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Salas AA, Gunawan E, Nguyen K, Reeves A, Argent V, Finck A, Carlo WA. Early Human Milk Fortification in Infants Born Extremely Preterm: A Randomized Trial. Pediatrics 2023; 152:e2023061603. [PMID: 37551512 PMCID: PMC10471508 DOI: 10.1542/peds.2023-061603] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 08/09/2023] Open
Abstract
OBJECTIVES Enteral nutrition with unfortified human milk during the first 2 postnatal weeks often leads to cumulative protein and energy deficits among preterm infants. Fortified human milk administered soon after birth could increase fat-free mass (FFM) and improve growth in these infants. METHODS This was a masked, randomized trial. Starting on feeding day 2, extremely preterm infants 28 weeks or younger fed maternal or donor milk were randomized to receive either a diet fortified with a human-based product (intervention group) or a standard, unfortified diet (control group). This practice continued until the feeding day when a standard bovine-based fortifier was ordered. Caregivers were masked. The primary outcome was FFM-for-age z score at 36 weeks of postmenstrual age (PMA). RESULTS A total of 150 infants were randomized between 2020 and 2022. The mean birth weight was 795±250 g, and the median gestational age was 26 weeks. Eleven infants died during the observation period. The primary outcome was assessed in 105 infants (70%). FFM-for-age z scores did not differ between groups. Length gain velocities from birth to 36 weeks PMA were higher in the intervention group. Declines in head circumference-for-age z score from birth to 36 weeks' PMA were less pronounced in the intervention group. CONCLUSIONS In infants born extremely preterm, human milk diets fortified soon after birth do not increase FFM accretion at 36 weeks' PMA, but they may increase length gain velocity and reduce declines in head circumference-for-age z scores from birth to 36 weeks' PMA.
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Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Emily Gunawan
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kelly Nguyen
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Audrey Reeves
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Victoria Argent
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amber Finck
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Waldemar A Carlo
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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2
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Assad M, Jerome M, Olyaei A, Nizich S, Hedges M, Gosselin K, Scottoline B. Dilemmas in establishing preterm enteral feeding: where do we start and how fast do we go? J Perinatol 2023; 43:1194-1199. [PMID: 37169912 DOI: 10.1038/s41372-023-01665-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 03/06/2023] [Accepted: 03/23/2023] [Indexed: 05/13/2023]
Abstract
Beginning and achieving full enteral nutrition is a key step in the care of preterm infants, particularly very low birth weight (VLBW) infants. As is true for many organ system-specific complications of prematurity, the gastrointestinal tract must complete in utero development ex utero while concurrently serving a physiologic role reserved for after completion of full term development. The preterm gut must assume the placental function of the interface between a source of energy, precursors for anabolism, and micronutrients, and the developing infant-through digestion and absorption of milk, instead of directly from the mother via the uteroplacental interface. The benefits of enteral nourishment in preterm infants are counterbalanced by gastrointestinal complications of prematurity: dysmotility leading to difficulty establishing and advancing feeds, and the risk of necrotizing enterocolitis (NEC). Concern for these complications can prolong the need for parenteral nutrition with an associated increase in risk for central line-associated bloodstream infection (CLABSI) and parenteral nutrition (PN)-associated cholestasis or liver disease (PNALD). Thus, a daily issue facing neonatologists caring for preterm infants is how to optimally begin, advance, and reach full enteral nutrition sufficient to satisfy the nutrient, energy, and fluid requirements of VLBW infants while minimizing risk. In this perspective, we provide an overview of the approaches and supporting data for starting and advancing enteral feeds in preterm infants, particularly very low birth weight infants, and we discuss the significant gaps in knowledge that accompany current approaches. This framework recognizes the dilemmas of preterm feeding initiation and advancement and identifies areas of opportunity for further investigation.
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Affiliation(s)
- Maushumi Assad
- Division of Neonatology, Department of Pediatrics, University of Massachusetts T.H.Chan School of Medicine, Worcester, MA, 01655, USA
| | - Maggie Jerome
- Graduate Programs in Human Nutrition, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Amy Olyaei
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Samantha Nizich
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Madeline Hedges
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA
| | - Kerri Gosselin
- Division of Neonatology, Department of Pediatrics, University of Massachusetts T.H.Chan School of Medicine, Worcester, MA, 01655, USA
| | - Brian Scottoline
- Division of Neonatology, Department of Pediatrics, Oregon Health & Sciences University, Portland, OR, 97239, USA.
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3
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Salas AA, Travers CP. The Practice of Enteral Nutrition: Clinical Evidence for Feeding Protocols. Clin Perinatol 2023; 50:607-623. [PMID: 37536767 PMCID: PMC10599301 DOI: 10.1016/j.clp.2023.04.005] [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: 08/05/2023]
Abstract
Establishing full enteral nutrition in critically ill preterm infants with immature gastrointestinal function is challenging. In this article, we will summarize emerging clinical evidence from randomized clinical trials suggesting the feasibility and efficacy of feeding interventions targeting the early establishment of full enteral nutrition. We will also examine trial outcomes of higher volume feedings after the establishment of full enteral nutrition. Only data from randomized clinical trials will be discussed extensively. Future opportunities for clinical research will also be presented.
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Affiliation(s)
- Ariel A Salas
- Division of Neonatology, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, 1700 6th Avenue South Women & Infants Center Suite 9380, Birmingham, AL 35233, USA.
| | - Colm P Travers
- Division of Neonatology, Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, 1700 6th Avenue South Women & Infants Center Suite 9380, Birmingham, AL 35233, USA
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4
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Murphy C, Baskind S, Aladangady N, Banerjee J. Measuring gut perfusion and blood flow in neonates using ultrasound Doppler of the superior mesenteric artery: a narrative review. Front Pediatr 2023; 11:1154611. [PMID: 37601136 PMCID: PMC10433905 DOI: 10.3389/fped.2023.1154611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/02/2023] [Indexed: 08/22/2023] Open
Abstract
The gut is a relatively silent organ in utero but takes on a major role after birth for the absorption and digestion of feed for adequate nutrition and growth. The neonatal circulation undergoes a transition period after birth, and gut perfusion increases rapidly to satisfy the oxygen demand and consumption. If this process is compromised at any stage, preterm and fetal growth restricted infants are at particular risk of gut tissue injury secondary to hypoxia, leading to necrotizing enterocolitis. Feeding can also be a challenge in these high-risk groups due to gut dysmotility. Superior mesenteric artery (SMA) Doppler is a safe, bedside investigation that could rapidly aid clinicians with feeding strategies and in monitoring high-risk infants. This article aims to establish normal patterns of gut blood flow velocity in neonates using SMA Doppler and reviews how it might be used clinically in pathologic states.
