Enteral feeding in very-low-birth-weight infants. A comparison of two nasogastric methods

Exposure to the smell and taste of milk to accelerate feeding in preterm infants

BACKGROUND

Preterm infants (born before 37 weeks' gestation) are often unable to co-ordinate sucking, swallowing, and breathing for oral feeding because of their immaturity. In such cases, initial nutrition is provided by orogastric or nasogastric tube feeding. Feeding intolerance is common and can delay attainment of full enteral and sucking feeds, prolonging the need for nutritional support and the hospital stay. Smell and taste play an important role in the activation of physiological pre-absorptive processes that contribute to food digestion and absorption. However, during tube feeding, milk bypasses the nasal and oral cavities, limiting exposure to the smell and taste of milk. Provision of the smell and taste of milk with tube feeds offers a non-invasive and low-cost intervention that, if effective in accelerating the transition to enteral feeds and subsequently to sucking feeds, would bring considerable advantages to infants, their families, and healthcare systems.

OBJECTIVES

To assess whether exposure to the smell or taste (or both) of breastmilk or formula administered with tube feeds can accelerate the transition to full sucking feeds without adverse effects in preterm infants.

SEARCH METHODS

We conducted searches in CENTRAL, MEDLINE, Embase, CINAHL, and Epistemonikos to 26 April 2023. We also searched clinical trial databases and conference proceedings.

SELECTION CRITERIA

We included randomised and quasi-randomised studies that evaluated exposure versus no exposure to the smell or taste of milk (or both) immediately before or at the time of tube feeds.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, and extracted data according to Cochrane Neonatal methodology. We performed meta-analyses using risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, with their respective 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included eight studies (1277 preterm infants). Seven studies (1244 infants) contributed data for meta-analysis. The evidence suggests that exposure to the smell and taste of milk with tube feeds has little to no effect on time taken to reach full sucking feeds (MD -1.07 days, 95% CI -2.63 to 0.50; 3 studies, 662 infants; very low-certainty evidence). Two studies reported no adverse effects related to the intervention. The intervention may have little to no effect on duration of parenteral nutrition (MD 0.23 days, 95% CI -0.24 to 0.71; 3 studies, 977 infants; low-certainty evidence), time to reach full enteral feeds (MD -0.16 days, 95% CI -0.45 to 0.12; 1 study, 736 infants; very low-certainty evidence) or risk of necrotising enterocolitis (RR 0.93, 95% CI 0.47 to 1.84; 2 studies, 435 infants; low-certainty evidence), although the evidence for time to reach full enteral feeds is very uncertain. Exposure to the smell and taste of milk with tube feeds probably has little to no effect on risk of late infection (RR 1.14, 95% CI 0.74 to 1.75; 2 studies, 436 infants; moderate-certainty evidence). There were no data available to assess feeding intolerance. The included studies had small sample sizes and methodological limitations, including unclear or lack of randomisation (four studies), lack of blinding of participants and personnel (five studies), unclear or lack of blinding of the outcome assessor (all eight studies), and different inclusion criteria and methods of administering the interventions.

AUTHORS' CONCLUSIONS

The results of our meta-analyses suggest that exposure to the smell and taste of milk with tube feeds may have little to no effect on time to reach full sucking feeds and time to reach full enteral feeds. We found no clear difference between exposure and no exposure to the smell or taste of milk on safety outcomes (adverse effects, necrotising enterocolitis, and late infection). Results from one ongoing study and two studies awaiting classification may alter the conclusions of this review. Future research should examine the effect of exposing preterm infants to the smell and taste of milk with tube feeds on health outcomes during hospitalisation, such as attainment of feeding skills, safety, feed tolerance, infection, and growth. Future studies should be powered to detect the effect of the intervention in infants of different gestational ages and on each sex separately. It is also important to determine the optimal method, frequency, and duration of exposure.

Oxygenation Instability during Bolus versus Continuous Feeding among Very Low Birth Weight Premature Infants, Supported by Noninvasive Ventilation: A Randomized Prospective Study

OBJECTIVE

 This study aimed to compare oxygenation instability, as documented by the oxygen saturation (SpO2) histograms, during bolus (over 30 minutes) versus continuous (over 2 hours) feeding among very low birth weight (VLBW) premature infants, supported with noninvasive ventilation (NIV).

STUDY DESIGN

 This was a randomized prospective study. VLBW infants supported with NIV received three consecutive feeds in a random order of bolus-continuous-bolus or continuous-bolus-continuous. During each feed, 30 minutes and 2 hours histograms were documented.

RESULTS

 Twenty-four infants (birth weight [mean ± standard deviation, SD] 820 ± 168 g, gestational age [mean ± SD] 27.0 ± 1.6 weeks) were included in our study (12 infants started with bolus feeding and 12 with continuous feeding) and 72 histograms were obtained (36 during bolus feeding and 36 during continuous feeding). No differences in mean fraction of inspired oxygen (FiO2), and number of apnea events were observed between the two feeding modes. Oxygenation instability as assessed by time spent in different SpO2 ranges and histogram types (stable or unstable) was comparable during bolus and continuous feedings. Changing feeding mode from bolus to continuous or vice versa did not significantly change the oxygenation instability of the group, though individual infants did show a consistence response to feeding length changes.

CONCLUSION

 Among VLBW infants supported with NIV, oxygenation instability, as documented by SpO2 histograms, was comparable between bolus and continuous feedings. Individual infants may benefit from specific feeding length, and this can be easily demonstrated by the SpO2 histograms.

KEY POINTS

· Feeding length did not affect oxygenation instability of preterm infants on noninvasive respiratory Support.. · Oxygen saturation histograms allow objective quantification of oxygenation instability at the bedside.. · Individual infants benefit from specific feeding length, as demonstrated by SpO2 histograms..

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..

A Comparison of Slow Infusion Intermittent Feeding versus Gravity Feeding in Preterm Infants: A Randomized Controlled Trial

BACKGROUND

The transition to full enteral feeding is important for ensuring adequate growth in preterm infants.

AIMS

The aim of this study was to investigate the effects of two different intermittent feeding methods on the transition to full enteral feeding in preterm infants.

STUDY DESIGN

A prospective, randomized controlled study was conducted in a neonatology and perinatology center.

SUBJECTS

Preterm infants with a gestational age between 24 + 0/7 and 31 + 6/7 were included in this study. They were divided into two groups: the SIF (slow infusion feeding) group and the IBF (intermittent bolus feeding) group. In the SIF group, feed volumes were administered over one hour using an infusion pump through an orogastric tube, with feeding occurring every three hours. The IBF group received enteral feeding using a gravity-based technique with a syringe through an orogastric tube, completed within 10 to 30 min.

OUTCOME MEASURES

The primary outcome was the achievement of full enteral feeding and the occurrence of feeding intolerance.

RESULTS

A total of 103 infants were enrolled in the study (50 in SIF and 53 in IBF). The time to achieve full enteral feeding did not differ significantly between the two groups (p = 0.20). The SIF group had significantly fewer occurrences in which gastric residual volume exceeded 50% (p = 0.01). Moreover, the SIF group had a significantly shorter duration of non-per-oral (NPO) status than the IBF group (p = 0.03).

CONCLUSIONS

It is our contention that the use of the SIF method as an alternative feeding method is appropriate for infants with feeding intolerance and those at high risk of feeding intolerance.

Enteral Nutrition in Preterm Infants (2022): A Position Paper From the ESPGHAN Committee on Nutrition and Invited Experts

OBJECTIVES

To review the current literature and develop consensus conclusions and recommendations on nutrient intakes and nutritional practice in preterm infants with birthweight <1800 g.

METHODS

The European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee of Nutrition (CoN) led a process that included CoN members and invited experts. Invited experts with specific expertise were chosen to represent as broad a geographical spread as possible. A list of topics was developed, and individual leads were assigned to topics along with other members, who reviewed the current literature. A single face-to-face meeting was held in February 2020. Provisional conclusions and recommendations were developed between 2020 and 2021, and these were voted on electronically by all members of the working group between 2021 and 2022. Where >90% consensus was not achieved, online discussion meetings were held, along with further voting until agreement was reached.

