
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Affiliation(s)
- Rahul Aggarwal
- Department of Neonatology, Apollo Cradle, Gurgaon, India.,Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nishad Plakkal
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Vishnu Bhat
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.,Department of Neonatology, Division of Research, Aarupadai Veedu Medical College and Hospital, Vinayaka Mission's Research Foundation, Pondicherry, India
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16
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Oddie SJ, Young L, McGuire W. Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants. Cochrane Database Syst Rev 2021; 8:CD001241. [PMID: 34427330 PMCID: PMC8407506 DOI: 10.1002/14651858.cd001241.pub8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early enteral feeding practices are potentially modifiable risk factors for necrotising enterocolitis (NEC) in very preterm or very low birth weight (VLBW) infants. Observational studies suggest that conservative feeding regimens, including slowly advancing enteral feed volumes, reduce the risk of NEC. However, it is unclear whether slow feed advancement may delay establishment of full enteral feeding, and if it could be associated with infectious morbidities secondary to prolonged exposure to parenteral nutrition. OBJECTIVES To determine the effects of slow rates of enteral feed advancement on the risk of NEC, mortality, and other morbidities in very preterm or VLBW infants. SEARCH METHODS We searched CENTRAL (2020, Issue 10), Ovid MEDLINE (1946 to October 2020), Embase via Ovid (1974 to October 2020), Maternity and Infant Care database (MIDIRS) (1971 to October 2020), CINAHL (1982 to October 2020), and clinical trials databases and reference lists of retrieved articles for eligible trials. SELECTION CRITERIA We included randomised or quasi-randomised controlled trials that assessed effects of slow (up to 24 mL/kg/d) versus faster rates of advancement of enteral feed volumes on the risk of NEC in very preterm or VLBW infants. DATA COLLECTION AND ANALYSIS Two review authors separately evaluated trial risk of bias, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of evidence. Outcomes of interest were NEC, all-cause mortality, feed intolerance, and invasive infection. MAIN RESULTS We included 14 trials involving a total of 4033 infants (2804 infants participated in one large trial). None of the trials masked parents, caregivers, or investigators. Risk of bias was otherwise low. Most infants were stable very preterm or VLBW infants of birth weight appropriate for gestation. About one-third of all infants were extremely preterm or extremely low birth weight (ELBW), and about one-fifth were small for gestational age, growth-restricted, or compromised as indicated by absent or reversed end-diastolic flow velocity in the foetal umbilical artery. Trials typically defined slow advancement as daily increments of 15 to 24 mL/kg, and faster advancement as daily increments of 30 to 40 mL/kg. Meta-analyses showed that slow advancement of enteral feed volumes probably has little or no effect on the risk of NEC (RR 1.06, 95% confidence interval (CI) 0.83 to 1.37; RD 0.00, 95% CI -0.01 to 0.02; 14 trials, 4026 infants; moderate-certainty evidence) or all-cause mortality prior to hospital discharge (RR 1.13, 95% CI 0.91 to 1.39; RD 0.01, 95% CI -0.01 to 0.02; 13 trials, 3860 infants; moderate-certainty evidence). Meta-analyses suggested that slow advancement may slightly increase feed intolerance (RR 1.18, 95% CI 0.95 to 1.46; RD 0.05, 95% CI -0.02 to 0.12; 9 trials, 719 infants; low-certainty evidence) and may slightly increase the risk of invasive infection (RR 1.14, 95% CI 0.99 to 1.31; RD 0.02, 95% CI -0.00 to 0.05; 11 trials, 3583 infants; low-certainty evidence). AUTHORS' CONCLUSIONS The available trial data indicate that advancing enteral feed volumes slowly (daily increments up to 24 mL/kg) compared with faster rates probably does not reduce the risk of NEC, death, or feed intolerance in very preterm or VLBW infants. Advancing the volume of enteral feeds at a slow rate may slightly increase the risk of invasive infection.
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Affiliation(s)
- Sam J Oddie
- Bradford Neonatology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Lauren Young
- Department of Neonatal Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
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17
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McLeod G, Farrent S, Gilroy M, Page D, Oliver CJ, Richmond F, Cormack BE. Variation in Neonatal Nutrition Practice and Implications: A Survey of Australia and New Zealand Neonatal Units. Front Nutr 2021; 8:642474. [PMID: 34409058 PMCID: PMC8365759 DOI: 10.3389/fnut.2021.642474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 06/24/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Significant global variation exists in neonatal nutrition practice, including in assigned milk composition values, donor milk usage, fortification regimens, probiotic choice and in methods used to calculate and report nutrition and growth outcomes, making it difficult to synthesize data to inform evidence-based, standardized nutritional care that has potential to improve neonatal outcomes. The Australasian Neonatal Dietitians' Network (ANDiN) conducted a survey to determine the degree to which neonatal nutritional care varies across Australia and New Zealand (A&NZ) and to highlight potential implications. Materials and Methods: A two-part electronic neonatal nutritional survey was emailed to each ANDiN member (n = 50). Part-One was designed to examine individual dietetic practice; Part-Two examined site-specific nutrition policies and practices. Descriptive statistics were used to examine the distribution of responses. Results: Survey response rate: 88%. Across 24 NICU sites, maximum fluid targets varied (150–180 mL.kg.d−1); macronutrient composition estimates for mothers' own(MOM) and donor (DM) milk varied (Energy (kcal.dL−1) MOM: 65–72; DM 69–72: Protein (g.dL−1): MOM: 1.0–1.5; DM: 0.8–1.3); pasteurized DM or unpasteurized peer-to-peer DM was not available in all units; milk fortification commenced at different rates and volumes; a range of energy values (kcal.g−1) for protein (3.8–4.0), fat (9.0–10.0), and carbohydrate (3.8–4.0) were used to calculate parenteral and enteral intakes; probiotic choice differed; and at least seven different preterm growth charts were employed to monitor growth. Discussion: Our survey identifies variation in preterm nutrition practice across A&NZ of sufficient magnitude to impact nutrition interventions and neonatal outcomes. This presents an opportunity to use the unique skillset of neonatal dietitians to standardize practice, reduce uncertainty of neonatal care and improve the quality of neonatal research.
