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Zheng L, Gai L, Wu Y, Kong C, Sun F, Gao J, Yuan W, Liu M, Jiang H, Tuo N, Yang F. Breast Milk Enema and Meconium Evacuation Among Preterm Infants: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e247145. [PMID: 38648060 DOI: 10.1001/jamanetworkopen.2024.7145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
Importance Delayed meconium evacuation and delayed achievement of full enteral feeding among premature infants are associated with poor short- and long-term outcomes. Identifying a more effective and safer enema for meconium evacuation is imperative for improving neonatal care. Objective To examine whether breast milk enemas can shorten the time to complete meconium evacuation and achievement of full enteral feeding for preterm infants. Design, Setting, and Participants This randomized, open-label, parallel-group, single-center clinical trial was conducted from September 1, 2019, to September 30, 2022, among 286 preterm infants with a gestational age of 23 to 30 weeks in the neonatal ward of the Shengjing Hospital of China Medical University in Shenyang. Interventions Preterm infants were randomly assigned to receive either breast milk enemas or normal saline enemas 48 hours after birth. Main Outcome and Measures The primary outcomes were time to complete meconium evacuation and time to achieve full enteral feeding. Secondary outcomes were duration of hospitalization, weight at discharge, and duration of total parenteral nutrition. Intention-to-treat and per-protocol analyses were conducted. Results In total, 286 preterm infants (mean [SD] gestational age, 198.8 [7.9] days; 166 boys [58.0%]) were eligible and included in this study. A total of 145 infants were randomized to the normal saline group, and 141 were randomized to the breast milk group. The time to achieve complete meconium evacuation was significantly shorter in the breast milk group than in the normal saline group (-2.2 days; 95% CI, -3.2 to -1.2 days). The time to achieve full enteral feeding was also significantly shorter in the breast milk group than in the normal saline group (-4.6 days; 95% CI, -8.0 to -1.2 days). The duration of total parenteral nutrition was significantly shorter in the breast milk group than in the normal saline group (-4.6 days; 95% CI, -8.6 to -1.0 days). There were no clinically notable differences in any other secondary or safety outcomes between the 2 groups. Conclusions and Relevance In this randomized clinical trial testing the effects of breast milk enema on meconium evacuation, breast milk reduced the time to achieve complete meconium evacuation and achieve full enteral feeding for preterm infants with a gestational age of 23 to 30 weeks. Subgroup analyses highlight the need for tailored interventions based on gestational age considerations. Trial Registration isrctn.org Identifier: ISRCTN17847514.
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Affiliation(s)
- Liqiang Zheng
- Clinical Research Centre, The International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- MOE-Shanghai Key Laboratory of Children's Environmental Health, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Gai
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
- Department of Nursing, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yani Wu
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chaonan Kong
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
- Department of Nursing, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Fangli Sun
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
- Department of Nursing, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Jinyue Gao
- School of Public Health, China Medical University, Shenyang, China
| | - Wei Yuan
- School of Public Health, China Medical University, Shenyang, China
| | - Min Liu
- School of Public Health, China Medical University, Shenyang, China
| | - Hong Jiang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
- Department of Nursing, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Nan Tuo
- Clinical Research Centre, The International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fan Yang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
- Department of Nursing, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
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Wen L, Xu L. The efficacy of glycerin suppositories for preterm infants: A meta-analysis of randomized controlled studies. Medicine (Baltimore) 2023; 102:e32516. [PMID: 37115086 PMCID: PMC10145745 DOI: 10.1097/md.0000000000032516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND The effect of glycerin suppositories on full enteral feeds remained controversial in preterm infants, and thus we conducted this meta-analysis to identify the influence of glycerin suppositories on full enteral feeds in preterm infants. METHODS The protocol was registered in PROSPERO (CRD20214283090). We searched PubMed, EMbase, Web of science, EBSCO and Cochrane library databases through February 2020, and included randomized controlled trials assessing the effect of glycerin suppositories on full enteral feeds in preterm infants. This meta-analysis was performed using the random-effect model. RESULTS Six Randomized controlled trials were included in the meta-analysis. Overall, compared with control group in preterm infants, glycerin suppositories demonstrated no significant effect on days to full enteral feeds (mean difference = -0.26; 95% confidence interval [CI] = -1.16 to 0.65; P = .58), the incidence of necrotizing enterocolitis (odd ratio = 3.62; 95% CI = 0.56-23.32; P = .18) or death (odd ratio = 1.46; 95% CI = 0.40-5.40; P = .57), but may increase the days under phototherapy (mean difference = 0.50; 95% CI = 0.43-0.57; P < .00001). Only low heterogeneity was seen among all outcomes. CONCLUSIONS Glycerin suppositories may provide no additional benefits to preterm infants.