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Affiliation(s)
- C. Murphy
- Neonatal Intensive Care Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
- Neonatal Intensive Care Unit, Queen Mary University of London, London, United Kingdom
| | - S. Baskind
- Neonatal Intensive Care Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
| | - N. Aladangady
- Neonatal Intensive Care Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
- Neonatal Intensive Care Unit, Queen Mary University of London, London, United Kingdom
| | - J. Banerjee
- Neonatal Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
- Neonatal Intensive Care Unit, Imperial College London, London, United Kingdom
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5
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Kosmeri C, Giapros V, Rallis D, Balomenou F, Serbis A, Baltogianni M. Classification and Special Nutritional Needs of SGA Infants and Neonates of Multiple Pregnancies. Nutrients 2023; 15:2736. [PMID: 37375640 DOI: 10.3390/nu15122736] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/01/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023] Open
Abstract
Data regarding the nutritional management of preterm small for gestational age (SGA) infants are scarce. In the recent report of ESPGHAN, the recommended energy for very preterm infants during hospitalization has been increased, yet this may not fit the needs of all preterm infants. It is important to distinguish fetal growth-restricted (FGR) infants from constitutional SGA infants, as well as preterm SGA from preterm AGA infants, since they may have different nutritional needs. Preterm FGR infants, and specifically infants < 29 weeks' gestation, accumulate nutrient deficits due to intrauterine malnutrition, prematurity, morbidities, delayed initiation of feeding, and feeding intolerance. Therefore, these infants may need more aggressive nutrition for optimal catch-up growth and neurologic development. However, a balance should be kept between optimal and excessive catch-up growth, since the combination of intrauterine malnutrition and excessive postnatal growth has been linked with later adverse metabolic consequences. Furthermore, multiple gestation is often complicated by FGR and prematurity. There is controversy in the definition of FGR in multiple gestations, and it should be noted that FGR in multiple gestation usually differs etiologically from FGR in singletons. The aim of this review is to summarize existing knowledge regarding the nutritional needs of preterm FGR and FGR infants of multiple gestation.
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Affiliation(s)
- Chrysoula Kosmeri
- Department of Pediatrics, University Hospital of Ioannina, 455 00 Ioannina, Greece
| | - Vasileios Giapros
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 455 00 Ioannina, Greece
| | - Dimitrios Rallis
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 455 00 Ioannina, Greece
| | - Foteini Balomenou
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 455 00 Ioannina, Greece
| | - Anastasios Serbis
- Department of Pediatrics, University Hospital of Ioannina, 455 00 Ioannina, Greece
| | - Maria Baltogianni
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 455 00 Ioannina, Greece
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Association between Abnormal Antenatal Doppler Characteristics and Gastrointestinal Outcomes in Preterm Infants. Nutrients 2022; 14:nu14235121. [PMID: 36501150 PMCID: PMC9738995 DOI: 10.3390/nu14235121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
Antenatal Doppler disturbances are associated with fetal hypoxia and may induce a brain-sparing vascular redistribution at the expense of splanchnic circulation, possibly predisposing to gut complications. We aimed to compare several gastrointestinal outcomes among very-low-birthweight (VLBW) preterm infants with different antenatal Doppler features. VLBW infants born between 2010-2022 were retrospectively included and stratified into the following clusters based on antenatal Doppler characteristics: normal Doppler (controls); absent or reversed end-diastolic flow in the umbilical artery (UA-AREDF) alone or also in the ductus venosus (UA+DV-AREDF); and abnormal Doppler with or without brain-sparing redistribution. The following outcomes were evaluated: time to reach full enteral feeds (FEF), feeding intolerance (FI), necrotizing enterocolitis (NEC), and spontaneous intestinal perforation (SIP). Overall, 570 infants were included. Infants born following UA+DV-AREDF had significantly higher FI, NEC, and SIP rates and achieved FEF later compared to controls. Increased FI prevalence and a longer time to FEF compared to controls were also observed among UA-AREDF infants and in the presence of brain-sparing redistribution, which also increased NEC rates. Antenatal Doppler abnormalities exacerbate the gastrointestinal risks of preterm infants. Detailed knowledge of Doppler features can aid in identifying those at highest risk of intestinal complications who may benefit from tailored enteral feeding management.
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7
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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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8
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Unterscheider J, Cuzzilla R. Severe early-onset fetal growth restriction: What do we tell the prospective parents? Prenat Diagn 2021; 41:1363-1371. [PMID: 34390005 DOI: 10.1002/pd.6030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 08/04/2021] [Accepted: 08/08/2021] [Indexed: 11/09/2022]
Abstract
Fetal growth restriction (FGR) is a common complication of pregnancy, associated with higher risk of perinatal mortality and adverse health and developmental outcomes for surviving infants. True FGR relates to a pathological restriction of fetal growth resulting from complex interactions between maternal, placental, fetal, and environmental factors. Early-onset FGR (onset <32 weeks' gestation) is often first suspected at routine mid-trimester sonographic assessment of fetal morphology, or identified as part of the placental syndrome, commonly maternal pre-eclampsia. Prenatal investigations may identify the cause of FGR. Timing of delivery is guided by serial sonographic surveillance of fetal growth and well-being and maternal condition, balancing the risk of stillbirth with the benefits of advancing gestation. This is particularly pertinent to severe early-onset FGR, a leading iatrogenic cause of very preterm birth. Prognosis is largely determined by the severity of FGR and its causes, gestation at birth, and birthweight. Pregnancy termination may be considered. Antenatal care and delivery in a tertiary center, provided by a multi-disciplinary team with expertise in managing high-risk pregnancies, are imperative to optimizing outcomes.
