[Expert consensus on enteral nutrition management of preterm infants (2024)].
Zhongguo dang dai er ke za zhi = Chinese journal of contemporary pediatrics
Providing adequate and balanced nutrition for preterm infants, especially extremely/very preterm infants, is the material basis for promoting their normal growth and development and improving long-term prognosis. Enteral nutrition is the best way to feed preterm infants. Previous systematic reviews have shown that using evidence-based standardized feeding management strategies can effectively promote the establishment of full enteral feeding, reduce the duration of parenteral nutrition, improve the nutritional outcomes of preterm infants, and not increase the risk of necrotizing enterocolitis or death. Based on relevant research in China and overseas, the consensus working group has developed 20 recommendations in 5 aspects including the goal of enteral nutrition, transitioning to enteral nutrition, stable growth period enteral nutrition, supplementation of special nutrients, and monitoring of enteral nutrition for preterm infants, using the Grading of Recommendations Assessment, Development and Evaluation. The aim is to provide recommendations for healthcare professionals involved in the management of enteral nutrition for preterm infants, in order to improve the clinical outcomes of preterm infants.
10.7499/j.issn.1008-8830.2402039
Approach to Feeding Difficulties in Neonates and Infants: A Comprehensive Overview.
Gulati Ish K,Sultana Zakia,Jadcherla Sudarshan R
Clinics in perinatology
Deglutition disorders (DD) can be transient and considered as physiologic during normal maturation. However, when oral feeding milestones are impaired and bothersome symptoms and aerodigestive consequences are associated, it is interpreted as DD with varying specific entities, such as feeding difficulties, swallowing disorders, aerodigestive illness, and aspiration syndromes. Symptoms related to DD are heterogeneous and managed empirically. This article clarifies current controversies, explains the potential role of safe feeding and physiologic and pathophysiologic perspectives, and highlights current advances in the field. Evidence basis for diagnostic strategies is discussed, and involves evaluation for structure and function tests, and nutrition and feeding assessment.
10.1016/j.clp.2020.02.006
Feeding dysfunctions and failure to thrive in neonates with congenital heart diseases.
Mangili Giovanna,Garzoli Elena,Sadou Youcef
La Pediatria medica e chirurgica : Medical and surgical pediatrics
Congenital heart disease (CHD) is the most common neonatal congenital malformation. The variety and severity of clinical presentation depend on the cardiac structures involved and their functional impact. The management of newborns with CHD requires a multidisciplinary approach, in which the nutritional aspect plays an important role. An adequate caloric intake during either preand post-surgical period, in fact, improves the outcome of these patients. In addition, the failure to thrive of these children in childhood has been related to long-term cognitive delay (attention deficit disorders, aggressive behaviour and poor social and emotional development). To date, there is a lack of standardized feeding protocols and caloric goals about how to feed neonates with CHD, and current practice varies widely between centres. The latest American Society for Parenteral and Enteral Nutrition guidelines reiterate the importance of proteins, and recommend early start of enteral nutrition, also in the most severe heart diseases, such as univentricular forms. Necrotizing enterocolitis (NEC), the most frequent and feared complication of early feeding of these newborns, often represents an obstacle in spreading this practice. Furthermore, as demonstrated in premature infants, breastfeeding seems to reduce the incidence of NEC. That is why breastfeeding must be encouraged, even if it can be difficult for these mothers due to delivery complications, associated with infant disease. In addition, eating difficulties may persist even after discharge, because these patients require nutritional support through nasogastric tubes or percutaneous endoscopic gastrostomies.
10.4081/pmc.2018.196
Oral feeding readiness in the neonatal intensive care unit.
Jones Luann R
Neonatal network : NN
Oral feeding is a complex sensorimotor process that is influenced by many variables, making the introduction and management of oral feeding a challenge for many health care providers. Feeding practice guided by tradition or a trial-and-error approach may be inconsistent and has the potential to delay the progression of oral feeding skills. Oral feeding initiation and management should be based on careful, individualized assessment of the NICU infant and requires an understanding of neonatal physiology and neurodevelopment. The purpose of this article is to help the health care provider with this complex process by (a) defining oral feeding readiness, (b) describing the importance of oral feeding in the NICU and the physiology of feeding, and (c) providing a review of the literature regarding the transition from gavage to oral feeding in the NICU.
10.1891/0730-0832.31.3.148
A key developmental step for preterm babies: achievement of full oral feeding.
Majoli Marta,Artuso Ilaria,Serveli Simona,Panella Monica,Calevo Maria Grazia,Antonio Ramenghi Luca
The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians
To investigate timing of oral feeding (OF) introduction and full oral feeding (FOF) achievement in preterm infants and to explore factors associated with feeding progression. Retrospective review of 100 medical records of preterms ≤32 weeks of gestation (GA) without major complications. Outcome measures were timing of OF introduction, transition time from nasogastric tube to FOF and FOF achievement. Variables such as sex, twins, GA, birthweight, respiratory supports used and duration of tube feeding, were also considered. Post menstrual age (PMA) for OF introduction was 33.6 ± 1.1 weeks. FOF was achieved at 35.1 ± 1.5 weeks. PMA at OF introduction and PMA at FOF correlated with: birthweight ( = .0001, = .001); duration of respiratory supports ( = 0.01, = .0001); PMA at which respiratory supports were stopped ( = .0001, = .0001); age of introduction of gavage ( = .0001, = .003) and time of utilization of tube feeding ( = .02, = .0001). Transition time was 1.5 ± 8.5 days. PMA at OF introduction significantly influenced PMA at FOF ( = .0001, = .61). OF introduction, transition time and FOF were correlated with duration of hospitalization ( = .004, = .0001, = .008). The achievement of feeding skills is confirmed to affect length of hospitalization, but the earlier you introduce OF, the earlier you reach FOF, so introduction should be anticipated. There is a clear trend to favor higher birthweight classes in FOF achievement. Feeding tube placement and need for respiratory supports may represent a nociceptive experience delaying feeding skills' achievement. This highlights the importance of prospective studies investigating the role of preventative interventions.