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Affiliation(s)
- Gemma McLeod
- Neonatology, Child and Adolescent Health Service, Nedlands, WA, Australia.,Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia.,Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | | | - Melissa Gilroy
- Mater Health Services, Brisbane, QLD, Australia.,Mater Research Institute, University of Queensland, Brisbane, QLD, Australia
| | - Denise Page
- Mater Health Services, Brisbane, QLD, Australia.,Mater Research Institute, University of Queensland, Brisbane, QLD, Australia
| | | | | | - Barbara E Cormack
- Starship Children's Health, Auckland, New Zealand.,Liggins Institute, University of Auckland, Auckland, New Zealand
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18
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Ibrahim NR, Van Rostenberghe H, Ho JJ, Nasir A. Short versus long feeding interval for bolus feedings in very preterm infants. Cochrane Database Syst Rev 2021; 8:CD012322. [PMID: 34415568 PMCID: PMC8407504 DOI: 10.1002/14651858.cd012322.pub2] [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: 12/12/2022]
Abstract
BACKGROUND There is presently no certainty about the ideal feeding intervals for preterm infants. Shorter feeding intervals of, for example, two hours, have the theoretical advantage of allowing smaller volumes of milk. This may have the potential to reduce the incidence and severity of gastro-oesophageal reflux. Longer feeding intervals have the theoretical advantage of allowing more gastric emptying between two feeds. This potentially provides periods of rest (and thus less hyperaemia) for an immature digestive tract. OBJECTIVES To determine the safety of shorter feeding intervals (two hours or shorter) versus longer feeding intervals (three hours or more) and to compare the effects in terms of days taken to regain birth weight and to achieve full feeding. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in CENTRAL (2020, Issue 6) and Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions, and CINAHL on 25 June 2020. We 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 short (e.g. one or two hours) versus long (e.g. three or four hours) feeding intervals in preterm infants of any birth weight, all or most of whom were less than 32 weeks' gestation. Infants could be of any postnatal age at trial entry, but eligible infants should not have received feeds before study entry, with the exception of minimal enteral feeding. We included studies of nasogastric or orogastric bolus feeding, breast milk or formula, in which the feeding interval is the intervention. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Our primary outcomes were days taken to achieve full enteral feeding and days to regain birth weight. Our other outcomes were duration of hospital stay, episodes of necrotising enterocolitis (NEC) and growth during hospital stay (weight, length and head circumference). MAIN RESULTS We included four RCTs, involving 417 infants in the review. One study involving 350 infants is awaiting classification. All studies compared two-hourly versus three-hourly feeding interval. The risk of bias of the included studies was generally low, but all studies had high risk of performance bias due to lack of blinding of the intervention. Three studies were included in meta-analysis for the number of days taken to achieve full enteral feeding (351 participants). The mean days to achieve full feeds was between eight and 11 days. There was little or no difference in days taken to achieve full enteral feeding between two-hourly and three-hourly feeding, but this finding was of low certainty (mean difference (MD) ‒0.62, 95% confidence interval (CI) ‒1.60 to 0.36). There was low-certainty evidence that the days taken to regain birth weight may be slightly longer in infants receiving two-hourly feeding than in those receiving three-hourly feeding (MD 1.15, 95% CI 0.11 to 2.20; 3 studies, 350 participants). We are uncertain whether shorter feeding intervals have any effect on any of our secondary outcomes including the duration of hospital stay (MD ‒3.36, 95% CI ‒9.18 to 2.46; 2 studies, 207 participants; very low-certainty evidence) and the risk of NEC (typical risk ratio 1.07, 95% CI 0.54 to 2.11; 4 studies, 417 participants; low-certainty evidence). No study reported growth during hospital stay. AUTHORS' CONCLUSIONS The low-certainty evidence we found in this review suggests that there may be no clinically important differences between two- and three-hourly feeding intervals. There is insufficient information about potential feeding complications and in particular NEC. No studies have looked at the effect of other feeding intervals and there is no long-term data on neurodevelopment or growth.
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Affiliation(s)
- Nor Rosidah Ibrahim
- Department of Paediatrics, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Paediatrics, Hospital USM, Kubang Kerian, Malaysia
| | - Hans Van Rostenberghe
- Department of Paediatrics, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Paediatrics, Hospital USM, Kubang Kerian, Malaysia
| | - Jacqueline J Ho
- Department of Paediatrics, RCSI & UCD Malaysia Campus (formerly Penang Medical College), George Town, Malaysia
| | - Ariffin Nasir
- Department of Paediatrics, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Paediatrics, Hospital USM, Kubang Kerian, Malaysia
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19
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Abstract
Necrotizing enterocolitis (NEC) is an inflammatory disease affecting premature infants. Intestinal microbial composition may play a key role in determining which infants are predisposed to NEC and when infants are at highest risk of developing NEC. It is unclear how to optimize antibiotic therapy in preterm infants to prevent NEC and how to optimize antibiotic regimens to treat neonates with NEC. This article discusses risk factors for NEC, how dysbiosis in preterm infants plays a role in the pathogenesis of NEC, and how probiotic and antibiotic therapy may be used to prevent and/or treat NEC and its sequelae.
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Affiliation(s)
- Jennifer Duchon
- Division of Newborn Medicine, Jack and Lucy Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 1000 10th Avenue, New York, NY 10019, USA
| | - Maria E Barbian
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, 3rd Floor, Atlanta, GA 30322, USA
| | - Patricia W Denning
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Emory University Hospital Midtown, 550 Peachtree Street, 3rd Floor MOT, Atlanta, GA 30308, USA.
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20
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A preoperative standardized feeding protocol improves human milk use in infants with complex congenital heart disease. J Perinatol 2021; 41:590-597. [PMID: 33547410 DOI: 10.1038/s41372-021-00928-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 11/06/2020] [Accepted: 01/15/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the hypothesis that implementation of a preoperative standardized feeding protocol increases human milk use in infants with complex congenital heart disease (CHD). STUDY DESIGN Single-center, quasi-experimental study of infants with complex CHD. A cohort of 546 infants pre protocol was compared to 55 patients post protocol. Feeding regimen and peri-operative outcomes information were collected. RESULT Human milk use increased significantly (58.4% versus 100%, p < 0.01) and there was no formula use post protocol (18.7% versus 0%, p < 0.01). Preoperative necrotizing enterocolitis occurred in 18/546 (3.3%) infants pre protocol versus 1/55 (1.8%) post protocol, p = 1.00. Days to full feeds and length of hospital stay in both cohorts were not significantly different. CONCLUSION Successful implementation of a preoperative standardized feeding protocol can increase human milk and decrease formula use in infants with complex CHD without significant adverse outcomes. A larger study is needed to evaluate the association of human milk use with peri-operative outcomes.
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21
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Effects of standardized feeding protocol on growth velocity and necrotizing enterocolitis in extremely low birth weight infants. J Perinatol 2021; 41:134-139. [PMID: 33281186 DOI: 10.1038/s41372-020-00892-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/26/2020] [Accepted: 11/20/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the effect of a standardized feeding protocol (SFP) on growth velocity (GV) and necrotizing enterocolitis (NEC) in extremely low birth weight infants. METHODS This single-study center retrospectively compared growth, nutritional, and gastrointestinal outcomes in two infant cohorts before (cohort 1; n = 145) and after (cohort 2; n = 69) SFP implementation. RESULTS Although weekly GV in the first 4 weeks of life did not differ between the two cohorts, median GV at 36 weeks' post-menstrual age (PMA) was higher in cohort 2 compared with cohort 1 (26.8 g/day [24.7, 28.9] vs 24.9 g/day [22.9, 28.3], p = 0.02). The odds of NEC were lower in cohort 2 by 63% after adjusting for birth weight, small-for-gestational-age, and gender (OR = 0.38, 95% CI 0.142-0.993, p = 0.047). CONCLUSION Our SFP was associated with improved GV at 36 weeks' PMA and a lower adjusted rate of NEC.
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22
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Chu SS, White HO, Rindone SL, Tripp SA, Rhein LM. An Initiative to Reduce Preterm Infants Pre-discharge Growth Failure Through Time-specific Feeding Volume Increase. Pediatr Qual Saf 2020; 6:e366. [PMID: 33403313 PMCID: PMC7774992 DOI: 10.1097/pq9.0000000000000366] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/14/2020] [Indexed: 01/07/2023] Open
Abstract
Very low birth weight infants often demonstrate poor postnatal longitudinal growth, which negatively impacts survival rates and long-term health outcomes. Improving extrauterine growth restriction (EUGR) among extremely premature infants has become a significant focus of quality improvement initiatives. Prior efforts in the University of Massachusetts Memorial Medical Center neonatal intensive care unit were unsuccessful in improving the EUGR rate at discharge.