RESULTS

In general, there is a lack of strong evidence for most nutrients and topics. The summary paper is supported by additional supplementary digital content that provide a fuller explanation of the literature and relevant physiology: introduction and overview; human milk reference data; intakes of water, protein, energy, lipid, carbohydrate, electrolytes, minerals, trace elements, water soluble vitamins, and fat soluble vitamins; feeding mode including mineral enteral feeding, feed advancement, management of gastric residuals, gastric tube placement and bolus or continuous feeding; growth; breastmilk buccal colostrum, donor human milk, and risks of cytomegalovirus infection; hydrolyzed protein and osmolality; supplemental bionutrients; and use of breastmilk fortifier.

CONCLUSIONS

We provide updated ESPGHAN CoN consensus-based conclusions and recommendations on nutrient intakes and nutritional management for preterm infants.

Continuous Glucose Monitoring in Preterm Infants: The Role of Nutritional Management in Minimizing Glycemic Variability

Glycemic variability (GV) is common in preterm infants. In the premature population, GV is a risk factor for morbidity and mortality. Both hypo- and hyperglycemia can impair neurodevelopment. We investigated the impact of continuous versus intermittent tube enteral feeding on GV. In our prospective observational study, 20 preterm infants with a gestational age ≤ 34 weeks at either continuous or intermittent bolus full enteral feeding. For five days, continuous glucose monitoring (CGM) was utilized, which was achieved through the subcutaneous insertion of a sensor. A total of 27,532 measurements of blood glucose were taken. The mean amplitude of glycemic excursions did not differ between the two cohorts statistically. Continuous feeding resulted in higher positive values, increasing the risk of hypo- and hyperglycemia. Subjects who were small for their gestational age had a higher standard deviation during continuous feeding (p = 0.001). Data suggest that intermittent bolus nutrition is better for glycemic control than continuous nutrition. Nutritional management optimization of preterm infants appears to be critical for long-term health. In the future, CGM may provide a better understanding of the optimal glucose targets for various clinical conditions, allowing for a more personalized approach to management.

Regional Splanchnic Oxygenation during Continuous versus Bolus Feeding among Stable Preterm Infants

Introduction: There is no agreement regarding the best method for tube-feeding preterm infants. Few studies, to date, have evaluated the influence of different methods of enteral feeding on intestinal oxygenation. The use of near-infrared spectroscopy (NIRS) has permitted the noninvasive measurement of splanchnic regional oxygenation (rSO₂S) in different clinical conditions. The aim of this prospective, single-center study was to compare rSO₂S during continuous versus bolus feeding among stable preterm infants. Methods: Twenty-one preterm infants, less than 32 weeks gestation and appropriate for gestational age, were enrolled. All infants were clinically stable and on full tube feedings. Each infant received a bolus feeding initially (20 min duration), and after 3 h, a continuous feeding (5 h duration). Infants were evaluated 30 min before and 30 min after the bolus and continuous feedings. The regional splanchnic saturation (rSO₂S) was measured using near-infrared spectroscopy (NIRS) technology and systemic saturation was measured with pulse oximetry. From these measurements, we calculated the splanchnic fractional oxygen extraction ratio (FOES) for each of the four intervals. Results: rSO₂S decreased after continuous vs. bolus feeding (p = 0.025), while there was a trend toward decreased SaO₂ after bolus feeding (p = 0.055). The FOES, which reflects intestinal oxygen extraction, was not affected by the feeding mode (p = 0.129). Discussion/Conclusion: Continuous vs. bolus feeding decreases rSO₂S but does not affect oxygen extraction by intestinal tissue; after bolus feeding there was a trend towards decreased systemic saturation.

Gastrointestinal and feeding issues for infants <25 weeks of gestation

Appropriate nutrition is essential for optimal development and growth of preterm infants. Infants less than 25 weeks corrected gestational age are frequently the most difficult group for which to provide adequate nutrition due to minimal energy stores and high fluid losses. Nutrient delivery becomes an integral, but also very challenging part in their management. Early administration of intravenous nutrients provides a critical bridge to full enteral nutrition. However, enteral feeding is challenging due to immaturities of the intestinal tract, feeding intolerance and the risk of catastrophic gastrointestinal disease such as necrotizing enterocolitis (NEC). Decreased gastric acid production, increased gut permeability, reduced immunoglobulins, immature intestinal epithelia and a decreased mucin barrier all contribute to weakness to gastrointestinal insult. This review aims to illustrate the importance of enteral feeding and the common challenges and approaches in the nutrition of infants born at this age.

Continuous versus bolus intermittent intragastric tube feeding for preterm and low birth weight infants with gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease is a particularly common condition among preterm and low birth weight infants. These infants are more likely to have excessive regurgitation, as they do not have a fully developed antireflux mechanism. Preterm and low birth weight infants who are unable to suck oral feeds are required to be fed via an intragastric tube for varying lengths of time. Intragastric tube feeding can be delivered by the intermittent bolus method or by the continuous feeding method. Use of continuous or intermittent bolus intragastric feeding may have a positive or negative effect on the incidence or severity of gastro-oesophageal reflux disease.

OBJECTIVES

• To determine whether continuous or intermittent bolus intragastric tube feeding reduces the number of episodes and the duration of gastro-oesophageal reflux disease (GORD) in preterm and low birth weight infants • To perform subgroup analyses for gestational age; birth weight; age in days from birth at full enteral feeding via intragastric tube (breast versus bottle); frequency of intermittent bolus feed; and type of medication for treatment of GORD (only if medication was prescribed and was given similarly to both intervention groups) SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 7), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), on 8 July 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

Published and unpublished RCTs and quasi-RCTs were eligible for inclusion in this review, as were cluster-randomised and cross-over randomised trials that compared the effects of continuous versus intermittent bolus intragastric tube feeding on gastro-oesophageal reflux disease in preterm and low birth weight infants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and quality. We planned to use the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We found no trials that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

We did not identify any randomised trials that evaluated the effects of continuous versus intermittent bolus intragastric tube feeding on gastro-oesophageal reflux disease in preterm and low birth weight infants. Well-designed and adequately powered trials are needed.

Management of abdominal distension in the preterm infant with noninvasive ventilation: Comparison of cenit versus 2x1 technique for the utilization of feeding tube

BACKGROUND

Preterm infants are fed by orogastric / nasogastric tube until they reach maturation and coordination of sucking, swallowing and respiration at approximately 32-34 weeks of corrected age. While being on non-invasive ventilation (NIV), they frequently present abdominal distension. Currently at our institution two techniques are used for the management of abdominal distension in preterm infants fed by bolus via orogastric tube: cenit and 2 x 1.The aim of this study was to compare the proportion of preterm infants presenting NIV-associated abdominal distension with each of these techniques.

STUDY DESIGN

We conducted a randomized clinical trial including infants of <  36.6 weeks of gestation and <  1500 g of birth weight who were admitted to our NICU during the period of April 1, 2016 to April 1, 2018 and received NIV. The presence of abdominal distension >  2 cm was the primary outcome. Secondary outcomes were presence of reflux, regurgitation, oxygen saturation during feeding and days to reach full feedings. Feeding tube drainage, stool characteristics and the use of prokinetics were confounding variables.

RESULTS

A total of 97 patients were included. Forty-six in the cenit group and 51 in the 2 x 1 group. There was no difference in the proportion of infants with abdominal distension >  2 cm between groups. Oxygen saturation during feeding at volume of 150 ml/kg/day was higher in the cenit group with statistical significance.

CONCLUSION

The use of cenit or 2 x 1 technique in preterm infants with NIV did not improve abdominal distension or other indicators of feeding tolerance.