10.1080/14767058.2019.1610733
Oral feeding readiness assessment in premature infants.
Gennattasio Annmarie,Perri Elizabeth A,Baranek Donna,Rohan Annie
MCN. The American journal of maternal child nursing
Oral feeding readiness is a complex concept. More evidence is needed on how to approach beginning oral feedings in premature hospitalized infants. This article provides a review of literature related to oral feeding readiness in the premature infant and strategies for promoting safe and efficient progression to full oral intake. Oral feeding readiness assessment tools, clinical pathways, and feeding advancement protocols have been developed to assist with oral feeding initiation and progression. Recognition and support of oral feeding readiness may decrease length of hospital stay and have a positive impact on reducing healthcare costs. Supporting effective cue-based oral feeding through use of rigorous assessment or evidence-based care guidelines can also optimize the hospital experience for infants and caregivers, which, in turn, can promote attachment and parent satisfaction.
10.1097/NMC.0000000000000115
The effects of oral feeding while on nasal continuous positive airway pressure (NCPAP) in preterm infants.
Dumpa Vikramaditya,Kamity Ranjith,Ferrara Louisa,Akerman Meredith,Hanna Nazeeh
Journal of perinatology : official journal of the California Perinatal Association
OBJECTIVE:To determine whether delaying oral feeding until coming off NCPAP will alter feeding and respiratory-related morbidities in preterm infants. DESIGN:In this retrospective pre-post analysis, outcomes were compared in two preterm infant groups (≤32 weeks gestation). Infants in Group 1 were orally fed while on NCPAP, while infants in Group 2 were only allowed oral feedings after ceasing NCPAP. RESULTS:Although infants in Group 2 started feeds at a later postmenstrual age (PMA), they reached full oral feeding at a similar PMA compared with Group 1. Interestingly, there was a positive correlation between the duration of oral feeding while on NCPAP and the time spent on respiratory support in Group 1. CONCLUSIONS:Delayed oral feeding until ceasing NCPAP did not contribute to feeding-related morbidities. We recommend caution when initiating oral feedings in preterm infants on NCPAP without evaluating the safety of the infants and their readiness for oral feedings.
10.1038/s41372-020-0632-2
Exploring the Effects of Various Early Hospital Feeding Approaches on Feeding Tolerance and Growth in Premature Infants.
Alternative therapies in health and medicine
Background:Feeding intolerance poses a significant risk of malnutrition in premature infants and may result in postnatal growth restriction, leading to irreversible damage to brain function and structure. Objective:This study aims to investigate the impact of various early hospital feeding methods on feeding tolerance and the early growth and development of premature infants. Design:A retrospective study design was adopted in this study. Setting:This study was conducted at Tongling Maternal and Child Health Hospital between January 2018 and June 2023. Participants:A total of premature, low birth-weight infants admitted to our hospital between January 2018 and June 2023 were selected for the study. The preterm infants were randomly assigned to either the experimental group (EG) or the control group (CG) using the random number table method. Interventions:The EG group received deep hydrolyzed protein formula (DHPF) milk for 1-3 weeks after opening, whereas the CG group received preterm infant formula milk continuously after the milk was opened. Primary Outcome Measures:(1) Growth and development, (2) Feeding tolerance, and (3) Incidence of complications. Results:Following 14 days of feeding, both study groups exhibited notable increases in body length, body weight, and head circumference (P < .05). These measurements were significantly higher in the EG compared to the CG (P < .05). Furthermore, the EG demonstrated a marked improvement in feeding tolerance relative to the CG (P < .01). Notably, there was no significant difference in the incidence of complications between the two groups (P > .05). Conclusions:The administration of deep hydrolyzed protein formula (DHPF) milk presents a promising strategy for enhancing the growth and development of premature infants while concurrently improving feeding tolerance. These findings underscore the potential clinical benefits of incorporating DHPF milk into neonatal care protocols.
Does the Infant-Driven Feeding Method Positively Impact Preterm Infant Feeding Outcomes?
Settle Margaret,Francis Kim
Advances in neonatal care : official journal of the National Association of Neonatal Nurses
BACKGROUND:Achievement of independent oral feeding is a major determinant of discharge and contributes to long lengths of stay. Accumulating evidence suggests that there is great variation between and within newborn intensive care units in the initiation and advancement of oral feeding. The Infant-Driven Feeding (IDF) method is composed of 3 behavioral assessments including feeding readiness, quality of feeding, and caregiver support. Each assessment includes 5 categories and is intended as a method of communication among caregivers regarding the infant's readiness and progression toward independent oral feeding. PURPOSE:To identify and summarize the available evidence on the use of the IDF method at initiation of oral feeds, time to independent oral feedings, and length of stay in the newborn intensive care unit or level II nursery for preterm infants. METHODS/SEARCH STRATEGY:Four databases including CINAHL, Medline/PubMed, Ovid Nursing, and Embase were searched for "infant guided feedings," "infant driven feeding," "cue-based feeding," and "co regulated feeding." The full text of 32 articles was reviewed to identify experimental, quasiexperimental, or retrospective design to assess the evidence related to cue-based feeding. FINDINGS:There were no randomized control, quasi-experimental, or retrospective studies utilizing the IDF method. There were 3 quality improvement projects utilizing the IDF method. The findings were conflicting: 1 project found the IDF method favorable in the achievement of full oral feedings, 2 projects found the IDF method favorable for reducing length of stay, and 1 project did not find differences in initiation, achievement of oral feedings, or length of stay. IMPLICATIONS FOR PRACTICE:There is scant evidence limited to quality improvement projects to support the use of the IDF method. IMPLICATIONS FOR RESEARCH:Research is needed to empirically validate the IDF method and to inform practice related to the initiation and advancement of oral feeding for preterm infants.