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Affiliation(s)
- Lingling Wen
- Department of Neonatology, Wenzhou People’s Hospital, The Third Affiliated Hospital of Shanghai University, The Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou Women's and Children's Hospital, Wenzhou, Zhejiang, China
| | - Liangyin Xu
- Department of Neonatology, Wenzhou People’s Hospital, The Third Affiliated Hospital of Shanghai University, The Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou Women's and Children's Hospital, Wenzhou, Zhejiang, China
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Lange M, Figura Y, Böhne C, Beske F, Bohnhorst B, Heep A. Management of Prolonged Meconium Evacuation in Preterm Infants - A Survey-based Analysis in German Neonatal Intensive Care Units. Acta Paediatr 2022; 111:2082-2089. [PMID: 36005894 DOI: 10.1111/apa.16528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/03/2022] [Accepted: 08/24/2022] [Indexed: 11/26/2022]
Abstract
AIM Due to the functional immaturity of bowel motility, a delayed passage frequently requires evacuation of meconium in preterm infants. Often rectal enemas and oral laxatives are used to manage these bowel evacuation disorders. METHODS An online survey was sent to all 163 high-level Neonatal Intensive Care Units (NICUs) in Germany. The participants were queried on rectal enemas, laxative therapy, and outcome incidences. RESULTS A total of 110/163 (67.5%) hospitals participated in the study. 103/110 (93.6%) participating sites applied rectal enemas in cases of delayed meconium evacuation and 63/110 (57.3%) additionally used oral laxatives. In total, 15 different solutions and 7 different application systems were used for rectal instillation. Preterm infants receiving enemas within the first 48 hours after birth were found to have a significantly lower incidence of FIP (p = 0.006). Altogether 8 different oral laxatives were utilized. CONCLUSION Therapeutic approaches to the management of prolongated meconium evacuation differ widely among German NICUs. Our survey highlights the diversity of applied substances, means of application, and differences in duration and frequency of interventions. Macrogol was commonly used in neonates as an oral laxative despite the lack of approval from the manufacturer.
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Affiliation(s)
- Matthias Lange
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany
| | - Yannick Figura
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany
| | - Carolin Böhne
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Germany
| | - Florian Beske
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany
| | - Bettina Bohnhorst
- Department of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Germany
| | - Axel Heep
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany
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Burchard PR, Lay R, Ruffolo LI, Ramazani SN, Walton JM, Livingston MH. Glycerin Suppositories and Enemas in Premature Infants: A Meta-analysis. Pediatrics 2022; 149:185633. [PMID: 35332357 DOI: 10.1542/peds.2021-053413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Premature infants are often given glycerin suppositories or enemas to facilitate meconium evacuation and the transition to enteral feeds. We reviewed the best-available evidence for the use of glycerin suppositories and enemas in premature infants. METHODS We searched MEDLINE, Embase, and Cochrane Central for randomized controlled trials (RCTs) of premature infants treated with glycerin suppositories or enemas through January 2022. Studies were screened and data extracted independently and in duplicate. We included RCTs of premature infants <32 weeks gestation and/or birth weight <1500 g who were treated with glycerin suppositories or enemas. Meta-analysis was performed using random effects and reported as relative risk or mean difference. RESULTS We identified 6 single-center, RCTs of 389 premature infants treated with glycerin suppositories (n = 207) or enemas (n = 182). Mortality rates ranged from 0% to 17%, and the meta-analysis revealed no differences between treatment groups (P = .86). Active treatment was associated with earlier meconium evacuation (mean, 1.5 days; 95% confidence interval, 3.0 to 0.01; P = .05) but not a faster time to enteral feeds (mean, 0.5 days; P = .48). We identified 1 ongoing trial with a target recruitment of 220 premature infants. The quality of evidence was very low to moderate because of inadequate statistical power and other methodologic issues. CONCLUSIONS The use of glycerin suppositories and enemas in premature infants is associated with earlier meconium evacuation, but the clinical significance of this finding is uncertain. Treatment has no definitive effects on mortality, necrotizing enterocolitis, or enteral feeds.