Continuous nasogastric milk feeding versus intermittent bolus milk feeding for preterm infants less than 1500 grams

BACKGROUND

Milk feedings can be given via nasogastric tube either intermittently, typically over 10 to 20 minutes every two or three hours, or continuously, using an infusion pump. Although the theoretical benefits and risks of each method have been proposed, their effects on clinically important outcomes remain uncertain.  OBJECTIVES: To examine the evidence regarding the effectiveness of continuous versus intermittent bolus tube feeding of milk in preterm infants less than 1500 grams.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 7) in the Cochrane Library; Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions; and CINAHL (Cumulative Index to Nursing and Allied Health Literature) on 17 July 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

We included RCTs and quasi-RCTs comparing continuous versus intermittent bolus nasogastric milk feeding in preterm infants less than 1500 grams.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for relevance and risk of bias. We used the standard methods of Cochrane Neonatal to extract data. We used the GRADE approach to assess the certainty of evidence. Primary outcomes were: age at full enteral feedings; feeding intolerance; days to regain birth weight; rate of gain in weight, length and head circumference; and risk of necrotising enterocolitis (NEC).

MAIN RESULTS

We included nine randomised trials (919 infants) in this updated Cochrane Review. One study is awaiting classification. Seven of the nine included trials reported data from infants with a maximum weight of between 1000 grams and 1400 grams. Two of the nine trials included infants weighing up to 1500 grams. Type(s) of milk feeds varied, including human milk (either mother's own milk or pasteurised donor human milk), preterm formula, or mixed feeding regimens. In some instances, preterm formula was initially diluted. Earlier studies also used water to initiate feedings. We judged six trials as unclear or high risk of bias for random sequence generation. We judged four trials as unclear for allocation concealment. We judged all trials as high risk of bias for blinding of care givers, and seven as unclear or high risk of bias for blinding of outcome assessors. We downgraded the certainty of evidence for imprecision, due to low numbers of participants in the trials, and/or wide 95% confidence intervals, and/or for risk of bias. Continuous compared to intermittent bolus (nasogastric and orogastric tube) milk feeding Babies receiving continuous feeding may reach full enteral feeding almost one day later than babies receiving intermittent feeding (mean difference (MD) 0.84 days, 95% confidence interval (CI) -0.13 to 1.81; 7 studies, 628 infants; low-certainty evidence).  It is uncertain if there is any difference between continuous feeding and intermittent feeding in terms of number of days of feeding interruptions (MD -3.00 days, 95% CI -9.50 to 3.50; 1 study, 171 infants; very low-certainty evidence). It is uncertain if continuous feeding has any effect on days to regain birth weight (MD -0.38 days, 95% CI -1.16 to 0.41; 6 studies, 610 infants; low-certainty evidence). The certainty of evidence is low and the 95% confidence interval is consistent with possible benefit and possible harm. It is uncertain if continuous feeding has any effect on rate of gain in weight compared with intermittent feeding (standardised mean difference (SMD) 0.09, 95% CI -0.27 to 0.46; 5 studies, 433 infants; very low-certainty evidence). Continuous feeding may result in little to no difference in rate of gain in length compared with intermittent feeding (MD 0.02 cm/week, 95% CI -0.04 to 0.08; 5 studies, 433 infants; low-certainty evidence). Continuous feeding may result in little to no difference in rate of gain in head circumference compared with intermittent feeding (MD 0.01 cm/week, 95% CI -0.03 to 0.05; 5 studies, 433 infants; low-certainty evidence). It is uncertain if continuous feeding has any effect on the risk of NEC compared with intermittent feeding (RR 1.19, 95% CI 0.67 to 2.11; 4 studies, 372 infants; low-certainty evidence). The certainty of evidence is low and the 95% confidence interval is consistent with possible benefit and possible harm.

AUTHORS' CONCLUSIONS

Although babies receiving continuous feeding may reach full enteral feeding slightly later than babies receiving intermittent feeding, the evidence is of low certainty. However, the clinical risks and benefits of continuous and intermittent nasogastric tube milk feeding cannot be reliably discerned from current available randomised trials. Further research is needed to determine if either feeding method is more appropriate for the initiation of feeds. A rigorous methodology should be adopted, defining feeding protocols and feeding intolerance consistently for all infants. Infants should be stratified according to birth weight and gestation, and possibly according to illness.

Bolus versus continuous feedings following treatment for medical necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is a serious, often fatal, disease of neonates. Minimal data exists regarding the optimal method for reintroducing feeds after successful treatment. This study aims to compare outcomes in patients reintroduced to bolus or continuous feeds after treatment for medical NEC.

METHODS

A retrospective review of infants treated for medical NEC in the neonatal intensive care unit (NICU) from 2011-2018 was performed. Demographics, information about initial feeds, clinical diagnosis data, and information about reintroduction of feeds were recorded. Patients with significant congenital heart disease or those who required procedures for treatment were excluded.

RESULTS

Sixty-one patients were analyzed; 45 were reintroduced to bolus feeds and 16 to continuous feeds. There were no differences between the two groups. Bolus-fed patients reached goal feeds quicker (p = 0.007), required fewer days of parenteral nutrition (p = 0.002), had shorter hospital stays (p = 0.013) and were discharged faster from diagnosis to discharge (p = 0.002). Differences were confirmed with multivariate regression.

CONCLUSION

Infants given bolus feeds reached goal feeds faster, required less time on PN, and were discharged quicker than those fed continuously. This suggests that, compared to continuous feeding, bolus feeding is associated with superior clinical outcomes among patients treated for medical NEC.

Continuous versus intermittent bolus milk feeding in preterm infants: a meta-analysis

Objectives

To analyze the evidence comparing the benefits and risks of continuous versus intermittent milk feeding in low birth weight (LBW) infants.

Methods

Three electronic databases were searched and screened to identify randomized controlled trials of continuous and intermittent milk feeding of LBW infants up to October 2016.

Results

Eight trials were included in this meta-analysis. Continuous feeding had no effect on days to full feeds and time to regain birth weight. There were no significant differences in the number of apneas, invasive ventilation, changes in body length, occipitofrontal circumference, skinfold thickness, and total protein, and in the number of stools between the two feeding strategies. Continuous feeding was associated with higher gastric residual volume, noninvasive ventilation, weight gain, increase in bilirubin, and longer nil by mouth. There were no significant differences in adverse events and confounders between the two feeding strategies.

Conclusions

Continuous milk feeding was superior to intermittent feeding in LBW infants in terms of weight gain. However, continuous feeding was also associated with increased nil by mouth duration, increased bilirubin, increased noninvasive support, and increased gastric residuals. Continuous feeding thus confers advantages in terms of weight gain, but also has disadvantages compared with bolus feeding.

Early enteral feeding in preterm infants

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.

Continuous feeding versus intermittent bolus feeding for premature infants with low birth weight: a meta-analysis of randomized controlled trials

Background/objectives

Clinical risks and advantages of both continuous feeding and intermittent feeding for preterm infants have been presented in previous studies. To determine the most appropriate feeding method for low-birth-weight infants, a meta-analysis was conducted.

Subjects/methods

Articles related to this topic were searched in PubMed, EMBASE, and Cochrane Library electronic database from the onset to May 2019. Heterogeneity analysis was performed with Chi-square and I² test. Pooled analysis was based on fixed effects model, if heterogeneity between the eligible studies was negligible (I² < 50%, P > 0.05). In contrast, a random effects model was carried out. The quality of including studies were evaluated by Cochrane assessment tool.

Results

A total of 1030 articles identified. Altogether, eight articles including 707 infants were included in final analysis based on eligibility criteria. In continuous feeding infants, time to achieving full feeds was longer (weight mean difference 0.98 (95% CI 0.26–1.71, P = 0.008) days) compared with intermittent feeding infants. Pooled analysis indicated there were no significant difference in other variables such as feeding intolerance, duration of hospitalization, days to regain birth weight, days to first successful oral feeding, duration of parenteral feeding, weight growth, length increment, head circumference growth, proven necrotizing enterocolitis, and probable necrotizing enterocolitis. In subgroup analysis for birth weight (<1000 g and >1000 g), we did not identify significant difference in time to full feeds, time to regain birth weight, and duration of hospitalization.

Conclusions

Intermittent feeding may be more beneficial for low-birth weight infants, However, well-designed studies and evidenced-based clinical practice are required to determine the most appropriate feeding method for premature infants with low birth weight.