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Affiliation(s)
- Julia Unterscheider
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rocco Cuzzilla
- Department of Obstetrics and Gynecology, The University of Melbourne, Melbourne, Victoria, Australia.,Neonatal Services and Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
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9
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Sadrudin Premji S, Chessell L, Stewart F. Continuous nasogastric milk feeding versus intermittent bolus milk feeding for preterm infants less than 1500 grams. Cochrane Database Syst Rev 2021; 6:CD001819. [PMID: 34165778 PMCID: PMC8223964 DOI: 10.1002/14651858.cd001819.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Milk feedings can be given via nasogastric tube either intermittently, typically over 10 to 20 minutes every two or three hours, or continuously, using an infusion pump. Although the theoretical benefits and risks of each method have been proposed, their effects on clinically important outcomes remain uncertain. OBJECTIVES: To examine the evidence regarding the effectiveness of continuous versus intermittent bolus tube feeding of milk in preterm infants less than 1500 grams. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 7) in the Cochrane Library; Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions; and CINAHL (Cumulative Index to Nursing and Allied Health Literature) on 17 July 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs and quasi-RCTs comparing continuous versus intermittent bolus nasogastric milk feeding in preterm infants less than 1500 grams. DATA COLLECTION AND ANALYSIS Two review authors independently assessed all trials for relevance and risk of bias. We used the standard methods of Cochrane Neonatal to extract data. We used the GRADE approach to assess the certainty of evidence. Primary outcomes were: age at full enteral feedings; feeding intolerance; days to regain birth weight; rate of gain in weight, length and head circumference; and risk of necrotising enterocolitis (NEC). MAIN RESULTS We included nine randomised trials (919 infants) in this updated Cochrane Review. One study is awaiting classification. Seven of the nine included trials reported data from infants with a maximum weight of between 1000 grams and 1400 grams. Two of the nine trials included infants weighing up to 1500 grams. Type(s) of milk feeds varied, including human milk (either mother's own milk or pasteurised donor human milk), preterm formula, or mixed feeding regimens. In some instances, preterm formula was initially diluted. Earlier studies also used water to initiate feedings. We judged six trials as unclear or high risk of bias for random sequence generation. We judged four trials as unclear for allocation concealment. We judged all trials as high risk of bias for blinding of care givers, and seven as unclear or high risk of bias for blinding of outcome assessors. We downgraded the certainty of evidence for imprecision, due to low numbers of participants in the trials, and/or wide 95% confidence intervals, and/or for risk of bias. Continuous compared to intermittent bolus (nasogastric and orogastric tube) milk feeding Babies receiving continuous feeding may reach full enteral feeding almost one day later than babies receiving intermittent feeding (mean difference (MD) 0.84 days, 95% confidence interval (CI) -0.13 to 1.81; 7 studies, 628 infants; low-certainty evidence). It is uncertain if there is any difference between continuous feeding and intermittent feeding in terms of number of days of feeding interruptions (MD -3.00 days, 95% CI -9.50 to 3.50; 1 study, 171 infants; very low-certainty evidence). It is uncertain if continuous feeding has any effect on days to regain birth weight (MD -0.38 days, 95% CI -1.16 to 0.41; 6 studies, 610 infants; low-certainty evidence). The certainty of evidence is low and the 95% confidence interval is consistent with possible benefit and possible harm. It is uncertain if continuous feeding has any effect on rate of gain in weight compared with intermittent feeding (standardised mean difference (SMD) 0.09, 95% CI -0.27 to 0.46; 5 studies, 433 infants; very low-certainty evidence). Continuous feeding may result in little to no difference in rate of gain in length compared with intermittent feeding (MD 0.02 cm/week, 95% CI -0.04 to 0.08; 5 studies, 433 infants; low-certainty evidence). Continuous feeding may result in little to no difference in rate of gain in head circumference compared with intermittent feeding (MD 0.01 cm/week, 95% CI -0.03 to 0.05; 5 studies, 433 infants; low-certainty evidence). It is uncertain if continuous feeding has any effect on the risk of NEC compared with intermittent feeding (RR 1.19, 95% CI 0.67 to 2.11; 4 studies, 372 infants; low-certainty evidence). The certainty of evidence is low and the 95% confidence interval is consistent with possible benefit and possible harm. AUTHORS' CONCLUSIONS Although babies receiving continuous feeding may reach full enteral feeding slightly later than babies receiving intermittent feeding, the evidence is of low certainty. However, the clinical risks and benefits of continuous and intermittent nasogastric tube milk feeding cannot be reliably discerned from current available randomised trials. Further research is needed to determine if either feeding method is more appropriate for the initiation of feeds. A rigorous methodology should be adopted, defining feeding protocols and feeding intolerance consistently for all infants. Infants should be stratified according to birth weight and gestation, and possibly according to illness.
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Affiliation(s)
| | | | - Fiona Stewart
- Cochrane Children and Families Network, c/o Cochrane Pregnancy and Childbirth, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
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10
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Alturk MR, Salama H, Al Rifai H, Al Qubaisi M, Alobaidly S. Prolonged empiric antibiotics and time to full enteral feed in preterm infants less than 29 weeks of gestational age. J Neonatal Perinatal Med 2021; 14:569-573. [PMID: 33523024 DOI: 10.3233/npm-200555] [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: 11/15/2022]
Abstract
BACKGROUND Early empiric antibiotic exposure appears to negatively influence feeding tolerance in preterm infants. However, the effect of prolonged antibiotic treatment is unknown. The objective of this study was to investigate whether prolonged antibiotics impact the time to full enteral feed in infants less than 29 weeks of gestational age with negative blood cultures. METHODS Retrospective data for infants less than 29 weeks gestation age were retrieved from the PEARL-Peristat perinatal registry in Qatar. Exclusion criteria were major congenital anomalies, conditions requiring surgery in the first 10 days of life, positive blood cultures in the first 48 hours of life, and death within the first week of life. Antibiotic courses were categorized as prolonged if continued more than 48 hours. The primary outcome was the duration of total parenteral nutrition. RESULTS Of 199 study infants, 185 (92.9%) underwent antibiotic treatment for > 48 hours despite negative blood cultures. The median duration of parenteral nutrition was not significantly different between the prolonged and short antibiotic groups (25 and 22 days, respectively; p = 0.139). Infants with prolonged antibiotic courses experienced non-significantly higher levels of necrotizing enterocolitis (7.1% and 18.4%, respectively), bronchopulmonary dysplasia (28.6% and 45.4%, respectively), and retinopathy of prematurity (14.3% and 38.4%, respectively). There were no differences in the late-onset sepsis rate (78.6% and 82.1%, respectively) and the in-hospital death rate (7.1% and 7.6%, respectively). CONCLUSIONS Prolonged antibiotic treatment in infants less than 29 weeks gestation with negative blood cultures has no significant impact on the time to full enteral feed.
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Affiliation(s)
- M R Alturk
- Critical Care Department, NICU, Women's Wellness and Research Center, Doha, Qatar
| | - H Salama
- Critical Care Department, NICU, Women's Wellness and Research Center, Doha, Qatar
| | - H Al Rifai
- Critical Care Department, NICU, Women's Wellness and Research Center, Doha, Qatar
| | - M Al Qubaisi
- Critical Care Department, NICU, Women's Wellness and Research Center, Doha, Qatar
| | - S Alobaidly
- Critical Care Department, NICU, Women's Wellness and Research Center, Doha, Qatar
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11
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Narendran N, Yusuf K. Fetal Doppler Assessment in Neonatal Care: Analysis of Fetal Doppler Abnormalities and Neonatal Outcomes. Neoreviews 2020; 20:e575-e583. [PMID: 31575779 DOI: 10.1542/neo.20-10-e575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Fetal Doppler ultrasonography provides an effective and noninvasive approach to identify circulatory abnormalities in the maternal-fetal circulation. It is invaluable to assess the hemodynamic status of the fetus under a wide range of physiologic, infectious, and abnormal anatomic conditions. Findings from these studies are often used to make clinical decisions, including whether to proceed with urgent delivery of the fetus. In this review, we focus on key literature describing the main uses of Doppler ultrasonography in neonatal medicine, including how abnormal findings may be implicated in immediate and long-term outcomes. Our review highlights the importance of fetal Doppler examination as an effective intrauterine management strategy, and its full potential is more likely to be realized when considered in context with other available clinical information.