10.1097/ANC.0000000000000577
Mother's Own Milk Feeding in Preterm Newborns Admitted to the Neonatal Intensive Care Unit or Special-Care Nursery: Obstacles, Interventions, Risk Calculation.
Heller Nadja,Rüdiger Mario,Hoffmeister Vanessa,Mense Lars
International journal of environmental research and public health
Early nutrition of newborns significantly influences their long-term health. Mother's own milk (MOM) feeding lowers the incidence of complications in preterm infants and improves long-term health. Unfortunately, prematurity raises barriers for the initiation of MOM feeding and its continuation. Mother and child are separated in most institutions, sucking and swallowing is immature, and respiratory support hinders breastfeeding. As part of a quality-improvement project, we review the published evidence on risk factors of sustained MOM feeding in preterm neonates. Modifiable factors such as timing of skin-to-skin contact, strategies of milk expression, and infant feeding or mode of delivery have been described. Other factors such as gestational age or neonatal complications are unmodifiable, but their recognition allows targeted interventions to improve MOM feeding. All preterm newborns below 34 weeks gestational age discharged over a two-year period from our large German level III neonatal center were reviewed to compare institutional data with the published evidence regarding MOM feeding at discharge from hospital. Based on local data, a risk score for non-MOM feeding can be calculated that helps to identify mother-baby dyads at risk of non-MOM feeding.
10.3390/ijerph18084140
Implementation of Cue-Based Feeding to Improve Preterm Infant Feeding Outcomes and Promote Parents' Involvement.
Thomas Tesi,Goodman Rebecca,Jacob Ani,Grabher Deborah
Journal of obstetric, gynecologic, and neonatal nursing : JOGNN
OBJECTIVE:To implement cue-based feeding for preterm infants and to assess its effects on time to achieve full oral feedings, length of stay, and parents' involvement in the feeding process. DESIGN:A quality improvement project with a pre-post evidence-based practice implementation design. SETTING:Level III NICU in a quaternary hospital in the U.S. Northeast. PARTICIPANTS:Medical records of preterm infants from 23 0/7 weeks to 31 6/7 weeks gestational age who were eligible for initiation of oral feeding. INTERVENTION/MEASUREMENTS:We implemented cue-based feeding through staff education and training. We completed a retrospective review of the medical records of 82 preterm infants before implementation and 167 preterm infants after implementation for the outcomes of time to achieve full oral feedings, length of stay, and parents' involvement in the feeding process. RESULTS:For infants 23 0/7 weeks to 27 6/7 weeks gestation, time to achieve full oral feedings decreased by 7 days, length of stay decreased by 4.4 days, and parents' involvement in the feeding process increased by 80% from before to after implementation. For infants 28 0/7 weeks to 31 6/7 weeks, time to achieve full oral feedings decreased by 6.6 days, length of stay decreased by 2.7 days, and parents' involvement in the feeding process increased by 49% from before to after implementation. The organization saved $103,950 per year by decreasing length of stay. CONCLUSIONS:Cue-based feeding decreased time to achieve full oral feedings, decreased length of stay, increased parents' involvement in the feeding process, and resulted in cost savings for the institution.
10.1016/j.jogn.2021.02.002
Impact of an Infant-Driven Feeding Initiative on Feeding Outcomes in the Preterm Neonate.
Advances in neonatal care : official journal of the National Association of Neonatal Nurses
BACKGROUND:Poor feeding techniques result in adverse outcomes for preterm infants. Infant-driven feeding (IDF) is a structured feeding method that standardizes neonatal cue-based feedings, and matches the neurodevelopmental stage of the preterm infant. The purpose of this quality improvement project is to assess whether initiation of an IDF initiative impacts time from first nipple feed (NF) to full NF and to discharge in infants born before 35 weeks' gestational age. Secondary aims include assessment of the impact of IDF on neonatal growth and feasibility of following an IDF protocol in a level III neonatal intensive care unit (NICU). METHODS:This quality improvement project assesses differences in time to first NF, length of hospital stay, and neonatal growth before and after usage of an IDF protocol. Eighty infants were included, 40 prior to and 40 after IDF intervention. Nurses were trained on IDF philosophy and methods prior to initiation. RESULTS:IDF was associated with discharge at a younger corrected gestational age (CGA), attainment of ad lib feeds at a younger CGA, and shorter amount of days between first NF and discharge. Infants utilizing IDF had slower weight gain, demonstrated by a larger drop in z score in the IDF group. The medical team and bedside nurses were able to follow the IDF protocol with few exceptions. IMPLICATIONS FOR PRACTICE/RESEARCH:IDF allows for optimization of a preterm infant's NICU stay and prepares infants for a safe discharge sooner. This could lead to increased parental satisfaction and decreased hospital cost. Further studies are indicated to ensure these benefits remain and focus on impact direct breastfeeding plays in the IDF model.
10.1097/ANC.0000000000001033
Nutrition of the preterm infant with persistent ductus arteriosus: existing evidence and practical implications.