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Affiliation(s)
| | - Raymond Lay
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | | | | | - J Mark Walton
- Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Michael H Livingston
- Division of Pediatric Surgery, University of Rochester Medical Center, Rochester, New York.,Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
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Gross M, Poets CF. Lipid enemas for meconium evacuation in preterm infants - a retrospective cohort study. BMC Pediatr 2021; 21:454. [PMID: 34657609 PMCID: PMC8522005 DOI: 10.1186/s12887-021-02905-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/13/2021] [Indexed: 12/21/2022] Open
Abstract
Background Enemas are used in preterm infants to promote meconium evacuation, but frequent high-volume enemas might contribute to focal intestinal perforation (FIP). To replace a regime consisting of frequent enemas of varying volume and composition, we implemented a once-daily, low-volume lipid enema (LE) regimen. We investigated its impact on meconium evacuation, enteral nutrition, and gastrointestinal complications in preterm infants. Methods We performed a single-center retrospective study comparing cohorts of preterm infants < 28 weeks gestation or < 32 weeks, but with birth weight < 10th percentile, before and after implementing LE. Outcomes were rates of FIP, necrotizing enterocolitis (NEC), and sepsis. We assessed stooling patterns, early enteral and parenteral nutrition. We used descriptive statistics for group comparisons and logistic regression to identify associations between LE and gastrointestinal complications and to adjust for group imbalances and potential confounders. Exclusion criteria were gastrointestinal malformations or pre-determined palliative care. Results Data from 399 infants were analyzed, 203 before vs. 190 after implementing LE; in the latter period, 55 protocol deviations occurred where infants received no enema, resulting in 3 groups with either variable enemas, LE or no enema use. Rates of FIP and sepsis were 11.9% vs. 6.4% vs. 0.0% and 18.4% vs. 13.5% vs. 14.0%, respectively. NEC rates were 3.0% vs. 7.8% vs. 3.5%. Adjusted for confounders, LE had no effect on FIP risk (aOR 1.1; 95%CI 0.5–2.8; p = 0.80), but was associated with an increased risk of NEC (aOR 2.9; 95%CI 1.0–8.6; p = 0.048). While fewer enemas were applied in the LE group resulting in a prolonged meconium passage, no changes in early enteral and parenteral nutrition were observed. We identified indomethacin administration and formula feeding as additional risk factors for FIP and NEC, respectively (aOR 3.5; 95%CI 1.5–8.3; p < 0.01 and aOR 3.4; 95%CI 1.2–9.3; p = 0.02). Conclusion Implementing LE had no clinically significant impact on meconium evacuation, early enteral or parenteral nutrition. FIP and sepsis rates remained unaffected. Other changes in clinical practice, like a reduced use of indomethacin, possibly affected FIP rates in our cohorts. The association between LE and NEC found here argues against further adoption of this practice. Trial registration Registered at the German Register of Clinical Trials (no. DRKS00024021; Feb 022021).
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Affiliation(s)
- Maximilian Gross
- Department of Neonatology, University Children's Hospital Tübingen, Calwerstr. 7, 72076, Tübingen, Germany
| | - Christian F Poets
- Department of Neonatology, University Children's Hospital Tübingen, Calwerstr. 7, 72076, Tübingen, Germany.
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Livingston MH, Elliott T, Williams C, Jones SA, Rosenbaum PL, Walton JM. Glycerin suppositories used prophylactically in premature infants (supp): A pilot randomized controlled trial. J Neonatal Perinatal Med 2020; 13:495-505. [PMID: 32083593 DOI: 10.3233/npm-190310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Glycerin suppositories are often used to facilitate meconium evacuation in premature infants. The evidence for this practice is inconclusive. The purpose of this study was to assess the feasibility of a multicenter randomized controlled trial on the effectiveness of this treatment strategy. STUDY DESIGN We conducted an external pilot study for a multicenter randomized controlled trial of premature infants randomized to glycerin suppositories or placebo procedure. Participants were included if they were gestational age of 24 weeks 0 days to 31 weeks 6 days and/or birthweight of 500 to 1500 grams. We excluded infants with life-threatening congenital anomalies, contraindications to receiving suppositories, or signs of clinical instability. Outcomes included cost, recruitment, and treatment-related adverse events. RESULT A total of 109 were screened, 79 were initially eligible, and 34 consented to participate. Four of these infants were excluded prior to randomization due to thrombocytopenia, 30 were randomized, and 26 reached full enteral feeds. Three infants (10%) experienced rectal bleeding 5 to 43 days after completing study treatments. An anal fissure was noted in two of these patients. There were no cases of rectal perforation but one infant assigned to active treatment developed necrotizing enterocolitis. CONCLUSIONS Conducting a multicenter randomized controlled trial on the use of glycerin suppositories in premature infants is feasible. Minor modifications to the study protocol are needed to increase participant recruitment and simplify the administration of study treatments.