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Affiliation(s)
- Nadia Narendran
- Section of Neonatology, Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Kamran Yusuf
- Section of Neonatology, Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
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12
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Martini S, Aceti A, Galletti S, Beghetti I, Faldella G, Corvaglia L. To Feed or Not to Feed: A Critical Overview of Enteral Feeding Management and Gastrointestinal Complications in Preterm Neonates with a Patent Ductus Arteriosus. Nutrients 2019; 12:nu12010083. [PMID: 31892190 PMCID: PMC7019993 DOI: 10.3390/nu12010083] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 12/19/2019] [Accepted: 12/24/2019] [Indexed: 12/20/2022] Open
Abstract
The management of enteral feeds in preterm infants with a hemodynamically significant patent ductus arteriosus (hs-PDA) is a major challenge for neonatologists due to the fear of gastrointestinal (GI) complications. This review aims to analyze the available evidence on the complex relation between the presence and management of PDA, enteral feeding practices, and GI outcomes in the preterm population. There is limited evidence, based on small and heterogeneous trials, that hs-PDA may affect the splanchnic hemodynamic response to enteral feeds. While the presence of PDA seems a risk factor for adverse GI outcomes, the benefits of feeding withholding during pharmacological PDA treatment are controversial. The lack of robust evidence in support of or against a timely feeding introduction or feeding withholding during pharmacological PDA closure in preterm neonates does not allow to draw any related recommendation. While waiting for further data, the feeding management of this population should be carefully evaluated and possibly individualized on the basis of the infants’ hemodynamic and clinical characteristics. Large, multicentric trials would help to better clarify the physiological mechanisms underlying the development of gut hypoperfusion, and to evaluate the impact of enteral feeds on splanchnic hemodynamics in relation to PDA features and treatment.
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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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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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Malhotra A, Allison BJ, Castillo-Melendez M, Jenkin G, Polglase GR, Miller SL. Neonatal Morbidities of Fetal Growth Restriction: Pathophysiology and Impact. Front Endocrinol (Lausanne) 2019; 10:55. [PMID: 30792696 PMCID: PMC6374308 DOI: 10.3389/fendo.2019.00055] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/22/2019] [Indexed: 12/11/2022] Open
Abstract
Being born small lays the foundation for short-term and long-term implications for life. Intrauterine or fetal growth restriction describes the pregnancy complication of pathological reduced fetal growth, leading to significant perinatal mortality and morbidity, and subsequent long-term deficits. Placental insufficiency is the principal cause of FGR, which in turn underlies a chronic undersupply of oxygen and nutrients to the fetus. The neonatal morbidities associated with FGR depend on the timing of onset of placental dysfunction and growth restriction, its severity, and the gestation at birth of the infant. In this review, we explore the pathophysiological mechanisms involved in the development of major neonatal morbidities in FGR, and their impact on the health of the infant. Fetal cardiovascular adaptation and altered organ development during gestation are principal contributors to postnatal consequences of FGR. Clinical presentation, diagnostic tools and management strategies of neonatal morbidities are presented. We also present information on the current status of targeted therapies. A better understanding of neonatal morbidities associated with FGR will enable early neonatal detection, monitoring and management of potential adverse outcomes in the newborn period and beyond.
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Affiliation(s)
- Atul Malhotra
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- *Correspondence: Atul Malhotra
| | - Beth J. Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Margie Castillo-Melendez
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Suzanne L. Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
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Kültürsay N, Bilgen H, Türkyılmaz C. Turkish Neonatal Society guideline on enteral feeding of the preterm infant. TURK PEDIATRI ARSIVI 2018; 53:S109-S118. [PMID: 31236024 PMCID: PMC6568297 DOI: 10.5152/turkpediatriars.2018.01811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Early initiation of enteral feeding with the own mother's milk and prevention of postnatal growth failure is the target of nutrition in preterm infants. Together with total parenteral nutrition, mouth care and minimal enteral nutrition is started with colostrum in the very early hours of life in small preterm infants. Expressed mother's milk is given via a gastric tube and gradually increased in accordance with the gestational age/birth weight and the risk factors. For infants born heavier than 1 000 grams, the aim is to reach total enteral feeding at the end of first week, and at the end of the second week for infants weighing less than 1000 grams. Supporting mothers in milk expression and kangaroo mother care, promoting non-nutritive feeding, appropriate fortification of mother' milk, and initiating and advancing breastfeeding as soon as the infant is ready are all crucial. Donor mother milk, and as a second choice, preterm formula is advised if the mother's milk is not available. Individualized post-discharge nutrition decisions can be taken in accordance with the actual growth at the time of discharge. The goal is optimal neurodevelopmental achievement together with the prevention of long-term metabolic problems. Late preterm infants, which constitute the majority of preterm infants, also need close nutritional attention and follow-up.
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Affiliation(s)
- Nilgün Kültürsay
- Division of Neonatology, Department of Pediatrics, Ege University, Faculty of Medicine, İzmir, Turkey
| | - Hülya Bilgen
- Division of Neonatology, Department of Pediatrics, Marmara University, Faculty of Medicine, Pendik Research and Training Hospital, İstanbul, Turkey
| | - Canan Türkyılmaz
- Division of Neonatology, Department of Pediatrics, Gazi University, Faculty of Medicine, Ankara, Turkey
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Athalye-Jape G, Minaee N, Nathan E, Simmer K, Patole S. Outcomes in preterm small versus appropriate for gestation infants after Bifidobacterium breve M-16 V supplementation. J Matern Fetal Neonatal Med 2018; 33:2209-2215. [PMID: 30394171 DOI: 10.1080/14767058.2018.1543657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Fecal bifidobacteria response after Bifidobacterium breve M-16 V supplementation was comparable in preterm small (SGA) versus appropriate for gestational age (AGA) infants.Objectives: To compare clinical outcomes between preterm SGA versus AGA infants after routine probiotic supplementation (RPS) with Bifidobacterium breve M-16V (3 × 109 CFU/day).Design: Retrospective cohort study (June 2012-August 2015) comparing outcomes between preterm (<34 weeks, subgroup: <29 weeks) SGA versus AGA infants after RPS with B. breve M-16 V using multivariable regression analysis. Primary outcome: necrotizing enterocolitis (NEC)≥Stage II/all-cause mortality. Secondary outcomes: NEC ≥ Stage II, all-cause mortality, late onset sepsis (LOS), postnatal age at full feeds (PAFF).Results: Outcomes in inborn 1380/1481 (162 SGA versus 1218 AGA) admissions were analyzed. Primary outcome "NEC ≥ Stage II /all-cause mortality" was higher in SGA versus AGA infants <29 weeks (21 versus 12%; p = .040), and showed trend toward reduction (8 versus 6%; p = .057) in AGA <34 weeks. NEC ≥ Stage II, LOS, and all-cause mortality was comparable in SGA versus AGA infants <34 weeks (3 versus 2, 9 versus 8, 9% versus 6%) and <29 weeks (5 versus 4, 16 versus 9, 18% versus 19%), respectively. Median (IQR) PAFF was significantly higher in SGA versus AGA infants <34 weeks (8 (6-12) versus 7 (5-10) days), and <29 weeks (14 (12-17) versus 11 (8-16) days).Conclusions: NEC, LOS and all-cause mortality rates were similar in preterm SGA versus AGA infants after RPS with Bifidobacterium breve M-16 V, but PAFF was higher in SGA infants.