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Affiliation(s)
- Sherman S Chu
- Department of Pediatrics, University of Massachusetts Memorial Medical Center, Worcester, Mass
| | - Heather O White
- Department of Pediatrics, University of Massachusetts Memorial Medical Center, Worcester, Mass
| | - Shannon L Rindone
- Department of Pediatrics, University of Massachusetts Memorial Medical Center, Worcester, Mass
| | - Susan A Tripp
- Department of Pediatrics, University of Massachusetts Memorial Medical Center, Worcester, Mass
| | - Lawrence M Rhein
- Department of Pediatrics, University of Massachusetts Memorial Medical Center, Worcester, Mass
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23
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Advancement of a standardised enteral feeding protocol in functional single ventricle patients following stage I palliation using cerebro-somatic near-infrared spectroscopy. Cardiol Young 2020; 30:1649-1658. [PMID: 32829739 DOI: 10.1017/s104795112000253x] [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: 11/07/2022]
Abstract
INTRODUCTION Infants with single ventricle following stage I palliation are at risk for poor nutrition and growth failure. We hypothesise a standardised enteral feeding protocol for these infants that will result in a more rapid attainment of nutritional goals without an increased incidence of gastrointestinal co-morbidities. MATERIALS AND METHODS Single-centre cardiac ICU, prospective case series with historical comparisons. Feeding cohort consisted of consecutive patients with a single ventricle admitted to cardiac ICU over 18 months following stage I palliation (n = 33). Data were compared with a control cohort and admitted to the cardiac ICU over 18 months before feeding protocol implementation (n = 30). Feeding protocol patients were randomised: (1) protocol with cerebro-somatic near-infrared spectroscopy feeding advancement criteria (n = 17) or (2) protocol without cerebro-somatic near-infrared spectroscopy feeding advancement criteria (n = 16). RESULTS Median time to achieve goal enteral volume was significantly higher in the control compared to feeding cohort. There were no significant differences in enteral feeds being held for feeding intolerance or necrotising enterocolitis between cohorts. Feeding cohort had significant improvements in discharge nutritional status (weight, difference admit to discharge weight, weight-for-age z score, volume, and caloric enteral nutrition) and late mortality compared to the control cohort. No infants in the feeding group with cerebro-somatic near-infrared spectroscopy developed necrotising enterocolitis versus 4/16 (25%) in the feeding cohort without cerebro-somatic near-infrared spectroscopy (p = 0.04). CONCLUSIONS A feeding protocol is a safe and effective means of initiating and advancing enteral nutrition in infants following stage I palliation and resulted in improved nutrition delivery, weight gain, and nourishment status at discharge without increased incidence of gastrointestinal co-morbidities.
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Webbe J, Gale C. NICE guidelines on neonatal parenteral nutrition: a step towards standardised care but evidence is scarce. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:645-646. [DOI: 10.1016/s2352-4642(20)30179-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
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Implications of continuity of care on infant caloric intake in the neonatal intensive care unit. J Perinatol 2020; 40:1405-1411. [PMID: 32157220 DOI: 10.1038/s41372-020-0636-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To estimate the association of continuity of neonatologist care with caloric intake and growth velocity (GV) in very low birth weight (VLBW) infants. STUDY DESIGN We created a daily continuity index (DCI) defined as the number of days the neonatologist worked in the previous week. We estimated the independent associations between this index and infants' daily caloric intake (kcal/kg/day) and GV (g/kg/day) through the first 6 weeks of life using regression analyses. RESULTS Twenty-eight neonatologists cared for 115 infants over 4643 patient-days. The DCI was independently associated with increased caloric intake (β = 1.27 kcal/kg/day per each day of continuity, p < 10-4); this effect was magnified (β = 3.33, p < 10-4) in the first 2 weeks. No association was observed between the index and GV. CONCLUSIONS Neonatologist continuity may contribute to caloric intake in VLBW infants. Quality metrics focused on this area of health care delivery warrant further discovery.
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Cormack B, Oliver C, Farrent S, Young J, Coster K, Gilroy M, Page D, Little H, McLeod G. Neonatal dietitian resourcing and roles in New Zealand and Australia: A survey of current practice. Nutr Diet 2019; 77:392-399. [PMID: 31762224 DOI: 10.1111/1747-0080.12592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/05/2019] [Accepted: 10/21/2019] [Indexed: 11/26/2022]
Abstract
AIM Dietitian-led implementation of evidence-based nutrition support practices improves nutrient intakes, clinical outcomes and growth, decreases length of stay and related costs, and reduces intravenous nutrition costs and prescription errors. We aimed to investigate current neonatal dietitian resourcing and roles in New Zealand and Australian neonatal units, and to compare this with dietitian workforce recommendations and previously reported survey data. METHODS A two-part electronic survey was emailed to 50 Australasian Neonatal Dietitians Network members and other dietitians working in neonatal intensive care or special care baby units in New Zealand and Australia. The survey ran from July to October 2018. Descriptive statistics were used to examine the distribution of responses. Responses were compared with other similar surveys and British Dietetic Association workforce recommendations. RESULTS There was an 88% response rate for Part 1. Forty-eight percent of respondents had worked in neonatology for more than 5 years. Ward rounds were attended weekly or more often by 43% of respondents. One-third regularly attended neonatal conferences or grand rounds. The majority spent less than 25% of their neonatal service allocation on teaching, developing policy or research. All respondents reported their unit had written enteral feeding guidelines. The neonatal dietitian workforce is at 23% of recommended levels. CONCLUSIONS Australasian neonatal dietitians have great potential to add value in neonatal units which has not yet been fully realised. Funding reallocation, upskilling and on-going professional development are needed to ensure the neonatal dietitian workforce is at the recommended level to be safe, sustainable and effective.
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Affiliation(s)
- Barbara Cormack
- Starship Child Health, Auckland City Hospital, Auckland, New Zealand.,Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Colleen Oliver
- The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Shelley Farrent
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Jacqui Young
- Sunshine Hospital, Melbourne, Victoria, Australia
| | - Keryn Coster
- The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Melissa Gilroy
- Mater Health, Mater Mothers and Mater Mothers Private Hospitals, Brisbane, Queensland, Australia
| | - Denise Page
- Mater Health, Mater Mothers and Mater Mothers Private Hospitals, Brisbane, Queensland, Australia
| | - Helen Little
- Christchurch Women's Hospital, Christchurch, New Zealand
| | - Gemma McLeod
- King Edward Memorial and Princess Margaret Hospitals, Perth, Western Australia, Australia.,The University of Western Australia, Perth, Western Australia, Australia
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27
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Abstract
Early enteral feeding is a potentially modifiable risk factor for necrotising enterocolitis (NEC) and late onset sepsis (LOS), however enteral feeding practices for preterm infants are highly variable. High-quality evidence is increasingly available to guide early feeding in preterm infants. Meta-analyses of randomised trials indicate that early trophic feeding within 48 h after birth and introduction of progressive enteral feeding before 4 days of life at an advancement rate above 24 ml/kg/day can be achieved in clinically stable very preterm and very low birthweight (VLBW) infants, without higher mortality or incidence of NEC. This finding may not be generalisable to high risk infants such as those born small for gestational age (SGA) or following absent/reversed end diastolic flow velocity (AREDFV) detected antenatally on placental Doppler studies, due to the small number of such infants in existing trials. Trials targeting such high-risk preterm infants have demonstrated that progressive enteral feeding started in the first 4 days is safe and does not lead to higher NEC or mortality; however, there is a paucity of data to guide feeding advancement in such infants. There is little trial evidence to support bolus or continuous gavage feeding as being superior in clinically stable preterm infants. Trials that examine enteral feeding are commonly unblinded for technical and practical reasons, which increases the risk of bias in such trials, specifically when considering potentially subjective outcome such as NEC and LOS; future clinical trials should focus on objective, primary outcome measures such as all-cause mortality, long term growth and neurodevelopment. Alternatively, important short-term outcomes such as NEC could be used with blinded assessment.
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Affiliation(s)
- T'ng Chang Kwok
- Division of Academic Child Health, University of Nottingham, E floor, East Block, Queens Medical Centre, Nottingham NG7 2UH, United Kingdom.
| | - Jon Dorling
- Division of Neonatal-Perinatal Medicine, IWK Health Centre, 5850/5890 University Avenue, Halifax, Nova Scotia, B3K 6R8, Canada.
| | - Chris Gale
- Neonatal Medicine, Imperial College London, Chelsea and Westminster Hospital campus, 4th floor, lift bank D, 369 Fulham Road, London, SW10 9NH, United Kingdom.