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Affiliation(s)
| | - T Elliott
- McMaster Pediatric Surgery Research Collaborative.,Division of Pediatric Surgery, McMaster University, Hamilton, ON, Canada
| | - C Williams
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.,Division of Neonatology, McMaster University, Hamilton, ON, Canada
| | - S A Jones
- Division of Pediatric Surgery, Western University, London, ON, Canada
| | - P L Rosenbaum
- Division of Neonatology, McMaster University, Hamilton, ON, Canada.,CanChild Center for Childhood Disability Research, McMaster University, Hamilton, ON, Canada
| | - J M Walton
- McMaster Pediatric Surgery Research Collaborative.,Division of Pediatric Surgery, McMaster University, Hamilton, ON, Canada
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Butler-O'Hara M, Reininger A, Wang H, Amin SB, Rodgers NJ, D'Angio CT. A Randomized Controlled Trial of Glycerin Suppositories During Phototherapy in Premature Neonates. J Obstet Gynecol Neonatal Nurs 2017; 46:220-228. [PMID: 28082211 DOI: 10.1016/j.jogn.2016.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2016] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine if glycerin suppositories were effective in reducing total duration of phototherapy in premature neonates. We hypothesized that glycerin suppositories would have no effect on phototherapy duration or total serum bilirubin levels. DESIGN Prospective randomized controlled double-blinded trial. SETTING Level IV NICU. PARTICIPANTS Neonates born between 30 weeks, 0 days and 34 weeks, 6 days gestational age who developed physiologic hyperbilirubinemia needing phototherapy. METHODS Neonates were randomized to the no-suppository group or to the suppository group. Neonates were randomized to receive glycerin suppositories every 8 hours while under phototherapy or to a sham group. The primary outcome was total hours of phototherapy. Secondary outcomes included peak total serum bilirubin levels, time from start to discontinuation of phototherapy, rate of decline in bilirubin levels, repeat episodes of phototherapy, and number of stools while the neonates received phototherapy. RESULTS A total of 39 neonates were assigned to the no-suppository group and 40 to the suppository group. Withholding suppositories was not inferior to providing suppositories. The total hours of phototherapy were not longer (i.e., noninferior) among neonates not provided suppositories (61 ± 53 hours) than among those given suppositories (72 ± 49 hours). There were no differences in peak bilirubin levels, rate of bilirubin decline, or repeat episodes of phototherapy. CONCLUSION Routine use of glycerin suppositories among preterm neonates who receive phototherapy does not affect bilirubin levels or phototherapy duration.
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Ibrahim T, Li Wei C, Bautista D, Sriram B, Xiangzhen Fay L, Rajadurai VS. Saline Enemas versus Glycerin Suppositories to Promote Enteral Feeding in Premature Infants: A Pilot Randomized Controlled Trial. Neonatology 2017; 112:347-353. [PMID: 28768263 DOI: 10.1159/000477999] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 06/02/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Meconium retention is associated with feeding intolerance. Trials using glycerol and Gastrografin to expedite the evacuation of meconium have failed to generate clinically valid results for efficacy and safety. OBJECTIVE We assessed the feasibility of aggressive meconium evacuation with saline rectal washout (RW) in very-low-birth-weight infants to reduce the time it took them to reach full enteral feeds. METHODS We conducted an open-label, pilot, randomized controlled trial (RCT) (birth weight stratified, i.e., to 750-999 g and 1,000-1,500 g) of early aggressive meconium evacuation with twice-daily normal saline RW compared to conventional management with glycerin suppositories (GS), until full enteral feeds (110 mL/kg/day) were reached. Primary outcome was time to reach full enteral feeds. Safety, process, and secondary efficacy outcomes were also evaluated. RESULTS Sixty-one infants were randomized, 28 to RW and 33 to GS. The process and feasibility outcomes were met. RW was found to be safe; none of the RW-randomized infants developed necrotizing enterocolitis (≥ stage II) or complications secondary to RW. Evidence of efficacy was supported: in the 750-999 g stratum (n = 15), the median time to full enteral feeds was shorter with RW (11.0 days, 95% CI: 10.4-11.6) than with GS (15.6 days, 95% CI: 13.0-18.2) by a reduction of 4.6 days (p = 0.027). In the 1,000-1,500 g stratum (n = 46), there was no evidence of benefit: RW 10.2 days (95% CI 8.3-12.1) and GS 10.1 days (95% CI 9.3-10.9, p = 0.304). CONCLUSION Our protocol was feasible and an adequately powered RCT is required to confirm the findings of this trial.