Pediatric research
The persistence of a patent ductus arteriosus (PDA) is a common condition in preterm infants with a prevalence inversely proportional to gestational age. PDA is associated with mild-to-severe gastrointestinal complications such as feeding intolerance, gastrointestinal perforation, and necrotizing enterocolitis, which represent a major challenge for the nutritional management in preterm infants. In this context, the Section on Nutrition, Gastroenterology and Metabolism and the Circulation Section of the European Society for Pediatric Research have joined forces to review the current knowledge on nutritional issues related to PDA in preterm infants. The aim of the narrative review is to discuss the clinical implications for nutritional practice. Because there is little literature on postnatal nutrition and PDA in preterm infants, further research with well-designed studies on this topic is urgently needed. Guidelines should also be developed to clearly define the implementation and course of enteral nutrition and the target nutritional intake before, during, and after pharmacologic or surgical treatment of PDA, when indicated. IMPACT: Persistent ductus arteriosus (PDA) is associated with gastrointestinal complications such as feeding intolerance, gastrointestinal perforation, and necrotizing enterocolitis, which pose a major challenge to the nutritional management of preterm infants. In PDA infants, fluid restriction may lead to inadequate nutrient intake, which may negatively affect postnatal growth and long-term health. The presence of PDA does not appear to significantly affect mesenteric blood flow and splanchnic oxygenation after enteral feedings. Initiation or maintenance of enteral nutrition can be recommended in infants with PDA.
10.1038/s41390-023-02754-4
Starting and Increasing Feeds, Milk Tolerance and Monitoring of Gut Health in Significantly Preterm Infants.
Nestle Nutrition Institute workshop series
Approaches to enteral feeding significantly preterm infants' impact short-term outcomes including survival, late-onset sepsis (LOS), and necrotizing enterocolitis (NEC), and neurodevelopmental and later health outcomes. Clinical practice and trial data are dominated by short-term outcomes (NEC and LOS) with limited longer-term outcomes. Strategies maximizing early maternal breast milk (MOM) exposure and duration of MOM use are key given global health benefits of MOM, but few feeding trials use these as outcomes. Current data support colostrum receipt, early introduction, and progression of volumes between 18 and 30 mL/kg/day, without adverse impact on NEC, LOS, or mortality. Little evidence supports choosing between route of gastric tube placement, bolus, or continuous feed delivery. Individual infants may have specific features that require individualized feed management, such as combinations of growth restriction, antenatal blood flow concerns, intensive supportive needs (including inotropes), and large open patent ductus arteriosus, currently poorly represented in feeding trials. Infant tolerance monitoring includes clinical observations (stooling, abdominal size, vomiting) but routine gastric aspiration appears unhelpful. Infants should be monitored biochemically, anthropometrically, and in the future through bedside microbiomics or metabolomics. Units and networks should audit and compare their rates of mortality, NEC, LOS, neurodevelopment, and growth achieved.
10.1159/000519384
Antenatal corticosteroids affecting enteral feeding and growth of preterm infants: A retrospective cohort study.
Luo Ping,Liu Xudong,Ma Liya,Chen You,Zhang Kun,Zhou Ping,Jiang Yan-Nan,Jiang Ping-Ping
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:Treatment of antenatal corticosteroids (ACSs) to women at risk of preterm labor can decrease neonatal mortality and morbidity. However, effect of ACS exposure on enteral feeding and body growth of preterm infants remains elusive. METHODS:This retrospective study collected information of eligible singleton infants born between 22 and 36 weeks' gestation from 2017 to 2019. Logistic regression and multivariate linear regression were adopted to examine the associations of the ACS exposure with various outcomes of enteral feeding and growth considering potential confounders. Stratified analysis was performed based on gestational age (GA) (<34 vs ≥34 weeks). RESULTS:Of the 1694 preterm infants included, 1222 (72.1%) were exposed to ACSs. Infants with ACS exposure had a higher incidence of feeding intolerance (odds ratio 1.51; 95% CI, 1.05 to 2.20; P = .03), slower advancement of enteral feeding (β coefficient -0.86; 95% CI, -1.48 to -0.25; P = .01), and lower delta body-weight z-scores (β coefficient-0.13; 95% CI, -0.18 to -0.08; P < .001). Unlike in infants with GA <34 weeks, ACS exposure was associated with slower advancement of enteral feeding, longer time to regain birth weight, and lower delta body-weight z-scores in the ones with GA ≥34 weeks. CONCLUSION:ACS exposure is associated with poorer enteral feeding process and body growth in our study population, which is more prominent in late preterm infants. A multicenter prospective study and mechanistic studies using animal models are required.
10.1002/jpen.2215
Sucking versus swallowing coordination, integration, and performance in preterm and term infants.
Mayerl Christopher J,Edmonds Chloe E,Catchpole Emily A,Myrla Alexis M,Gould Francois D H,Bond Laura E,Stricklen Bethany M,German Rebecca Z
Journal of applied physiology (Bethesda, Md. : 1985)
Mammalian infants must be able to integrate the acquisition, transport, and swallowing of food to effectively feed. Understanding how these processes are coordinated is critical, as they have differences in neural control and sensitivity to perturbation. Despite this, most studies of infant feeding focus on isolated processes, resulting in a limited understanding of the role of sensorimotor integration in the different processes involved in infant feeding. This is especially problematic in the context of preterm infants, as they are considered to have pathophysiological brain development and often experience feeding difficulties. Here, we use an animal model to study how the different properties of food acquisition, transport, and swallowing differ between term and preterm infants longitudinally through infancy to understand which processes are sensitive to variation in the bolus being swallowed. We found that term infants are better able to acquire milk than preterm infants, and that properties of acquisition are strongly correlated with the size of the bolus being swallowed. In contrast, behaviors occurring during the pharyngeal swallow, such as hyoid and soft palate movements, show little to no correlation with bolus size. These results highlight the pathophysiological nature of the preterm brain and also demonstrate that behaviors occurring during oral transport are much more likely to respond to sensory intervention than those occurring during the "pharyngeal phase." Physiological maturation of infant feeding is clinically and developmentally significant, but seldom examined as an integrated function. Using longitudinal high-speed videofluoroscopic data, we found that properties of sucking, such as the length of the suck, are more sensitive to swallow physiology than those associated with the pharyngeal swallow itself, such as hyoid excursion. Prematurity impacted the function and maturation of the feeding system, resulting in a physiology that fundamentally differs from term infants by weaning.