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28
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Agrawal G, Wazir S, Kumar S, Yadav BS, Balde M. Routine versus Selective Fortification of Human Milk with Powdered Human Milk Fortifiers in Very Low Birth Weight (VLBW) Preterm Infants: A Retrospective Pre-Post Cohort Study. J Trop Pediatr 2019; 65:439-445. [PMID: 30544244 DOI: 10.1093/tropej/fmy074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES The objective of this study was to show the effects of routine vs. selective fortification of human milk (HM) on short-term growth and metabolic parameters. METHODS Single-centre retrospective pre-post cohort study in India. Preterm infants ≤32 weeks' gestation and weighing ≤1500 g were included. Routine fortification: pre-fixed feed volume (100 ml/kg/day in our unit) at which fortification was done. Selective fortification: feed volume was gradually optimized till 180-200 ml/kg/day. If weight gain was below the expected threshold (<10 g/kg/day), then fortification was considered. Primary outcome measure was rate of growth till discharge. RESULTS The median rate of weight gain (g/kg/day) in the routine fortification group [10.8 (3.3, 17.1)] was comparable with that in the selective fortification group [8.4 (0, 14.2), p = 0.6]. Serum phosphorus showed a significantly higher value (5.9 vs. 4.8, p = 0.03), while rest of the metabolic parameters showed a trend towards a favourable outcome in the selective fortification group. Adverse outcomes showed a trend towards decreased feed intolerance, necrotizing enterocolitis, and sepsis in the selective fortification group. CONCLUSIONS Selective fortification had a comparable growth rate and showed a trend towards better metabolic parameters and lesser adverse outcomes compared with routine fortification of HM.
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Affiliation(s)
- Gopal Agrawal
- Department of Paediatrics and Neonatology, Cloudnine Hospital, Gurgaon, Haryana, India
| | - Sanjay Wazir
- Department of Paediatrics and Neonatology, Cloudnine Hospital, Gurgaon, Haryana, India
| | - Surender Kumar
- Department of Paediatrics and Neonatology, Cloudnine Hospital, Gurgaon, Haryana, India
| | - Bir Singh Yadav
- Department of Paediatrics and Neonatology, Cloudnine Hospital, Gurgaon, Haryana, India
| | - Manish Balde
- Department of Paediatrics and Neonatology, Cloudnine Hospital, Gurgaon, Haryana, India
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29
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Wang J, Kortsalioudaki C, Heath PT, Buttery J, Clarke P, Gkentzi D, Anthony M, Tan K. Epidemiology and healthcare factors associated with neonatal enterococcal infections. Arch Dis Child Fetal Neonatal Ed 2019; 104:F480-F485. [PMID: 30425112 DOI: 10.1136/archdischild-2018-315387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 09/28/2018] [Accepted: 10/09/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the epidemiology and healthcare factors associated with late-onset neonatal enterococcal infections. DESIGN Multicentre, multinational retrospective cohort study using prospectively collected infection data from a neonatal infection surveillance network between 2004 and 2016; this was supplemented with healthcare data from a questionnaire distributed to participating neonatal units. SETTING Sixty neonatal units across Europe (UK, Greece, Estonia) and Australia. PATIENTS Infants admitted to participating neonatal units who had a positive culture of blood, cerebrospinal fluid or urine after 48 hours of life. RESULTS In total, 414 episodes of invasive Enterococcus spp infection were reported in 388 infants (10.1% of a total 4083 episodes in 3602 infants). Enterococcus spp were the second most common cause of late-onset infection after coagulase-negative Staphylococcus spp and were strongly associated with necrotising enterocolitis (NEC) (adjusted OR 1.44, 95% CI 1.02 to 2.03, p=0.038), total parenteral nutrition (TPN) (adjusted OR 1.34, 95% CI 1.06 to 1.70, p=0.016), increasing postnatal age (per 1-week increase: adjusted OR 1.04, 95% CI 1.02 to 1.06, p<0.001) and decreasing birth weight (per 1 kg increase: adjusted OR 0.85, 95% CI 0.74 to 0.97, p=0.017). There was no evidence that inadequate nurse to patient staffing ratios in high-dependency units were associated with a higher risk of enterococcal infections. CONCLUSIONS Enterococcus spp were the second most frequent cause of late-onset infections. The association between enterococcal infections, NEC and TPN may inform empiric antimicrobial regimens in these contexts and provide insights into reducing these infections.
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Affiliation(s)
- Joanna Wang
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Christina Kortsalioudaki
- Paediatric Infectious Diseases Research Group, Infection and Immunity, St George's University of London, London, UK
| | - Paul T Heath
- Paediatric Infectious Diseases Research Group, Infection and Immunity, St George's University of London, London, UK
| | - Jim Buttery
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.,Monash Children's Hospital, Melbourne, Victoria, Australia.,Monash Centre for Health Research and Implementation, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Paul Clarke
- Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Despoina Gkentzi
- Department of Paediatrics, University General Hospital of Patras, Patras, Greece
| | - Mark Anthony
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kenneth Tan
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.,Monash Children's Hospital, Melbourne, Victoria, Australia
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30
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Xu JH, Coo H, Fucile S, Ng E, Ting JY, Shah PS, Dow K. A national survey of the enteral feeding practices in Canadian neonatal intensive care units. Paediatr Child Health 2019; 25:529-533. [PMID: 33354263 DOI: 10.1093/pch/pxz112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/28/2019] [Indexed: 11/14/2022] Open
Abstract
Aim Nutrition affects the growth and neurodevelopmental outcomes of preterm infants, yet controversies exist about the optimal enteral feeding regime. The objective of this study was to compare enteral feeding guidelines in Canadian neonatal intensive care units (NICUs). Method The research team identified key enteral feeding practices of interest. Canadian Neonatal Network site investigators at 30 Level 3 NICUs were contacted to obtain a copy of their 2016 to 2017 feeding guidelines for infants who weighed less than 1,500 g at birth. Each guideline was reviewed to compare recommendations around the selected feeding practices. Results Five of the 30 NICUs did not have a feeding guideline. The other 25 NICUs used 22 different enteral feeding guidelines. The guidelines in 40% of those NICUs recommend commencing minimal enteral nutrition (MEN) within 24 hours of birth and maintaining that same feeding volume for 24 to 96 hours. In 40% of NICUs, the guideline recommended that MEN be initiated at a volume of 5 to 10 mL/kg/day for infants born at <1,000 g. Guidelines in all 25 NICUs recommend the use of bovine-based human milk fortifier (HMF), and in 56% of NICUs, it is recommended that HMF be initiated at a total fluid intake of 100 mL/kg/day. Guidelines in only 16% of NICUs recommended routine gastric residual checks. Donor milk and probiotics are used in 76% and 72% of the 25 NICUs, respectively. Conclusion This study revealed substantial variability in recommended feeding practices for very low birth weight infants, underscoring the need to establish a national feeding guideline for this vulnerable group.