Exposure to the smell and taste of milk to accelerate feeding in preterm infants

BACKGROUND

Preterm infants are often unable to co-ordinate sucking, swallowing and breathing for oral feeding because of their immaturity; in such cases, initial nutrition is provided by orogastric or nasogastric tube feeding. Feed intolerance is common and can delay attainment of full enteral feeds and sucking feeds, which prolongs the need for intravenous nutrition and hospital stay. Smell and taste play an important role in the activation of physiological pre-absorptive processes that contribute to food digestion and absorption. However, during tube feedings, milk bypasses the nasal and oral cavities, which limits exposure to the smell and taste of milk. Provision of the smell and taste of milk with tube feedings is non-invasive and inexpensive; and if it does accelerate the transition to enteral feeds, and then to sucking feeds, it would be of considerable potential benefit to infants, their families, and the healthcare system.

OBJECTIVES

To assess whether exposure to the smell or taste (or both) of milk administered with tube feedings can accelerate progress to full sucking feeds without adverse effects in preterm infants.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 1 June 2018), Embase (1980 to 1 June 2018), and CINAHL (1982 to 1 June 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised and quasi-randomised trials.

SELECTION CRITERIA

We included randomised and quasi-randomised studies that compared the provision of the smell or taste of milk (or both) immediately before or at the time of tube feedings, with no provision of smell or taste.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data according to Cochrane Neonatal methodology; they also assessed risk of bias, and the quality of evidence at the outcome level using the GRADE approach. We performed meta-analyses using risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with their respective 95% confidence intervals (CIs).

MAIN RESULTS

Three trials involving a total of 161 preterm infants were included in this review, but only two trials (131 infants) contributed data for meta-analysis. There was no evidence of a clear effect of exposure to the smell and taste of milk with tube feedings on time taken to reach full sucking feeds (MD -2.57 days, 95% CI -5.15 to 0.02; I2 = 17%; 2 trials, 131 infants; very low-quality evidence). One trial reported no adverse effects. There was no evidence of a clear effect of exposure to the smell and taste of milk on the following outcomes: time taken to reach full enteral feeds (MD -1.57 days, 95% CI -6.25 to 3.11; 1 trial, 51 infants; very low-quality evidence), duration of parenteral nutrition (MD -2.20 days, 95% CI -9.49 to 5.09; 1 trial, 51 infants; very low-quality evidence), incidence of necrotising enterocolitis (RR 0.62, 95% CI 0.15 to 2.48; 1 trial, 51 infants; low-quality evidence), and late infection (RR 2.46, 95% CI 0.27 to 22.13; 1 trial, 51 infants; low-quality evidence). There was very low-quality evidence demonstrating that exposure to the smell and taste of milk decreased duration of hospitalisation by almost four days (MD -3.89 days, 95% CI -7.03 to -0.75; I2 = 51%; 2 trials, 131 infants). In two trials, an increased growth velocity was noted in infants exposed to the intervention, but we were unable to combine data to perform meta-analysis. No data were available to assess feed intolerance and rates of exclusive breastfeeding at discharge. Included trials were small and had methodological limitations including lack of randomisation (one trial), lack of blinding, and different inclusion criteria and administration of the interventions.

AUTHORS' CONCLUSIONS

Evidence from two trials suggests that exposure to the smell and taste of milk with tube feedings has no clear effect on time taken to reach full sucking feeds, but it may decrease length of hospitalisation. However, these results are uncertain due to the very low quality of the evidence. There is also limited evidence about the impact on other important clinical outcomes and on safety. Future research should examine the effect of exposure to the smell and taste of milk with tube feedings on clinical outcomes during hospitalisation, such as attainment of full enteral and sucking feeds, safety, feed tolerance, incidence of infection, and infant growth. Additionally, future research should be sufficiently powered to evaluate the effect of the intervention in infants of different gestational ages, on each sex separately, and on the optimal frequency and duration of exposure.

Feeding Intervals in Premature Infants ≤1750 g: An Integrative Review

BACKGROUND

The timely establishment of enteral feeds and a reduction in the number of feeding interruptions are key to achieving optimal nutrition in premature infants. Nutritional guidelines vary widely regarding feeding regimens and there is not a widely accepted consensus on the optimal feeding interval.

PURPOSE

To critically examine the evidence to determine whether there is a relationship to feeding intervals and feeding outcomes in premature infants.

METHODS

A systematic review of the literature in the following databases: PubMed, CINAHL, Embase and the Cochrane Library. The search strategy used the terms infant premature, low birth weight, enteral feeding, feed tolerance and feed intervals.

RESULTS

Search results yielded 10 studies involving 1269 infants (birth weight ≤1750 g). No significant differences in feed intolerance, growth, or incidence of necrotizing enterocolitis were observed. Evidence suggests that infants fed at 2 hourly intervals reached full feeds faster than at 3 hourly intervals, had fewer days on parenteral nutrition, and fewer days in which feedings were withheld. Decrease in the volume of gastric residuals and feeding interruptions were observed in the infants fed at 3 hourly intervals than those who were continuously fed.

IMPLICATIONS FOR PRACTICE

Reducing the feed interval from 3 to 2 hourly increases nurse workload, yet may improve feeding outcomes by reducing the time to achieve full enteral feeding.

IMPLICATIONS FOR RESEARCH

Studies varied greatly in the definition and management of feeding intolerance and in how outcomes were measured, analyzed, and reported. The term "intermittent" is used widely but can refer to a 2 or 3 hourly interval.

Impact of Continuous vs Bolus Feeding on Splanchnic Perfusion in Very Low Birth Weight Infants: A Randomized Trial

OBJECTIVE

To detect changes in splanchnic perfusion and oxygenation induced by 2 different feeding regimens in infants with intrauterine growth restriction (IUGR) and those without IUGR.

STUDY DESIGN

This was a randomized trial in 40 very low birth weight infants. When an enteral intake of 100 mL/kg/day was achieved, patients with IUGR and those without IUGR were randomized into 2 groups. Group A (n = 20) received a feed by bolus (in 10 minutes), then, after at least 3 hours, received the same amount of formula by continuous nutrition over 3 hours. Group B (n = 20) received a feed administered continuously over 3 hours, followed by a bolus administration (in 10 minutes) of the same amount of formula after at least 3 hours. On the day of randomization, intestinal and cerebral regional oximetry was measured via near-infrared spectroscopy and Doppler ultrasound (US) of the superior mesenteric artery was performed. Examinations were performed before the feed and at 30 minutes after the feed by bolus and before the feed, at 30 minutes after the start of the feed, and at 30 minutes after the end of the feed for the 3-hour continuous feed.

RESULTS

Superior mesenteric artery Doppler US showed significantly higher perfusion values after the bolus feeds than after the continuous feeds. Near-infrared spectroscopy values remained stable before and after feeds. Infants with IUGR and those without IUGR showed the same perfusion and oxygenation patterns.

CONCLUSION

According to our Doppler US results, bolus feeding is more effective than continuous feeding in increasing splanchnic perfusion.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01341236.

Intraday glucose fluctuation is common in preterm infants receiving intermittent tube feeding

BACKGROUND

We previously reported on three preterm infants with blood glucose abnormalities after reaching full enteral feeding. Recently, it has been shown that clinically stable preterm infants may have large fluctuations in blood glucose after the establishment of enteral nutrition. We hypothesized that intraday glucose fluctuation is a common finding in preterm infants, but improves at term post-conceptual age. This report describes a case series.

METHODS

From June 2010 to July 2012, 13 preterm infants (29.5 ± 2.1 post-conceptual weeks, 1144 ± 319 g) were enrolled in this study. Continuous glucose monitoring (CGM) was conducted on average at 33.5 ± 1.4 post-conceptual weeks, when they received gastric tube feeding every 3 h in the absence of i.v. glucose supply.

RESULTS

Eight infants (62%) had large intraday glucose fluctuation with repeated hyperglycemic (>150 mg/dL) and hypoglycemic (<50 mg/dL) events. In five infants, follow-up CGM at 36-38 weeks post-conceptual age showed more stable glycemic changes without any abnormal glucose levels.