10.1152/japplphysiol.00668.2020
Randomised controlled trial to compare the effect of PIOMI (structured) and routine oromotor (unstructured) stimulation in improving readiness for oral feeding in preterm neonates.
Frontiers in pediatrics
Background:Oral motor stimulation interventions improve oral feeding readiness and earlier full oral feeding in preterm neonates. However, using a structured method may improve the transition time to full oral feeds and feeding efficiency with respect to weight gain and exclusive breastfeeding when compared to an unstructured intervention. Objective:To compare the effect of Premature Infant Oral Motor Intervention (PIOMI) and routine oromotor stimulation (OMS) on oral feeding readiness. Methods:Randomised controlled trial conducted in a neonatal intensive care unit between June-December 2022. Preterm neonates, 29-33 weeks corrected gestational age, were studied. The intervention group received PIOMI and the control group received OMS. Primary outcome: time to oral feeding readiness by Premature Oral Feeding Readiness Assessment Scale POFRAS) score ≥30. Secondary outcomes: time to full oral feeds, duration of hospitalisation, weight gain, and exclusive breastfeeding rates. Results:A total of 84 neonates were included and were randomised 42 each in PIOMI and OMS groups. The mean chronological age and time to oral feeding readiness were lower by 4.6 and 2.7 days, respectively, for PIOMI. The transition time to full oral feeds was 2 days lower for PIOMI and the duration of hospitalisation was 8 days lower. The average weight gain was 4.9 g/kg/day more and the exclusive breastfeeding rates at 1 month and 3 months post-discharge were higher by 24.5% and 27%, respectively, for the PIOMI group. The subgroup analysis of study outcomes based on sex and weight for gestational age showed significant weight gain on oral feeds in neonates receiving PIOMI. Similarly, the subgroup analysis based on gestational age favoured the PIOMI group with significantly earlier transition time and weight gain on oral feeds for the neonates >28 weeks of gestational age. The odds of achieving oral feeding readiness by 30 days [OR 1.558 (0.548-4.426)], full oral feeds by 45 days [OR 1.275 (0.449-3.620)], and exclusive breastfeeding at 1 month [OR 6.364 (1.262-32.079)] and 3 months [3.889 (1.186-12.749)] after discharge were higher with PIOMI. Conclusion:PIOMI is a more effective oromotor stimulation method for earlier and improved oral feeding in preterm neonates. Clinical trial registration:https://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=70054&EncHid=34792.72281&modid=1&compid=19','70054det', identifier, CTRI/2022/06/043048.
10.3389/fped.2023.1296863
Supporting Feeding of Late Preterm Infants in the Hospital: A Quality Improvement Project.
MCN. The American journal of maternal child nursing
BACKGROUND:Feeding difficulty is the most common cause of delayed hospital discharge and readmission of late preterm infants. Frequent and adequate feedings from birth are protective against dehydration, hypoglycemia, and jaundice. The National Perinatal Association's feeding guidelines provide the foundation for late preterm infant standards of care. Feeding at least every 3 hours promotes nutritional status and neurologic development. One feeding assessment every 12 hours during the hospital stay can ensure quality of infant feeding. PROBLEM:At a large urban hospital, medical record reviews were completed to evaluate nursing care practices consistent with the hospital's late preterm infant care standard policy. Feeding frequency and nurse assessment of feeding effectiveness were far below acceptable targets. A quality improvement team was formed to address inconsistency with expected practice. METHODS:The project included an investigation using the define, design, implement, and sustain method of quality improvement. Parent education, nurse education, and visual cues were developed to sustain enhanced nursing practice. RESULTS:Late preterm infants who received feedings at least every 3 hours increased from 2.5% (1 of 40) to 27% (11 of 40); (M = 0.275, SD = 0.446), p = 0.001. Documented breastfeeding assessments increased from 2% (5 of 264) to 8% (10 of 126), p = 0.001. Documented bottle-feeding assessments increased from 15% (39 of 264) to 31% (53 of 172), p < 0.001. Intervention time was cut short due to reprioritization of efforts in response to the COVID-19 pandemic. CONCLUSION:Interventions and implementation of this process improvement is easy to replicate through attainable and sustainable goals directed toward improved outcomes for late preterm infants.
10.1097/NMC.0000000000000769
Dilemmas in initiation of very preterm infant enteral feeds-when, what, how?
Journal of perinatology : official journal of the California Perinatal Association
With limited clinical evidence available to guide common nutritional decisions, significant variation exists in approaches to enteral feeding for very preterm infants, specifically when feedings are initiated, what is fed, and the method used for feedings. Preclinical studies have highlighted the benefits associated with avoiding nil per os and providing early-stage mother's own milk or colostrum. However, these recommended approaches are often mutually exclusive due to the delays in lactation associated with very preterm delivery, resulting in uncertainty regarding which approach should be prioritized. Few studies have evaluated feeding frequency in preterm infants, with limited generalizability to extremely preterm infants. Therefore, even evidence-based approaches to very preterm infant feed initiation can differ. Future research is needed to identify optimal strategies for enteral nutrition in very preterm infants, but, until then, evidence-informed approaches may vary depending on each neonatal intensive care unit's assessment of risk and benefit.