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Affiliation(s)
- Thowfique Ibrahim
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore
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Kamphorst K, Sietsma Y, Brouwer AJ, Rood PJT, van den Hoogen A. Enemas, suppositories and rectal stimulation are not effective in accelerating enteral feeding or meconium evacuation in low-birthweight infants: a systematic review. Acta Paediatr 2016; 105:1280-1287. [PMID: 27506482 DOI: 10.1111/apa.13540] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/21/2016] [Accepted: 08/08/2016] [Indexed: 01/11/2023]
Abstract
Early full enteral feeding in preterm infants decreases morbidity and mortality. Our systematic review covered the effectiveness of rectal stimulation, suppositories and enemas on stooling patterns and feeding tolerance in low-birthweight infants born at up to 32 weeks. It comprised seven studies published between 2007 and 2014 and covered 495 infants. CONCLUSION Suppositories were ineffective in shortening the time to reach full enteral feeding, and the evidence on enemas was contradictory. Enemas and rectal stimulation did not shorten the time until complete meconium evacuation was reached. Further research into safe, effective interventions to accelerate meconium excretion is needed.
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Affiliation(s)
- Kim Kamphorst
- Department of Neonatology; Lucas Hospital; Apeldoorn The Netherlands
- Department of Gynecology, Obstetrics; Reproductive Medicine and Children; Deventer Hospital; Deventer The Netherlands
- Department Clinical Health Science; University Utrecht; Utrecht The Netherlands
| | - Ydelette Sietsma
- Department Clinical Health Science; University Utrecht; Utrecht The Netherlands
- Department Viaa; Christian University of Applied Sciences; Zwolle The Netherlands
| | - Annemieke J. Brouwer
- Department Clinical Health Science; University Utrecht; Utrecht The Netherlands
- Intensive Care Neonatology; Wilhelmina Children's Hospital; University Medical Centre Utrecht; Utrecht The Netherlands
| | - Paul J. T. Rood
- Department Clinical Health Science; University Utrecht; Utrecht The Netherlands
- Department of Intensive Care Medicine; Radboud University Medical Centre; Nijmegen The Netherlands
| | - Agnes van den Hoogen
- Department Clinical Health Science; University Utrecht; Utrecht The Netherlands
- Intensive Care Neonatology; Wilhelmina Children's Hospital; University Medical Centre Utrecht; Utrecht The Netherlands
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Deshmukh M, Balasubramanian H, Patole S. Meconium Evacuation for Facilitating Feed Tolerance in Preterm Neonates: A Systematic Review and Meta-Analysis. Neonatology 2016; 110:55-65. [PMID: 27050644 DOI: 10.1159/000444075] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 01/17/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND A delayed passage of meconium is considered as a risk factor for feed intolerance in preterm neonates. OBJECTIVES The aim of this study was to review the effects of different therapeutic agents for meconium evacuation on feed tolerance in preterm neonates. METHODS A systematic review of randomised controlled trials (RCTs) of different therapeutic agents for meconium evacuation in preterm neonates (gestation <32 weeks and/or birth weight <1,500 g) using the Cochrane systematic review methodology was undertaken. Databases including Google Scholar were searched in January 2016. The primary outcome was the time to reach full feeds (TFF; ≥120 ml/kg feeds with stoppage of parenteral nutrition >24 h). Secondary outcomes included necrotising enterocolitis (NEC), weight at discharge and adverse effects. The results were summarised as per the GRADE guidelines. RESULTS Six RCTs (2 each of glycerine suppository and enema, 1 normal saline enema and 1 oral osmotic contrast agent; n = 442) with a low or unclear risk of bias were included. The pooled estimate (random effects model) showed no reduction in TFF [mean difference (MD) -0.03, 95% CI -2.47, 2.41, p = 0.98; level of evidence: low]. No differences in NEC [risk ratio (RR) 1.71, 95% CI 0.63, 4.65, p = 0.30; level of evidence: low] and weight at discharge (MD -0.08, 95% CI -0.30, 0.15, p = 0.50; level of evidence: low) were found. The trial assessing oral osmotic contrast agents reported a trend towards a higher incidence of NEC ≥ stage II. There were no other adverse effects. CONCLUSION Limited low-quality evidence indicates that prophylactic glycerine suppository, small volume glycerine/normal saline enema or oral osmotic contrast agents to evacuate meconium did not reduce TFF in preterm neonates. Large, well-designed trials are essential to study this clinically significant issue.