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Affiliation(s)
- Gayatri Athalye-Jape
- Neonatal Directorate, King Edward Memorial Hospital for Women, Perth, Australia.,School of Paediatrics and Child Health, Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
| | - Novia Minaee
- Department of Biostatistics, Women and Infants Research Foundation, Subiaco, Australia
| | - Elizabeth Nathan
- Department of Biostatistics, Women and Infants Research Foundation, Subiaco, Australia
| | - Karen Simmer
- Neonatal Directorate, King Edward Memorial Hospital for Women, Perth, Australia.,School of Paediatrics and Child Health, Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
| | - Sanjay Patole
- Neonatal Directorate, King Edward Memorial Hospital for Women, Perth, Australia.,School of Paediatrics and Child Health, Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
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Aradhya AS, Mukhopadhyay K, Saini SS, Sundaram V, Dutta S, Kumar P. Feed intolerance in preterm neonates with antenatal reverse end diastolic flow (REDF) in umbilical artery: a retrospective cohort study. J Matern Fetal Neonatal Med 2018; 33:1846-1852. [PMID: 30373425 DOI: 10.1080/14767058.2018.1531123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Feed intolerance is common in growth-restricted infants with antenatal AREDF (absent or reverse end-diastolic flow) and presumed to be more severe in those with reverse end diastolic flow (REDF). Natural history of feeding in REDF is rarely reported in the literature.Aims and objectives: To determine the incidence of feed intolerance and necrotizing enterocolitis (NEC) in neonates with antenatal REDF.Design: Preterm inborn neonates with gestation <37 weeks with antenatal REDF diagnosed between January 2015 and September 2017 were included in this retrospective cohort study. The primary outcome was the proportion of neonates having feed intolerance and NEC till discharge or death or transfer to other hospitals and time to achieve full enteral feeding (150 ml/kg/day).Results: Out of total 67 born with antenatal REDF, 8 were transferred out within 48 hours, 8 records not available and 4 excluded due to major malformations. The mean (SD) gestation and birth weight of the remaining 48 neonates were 32 (2) weeks and 1096 (291) g. The median (IQR) age of initiation of feeds was 30 (24-37) hours. Feeds were advanced by median (range) 20 (10-20) ml/kg/day in which 22 babies (45%) had at least 1 episode of feed intolerance at a median (IQR) age of 79 (40-120) hours requiring nil per oral for next 48 (18-96) hours. Full feeds were reached by median age (IQR) of nine (8-12) days. Only 3 neonates (6%) had NEC stage 2 or above as per Bell's staging.Conclusions: Feed intolerance is common in neonates with REDF though the risk of NEC is not high.What is known on this subject?Neonates with antenatal AREDF are at increased risk of feed intolerance and necrotizing enterocolitis.Early introduction of enteral feeds in neonates with AREDF with appropriate monitoring is safe without increased risk of necrotizing enterocolitis.AEDF which progresses to REDF is associated with increased morbidity.What does this study add?Early enteral feeding as early as 24 hours can be initiated in REDF if there are no abdominal symptoms and signs.Feed intolerance is high in REDF cases.The risk of NEC is not higher than what is seen in AEDF cases.
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Affiliation(s)
| | - Kanya Mukhopadhyay
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shiv Sajan Saini
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Venkataseshan Sundaram
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sourabh Dutta
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Costa S, Maggio L, Alighieri G, Barone G, Cota F, Vento G. Tolerance of preterm formula versus pasteurized donor human milk in very preterm infants: a randomized non-inferiority trial. Ital J Pediatr 2018; 44:96. [PMID: 30115086 PMCID: PMC6097280 DOI: 10.1186/s13052-018-0532-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/06/2018] [Indexed: 12/22/2022] Open
Abstract
Background Human milk (HM) is the best feeding for premature infants. When own mother’s milk (OMM) is insufficient or unavailable, pasteurized donor human milk (PDHM) and preterm formula (PF) are the alternative nutritional sources, but the benefits of donor milk over formula are not defined. This study aimed to assess whether, in the absence of OMM, the PF could guarantee a feeding tolerance not inferior to that seen with the use of PDHM during the first two weeks of life of very preterm infants. Methods Infants with gestational age (GA) of ≤32 weeks who started enteral feeding within the first 7 days of life were randomized to receive PDHM or PF as a supplement to the OMM insufficient or unavailable. The primary outcome was the day of life when full enteral feeding (FEF) of 150 mL/Kg/d was achieved. Results Seventy infants were randomized, 35 in the PF group (GA 30.2 ± 1.7 weeks; BW 1342 ± 275 g), 35 in the PDHM group (GA 30 ± 1.9 weeks; BW 1365 ± 332 g). The time to achieve FEF was the same for infants fed with PF and for infants fed with PDHM (12.3 ± 7.0 days vs 12.8 ± 6.5). Conclusions This trial shows that PF could be a valid alternative for the early feeding of very preterm infants when OMM is insufficient or unavailable. Trial registration UMIN000013922. Date of formal registration: December 31, 2014.
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Affiliation(s)
- Simonetta Costa
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Luca Maggio
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Giovanni Alighieri
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Giovanni Barone
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Francesco Cota
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Giovanni Vento
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
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20
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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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Feed-related Splanchnic Oxygenation in Preterm Infants With Abnormal Antenatal Doppler Developing Gut Complications. J Pediatr Gastroenterol Nutr 2018; 66:755-759. [PMID: 29112084 DOI: 10.1097/mpg.0000000000001804] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Preterm infants with antenatal absent or reversed end diastolic flow (AREDF) in umbilical arteries are at major risk for gastrointestinal (GI) complications, such as necrotizing enterocolitis, intestinal perforation and feeding intolerance. Near-infrared spectroscopy provides continuous monitoring of splanchnic oxygenation (SrSO2) and may represent a useful tool to predict GI outcomes in this high-risk population. This observational, pilot study assessed feed-related SrSO2 patterns at enteral feeding introduction and full enteral feeding (FEF) achievement in twenty AREDF infants with gestational age ≤34 weeks. Enrolled infants were divided into 2 groups according to the development versus lack of GI complications. Infants developing GI complications showed significantly lower SrSO2 and increased splanchnic oxygen extraction in response to enteral feeds at both enteral feeding introduction and FEF. The potential role of these findings in predicting GI complications in AREDF preterm infants seems promising and deserves further evaluation.