CONCLUSIONS

On CGM, in some preterm infants intermittent tube feeding resulted in large intraday glucose fluctuation at 31-35 post-conceptual weeks, but the pattern disappeared before discharge (36-38 post-conceptual weeks).

Intermittent Bolus or Semicontinuous Feeding for Preterm Infants?

OBJECTIVES

The aim of the present study was to assess the clinical benefits and risks of semicontinuous (CON) versus intermittent nasogastric tube feeding in low-birth-weight infants.

METHODS

Infants with a birth weight <1750 g and gestational age <32 weeks were stratified according to birth weight and assigned to either CON or intermittent bolus (BOL) feeding. The primary endpoint was days to full enteral feeding (defined as 120 mL(-1) · kg(-1) · day(-1)). We also collected data on feeding tolerance, weight gain, respiratory support, and complications (sepsis, necrotising enterocolitis, and death).

RESULTS

There was no difference between the 2 groups (CON n = 121, BOL n = 125) in days to reach full enteral feeding--7 (5-10) versus 6 (5-8) days, respectively, with a difference 1 (-0.05 to 2.1). Mean daily gastric residual volumes, however, were significantly lower in the BOL group (4.8 vs 3.9 mL/day, difference 0.9 mL/day [0.1-1.7]), as was the total number of patients with feeding interruptions (76 vs 59, difference 16% [3%-28%]).

CONCLUSIONS

Bolus and continuous feeding are equally suitable feeding strategies for preterm neonates. BOL feeding, however, may be preferable.

Cardiorespiratory events with bolus versus continuous enteral feeding in healthy preterm infants

We evaluated the effects of bolus vs continuous tube feeding on cardiorespiratory events, detected by polysomnographic monitoring, in healthy preterm infants. Continuous tube feeding resulted in a significant increase of apneas and apneas-related hypoxic episodes compared with bolus feeding.

Continuous versus bolus intragastric tube feeding for preterm and low birth weight infants with gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease is a particularly common condition in preterm and low birth weight infants. These infants are also more likely to have excessive regurgitation, as they do not have a fully developed antireflux mechanism. Preterm and low birth weight infants who are unable to suck oral feeds are required to be fed via an intragastric tube for varying lengths of time. Intragastric tube feeding can be delivered by the intermittent bolus or continuous feeding method. Use of continuous or intermittent bolus intragastric feeding may have a positive or negative effect on the incidence or severity of gastro-oesophageal reflux disease.

OBJECTIVES

To determine whether continuous or intermittent bolus intragastric tube feeding reduces the number of episodes and the duration of gastro-oesophageal reflux disease (GORD) in preterm and low birth weight infants.We intended to perform subgroup analyses for gestational age; birth weight; age in days from birth at full enteral feeding via intragastric tube (breast vs bottle); frequency of intermittent bolus feed; and type of medication for treatment of GORD (only if medication prescribed and given similarly to both intervention groups).

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Group as described in The Cochrane Library (www.thecochranelibrary.com) to search for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 9), MEDLINE (1966 to September 2013), EMBASE (1980 to September 2013) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to September 2013). We also searched previous reviews, including cross-references, abstracts and conference and symposia proceedings of the Perinatal Society of Australia and New Zealand and the Pediatric Academic Societies (American Pediatric Society/Society for Pediatric Research and European Society for Paediatric Research) from 1990 to 2012.

SELECTION CRITERIA

Published and unpublished RCTs and quasi-RCTs were eligible for inclusion in this review, as were cluster-randomised and cross-over randomised trials that compared the effects of continuous versus intermittent bolus intragastric tube feeding on gastro-oesophageal reflux disease in preterm and low birth weight infants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and quality.

MAIN RESULTS

We found no trials that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

We did not identify any randomised trials that evaluated the effects of continuous versus intermittent bolus intragastric tube feeding on gastro-oesophageal reflux disease in preterm and low birth weight infants. Well-designed and adequately powered trials are needed.

[Efficacy of feeding pump for patients on enteral tube feeding: a systematic literature review and analysis]

BACKGROUND/AIMS

This study was conducted to establish a guideline on the utilizing of feeding pump in patients requiring enteral tube feeding.

METHODS

As a first step, textbooks on nutrition and guidelines from regional clinical nutrition societies were analyzed. Afterwards, data on the efficacy, safety, and practicality of feeding pump application were collected and evaluated by systematically reviewing the related literature. As data sources, 8 domestic databases including KoreaMed and global databases such as Ovid-MEDLINE, Ovid-EMBASE, and Cochrane Library were utilized. A total of 2,016 related articles was selected by applying the keyword "(enteral feeding.mp AND pump.mp)".

RESULTS

Textbooks and guidelines were not able to draw conclusions on the effects of the feeding pump because the injection speed, tube size, and etcetera were different for enteral feeding. Feeding pump assisted enteral tube feeding was an efficient, safe, and practical procedure for reducing maladjustment-related complications of enteral tube feeding, which are obvious obstacles for maintaining nutritional balances in patients requiring tube feeding.

CONCLUSIONS

Feeding pump application can be considered an efficient and safe measure that is acceptable in patients on small intestinal tube feeding, critically-ill patients on gastro-intestinal tube feeding, premature babies, and critically-ill or severely malnourished children (recommendation grade D).

Continuous milk feeding versus intermittent bolus feeding in preterm infants

We aimed to assess the current knowledge on continuous versus intermittent bolus feeding in preterm infants. We found that existing evidence does not support the firm recommendation of one strategy among the many alternatives. However, although many areas remain to be investigated, it is probable that continuous feeding might be advantageous compared to intermittent feeding in favoring the faster establishment of full enteral feeding, and decreasing the risk of hypoxic-ischemic gut damage in preterm neonates in critical condition, especially SGA infants, by limiting their gastrointestinal oxygen requirement.

Near-infrared spectroscopy measurements of splanchnic tissue oxygenation during continuous versus intermittent feeding method in preterm infants

OBJECTIVES

The aim of the present study was to compare the effects of continuous and intermittent bolus milk feeding on splanchnic regional oxygenation (rSO₂S) in small-for-gestational age (SGA) and appropriate-for-gestational age (AGA) preterm infants.

METHODS

Infants with gestational age <32 weeks were prospectively studied by near-infrared spectroscopy. Each infant was given a milk bolus in ~10 minutes (intermittent feeding) followed after 3 hours by a 3-hour continuous feeding. rO₂S and splanchnic fractional oxygen extraction ratio (FOES [S = splanchnic]) were recorded 30 minutes before (T₀) and 30 minutes after the beginning of bolus feeding (T₁), 30 minutes before (T₂), at the end (T₃), and 30 minutes after the continuous feeding period (T₄).

RESULTS

rSO2S increased at T₁ in both AGA and SGA groups, whereas FOES did not vary during the study period. Moreover, we found that rSO2S was higher and FOES was lower at T₁ and T₃ in the AGA than in the SGA group.

CONCLUSIONS

Bolus milk feeding increases splanchnic oxygenation in both AGA and SGA infants, whereas continuous feeding does not. Splanchnic oxygenation is higher in AGA than in SGA infants both during bolus and continuous feeding. Continuous enteral feeding could help to limit the risk of hypoxic-ischemic gut damage in preterm infants in critical condition, especially in AGA infants.

How to feed small for gestational age newborns

Feeding small for gestational age (SGA) newborns is extremely challenging and the neonatologist should be brave and cautious at the same time. Although these babies have a high risk of milk intolerance and necrotising enterocolitis, enteral feeding guidelines are not well established and practice varies widely among different neonatal units. Currently available studies on this topic include extremely and very low birth weight neonates, but are not focused specifically on small for gestational age infants. This review analyzes papers focused on feeding interventions in order to provide the best available evidences about the optimum timing for introduction of enteral feeding, how fast feed volume can be advanced, which milk and which feeding method is more appropriate in SGA infants.

The gustatory and olfactory systems during infancy: implications for development of feeding behaviors in the high-risk neonate

This article reviews the development of the senses of taste and smell, which provide information on the flavor of foods, and discusses how innate predispositions interact with early-life feeding experiences to form children's dietary preferences and habits. A basic understanding of the development and functioning of the chemical senses during early childhood may assist in forming evidence-based strategies to improve children's diets, especially for those who experience a discontinuity or disruption in early flavor experiences.

Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams

BACKGROUND

Milk feedings can be given via nasogastric tube either intermittently, typically over 10 to 20 minutes every two or three hours, or continuously, using an infusion pump. Although theoretical benefits and risks of each method have been proposed, effects on clinically important outcomes remain uncertain.

OBJECTIVES

To examine the evidence regarding the effectiveness of continuous versus intermittent bolus nasogastric milk feeding in premature infants less than 1500 grams.

SEARCH METHODS

Searches were performed of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2011), MEDLINE, CINAHL and HealthSTAR up to July 2011.

SELECTION CRITERIA

Randomised and quasi-randomised clinical trials comparing continuous versus intermittent bolus nasogastric milk feeding in premature infants less than 1500 grams.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for relevance and methodologic quality. The standard methods of the Cochrane Neonatal Review Group were used to extract data.

MAIN RESULTS

Overall, the seven included trials, involving 511 infants, found no differences in time to achieve full enteral feeds between feeding methods (weighted mean difference (WMD) 2 days; 95% CI -0.3 to 3.9) . In the subgroup analysis of those studies comparing continuous nasogastric versus intermittent bolus nasogastric milk feedings the findings remained unchanged (WMD 2 days, 95% CI -0.4 to 4.1). There was no significant difference in somatic growth and incidence of NEC between feeding methods irrespective of tube placement. One study noted a trend toward more apneas during the study period in infants fed by the continuous tube feeding method compared to those fed by intermittent feedings delivered predominantly by orogastric tube placements [mean difference (MD) 14.0 apneas during study period; 95% CI -0.2 to 28.2]. In subgroup analysis based on weight groups, one study suggested that infants less than 1000 grams and 1000 to 1250 grams birth weight gained weight faster when fed by the continuous nasogastric tube feeding method compared to intermittent nasogastric tube feeding method (MD 2.0 g/day; 95% CI 0.5 to 3.5; MD 2.0 g/day; 95% CI 0.2 to 3.8, respectively). A trend toward earlier discharge for infants less than 1000 grams birth weight fed by the continuous tube feeding method compared to intermittent nasogastric tube feeding method (MD -11 days; 95% CI -21.8 to -0.2).

AUTHORS' CONCLUSIONS

Small sample sizes, methodologic limitations, inconsistencies in controlling variables that may affect outcomes, and conflicting results of the studies to date make it difficult to make universal recommendations regarding the best tube feeding method for premature infants less than 1500 grams. The clinical benefits and risks of continuous versus intermittent nasogastric tube milk feeding cannot be reliably discerned from the limited information available from randomised trials to date.

Role of newborn nurses in newborn feeding

OBJECTIVE

The aim of this study was to determine the function of newborn nurses given at newborn feeding in the newborn units of public hospitals in Konya, Turkey, besides it was also to determine the effect of nurses which had short-term training, aka education, in practice and in theory.

METHODS

This was an experimental study conducted with a total of 50 newborn nurses between 15 September 2004 and 30 February 2005. In collecting the data, a survey sheet including the demographic characteristics of newborn nurses and their knowledge on newborn feeding was applied, along with another remark form that shows clinical practices about newborn feeding.

RESULTS

Considering the nurses, their knowledge mean score 'after education (AE)' was calculated to be 72.4 ± 10.4, which was significantly higher than that of 'before education (BE)', which was 58.0 ± 9.3, (p < 0.05). Likewise, the implementation mean score of these nurses AE (57.2 ± 4.9) was also found higher than the mean score BE (54.4 ± 5.0) (p < 0.05). There were statistically significant differences in the posteducation mean scores of nurses for the number of children they had, and for the hospital they work.

CONCLUSION

In this study, it was determined that the nurses had knowledge deficits about newborn feeding both in theory and practice, but after a short educational program on newborn feeding their theoretical and practical knowledge had shown increases.

Early enteral feeding for the very low birth weight infant: the development and impact of a research-based guideline

Providing optimal nutrition for the very low birth weight (VLBW) infant is critical during the neonatal period. Evidence-based practice guidelines are essential in managing these fragile infants. Putting scientific research into daily clinical practice may be arduous at times, however. A multidisciplinary team of health care providers successfully established a practical feeding guideline for a 52-bed, teaching-affiliated, Level III neonatal intensive care unit in St. Louis. This guideline identifies human milk as the recommended source of nutrition for the VLBW infant, a suggestion that has significantly affected lactation services in the unit. This article describes the process of developing, implementing, and evaluating a feeding guideline based on current research and describes the impact on lactation rates of having such a guideline in place within the unit.

Continuous feeding promotes gastrointestinal tolerance and growth in very low birth weight infants

OBJECTIVE

To compare the effects of continuous versus intermittent feeding on gastrointestinal tolerance and growth in very low birth weight (VLBW) infants.

STUDY DESIGN

In a randomized, controlled trial conducted at 3 neonatal units, 70 premature infants with a gestational age 24 to 29 weeks and birth weight < 1200 g were assigned to 1 of 3 feeding methods: continuous nasogastric feeding, intermittent nasogastric feeding, or intermittent orogastric feeding. Feeding was initiated within 30 hours of birth. Daily enteral and parenteral volumes, caloric and protein intakes, growth, enteral intolerance, and clinical complications were recorded. Cox regression analysis was used to determine primary outcome, the time to achieve full enteral feeding.

RESULTS

The continuously fed infants achieved full enteral feeding significantly faster than the intermittently fed infants (hazard ratio [HR] = 1.86; 95% confidence interval [CI] = 1.07 to 3.22). In stratified analysis according to birth weight, the improvement was even more pronounced in the smallest infants, those with birth weight < or = 850 g (adjusted HR = 4.13; 95% CI = 1.48 to 11.53). Growth rate was significantly faster in the continuously fed infants ( P = .002).

CONCLUSION

In VLBW infants, continuous feeding seems to be better than intermittent feeding with regard to gastrointestinal tolerance and growth.

Enteral feeding for high-risk neonates: a digest for nurses into putative risk and benefits to ensure safe and comfortable care

Enteral feeding is considered a relatively safe method of providing nutritional support to high-risk neonates. Nonetheless, there are associated risks, which can be classified as follows: factors to consider before initiating enteral feeding; feeding tube placement; delivery of milk feedings; and gastrointestinal, environmental, and technical factors. For each classification, this article highlights adverse consequences and synthesizes the literature for evidence-based nursing practice recommendations, which are summarized in the "Conclusion" section. Many gaps are identified in the research literature, and directions for future research are described to ensure safe and comfortable care for high-risk neonates receiving enteral feedings.

Gastric residual volumes in critically ill paediatric patients: a comparison of feeding regimens

This study examined the effect of gastric feeding regimens, either continuous or intermittent, on fourth hourly gastric residual volumes (GRV) in a group of critically ill paediatric patients where delayed gastric emptying is defined as a GRV greater than 5ml/kg. A randomised controlled trial was conducted in a tertiary paediatric intensive care unit (PICU), with 45 participants being randomly assigned to either the continuous (n=22) or intermittent (n=23) gastric feeding groups. Participants remained in the assigned group for the duration of the study and, fourth hourly, GRV were assessed to monitor the incidence of delayed gastric emptying. Both groups were similar in age, weight, gender, diagnosis, paediatric index mortality (PIM) score, and usage of pharmacological agents known to affect the gastrointestinal tract. No differences emerged in study duration or the volume of administered enteral formula (ml/kg/day). The intermittent feeding group commenced enteral feeding earlier in the PICU admission (13.0 hours versus 18.5 hrs, p=0.05). Repeated measures analysis revealed no overall difference in median GRV/kg values between treatment groups over the 72 hour study period. Additionally, the incidence of fourth hourly GRV, greater than 5ml/kg, was not different between the continuous and intermittent feeding groups. The provision of enteral nutrition via the gastric route is a common treatment in the PICU, and GRV are frequently used as a measure of gastric tolerance. The result of this analysis provides some support for the theoretical definition of delayed gastric emptying being >5ml/kg. However, further work is required to confirm this finding and to determine its relevance when providing enteral nutrition to the critically ill paediatric patient.