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Affiliation(s)
| | - Helen Coo
- Department of Pediatrics, Queen's University, Kingston, Ontario
| | - Sandra Fucile
- Department of Pediatrics, Queen's University, Kingston, Ontario
| | - Eugene Ng
- Department of Paediatrics, University of Toronto, Toronto, Ontario.,Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Joseph Y Ting
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia
| | - Prakesh S Shah
- Department of Paediatrics, University of Toronto, Toronto, Ontario.,Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario.,Department of Pediatrics, Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario
| | - Kimberly Dow
- Department of Pediatrics, Queen's University, Kingston, Ontario
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31
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Chu S, Procaskey A, Tripp S, Naples M, White H, Rhein L. Quality improvement initiative to decrease time to full feeds and central line utilization among infants born less than or equal to 32 0/7 weeks through compliance with standardized feeding guidelines. J Perinatol 2019; 39:1140-1148. [PMID: 31197237 DOI: 10.1038/s41372-019-0398-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/10/2019] [Accepted: 04/17/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND There are emerging evidences that support more aggressive feeding advancement among preterm infants. Our NICU had conservative feeding advancement guidelines that delayed enteral feeding and prolonged central line use. We aimed to reduce time to full feeds among infants born ≤ 32 0/7 weeks from 12.8 days to 8 days. METHODS A multidisciplinary team implemented evidence-based feeding guidelines using quality improvement methods. Days to full enteral feeds, central line days, necrotizing enterocolitis (NEC) rates, and extrauterine growth restriction (EUGR) rates were analyzed. RESULTS Average days to full enteral feeds decreased from 12.8 to 7.7 days and from 17.5 to 9.1 days for infants born ≤ 32 0/7 weeks and ≤ 28 0/7 weeks respectively, without significant change in NEC rate. Central line days decreased by 35%. Insignificant improvement in EUGR rate was found. CONCLUSIONS Faster feeding advancement guidelines led to earlier full enteral feeds and reduced central line utilization without increasing complications.
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Affiliation(s)
- Sherman Chu
- University of Massachusetts Memorial Medical Center, Worcester, MA, USA.
| | | | - Susan Tripp
- University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Mary Naples
- University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Heather White
- University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Lawrence Rhein
- University of Massachusetts Memorial Medical Center, Worcester, MA, USA
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32
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Ashina M, Fujioka K, Totsu S, Shoji H, Miyazawa T, Wada K, Iijima K, Morioka I. Feeding interval and use of donor breast milk for very low birthweight infants: A nationwide survey in Japan. Pediatr Neonatol 2019; 60:245-251. [PMID: 30122363 DOI: 10.1016/j.pedneo.2018.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/24/2018] [Accepted: 07/09/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Enteral feeding is critical for postnatal growth of very low birthweight infants (VLBWI); however, a standard feeding strategy has not been established in Japan. A 2- or 3-h feeding interval is generally used, but no clear evidence supports either approach. Additionally, there is no nationwide breast milk bank in Japan and no consensus exists on the use of donor breast milk (DBM). To clarify the current feeding strategies for VLBWI in Japan, we undertook a nationwide survey. METHODS We sent a questionnaire to the 382 NICUs included in the Neonatal Research Network in Japan. We sought information on NICU size, number of admissions, necrotizing enterocolitis (NEC) incidence, feeding interval, and use of DBM. RESULTS We received responses from 217 NICUs (56.8%), including 76 tertiary centers and 140 regional centers. We only analyzed data obtained from tertiary perinatal centers with a high response rate (77.6%) owing to the insufficient response rate of lower-level facilities (<50%). Most NICUs (71.1%) used a 3-h feeding interval. Only 9.2% used a 2-h interval for all VLBWI. Most NICUs (64.5%) never used DBM, which is not routinely pasteurized. DBM was used in 27 NICUs (35.5%), with and without limitations. Data from 14,233 VLBWI were analyzed; 258 infants (1.8%) were diagnosed with NEC from 2011 to 2015. The incidence of NEC was higher in NICUs that used a 2-h interval (2.7%) than in others. No association was found between NEC and the use of DBM. The NEC incidence did not differ between centers using the most common strategy of a 3-h interval without DBM and those using other strategies. CONCLUSION Most NICUs in Japan use a 3-h feeding interval and do not use DBM for VLBWI. Further prospective studies including multiple confounders are required to clarify the relationship between feeding strategy and the incidence of NEC.
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Affiliation(s)
- Mariko Ashina
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazumichi Fujioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Satsuki Totsu
- Department of Neonatology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiromichi Shoji
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tokuo Miyazawa
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Kazuko Wada
- Department of Neonatology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ichiro Morioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan; Department of Pediatrics, Nihon University School of Medicine, Tokyo, Japan
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33
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Abstract
Multicenter groups have reported reductions in the incidence of necrotizing enterocolitis (NEC) among preterm infants over the past 2 decades. These large-scale prevalence studies have coincided with reports from multicenter consortia and single centers of modifications in practice using quality-improvement techniques aimed at either reducing NEC risk specifically or reducing risk of mortality and multiple morbidities associated with extreme prematurity. The modifications in practice have been based on mechanistic studies, epidemiologic association data, and clinical trials. Recent reports from centers modifying practice to reduce NEC are reviewed and select modified/modifiable practices discussed.
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Affiliation(s)
- C Michael Cotten
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Duke University School of Medicine, Box 2739 DUMC, Durham, NC 27710, USA.
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34
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Teresa C, Antonella D, de Ville de Goyet Jean. New Nutritional and Therapeutical Strategies of NEC. Curr Pediatr Rev 2019; 15:92-105. [PMID: 30868956 DOI: 10.2174/1573396315666190313164753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/09/2018] [Accepted: 03/06/2019] [Indexed: 11/22/2022]
Abstract
Necrotizing enterocolitis (NEC) is an acquired severe disease of the digestive system affecting mostly premature babies, possibly fatal and frequently associated to systemic complications. Because of the severity of this condition and the possible long-term consequences on the child's development, many studies have aimed at preventing the occurrence of the primary events at the level of the bowel wall (ischemia and necrosis followed by sepsis) by modifying or manipulating the diet (breast milk versus formula) and/or the feeding pattern (time for initiation after birth, continuous versus bolus feeding, modulation of intake according clinical events). Feeding have been investigated so far in order to prevent NEC. However, currently well-established and shared clinical nutritional practices are not available in preventing NEC. Nutritional and surgical treatments of NEC are instead well defined. In selected cases surgery is a therapeutic option of NEC, requiring sometimes partial intestinal resection responsible for short bowel syndrome. In this paper we will investigate the available options for treating NEC according to the Walsh and Kliegman classification, focusing on feeding practices in managing short bowel syndrome that can complicate NEC. We will also analyze the proposed ways of preventing NEC.
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Affiliation(s)
- Capriati Teresa
- Artificial Nutrition in Pediatric Children's Hospital, Bambino Gesu, Rome, Italy
| | - Diamanti Antonella
- Artificial Nutrition in Pediatric Children's Hospital, Bambino Gesu, Rome, Italy
| | - de Ville de Goyet Jean
- Pediatric Department for the Treatment and Study of abdominal Disease and Abdominal Transplants, ISMETT-UPMC, Palermo, Italy
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35
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Abstract
Enteral feeding and composition play a chief role in the prevention and treatment of necrotizing enterocolitis (NEC). In the face of decades of research on this fatal disease, the exact mechanism of disease is still poorly understood. There is established evidence that providing mother's own breast milk and standardization of feeding regimens leads to a decreased risk for NEC. More recent studies have focused on the provision of donor human milk or an exclusive human milk diet in the endeavor to prevent NEC while still maintaining adequate nutrition to the premature infant. There is growing literature on the provision of specific human milk components and its effect on the incidence of NEC.
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Affiliation(s)
- Diomel de la Cruz
- University of Florida, Department of Pediatrics, Division of Neonatology, Gainesville, FL, USA.
| | - Catalina Bazacliu
- University of Florida, Department of Pediatrics, Division of Neonatology, Gainesville, FL, USA
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36
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Gephart SM, Moore EF, Fry E. Standardized Feeding Protocols to Reduce Risk of Necrotizing Enterocolitis in Fragile Infants Born Premature or with Congenital Heart Disease: Implementation Science Needed. Crit Care Nurs Clin North Am 2018; 30:457-466. [PMID: 30447806 DOI: 10.1016/j.cnc.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although a unit-adopted standardized feeding protocol (SFP) for neonates is standard of care, implementation strategies for SFPs vary across neonatal and pediatric intensive care. Besides improving growth and reducing feeding interruptions, SFPs reduce risk for necrotizing enterocolitis in infants with heart disease or born premature. The purpose of this article is to bridge the gap between recommended and actual care using SFPs.
