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

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.

Unpredictable supplementation of vitamin D to infants in the neonatal intensive care unit: An experimental study

AIM

Extremely premature infants receive nutrition and medication through nasogastric tubes. Breastmilk given accordingly is subject to fat loss. This study aimed to investigate whether this could also apply to vitamin D.

METHODS

A questionnaire investigated vitamin D administration at a level III neonatal intensive care unit in Sweden in 2021. Feeding simulations with breastmilk and various vitamin D mixtures were done accordingly. After administration, vitamin D3 concentration was analysed using chromatography with mass spectrometry, followed by repeated simulations with vitamin D mixtures without breastmilk in 2023.

RESULTS

The questionnaire was completed by 10 persons. Vitamin D was administered as drops using an enteral syringe and a nasogastric tube in conjunction with a breastmilk meal. In the feeding simulations, vitamin D3 concentration after administration was significantly higher using a syringe alone compared to standard administration. When vitamins were administered according to standard but without breastmilk, 100% of the vitamin D and 40% of the multivitamins were lost. The vitamins adhered to the material, mainly in the nasogastric tube.

CONCLUSION

Our findings indicate that standard vitamin D supplementation in the neonatal intensive care unit may be unpredictable when administered by enteral syringe and nasogastric tube. We suggest using direct oral administration whenever possible.

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..

Neonatal Diet Type and Associations With Adverse Feeding Outcomes in Neonates With Critical Congenital Heart Defects

BACKGROUND

Neonates with critical congenital heart defects (CCHD neonates) experience high rates of feeding intolerance, necrotizing enterocolitis (NEC), and malnutrition. The benefits of human milk and direct chest/breastfeeding are well known, but research is limited in CCHD neonates. Therefore, the purpose of this study is to examine the impact of neonatal diet and feeding modality on the incidence of feeding intolerance, NEC, and malnutrition among a cohort of CCHD neonates.

METHODS

A single-center retrospective study was conducted using electronic health record data of CCHD neonates admitted to a cardiac intensive care unit between April 2016 and April 2020. Regression models were fit to analyze associations between neonatal diet, feed modality, and adverse feeding outcomes.

RESULTS

Seventy-four CCHD neonates were included. Increased days of direct chest/breastfeeding were associated with fewer signs of gastrointestinal distress ( P = .047) and bloody stools ( P = .021). Enteral feeding days of "all human milk" were associated with higher growth trajectory ( P < .001).

CONCLUSIONS

Human milk and direct chest/breastfeeding may be protective against some adverse feeding outcomes for CCHD neonates. Larger, multicenter cohort studies are needed to continue investigating the effects of neonatal diet type and feeding modality on the development of adverse feeding outcomes in this unique population.

Human Milk Fortification for Very Preterm Infants: Toward Optimal Nutrient Delivery, Neonatal Intensive Care Unit Growth, and Long-Term Outcomes

Human milk is the preferred diet for very preterm infants due to short-term and long-term benefits for health and neurodevelopment. Fortification of human milk is required to deliver sufficient nutrients to attain recommended growth targets during the neonatal hospitalization. Intrinsic variability in human milk composition poses a challenge in clinical practice because some infants fail to meet recommended nutrient intakes even with existing approaches of standard (fixed-dose) and adjustable fortification. Individually targeted fortification is an emerging strategy to minimize nutrition delivery gaps through application of point-of-care human milk analysis and has potential to improve growth and related outcomes.

Current Practices, Challenges, and Recommendations in Enteral Nutrition After Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a neonatal disease with high mortality and morbidity. There is a lack of evidence-based recommendations on nutritional rehabilitation following NEC, and much of the current practice is guided by institutional policies and expert opinions. After a diagnosis of NEC, infants are exposed to an extended period of bowel rest and a prolonged course of antibiotics. Recognizing the patient characteristics that predict nutritional tolerance, early initiation of enteral nutrition, minimizing periods of bowel rest and antibiotic exposure, and standardization of dietary practices are the mainstay of post-NEC nutrition.

Application of visual placement of a nasojejunal indwelling feeding tube in intensive care unit patients receiving mechanical ventilation

Background

Compared with nasogastric nutrition, nasojejunal nutrition may prevent some complications of critically ill patients by maintaining better nutritional status, and blind placement of nasojejunal dwelling feeding tubes is widely used. However, the visual placement seems to be safer and more effective than the blind placement, and is still seldom reported.

Objective

We tried to develop visual placement of a nasojejunal feeding tube in intensive care unit patients.

Methods

A total of 122 patients receiving mechanical ventilation were admitted to the Department of Critical Care Medicine of the Fifth Affiliated Hospital of Wenzhou Medical University and received the placement of nasojejunal feeding tubes. These patients were randomly and evenly assigned into two groups, one group receiving visual placement of nasojejunal dwelling feeding tubes and another group receiving blind placement. Actual tube placement was confirmed by X-ray. The primary outcome included the success rates of first placement of feeding tubes. The secondary outcome included the time of tube placement, complications, the total cost, heart rates and respiratory rates.

Results

The primary outcome showed that the success rates of first placement were 96.70% (59 cases/61 cases) in the visual placement group, and two cases failed due to pyloric stenosis and gastroparesis. The success rates were 83.6% (51 cases/61 cases) in the blind placement group and 10 cases failed due to either wrong placement or retrograde tube migration. The success rates in the visual placement group were higher than that in the blind placement group (P = 0.015). The secondary outcome showed that the time of tube placement in the visual placement group was shorter than that in the blind placement group (P < 0.0001). The cost of tube placement in the visual placement group was higher than that in the blind placement group (P < 0.0001). The statistical differences in complications, heart and respiratory rates were insignificant between the two groups (P > 0.05).

Conclusion

Compared with the blind placement, the visual placement shortened the time of nasojejunal tube placement and increased success rates of first placement. The visual placement was more efficient, easy to operate, safe, and has potential clinical applications.