Fat Loss in Continuous Enteral Feeding of the Preterm Infant: How Much, What and When Is It Lost?

A simple step to improve fat and energy delivery of human milk delivered via bottle-feeding pump: An experimental study

BACKGROUND

Enteral feeding pump systems deliver decreased amounts of macronutrients in human milk to neonates. This study determined the macronutrient loss associated with a bottle-feeding pump system and the effect of manually mixing the human milk during extended feeds.

METHODS

Macronutrient content from samples of donor human milk was analyzed after simulated extended feeds with a bottle-feeding pump system, using a human milk analyzer. Simulations were repeated using manual mixing of the bottle every 30 min during feeding. The percentage of the baseline was calculated, and one-sample t tests and analysis of variance compared the effect of manual mixing and the duration of feeding on macronutrient delivery.

RESULTS

The delivery of fat and energy was lower over time, but manual mixing considerably improved retention. The length of feeding impacted fat delivery, with less fat delivered over time (P < 0.001). Manually mixing significantly increased fat delivery (P < 0.001). Similar results were found for energy, with a significant reduction in energy delivery over time (P < 0.001) and significantly more energy delivered with mixing (P < 0.001). Mixing and the duration of feeding had minimal effect on protein or carbohydrate delivery.

CONCLUSIONS

Bottle-feeding pump systems are associated with a significant reduction in the delivery of fat and energy of donor human milk. The manual mixing of donor human milk during prolonged feeds is a simple way to improve fat and energy delivery to the neonate.

Comparison of Three Modalities of Feeding in Preterm Infants ≤32 Weeks and ≤1,250 G: A Randomized Controlled Trial

OBJECTIVE

Early establishment of enteral feeds is desirable in very preterm infants, but it may be associated with feeding intolerance. Several feeding methods have been studied with no strong evidence to suggest the preferred feeding method to establish early full enteral feeds. We studied three modalities of feeding in preterm infants ≤32 weeks and ≤1,250 g: continuous infusion (CI), intermittent bolus by infusion (IBI), and intermittent bolus by gravity (IBG) for their effect on time to reach full enteral feeds of 180 mL/kg/d.

STUDY DESIGN

We randomized 146 infants, 49 infants in each CI and IBI group and 48 infants in the IBG group. In the CI group, feeds were delivered by an infusion pump continuously over 24 hours. In the IBI group, feeds were given every 2 hours and infused over 15 minutes by an infusion pump. In the IBG group, feeds were delivered by gravity over 10 to 30 minutes. The intervention was continued till infants reached direct breast/cup feeds.

RESULTS

The mean (standard deviation) gestation in CI, IBI, and IBG groups were 28.4 (2.2), 28.5(1.9), and 28.6 (1.8) weeks, respectively. The time to reach full feeds in CI, IBI, and IBG were not significantly different (median [interquartile range]: 13 [10-16], 11.5 [9-17], and 13 [9.5-14.2] d, respectively, p = 0.71). The proportions of infants who developed feeding intolerance in CI, IBI, and IBG were similar (n [%]: 21 [51.2%], 20 [52.6%], and 22 [64.7%], respectively, p = 0.45). There was no difference in necrotizing enterocolitis ≥2 (p = 0.80), bronchopulmonary dysplasia (p = 0.86), intraventricular hemorrhage ≥2 (p = 0.35), patent ductus arteriosus requiring treatment (p = 0.44), retinopathy of prematurity requiring treatment (p = 0.51), and growth parameters at discharge.

CONCLUSION

In preterm infants, ≤32 weeks of gestation and birth weight ≤1,250 g, there was no difference in time to reach full enteral feeds in the three modalities of feeding. This study is registered with Clinical Trials Registry India (CTRI) and the registration number is CTRI/2017/06/008792.

KEY POINTS

· Gavage feeding in preterm infants is either continuous or intermittent bolus feeding.. · Intermittent bolus feeding was evaluated in a controlled time by infusion over 15 minutes.. · The time to reach full feeds was comparable for all three methods..

Mother's Own Milk Versus Donor Human Milk: What's the Difference?

Mother's own milk (MOM) is known to decrease complications in preterm infants and when unavailable, it is recommended that preterm very low-birth weight infants be fed donor human milk (DHM). Due to the pasteurization, processing, and lactation stage of donors, DHM does not contain the same nutritional, immunologic, and microbial components as MOM. This review summarizes the differences between MOM and DHM, the potential effects on health outcomes, and the clinical implications of these differences. Finally, implications for research and clinical practice are discussed.

Factors Influencing Breast Milk Fat Loss during Administration in the Neonatal Intensive Care Unit

The objective of this study was to investigate factors influencing fat loss during tube feeding of breast milk to preterm infants. An experimental study with 81 feeding simulations was performed, with nine continuous infusions in each of six modalities: Horizontal Higher, Horizontal Matched, Horizontal Lower, Tilted Higher, Tilted Matched, and Tilted Lower, and for comparison, 27 bolus feedings: nine flushed with air, nine with water, and nine that were not flushed, done at matched height. Each simulation utilized 16 mL of breast milk given over four hours. Continuous infusions were given with a flow rate of 4 mL/h. Bolus was given as 8 mL over the course of 15–20 min every other hour. Analysis for fat, true protein, carbohydrate, total solids, and energy was performed before and after each simulation. The percent of macronutrient loss was compared between all simulations. Continuous infusion resulted in an average fat loss of 40%. Bolus feedings resulted in an average fat loss of 11% (p ≤ 0.001). Considerable fat loss is seen during continuous tube feeding. Neither height in relation to the infant nor tilting of the pump reduce fat loss. To limit fat loss, the bolus feeding method should be utilized.

Challenges in Implementing Exclusive Human Milk Diet to Extremely Low-Birth-Weight Infants in a Level III Neonatal Intensive Care Unit

PROBLEM

Extremely low-birth-weight (ELBW) infants require fortification of human milk (HM) to prevent growth failure. Bovine milk-based fortifiers (BOV-f) may be associated with feeding intolerance and necrotizing enterocolitis. Evidence suggests that an exclusive HM diet (EHMD) using HM-based fortifier (HM-f) may improve these outcomes.

INTERVENTION

EHMD was introduced as a quality improvement project to improve feeding tolerance in ELBW infants.

METHOD

Implementation included establishing EHMD feeding protocol and growth monitoring. We compared infants receiving HM with BOV-f (n = 49) with infants receiving an EHMD (n = 15). The primary outcome was a reduction of no oral intake days due to feeding intolerance.

RESULTS

The EHMD cohort had a more advanced GA (28 vs 26 weeks; P = .03), more males (66.7% vs 42.9%; P = .02), and higher incidence of SGA (40.0% vs 18.4%; P = .16) compared with the HM-f group. The EHMD cohort had fewer days with no oral intake (2 vs 5; P < .005), which is insignificant when adjusted for small for gestational age (SGA) (P = .26). The EHMD cohort vs. the HM-f cohort had a significant decrease in weight and length z-scores from birth to discharge (-1.09 vs -0.26 [P = .002]; -1.76 vs -0.83 [P = .02]). Inadequate weight gain persisted after adjustment for SGA. Interventions were performed to increase caloric intake and institute milk preparation changes.

CONCLUSION

EHMD improved feeding tolerance in our ELBW infants. Observed growth failure might be skewed by SGA prevalence. We highlight that implementation of EHMD requires close growth assessment, especially for SGA infants.