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Affiliation(s)
- Mangesh Deshmukh
- Department of Neonatology, St. John of God Hospital, Perth, W.A., Australia
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Anabrees J, Shah VS, AlOsaimi A, AlFaleh K. Glycerin laxatives for prevention or treatment of feeding intolerance in very low birth weight infants. Cochrane Database Syst Rev 2015; 2015:CD010464. [PMID: 26421424 PMCID: PMC8720275 DOI: 10.1002/14651858.cd010464.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Feeding intolerance is a common clinical problem among preterm infants. It may be an early sign of necrotising enterocolitis, sepsis or other serious gastrointestinal conditions, or it may result from gut immaturity with delayed passage of meconium. Glycerin laxatives stimulate passage of meconium by acting as an osmotic dehydrating agent and increasing osmotic pressure in the gut; they stimulate rectal contraction, potentially reducing the incidence of feeding intolerance. OBJECTIVES To assess the effectiveness and safety of glycerin laxatives (enemas/suppositories) for prevention or treatment of feeding intolerance in very low birth weight (VLBW) infants. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 4), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We restricted our search to all randomised controlled trials and applied no language restrictions. We searched the references of identified studies and reviews on this topic and handsearched for additional articles. We searched the database maintained by the US National Institutes of Health (www.clinicaltrials.gov) and European trial registries to identify ongoing trials. SELECTION CRITERIA We considered only randomised or quasi-randomised controlled trials that enrolled preterm infants < 32 weeks' gestational age (GA) and/or < 1500 g birth weight. We included trials if they administered glycerin laxatives and measured at least one prespecified clinical outcome. DATA COLLECTION AND ANALYSIS We used standard methods of The Cochrane Collaboration and its Neonatal Group to assess methodological quality of trials, to collect data and to perform analyses. MAIN RESULTS We identified three trials that evaluated use of prophylactic glycerin laxatives in preterm infants. We identified no trials that evaluated therapeutic use of glycerin laxatives for feeding intolerance. Our review showed that prophylactic administration of glycerin laxatives did not reduce the time required to achieve full enteral feeds and did not influence secondary outcomes, including duration of hospital stay, mortality and weight at discharge. Prophylactic administration of glycerin laxatives resulted in failure of fewer infants to pass stool over the first 48 hours. Included trials reported no adverse events. AUTHORS' CONCLUSIONS Our review of available evidence for glycerin laxatives does not support the routine use of prophylactic glycerin laxatives in clinical practice. Additional studies are needed to confirm or refute the effectiveness and safety of glycerin laxatives for prevention or treatment of feeding intolerance in VLBW infants.
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Affiliation(s)
- Jasim Anabrees
- Sulaiman Al Habib Medical GroupNeonatal CareArrayan HospitalP.O. Box 272069RiyadhSaudi Arabia11352
| | - Vibhuti S Shah
- University of TorontoDepartment of Paediatrics and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoONCanadaM5G 1X5
| | - Ahlam AlOsaimi
- College of Medicine, King Saud UniversityRiyadhSaudi Arabia
| | - Khalid AlFaleh
- King Saud UniversityDepartment of Pediatrics (Division of Neonatology)King Khalid University Hospital and College of MedicineDepartment of Pediatrics (39), P.O. Box 2925RiyadhSaudi Arabia11461
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Livingston MH, Zequeira J, Blinder H, Pemberton J, Williams C, Walton JM. Glycerin suppositories used prophylactically in premature infants (SUPP) trial: a study protocol for a pilot randomized controlled trial. Pilot Feasibility Stud 2015; 1:31. [PMID: 27965809 PMCID: PMC5153876 DOI: 10.1186/s40814-015-0024-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 08/12/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Feeding is a significant challenge for premature infants in the neonatal intensive care unit (NICU). These patients are often treated with glycerin suppositories to stimulate the passage of meconium and prevent feeding intolerance. Unfortunately, the evidence for this practice is inconclusive. METHODS/DESIGN This protocol is for an external pilot study that will assess the feasibility of a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. Participants are premature infants treated in a level 3 NICU with a gestational age 24 to 32 weeks and/or birth weight of 500 to 1500 g. Thirty participants will be recruited as part of this external pilot study. Participants will be randomized to glycerin suppository (250 mg) or placebo starting 48 to 72 h after birth and continuing once daily until meconium evacuation is complete or for a maximum of 12 days. The placebo consists of a 250-mg glycerin suppository placed in the diaper rather than the rectum. Study treatments are administered by the charge nurse on duty who is not otherwise involved in patient care. All other clinicians and research personnel will remain blinded. Outcomes for the pilot study are percentage of eligible participants randomized, percentage of infants reaching full enteral feeds, cost, and treatment-related adverse events (rectal bleeding, rectal perforation, and anal fissure). DISCUSSION This external pilot study will assess the feasibility of a multicenter randomized controlled trial of glycerin suppositories in premature infants. The subsequent multicenter trial will have sufficient power to determine whether this treatment strategy is associated with decreased time to full enteral feeds. TRIAL REGISTRATION ClinicalTrials.gov: NCT02153606.