10.1038/s41372-022-01564-6
Feeding the preterm infant: an overview of the evidence.
Poulimeneas Dimitrios,Bathrellou Eirini,Antonogeorgos George,Mamalaki Eirini,Kouvari Matina,Kuligowski Julia,Gormaz María,Panagiotakos Demosthenes B,Yannakoulia Mary,
International journal of food sciences and nutrition
Feeding from own mother's milk is not always an option for preterm infants, and choosing between alternative means of feeding should be made in light of their effect on infants' health. In this work, we aimed to present evidence regarding feeding pre-term infants with human milk, either own mother's or donor milk (DM), and the potential effects on growth and other health related outcomes. Exclusive breastfeeding (BF) remains the optimal option, whereas feeding with DM as a sole diet or supplemental to maternal milk confers immunological advantages and fewer rates of necrotising enterocolitis against preterm formula feeding, yet the latter results in greater growth velocity. Literature gaps in the use of DM, practical suggestions for choosing suitable feeding means (i.e. continuous support of BF, adequate education regarding feeding preterm infants, including DM), and future perspectives on the potential effects of dietary manipulations of the maternal diet, are also discussed.
10.1080/09637486.2020.1754352
A Guide to Feeding Term and Preterm Newborns.
Kolnik Sarah E,Billimoria Zeenia C
Pediatric annals
The management of feeding term and preterm newborns encompasses knowing the physiologic mechanics of nutritive feeding and requirements for good somatic and neurodevelopmental growth. Feeding in newborns can be fraught with challenges that each individual infant-family unit presents. Management is multifactorial and requires fluidity as the infant progresses. Pediatricians are tasked with one of the most important responsibilities in the newborn period-partnering with families to ensure optimal feeding regimen and infant growth. This article's aim is to outline general recommendations on evidence-based feeding practices in term and preterm infants with a goal to help guide pediatricians create an optimal individualized feeding regimen and address some known hurdles. [Pediatr Ann. 2020;49(2):e71-e76.].
10.3928/19382359-20200123-01
Feeding Problems and Long-Term Outcomes in Preterm Infants-A Systematic Approach to Evaluation and Management.
Kamity Ranjith,Kapavarapu Prasanna K,Chandel Amit
Children (Basel, Switzerland)
Preterm infants are known to have long-term healthcare needs. With advances in neonatal medical care, younger and more preterm infants are surviving, placing a subset of the general population at risk of long-term healthcare needs. Oral feeding problems in this population often play a substantial yet under-appreciated role. Oral feeding competency in preterm infants is deemed an essential requirement for hospital discharge. Despite achieving discharge readiness, feeding problems persist into childhood and can have a residual impact into adulthood. The early diagnosis and management of feeding problems are essential requisites to mitigate any potential long-term challenges in preterm-born adults. This review provides an overview of the physiology of swallowing and oral feeding skills, disruptions to oral feeding in preterm infants, the outcomes of preterm infants with feeding problems, and an algorithmic approach to the evaluation and management of neonatal feeding problems.
10.3390/children8121158
Promoting enteral tube feeding safety and performance in preterm infants: A systematic review.
Lin Tian,Hu Jiale,Zhang Lifeng,Qin Xiuqun,Liu Xuelian,Lan Yutao,Chen Ken,You Tianhui
International journal of nursing studies
BACKGROUND:Enteral tube feeding is commonly used in preterm infants to provide enteral nutrition. Nurses play a crucial role in promoting feeding safety and performance. OBJECTIVES:The aims of this systematic review were to identify nursing practices regarding feeding safety and performance promotion in preterm infants with enteral tube feeding and summarize evidence on the effectiveness of these practices. METHODS:A comprehensive search was performed in six databases (MEDLINE, EMBASE, CINAHL, Web of Science, Cochrane Library, and Scopus). Studies on nursing practices aimed at promoting feeding safety and performance in preterm infants with enteral tube feeding were included. Risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2) for randomized controlled studies and the tool of risk-of-bias in non-randomized studies of interventions (ROBINS-I) for non-randomized studies of interventions. A narrative synthesis strategy was employed to gather evidence and analyze data. RESULTS:61 studies (47 randomized controlled studies and 14 quasi-experimental studies) covering seven categories of practices were included. The identified nursing practices included controlling feeding interval, selecting feeding position, monitoring gastric residual, disposing of gastric residual, managing feeding temperature, feeding promotion stimulation, and supplementary methods during the transition from tube to oral feeding. Evidence supported the effectiveness of oro-motor stimulation and non-nutritive sucking as feeding performance promotion strategies in preterm infants. Other practices were suggested to be used cautiously or recommended to be further studied due to limited evidence. CONCLUSIONS:The review identified seven categories of nursing practices in promoting feeding safety and performance in preterm infants receiving enteral tube feeding. Oro-motor stimulation and non-nutritive sucking can be used in clinical settings to promote feeding performance in preterm infants with enteral tube feeding. Other practices will continue to be dictated by local preferences and cost factors until more robust evidence becomes available. REGISTRATION:PROSPERO database (CRD42020196256).
10.1016/j.ijnurstu.2022.104188
Early full enteral feeding for preterm or low birth weight infants.