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22
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Salas AA, Li P, Parks K, Lal CV, Martin CR, Carlo WA. Early progressive feeding in extremely preterm infants: a randomized trial. Am J Clin Nutr 2018; 107:365-370. [PMID: 29529231 PMCID: PMC6692650 DOI: 10.1093/ajcn/nqy012] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 01/11/2018] [Indexed: 11/13/2022] Open
Abstract
Background Due to insufficient evidence, extremely preterm infants (≤28 wk of gestation) rarely receive early progressive feeding (small increments of feeding volumes between 1 and 4 d after birth). We hypothesized that early progressive feeding increases the number of full enteral feeding days in the first month after birth. Objective The aim of this study was to determine the feasibility and efficacy of early progressive feeding in extremely preterm infants. Design In this single-center randomized trial, extremely preterm infants born between September 2016 and June 2017 were randomly assigned to receive either early progressive feeding without trophic feeding (early feeding group) or delayed progressive feeding after a 4-d course of trophic feeding (delayed feeding group). Treatment allocation occurred before or on feeding day 1. The primary outcome was the number of full enteral feeding days in the first month after birth. Secondary outcomes were death, necrotizing enterocolitis (NEC), culture-proven sepsis, growth percentiles at 36 wk postmenstrual age, use of parenteral nutrition, and need for central venous access. Results Sixty infants were included (median gestational age: 26 wk; mean ± SD birth weight: 832 ± 253 g). The primary outcome differed between groups (median difference favoring the early feeding group: +2 d; 95% CI: 0, 3 d; P = 0.02). Early progressive feeding reduced the use of parenteral nutrition (4 compared with 8 d; P ≤ 0.01) and the need for central venous access (9 compared with 13 d; P ≤ 0.01). The outcome of culture-proven sepsis (10% compared with 27%; P = 0.18), restricted growth (weight, length, and head circumference <10th percentile) at 36 wk postmenstrual age (25% compared with 50%; P = 0.07), and the composite outcome of NEC or death (27% compared with 20%; P = 0.74) did not differ between groups. Conclusion Early progressive feeding increases the number of full enteral feeding days in extremely preterm infants. This trial was registered at www.clinicaltrials.gov as NCT02915549.
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Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, School of Medicine; and Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Peng Li
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Kelli Parks
- Department of Pediatrics, School of Medicine; and Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Charitharth V Lal
- Department of Pediatrics, School of Medicine; and Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Camilia R Martin
- Department of Neonatology and Division of Translational Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Waldemar A Carlo
- Department of Pediatrics, School of Medicine; and Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
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23
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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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Ahamed MF, Dar P, Vega M, Kim M, Gao Q, Havranek T. Early feeding tolerance in small for gestational age infants with normal versus abnormal antenatal Doppler characteristics. J Neonatal Perinatal Med 2017; 10:43-48. [PMID: 28304325 DOI: 10.3233/npm-1682] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To determine differences in feeding tolerance amongst preterm small for gestational age (SGA) infants with normal versus abnormal umbilical artery Doppler flow defined as absent or reversed end diastolic flow (AREDF). METHODS This was a retrospective cohort study of infants <35 weeks gestational age (GA) and birth weight (BW) <10th percentile. Day of initiation of feeds, days to full feeds and CRIB II scores were the primary outcomes. Clinical characteristics were compared between the groups of SGA infants with normal and AREDF. Multivariable regression models were fit to the data to adjust for potential confounders of the association of AREDF and feeding intolerance. RESULTS 120 infants with normal and 64 infants with AREDF were included. The infants with AREDF were smaller (971 g vs. 1183 g, p = 0.0002), less mature (29.9 wks vs. 31.2 wks, p = 0.0009), had higher CRIB II score (7.2 vs. 5.2, p = 0.0033), started feeding later (4.1 days vs. 3.3 days, p = 0.020) and advanced slower to full feeds (17.7 days vs. 13.7 days, p = 0.0017). Necrotizing enterocolitis was similar between the groups (p = 0.18). After adjusting for confounders, Doppler flow was no longer a significant predictor of the initiation (p = 0.37) and advancement of feeds (p = 0.44). CONCLUSIONS Infants with AREDF are sicker at birth and have more feeding difficulties; after adjusting for BW and GA, Doppler flow was no longer a significant predictor of feeding intolerance.
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Affiliation(s)
- M F Ahamed
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Southern Illinois University School of Medicine, IL, USA
| | - Pe'er Dar
- Department of Obstetrics and Gynecology and Women's Health, Division of Fetal Medicine and OBGYN Ultrasound, Montefiore Medical Center, Albert Einstein College of Medicine, NY, USA
| | - M Vega
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, NY, USA
| | - Mimi Kim
- Department of Epidemiology & Population Health, Division of Biostatistics, Albert Einstein College of Medicine, NY, USA
| | - Q Gao
- Department of Epidemiology & Population Health, Division of Biostatistics, Albert Einstein College of Medicine, NY, USA
| | - T Havranek
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, NY, USA
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Salas AA, Kabani N, Travers CP, Phillips V, Ambalavanan N, Carlo WA. Short versus Extended Duration of Trophic Feeding to Reduce Time to Achieve Full Enteral Feeding in Extremely Preterm Infants: An Observational Study. Neonatology 2017; 112:211-216. [PMID: 28704816 DOI: 10.1159/000472247] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/27/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Trophic feeding compared to no enteral feeding prevents atrophy of the gastrointestinal tract. However, the practice of extending the duration of trophic feeding often delays initiation of full enteral feeding in extremely preterm infants. We hypothesized that a short duration of trophic feeding (3 days or less) is associated with early initiation of full enteral feeding. METHODS A total of 192 extremely preterm infants (23-28 weeks' gestation) born between 2013 and 2015 were included. Infants were divided into 2 groups according to the duration of trophic feeding (short vs. extended). The primary outcome was time to achieve full enteral feeding and the safety outcome was necrotizing enterocolitis (NEC) and/or death. RESULTS A short duration of trophic feeding was associated with a reduction in time to achieve full enteral feeding after adjustment for birth weight, gestational age, race, sex, type of enteral nutrition, and day of initiation of trophic feeding (mean difference favoring a short duration of trophic feeding: -4.1 days; 95% CI: -2.3 to -5.8; p < 0.001). A short duration of trophic feeding was not associated with a higher risk of NEC and/or death after achieving full enteral feeding (AOR: 0.91; 95% CI: 0.30-2.77; p = 0.87). CONCLUSIONS A short duration of trophic feeding is associated with early initiation of full enteral feeding. A short duration of trophic feeding is not associated with a higher risk of NEC, but our study was underpowered for this safety outcome. Randomized trials are needed to test this study hypothesis.