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Affiliation(s)
- Sheila M Gephart
- Community and Health Systems Science, College of Nursing, The University of Arizona, PO Box 210203, Tucson, AZ 85721, USA.
| | - Emily F Moore
- Regional cardiology program, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Emory Fry
- Cognitive Medical Systems, 9444 Waples Street, Suite 300, San Diego, CA 92121, USA
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37
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Ferreira INA, Soares FVM, da Costa ACC, Moreira MEL. INFLUENCE OF DILUTION, TIME, AND TEMPERATURE AFTER PREPARATION ON THE OSMOLALITY OF INFANT FORMULAS GIVEN TO NEWBORNS. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2018; 36:415-421. [PMID: 30462778 PMCID: PMC6322801 DOI: 10.1590/1984-0462/;2018;36;4;00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/24/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To analyze the influence of dilution, time, and temperature after preparation on the osmolality of infant formulas given to newborns (NBs). METHODS Experimental and descriptive study with samples of different neonatal formulas to verify the osmolality of the milk according to dilution, time, and temperature after preparation. We analyzed seven neonatal formulas in the following times after preparation: immediately (up to 5 minutes); 20 and 40 minutes; every hour up to 8 hours; and 12 and 24 hours. The samples were evaluated at room temperature and after refrigeration. Osmolality curves were designed with the mean of triplicate samples of each milk sample. The digital Osmometer A+, model 3320, from Advanced Instruments measured the osmolality. RESULTS The time and temperature at which the milk was subjected after preparation did not cause the osmolality to exceed its safety cut-off point at a 1:30 dilution in any of the types of milk analyzed. At a 1:25 dilution, the formula with prebiotics in its composition went over the limit after 4 hours. CONCLUSIONS The milk tested did not exceed the cut-off point of 450 mOsm/kg (approximately 400 mOsm/L), indicated as safe by the American Academy of Pediatrics (AAP) at a dilution recommended by manufacturers. It is important to know the factors that may or may not contribute to the rise of osmolality, in order to establish safe and quality practices for NBs, following protocols based on scientific evidence.
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38
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Reducing time to initiation and advancement of enteral feeding in an all-referral neonatal intensive care unit. J Perinatol 2018; 38:936-943. [PMID: 29740193 DOI: 10.1038/s41372-018-0110-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 03/08/2018] [Accepted: 03/14/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Decrease time to enteral feeding initiation and advancement. STUDY DESIGN In our all-referral neonatal intensive care unit, we developed an evidence-based guideline addressing feeding initiation and advancement. During 6 months before and 7 months after guideline implementation, we measured time to initiate feeding, time to 100 ml/kg/day of feeding, gastric residual measurement frequency, and incidence of necrotizing enterocolitis (balancing measure). RESULT Two hundred twenty-three infants were studied. Time from admission to feeding initiation was shorter after guideline implementation (mean 0.5 days [95% CI: 0.4-0.7] vs. 1.1 days [95% CI: 0.7-1.5], p = 0.01). Time from admission to 100 ml/kg/day feeding was also shorter (3.6 days [95% CI: 2.8-4.4] vs. 6.2 days [95% CI: 4.4-8.1], p = 0.01). After guideline implementation, routine gastric residual measurements were discontinued. CONCLUSION After implementation of an enteral feeding guideline, which included discontinuation of routine gastric residual assessment, we observed a faster initiation of enteral feeding and shorter time to reach 100 ml/kg/day.
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39
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Olsen SL, Park ND, Tracy K, Younger D, Anderson B. Implementing Standardized Feeding Guidelines, Challenges, and Results. Neonatal Netw 2018; 37:218-223. [PMID: 30567919 DOI: 10.1891/0730-0832.37.4.218] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this article was to develop standardized nutritional guidelines that would promote increased growth velocity (GV) in premature infants. DESIGN Evidence-based standardized nutritional guidelines were developed. Guidelines included total parenteral nutrition advancement; enteral feeding advancement; and a bedside nurse gastric residual management algorithm. Staff education was given. Guideline compliance was measured. Nutritional intake and daily weights were recorded. SAMPLE Infants of birth weight <1,500 grams who were admitted to the NICU before day of life four. MAIN OUTCOME VARIABLE Increase in GV from 12 to 15 g/kg/d. RESULTS Growth velocity was unchanged. Compliance to the nutritional guidelines was 70 percent. No difference was seen in length of stay. Rate of necrotizing enterocolitis was decreased.
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40
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A quality improvement initiative to reduce necrotizing enterocolitis across hospital systems. J Perinatol 2018; 38:742-750. [PMID: 29679047 DOI: 10.1038/s41372-018-0104-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/27/2018] [Accepted: 02/28/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Necrotizing enterocolitis (NEC) is a devastating intestinal disease in premature infants. Local rates of NEC were unacceptably high. We hypothesized that utilizing quality improvement methodology to standardize care and apply evidence-based practices would reduce our rate of NEC. STUDY DESIGN A multidisciplinary team used the model for improvement to prioritize interventions. Three neonatal intensive care units (NICUs) developed a standardized feeding protocol for very low birth weight (VLBW) infants, and employed strategies to increase the use of human milk, maximize intestinal perfusion, and promote a healthy microbiome. RESULTS The primary outcome measure, NEC in VLBW infants, decreased from 0.17 cases/100 VLBW patient days to 0.029, an 83% reduction, while the compliance with a standardized feeding protocol improved. CONCLUSION Through reliable implementation of evidence-based practices, this project reduced the regional rate of NEC by 83%. A key outcome and primary driver of success was standardization across multiple NICUs, resulting in consistent application of best practices and reduction in variation.
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Viswanathan S, Merheb R, Wen X, Collin M, Groh-Wargo S. Standardized slow enteral feeding protocol reduces necrotizing enterocolitis in micropremies. J Neonatal Perinatal Med 2018; 10:171-180. [PMID: 28409756 DOI: 10.3233/npm-171680] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Compared to early enteral feeds, delayed introduction and slow enteral feeding advancement to reduce necrotizing enterocolitis (NEC) is not well studied in micropremies (<750g birth weight). METHODS Pre-post case control study. Micropremies who followed a standardized slow enteral feeding (SSEF) protocol (September 2009 to March 2015) were compared with a similar group of historical controls (PreSSEF, January 2003 to July 2009). Enteral feeding withheld for first 10-14 days and advanced at <10 ml/kg/day in the SSEF group. RESULTS Ninety-two infants in the SSEF group were compared with 129 PreSSEF group. Birth weight and gestational age in SSEF and PreSSEF were similar. Breast milk initiation rate was higher in SSEF (87.0 vs. 72.0%, p = 0.01) compared to PreSSEF, but were similar at full enteral feeds. Compared with PreSSEF, feeding initiation day, full enteral feeding day, parenteral nutrition days, and total central line days were longer in SSEF. There was significant reduction in NEC (1.1 vs. 16.2%, p < 0.01), surgical NEC (0.0 vs. 7.8%, p < 0.01) and NEC/death (7.6 vs. 29.5%, p < 0.01), in SSEF compared to PreSSEF. SSEF, compared to PreSSEF, had more cholestasis (41.8 vs 28.8%, p = 0.04), higher peak serum alkaline phosphatase (638 vs. 534 IU/dL, p < 0.01), but similar rates of late-onset sepsis (39.1 vs 43.4%, p = 0.53). In infants who survived to discharge, SSEF had higher discharge weight, lower extra-uterine growth restriction, and similar length of stay, compared to PreSSEF. CONCLUSIONS A SSEF protocol significantly reduces the incidence of NEC and combined NEC/death in micropremies.