Gastric Feeding in Critically Ill Children: A Randomized Controlled Trial

• Background Provision of enteral nutrition via the gastric route is a common nursing procedure in pediatric intensive care units. Little research, however, has focused on children’s tolerance of different types of gastric feeding regimens.

• Objectives To examine the relationship between 2 gastric feeding regimens, continuous and intermittent, and children’s tolerance as measured by the number of stools and prevalences of diarrhea and vomiting.

• Methods A randomized controlled trial was conducted in an Australian pediatric intensive care unit; 45 children were randomly assigned to either the continuous or the intermittent gastric feeding groups. Participants remained in the assigned feeding group for the duration of the study, and values of variables used to monitor patients’ tolerance were recorded.

• Results Both feeding groups were similar with respect to Pediatric Index Mortality score, age, weight, sex, diagnosis, and use of pharmacological agents known to affect the gastrointestinal tract. Additionally, the 2 groups did not differ in study duration or the daily volume of administered enteral formula per kilogram of body weight. The number of stools per day and the prevalences of diarrhea and vomiting did not differ significantly between the 2 groups.

• Discussion Continuous and intermittent gastric feeding regimens have similar outcomes with respect to the number of stools per day and the prevalence of diarrhea and vomiting in pediatric intensive care patients. Further gastric feeding studies and the development of enteral feeding guidelines for critically ill children are needed.

Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams

BACKGROUND

Most premature infants less than 1500 grams birth weight must be fed initially by tube because of their inablity to suck effectively, or to coordinate sucking, swallowing and breathing. Milk feedings can be given by tube either intermittently, typically over 10-20 minutes every two or three hours, or continuously, using an infusion pump. Although theoretical benefits and risks of each method have been proposed, effects on clinically important outcomes remain uncertain.

OBJECTIVES

To examine the evidence from randomized trials regarding the effectiveness of continuous versus intermittent bolus nasogastric milk feeding in premature infants less than 1500 grams. The primary outcomes reviewed included feeding tolerance, days to reach full enteral feeding, somatic growth, days to discharge and incidence of necrotizing enterocolitis (NEC).

SEARCH STRATEGY

Searches were performed of MEDLINE, CINAHL, and HealthSTAR, each up to February 2002, and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002). As well, studies identified from abstracts and conference proceedings and references from relevant publications were retrieved.

SELECTION CRITERIA

Randomized and quasi-randomized clinical trials that met the following criteria for relevance: a) Enrollment of infants < 1500 grams birth weight with no major congenital anomalies which might interfere with feeding tolerance b) Comparison of continuous nasogastric versus intermittent bolus tube feedings using breastmilk or formula c) Assessment of relevant outcomes including feeding tolerance, days to full feeds, somatic growth, days to discharge, and complications such as NEC or apnea

DATA COLLECTION AND ANALYSIS

All articles retrieved from the complete search were assessed independently by the two reviewers for relevance (see selection criteria), and for methodologic quality using the following criteria: blinding of randomization, blinding of intervention, complete follow-up and blinding of outcome measurement. Only those articles judged by both reviewers to be relevant and to have appropriate methodologic quality were included in the analysis. Differences were resolved through discussion and consensus of the reviewers.

MAIN RESULTS

Infants fed by continuous tube feeding method took longer to reach full enteral feeds (weighted mean difference 3.0 days; 95% CI 0.7, 5.2). Although there was no evidence of a difference in the days to discharge overall, one study suggested a trend toward earlier discharge for infants less than 1000 grams birth weight fed by the continuous tube feeding method (mean difference (MD) -11 days; 95% CI -21.8, -0.2). Overall, there was no evidence of a difference in somatic growth (weight, length, head circumference or skinfold thickness) between the two groups, but subgroup analyses in one study suggested that infants less than 1000 grams and 1000 - 1250 grams birthweight gained weight faster when fed by the continuous tube feeding method (MD 2.0 g/day; 95% CI 0.5, 3.5; MD 2.0 g/day; 95% CI 0.2, 3.8, respectively). There was no evidence of a difference in the incidence of NEC. One study showed a trend toward more apneas during the study period in infants fed by the continuous tube feeding method (MD 14.0 apneas during study period; 95% CI -0.2, 28.2).

REVIEWER'S CONCLUSIONS

Infants fed by the continuous tube feeding method took longer to reach full feeds, but there was no significant difference in somatic growth, days to discharge, or the incidence of NEC for infants fed by continuous versus intermittent bolus tube feeds. Small sample sizes, methodologic limitations and conflicting results of the studies to date, together with inconsistencies in controlling variables that may affect outcomes, make it difficult to make universal recommendations regarding the best tube feeding method for premature infants less than 1500 grams. The clinical benefits and risks of continuous versus intermittent nasogastric tube milk feeding cannot be reliably discerned from the limited information available from randomized trials to date.

Feeding the ill or preterm infant

Illness and immaturity often interfere with a neonate's ability to receive full enteral feedings during the first week of life. The goals of feeding in the NICU are to nourish the preterm infant for appropriate growth and development and to facilitate the earliest possible discharge from the NICU. Early, small-volume feedings, or trophic feedings, have been studied as a method for achieving these goals. The high-risk infant given such trophic feedings not only receives minimum enteral nutrition, but also attains earlier full nutritional feedings and, consequently, is discharged home earlier. Oro- or nasal-gastric gavage feedings are usually indicated for this group of infants because of their physiologic immaturity and the frequent presence of respiratory illness. Recent studies support the use of intermittent bolus feedings, which have long been used for the premature infant. Several authors have noted advantages to continuous infusions as well. Because the infant is unable to pace or refuse gavage feedings, the caretaker must determine the appropriate volume of each feeding. The optimal volume for initiation and advancement of trophic and nutritional feedings is still under investigation, but reports have demonstrated safe volumes for even the extremely premature infant.

Evidence-based feeding guidelines for very low-birth-weight infants

Clinical practice guidelines (CPG) for the nutritional management of premature infants are limited. This project focused on the development of a research-based enteral feeding CPG for infants of < 1,500 g. The CPG was based on an extensive literature review and developed through a process of consensus decision making by a team of clinical researchers. Infants that weigh < 1,000 g initiate minimal enteral nutrition (MEN) at 48 hours; nutritional feedings begin on day 5 to 6 of life. For infants between 1,000 and 1,500 g, nutritional feedings begin at 48 hours and are advanced at a rate of less than 30 mL/kg per day. The benefits and risks of continuous versus intermittent nasogastric tube feeding were inconclusive; therefore, the CPG does not stipulate a feeding method. Breast milk is used preferentially, and specific guidelines for the definition and management of feeding intolerance are provided. A follow-up study testing this CPG has been completed and is published in the original research section of this issue.

Early aggressive nutrition in preterm infants

Increasingly, neonatologists are realizing that current feeding practices for preterm infants are insufficient to produce reasonable rates of growth, and earlier and larger quantities of both parenteral and enteral feeding should be provided to these infants. Unfortunately, there is very little outcome data to recommend any particular nutritional strategy to achieve better growth. Instead, the rationale for feeding regimens in many nurseries has been quite variably extrapolated from animal data and human studies conducted in gestationally more mature and/or stable neonates. Additionally, there are no well-controlled, prospective studies that validate any nutritional regimen for the very preterm and or sick, unstable neonate. The goal of this review is to present available data to help define the risks and benefits of early parenteral and enteral nutrition, particularly in very preterm neonates, concluding with a more aggressive approach to feeding these infants than has been customary practice.

Feeding tolerance in preterm infants: randomized trial of bolus and continuous feeding

OBJECTIVE

To test the hypothesis that continuous gastric infusion (CGI) is better tolerated than intermittent gastric bolus (IGB) in small very low birth weight (VLBW) infants.

DESIGN

Two-center, prospective, randomized, unmasked clinical trial.

PATIENTS

28 VLBW infants (birth weight <1250 g). A strict feeding protocol was followed.

INTERVENTION

Patients were randomized to IGB or CGI.