Walsh Verena,Brown Jennifer Valeska Elli,Copperthwaite Bethany R,Oddie Sam J,McGuire William
The Cochrane database of systematic reviews
BACKGROUND:The introduction and advancement of enteral feeds for preterm or low birth weight infants is often delayed because of concerns that early full enteral feeding will not be well tolerated or may increase the risk of necrotising enterocolitis. Early full enteral feeding, however, might increase nutrient intake and growth rates; accelerate intestinal physiological, metabolic, and microbiomic postnatal transition; and reduce the risk of complications associated with intravascular devices for fluid administration. OBJECTIVES: To determine how early full enteral feeding, compared with delayed or progressive introduction of enteral feeds, affects growth and adverse events such as necrotising enterocolitis, in preterm or low birth weight infants. SEARCH METHODS:We used the standard search strategy of Cochrane Neonatal to search Cochrane Central Register of Controlled Trials; MEDLINE Ovid, Embase Ovid, Maternity & Infant Care Database Ovid, the Cumulative Index to Nursing and Allied Health Literature, and clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials to October 2020. SELECTION CRITERIA:Randomised controlled trials that compared early full enteral feeding with delayed or progressive introduction of enteral feeds in preterm or low birth weight infants. DATA COLLECTION AND ANALYSIS:We used the standard methods of Cochrane Neonatal. Two review authors separately assessed trial eligibility, evaluated trial quality, extracted data, and synthesised effect estimates using risk ratios (RR), risk differences, and mean differences (MD) with 95% confidence intervals (CI). We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS:We included six trials. All were undertaken in the 2010s in neonatal care facilities in India. In total, 526 infants participated. Most were very preterm infants of birth weight between 1000 g and 1500 g. Trials were of good methodological quality, but a potential source of bias was that parents, clinicians, and investigators were not masked. The trials compared early full feeding (60 mL/kg to 80 mL/kg on day one after birth) with minimal enteral feeding (typically 20 mL/kg on day one) supplemented with intravenous fluids. Feed volumes were advanced daily as tolerated by 20 mL/kg to 30 mL/kg body weight to a target steady-state volume of 150 mL/kg to 180 mL/kg/day. All participating infants were fed preferentially with maternal expressed breast milk, with two trials supplementing insufficient volumes with donor breast milk and four supplementing with preterm formula. Few data were available to assess growth parameters. One trial (64 participants) reported a slower rate of weight gain (median difference -3.0 g/kg/day), and another (180 participants) reported a faster rate of weight gain in the early full enteral feeding group (MD 1.2 g/kg/day). We did not meta-analyse these data (very low-certainty evidence). None of the trials reported rate of head circumference growth. One trial reported that the mean z-score for weight at hospital discharge was higher in the early full enteral feeding group (MD 0.24, 95% CI 0.06 to 0.42; low-certainty evidence). Meta-analyses showed no evidence of an effect on necrotising enterocolitis (RR 0.98, 95% CI 0.38 to 2.54; 6 trials, 522 participants; I² = 51%; very low-certainty evidence). AUTHORS' CONCLUSIONS:Trials provided insufficient data to determine with any certainty how early full enteral feeding, compared with delayed or progressive introduction of enteral feeds, affects growth in preterm or low birth weight infants. We are uncertain whether early full enteral feeding affects the risk of necrotising enterocolitis because of the risk of bias in the trials (due to lack of masking), inconsistency, and imprecision.
10.1002/14651858.CD013542.pub2
Nutritional Management of the Critically Ill Neonate: A Position Paper of the ESPGHAN Committee on Nutrition.
Journal of pediatric gastroenterology and nutrition
OBJECTIVES:The nutritional management of critically ill term neonates and preterm infants varies widely, and controversies exist in regard to when to initiate nutrition, mode of feeding, energy requirements, and composition of enteral and parenteral feeds. Recommendations for nutritional support in critical illness are needed. METHODS:The ESPGHAN Committee on Nutrition (ESPGHAN-CoN) conducted a systematic literature search on nutritional support in critically ill neonates, including studies on basic metabolism. The Medline database and the Cochrane Library were used in the search for relevant publications. The quality of evidence was reviewed and discussed before voting on recommendations, and a consensus of 90% or more was required for the final approval. Important research gaps were also identified. RESULTS:This position paper provides clinical recommendations on nutritional support during different phases of critical illness in preterm and term neonates based on available literature and expert opinion. CONCLUSION:Basic research along with adequately powered trials are urgently needed to resolve key uncertainties on metabolism and nutrient requirements in this heterogeneous patient population.
10.1097/MPG.0000000000003076
Factor Affecting Duration of Exclusive Breast Feeding in Preterm Infants With Gestational Age ≤ 34 Weeks.
Indian pediatrics
OBJECTIVES:To study the factors influencing the duration of exclusive breastfeeding (EBF) in preterm (≤34 weeks) infants. METHODS:This study was done in 113 preterm infants with gestational age ≤34 weeks who were attending the well-baby clinic at the corrected age (CA) of 6 month. The birth details were noted from hospital records and feeding details were collected through a personal interview. RESULTS:The mean (SD) duration of EBF was 3.61 (2.3) months, and 35.3% babies had received EBF till CA of 6 month. Operative delivery [aOR (95% CI): 3.8 (1.0, 13.4) P=0.037], delay in initiating tube feeding, [aOR; 1.5 (1.0, 2.1); P=0.017], and delay in establishment of oral feeds [aOR1 (1.0, 1.08) P=0.016] were associated with a shorter duration of EBF. CONCLUSION:The prevalence of EBF till 6 months CA in preterm ≤34 weeks was 35.3%. Earlier initiation and establishment of full oral feeds may help in improving the duration of EBF.
Improving Time to Independent Oral Feeding to Expedite Hospital Discharge in Preterm Infants.