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Affiliation(s)
- S Viswanathan
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH, USA
| | - R Merheb
- Division of Neonatology, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Xintong Wen
- Division of Neonatology, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - M Collin
- Division of Neonatology, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - S Groh-Wargo
- Division of Neonatology, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Necrotizing Enterocolitis in Infants with Hypoplastic Left Heart Syndrome Following Stage 1 Palliation or Heart Transplant. Pediatr Cardiol 2018; 39:774-785. [PMID: 29392349 DOI: 10.1007/s00246-018-1820-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 01/20/2018] [Indexed: 10/18/2022]
Abstract
Previous studies of necrotizing enterocolitis (NEC) among infants with hypoplastic left heart syndrome (HLHS) were conducted in single centers or had small sample sizes. This study aimed to determine the mortality rate and the risk factors for NEC among infants with HLHS who were discharged over a 10-year period (2004-2013) from 41 Pediatric Health Information System affiliated children's hospitals. Either stage 1 palliation and/or heart transplant were completed prior to patient's death or hospital discharge. We compared the characteristics of infants with HLHS who did not develop NEC and those who developed medical or surgical NEC and of patients who had medical vs. surgical NEC. The primary outcome was mortality over time and by birth weight category (low birth weight [LBW], birth weight < 2500 vs. ≥ 2500 g). Multivariable analyses were performed to identify the risk factors for developing NEC and for mortality among infants with HLHS. The study evaluated 5720 infants with HLHS including 349 patients (6.1%) with medical or surgical NEC. Fifty-two patients (0.9%) required laparotomy or percutaneous abdominal drainage. On univariable analysis, the overall mortality rate for infants who developed NEC was significantly higher than infants who did not develop NEC (23.5 vs. 13.9%, P < 0.001). On multivariable analysis, neither medical nor surgical NEC was a significant predictor of mortality in the study population. LBW infants were at higher risk for mortality in both the univariable and the multivariable models. Nevertheless, LBW did not significantly predispose infants with HLHS to develop NEC. Our results provide a national benchmark incidence of NEC, its risk factors, and outcomes among a large cohort of infants with HLHS and establish that NEC is not a significant risk factor for mortality in this population.
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Paul SP, Kirkham EN, Hawton KA, Mannix PA. Feeding growth restricted premature neonates: a challenging perspective. Sudan J Paediatr 2018; 18:5-14. [PMID: 30799892 DOI: 10.24911/sjp.106-1519511375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Nutrition in the postnatal period is essential to achieve optimal growth and maintain biochemical normality. Feeding growth-restricted premature neonates remains a big challenge for pediatricians and neonatologists. The choice of milk is one of the biggest challenges. Breast milk is recommended, although feeding with preterm formulas can ensure a more consistent delivery of optimal levels of nutrients. The timing of introduction of feeds and the rate of advancement of those feeds in preterm infants are both topics of significant controversy. Early feeding is advantageous because it improves the functional adaptation of the gastrointestinal tract and reduces the duration of total parenteral nutrition. A faster rate of advancement will also reduce the duration of need for parenteral nutrition. Despite this, enteral feeding is often delayed and is often slowly increased in high-risk infants because of a possible increased risk of necrotizing enterocolitis (NEC). Growth-restricted neonates are at increased risk of developing NEC due to a combination of antenatal and postnatal disturbances in gut perfusion. If enteral feeding is introduced earlier and advanced more quickly, this may lead to increased risk of NEC, but slower feeds extend the duration of parenteral nutrition and its risks and may have adverse consequences for survival, growth, and development. Premature infants pose a significant nutritional challenge. Overall, we would suggest the preferential use of human breast milk, early minimal enteral feeds, and standardized feeding protocols with cautious advancements of feeds to facilitate gastrointestinal adaptation and reduce the risk of NEC, however further research is needed.
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Patel S, Chaudhari M, Kadam S, Rao S, Patole S. Standardized feeding and probiotic supplementation for reducing necrotizing enterocolitis in preterm infants in a resource limited set up. Eur J Clin Nutr 2017; 72:281-287. [PMID: 29255185 DOI: 10.1038/s41430-017-0040-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 09/19/2017] [Accepted: 10/16/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND/OBJECTIVES Necrotizing enterocolitis (NEC ≥ Stage II) is associated with high mortality and morbidity in preterm infants. To assess if introduction of standardized feeding regimen (SFR) and routine probiotic supplementation (RPS) was associated with reduced incidence of NEC in preterm infants in our nursery in a resource limited set up. SUBJECTS/METHODS This was a retrospective cohort study assessing the incidence of NEC ≥ Stage II before (Epoch 1: N = 144) vs. after (Epoch 2, N = 144) implementation of SFR and RPS in preterm infants < 35 weeks. RESULTS The median (IQR) gestation and birth weight in epoch 1 and epoch 2 was [32 (30, 33.5) vs. 31.5 (30, 34) weeks, p = 0.829], and [1350 (1100, 1700) vs. 1370 (1110, 1550) g, p = 0.363] respectively. Both groups had predominantly outborn infants (Epoch 1: 79.2% vs. Epoch 2: 78.2%; p = 1.00). Multivariate analysis after adjusting for potential confounders found a significantly lower incidence of NEC ≥ Stage II after implementing SFR and RPS (Epoch 1: 17.4% vs. Epoch 2:9.0%, adjusted odds ratio aOR: 0.19; 95% CI: 0.05, 0.71, p = 0.013). The incidence of the composite outcome of 'NEC or Mortality' was also significantly lower after the intervention (Epoch 1: 21.5% vs. Epoch 2: 14.6%; aOR 0.24, 95% CI: 0.07, 0.85, p = 0.027). CONCLUSIONS Introduction of SFR and RPS was associated with significant reduction in NEC ≥ Stage II and the composite outcome of NEC ≥ Stage II /mortality in preterm infants.
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Affiliation(s)
- Saurabh Patel
- Department of Neonatology, Ratna Memorial Hospital, Pune, India
| | - Mayur Chaudhari
- Department of Neonatology, Ratna Memorial Hospital, Pune, India
| | - Sandeep Kadam
- Department of Neonatology, Ratna Memorial Hospital, Pune, India.
| | - Shripada Rao
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
| | - Sanjay Patole
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
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Gephart SM, Hanson C, Wetzel CM, Fleiner M, Umberger E, Martin L, Rao S, Agrawal A, Marin T, Kirmani K, Quinn M, Quinn J, Dudding KM, Clay T, Sauberan J, Eskenazi Y, Porter C, Msowoya AL, Wyles C, Avenado-Ruiz M, Vo S, Reber KM, Duchon J. NEC-zero recommendations from scoping review of evidence to prevent and foster timely recognition of necrotizing enterocolitis. Matern Health Neonatol Perinatol 2017; 3:23. [PMID: 29270303 PMCID: PMC5733736 DOI: 10.1186/s40748-017-0062-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/28/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Although decades have focused on unraveling its etiology, necrotizing enterocolitis (NEC) remains a chief threat to the health of premature infants. Both modifiable and non-modifiable risk factors contribute to varying rates of disease across neonatal intensive care units (NICUs). PURPOSE The purpose of this paper is to present a scoping review with two new meta-analyses, clinical recommendations, and implementation strategies to prevent and foster timely recognition of NEC. METHODS Using the Translating Research into Practice (TRIP) framework, we conducted a stakeholder-engaged scoping review to classify strength of evidence and form implementation recommendations using GRADE criteria across subgroup areas: 1) promoting human milk, 2) feeding protocols and transfusion, 3) timely recognition strategies, and 4) medication stewardship. Sub-groups answered 5 key questions, reviewed 11 position statements and 71 research reports. Meta-analyses with random effects were conducted on effects of standardized feeding protocols and donor human milk derived fortifiers on NEC. RESULTS Quality of evidence ranged from very low (timely recognition) to moderate (feeding protocols, prioritize human milk, limiting antibiotics and antacids). Prioritizing human milk, feeding protocols and avoiding antacids were strongly recommended. Weak recommendations (i.e. "probably do it") for limiting antibiotics and use of a standard timely recognition approach are presented. Meta-analysis of data from infants weighing <1250 g fed donor human milk based fortifier had reduced odds of NEC compared to those fed cow's milk based fortifier (OR = 0.36, 95% CI 0.13, 1.00; p = 0.05; 4 studies, N = 1164). Use of standardized feeding protocols for infants <1500 g reduced odds of NEC by 67% (OR = 0.33, 95% CI 0.17, 0.65, p = 0.001; 9 studies; N = 4755 infants). Parents recommended that NEC information be shared early in the NICU stay, when feedings were adjusted, or feeding intolerance occurred via print and video materials to supplement verbal instruction. DISCUSSION Evidence for NEC prevention is of sufficient quality to implement. Implementation that addresses system-level interventions that engage the whole team, including parents, will yield the best impact to prevent NEC and foster its timely recognition.