MAIN OUTCOME MEASURES

Time to reach full feeds (160 cc/kg/d)(by design and real), daily weight, caloric intake, residual gastric volume and type of feeding (formula vs. human milk vs. both).

RESULTS

Five infants failed to complete the study because of death (n = 4) or protocol violation (n = 1). The two groups did not differ by birth weight or gestational age; infants fed via IGB reached full feeds earlier (p = 0.03) and had less delay in reaching full feeds than infants fed via CGI.

CONCLUSION

Contrary to our hypothesis, gravity IGB is more effective than CGI in improving feeding tolerance in small VLBW infants.

Energy expenditure in the extremely low-birth weight infant

Information about energy requirements of extremely low-birth weight infants is sparse, despite the rapidly improving survival rates of this population. Metabolizable energy intake can be estimated from energy balance studies and the percentage of caloric intake that is actually absorbed by these infants is approximately 87%. Data on energy expenditure in extremely premature infants is limited; however, energy expenditure has been shown to increase with postnatal age. Because both intake and expenditure are affected by multiple factors, there is significant variability in estimates of the energy requirements in extremely low-birth weight infants. At present, no valid recommendations can be made regarding optimal energy requirements for the extremely low-birth weight infant, except that their requirements probably exceed those of stable, growing very low-birth weight infants, currently estimated at 105 to 135 kcal.kg-1d-1.

Enteral feeding of the micropremie

Clinical practice demands knowledge of gastrointestinal ontogeny and the factors that affect our ability to use enteral feeding in the micropremie. The decisions regarding milk type (when and how it should be given) are considered in the light of current physiologic and clinical evidence. Special considerations apply in the micropremie who is also small for gestational age and NEC must be avoided. Trophic feeding now has an established role, allowing the infant to benefit from enteral feeds even when full nutritive milk feeding is not possible.

Enteral feeding in the preterm infant

In planning enteral feeding in the preterm infant, decisions need to be made regarding the feeding schedule, choice of milk, and the route of administration. Feeds should be commenced within a week after birth beginning with subnutritional quantities. Preterm human milk from the infant's own mother is the milk of choice. When full enteral feeding is established, supplementation with human milk fortifier is recommended. Donor human milk and preterm formula are alternatives. Early establishment of enteral nutrition and maintenance of optimal nutrition during infancy are important as dietary manipulations in preterm infants have potential long-term influences on their health, growth and neurodevelopment.

Feeding strategies for premature infants: randomized trial of gastrointestinal priming and tube-feeding method

BACKGROUND

Data on enteral feeding management of premature infants are limited and often not the subject of randomized clinical trials. Several small studies suggest benefits from the early initiation of feeding, but do not assess the combined effects of time of initiation of feeding, tube-feeding method, and type of milk used. Either singly or in combination, these treatments may affect growth, bone mineralization, biochemical measures of nutritional status, and feeding tolerance, and, ultimately, the duration of hospitalization.

METHODS

A total of 171 premature infants, stratified by gestational age (26 to 30 weeks) and diet (human milk or preterm formula) were assigned randomly among four treatment combinations in a balanced two-way design comparing the presence or absence of gastrointestinal (GI) priming for 10 days and continuous infusion versus intermittent bolus tube-feeding.

RESULTS

The major outcome, time required for infants to attain full oral feeding, was similar among treatments. GI priming was not associated with any measured adverse effect and was associated with better calcium and phosphorus retention, higher serum calcium and alkaline phosphatase activity, and shorter intestinal transit times. The bolus tube-feeding method was associated with significantly less feeding intolerance and greater rate of weight gain than the continuous method. In addition, the greater the quantity of human milk fed, the lower the morbidity.

CONCLUSIONS

Early GI priming with human milk, using the bolus tube-feeding method, may provide the best advantage for the premature infant.

Margin of safety for discharge after apnea in preterm infants

OBJECTIVE

Most neonatologists include an apnea-free period in the criteria for the discharge of preterm infants. However, the length of time one should wait after the cessation of apnea before sending an infant home without a monitor is debated. We undertook this study in an attempt to define a minimal and safe observation period between the time of the last apnea episode and discharge.

METHODS

We reasoned that in infants with idiopathic apnea of prematurity, the intervals between days on which apnea occurs gradually increase until some point at which clinically significant apnea ceases. Therefore, knowledge about the intervals between days on which apnea occurred just before the last apnea would provide a reasonable estimate of the minimal safe observation interval between the last apnea and discharge. We reviewed the charts of 266 infants born in 1993 and 1994 at </=32 weeks' gestational age or weighing </=1500 g at birth from two institutions to determine the intervals between the day on which the last apnea occurred and the previous two days on which apnea occurred. One hundred seventy-five infants were excluded because they never experienced apnea, or data about the last apnea was missing, or they were on xanthines during the period encompassing the last 3 apnea days, or they weighed <1500 g or were <34 weeks' postmenstrual age at the time of the last apnea. Of the 91 remaining infants, gestational age at birth, birth weight, 1- and 5-minute Apgar scores, and discharge weight were not different between the two institutions. For each infant we determined the longest of the intervals between the 2 days on which apnea occurred previous to the day of the last apnea (MAXINT for maximum interval). The infants were then ordered by MAXINT and, starting at the longest MAXINT, the medical records of each infant were carefully examined for other conditions known to be associated with apnea (eg, recovering from anesthesia, sepsis, chronic lung disease, and so forth). The minimal safe observation period was then defined as the longest MAXINT in which there was at least 1 infant with no other explanation for the apnea other than prematurity.

RESULTS

The median duration of the intervals between the 2 days on which apnea occurred previous to the day on which the last apnea occurred were 3. 0 and 2.0 days and the median duration of the MAXINT was 4.0 days. On careful examination of the charts, it was determined that each of 13 infants with a MAXINT preceding the day on which the last apnea occurred of greater than 8 days had some other condition that might result in apnea, including residual lung disease, sepsis, surgery, and so forth. In contrast, among the group of infants with a MAXINT of </=8 days, at least 1 infant at each MAXINT (eg, 1 to 8) had significant apnea with no other explanation other than prematurity.

CONCLUSIONS

We conclude that otherwise healthy preterm infants continue to have apneas separated by as many as 8 days before the last apnea before discharge. Conversely, infants with longer apnea intervals often have identifiable risk factors other than apnea of prematurity.

A prospective randomized trial of feeding methods in very low birth weight infants

OBJECTIVE

To test the hypothesis that very low birth weight infants fed by continuous nasogastric gavage (CNG) would achieve full enteral feedings (100 kcal/kg/d) at an earlier postnatal age and have less feeding intolerance (FI) than infants fed by intermittent bolus gavage (IBG).

METHODS

Eighty infants were stratified by birth weight (700 to 1000 g and 1001 to 1250 g) and randomized into CNG or IBG feeding groups. CNG infants were comparable with IBG in birth weight, gestational age, sex, race, and day of onset of feeding (5.7 +/- 2.1 days vs 5.6 +/- 2.2 days, respectively). Feedings were given as undiluted Similac Special Care formula (Ross Laboratories, Columbus, OH) via a specific protocol designed for each 50 to 100 g birth weight category. Feedings were advanced isoenergetically by a maximum of 25 mL/kg/d until an endpoint of 100/kcal/kg/d for at least 48 hours was reached. An infant whose feedings were withheld for >12 hours based on predetermined criteria was considered to have an episode of FI.

RESULTS

Infants in the CNG group reached full enteral feeding at 17.1 +/- 8.9 days compared with 15.5 +/- 5.5 days in the IBG group; these were not statistically different. Secondary outcome variables such as days to regain birth weight (CNG, 12.6 +/- 5 days vs IBG, 12.5 +/- 3.7 days), days to reach discharge weight of 2040 g (CNG, 60 +/- 13.4 days vs IBG, 62 +/- 13.6 days), and number of episodes of FI were not significantly different between feeding methods. FI was primarily associated with birth weight </=1000 g (71%) vs 1001 to 1250 g (38%).

CONCLUSION

Feeding methods are associated with similar outcomes when feeding regimens are comparable.