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Affiliation(s)
- Michael H. Livingston
- McMaster Pediatric Surgery Research Collaborative, McMaster Children’s Hospital, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
- Clinician Investigator Program, Postgraduate Medical Education, McMaster University, MDCL Rm 3101, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
| | - Jorge Zequeira
- McMaster Pediatric Surgery Research Collaborative, McMaster Children’s Hospital, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
- Division of Pediatric Surgery, University of Puerto Rico School of Medicine, University of Puerto Rico—Medical Sciences Campus, San Juan, 00921 Puerto Rico
| | - Henrietta Blinder
- McMaster Pediatric Surgery Research Collaborative, McMaster Children’s Hospital, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
- Division of Pediatric Surgery, Department of Surgery, McMaster University, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
| | - Julia Pemberton
- McMaster Pediatric Surgery Research Collaborative, McMaster Children’s Hospital, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
- Division of Pediatric Surgery, Department of Surgery, McMaster University, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
| | - Connie Williams
- Division of Neonatology, Department of Pediatrics, McMaster University, Health Sciences Centre Room 4F5, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
| | - J Mark Walton
- McMaster Pediatric Surgery Research Collaborative, McMaster Children’s Hospital, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
- Division of Pediatric Surgery, Department of Surgery, McMaster University, Health Sciences Centre Room 4E3, 1280 Main Street West, Hamilton, Ontario L8S 4K1 Canada
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Livingston MH, Shawyer AC, Rosenbaum PL, Williams C, Jones SA, Walton JM. Glycerin enemas and suppositories in premature infants: a meta-analysis. Pediatrics 2015; 135:1093-106. [PMID: 25986027 DOI: 10.1542/peds.2015-0143] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Premature infants are often given glycerin enemas or suppositories to facilitate meconium evacuation and transition to enteral feeding. The purpose of this study was to assess the available evidence for this treatment strategy. METHODS We conducted a systematic search of Medline, Embase, Central, and trial registries for randomized controlled trials of premature infants treated with glycerin enemas or suppositories. Data were extracted in duplicate and meta-analyzed using a random effects model. RESULTS We identified 185 premature infants treated prophylactically with glycerin enemas in one trial (n = 81) and suppositories in two other trials (n = 104). All infants were less than 32 weeks gestation and had no congenital malformations. Treatment was associated with earlier initiation of stooling in one trial (2 vs 4 days, P = .02) and a trend towards earlier meconium evacuation in another (6.5 vs 9 days, P = .11). Meta-analysis demonstrated no effect on transition to enteral feeding (0.7 days faster, P = .43) or mortality (P = 0.50). There were no reports of rectal bleeding or perforation but there was a trend towards increased risk of necrotizing enterocolitis with glycerin enemas or suppositories (risk ratio = 2.72, P = .13). These three trials are underpowered and affected by one or more major methodological issues. As a result, the quality of evidence is low to very low. Three other trials are underway. CONCLUSIONS The evidence for the use glycerin enemas or suppositories in premature infants in inconclusive. Meta-analyzed data suggest that treatment may be associated with increased risk of necrotizing enterocolitis. Careful monitoring of ongoing trials is required.
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Affiliation(s)
- Michael H Livingston
- McMaster Pediatric Surgery Research Collaborative, Clinician Investigator Program
| | - Anna C Shawyer
- Division of Pediatric Surgery, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Peter L Rosenbaum
- CanChild Center for Childhood Disability Research, Department of Pediatrics, and
| | | | - Sarah A Jones
- Divisions of Pediatric Surgery, Western University, London, Ontario, Canada; and
| | - J Mark Walton
- McMaster Pediatric Surgery Research Collaborative, Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada;
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Shloim N, Rudolf M, Feltbower RG, Mohebati L, Hetherington M. Breast is best: Positive mealtime interactions in breastfeeding mothers from Israel and the United Kingdom. Health Psychol Open 2015; 2:2055102915579605. [PMID: 28070352 PMCID: PMC5193277 DOI: 10.1177/2055102915579605] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We examined mealtime interactions to assess whether they varied according to maternal body mass index, country and mode of feeding in 41 Israeli and UK mother–infant dyads. Feeding behaviours were coded using the Simple Feeding Element Scale. Significantly, more UK mothers breastfed during the filmed meal compared to Israeli mothers. Mealtime interactions did not vary according to maternal body mass index or country. Women who breastfed (as opposed to those who bottle fed or fed solids) provided fewer distractions during the meal, a more ideal feeding environment and fed more responsively.