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Affiliation(s)
- Ariel A Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
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Early docosahexaenoic and arachidonic acid supplementation in extremely-low-birth-weight infants. Pediatr Res 2016; 80:505-10. [PMID: 27356083 DOI: 10.1038/pr.2016.118] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/07/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Extremely-low-birth-weight (ELBW) infants accrue large deficits in docosahexaenoic acid (DHA) and arachidonic acid (ARA) and require improved supplementation strategies. We hypothesized that once daily DHA+ARA drops applied to buccal mucosa will increase blood levels. METHODS Thirty ELBW infants were randomized to receive DHA 20 mg/kg/d + ARA 40 or 60 mg/kg/d + ARA 120 mg/kg/d or placebo within 72 h of age for 8 wk duration. Red blood cell phospholipid levels of DHA (primary) and ARA (secondary) were measured at 2 and 8 wk of age. RESULTS Twenty-eight survivors with a median birth weight of 806 g completed dosing and sampling. Red blood cell levels were similar between the three groups at 2 wk (DHA: 4.62 wt% (interquartile range (IQR) 4.1-5.5) for all, P = 0.29 between groups; ARA: 21.1 wt% (IQR 18.78-22.6) for all, P = 0.41 between groups) and 8 wk (DHA: 6.0 wt% (IQR 5.1-7.1) for all, P = 0.57 between groups; ARA: 20.1 wt% (IQR 18.3-23.1) for all, P = 0.63 between groups). DHA in all infants showed a median increase of 31% from 2 to 8 wk (P < 0.04). ARA levels did not significantly change over time (P > 0.6). CONCLUSION Daily buccal DHA and ARA supplements did not affect fatty acid levels in ELBW infants.
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Crowe L, Chang A, Wallace K. Instruments for assessing readiness to commence suck feeds in preterm infants: effects on time to establish full oral feeding and duration of hospitalisation. Cochrane Database Syst Rev 2016; 2016:CD005586. [PMID: 27552522 PMCID: PMC6464358 DOI: 10.1002/14651858.cd005586.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND One of the most challenging milestones for preterm infants is the acquisition of safe and efficient feeding skills. The majority of healthy full term infants are born with skills to coordinate their suck, swallow and respiration. However, this is not the case for preterm infants who develop these skills gradually as they transition from tube feeding to suck feeds. For preterm infants the ability to engage in oral feeding behaviour is dependent on many factors. The complexity of factors influencing feeding readiness has led some researchers to investigate the use of an individualised assessment of an infant's abilities. A limited number of instruments that aim to indicate an individual infant's readiness to commence either breast or bottle feeding have been developed. OBJECTIVES To determine the effects of using a feeding readiness instrument when compared to no instrument or another instrument on the outcomes of time to establish full oral feeding and duration of hospitalisations. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 22 February 2016), EMBASE (1980 to 22 February 2016), and CINAHL (1982 to 22 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised and quasi-randomised trials comparing a formal instrument to assess a preterm infant's readiness to commence suck feeds with either no instrument (usual practice) or another feeding readiness instrument. DATA COLLECTION AND ANALYSIS The standard methods of Cochrane Neonatal were used. Two authors independently screened potential studies for inclusion. No studies were found that met our inclusion criteria. MAIN RESULTS No studies met the inclusion criteria. AUTHORS' CONCLUSIONS There is currently no evidence to inform clinical practice, with no studies meeting the inclusion criteria for this review. Research is needed in this area to establish an evidence base for the clinical utility of implementing the use of an instrument to assess feeding readiness in the preterm infant population.
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Affiliation(s)
- Linda Crowe
- Mater Health ServicesNursing Research CentreBrisbaneAustralia
| | - Anne Chang
- Queensland University of TechnologySchool of NursingBrisbaneQueenslandAustralia
| | - Karen Wallace
- Mater Health ServicesMater Mothers HospitalLevel 1 Augbiny PlaceRaymond TerraceBrisbaneQueenslandAustralia
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Mena P, Milad M, Vernal P, Escalante MJ. [Nutrition in the preterm hospitalized newborn. Recommendations of the Chilean Neonatology Branch, Chilean Pediatric Society]. ACTA ACUST UNITED AC 2016; 87:305-21. [PMID: 27156140 DOI: 10.1016/j.rchipe.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 03/29/2016] [Indexed: 11/27/2022]
Abstract
Recommendations based on current publications are presented for postnatal preterm nutrition, depending on birth weight: less 1000g, between 1000 and 1500g, and above 1500g, as well for the development periods: adaptation, stabilisation, and growth. A review is also presented on the nutritional management of morbidities that affect or may affect nutrition, such as: osteopenia, bronchopulmonary dysplasia, patent ductus arteriosus, red cell transfusion, and short bowel syndrome.
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Affiliation(s)
- Patricia Mena
- Departamento de Neonatología, Facultad de Medicina, Pontificia Universidad Católica de Chile y Servicio de Recién Nacidos Hospital Dr. Sótero del Río, Santiago, Chile.
| | - Marcela Milad
- Servicio de Neonatología, Clínica Santa María, Santiago, Chile
| | - Patricia Vernal
- Servicio de Recién Nacidos, Hospital San José, Santiago, Chile
| | - M José Escalante
- Departamento de Neonatología, Facultad de Medicina, Pontificia Universidad Católica de Chile y Servicio de Recién Nacidos Hospital Dr. Sótero del Río, Santiago, Chile
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Patole SK, Keil AD, Nathan E, Doherty D, Esvaran M, Simmer KN, Conway P. Effect of Bifidobacterium breve M-16V supplementation on faecal bifidobacteria in growth restricted very preterm infants – analysis from a randomised trial. J Matern Fetal Neonatal Med 2016; 29:3751-5. [DOI: 10.3109/14767058.2016.1147554] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Sanjay K. Patole
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, Perth, Australia,
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia,
| | - Anthony D. Keil
- PathWest Laboratory Medicine Western Australia, Perth, Australia,
| | - Elizabeth Nathan
- Women and Infants Research Foundation, King Edward Memorial Hospital for Women, Perth, Australia,
- School of Women’s and Infants’ Health, University of Western Australia, Perth, Australia, and
| | - Dorota Doherty
- Women and Infants Research Foundation, King Edward Memorial Hospital for Women, Perth, Australia,
- School of Women’s and Infants’ Health, University of Western Australia, Perth, Australia, and
| | - Meera Esvaran
- Centre for Marine Bio-Innovation (CMB), University of New South Wales, Sydney, Australia
| | - Karen N. Simmer
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, Perth, Australia,
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia,
| | - Patricia Conway
- Centre for Marine Bio-Innovation (CMB), University of New South Wales, Sydney, Australia
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Jain S, Mukhopadhyay K, Jain V, Kumar P. Slow versus rapid enteral feed in preterm neonates with antenatal absent end diastolic flow. J Matern Fetal Neonatal Med 2015; 29:2828-33. [PMID: 26452650 DOI: 10.3109/14767058.2015.1105954] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Incidence of feed intolerance (FI) and necrotizing enterocolitis (NEC) in preterm neonates with Doppler evidence of absent end diastolic flow (AEDF) velocities in the fetal umbilical artery when enteral feed volumes were started by 6-72 h and advanced either slowly or rapidly. METHODS Stable inborn neonates, 30-36 weeks gestation, weighing ≥1000 g and with antenatal evidence of AEDF were included in this pilot study. Infants (stratified in <1250 g and ≥1250 g birth weight categories) were allocated under randomized controlled trial, to receive either slow or rapid advancement of enteral feeding, while initiating the feeds after 6 h of birth if bowel sounds were present. Primary outcome measure was, FI and NEC till day 7 after reaching full feeds. RESULTS Of 159 eligible infants, 83 were randomized: 53 infants in the ≥1250 g category (28 in rapid and 25 in slow group) and 30 in the <1250 g category (15 in each group). FI was present in 11% versus 16% in ≥1250 g (p = 0.570) and 27% versus 33% in <1250 g (p = 0.690), NEC developed in 8.4% (3 versus 1) in ≥1250 g and (1 versus 2) in <1250 g, in slow versus rapid feeding. CONCLUSION This trial did not find increase in incidence of feed intolerance with very early introduction and rapid advancement of enteral feeds in stable preterm neonates with AEDF and birth weight ≥1250 g.