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Affiliation(s)
- Sheila M. Gephart
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
| | | | | | | | | | | | - Suma Rao
- Banner Health, Banner University Medical Center-Phoenix, Phoenix, AZ USA
- Phoenix Perinatal Associates, Mesa, AZ USA
- Clinical Assistant Professor and Vice-Chair, Department of Pediatrics, The University of Arizona, Tucson, AZ USA
| | - Amit Agrawal
- Banner Health, Thunderbird Medical Center, Glendale, AZ USA
- Envision Physician Services, Lawrenceville, GA USA
| | - Terri Marin
- Augusta University College of Nursing, Athens, GA USA
| | - Khaver Kirmani
- Banner Health, Cardon Children’s Medical Center, Mesa, AZ USA
- Phoenix Perinatal Associates, Mesa, AZ USA
| | - Megan Quinn
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
- Banner Health, Cardon Children’s Medical Center, Mesa, AZ USA
| | - Jenny Quinn
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
- NorthBay Medical Center, Fairfield, CA USA
| | - Katherine M. Dudding
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
| | | | - Jason Sauberan
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA USA
| | - Yael Eskenazi
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
| | - Caroline Porter
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
| | | | - Christina Wyles
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
| | | | - Shayla Vo
- Robert Wood Johnson Foundation Nurse Faculty Scholar, The University of Arizona College of Nursing, PO Box 210203, Tucson, AZ 85721 USA
| | - Kristina M. Reber
- Nationwide Children’s Hospital and The Ohio State Wexner Medical Center, Columbus, OH USA
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Riskin A. Meeting the nutritional needs of premature babies: their future is in our hands. Br J Hosp Med (Lond) 2017; 78:690-694. [PMID: 29240511 DOI: 10.12968/hmed.2017.78.12.690] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The goals of early nutrition in preterm infants are to provide all the necessary vital nutrients, achieve extra-uterine growth rates similar to fetuses of the same gestational age, and support functional neurodevelopmental outcomes that are comparable to those of infants born at term. It is vital to provide nutrition that will maximally support brain growth and development, but over-feeding with accelerated growth, fat accumulation and long-term metabolic consequences should also be avoided. Because the morbidity associated with prematurity increases nutritional and energetic demands, the basic approach is of providing early intensive nutrition. Protein is the main driving force for growth and brain development. Since deficits in protein occur from the first day of extra-uterine life, sufficient quantities of parenteral amino acids should be provided from the first hours of life. With protein and carbohydrates, enough energy should also be provided, via concomitant early administration of intravenous lipid emulsions. Early initiation of enteral feeding with advancement to full enteral nutrition is associated with better maturation of the gut and better neuro-developmental outcomes. Human milk is the best food for preterm babies, although enrichment may be needed.
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Affiliation(s)
- Arieh Riskin
- Department of Neonatology, Bnai Zion Medical Center, Bruce & Ruth Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Gephart SM, Wyles C, Canvasser J. Expert consensus to weight an adherence score for audit and feedback of practices that prevent necrotizing enterocolitis in very low birth weight infants. Appl Nurs Res 2017; 39:182-188. [PMID: 29422156 DOI: 10.1016/j.apnr.2017.11.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/15/2017] [Accepted: 11/02/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Necrotizing enterocolitis (NEC) is a catastrophic abdominal complication threatening the life of premature infants, but adoption of prevention and early recognition practices differs as do NEC rates in Neonatal Intensive Care Units (NICUs). The purpose of this research was to validate and weight an evidence-based adherence score (aka NEC-Zero Adherence Score) to prevent and foster timely recognition of NEC. STUDY DESIGN An electronic Delphi (e-Delphi) approach was used to identify consensus. NEC experts were recruited via the NEC Society and surveyed until consensus and stability criteria for the Delphi were met (≥70% consensus and mean responses changed <15% between rounds). RESULTS Expert panelists (n=22) were experienced (M=17.6, SD 11years) and predominately physicians (68%) or neonatal nurse practitioners (18%). Consensus (>70% by item) supported a 10 point score. Points were distributed across 1) an exclusive human milk diet (5 points), 2) standardized feeding protocols (3 points), 3) antibiotic stewardship (1 point), and 4) a unit-specified approach to early recognition (1 point). Withholding feeding during transfusion was controversial (M=0.50, SD 0.73) and met consensus criteria to drop from the score. CONCLUSIONS Holding feeding during transfusion was dropped from the score. Relationships between the score and unit NEC rates as well as its utility for use in audit and feedback should be studied in the future.
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Affiliation(s)
- Sheila M Gephart
- The University of Arizona College of Nursing, Tucson, AZ, United States.
| | - Christina Wyles
- The University of Arizona College of Nursing, Tucson, AZ, United States
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Embleton ND, Zalewski SP. How to feed a baby recovering from necrotising enterocolitis when maternal milk is not available. Arch Dis Child Fetal Neonatal Ed 2017; 102:F543-F546. [PMID: 28780499 DOI: 10.1136/archdischild-2016-311964] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/22/2017] [Accepted: 06/22/2017] [Indexed: 11/03/2022]
Abstract
Necrotising enterocolitis (NEC) is a devastating disease with significant mortality and serious adverse outcomes in at least 50% including short gut and poor neurodevelopment. Research and management are complicated by a lack of robust clinical markers, and without histological confirmation, there is a risk of both underdiagnosis and overdiagnosis. Interunit variations in the thresholds for surgical referral, laparotomy and postmortem rates mean the actual incidence is difficult to determine, especially because the histological term 'NEC' is used in practice to describe a heterogeneous clinical syndrome. In this article, we discuss issues relating to choice of milk feed type following a clinical diagnosis of 'NEC' where mother's own milk is not available. We review common clinical concerns relating to feeding following NEC and the rationale for modifications of the macronutrient composition and quality of formula milk.
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Affiliation(s)
- Nicholas D Embleton
- Newcastle Neonatal Service, Newcastle Hospitals NHS Foundation Trust & Newcastle University, Newcastle upon Tyne, UK
| | - Stefan P Zalewski
- Newcastle Neonatal Service, Newcastle Hospitals NHS Foundation Trust & Newcastle University, Newcastle upon Tyne, UK
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Moreno Algarra MC, Fernández Romero V, Sánchez Tamayo T, Espinosa Fernández MG, Salguero García E. Variabilidad en las prácticas sobre alimentación enteral del prematuro entre hospitales españoles de la red SEN-1500. An Pediatr (Barc) 2017; 87:245-252. [DOI: 10.1016/j.anpedi.2016.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 09/19/2016] [Accepted: 09/26/2016] [Indexed: 12/20/2022] Open
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Moreno Algarra MC, Fernández Romero V, Sánchez Tamayo T, Espinosa Fernández MG, Salguero García E. Variability in enteral feeding practices of preterm infants among hospitals in the SEN1500 Spanish neonatal network. An Pediatr (Barc) 2017. [DOI: 10.1016/j.anpede.2016.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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