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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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Jannin V, Lemagnen G, Gueroult P, Larrouture D, Tuleu C. Rectal route in the 21st Century to treat children. Adv Drug Deliv Rev 2014; 73:34-49. [PMID: 24871671 DOI: 10.1016/j.addr.2014.05.012] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 02/07/2014] [Accepted: 05/19/2014] [Indexed: 02/06/2023]
Abstract
The rectal route can be considered a good alternative to the oral route for the paediatric population because these dosage forms are neither to be swallowed nor need to be taste-masked. Rectal forms can also be administered in an emergency to unconscious or vomiting children. Their manufacturing cost is low with excipients generally regarded as safe. Some new formulation strategies, including mucoadhesive gels and suppositories, were introduced to increase patient acceptability. Even if recent paediatric clinical studies have demonstrated the equivalence of the rectal route with others, in order to enable the use of this promising route for the treatment of children in the 21st Century, some effort should be focused on informing and educating parents and care givers. This review is the first ever to address all the aforementioned items, and to list all drugs used in paediatric rectal forms in literature and marketed products in developed countries.
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Glycerin suppository for promoting feeding tolerance in preterm very low birthweight neonates: A Randomized Controlled Trial. Indian Pediatr 2014; 51:367-70. [DOI: 10.1007/s13312-014-0418-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Randomized controlled trial of prophylactic rectal stimulation and enemas on stooling patterns in extremely low birth weight infants. J Perinatol 2013; 33:858-60. [PMID: 23907087 DOI: 10.1038/jp.2013.86] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 06/19/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We hypothesized that rectal stimulation and small volume enemas would accelerate normalization of stooling patterns in extremely low birth weight infants. STUDY DESIGN In a randomized controlled trial, infants with a gestational age 28 weeks received one of the following: twice daily rectal stimulation and/or enemas until two stools were passed daily, without enemas or stimulation, for three consecutive days. Intervention only occurred when symptoms, abdominal distension and no defecation, occurred in the previous 24 h. Enema administration occurred if abdominal distension persisted without defecation occurring after rectal stimulation. Multivariable linear regression was used to determine the contribution of a patent ductus arteriosus (PDA) on normalization of stooling patterns and feeding tolerance. RESULT Rectal stimulation and/or small volume enemas did not accelerate the median (quartile range) time normalization of stooling patterns, 13 (11-20) days in control group and 16 (12-25.5) days in intervention group. A higher frequency of PDA occurred in the intervention than the non-intervention group. Infants with a persistent PDA had a longer duration of parenteral nutrition, worse feeding tolerance and more days to achieve normal stooling patterns. In multivariable regression analysis, a PDA, not repeated rectal stimulation and/or enemas, was significantly related to stooling and feeding tolerance. CONCLUSION Twice daily administration of rectal stimulation and/or enemas did not normalize stooling patterns (fecal frequency). A PDA is an important determinant of acquisition of normal stooling patterns and feeding tolerance of very immature newborns.
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Maas C, Mitt S, Full A, Arand J, Bernhard W, Poets CF, Franz AR. A historic cohort study on accelerated advancement of enteral feeding volumes in very premature infants. Neonatology 2013; 103:67-73. [PMID: 23095283 DOI: 10.1159/000342223] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 07/23/2012] [Indexed: 01/24/2023]
Abstract
BACKGROUND The optimal rate of enteral feeding (EF) advancement in very low birth weight infants is under debate. OBJECTIVES To evaluate the effects of accelerated EF advancement on the time to full enteral feeds, on early postnatal growth as well as on the frequency of necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) in very premature infants. METHODS In a retrospective single-center historic cohort study, infants with a gestational age <32 weeks at birth and birth weight <1,500 g, born between January 1, 2006, and December 31, 2007 (n = 136), were compared with infants born between January 1, 2010, and December 31, 2010 (n = 88). In 2006/2007, enteral feeds were initiated on day 1 with 10-15 ml/kg/day and advanced by 15-20 ml/kg/day. In 2010, enteral feeds were initiated with 20 ml/kg/day on day 1 and advanced by 25-30 ml/kg/day. Full enteral feeds were defined as ≥ 140 ml/kg/day. Data are presented as median (P25-P75). RESULTS The time to establish full enteral feeds was shorter in 2010: 8 (7-11) days in 2006/2007 versus 6 (5-9) days in 2010. The incidences of NEC and FIP were 2.7 and 4.1% in 2006/2007 and 3.3 and 2.2% in 2010, respectively. Weight gain was not affected by the rate of EF advancement. Higher parenteral protein intake during week 1 in 2006/2007 was associated with better head circumference growth. CONCLUSIONS The new approach was associated with a significantly shorter period to establish full enteral feeds. No difference in the incidence of FIP or NEC was observed; however, the study was underpowered to detect small but possibly important differences.
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Affiliation(s)
- C Maas
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Germany
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Athalye-Jape G, More K, Patole S. Progress in the field of necrotising enterocolitis – year 2012. J Matern Fetal Neonatal Med 2012; 26:625-32. [DOI: 10.3109/14767058.2012.746296] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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