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Affiliation(s)
- Suksham Jain
- a Department of Pediatrics , Post Graduate Institute of Medical Education and Research , Chandigarh , India and
| | - Kanya Mukhopadhyay
- a Department of Pediatrics , Post Graduate Institute of Medical Education and Research , Chandigarh , India and
| | - Vanita Jain
- b Department of Obstetrics and Gynecology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Praveen Kumar
- a Department of Pediatrics , Post Graduate Institute of Medical Education and Research , Chandigarh , India and
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Dutta S, Singh B, Chessell L, Wilson J, Janes M, McDonald K, Shahid S, Gardner VA, Hjartarson A, Purcha M, Watson J, de Boer C, Gaal B, Fusch C. Guidelines for feeding very low birth weight infants. Nutrients 2015; 7:423-42. [PMID: 25580815 PMCID: PMC4303848 DOI: 10.3390/nu7010423] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 12/19/2014] [Indexed: 11/16/2022] Open
Abstract
Despite the fact that feeding a very low birth weight (VLBW) neonate is a fundamental and inevitable part of its management, this is a field which is beset with controversies. Optimal nutrition improves growth and neurological outcomes, and reduces the incidence of sepsis and possibly even retinopathy of prematurity. There is a great deal of heterogeneity of practice among neonatologists and pediatricians regarding feeding VLBW infants. A working group on feeding guidelines for VLBW infants was constituted in McMaster University, Canada. The group listed a number of important questions that had to be answered with respect to feeding VLBW infants, systematically reviewed the literature, critically appraised the level of evidence, and generated a comprehensive set of guidelines. These guidelines form the basis of this state-of-art review. The review touches upon trophic feeding, nutritional feeding, fortification, feeding in special circumstances, assessment of feed tolerance, and management of gastric residuals, gastro-esophageal reflux, and glycerin enemas.
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Affiliation(s)
- Sourabh Dutta
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Balpreet Singh
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Lorraine Chessell
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Jennifer Wilson
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Marianne Janes
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Kimberley McDonald
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Shaneela Shahid
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Victoria A Gardner
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Aune Hjartarson
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Margaret Purcha
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Jennifer Watson
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Chris de Boer
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Barbara Gaal
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
| | - Christoph Fusch
- Division of Neonatology, Department of Pediatrics, McMaster University Children's Hospital, Hamilton L8S4L8, Ontario, Canada.
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Morgan J, Young L, McGuire W. Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants. Cochrane Database Syst Rev 2014; 2014:CD001970. [PMID: 25436902 PMCID: PMC7063979 DOI: 10.1002/14651858.cd001970.pub5] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The introduction of enteral feeds for very preterm (less than 32 weeks' gestation) or very low birth weight (VLBW; less than 1500 g) infants is often delayed for several days or longer after birth due to concern that early introduction may not be tolerated and may increase the risk of necrotising enterocolitis (NEC). However, delaying enteral feeding could 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 effect of delayed introduction of progressive enteral feeds on the incidence of NEC, mortality and other morbidities in very preterm or VLBW infants. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2014, Issue 8), MEDLINE (1966 to September 2014), EMBASE (1980 to September 2014), CINAHL (1982 to September 2014), conference proceedings and previous reviews. SELECTION CRITERIA We included randomised or quasi-randomised controlled trials that assessed the effect of delayed (more than four days after birth) versus earlier introduction of progressive enteral feeds on the incidence of NEC, mortality and other morbidities in very preterm or VLBW infants. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and risk of bias and undertook data extraction. We analysed the treatment effects in the individual trials and reported the risk ratio (RR) and risk difference for dichotomous data and mean difference for continuous data, with respective 95% confidence intervals (CI). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses. MAIN RESULTS We identified nine randomised controlled trials in which 1106 infants participated. Few participants were extremely preterm (less 28 weeks' gestation) or extremely low birth weight (less than 1000 g). The trials defined delayed introduction of progressive enteral feeds as later than four to seven days after birth and early introduction as four days or less after birth. Meta-analyses did not detect statistically significant effects on the risk of NEC (typical RR 0.93, 95% CI 0.64 to 1.34; 8 trials; 1092 infants) or all-cause mortality (typical RR 1.18, 95% CI 0.75 to 1.88; 7 trials; 967 infants). Four of the trials restricted participation to growth-restricted infants with Doppler ultrasound evidence of abnormal fetal circulatory distribution or flow. Planned subgroup analyses of these trials found no statistically significant effects on the risk of NEC or all-cause mortality. Infants who had delayed introduction of enteral feeds took longer to establish full enteral feeding (reported median differences two to four days). AUTHORS' CONCLUSIONS The evidence available from randomised controlled trials suggested that delaying the introduction of progressive enteral feeds beyond four days after birth did not reduce the risk of developing NEC in very preterm or VLBW infants, including growth-restricted infants. Delaying the introduction of progressive enteral feeds resulted in a few days' delay in establishing full enteral feeds but the clinical importance of this effect was unclear. The applicability of these findings to extremely preterm or extremely low birth weight was uncertain. Further randomised controlled trials in this population may be warranted.
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Affiliation(s)
- Jessie Morgan
- Hull York Medical School & Centre for Reviews and Dissemination, University of YorkYorkUKY010 5DD
| | - Lauren Young
- Mercy Hospital for WomenNeonatal Unit163 Studley RoadHeidelbergVictoriaAustralia3084
| | - William McGuire
- Hull York Medical School & Centre for Reviews and Dissemination, University of YorkYorkUKY010 5DD
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