Pediatrics
BACKGROUND AND OBJECTIVES:Achievement of independent oral feedings remains the most common barrier to discharge in preterm infants. Early oral feeding initiation may be associated with a lower postmenstrual age (PMA) at independent oral feeding and discharge. In preterm infants born between 25 and 32 weeks' gestation, our aim was to decrease the PMA at independent oral feedings and discharge by 1 week between June 2019 and June 2020. METHODS:Following formation of a multidisciplinary team, the following plan-do-study-act cycles were targeted: (1) oral feeding initiation at <33 weeks' PMA, (2) cue-based feeding, and (3) practitioner-driven feeding in infants who had not yet achieved independent oral feedings by 36 weeks' PMA. Outcome measures included the PMA at independent oral feeding and discharge. Process measures included adherence to cue-based feeding assessments and PMA at oral feeding initiation. RESULTS:In total, 552 infants with a median gestational age of 30.3 weeks' (interquartile range 28.1-32.0) and birth weight of 1320 g (interquartile range 1019-1620) were included. The PMA at discharge decreased from 38.8 to 37.7 weeks during the first plan-do-study-act cycle, which coincided with an increase in the number of infants initiated on oral feeds at <33 weeks' PMA from 47% to 80%. The age at independent oral feeding decreased from 37.4 to 36.5 weeks' PMA. CONCLUSIONS:In preterm infants born between 25 and 32 weeks' gestation, earlier oral feeding initiation was associated with a decreased PMA at independent oral feeding and discharge.
10.1542/peds.2021-052023
Compatibility of rapid enteral feeding advances and noninvasive ventilation in preterm infants-An observational study.
Pediatric pulmonology
AIM:To evaluate safety and clinical outcome of rapid enteral feeding advances in preterm infants <1500 g birthweight (BW). METHODS:In this single-center retrospective cohort study, 293 preterm infants born during 2015-2018 were comparatively analyzed before (n = 145) and after (n = 148) the implementation of a rapid enteral feeding protocol with daily milk increments of 20-30 ml/kg of body weight. Major outcome parameters were focused toward pulmonary morbidities and nutritional variables. RESULTS:Preterm infants in the rapid feeding advancement group were more successfully stabilized on noninvasive ventilation (p < 0.001) never requiring mechanical ventilation. Duration of respiratory support (0.465) and frequency of bronchopulmonary dysplasia (BPD) (p = 0.341) and severe BPD (0.273) did not differ between both groups. Furthermore, patients in the rapid feeding group achieved full volume feedings faster (p < 0.001), regained BW earlier (p = 0.009), and displayed significantly improved somatic growth at 36 weeks gestational age (p < 0.001). There was no increased risk for further morbidities of prematurity including feeding intolerance, necrotizing enterocolitis (NEC), and focal intestinal perforation. CONCLUSION:Rapid enteral feeding advancements in preterm infants <1500 g BW are safe and do not impede stabilization on noninvasive ventilation.
10.1002/ppul.25868
The Practice of Enteral Nutrition: Clinical Evidence for Feeding Protocols.
Clinics in perinatology
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.
10.1016/j.clp.2023.04.005
Feeding Strategies in Preterm Very Low Birth-Weight Infants: State-of-the-Science Review.
Advances in neonatal care : official journal of the National Association of Neonatal Nurses
BACKGROUND:Providing enteral feeds to preterm very low birth-weight (VLBW) infants is critical to optimize nutrition, enhance growth, and reduce complications. Protocols guiding feeding practices can improve outcomes, but significant variation exists between institutions, which may limit their utility. To be most effective, protocols should be based on the best available evidence. PURPOSE:To examine the state of the science on several key components of feeding protocols for VLBW infants. SEARCH STRATEGY:The authors searched PubMed, CINAHL, and EMBASE databases for terms related to feeding VLBW infants less than 32 weeks' gestational age, including initiation of feedings, rate of feeding advancement, timing of human milk (HM) fortification, and feeding during blood transfusions, when diagnosed with a patent ductus arteriosus (PDA) and during medical treatment of PDA closure. RESULTS:Initiation of feeds within the first 3 days of life and advancement by 30 mL/kg/d may decrease time to attain full feeds without increasing complications. Insufficient evidence guides optimal timing of HM fortification, as well as feeding infants undergoing blood transfusions, infants diagnosed with a PDA, and infants receiving medical treatment of PDA closure. IMPLICATIONS FOR PRACTICE:Integration of existing research regarding feeding initiation and advancement into feeding protocols may improve outcomes. Infants at highest risk of feeding-related complications may benefit from a personalized feeding approach. IMPLICATIONS FOR RESEARCH:Additional research is needed to provide evidence concerning the optimal timing of HM fortification and feeding strategies for infants undergoing blood transfusions and those diagnosed with a PDA or receiving medical treatment of PDA closure to incorporate into evidence-based feeding protocols.
10.1097/ANC.0000000000000849
Dilemmas in establishing preterm enteral feeding: where do we start and how fast do we go?
Journal of perinatology : official journal of the California Perinatal Association
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.
10.1038/s41372-023-01665-w
Nutrition in late preterm infants.
Asadi Sharin,Bloomfield Frank H,Harding Jane E
Seminars in perinatology
Late preterm infants comprise the majority of preterm infants, yet there are few data to support best nutritional practice for these infants. Breastmilk is considered the best choice of enteral feeding for late preterm infants. However, supplementation of breastmilk may be indicated to promote optimal growth. Preterm formulas can be used for supplementation of breastmilk or as a breastmilk substitute but there is little evidence for their use in the late preterm infant. Feeding difficulties are common and some infants require intravenous nutritional support soon after birth. Others require tube feeding until full sucking feeds are established. Future research should focus on whether nutritional support of late preterm babies pending exclusive breastfeeding influences growth, body composition and long-term outcomes of late preterm infants and, if so, how nutritional interventions can optimise these outcomes.
10.1053/j.semperi.2019.06.008
Early enteral feeding in preterm infants.
Kwok T'ng Chang,Dorling Jon,Gale Chris
Seminars in perinatology
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.
10.1053/j.semperi.2019.06.007